Every finding on record at Sycamore Heights Health and Rehabilitation

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and helped prevent the development and transmission of communicable diseases and infections for five (5) of seven (7) sampled residents reviewed for infection control out of a total sample of 25 residents, Resident (R)2, R51, R78, R83, R340. Observation on 09/19/2024 at 8:45 AM, revealed Registered Nurse (RN)2 entered R2's room without donning proper Personal Protective Equipment (PPE) while the resident was in enhanced barrier precautions (EBP). RN2 provided direct contact resident care by obtaining R2's vital signs. RN2 then exited R2's room with the blood pressure machine, and failed to sanitize the machine. Additionally, observation on 09/19/2024 at 8:51 AM, revealed the Minimum Data Set (MDS)/Infection Prevention (IP) Nurse, and the Admission Coordinator (AC) entered R2's EBP room without donning proper PPE and shut the door. In an interview, the nurses stated they had provided direct contact resident care without the proper PPE. Observation of medication pass, on 09/18/2024, revealed Certified Medication Technician (CMT)3 dropped R78's pill onto the top of the medication cart, picked up the pill with her ungloved hand, placed the pill in the cup with the other medications, and administered the cup of pills to the resident. Observation on 09/18/2024, revealed RN2 failed to sanitize the blood pressure machine after using it on R83, and before using it on R51. Observation on 09/18/2024, revealed RN3 failed to sanitize the blood pressure machine after using it on R340. The findings include: 1. Review of R2's Face Sheet located in the Electronic Medical Record (EMR) revealed the facility admitted the resident on 03/28/2013 with diagnoses including dementia, cerebral infarction, and major depressive disorder. Review of R2's Physician's Orders, dated 07/23/2024, revealed orders for Enhanced Barrier Precautions related to Suprapubic catheter use. Observation on 09/19/2024 at 8:45 AM, revealed Enhanced Barrier Protection (EBP) signage posted on R2's door (Room E9). There was Personal Protective Equipment (PPE) outside the door to include gloves and gowns. RN2 entered the room without donning gloves or gown. RN2 was then observed to bring a blood pressure machine out of R2's room. RN2 failed to sanitize the machine before taking it down the hall. During an interview, on 09/19/2024 at 9:21 AM, with RN2, he stated the EBP signage meant that he should wear gloves when providing direct resident care for R2. He stated he had obtained R2's vital signs with the blood pressure machine which was considered direct resident care. In further interview, he stated the blood pressure machine he used for obtaining R2's vital signs should have been disinfected with bleach wipes after use. 2. Observation on 09/19/2024 at 8:51 AM, revealed Enhanced Barrier Protection (EBP) signage posted on R2's door (Room E9). The Minimum Data Set (MDS)/Infection Prevention (IP) Nurse, and the Admission Coordinator (AC) entered R2's room without donning PPE and closed the door. Upon exiting the room, the MDS/IP Nurse and the AC were interviewed and questioned about the care they were providing in Room E9. The MDS/IP Nurse stated they were pulling R2 up in the bed and emptying his catheter. When asked what the signage on the door meant, the MDS/IP nurse and the AC both stated they should have donned a gown and gloves prior to entering the room and providing resident care. 3. Observation of medication pass, on 09/18/2024 at 9:07 AM, revealed Certified Medication Technician (CMT)3 dropped a pill for R78 onto the top of the medication cart. CMT3 picked up the pill with her ungloved hand, placed the pill in the cup with the other medications, and administered the cup of pills to the resident. In an interview, on 09/18/2024 at 9:07 AM, with CMT3, she stated R78's pill fell on to the medication cart and should not have been picked up and placed with the rest of R78's medications for administration due to infection control reasons. During an interview, on 09/20/2024 at 8:56 AM, Unit Manager (UM)2 stated any pill dropped on the medication cart should be discarded. Additionally, UM2 stated if a resident was in EBP, staff should don a gown and gloves prior to entering the resident's room to provide direct resident care. UM2 defined direct resident care as care that involved touching the resident and stated delivering a meal tray or water was not considered direct resident care. In an interview, with the Assistant Director of Nursing (ADON), on 09/20/2024 at 9:24 AM, he stated he expected anyone administering a medication to dispose of any pills that had been dropped. He further stated he expected PPE (gown and gloves) to be donned when staff was performing direct resident care for a resident with EBP orders. He clarified that pulling a resident up in bed or emptying a catheter was considered direct resident care, but delivering water, a meal tray, or answering a resident's question was not be considered direct resident contact. In an interview, on 09/19/2024 at 3:24 PM, with the Director of Nursing (DON), she stated staff should dispose of any pills that were dropped on the medication cart. Additionally, she stated when staff saw an EBP sign on a resident's door, they should view it as a stop sign. It should alert staff the resident had a wound or a portal for infection such as a catheter, feeding tube, or intravenous (IV) catheter. Per interview, staff was expected to perform hand hygiene and put on a gown and gloves prior to entering the resident's room with EBP signage to provide care. She stated staff had received multiple training sessions related to EBP. During an interview with the Administrator, on 09/20/2024 at 11:18 AM, she stated if staff dropped a pill on the medication cart, she would expect the staff member to discard the pill. In further interview, the Administrator stated she expected staff to read and adhere to the signage for EBP. This meant that if staff was providing hands on care, they should don PPE. The PPE needed was a gown and gloves for EBP. 4. Observation on 09/18/2024 at 8:13 AM, revealed RN2 obtained vital signs on R83 using the blood pressure (B/P) machine, and then administered R83's medications. RN2 failed to sanitize the B/P machine before taking it into R51's room and using it to obtain vital signs on R51. Afterwards, RN2 again failed to sanitize the B/P machine, and left it in the hallway. In an interview on 09/19/2024 at 9:21 AM, with RN2, he stated the blood pressure machine should be sanitized after use and between residents. 5. Observation on 09/18/2024 at 9:19 AM, revealed RN3 took the blood pressure machine into R340's room to obtain her vital signs. RN3 failed to sanitize the blood pressure machine afterward. In an interview with RN3, on 09/18/2024 at 9:19 AM, she stated the blood pressure machine should be sanitized after use, and before using it on another resident.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure the resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility. This affected all residents in the facility. During a Group Interview conducted on 09/18/2024 by the State Survey Agency (SSA), Resident (R) 25 and R70 both complained they did not receive mail on Saturdays. In an interview with the Activitie's Director on 09/20/2024, it was confirmed, mail delivered on Saturday was locked in her office until Monday morning. The findings include: Review of the facility's policy titled, Resident Rights, dated 01/02/2022, revealed the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Further review revealed residents had the right to send and receive mail, and to receive letters, packages, and other material delivered to the facility for the resident through a means other than the postal service. During a Group Interview, conducted on 09/18/2024 at 3:00 PM, by the SSA, R25 and R70 both stated they did not receive mail on Saturdays. Review of R25's Quarterly Minimum Data Set (MDS) Assessment, dated 08/21/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a 15 out of 15 indicating intact cognition. Review of R70's Quarterly MDS Assessment, dated 07/23/2024, revealed the facility assessed the resident as having a BIMS of a 15 out of 15 indicating intact cognition. In an interview with the Director of Nursing (DON), on 09/19/2024 at 3:24 PM, she stated she thought the residents received mail on Saturdays, but she was unsure. In an interview with Unit Manager (UM)2, on 09/20/2024 at 8:56 AM, he stated he thought activitie's personnel passed out resident mail on Saturdays, the same as they did the rest of the week. In an interview with the Activitie's Director, on 09/20/2024 at 9:18 AM, she stated mail delivered on Saturday was locked in her office until the Business Office Manager could go through it and remove the facility's mail on Monday morning. The Activitie's Director further stated, after the facility's mail was removed from Saturday's mail, the residents' mail would then be delivered. In an interview with the Assistant Director of Nursing (ADON), on 09/20/2024 at 9:24 AM, he stated he did not know if mail was delivered to residents on Saturday. In an interview, on 09/20/2024 at 11:18 AM, the Administrator stated it was his expectation the Manager on Duty (MOD) passed out the residents' mail on Saturdays.

Based on observation, and interview, the facility failed to store food in accordance with professional standards for food service safety for three (3) of four (4) unit refrigerators used to store food for residents. Observation on 09/18/2024 of the resident nourishment refrigerators for the A-D, E, and F units, revealed ice packs stored in the freezer compartments. The findings include: Observation on 09/18/2024 at 9:18 AM, of the E unit resident nourishment refrigerator, revealed five (5) ice packs in the freezer stored along with one (1) mesh bag of popsicles, one (1) box of popsicles, and one (1) frozen sweet and sour chicken dinner. Observation on 09/18/2024 at 9:22 AM, of the F unit resident nourishment refrigerator, revealed eight (8) ice packs stored in the freezer. Observation on 09/18/2024 at 9:42 AM, of the A-D unit resident nourishment refrigerator, revealed three (3) ice packs stored along with one (1) popsicle. During an interview, on 09/20/2024 at 10:33 AM, with Unit Manager1 for the A-D unit, he stated ice packs were to be stored in the medication refrigerators and not in the resident nourishment refrigerators. He stated storing the ice packs in the resident nourishment refrigerators could lead to cross-contamination with food. In an interview with Unit Manager2 for B, E, and F units, on 09/20/2024 at 12:00 PM, he stated the ice packs should not be stored in the resident nourishment refrigerators as this was an infection control issue. He further stated the ice packs should be stored in the medication refrigerators. During an interview with the Administrator, on 09/20/2024 at 2:09 PM, she stated the ice packs were used to keep applesauce, supplements, and pudding cold on the medication cart. She further stated the ice packs should be stored in the medication room refrigerators.

Based on observation, interview, and review of facility policy, the facility failed to ensure drugs were stored under proper temperature controls; and were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions. Observation on 09/18/2024, revealed the top drawer of the medication cart for Hallway A, had a cup of pills with a resident's first name handwritten on the cup. Additionally, observation revealed eye drops and suppositories were stored in the door of the refrigerator in the hallway B medication room. The findings include: Review of the facility's policy titled, Medication Storage, dated 05/20/2020, revealed it is the policy of the facility to ensure all medications housed on our premises be stored in accordance with the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Further review revealed during medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area. Refrigerated products were to be stored in refrigerators located in the pharmacy and at each medication room. Temperatures were to be maintained within 36-46 degrees Fahrenheit. Review of the facility's policy titled, Medication Administration, dated 01/21/2022, revealed medications are administered by licensed nurses, or other staff who were legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 1. During observation of medication pass on 09/18/2024 at 9:20 AM, with Registered Nurse (RN)3, it was noted there was a cup of pills with a resident's first name handwritten on the cup in the top drawer of Medication Cart A. During an interview with RN3, on 09/18/2024 at 9:20 AM, she stated she had pulled the medications and put them in a cup and then realized the resident had gone to therapy. She further stated she placed the cup of medications in the medication cart drawer and elected to wait until the resident returned from therapy to administer the medication. In further interview, RN3 stated she was unsure of what issues could occur with leaving the cup of pills in the medication drawer because she knew who they belonged to and the resident's name was written on the cup. In an interview with Unit Manager (UM)2, on 09/20/2024 at 8:56 AM, she stated if a resident was not available to take their medications, he expected staff to dispose of the medications and pull new medications when the resident was available. In an interview with the Assistant Director of Nursing (ADON), on 09/20/2024 at 9:24 AM, he stated it was his expectation for staff to dispose of medications if the resident was not available to take them once they had been prepared. He stated a cup of pills should never be put back in the medicine cart for later because staff might forget to give them, or the pills might get lost. Further, depending on the type of medication, this could cause a bad outcome. In an interview with the Director of Nursing (DON), on 09/19/2024 at 3:24 PM, she stated if the medications had been pulled for administration and placed in a cup, and the resident was not available in order for medications to be administered, the medications should not be saved. Instead, they should be disposed of appropriately and this should be noted in the resident's. Further, the family and the physician should be notified. In continued interview, she stated when the resident returned to the facility, she expected staff to find out if the physician wanted the medications administered or held. In an interview with the Administrator, on 09/20/2024 at 11:18 AM, she stated it was her expectation staff made sure the resident was available before they pulled the resident's medications for administration. She stated if staff did inadvertently pull the medications for a resident that was out of the facility or busy at an activity, the medications should be thrown away. Further, she stated a cup of pills should not be placed back into the medication cart because the medications could get lost, forgotten, or given to another resident. 2. Observation on 09/18/2024 at 9:55 AM, of the medication refrigerator in the medication room on Hallway B, revealed there were eye drops and suppositories stored in the door of the refrigerator. There was a thermometer in the door with the medications and it read 43 degrees Fahrenheit. During an interview, on 09/18/2024 at 9:55 AM, RN4 stated medications should not be stored in the door of the refrigerator because there could be fluctuations in temperature causing them to loose their potency.

Based on observation, interview, record review, and review of facility policies, the facility failed to implement the comprehensive person-centered care plan in order to meet the resident's medical, and nursing needs for three (3) of 25 sampled residents, Resident (R)45, R52, and R83. Observation on 09/17/2024 and 09/18/2024, revealed R45's Comprehensive Care Plan (CCP) was not implemented related to oxygen settings. Furthermore, observation on 09/17/2024, revealed R83's CCP was not implemented related to wearing a smoking apron while smoking. Moreover, continuous observation on 09/19/2024 from 8:15 AM to 10:15 AM, revealed staff had not checked R52's brief or taken him to the bathroom, as per the CCP. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 08/30/2022, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, to meet a resident's medical, physical, mental, and psychosocial needs. 1. Review of the facility's Resident Smoking policy, last reviewed/revised 04/24/2024, revealed . all safe smoking measures will be documented on each resident's care plan and communicated to all staff . who will be responsible for supervising resident's while smoking. Review of R83's History and Physical note, dated 08/04/2024, located in the Electronic Medical Record (EMR), revealed the facility admitted the resident on 08/01/2024 with diagnoses including peripheral vascular disease, degenerative joint disease, and tobacco abuse. Review of R83's Admission Minimum Data Set (MDS) Assessment, dated 08/05/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating intact cognition. The MDS Assessment further revealed the resident smoked cigarettes. Review of R83's Comprehensive Care Plan (CCP), revised 09/17/2024, revealed a focus of Respiratory, specifically nicotine dependence, related to smoking cigarettes. The goal stated the resident would be injury free from unsafe smoking practices. An intervention dated 08/02/2024, revealed the resident required a smoking apron while smoking. A continuous observation of R83, was conducted on 09/17/2024 from 9:00 AM until 9:25 AM, and during this time the resident smoked two (2)cigarettes without wearing a smoking apron. A continuous observation of R83 was conducted on 09/17/2024 from 11:00 AM until 11:23 AM, and during this time the resident smoked one (1)cigarette without wearing a smoking apron. During an interview with R83, on 09/16/2024 at 2:48 PM, he stated he had five (5) opportunities per day for smoking. He further stated the facility did not provide a smoking apron for him when he smoked. During further interview with R83, on 09/20/2024 at 4:45 PM, he stated he was never offered a smoking apron, but if he were offered one, he would have worn it when he smoked. In an interview with the Activity Director (AD), on 09/20/2024 at 11:58 AM, she stated she checked the care plans for residents who smoked in order to be aware of any interventions related to smoking. Afterwards, she notified her staff of the interventions. She further stated if a resident was care planned to wear a smoking apron while smoking, but did not, ashes could drop on his clothes, or he could drop a cigarette onto himself which could lead to a burn. During an interview with the Social Services Director (SSD), on 09/20/2024 at 12:13 PM, she stated if R83 was care planned to wear a smoking apron and did not wear the apron when smoking, he could possibly burn himself. During an interview with the Minimum Data Set (MDS) Coordinator, on 09/20/2024 at 2:13 PM, she stated she had entered the care plan intervention for R83 to wear a smoking apron while smoking. She further stated if a resident had a care plan intervention to wear a smoking apron and did not wear the apron, this could lead to a burn or severe injury. In an interview with the Registered Nurse (RN)1, on 09/20/2024 at 2:30 PM, she stated she would review the resident's care plan to identify what interventions were to be implemented for a resident who smoked. In an interview with the Administrator, on 09/20/2024 at 3:28 PM, she stated she did not think R83 was assessed for smoking independently. She further stated if R83 should wear a smoking apron and did not wear the apron, the cigarette could cause burns, ruin his clothing, or start a fire. 2. Review of the facility's policy titled, Oxygen Administration, revised 03/24/2022, revealed oxygen is administered under orders of a physician. Further review revealed the resident's care plan would identify the interventions, based on the resident's orders, specifically, equipment setting for prescribed oxygen flow rates. Review of R45's Face sheet dated 09/18/2024, located in the Electronic Medical Record (EMR), revealed the facility admitted R45 on 06/18/2021 with diagnoses including unspecified dementia and acute pulmonary edema (congestion). Review of the Admission Minimum Data Set (MDS) Assessment, dated 08/21/2024, revealed the facility assessed R45 as having a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Additional review of the MDS revealed R45 received oxygen therapy. Review of R45's Comprehensive Care Plan (CCP), revised 09/18/2024, revealed she required oxygen therapy for acute pulmonary edema (congestion). The goal stated she would not have signs of hypoxia (low oxygen levels in body tissues). An intervention to administer oxygen at two (2) liters per minute was initiated on 04/04/2023. Review of R45's Active September 2024 Physician's Orders revealed orders to administer oxygen at two (2) liters per minute with a start date of 06/07/2023. An observation on 09/17/2024 at 10:25 AM, revealed the oxygen setting on R45's oxygen concentrator (medical device that provides extra oxygen) was set at three (3) liters per minute. An observation on 09/18/2024 at 2:24 PM, revealed R45's oxygen setting on her oxygen concentrator was set at three (3) liters per minute. During an interview, with the Director of Nursing (DON), on 09/19/2024 at 4:29 PM, she stated it was the nurse's responsibility to ensure the correct oxygen setting on the concentrator to ensure the resident was receiving oxygen as per the physician's orders and the care plan. In further interview, she stated if the resident received too much oxygen it could cause an increased heart rate, and restlessness, along with other adverse effects. In an interview with the Administrator, on 09/20/2024 at 3:42 PM, she stated if staff did not not follow R45's care plan related to oxygen therapy, this could cause changes in the resident's condition such as respiratory changes, and a change in her mental status. 50442 3. Review of the facility's policy titled, Activities of Daily Living, dated 08/15/2020, revealed a resident that was unable to carry out activities of daily living (ADLs) would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Further review revealed the facility would maintain individual objectives of the care plan with periodic review and evaluation. Review of R52's Face Sheet located in the Electronic Medical Record (EMR), revealed the facility admitted the resident on 10/01/2021 with diagnoses including dementia, type II diabetes, major depressive disorder, attention and concentration deficit, and hyperlipidemia. Review of R52's Quarterly Minimum Data Set (MDS) Assessment, dated 07/15/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderate cognitive impairment. Per the MDS, R52 required partial to moderate assistance with toileting and personal hygiene; could walk independently, and was incontinent of bowel and bladder. Continued review of R52's MDS revealed he was not assessed as rejecting care. Review of R52's Comprehensive Care Plan, dated 07/22/2024, revealed a focus of urinary incontinence with a goal stating the resident would not experience skin breakdown because of incontinence. The interventions included: check for incontinence episodes every two (2) hours, initiated on 07/22/2024. Further review of R52's CCP, dated 07/22/2024, revealed a focus of resistant to care with a goal stating the resident would not exhibit resistance to care. The interventions included actively involving the resident in his care, establishing clear boundaries, contact family if resident resisted care, and reiterate the purpose and advantage of treatment to the resident. All interventions were initiated on 07/22/2024. Additional review of R52's CCP, dated 07/22/2024, revealed a focus of impaired decision making related to dementia with a goal that he would have positive experiences in daily routine without overly demanding tasks and without being overly stressed. The interventions included provide cues and supervision for activities of daily living (ADLs), initiated on 07/22/2024. In an interview with Family Member (F)5, on 09/17/2024 at 6:00 PM, she stated it was an ongoing issue for R52 to be left in a soiled bed and in dirty clothing. F5 stated she just wanted the facility to take care of R52 by following what was written in R52's care plan which was to change or toilet the resident every two (2) hours. F5 further stated the nurses and floor managers did not help or supervise the aides to ensure R52's care plan was followed. In an interview with F6, on 09/17/2024 at 6:26 PM, she stated staff should be following the care plan related to toileting R52 every two to three (2 to 3) hours, but was not following through with this. Recently, when she came to visit R52, he was found in a wet bed. She stated she was now R52's guardian and was tired of the excuses for why R52 was not getting the care he needed. F6 stated there was not enough staff to take care of the residents appropriately. F6 further stated each time she talked with the Director of Nursing (DON) or the Administrator about why R52 was left wet, they would tell her that they were short staffed. Observation of R52, on 09/19/2024 at 08:15 AM, revealed the resident was sitting in his recliner eating breakfast. Observation of R52, 09/19/2024 at 8:20 AM, revealed a State Registered Nurse Aide (SRNA) entered R52's room. She checked on him, asking him if he needed anything, but did not take the resident to the bathroom or provide incontinence care. Observation on 09/19/2024 at 9:28 AM, revealed RN2 entered R52's room to take his vital signs and administer his medications. RN2 did not take R52 to the bathroom or check to see if he needed incontinence care. Observation on 09/19/2024 at 9:50 AM, revealed SRNA9 entered R52's room, found him asleep, and left the room without toileting him or providing incontinence care. Continuous observation on 09/19/2024 from 8:15 AM to 10:15 AM, revealed staff did not provide incontinence care for R52 or assist him to the bathroom. In an interview, on 09/19/2024 at 10:22 AM, with RN2, he stated he was assigned to R52 today, and the SRNAs rounded on residents at different times depending on the the residents' needs. He stated some residents needed more frequent monitoring. RN2 stated he expected his SRNAs to round on all residents at least hourly, and to follow the residents' care plans. In an interview with SRNA9, on 09/19/2024 at 10:25 AM, she stated she was assigned to R52 today, and the resident was incontinent of bowel and bladder. She further stated she had to remind him to go to the bathroom, as he would not go to the bathroom on his own. SRNA9 stated the resident needed to be taken to the toilet every one (1) to two (2) hours. During an interview, on 09/20/2024 at 8:56 AM, Unit Manager (UM)2 stated SRNAS should check on R52 and provide incontinence care or toilet the resident every two (2) hours as per the CCP. UM2 stated R52 did refuse to be toileted or changed at times, and if he refused, they should try again later. In an interview with the Assistant Director of Nursing (ADON), on 09/20/2024 at 9:24 AM, he stated staff should be rounding on R52 every two (2) hours. When staff rounded on R52, he should be taken to the bathroom and provided incontinence care if he was soiled as per the care plan. Further, if he refused incontinence care or toileting, staff should try again later. The ADON stated R52 was known to refuse care, such as toileting and getting his brief changed. In an interview, with the Director of Nursing (DON), on 09/19/2024 at 3:24 PM, she stated staff should check on R52 every two (2) hours to see if he was soiled and provide incontinence care or to take him to the bathroom for toileting as per the care plan. The DON stated R52 was care planned for refusal of care and often did refuse to allow staff to change his brief or take him to the toilet. If he refused incontinence care, staff should try again later or have another staff member try to provide care. In an interview with the Administrator, on 09/20/2024 at 11:18 AM, she stated she expected staff to toilet or check R52 to see if he was wet/soiled every two (2) hours as per the care plan. She further stated, sometimes R52 did refuse incontinence care and would deny that he was wet. He would sometimes not allow staff to provide other care and would refuse to get out of bed. The Administrator stated when R52 refused care, staff should get someone else to try to approach him in an attempt to provide the care that was needed.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide oxygen as ordered for one (1) of 25 sampled residents, Resident (R)45. Although R45's Active Physician's orders revealed orders to administer oxygen at two (2) liters per minute via nasal cannula, observation on 09/17/2024 and 09/18/2024, revealed the resident was receiving oxygen at three (3) liters per minute. The findings include: Review of the facility's Oxygen Administration policy, revised 03/24/2022, revealed oxygen was administered under orders of a physician. Further review revealed the resident's care plan would identify the interventions, based on the resident's orders. Review of R45's Face Sheet, located in the resident's Electronic Medical Record (EMR), revealed the facility admitted R45 on 06/18/2021 with diagnoses including unspecified dementia and acute pulmonary edema (congestion). Review of R45's Quarterly Minimum Data Set (MDS) Assessment, dated 08/21/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The MDS further revealed the resident received oxygen therapy. Review of R45's Active Orders, dated 09/2024, revealed a physician's order, with a start date 06/07/2023, to administer oxygen at two (2) liters per minute via nasal cannula. Review of R45's Comprehensive Care Plan (CCP), revised 09/18/2024, revealed a focus of oxygen therapy for acute pulmonary edema (congestion). The goal stated the resident would not have signs of hypoxia (low oxygen levels in body tissues). An intervention to administer oxygen at two (2) liters per minute was initiated on 04/04/2023. Observation on 09/17/2024 at 10:25 AM, revealed the oxygen setting on R45's oxygen concentrator (medical device that provides oxygen) was set at three (3) liters per minute, while the resident was receiving oxygen via nasal cannula. Observation on 09/18/2024 at 2:24 PM, revealed R45's oxygen setting on her oxygen concentrator was set at three (3) liters per minute, while the resident was receiving oxygen via nasal cannula. During an interview with Registered Nurse (RN)4, on 09/19/2024 at 3:41 PM, she stated it was the nurse's responsibility to check physician's orders and check the oxygen concentrators to ensure residents were receiving oxygen as ordered. Furthermore, she stated too much oxygen could cause the resident harm. During an interview with Unit Manager (UM)1, on 09/19/2024 at 4:01 PM, he stated the oxygen concentrator setting was to be checked by the nurse constantly, but at a minimum once every shift. He further stated, too much oxygen could cause the resident's breathing to slow down with the potential of death. During an interview, with the Director of Nursing (DON), on 09/19/2024 at 4:29 PM, she stated it was the nurse's responsibility to ensure the correct oxygen setting on the concentrator. She further stated the oxygen setting was to be checked according to the physician's orders. In continued interview, she stated if the resident received too much oxygen it could cause an increased heart rate, and restlessness, along with other adverse effects. During an interview with the Administrator, on 09/20/2024 at 3:32 PM, she stated the nurse should compare the physician's orders for oxygen administration with the settings of the oxygen concentrator to ensure a correct setting. She stated an incorrect oxygen setting could cause the resident to have respiratory issues.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure residents who were unable to carry out Activities of Daily Living (ADLs) received the necessary services related to toileting and incontinence care for one (1) of 25 sampled residents, Resident (R)52. The findings include: Review of the facility's policy titled, Activities of Daily Living, dated 08/15/2020, revealed a resident that was unable to carry out activities of daily living (ADLs) would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Further review revealed the facility would maintain individual objectives of the care plan and periodic review and evaluation. Review of facility's policy titled, Perineal Care, dated 01/02/2020, revealed it was the practice of the facility to provide perineal care for all incontinent residents during routine baths and as needed in order to promote cleanliness and comfort, prevent infections to the extent possible, and prevent and assess for skin breakdown. Review of the facility's policy titled, Dementia Care, dated 01/02/2020, revealed that it was the policy of the facility to provide the appropriate treatment and services to every resident who displayed signs of, or was diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. Review of R52's Face Sheet' located in the Electronic Medical Record (EMR) revealed the facility admitted the resident on 10/01/2021 with diagnoses which included dementia, type II diabetes, major depressive disorder, attention and concentration deficit, and hyperlipidemia. Review of R52's Quarterly Minimum Data Set (MDS) Assessment, dated 07/15/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 10 out of 15, revealing moderate cognitive impairment. Further review of the MDS, revealed R52 required partial to moderate assistance with toileting, and personal hygiene, and walked independently. R52 was further assessed as incontinent of bowel and bladder. Additional review of R52's MDS revealed he was not assessed as rejecting care. Review of R52's Comprehensive Care Plan, dated 07/22/2024, revealed a focus of urinary incontinence with a goal stating the resident would not experience skin breakdown because related to incontinence. The interventions initiated 07/22/2024 included: check for incontinence episodes every two (2) hours, and use a brief at night when resident was in bed, but use underwear when resident was out of bed. Further review of R52's CCP, dated 07/22/2024, revealed a focus of resistant to care with a goal stating the resident would not exhibit resistance to care. The interventions initiated 07/22/2024 included: actively involve the resident in his care, establish clear boundaries, contact family if resident resists care, and reiterate the purpose and advantage of treatment to the resident. Additional review of R52's CCP, dated 07/22/2024, revealed a focus of impaired mobility to perform or complete toileting activities as evidenced by resisting care. The goal stated resident would maintain adequate nutrition, hydration, and elimination. The interventions initiated 07/22/2024 included: allow resident to choose options, encourage resident to take gradually increasing responsibility for hydration, nutrition, elimination, sleep, activity, and other self-care needs, and maintain a calm environment and approach to resident. Continued review of R52's CCP, dated 07/22/2024, revealed a focus of impaired decision making related to dementia with a goal that he would have positive experiences in daily routine without overly demanding tasks and without being overly stressed. The interventions initiated 07/22/2024 included: provide cues and supervision for activities of daily living (ADLs), and respect resident's right to make decisions. Review of R52's Event Report, dated 04/03/2024, revealed resident refused his brief to be changed. The Interdisciplinary Team (IDT) team met to discuss the event; and it was noted the family wanted to be notified when he refused care. Review of R52's Event Report dated 06/11/2024, revealed the resident was exhibiting the behavior of removing his unsoiled brief frequently. Staff spoke with his guardian and evaluations were received from psychiatry and the Advanced Practice Registered Nurse (APRN). The IDT met to discuss ways to prevent this behavior. The evaluation portion of the Event Report, revealed the resident's care plan was updated with new interventions from the IDT team meeting. The report stated the interventions were in place and effective; however, the report did not specify which interventions had been put in place. During an interview, with Family Member (F)5, on 09/17/2024 at 6:00 PM, she stated R52 was often left in a soiled bed and in dirty clothing and this was an ongoing issue. F5 stated R52 did not get the help he required with his activities of daily living (ADLs). F5 further stated the Administrator wanted to meet monthly to discuss this issue and how to alleviate it, but she did not want to meet monthly. F5 stated she just wanted the facility to take care of R52 by following what was written in his care plan which was to change or toilet the resident every two (2) hours. F5 stated there was no chain of command at the facility, and no one was held accountable when R52 did not receive the required care. Per interview, the nurses and floor managers did not help or supervise the aides. F5 further stated, once she found R52 without a brief because the brief was laying on his bedside commode. Additional interview with F5, on 09/17/2024 at 6:00 PM, revealed on another occasion she found R52 sitting in wet clothing. She then rang the call bell and called out to get him cleaned up. She further stated the aide did not come for 20 minutes and by that time F5 had R52 cleaned up and his clothes changed. F5 stated R52 had dementia and would tell staff that he did not need to be changed or was not wet even though he required incontinence care. F5 stated there was frequent staff turn over at the facility and staff was often unaware of R52's medical diagnosis of dementia. In continued interview, she stated she spoke with a nurse last week after finding R52 wet again, but she could not remember which nurse. The nurse thought R52 should turn on the call light and ask to go to the bathroom or to be changed. F5 stated R52 had dementia, and he could not remember to turn on his call light. She stated that was the first and only time she saw this nurse working at the facility. In an interview with F6, on 09/17/2024 at 6:26 PM, she stated she was R52's guardian and was tired of the excuses for why R52 was not getting the care he required as per his care plan. She stated staff should be following the care plan related to toileting him every two to three (2 to 3) hours, but were not following through with this. Per interview, on a recent visit, R52 was found in a wet bed. F6 further stated each time she talked with the Director of Nursing (DON) or the Administrator about why R52 was left wet, they would tell her that they were short staffed. F6 stated there was not enough staff to take proper care of the residents. Observation of R52 on 09/18/2023 at 1:30 PM revealed he was sitting in his recliner watching television and eating his lunch in his room. R52's room smelled of urine. R52 stated he was able to clean himself up, and he could get himself up unassisted and take himself to the bathroom. When asked if he was wearing a brief, R52 stated he wore regular underwear and not a brief. During an interview, on 09/18/2024 at 1:41 PM, with State Registered Nurse Aide (SRNA)4, she stated she was assigned to R52 today and when assigned to the resident she would check on him at 7:00 AM after breakfast, after lunch, and right before going home in the evening. Further, she checked on him every two to three (2-3) hours to see if he was soiled, and if he was not soiled, she would take him to the bathroom. SRNA4 further stated R52 did refuse care at times, and when he refused to get changed or to be toileted, she would redirect him and he would usually allow her to provide incontinence care or take him to the bathroom. During an interview, with Registered Nurse (RN)1, on 09/18/2024 at 1:58 PM, she stated she was assigned to R52 today, and the aides rounded on the resident every two (2) hours. RN1 stated R52 was incontinent, and would refuse care or refuse to be changed or toileted at times. Observation of R52, on 09/19/24 at 8:15 AM, revealed R52 was sitting in his recliner eating breakfast. Observation of R52, on 09/19/2024 at 8:20 AM, revealed an SRNA entered R52's room. She asked him if he needed anything, but did not take the resident to the bathroom or check his brief. Observation on 09/19/2024 at 9:28 AM, revealed RN2 entered R52's room to obtain his vital signs and administer his medications. RN2 did not provide incontinence care, nor did the nurse take the resident to the bathroom. Observation on 09/19/2024 at 9:50 AM, revealed SRNA9 entered R52's room, found him asleep, and then left the room without toileting or checking to see if the resident required incontinence care. Continuous observation of R52 on 09/19/2024 from 8:15 AM to 10:15 AM, revealed staff did not check R52's brief to assess if he required incontinence care or assist him to the bathroom. During an interview on 09/19/24 at 10:22 AM, with RN2, he stated some residents needed more frequent monitoring, but he expected his SRNAs to round on residents at least hourly. He stated he was assigned to R52 today and the resident should be checked hourly as he was dependent on staff for ADLs. During an interview with SRNA9, on 09/19/2024 at 10:25 AM, she stated she was assigned to R52 today, and the resident was incontinent of bowel and bladder. She further stated she had to check him for incontinence and remind him to go to the bathroom, as he would not go to the bathroom on his own. SRNA9 further stated the resident needed to be taken to the toilet every one (1) to two (2) hours. During an interview on 09/20/2024 at 8:56 AM, Unit Manager (UM)2 stated the SRNAS should check on R52 and provide incontinence care or toilet the resident every two (2) hours. UM2 stated R52 did refuse to be toileted or changed at times, and if he refused, they should approach the resident later. During an interview with the Assistant Director of Nursing (ADON), on 09/20/2024 at 9:24 AM, he stated staff should be rounding on R52 every two (2) hours, and during rounds the resident should be taken to the bathroom and provided incontinence care if he was soiled. He stated if R52 refused incontinence care or toileting, staff should try again later. Further, if the resident continued to refuse care, this should be reported to the nurse and the nurse should document the refusals in R52's medical record. He stated at that point the nurse assigned to the resident, should try to perform incontinence care as the resident would allow. The ADON further stated R52 was known to refuse care, such as toileting and getting his brief changed. During an interview with the Director of Nursing (DON), on 09/19/2024 at 3:24 PM, she stated it was her expectation staff follow facility policies and state regulations while providing care for R52. She further stated staff should check on R52 every two (2) hours to see if he was soiled and provide incontinence care or to take him to the bathroom for toileting as per the care plan. The DON stated R52 was care planned for refusal of care and often refused to allow staff to change his brief or take him to the toilet. During those times when he refused incontinence care, staff should try again later or have another staff member try to provide care. During an interview with the Administrator, on 09/20/2024 at 11:18 AM, she stated she expected staff to toilet or check R52 to see if he was wet/soiled at least every two (2) hours. She further stated, sometimes R52 refused incontinence care and denied that he was wet. He would sometimes not allow staff to provide other care or would refuse to get out of bed. The Administrator further stated when R52 refused care, staff should have someone else to try to approach him in an attempt to provide the care that was needed. Staff should then report any refusals of care to their managers. The Administrator stated, because of R52's dementia, he was not aware he could no longer care for himself as he once did. Further, it was difficult at times to provide R52 care when he refused, as staff could not force a resident to do something. She stated the key to providing care for R52 after he refused care, was to allow him time to think about it, and then reapproach him.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure Advanced Directives were completed by the Legal Guardian for one (1) of 25 sampled residents, Resident (R)43. Although a Judge signed a court order to appoint the Cabinet for Health and Family Services (CHFS) Guardianship for R43, effective [DATE]; the facility did not verify the resident's code status, and accepted a Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) Order form, dated [DATE], signed by R43's family member. The findings include: Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives reviewed/revised [DATE], revealed the facility supported and facilitated a resident's right to request, refuse, and/or discontinue treatment and formulate an advance directive. Per policy, an advance directive was a written instruction recognized under State law related to the provision of health care when an individual was incapacitated. Further review of the policy, revealed during the care planning process the facility would review with the legal representative whether they desired to make any changes related to any advance directives. Review of R43's Face Sheet located in the Electronic Medical Record (EMR) revealed the facility admitted the resident on [DATE]. Further review of R43's Face Sheet revealed diagnoses including vascular dementia, cognitive communication deficit, and cerebral infarction. Review of R43's Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) Order form revealed the R43's family member signed the form on [DATE]. Review of R43's Physician's order, dated [DATE], revealed orders for DNR code status. Review of R43's Comprehensive Care Plan, dated [DATE] revealed the resident's code status was DNR, as of [DATE], with an intervention to withhold Cardiopulmonary Resuscitation (CPR) in the event the resident was found without pulse or respirations. Review of the Order of Appointment of Conservator from the Commonwealth of Kentucky, dated [DATE], revealed a Judge signed R43's court order to appoint the Cabinet for Health and Family Services (CHFS) Guardianship, as the resident's Conservator. Review of the Order of Appointment of Guardian from the Commonwealth of Kentucky, dated [DATE], revealed a Judge signed CHFS Guardianship as R43's appointed Guardian. Review of the Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) Order form, dated [DATE], revealed R43's family member signed the DNR form. Review of R43's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of zero (0) out of 15, indicating severe cognitive impairment. During an interview, on [DATE] at 11:16 AM, the State Guardian (SG) stated R43 was a full code status (meaning if the resident's heart or lungs stopped working the medical staff is permitted to perform necessary procedures to save their lift including CPR ). The SG stated the state was appointed the resident's guardian on [DATE] and no one else had the authority to make a change to R43's code status after the state was appointed her guardian. The SG further stated even if a resident had an advance directive of DNR prior to state guardianship, once the state became the resident's guardian the resident's code status became full code. The SG also stated for a resident under state guardianship to change to a DNR code status, the decision did not come from her, but a state nurse would need to complete a review of the resident's medical condition to determine if a DNR status was appropriate. The SG stated she informed the facility's Social Services Director and the Director of Nursing the resident was a full code once the SG was appointed. During an interview, on [DATE] at 3:28 PM, Registered Nurse (RN) 5 stated when a resident returned from the hospital the facility checked the resident's code status from the hospital. She stated R43 transferred to the hospital in [DATE]. She further stated R43 was on another hall at that time and she did not work with her when she returned from the hospital. In an interview on [DATE] at 3:41 PM, RN4 stated she could not recall if she worked with R43 when she returned from the hospital in [DATE]. She stated a resident's code status did not change upon return from the hospital unless there was a drastic change in care. She further stated if a resident had a State Guardian (SG), the SG was responsible for a resident's advanced directive and the facility's management handled it. RN4 stated an advance directive let the facility know what the resident's end of life choices were. She stated if a resident's code status was DNR, she would not provide the resident CPR if the resident's heart stopped and the resident could possibly die. In an interview on [DATE] at 4:01 PM, Unit Manager (UM)1 stated when a resident returned from the hospital, the resident's advance directive was handled by the social services department. He stated the resident's code status should be updated when the resident returned from the hospital. The UM further stated the purpose of the DNR was to prevent CPR. He stated if a resident did not receive needed CPR the resident could expire. He further stated when a resident returned from the hospital, social services was responsible to review resident's code status during the Interdisciplinary Team (IDT) meetings. Further, he could not recall if R43's code status was reviewed in the IDT. During an interview on [DATE] at 4:30 PM, the Director of Nursing (DON) stated social services reviewed the advance directives and reviewed re-admissions in the IDT meeting. The DON stated if a resident in the facility was later provided a State Guardian (SG), the social services department was responsible to follow up with the SG for the resident's code status. The DON stated she could not recall discussing R43 with the SG. She further stated only the SG could sign advance directives for a resident after the resident obtained a SG. The DON also stated she could not remember if R43's advance directives were discussed when she returned from the hospital in [DATE]. She stated the DNR form reflected the wishes of the resident or their Power of Attorney (POA). She further stated if a resident had a SG and was to be full code status, but the DNR form was signed by someone other than the SG for DNR code status, the resident would not receive CPR and a potential outcome could be death. During an interview, on [DATE] at 2:10 PM, the Administrator stated R43 went to the hospital after the State became her guardian and the hospital obtained the DNR form from the resident's family member. She stated upon the resident's return, the facility took the information from the hospital.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (1) of nine (9) residents who smoked out of a total sample of 25 residents, Resident (R)83. The facility was a smoke free facility and only those residents who were grandfathered in could smoke on facility grounds. However, R83 was admitted after the facility went smoke free and was observed on 09/17/2024 smoking on facility grounds, without wearing a smoke apron. Furthermore, there was no documented evidence a smoking evaluation was completed for this resident to ensure the resident could safely smoke. The findings include: Review of the facility's Smoking Policy, undated, located within the Admission Agreement packet, revealed the facility was a non-smoking facility. Further review revealed residents who smoked were supervised. Additional review revealed a Safe Smoking Evaluation was to be performed and include accommodations the resident would need, example: smoking apron. Review of the facility's Resident Smoking policy, last reviewed/revised 04/24/2024, revealed residents who smoke will be further assessed, using the Resident Safe Smoking Assessment. The policy further revealed, all safe smoking measures will be documented on each resident's care plan and communicated to all staff . who will be responsible for supervising resident's while smoking. Review of R83's History and Physical note, dated 08/04/2024, located in the resident's Electronic Medical Record (EMR), revealed the facility admitted R83 on 08/01/2024 with diagnoses which included peripheral vascular disease, degenerative joint disease, and tobacco abuse. Review of R83's Admission Minimum Data Set (MDS) Assessment, dated 08/05/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Further review of the MDS, revealed the resident smoked cigarettes. Review of R83's Comprehensive Care Plan (CCP), revised 09/17/2024, revealed an intervention stating the resident required a smoking apron while smoking, dated 08/02/2024. Review of the facility's list of residents who smoked, provided by the Administrator, on 09/16/2024, revealed R83 was not listed. Continuous observation of R83, was conducted on 09/17/2024 from 9:00 AM until 9:25 AM, while the resident was smoking in the courtyard, in the designated smoking area. R83 was observed to smoke two (2) cigarettes. R83 handled both cigarettes without difficulty; however the resident was not wearing a smoking apron as per the care plan. R83 was observed to be supervised by an activity staff member while smoking. Ashtrays were observed in the courtyard. Further continuous observation of R83 was conducted on 09/17/2024 from 11:00 AM until 11:23 AM, while the resident was in the courtyard, in the designated smoking area. R83 was observed to smoke one (1) cigarette without wearing a smoking apron. He was being supervised by an activity staff member. Ashtrays were observed in the courtyard. R83 was observed to handle the cigarette without difficulty. During an interview with R83, on 09/16/2024 at 2:48 PM, he stated the facility had a designated smoking area, outside in the courtyard. He further stated he had five (5) opportunities per day for smoking, but the facility did not provide a smoking apron for him when he smoked. He stated the facility staff was always present when he smoked. In a follow up interview with R83, on 09/20/2024 at 4:45 PM, he stated he was never offered a smoking apron, but if he were offered one, he would have worn it when he smoked. An interview was conducted with Hospitality Aide (HA)1, on 09/20/2024 at 11:39 AM, with translation assistance from Unit Manager2. HA1 stated the Activitie's Director (AD) or the resident's nurse would notify her of interventions or assistance needed for the residents when they smoked. She stated a resident who would need to wear a smoking apron, but did not, could have an accident and burn his skin. In an interview with the Activitie's Assistant (AA), on 09/20/2024 at 11:46 AM, she stated she was given a list of residents who smoked along with their safety requirements from her supervisor, the Activitie's Director (AD). She stated her list was updated every six (6) months and with every new resident admission. She further stated R83 did not go to the courtyard to smoke because the facility admitted him after the facility went smoke free. She stated a resident who would need to wear a smoking apron, but did not, could burn himself or burn holes in his clothes. In an interview with the AD, on 09/20/2024 at 11:58 AM, she stated she would review the care plan or speak with the Director of Nursing (DON) or the Nursing Administrator for required safety interventions for a resident who smoked. Afterwards, she notified her staff of the interventions. She stated if a resident refused to wear a smoking apron, she documented the refusal in the progress notes of the EMR and the nurse was notified. She stated if a resident had an intervention in his care plan to wear a smoking apron, but did not, ashes could drop on his clothes, or he could drop a cigarette onto himself which would lead to a burn. She stated residents admitted after the facility became smoke-free were not allowed to smoke. No documentation of R83's refusal to wear a smoking apron was found in the EMR. In an interview with the Social Services Director (SSD), on 09/20/2024 at 12:13 PM, she stated the residents received the facility's smoking policy on admission to the facility. She further stated the only residents who smoked were the ones who were grandfathered in. She could not recall when the facility became smoke-free. The SSD stated she thought R83 had to check himself out to smoke, meaning he would have to leave the facility to smoke. She stated she did not know R83 was smoking in the courtyard. She further stated if R83 had an intervention on his care plan to wear a smoking apron and did not, he could possibly burn himself. During an interview with the Minimum Data Set (MDS) Coordinator, on 09/20/2024 at 2:13 PM, she stated she entered the intervention to wear a smoking apron while smoking on R83's care plan. The MDS coordinator stated she did not know when the facility became smoke- free. She stated the primary nurse would perform the Safe Smoking Evaluation, which determined if interventions were needed for a resident who smoked. The MDS coordinator could not locate the Safe Smoking Evaluation in R83's EMR. She further stated if a resident had a care plan intervention to wear a smoking apron and did not, this could lead to a burn or severe injury. In an interview with the Registered Nurse (RN) 1, on 09/20/2024 at 2:30 PM, she stated she did not observe the residents while they smoked. However, she stated if a resident had a care plan intervention to wear a smoking apron and did not, this could lead to an injury or burn. In an interview with the Admissions Director, on 09/20/2024 at 2:55 PM, she stated the facility became a smoke-free facility last year, but she could not recall the date. She stated a resident admitted after the facility became smoke-free, would need to sign themselves out of the facility and smoke off the facility's property. In an interview with the Administrator, on 09/20/2024 at 3:28 PM, she stated the facility was a smoke-free facility when R83 was admitted . She stated R83 should not have been on the grandfathered list. She further stated she did not think R83 was assessed to evaluate if he could smoke independently; however, the resident did not exhibit any unsafe smoking tendencies. In further interview, she stated if R83 should wear a smoking apron and did not, the cigarette could cause burns, ruin his clothing, or a fire could be started.

Based on observation, interview, record review, and facility document and policy review, the facility failed to have an effective system to develop and implement the comprehensive care plan with effective interventions to protect residents from accidents and hazards for one (1) of fifteen (15) sampled residents (Resident #7). The facility admitted Resident #7 (R7) with diagnoses of paranoid schizophrenia and impulse disorder. The facility care planned the resident on 11/01/2023, for attempting to manipulate objects such as forks and coat hangers into protective objects, as he was seeing hallucinations in his room. However, the facility failed to develop interventions for staff to continuously monitor and document the findings to ensure objects he could manipulate into weapons were removed from his room. On 03/11/2024 at approximately 3:40 AM, a Certified Nurse Aide (CNA) entered Residents #7 and #6's shared room and observed Resident #6 lying on his bed with blood on his face and a laceration to the left eye. The CNA observed R7 sitting in a chair next to R6's bed, with a bloody, plastic fork in one (1) hand, and both hands covered with blood. R7 told staff he thought R6 was trying to hurt him. The facility's failure to have an effective system in place to ensure each resident's care plan was developed and implemented to protect residents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 04/01/2024 and was determined to exist on 03/11/2024 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; and 42 CFR 483.25 Quality of Care, F689 at a Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was also identified at 42 CFR 483.25 Quality of Care, F689. The facility was notified of the Immediate Jeopardy on 04/01/2024. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 04/05/2024, alleging removal of the IJ on 03/15/2024. An Extended Survey was initiated on 04/08/2024. The State Survey Agency (SSA) validated the facility's IJ Removal Plan on 04/12/2024. The SSA determined the IJ had been removed 03/15/2024, as alleged and was Past IJ. Refer to F689. The findings include: Review of the facility's policy entitled, Comprehensive Care Plans, implemented on 08/30/2022, and revised 02/2024, revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident, which met their medical, physical, mental, and psychosocial needs. Continued review of the policy revealed the facility's care plan process was to include an assessment of each resident's strengths and needs and incorporate the resident's personal and cultural preferences in developing goals for their care. Review of the facility's policy titled, Accidents and Supervision, dated 01/02/2020, and revised 02/21/2024, revealed the facility was to provide a resident environment as free of accident hazards as possible, and provide each resident adequate supervision and assistive devices to prevent accidents. Continued review revealed the facility would implement interventions to reduce hazards and risks, and monitor for effectiveness, and modify those interventions when necessary. 1. Review of Resident #6's (R6) medical record revealed the facility admitted him on 08/18/2022, with diagnoses including unspecified dementia and major depressive disorder. Review of R6's Quarterly Minimum Data Set Assessment (MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 01 which indicated he was severely cognitively impaired. An interview was not conducted. Review of R6's comprehensive person-centered care plan revealed the facility care planned the resident on 08/18/2022, for cognitive loss and dementia with a goal for the resident to have positive experiences in his daily routine without overly demanding tasks and without becoming overly stressed. Continued review revealed the interventions included encouraging small group programs, verbalization of his feelings, supervision with Activities of Daily Living (ADLs) respecting his right to make decisions and supporting and reassuring the resident in new situations. Review of the nurse's progress note, documented by Registered Nurse #3 (RN3) on 03/11/2024 at 5:02 AM, revealed a Certified Nurse Aide (CNA) entered R6's and R7's shared room, and saw R6 injured with blood all over his face and bed. Continued review revealed the CNA called for RN3 to come to the room. Per review of the Note, when the RN entered the room, she observed R6 seriously injured, and not responding to verbal commands. The review revealed the resident's roommate (R7) was observed sitting next to R6's bed holding a fork and toothpaste in his hands which were all bloody. The facility transferred R6 was to the hospital related to his injuries. Observation of R6 on 03/27/2024 at 11:05 AM, revealed the resident had one to one (1:1) supervision due to the recent event of being injured by R7. Continued observation revealed R6's left eye had a covering taped over it. 2. Review of Resident #7's (R7) medical record revealed the facility admitted him on 05/22/2023, with diagnoses including unspecified dementia, impulse disorder, and paranoid schizophrenia. Review of R7's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of 00, indicating he was severely cognitively impaired. Review of R7's care plan revealed the facility care planned him on 11/01/2023, for attempting to manipulate objects such as coat hangers and forks into protective objects related to his hallucinations. Per review Social Services Director #18 (SSD18) developed the care as she had discussions with the resident and had seen him holding objects. Continued review revealed staff were to be aware and lessen the resident's efforts to make protective objects which had the potential to be unsafe. The interventions included: serving only plastic ware to the resident on his meal trays; and having staff monitor the resident's room to prevent him from having materials which could be manipulated into protective objects. Review of the nurse's progress note, documented by RN3 on 03/11/2024 at 6:05 AM, revealed on 03/11/2024 at 6:05 AM, when she entered R7's room, she observed him sitting next to R6's bed holding a bloody fork in one (1) hand and both hands were all bloody. Continued review revealed the resident's roommate, R6 was seriously injured on his face and his left eye. Further review revealed RN3 called the police and they came to the facility, and emergency medical services (EMS) transported the victim (R6) to the hospital. In addition, the RN noted R7 needed to be sent out for evaluation as well, as he was in his room pacing quietly at the time. Record review revealed the facility transferred Resident #7 to the hospital on 03/11/2024, under a mental inquest warrant (involuntary admission of a mentally handicapped person). In interview on 03/29/2024 at 1:40 PM, the Administrator stated R7 would not be returning to the facility after his hospitalization . In interview on 03/27/2024 at 3:07 PM, RN3 stated on the night of the incident she was assigned to care for both Residents #6 and #7. RN3 stated she thought the incident had taken place around 4:00 AM or 5:00 AM. She stated her shift had started around 6:00 PM or 7 :00 PM, the previous night (03/10/2024). RN3 stated on the morning of the incident, a CNA went into the residents' room to check on them during her rounds and discovered R7 sitting next to R6's bed holding a bloody fork. She stated the CNA came to get her, and she went to the residents' room. The RN stated she saw R7 sitting beside R6's bed with blood on him and R6 was injured and not responding well. RN3 stated 911 and emergency medical services (EMS) were called and responded to the facility. In an interview with RN4 on 03/27/2024 at 4:10 PM, he stated he was the nurse who took over for RN3 on 03/11/2024. He stated he had provided care for R7 several time in the past and was familiar with him and his safety concerns and how he was always talking about self-protection. In an interview on 03/29/2024 at 1:00 PM, RN4 stated people had brought R7 things like combs from time to time, and once the resident had a sharp point comb that staff took away to be on the safe side. He stated that prior to the incident, R7 had been having visual and auditory hallucinations. RN4 stated facility staff had not had a day to day working fear of R7; however, they knew the resident had hallucinations. The RN stated when he had concerns about a resident he shared those concerns with the DON in order to have the resident's care plan updated. He stated nursing staff were not required to review residents' care plans daily; however, he did look at them for sure when the resident was new. In continued interview RN4 stated he had continually worked with R7 to help him focus on things that were real like television (TV) in order to keep him oriented. He stated in the auditory side of R7's hallucinations, he would have conversations with people that were not there. In interview on 04/01/2024 at 1:39 PM, the former SSD/Memory Care Director #18 (SSD/MCD18) stated she recalled working with R6 and R7, but did not recall any specific incident regarding R7 harming anyone. She stated she recalled that R7 had severe hallucinations and used items as weapons to defend against the hallucinations. The SSD/MCD18 stated she saw R7 with items like a coat hanger and a fork in his hand and saw him explaining to others that he wanted to use those items to defend himself. She stated she had never seen R7 use those items as a weapon against another person though. The SSD/MCD18 stated she recalled on at least three (3) separate instances R7 holding objects he perceived as items of defense against his hallucinations. She stated she initiated R7's care plan because she was the person with the firsthand knowledge that he was perceiving items as weapons. However, she did not know how the facility ensured the intervention for monitoring R7 took place. In interview on 04/01/2024 at 12:00 PM, Dietary Manager #21 (DM21) stated the plastic ware intervention for R7 began around 11/07/2023. She stated the head nurse instructed her to put the plastic utensils in place with instruction to take them out after each meal. The DM stated a meal tray card was created that noted plastic utensils were to be used for R7, and the utensils needed to be removed after each meal. She stated R7 was served with a plastic spoon and fork with each meal; he was not given a knife. DM21 stated she and other staff collected the utensils after each meal and made rounds to ensure all the utensils were taken out of R7's room. The DM stated staff were not required to sign anything like a log sheet or document electronically to verify that the utensils had been removed. She further stated they also confirmed in the kitchen that R7's tray returned with the utensils on them. In addition, she stated the plan was to communicate and talk to the nurses about the removal of R7's plastic utensils. DM21 stated R7 was permitted to eat alone in his room and did not require observation by staff. During an interview with Certified Nurse Aid #8 (CNA8) she stated on 04/01/2024 at 12:43 PM. on the evening of the incident she was caring for Resident #7. She stated she did not recall where resident had dinner on the night of the incident. She stated Resident #7 was always had plastic utensils with meals, and staff ahd to pick them up after the meal. However, she stated she was not told why. CNA8 stated that she had not been required to tell anyone when she checked R7's tray for the plastic utensils. She stated there had been no formal documentation process required for documenting the removal of the plastic ware. In an interview on 03/28/2024 at 9:30 AM, the DON stated she had been involved in conducting the facility's internal investigation after the incident took place. She stated she was not aware of R7 having any significant symptoms prior to the incident that occurred on 03/11/2024. The DON stated she did not recall if any specific changes were made to R7's care plan once his schizophrenia diagnosis was recognized. The DON stated she felt the supervision on the night of the incident by staff had been adequate. She stated after the incident took place, staff education was provided regarding dementia residents and behaviors that were not normal. In an interview on 03/29/2024 at 2:00 PM, the DON stated she did not feel R7 had been a danger to anyone prior to the incident. The DON stated R7 had not shown any aggression towards staff, so We were not doing more monitoring. She stated she did not know how or why the monitoring intervention ended up on the care plan other than being made aware of an incident where a hanger was broken but said she also did not know specifics of that incident. The DON stated she believed it would be easier for a resident to harm someone if he/she were allowed to have objects in his/her room. The Administrator provided a copy of the meal ticket record from 11/08/2023 (when the DM said the intervention for plastic ware began) for R7. Review of the meal ticket document revealed it noted staff were to remove all plastic ware at the end of the resident's meal. The Administrator provided an undated document entitled, profile care plan approaches. Per review of this document, staff were to monitor what was in R7's room to prevent him from having materials that could be manipulated into protective items. However, there was no documentation noting how often staff were to monitor the resident's room/environment for those items or that staff consistently monitored the resident's room. In interview on 03/29/2024 at 1:40 PM, the Administrator stated she had not thought R7 was a danger to anyone in the facility prior to the incident and had not felt the resident required increase monitoring. The Administrator stated staff became concerned when R7 broke a clothes hanger in a room, and they felt he could have used it as a weapon. She stated staff had been required to remove the utensils from the resident's room. However, they did not document this. intervention. She stated R7 was ambulatory and had no restrictions and could ambulate freely throughout the unit. During the interview, she stated it was the facility's duty to maximize safety for all residents, and staff needed to be observant and aware of what was taking place around them.

Based on observation, interview, record review, facility document and policy review, the facility failed to provide an effective system to monitor and supervise residents to prevent accidents hazards for one (1) of fifteen (15) sampled residents (Resident #6). On 03/11/2024 at approximately 3:40 AM, Resident #6 (R6) and Resident #7 (R7), who were roommates, were in their room alone with the door opened. Staff entered the residents' room and observed R7 sitting in a chair next to R6's bed, with a plastic fork in one hand and both hands covered with blood. R6 was lying on his bed with blood on his face and a laceration to his left eye. When staff asked R7 about the incident the resident stated he did it because he believed R6 was trying to harm him. The facility's failure to have an effective system to ensure each resident received adequate supervision and monitoring to prevent accident hazards has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 04/01/2024 and was determined to exist on 03/11/2024, in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; and 42 CFR 483.25 Quality of Care, F689 at a Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was also identified at 42 CFR 483.25 Quality of Care, F689. The facility was notified of the Immediate Jeopardy on 04/01/2024. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 04/05/2024, alleging removal of the IJ on 03/15/2024. A Partial Extended Survey was initiated on 04/08/2024. The State Survey Agency (SSA) validated the facility's IJ Removal Plan on 04/12/2024. The SSA validated the immediacy of the IJ had been removed on 03/15/2024, as alleged, prior to the start of the survey. The IJ was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy entitled, Abuse, Neglect, and Exploitation, dated 01/02/2020 with a revision date of 08/30/2022, revealed the facility was to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibited and prevented abuse, as well as neglect and exploitation of residents. Review of the facility's policy entitled, Accidents and Supervision, revised 02/21/2024, revealed the residents' environment was to remain as free of accident hazards as possible. Continued review revealed each resident was to receive adequate supervision and assistive devices to prevent accidents which included: identifying, evaluating and analyzing hazards and risks, and implementing interventions to reduce those hazards and risks. Per policy review, the facility was to monitor for effectiveness, and modify interventions when necessary. Further review of the policy revealed supervision was an intervention which meant mitigating accident risk, and the facility was to provide adequate supervision to prevent accidents for its residents. 1. Review of R6's medical record revealed the facility admitted him on 08/18/2022, with diagnoses that included unspecified dementia, major depressive disorder, and insomnia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed R6 to have a Brief Interview for Mental Status (BIMS) score of 01,. This score indicated severe cognitive impairment; an interview was not completed. Review of R6's Nursing Progress Note dated 03/11/2024 at 5:02 AM, documented by Registered Nurse (RN) #3 revealed upon entering R6's and R7's shared room, a Certified Nurse Aide (CNA) found R6 injured with blood all over his face and bed. Per review of the Note, the CNA called RN3 to come to the room. The RN found R6 seriously injured, and breathing but not responding to verbal commands. Continued review of the Note revealed R7 was sitting next to R6's bed with a fork in one (1) of his hands, with both hands all bloody. Further review revealed RN3 asked the roommate (R7) what had happened, and the roommate said, I cannot take it anymore. In addition, RN3 and the CNA quickly went out of the room when they found out the roommate (R7) had caused the injury to R6 and called the police. Review of the Note also revealed R6 was taken to the hospital right away. 2. Review of R7's medical record revealed the facility admitted the resident on 05/22/2023, with diagnoses which included unspecified dementia, paranoid schizophrenia, and impulse disorder. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed R7 to have a BIMS' score of 00, which indicated severe cognitive impairment. Continued record review revealed Resident #7 had a state appointed guardian. Review of R7's comprehensive care plan revealed on 11/01/2023, the facility developed a care plan problem noting the resident attempted to manipulate objects, such as forks or coat hangers into protective objects to use, due to him seeing hallucinations in his room which bothered him. Continued review revealed Social Services Director (SSD) #18 had initiated the care plan dated 11/01/2023. Additional review revealed the goal which noted staff were to be aware and mitigate the resident's efforts to make protective objects which had the potential to be unsafe. Further review revealed the interventions included: psychiatry support with medication and talk therapy; serving him only plastic ware with meal trays; and monitoring what was in his room to prevent him from having materials that could be manipulated. The facility provided an undated document entitled, profile care plan approaches for R7. The document stated that staff would monitor what was in the resident's room to prevent him from having materials that could be easily manipulated into protective materials (weapons). However, Review of R7's Nursing Progress Note dated 03/11/2024 at 6:05 AM, written by Registered Nurse (RN) #3, revealed upon entering R6's and R7's shared room, R7 was observed sitting next to his roommate's bed (R6) with a fork in one (1) had and both hands all bloody. Continued review of the Note revealed R6 was seriously injured on his face and left eye. RN3 noted this nurse asked R7 what had happened, and the resident stated, I cannot take it anymore. Per review of the Note, RN3 called the police, and they came to the facility and emergency medical services (EMS) took the victim, (R6) to the hospital. The Director of Nursing (DON) and Nurse Practitioner (NP) were notified. Review of a progress note dated 03/20/2024 and transcribed by Nurse Practitioner #3 (NP3) revealed R6 had sustained, left orbital floor and medial wall fracture, a para-falcine subarachnoid hemorrhage, left eye subconjunctival hemorrhage, a full-thickness canaliculus laceration in the left eye, and a vitreous hemorrhage in the left eye with traumatic mydriasis. Patient had undergone repair of his lacrimal structure. Observation of R6 on 03/27/2024 at 11:05 AM, revealed the resident had staff present performing one on one (1:1) supervision and care of him. Per observation, R6's left eye had a covering taped over it. During an interview with RN3 on 03/27/2024 at 3:07 PM, she stated she had been the nurse assigned to both R6 and R7 on the night of the incident. RN3 stated she thought the incident took place around 4:00 AM or 5:00 AM in the morning on 03/11/2024. She stated her shift had started around 6:00 PM or 7:00 PM the previous night (03/10/2024), and R7 had been acting normally. However, RN3 stated when a nurse aide went into the residents' (shared) room to check on them during her rounding she discovered Resident #7 holding a bloody fork. She stated the aide left the room to get her (RN3). She stated she immediately went to the room and saw blood on R7 and R6 was seriously injured and not responding well. A call was placed to 911 due to Resident #6's condition and to the police related to the incident. She stated when she first entered the room, R7 was sitting in a chair near R6's bed and told her he cannot take it anymore. In interview on 03/29/2024 at 1:00 PM, RN4 stated he had not ever seen the resident perceive plastic utensils as weapons, nor had he heard him discussing such prior to the 03/11/2024 incident. RN4 stated people had given R7 things like combs from time to time. He stated he recalled a time R7 had a comb with a sharp point that staff took away from the resident to be on the safe side. He stated staff would engage in interventions like reorientation and reality checks to help R7 when he had hallucinations or impulse issues. RN4 stated prior to the 03/11/2024 incident, R7, had experienced visual and auditory hallucinations. Per the RN, staff had not had a day to day working fear of R7, and knew the resident had hallucinations. He stated nursing staff looked at residents' care plans when the resident was new; however, they were not required to review the care plans daily. He stated R7 had auditory hallucinations (as well as visual hallucinations) where he conversed with people who were not there. In continued interview on 03/27/2024 at 3:07 PM, RN3 stated EMS and law enforcement responded. The RN stated a police officer took the bloody fork that R7 was still holding and moved him over to his bed. RN3 stated she asked R7 why he was saying, I cannot take it anymore and why the incident took place, and the resident provided a disorganized and non-sensical response. She stated she stood at the residents' room door, but did not enter the residents' room. The RN stated other staff also did not enter the room, as they were afraid if they started trying to move him (R6), R7 would begin acting out again, and exacerbate his condition. RN3 stated when EMS personnel arrived, they quickly moved R6 to the stretcher and transported him out to the emergency room (ER). The RN further stated R7 remained in the room and was placed on 1:1 monitoring for the remainder of the shift. In interview on 03/27/2024 at 6:00 PM, Psych Nurse Practitioner (PNP4) #4 stated initially the facility had not been told R7 had a psych history. He stated he saw the resident for the first time around August of 2023. The Psych NP stated over time R7 became more delusional and he saw in an old medical record from a previous hospitalization that R7 that he had a history of paranoid schizophrenia. PNP4 stated R7's behaviors continued to be monitored and assessed and treated. However, by November 2023 the resident was becoming more aggressive and started to need some Geodon (an antipsychotic medication). During an interview with city Metro Police Officer #22 on 03/28/2024 at 6:12 PM, he stated he was dispatched to the facility on [DATE], because of the assault of R6 by R7. He stated staff told him they refused to intervene physically because they were afraid of R7. The Police Officer stated R6 had blood on his face and had blood splattered on the wall behind him. He stated the staff members were all standing outside of the residents' room door, and nobody had done anything to separate the two (2) residents. He stated it was clear no one had done anything to render aid to R6. Metro Police Officer #22 stated he asked R7 why he did it (assaulted R6) and the resident stated R6 was trying to do something to harm his (R7's) family. The Police Officer stated it was clear R7 was talking out of his mind. He stated he was taken aback by the fact that nursing staff had done nothing to render aid or evaluate the residents. Per the Police Officer, staff stated they wanted to wait until EMS arrived before they did anything further. In continued interview on 03/28/2024 at 6:12 PM, Metro Police Officer #22 stated when he arrived on the scene, R7 had a potato chip bag clip in his hand, and the fork that he used in the assault was sitting on his nightstand covered in blood. He stated R7's hands were covered with blood, and the victim (R6) did not speak to the officer much, just indicated he was okay. The Police Officer stated the suspect, R7 was compliant, and his focus stayed on R7 as he was not thinking clearly. He stated the group working was an all-female staff, and they stated they were afraid of R7 and did not want to approach him. The Police Officer stated nobody really assessed the victim (R6) until EMS arrived and assessed the resident. During an interview with CNA3 on 03/28/2024 at 10:30 AM, she stated she had been assigned to the care of both R6 and R7 on the night of the incident. She stated R7 could become anxious at times and had episodes where he paced in the hallway. However, on that night he had been very calm. The CNA stated both residents were typically quiet, but when she performed her rounds around 4:00 AM, and entered the residents' room, what she saw didn't seem real. CNA3 stated R7 was sitting right beside R6, and there was blood everywhere. She stated R7 had blood on his arms and had not been moving. The CNA stated, the team decided to standby and be at the room as an intervention. CNA #3 stated staff feared for their own safety, and law enforcement was called. She stated staff had not attempted to move R7 until law enforcement arrived. The CNA stated she had been afraid of R7 prior to the incident as he was a large, tall guy who was intimidating. She stated she had conversations in the past with R7 where he made her afraid but could not think of a time where she formally discussed or reported her fear or to the facility's leadership or reported the resident to leadership. During an interview with CNA8 on 04/01/2024 at 12:43 PM, she stated she had worked at the facility since November 2022. She stated on the evening of the incident, she was caring for R7; however, she did not recall where R7 ate his meal, whether it was in his room or in the dining hall that night. She stated R7 was always served plastic utensils with meals, and they (the utensils) had to be picked up after every meal. CNA8 said she did not recall how she was first informed R7 had to use plastic utensils or why. The CNA stated the intervention had been in place for a few months before the incident took place. She stated she was simply told that whatever was taken into R7's room, she needed to bring back out of the room. The CNA stated when she removed R7's dietary trays and utensils, her process had been to just check the utensils, then remove the tray from the room, and place it on a dietary cart. CNA4 stated she had not been required to tell anyone when she checked R7's tray for the plastic utensils, and there had been no formal documentation process required for documenting the removal of the plastic ware. In interview on 04/01/2024 at 1:39 PM, the former SSD/Memory Care Director #18 stated she recalled R6 and R7 and remembered working with both. She stated a collection of occurrences had taken place with R7's behaviors, but she did not recall a specific incident regarding Resident #7 harming anyone. SSD/Memory Care Director #18 stated R7 had experienced severe hallucinations and had made items such as forks or coat hangers into what he thought were weapons he could use to defend against the hallucinations. She stated she had never seen R7 use an item as a weapon against another person. Per the SSD/Memory Care Director #18, she had seen R7 explaining to others he wanted to use those type items to defend himself. She stated R7 told staff he would keep the items in his hand to protect himself against the people he perceived to be in his room. She further stated she personally had seen at least three (3) separate instances where Resident #7 was holding objects he perceived as items of defense against his hallucinations. The SSD/Memory Care Director #18 stated she initiated R7's care plan (on 11/01/2023) because she was the person who had the firsthand knowledge that the resident was perceiving items as weapons. In addition, she stated she did not know how the facility ensured the intervention for monitoring R7 took place. Review of a copy of the facility's meal ticket record for R7, provided by the Administrator, dated 11/08/2023, revealed facility staff were to remove all plastic ware after the resident's meal. During an interview with Dietary Manager #21 (DM21) on 04/01/2024 at 12:00 PM, she stated she started working at the facility on 07/03/2023. DM21 stated she was aware of the incident in which R7 injured R6. She stated the use of plastic ware for R7 had been put into place for the resident's safety around 11/07/2023. However, she was not told specifically why the resident needed plastic ware. DM21 stated the head nurse instructed her to put the plastic utensils in place with instructions to take the utensils out of R7's room after each meal. The DM stated a meal tray card was created that stated plastic ware utensils were to be used for R7 and were to be removed with the completion of each meal. She stated she and other staff collected R7's utensils after each meal and also made rounds to make sure all utensils were taken out of the resident's room. DM21 stated they also confirmed the utensils used by R7 were on the resident's tray upon return to the kitchen. In continued interview on 04/01/2024 at 12:00 PM, the DM stated R7 was permitted to eat alone in his room and did not require observation. She stated sometimes the CNAs collected meal trays and sometimes dietary staff did it, but they all always communicated with each other when the tray had been picked up and that it had the utensils on it. The Dietary Manager stated staff had never been required to sign a log sheet or were required to electronically document the verification that R7's utensils had been removed as required. In an interview on 03/28/2024 at 9:30 AM, the Director of Nursing (DON) stated she had been involved in the facility's internal investigation. She stated she was unaware of Resident #7 ever having displayed any significant symptoms prior to the event on 03/11/2024. The DON stated she did not recall if any specific changes were made to R7's care plan once his schizophrenia diagnosis was recognized. She stated in the weeks leading up to the incident on 03/11/2024, expectations or procedures for supervision had not changed because R7 had not displayed any type of assaultive behaviors. The DON stated she felt the supervision of R7 on the night of the incident by the staff had been adequate. She stated after the incident education for staff had been provided regarding dementia residents and behaviors that were not normal. Per the DON, it was her expectation if a staff member witnessed abuse of resident, they were to intervene to separate the residents, and place both residents on 1:1 supervision. She also stated her expectations included for a nurse to assess each of the residents involved and report the event to the DON and/or Administrator. In an additional interview in 03/29/2024 at 2:00 PM, the DON stated she had not felt R7 was a danger to anyone, and he had not shown aggression towards staff or other residents before the incident, so we were not doing more monitoring of him. The DON stated no one had ever seen R7 make a weapon. The DON stated she did not know why or how the problem noting the resident attempted to manipulate objects, such as forks or coat hangers into protective objects due to him seeing hallucinations in his room had ended up on his care plan, other than an incident with him breaking a coat hanger. She stated she did not believe the incident could have been prevented if monitoring for items such as forks or coat hangers had been happening more frequently. The DON stated the resident could have made a weapon out of a chair if he wanted to, and he would have needed more supervision if that occurred. In interview on 03/29/2024 at 1:40 PM, the Administrator stated she had not felt R7 was a danger to others in the facility before the incident occurred (on 03/11/2024) and had not thought he required increased monitoring. She stated when R7 broke a clothes hanger in a room, staff became concerned, as they thought the resident could have used it as a weapon. The Administrator stated the facility had not documented removing R7's plastic ware at meal's end on a log sheet or in his medical record, but staff had been required to remove the plastic ware from the resident's room. She stated R7 was ambulatory, and had freely ambulated about his unit with no restrictions to prevent him from possessing small objects. The Administrator stated she felt staff had done a good job keeping harmful objects out of the resident's room prior to the incident. She stated staff needed to be aware and observant of what was taking place around them.

Based on interview, record review and policy review, it was determined the facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated, failed to prevent further abuse while an investigation was in progress, and failed to report the results of all investigations to the Administrator or his/her designated representative and to other officials in accordance with State law, including to the State Survey Agency within five (5) working days of the incident, and if the alleged violation was verified appropriate corrective action must be taken. The findings include: Review of the policy titled, Abuse and Neglect-Clinical Protocol, reviewed 02/27/2020, defined sexual abuse as non-consensual sexual contact of any type with a resident. The nurse assessed the individual and documented related findings. Assessment data included injury assessment, pain assessment, current behavior, patient's age and sex, all current medications especially anticoagulants, non-steroidal anti-[CONDITION(S)] drugs, other platelet inhibitors, vital signs, behavior over last twenty-four hours, history of any tendency towards bruising, all active diagnoses, and any recent labs. The nurse reported findings to the physician. As needed, the physician assessed such findings, especially if the cause or source of the problem was unclear. The staff, with the physician's input as needed investigated alleged occurrences of abuse to clarify what happened and identify possible causes. The facility management and staff instituted measures to address the needs of residents and minimized the possibility of abuse. The management and staff, with the support of the physicians, addressed situations of suspected or identified abuse and reported them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. The staff and the physician monitored individuals who have been abused at least until their medical condition, mood, and function stabilized and periodically thereafter. Observation of Resident #7, on 03/25/2021 at 9:00 AM, on the Memory Care Unit, revealed the resident sitting in a chair close to the nursing station. The resident appeared clean, without odor, and was dressed appropriately for the season. No visible injuries were observed. Record review revealed the facility admitted the resident on 01/06/2021 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Comprehensive Minimum Data Set (MDS) dated and signed on 01/19/2021, revealed the facility assessed the resident with a score of three (3) on a Brief Interview Mental Status exam and determined the resident was not interviewable. Continued review revealed the facility assessed the resident displayed verbal behavioral symptoms directed towards others for one (1) to three (3) days during the MDS look back period. The resident displayed wandering behavior for one (1) to three (3) days during the MDS look back period. Resident #7 required oversight with bed mobility, transfers, walking, eating, toilet use, and personal hygiene. Closed record review of Resident #5's clinical record revealed the facility discharged the resident on 03/09/2021 with his/her Power of Attorney (POA). Continue review of Resident #5's closed record revealed the facility admitted the resident on 12/04/2020 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Comprehensive Minimum Data Set (MDS), signed and dated 12/22/2020, revealed the facility admitted the resident from an acute care hospital. Review of the Brief Interview Mental Status revealed the resident scored a seven (7) and the facility determined the resident was not interviewable. Continued review of the MDS revealed Resident #5 displayed inattention, and disorganized thinking which fluctuated (comes and goes, changes in severity). The resident was also assessed to display verbal behavior symptoms directed towards others which occurred one (1) to three (3) days during the MDS look back period. Interview with Certified Nursing Assistant (CNA) #1, on 03/25/2021 at 9:20 AM and 03/26/2021 at 10:43 AM, revealed she worked at the facility on an as needed basis (PRN). She revealed on 01/17/2021 she overheard Resident #7 yell and when CNA #1 approached Resident #7, the resident pointed at Resident #5, and stated Resident #5 had tried to have sex with me. The CNA stated Resident #5 was not far from Resident #7 and once Resident #5 saw the CNA the resident went back to his/her room. CNA#1 revealed she attempted to notify the Director of Nursing (DON) about the incident via cellphone, on 01/17/2021 at 11:36 AM and then again at 11:42 AM. She stated the DON returned her call on 01/17/2021 at 11:42 AM and she informed the DON of the incident. Continued interview with CNA #1 revealed she could not recall the nurse on duty on 01/17/2021, and could not recall if she had informed the nurse of the incident. She stated she normally would let the nurse know about any suspected abuse, and she would also document the behaviors of the Residents in Point Click Care (PCC). She could not recall if she documented the behaviors or not. Record review of the Care Tracker Notes for Resident #5 and Resident #7 on 01/17/2021 did not reveal any behaviors observed or documented by staff. Interview with Licensed Practical Nurse #1 on 03/25/2021 at 9:00 AM, and again on 03/26/2021 at 10:00 AM, revealed she was the nurse in charge on 01/17/2021 and did not overhear Resident #7. She revealed she did recall CNA #1 told her she had spoken with the DON that morning but she was not sure of the reason. She revealed if she had know about the incident between Resident #5 and Resident #7, she would have immediately notified the DON or the Administrator and assessed the resident for injuries. The LPN revealed documentation regarding the incident would have been made in the residents medical records. She stated facility Management would notify the physician, and the responsible party (RP) as well. She stated the CNA's routinely reported issues to the DON and not the nurse, even with issues the nurse should be involved in. Interview with the DON, on 03/26/2021 at 9:45 AM and 03/30/2021 at 11:15 AM, revealed she did not recall being notified by CNA#1 on 01/17/2021 regarding the incident between Resident #7 and Resident #5. She revealed if the incident was reported to her by the staff, she would have immediately kept all the residents safe, started an investigation to include resident interviews and skin assessments, and reported the allegation of abuse to the Office Inspector General, the Physician, and the Responsible Party (RP). She revealed staff had received education to follow the chain of command when reporting an allegation of suspected abuse. She revealed CNA#1 should have immediately reported the incident to LPN#1, and if CNA #1 felt like nothing was being done, then she should report the allegation of abuse to the DON or the Administrator. She revealed all allegations of abuse must be reported to the Office Inspector General within two (2) hours of the allegation. Interview with Unit Manager (UM) #1 revealed she was the UM for the Memory Care Unit and Resident #5 and Resident #7 had both resided on the unit on 01/17/2021. She revealed staff were educated on abuse, and when abuse occurred or was suspected, she expected staff to separate the residents, and immediately notify the charge nurse. She revealed the charge nurse then notified her, and she notified the DON. She revealed both she and the DON began an investigation, conducted interviews, and performed skin assessments on all the residents. She revealed if the allegation of abuse occurred on the weekend, the nurse should contact the member of Administration who was on-call. She revealed she was not aware of the allegation Resident #7 made against Resident #5. She revealed the allegation of abuse would also have been discussed in the morning meeting, and the meetings she had been present at did not discuss the allegation of sexual abuse Resident # 7 made against Resident #5. Interview with LPN #4, on 03/30/2021 at 1:20 PM, revealed she received training on abuse, and what to do if a resident alleged abuse. She revealed she expected the CNA's to report abuse allegations directly to her, and then she would notify the DON and the Administrator after ensuring the residents were safe. She revealed any allegation of abuse should be documented in the resident (s) progress note. LPN #4 stated the DON/Administrator began their investigation after they received notification. Interview with CNA #2, on 03/30/2021 at 2:30 PM, revealed he received abuse education by the Administration. He revealed whenever abuse was suspected or alleged, he would immediately keep the resident(s) safe, and reported the incident to his charge nurse. He stated if the charge nurse was not available, he would immediately report the incident to Administration. CNA#2 revealed he would also document the behaviors of the resident (s) in Care Tracker. Record review revealed CNA #1 received education on 11/13/2020 titled, All Abuse Must Be Reported to Your Immediate Supervisor Even If You Are Unsure An Act of Abuse Occurred You Must Report It. Interview with the Administrator, on 03/31/2021 at 11:45 AM, revealed the facility mandated training and education for all staff upon hire, and then yearly. He revealed he was unaware of the allegation of abuse on 01/17/2021 between Resident #5 and Resident #7.

Based on interview, closed and open record review, and policy review, it was determined the facility failed to ensure that all alleged violations involving abuse were reported immediately but not later than two (2) hours to the Administrator of the facility and to other officials, including the State Survey Agency, and adult protective services for one (1) of eight (8) sampled residents, Resident #7 alleged to staff that Resident #5 tried to sexually abuse him/her. The findings include: Review of the facility policy titled, Abuse Investigation and Reporting, dated 07/2017 revealed all reports of resident abuse shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility Management. Findings of abuse investigations will also be reported. Observation of Resident #7, on 03/25/2021 at 9:00 AM on the Memory Care Unit revealed the resident sitting in a chair close to the nursing station. The resident appeared clean, without odor, and was dressed appropriately for the season. No visible injuries were observed. Record review revealed the facility admitted Resident #7 on 01/06/2021 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Comprehensive Minimum Data Set (MDS), dated and signed on 01/19/2021 revealed the facility assessed the resident with a score of three (3) on a Brief Interview Mental Status (BIMS) exam and determined the resident was not interviewable. The resident displayed verbal behavioral symptoms directed towards others for one (1) to three (3) days during the MDS look back period. The resident displayed wandering behavior for one (1) to three (3) days during the MDS look back period. Resident #7 required oversight with bed mobility, transfers, walking, eating, toilet use, and personal hygiene. Closed record review of Resident #5's clinical record revealed the resident was discharged from the facility 03/09/2021 accompanied by his/her Power of Attorney (POA). Continue review of Resident #5's closed record revealed the facility admitted the resident on 12/04/2020 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Comprehensive Minimum Data Set (MDS), signed and dated 12/22/2020, revealed the facility admitted the resident from an acute care hospital. Review of the Brief Interview Mental Status (BIMS) revealed the resident scored a seven (7) and the facility determined the resident was not interviewable. Continued review of the MDS revealed Resident #5 displayed inattention, and disorganized thinking which fluctuated (comes and goes, changes in severity). The resident was also assessed to display verbal behavior symptoms directed towards others which occurred one (1) to three (3) days during the MDS look back period. The resident was also assessed to reject care one (1) to three (3) days during the MDS look back period. Resident #5 was independent with walking, and toilet use. Interview with Certified Nursing Assistant (CNA) #1, on 03/25/2021 at 9:20 AM and 03/26/2021 at 10:43 AM, revealed she worked at the facility on an as needed basis (PRN). She revealed on 01/17/2021 she overheard Resident #7 yell down the hallway. When CNA #1 approached Resident #7 the resident pointed at Resident #5, and stated Resident #5 had tried to have sex with me. The CNA stated Resident #5 was not far from Resident #7 and revealed once Resident #5 saw her (the CNA) the resident then went back into his/her room. CNA#1 revealed she attempted to notify the Director of Nursing (DON) about the incident via cellphone on 01/17/2021 at 11:36 AM and then again at 11:42 AM. She stated the DON returned her call on 01/17/2021 at 11:42 AM at which time she informed the DON of the incident between Resident #5, and Resident #7 and the response from the DON was okay, just keep an eye on Resident #5. Continued interview with CNA #1 revealed she could not recall the nurse on duty on 01/17/2021, and could not recall if she informed the nurse of the incident between Resident #5 and Resident #7. She stated she normally notified the nurse about any suspected abuse, and also documented the behaviors of the Residents in Point Click Care (PCC). She could not recall if she documented the behaviors or not. Interview with Licensed Practical Nurse (LPN) #1, on 03/25/2021 at 9:00 AM, and again on 03/26/2021 at 10:00 AM, revealed she was the nurse in charge on 01/17/2021 and did not overhear Resident #7 yell. She revealed she did recall CNA #1 stated she spoke with the DON that morning but LPN #1 was not sure why. She revealed if she had been made aware by CNA#1 regarding the incident between Resident #5, and Resident #7, she would have kept the residents safe, notified the DON or the Administrator, and assessed Resident#7 for injuries. The LPN revealed documentation regarding the allegation of abuse would have been made in the residents medical records. Record review of the Progress Notes and the Caretracker Notes for 01/17/2021 did not provide documentation an incident had occured between Resident #5 and Resident #7. Interview with the DON, on 03/26/2021 at 9:45 AM and 03/30/2021 at 11:15 AM, revealed she did not recall being notified on 01/17/2021 by CNA #1 about the abuse alleged by Resident #7. She revealed if the incident had been reported to her, she would have immediately started an investigation and would have reported the incident to the Office Inspector General within two (2) hours of the allegation. She revealed the facility expected staff to follow the chain of command when reporting an allegation of suspected abuse. She revealed CNA #1 should have immediately reported the incident to LPN #1, and if CNA #1 felt like nothing was being done, then she should report the allegation of abuse to the DON or the Administrator. Interview with LPN #4 on 03/30/2021 at 1:20 PM revealed she received training on abuse, and what to do in case an abuse allegation was made by a resident. She revealed she expected the CNA's to report abuse allegations directly to her, and then she would notify the DON and the Administrator after she made sure the residents were ok. She revealed any allegation of abuse should be documented in the resident(s) progress notes. LPN #4 stated once the DON/Administrator were notified, they would immediately come to the facility and begin an abuse investigation. Interview with CNA #2 on 03/30/2021 at 2:30 PM revealed he received abuse education by the Administration. He stated whenever abuse was suspected or alleged, he would immediately keep the resident (s) safe, and report the incident to his charge nurse. He stated at that time, the charge nurse would take over. He stated if the charge nurse was not available, he would report the incident to Administration. CNA #2 revealed he would also document the behaviors of the resident (s) in Care Tracker. Record review revealed CNA #1 received education on 11/13/2020 titled, All Abuse Must Be Reported to Your Immediate Supervisor Even If You Are Unsure An Act of Abuse Occurred You Must Report It. Continued review revealed CNA#1 received an in-service on abuse on 03/25/2021. Interview with the Administrator, on 03/31/2021 at 11:45 AM, revealed the facility mandated abuse training and education for all staff upon hire, and then yearly. He revealed if the allegation of abuse on 01/17/2021 between Resident #5, and Resident #7 had been reported to him through the chain of command, the charge nurse could have completed an assessment on Resident #7, and the DON and himself would have immediately entered the facility and began an abuse investigation as well as make a report to the proper authorities. He revealed the Office of Inspector General should be notified within two (2) hours of an abuse allegation.

Based on interview, closed record review, and policy review, it was determined the facility failed to provide pharmaceutical services for one (1) of eight (8) sampled residents. Resident #3 did not receive all doses of the medication [MEDICATION(S)] as prescribed by the medical provider. The findings include: Review of the policy titled, Medication Therapy, dated 04/2007, revealed all medication orders will be supported by appropriate care processes and practice. Closed record review revealed the facility admitted Resident #3 on 11/03/2020 with the following diagnoses: Pancytopenia, Type II Diabetes Mellitus, Portal Vein [CONDITION(S)], Alcoholic [CONDITION(S)] of the Liver with Ascites, and Hepatic Failure without Coma. Review of the document titled, Order Listing Report, dated 11/03/2020 through 03/31/2021, revealed a physician order [MEDICATION(S)] ( a non-absorbable sugar used in the treatment of constipation and hepatic encephalopathy) ten (10) grams (GM) per fifteen (15) milliters (ML), give forty-five (45) ML every six (6) hours for ascites. Review of the Medication Administration Record (MAR) for January 2021 revealed the [MEDICATION(S)] start date was 11/21/2020 with a discontinue date of 02/15/2021. The [MEDICATION(S)] was reordered on 02/15/2021 with no end date. Review of Resident #3's MAR for January, 2021, revealed the medication was not documented by staff as administered per medical provider order for the following dates and times: 01/25/2021 at 12:00 PM, and 6 PM; 01/26/2021 at midnight, 6 AM, noon, and 6 PM; 01/27/2021 at midnight and 6 AM; 11/28/2020 at 6:00 AM; and 01/31/2020 at noon, and 6 PM. No explanation was documented as to why the medication was not administered to Resident #3 on the MAR or in the Progress Notes. Review of the resident's MAR for February, 2021, revealed the medication was not documented by staff as administered per order for the following dates and times: 02/04/2021 at midnight and 6:00 AM; 02/06/2021 at midnight and 6:00 PM; 02/11/2021 at midnight and 6:00 AM; 02/13/2021 at midnight and 6:00 AM; and 02/14/2021 at noon and 6:00 PM; 02/17/2021 at midnight and 6:00 AM; 02/18/2021 at noon; 2/20/2021 at 6:00 AM; and 02/23/2021 at midnight and 6:00 PM. No explanation was documented why the medication was not administered to Resident #3 on the MAR or in the Progress Notes. Continued review of the MAR dated March, 2021, revealed the [MEDICATION(S)] was not been administered as ordered on 03/01/2021 at noon; 03/03/2021 at midnight and 6:00 AM; 03/05/2021 at midnight and 6:00 AM; and 03/08/2021 at 6:00 AM. No explanation was documented as to why the medication was not administered to Resident #3 on the MAR or in the Progress Notes. Interview, on 03/29/2021 at 12:26 PM, with Licensed Practical Nurse (LPN) #3 revealed she was the nurse caring for Resident #3 on the third (3rd) shift on 01/28/2021, 02/04/2021, 02/06/2021, 02/11/2021, 02/13/2021, 02/14/2021 and 03/03/2021. She stated she sometimes forgot to document administration of medication depending on how busy the shift was; sometimes the medication may not have been available, and sometimes the resident refused the medication. Interview with Infectionist Preventionist (IP), on 03/30/2021 at 1:55 PM, she sometimes took a resident assignment. She stated if a medication was not in-house for a resident, she first checked the Emergency Kit (E-kit). If the medication was not in the E-Kit, she called the doctor, notified the family, and notified the pharmacy via fax, or phone call. She revealed she documented all of this in the Progress Notes. Interview with Licensed Practical Nurse #2, on 03/31/2021 at 10:15 AM, revealed any time a medication was not administered as ordered she called the pharmacy. She revealed she documented the issue in the progress notes with an explanation as to why the resident did not receive the medication. She revealed she also notified the physician for alternate orders. Interview with the Director of Nursing (DON), on 03/30/2021 at 11:15 PM, revealed she noticed some missed doses of Resident #3's [MEDICATION(S)] on the MARs. She revealed without documentation she could not explain why staff did not give the medication. She stated many times staff forgot to document the medication as given. Interview with the Administrator, on 03/31/2021 at 11:45 AM, revealed his expectations were that all residents received their medications. If a resident refused their medications an explanation was to be documented.

Based on observation, interview, record review, and policy review it was determined the facility failed to protect one (1) of five (5) sampled residents, Resident #4. On [DATE] at approximately 8:00 PM, facility staff observed Resident #3 in Resident #4's room in the act of inappropriately touching Resident #4. The findings include: Review of the policy titled, Abuse and Neglect-Clinical Protocol, revised date of ,d+[DATE], revealed the definition of abuse was any type of willful mental or physical action which resulted in emotional or physical harm or pain. The policy defined willful as a deliberate action performed, but did not purposefully intend to cause harm or injury. Further review revealed the policy contained steps for recognition, assessment, possible cause, treatment, and monitoring related to abuse allegations. Review of the policy titled, Abuse Investigation and Reporting, revised date of ,d+[DATE], revealed abuse investigations were reported to the appropriate agencies. Per the policy, the investigator conducted discreet interviews with a thorough review of the involved resident's medical record. Review of the facility's staff abuse education record, dated [DATE] revealed the facility's abuse policy was reviewed with all facility staff in-person and by telephone. Review of the facility's Incident Report (IR), dated [DATE], revealed facility staff walked into Resident #4's room and discovered Resident #3 being sexually inappropriate with Resident #4. Continued review revealed Registered Nurse (RN) #2 removed Resident #3 from Resident #4's room and performed an assessment on Resident #4 which included vital signs. Further review revealed RN #2 initiated an intervention for staff to check on Resident #4 every fifteen (15) minute checks by staff for Resident #4. Review of Resident #3's medical record revealed the facility admitted the resident on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) indicating he/she was cognitively impaired. Further review revealed no behaviors were noted, and the facility assessed Resident #3 to ambulate around his/her room and the unit with set up assistance and a walker. Review of Resident #3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the order was discontinued on [DATE]. The Surveyor requested the facility's 1:1 supervision documentation for Resident #3, from [DATE] through [DATE], when it was discontinued. However, the facility was unable to provide documented evidence of the 1:1 of Resident #3 for that timeframe. Review of Resident #3's Progress Notes, dated [DATE] through [DATE], revealed no documented evidence Resident #3 displayed abusive behaviors towards other residents prior to [DATE]. Further review revealed on [DATE], [DATE], [DATE], and [DATE] revealed the resident was provided 1:1 care with no behaviors noted. Continued review revealed no documented evidence of further abusive behaviors by the resident. Review of the Gates Wandering Tool, used by the facility to assess wandering risk, dated [DATE], revealed an assessment score of six (6) which indicated the resident was a low risk for wandering. Review of the [DATE] wandering risk assessment tool revealed a score of twelve (12) identifying the resident as being a high risk for wandering. Review of Resident #3's Comprehensive Care Plan, initiated on [DATE] and last revised on [DATE], revealed the facility had noted interventions for the resident for wandering and inappropriate sexual behavior. Continued review revealed the facility revised the resident ' s care plan on [DATE], with interventions for wandering which included staff to provide distraction from wandering, to encourage Resident #3 not to enter other residents ' rooms. The revised wandering interventions, dated [DATE], also included for staff to reorient Resident #3 and provide redirection as needed. Further review revealed Resident #3 ' s care plan was additionally revised for interventions to prevent inappropriate sexual behavior on [DATE]. The interventions included having Resident #3 evaluated by a Psychiatrist, staff to provide 1:1 supervision of the resident. In addition, the interventions to prevent inappropriate sexual behavior included discussing inappropriate behaviors with the resident and for staff to intervene as necessary. Review of the Certified Nurse Aide (CNA) documentation for Resident #3, dated [DATE] through [DATE], revealed no documented evidence of inappropriate behaviors. Observation of Resident #3, on [DATE] at 11:41 AM, revealed the resident lying on his/her bed watching television. Continued observation revealed the resident was well groomed, dressed appropriately, and there no odors present. Interview was attempted during the time of observation, and the resident was noted to have a flat affect. During the interview attempt, Resident #3 did not answer the Surveyor ' s questions. Review of Resident #4's closed medical record revealed the facility admitted the resident on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #4 ' s medical record revealed the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Comprehensive MDS Assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS score of ten (10), indicating he/she was moderately cognitively impaired. Continued review revealed the facility assessed Resident #4 as highly hearing impaired with use of a hearing aid appliance, and to have limited range of motion in his/her upper and lower extremities, and unable to ambulate. Further review revealed Resident #4 was assessed to be able to understand and be understood by others. In addition, the MDS Assessment further revealed the facility assessed Resident #4 to receive pain management, require one (1) person assist for eating, and two (2) person assist for bed transfers. Review of Resident #4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Comprehensive Care Plan, initiated on [DATE] and revised on [DATE], revealed the facility had care planned the resident for impaired cognitive status, contractures of upper body, hyperextension of neck, impaired hearing with the use of an amplifier and visual impairment with interventions. Additional review of Resident #4's medical record revealed a Progress Note dated [DATE] which noted at 2:53 AM Registered Nurse (RN) #2 entered Resident #4's room and witnessed Resident #3 there with his/her pants down. Further review revealed Resident #3 ' s genitals were in Resident #4 ' s hands. Interviews with Residents #6, #7, and #8, on [DATE] at 2:32 PM, revealed they had no concerns related to abuse by other residents, or of other residents wandering into their rooms. Interview with Certified Medical Technician (CMT) #1 on [DATE] at 9:15 AM, revealed Resident #4 did not talk much and was not alert enough to tell someone to leave his/her room. She stated Resident #4 could press the call light and ask for snacks. Per the CMT, she had not observed Resident #3 wandering into other residents ' rooms. Interview with Certified Nursing Assistant (CNA) #6, on [DATE] at 9:58 AM, revealed Resident #4 was very hard of hearing and he/she pressed the call light when he/she needed something. Per the CNA, she had not observed Resident #3 wandering into other residents' rooms. Interview with RN #2, on [DATE] at 12:11 PM, revealed Resident #4 had contracted arms, could move his/her hands, and was always looking up due to a hyperextended neck. RN #2 revealed Resident #4 had impaired hearing and vision. Per the RN, Resident #3 talked to his/her roommate, and to other residents when he/she went outside to smoke. According to RN #2, on [DATE], sometime after 8:00 PM, she entered Resident #4's room because she had noticed a non-employee figure standing by the bed with the curtain drawn. The RN reported witnessing Resident #3 standing next to Resident #4 ' s bed with his/her pants down and his/her private parts in Resident #4's hands. She stated she asked Resident #3 what he was doing, and the resident laughed. Continued review revealed Resident #3 was removed from Resident #4 ' s room, and was under 1:1 supervision for the remainder of her shift. RN #2 stated she assessed Resident #4 for injuries and notified the Director of Nursing (DON) and Administrator. The RN revealed prior to [DATE], Resident #4 had been experiencing a decline in his/her health, and probably didn ' t know what was going on when the incident occurred. Further interview revealed Resident #3 had not been at risk for wandering prior to [DATE]. Interview with CNA #5, on [DATE] at 4:15 PM, revealed prior to Resident #4 ' s death on [DATE], the resident did not press his/her call light much. According to the CNA, staff kept Resident #4 ' s door opened with the curtain pulled back in order to see the resident from the door. CNA #5 stated Resident #3 usually stayed in his/her room watching television; however, did go outside to smoke. Further interview revealed Resident #3 had not wandered in other residents ' rooms or stood in their doorways prior to the incident on [DATE]. CNA #5 further revealed abuse education was conducted with staff on [DATE]. Interview with CNA #3, on [DATE] at 11:35 AM, revealed he provided 1:1 supervision by sitting outside of Resident #3's door. He further stated staff were not asked to document the 1:1 supervision. Per interview, CNA #3 stated he received abuse re-education after [DATE] and signed the attendance roster. Interview with the DON, on [DATE] at 11:08 AM, revealed RN #2 had notified her of the incident involving Resident #3 and #4 on [DATE]. According to the DON, when Resident #3 was interviewed about the incident, he/she would not answer any questions regarding the incident. The DON stated Resident #4 could not recall the incident when interviewed. She revealed Resident #4 had contracted legs, a hyperextended neck and used a soft touch call light. Continued interview revealed Resident #4 ' s son came to the facility that night and Resident #4 did not know what had happened regarding the incident. Per the DON, she relocated Resident #3 to another area of the facility, and had staff provide 1:1 supervision for him/her. Further interview revealed the facility continued the 1:1 supervision of Resident #3 until [DATE]. The DON further revealed on [DATE], both Resident #3 and Resident #4 were evaluated and there were no injuries or psychological concerns noted. Interview with the Administrator, on [DATE] at 12:38 PM, revealed he attempted to question Resident #3 about the [DATE] incident; however, the resident would not talk to him. He stated his interviews with staff and residents on the involved unit revealed no concerns in regards to Resident #3 displaying sexual behaviors or wandering into other residents ' rooms. Per the Administrator, he redirected Resident #3 to return to his/her room if the resident was observed standing in another resident's doorway. Continued interview revealed the Administrator's interactions were short response interactions. He stated the facility investigation revealed the allegation of inappropriate touching was an isolated event, and was unsubstantiated as both Resident #3 and Resident #4 were cognitively impaired. Further interview revealed it was unknown what interaction took place between the two (2) residents prior to RN #2 entering Resident #4 ' s room.

Based on interview, record review, and policy review, it was determined the facility failed to ensure alleged allegations of abuse were reported timely to the Office of Inspector General (OIG) and adult protective services for one (1) of five (5) sampled residents. Resident #1 alleged to staff that he/she was assaulted at the facility, however, the facility did not report the allegation to the appropriate agencies. The findings include: Review of the policy titled, Abuse and Neglect Clinical Protocol, dated 07/2017, revealed, Treatment/Management, the management addressed situations of suspected or identified abuse and reported them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. Review of the policy titled, Abuse Investigation and Reporting, dated 07/2017, stated all reports of resident abuse were promptly reported to local, state and federal agencies (as defined by current regulations). Findings of abuse investigations were reported. All alleged violations of abuse were reported immediately, but not later than two (2) hours if the alleged violation involved abuse. The Administrator, or his/her designee, provided the appropriate agencies with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. The facility admitted Resident #1 on 04/05/17. Current [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated and signed on 08/26/2020, revealed the facility assessed the resident with a Brief Interview for Mental Status exam score of fourteen (14) and determined the resident was interviewable. Continued review of the MDS revealed the resident had not displayed any behaviors. Telephonic interview with Resident #1, on 10/23/2020 at 12:43 PM, and 10/26/2020 at 9:23 AM revealed he/she was currently a patient in a local acute care hospital. The resident stated on 09/26/2020 he/she fell asleep in the wheelchair in front of the television in his/her room. The resident revealed he/she had been in a deep sleep when he/she woke up around 5:00 PM that same evening. The resident stated when he/she woke up, he/she felt an uncomfortable pain in his/her abdomen and it felt that someone had taken a stick and moved all my organs inside. Resident #1 stated he/she did not know what had happened to him/her while he/she had been asleep but felt like he/she may have been sexually assaulted. The resident continued to state he/she had not reported any of his/her allegations to staff until the 10/02/2020 because he/she did not want this on his/her record, and coming back on me. Resident #1 revealed on 10/02/2020 he/she revealed to the Director of Rehabilitation what he/she believed had occurred to him/her on 09/26/2020. Interview with the Director of Rehabilitation, on 10/23/2020 at 1:16 PM, revealed he had a good relationship with Resident #1, and around the end of September 2020, or beginning of October 2020, the resident asked him to come to his/her room so he/she could ask him a question. He stated Resident #1 inquired upon him to help him/her obtain a pregnancy test. The Director of Rehabilitation stated he then asked the resident why, and the resident revealed to him that he/she felt like someone in the facility had done something to him/her while he/she had been asleep because he/she felt funny in his/her stomach upon awakening. The Director of Rehabilitation stated at that point, he informed the resident he would have to report her allegations to the Administrator, and the resident was in agreement to speak with the Administrator. He revealed he immediately notified the Administrator and both he and the Administrator returned to Resident #1's room, and the resident told the Administrator what he/she had told him. Review of the facility's Investigation Timeline no dates, stated the Director of Rehabilitation conveyed Resident #1 believed he/she was assaulted during the previous weekend. The resident alleged after he/she awoke from a nap that he/she felt a discomfort in his/her pelvic area. Interview with the Director of Nursing (DON), on 10/27/2020 at 11:30 AM, revealed in an interview with the resident on 10/02/2020, the resident informed her he/she awoke from a nap, and felt tingly down there (pelvic area) and had a bad taste in his/her mouth. The DON revealed the resident told her he/she had a good dream. Continued interview with the DON revealed she was not aware the resident had conveyed to the Director of Rehabilitation that he/she felt like he/she had been assaulted. The DON went on to state if she had been made aware that the resident had used the terminology assaulted, she would have reported the allegation immediately to the Office of Inspector General, and to Adult Protective Services. Interview with the Administrator, on 10/23/2020 at 2:24 PM, and 10/27/2020 at 10:02 AM stated he was informed by the Director of Rehabilitation on 10/02/2020 that Resident #1 requested a pregnancy test. The Administrator revealed he immediately went into the resident's room to interview him/her, and the resident agreed to talk with him. He stated the resident revealed to him he/she awoke from a dream a few days earlier, and felt a tingling down there (pelvic area). He revealed he informed Resident #1 that he would send the DON into interview her as well. The Administrator revealed the resident told the DON the tingling might have all been a dream. He revealed during the course of the facility investigation, the resident had reported vivid dreams, did not have any injuries, therefore, the facility did not feel the resident had been sexually assaulted and did not report the incident to the appropriate agencies. The Administrator revealed it was his role to lead an abuse investigation. He stated if an allegation of abuse was made by a resident, the facility should notify the Office of Inspector General, the Ombudsman, and the state officials within one (1) hour. He revealed the facility investigation did not substantiate an allegation of abuse because the resident had stated he/she felt like he/she had experienced a dream, and there were so many discrepancies in the details the resident supplied. He revealed it did not seem like there was anything to report, there was no factual evidence to go on and the facility felt it would have been impossible for someone to assault the resident in a scooter.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received timely treatment and care to manage pain for one (1) of twenty-one (21) sampled residents, Resident #36. Resident #36 fell on [DATE] at approximately 1:00 PM. The resident complained of hip pain at approximately 3:30 PM; however, was not sent out to the hospital for evaluation and treatment until approximately 8:00 PM, four (4) and a half hours later. The findings include: Review of the facility's policy, Acute Condition Changes - Clinical Protocol, revised (MONTH) (YEAR), revealed direct care staff, including Nursing Assistants would be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the nurse. Before contacting a physician about someone with an acute change of condition, the nursing staff should make detailed observations and collect pertinent information to report to the physician, and nursing staff should contact the physician based on the urgency of the situation. According to the policy, staff would monitor and document the resident's progress and responses to treatment, and the physician would adjust treatment accordingly. If it was decided, after sufficient review, that care or observation could not reasonably be provided in the facility, the attending physician would authorize transfer to an acute hospital, emergency room , or another appropriate setting. Review of the clinical record revealed the facility admitted Resident #36 on 12/12/18, 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 fifteen (15) of fifteen (15) and determined he/she was interviewable. Observation of and interview with Resident #36, on 04/01/19 at 7:19 PM and 04/04/19 at 9:02 AM, revealed the resident in bed with an abductor cushion positioned between his/her legs. The resident stated he/she had fallen in the bathroom and fractured a hip. The resident stated when he/she fell ; he/she heard a crack and stated it hurt very badly. The resident revealed he/she could not recall if the nurse administered pain medication because, when you hurt like that, it is like you go out of it. The resident further stated after the fall, the facility did not send him/her to the emergency room (ER) until four (4) or five (5) hours later. Review of Resident #36's neurological assessments, dated 03/07/19, revealed the resident complained of pain beginning at 3:30 PM and continued throughout the day until he/she was transferred to the ER at approximately 8:00 PM; however, the severity of the pain was not assessed. Further review revealed there was no assessment for motor function of the left lower extremity from 12:30 PM to 3:30 PM. Review of Resident #36's Medication Administration Record [REDACTED]. Further review revealed there was no documentation for administration of pain medication on the day of the fall, 03/07/19; however, review of the Controlled Drug Record for [MEDICATION NAME] 5-325 milligram (mg) revealed staff removed pain medication from the package at 2:00 PM and 8:00 PM. Review of the Situation, Background, Assessment, Recommendation (SBAR) Note, dated 03/07/19, revealed Resident #36 sustained an unwitnessed fall at around 1:00 PM. There were no changes in the resident's condition following the fall, including functional status; however, the neurological assessment revealed there was no assessment for motor function of the left lower extremity from 12:30 PM to 3:30 PM. Further review of the SBAR revealed the resident complained of hip pain and a physician's orders [REDACTED]. Review of the Progress Notes, dated 03/07/19 at 9:15 PM, revealed Resident #36 was transferred to the ER for evaluation of the left hip related to an unwitnessed fall and complaints of excruciating pain with severity rated as ten (10) out of ten (10) (pain scale from one (1) to ten (10). Further review revealed there was no documentation regarding pain assessment or management prior to 9:15 PM. Review of the ER Note, dated 03/07/19, revealed Resident #36 arrived at the ER at 8:27 PM with a pain score of ten (10) out of ten (10). Further review revealed x-ray of the left femur revealed an acute [MEDICAL CONDITION] femoral neck. Interview with Licensed Practical Nurse (LPN) #5, on 04/04/19 at 2:29 PM, revealed she assessed Resident #36 post fall and discovered the resident had difficulty with movement of the left leg because it hurt. She stated she notified the physician and received an order for [REDACTED].#5 revealed the resident complained of increased pain severity (eight (8) out of ten (10)) about an hour after the fall and she administered pain medication; however, she did not document the pain assessment or administration of the medication, and she did not document if the pain medication was effective. Further interview with LPN #5 revealed x-ray results were faxed to the main nurses' station (A, B, and C Halls) and nurses used their own judgement to check for results. According to LPN #5, she gave report at the end of the shift for LPN #6 to follow-up with the resident. Interview with LPN #6, on 04/04/19 at 4:11 PM, revealed Resident #36 was grimacing and appeared to be in distress when he performed initial rounds at around 3:00 PM. He revealed LPN #5 reported the resident had fallen around 12:00 PM or 1:00 PM; however, x-ray staff had not arrived yet. He stated at around 5:00 PM, he called to find out the status of the x-ray and discovered it was not ordered STAT. The LPN stated because the resident was in severe pain, he requested the order be changed to STAT. The nurse further revealed when he assisted with the x-ray the resident was in excruciating pain. According to LPN #6, the x-ray should have been performed within an hour or so of the fall. He stated he waited a while to notify the physician of the resident's pain because he was waiting for the x-ray results to come back, but the resident's pain was so bad he went ahead and called the physician. According to LPN #6, the x-ray report/results had not arrived prior to the resident's transfer to the ER. The facility did not provide a copy of the resident's x-ray results. Interview, on 04/04/19 at 2:34 PM, with the Vice President of Operations for the radiology company revealed LPN #5 called in a routine x-ray order at 12:52 PM. He further revealed LPN #6 changed the order to STAT at 4:14 PM, the x-ray was completed at 5:38 PM, and the report was faxed to the facility at 5:58 PM with findings of a femoral neck fracture; however, interview with LPN #6 revealed the results were not received prior to the resident's transfer to the ER (approximately 8:00 PM). Interview with the Unit Manager, on 04/05/19 at 1:37 PM, revealed nurses were responsible for monitoring the fax machine for x-ray results. The UM further revealed there was only one (1) fax machine for the facility and reports could potentially get mixed in with other paperwork. She stated the facility did not have a tracking system for x-ray reports and the current process for receipt of reports was not effective. Interview with the Assistant Director of Nursing (ADON), on 04/05/19 at 9:32 AM, revealed LPN #5 assessed Resident #36 post-fall and the resident did not have classic signs and symptoms of a [MEDICAL CONDITION]. She revealed the resident was able to bear weight and stand when staff assisted him/her back to the wheelchair following the fall. The ADON stated she did not have the nurse order the x-ray STAT because the resident was not screaming out in pain. According to the ADON, the nurse should have sent the resident to the ER if the pain medication was not effective. The ADON revealed she was not aware of any issues related to pain management or delay of the x-ray results. Interview with the Administrator, on 04/05/19 at 3:42 PM, revealed he was not aware of any issues related to timeliness of x-ray reports/results. He further revealed there was potential for both psychosocial and physical harm related to pain management; however, he was not aware of an issues related to Resident #36's pain management post fall.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide effective supervision to prevent accidents for one (1) of two (2) sampled residents, Resident #36. Per interview, on 03/07/19, Resident #36 resident fell and sustained a [MEDICAL CONDITION] when he/she transferred without assistance in the bathroom. Per interview and record review, the resident was not wearing non-skid footwear, which was an intervention the facility had put in place for the resident to prevent falls. The findings include: Review of the facility's policy, Falls Management Program Guidelines, effective 12/01/18, revealed the purpose of the policy was to maintain a hazard free environment, mitigate fall risk factors, and implement preventative measures. The policy revealed a fall risk assessment should be included as part of the admission, quarterly, and when a fall occurred. Identified risk factors should be evaluated for the contribution they might have to the resident's likelihood of falling and care plan interventions should be implemented that address the resident's risk factors. Review of the facility's policy, Quality of Life - Accommodation of Needs, revised (MONTH) 2009, revealed in order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the residents' wishes. Review of the clinical record revealed the facility admitted Resident #36 on 12/12/18, 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 fifteen (15) of fifteen (15) and determined he/she was interviewable. Further review of the MDS revealed the resident required the assistance of two (2) persons for transfers and one (1) person for toileting. Review of the Care Plan, initiated 12/13/18, revealed the resident was at high risk for falls. Interventions included non-skid footwear for ambulating/transfers, anticipating resident's needs, and ensuring prompt response to all requests for assistance. Observation, on 04/01/19 at 7:19 PM, revealed Resident #36 lying in bed with an abductor cushion positioned between his/her legs. Interview during observation revealed the resident had fallen in the bathroom and fractured a hip. The resident stated he/she activated the call light but staff did not respond and he/she went to the bathroom unassisted because he/she did not want to pee on himself/herself. Review of the Fall Risk Assessment, dated 03/07/19, revealed the facility assessed the resident with a score of 25 indicating he/she was at moderate risk for a fall. Review of the Situation, Background, Assessment, Recommendation (SBAR) Note, dated 03/07/19, revealed Resident #36 sustained an unwitnessed fall at around 1:00 PM. According to the note, there were no changes in the resident's condition following the fall, including functional status. Further review revealed the resident complained of hip pain and a physician's orders [REDACTED]. Review of the Progress Notes, dated 03/07/19 at 9:15 PM, revealed Resident #36 was transferred to the emergency room (ER) for evaluation of the left hip related to an unwitnessed fall. Review of the ER Note, dated 03/07/19, revealed Resident #36 arrived at the ER at 8:27 PM and x-ray of the left femur revealed an acute [MEDICAL CONDITION] femoral neck. Review of the Interdisciplinary Team (IDT) Post Fall Review, signed 03/08/19, revealed there were no predisposing diseases or conditions that might have contributed to the fall. The review revealed the resident was wearing open heel slippers at the time of the fall; however, review of the care plan revealed the resident was to have non-skid footwear when ambulating/transfer. Further review revealed an intervention to ensure the slippers were put up. Interview with Certified Nursing Assistant (CNA) #5, on 04/05/19 at 8:38 PM, revealed she went to Resident #36's room to pick up a lunch tray when she heard someone say help me. The CNA stated she looked in the bathroom, discovered the resident lying on the floor, and notified the nurse. Further interview with CNA #5 revealed she provided incontinent care later in the afternoon and stated the resident was still hurting. According to the CNA, the resident needed one (1) person to assist with transfers and toileting; however, the resident was good by himself/herself prior to the fall. The CNA did not recall if the resident's call light was activated. Interview with CNA #3, on 04/05/19 at 1:37 PM, revealed she checked on residents every hour or two (2) and when she answered call lights. She revealed staff should be aware of resident needs to ensure their safety and stated CNAs were responsible for ensuring interventions were in place to prevent potential falls, including appropriate footwear. Interview with Licensed Practical Nurse (LPN) #5, on 04/04/19 at 2:29 PM, revealed the root cause of the fall was the resident got up unassisted to the bathroom; however, she could not recall if the call light was activated because she was charting at the nurses' station at the time of the fall. Interview with the Assistant Director of Nursing (ADON), on 04/05/19 at 9:32 AM, revealed Resident #36 was able to transfer and toilet independently prior to the fall, depending on how the resident felt, and improper footwear was the root cause of the fall. She stated she asked the resident what happened and the resident said he/she had on open heeled shoes and his/her foot came out the shoe and he/she lost his/her balance and fell . The ADON revealed she did not know if the resident's call light was activated or not and she did not think there was a call light report. Interview with the Director of Nursing (DON), on 04/05/19 at 2:31 PM, revealed the Unit Managers were responsible for monitoring CNAs and nurses to ensure compliance and resident safety. Interview with the Administrator, on 04/05/19 at 3:42 PM, revealed the Unit Manager, ADON, and DON were responsible for oversight of the clinical process to ensure systems were in place and working.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement or develop the care plan for two (2) of twenty-one (21) sampled residents, Resident #8 and #36. The facility care planned for Resident #36 to have on non-skid footwear for ambulating/transfers; however, staff failed to implement Resident #36's care plan to prevent a fall and the resident fell and sustained a [MEDICAL CONDITION]. In addition, the facility failed to develop a care plan related to Resident #8's dental problems. The findings include: Review of the facility's Care Plan Policy, revised (MONTH) (YEAR), revealed the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident. The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The policy further revealed the comprehensive care plan would describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the facility's policy, Falls Management Program Guidelines, effective 12/01/18, revealed the purpose of the policy was to maintain a hazard free environment, mitigate fall risk factors, and implement preventative measures. Identified risk factors should be evaluated for the contribution they might have to the resident's likelihood of falling and care plan interventions should be implemented that address the resident's risk factors. 1. Review of the clinical record revealed the facility admitted Resident #36 on 12/12/18, 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 fifteen (15) of fifteen (15) and determined he/she was interviewable. Further review of the MDS revealed the resident required the assistance of two (2) persons for transfers and one (1) person for toileting. Review of the Care Plan, initiated 12/13/18, revealed the resident was at high risk for falls. Interventions included non-skid footwear for ambulating/transfers, anticipating the resident's needs, and ensuring prompt response to all requests for assistance. Observation of Resident #36, on 04/01/19 at 7:19 PM, revealed the resident in bed with an abductor cushion positioned between his/her legs. Interview during observation revealed he/she went to the bathroom unassisted when staff did not answer the call light, because he/she did not want to pee on himself/herself, and fell and sustained a [MEDICAL CONDITION] a few weeks ago. Review of the Progress Notes, dated 03/07/19 at 9:15 PM, revealed Resident #36 was transferred to the emergency room (ER) for evaluation of the left hip related to an unwitnessed fall and complaints of excruciating pain. Further review of the Physician Orders, dated 03/07/19, revealed an order to transfer the resident to the ER for evaluation of the left hip pain. Review of the ER Note, dated 03/07/19, revealed Resident #36 arrived at the ER at 8:27 PM and the x-ray of the left femur revealed an acute [MEDICAL CONDITION] femoral neck. Review of the Interdisciplinary Team (IDT) Post Fall Review, signed 03/08/19, revealed the resident was wearing open heel slippers at the time of the fall; however, review of the care plan revealed the resident was to have non-skid footwear for ambulating and transfers. Interview with Certified Nursing Assistant (CNA) #5, on 04/05/19 at 8:38 AM, revealed Resident #36 required assistance with transfers and toileting; however, the resident was good by himself/herself prior to the fall. Interview with CNA #3, on 04/05/19 at 1:37 PM, revealed she checked on residents every one (1) to two (2) hours and stated the CNAs were responsible for ensuring fall interventions were in place. According to CNA #3, some residents required supervision in the bathroom to ensure their safety. Interview with Licensed Practical Nurse (LPN) #5, on 04/04/19 at 2:29 PM, revealed Resident #36 needed the assistance of one (1) person for transfers and toileting. The nurse stated she tried to monitor throughout the shift to ensure CNAs assisted residents with Activities of Daily Living (ADL). The nurse stated the purpose of the care plan was to communicate resident needs and prevent future falls. Interview with the Assistant Director of Nursing (ADON), on 04/05/19 at 9:32 AM, revealed Resident #36 should be an assist of one (1), but he/she had the capability to transfer independently. She further revealed improper footwear was the root cause of the fall. She asked the resident what happened and the resident said he/she had on open heeled shoes and his/her foot came out the shoe and he/she lost his/her balance and fell . The ADON stated she monitored staff throughout the day; however, she did not use an audit tool to document her findings. Interview with the Director of Nursing (DON), on 04/05/19 at 2:31 PM, revealed staff was responsible for implementing the care plan based on the assessed needs of the resident. Interview with the Administrator, on 04/05/19 at 3:42 PM, revealed he was not aware of any concerns related to implementation of care plans. 2. Review of the clinical record revealed the facility admitted Resident #8 on 03/18/13, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #8 with a BIMS score of fifteen (15) of fifteen (15) and determined he/she was interviewable. Interview with Resident #8, on 04/02/19 at 9:00 AM, revealed the resident had a toothache for about a week. According to the resident, he/she took medication for pain and the facility scheduled a dental appointment. Further review of the clinical record revealed a care plan was not developed to reflect Resident #8's dental problems. Interview with LPN #5, on 04/03/19 at 1:48 PM, revealed the nurse was responsible for initiating new problems on the care plan. She stated she was not aware of Resident #8's toothache and stated she learned recently through hearsay. Interview with the MDS Coordinator, on 04/05/19 at 3:31 PM, revealed she revised care plans quarterly and the nurses or Unit Managers were responsible for developing care plans with episodic issues. Interview with the ADON, on 04/05/19 at 9:32 AM, revealed she first became aware of Resident #8's dental issues within the last 24 hours. She revealed there were some communication issues and staff sometimes did not give full details or the extent of a resident's problem. Interview with the DON, on 04/05/19 at 2:31 PM, revealed care plans were developed and revised to ensure resident needs were met. Interview with the Administrator, on 04/05/19 at 3:42 PM, revealed he was not aware of any concerns related to care plans.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure residents received their personal clothing items back from laundry in a timely manner for eight (8) of eight (8) sampled residents, Resident #5, #22, #26, #29, #32, #47, #50, and #71. The findings include: Review of the facility's policy, Quality of Life - Accommodation of Needs, revised (MONTH) 2009, revealed the facility's environment and staff behaviors were directed toward assisting residents in maintaining and/or achieving independent functioning, dignity, and well-being. The resident's individual needs and preferences would be accommodated to the extent possible. Interview during the Resident Group Meeting, on 04/02/19 at 2:20 PM, revealed Resident #5, #22, #26, #29, #32, #47, #50, and #71 stated they did not get their personal clothing back from laundry in a timely manner, and sometimes not at all. Observation of the Laundry Room, on 04/05/19 at 10:29 AM, revealed five (5) large containers of soiled resident clothing. Interview with Laundry Staff, on 04/05/19 at 10:29 AM, during the observation, revealed the facility only had one (1) working dryer, as the other one was broken, and she had five (5) large containers of personal clothing items to process. She stated the Certified Nursing Assistants (CNA) would call and tell her a resident was looking for their clothes. She stated she felt bad because the residents did not have their clothes. Interview with CNA #1, on 04/04/19 at 9:41 AM, revealed the facility had a big problem with the laundry and residents reported missing clothing items such as trousers, shirts, underwear, and dresses. CNA #1 stated some residents understood they had to wait a long time to get their clothes laundered; however, they should not have to wait for a week or more and the situation was not acceptable for the residents. Interview with CNA #2, on 04/04/19 at 9:51 AM, revealed some residents were missing their personal clothing items and she went to the laundry to see if she could locate the items; however, sometimes the clothes were not found. CNA #2 further stated clothes were expensive and if residents' personal clothes were lost, they might not be able to buy any. Interview with CNA #3, on 04/04/19 at 10:17 AM, revealed residents had informed her about missing clothes and she was unsure if the items had been located. She stated residents should get their clothes back in a timely manner, in about two (2) days, after sending the items to the laundry. Interview with CNA #4, on 04/04/19 at 11:25 AM, revealed she was aware several residents were missing clothes, such as shirts and pants, and she was unsure if the facility had resolved the issue. The CNA stated residents had a right to get their laundered clothes back within two (2) days of sending their clothes to the laundry. Interview with the Housekeeping Supervisor, on 04/05/19 at 10:40 AM, revealed he was concerned about not having adequate equipment, as the facility had only one (1) working dryer at the time. He stated residents stopped him frequently and asked about their clothes and the residents were frustrated about not getting them back. Interview with the Director of Nursing (DON), on 04/05/19 at 2:22 PM, revealed she knew residents had missing clothing items and she spoke to housekeeping about the missing items; however, a lot of time the clothes were not lost but had not come back from laundry. She stated residents should receive their clothing items back in a timely manner and should have clean clothes available in their closet. She was aware one of the dryers in the laundry was not working.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have a system in place to ensure the staff provided care in accordance with the Comprehensive Plan of Care for three (3) of sixteen (16) sampled residents (Residents #6, #12, and #13). Certified Nursing Assistant (CNA) #5 failed to follow Resident #6's care plan which stated the staff was to assist with meals and place fall mats next to the bed which resulted in a fracture from a fall. CNA #2 failed to utilize two assistants when care was provided to Resident #12 during a bed bath that resulted in a fall with a fracture. Resident #13's care plan stated staff was to utilize a wheelchair for transport only and transfer the resident to a mat or bean bag chair. Staff found Resident #13 on the floor face down with a bloody nose and cut lip. The findings include: Review of the facility's policy regarding Plans of Care, dated 09/01/15, revealed an interdisciplinary care plan would be established for each resident and updated in accordance with state and federal regulatory requirements and on an as needed basis. Direct care staff would be aware, understand and follow their Resident's Plan of Care. Review of the facility's policy regarding the Nurse Tech Information Kardex, dated 11/30/14, revealed a Nurse Tech Information Kardex would be completed by the Unit Manager or Care Plan Coordinator or designee for each resident. The Nurse Tech would utilize the Kardex as a resource to provide care. 1. Review of the medical record for Resident #6 revealed the facility admitted the resident on 09/22/10 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set Assessment, dated 02/14/15, revealed the facility staff assessed Resident #6 as needing extensive assistance of two (2) persons with bed mobility and limited assistance of one (1) person with toileting and eating. Resident #6 was assessed by the facility using the Brief Interview for Mental Status (BIMS) and scored a three (3), meaning he/she was not interviewable. Review of the comprehensive care plan for Resident #6, dated 02/27/15 and reviewed on 05/06/15 and 07/11/15, revealed he/she was at risk for falls/injury. The facility set a goal to maintain preventative measures and manage any fall related injuries thru the next review. Resident #6 was care planned for assistance with turning and repositioning, fall mats were to remain at the bedside and staff was to provide assistance to the toilet before and after meals. The staff was to provide assistance with meals in the dining room and removal from dining room for toileting immediately following meals. Review of the Fall Root Cause Investigation Report Form for Resident #6, revealed he/she experienced a fall on 07/11/15, while pushing the over the bed table away from the bed. The fall mat was not at the bedside at the time of the fall. The fall mat was moved to accommodate the over the bed table. Changing the fall mat to a beveled mat was the intervention put in place to minimize future fall occurrences. Review of the Bowel and Bladder report, dated 07/11/15, revealed Resident #6 had an episode of incontinence at 4:08 AM, but there was no further documentation by the CNAs regarding the toileting of Resident #6 for the remainder of the day. Telephone interview with the Interim Director of Nursing, on 10/15/15 at 11:49 AM, revealed she investigated Resident #6's 07/11/15 fall. She had concluded that CNA #5 brought Resident #6's dinner tray to his/her room, moved the fall mat aside to roll the over the bed table in place, left the dinner tray on his/her table. Per the investigation, it was determined CNA #5 did not assist Resident #6 with his/her meal or collect the tray. CNA #5 did not reposition the over the bed table; did not return the fall mat to the bedside; and, did not toilet Resident #6 following his/her meal as care planned. The facility provided an incorrect phone number for CNA #5, according to the individual answering that phone on 10/15/15 at 9:14 AM. No one responded to the two (2) voice mail messages left at CNA #5's emergency contact number, at 9:45 AM and 1:00 PM on 10/15/15. Interview with CNA #4, on 10/15/15 at 10:00 AM, revealed she always got Resident #6 up and out of bed as soon as Resident #6 woke up, otherwise he/she tried to get up by himself/herself and would fall. CNA #4 stated she finds out from the Kardex how to care for her assigned residents. Interview with LPN #3 by phone, on 10/15/15 at 9:18 AM, revealed he utilized the individualized plans of care to guide him in the care of his assigned residents. Interview with Unit Manager #1, on 10/15/15 at 9:00 AM, revealed the Plans of Care were everyone's responsibility. Care plans were communicated to the CNAs through the Kardex and she made rounds on the staff to ensure interventions were implemented; however, she did not document those rounds. 2. Review of the clinical record for Resident #12, revealed the facility readmitted the resident on 08/02/12 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set Assessment, dated 06/22/15, revealed the facility assessed Resident #12 as interviewable with a score of twelve (12) on the Brief Interview for Mental Status. In addition, the resident required extensive assistance of two (2) staff for bed mobility. Review of Resident #12's comprehensive care plan, dated 01/20/15, with a target date of 10/03/15, revealed the resident was care planned for self-care deficit related to immobility syndrome and for all care needs to be provided with two (2) staff members. Review of Resident #12's Kardex, not dated, revealed the resident was an assist of two (2) for bed mobility. Review of the Fall Root Cause Investigation Report, dated 09/01/15, revealed Resident #12 rolled from the bed onto the floor during a bed bath and was sent to the acute hospital for assessment. The resident sustained [REDACTED]. Interview with CNA #2, on 10/15/15 at 11:20 AM, revealed she checked the Kardex and was aware two (2) staff was to be present when providing care for Resident #12. She stated CNAs on the unit told her she would not need help because Resident #12 was able to roll himself/herself using the bed rails. She stated she gave the resident a bed bath and while she was changing the sheets, the resident rolled to the side of the bed and kept rolling and fell to the floor. Interview with LPN #1, on 10/15/15 at 2:15 PM, via telephone revealed she monitored care plans were followed by correcting the CNAs if she saw them do something wrong. However, she was unsure how many staff was needed to provide care for Resident #12. Interview with the A and D Hall Unit Manager (UM), on 10/15/15 at 2:25 PM, revealed Resident #12 required two (2) staff when care was provided. She stated she educated CNA #2 on checking the Kardex for assist required for resident care. She further stated she monitored care plans were being followed by sitting on the units frequently watching staff, doing rounds, and every week she would pick a different staff member and observe them completing tasks. Interview with Resident #12, on 10/15/15 at 2:50 PM, revealed two (2) CNAs were usually present when he/she would get a bath; however, on the day of the fall, only one (1) CNA was in the room. 3. Review of Resident #13's clinical record revealed the facility admitted the resident on 04/16/14 with [DIAGNOSES REDACTED]. Review of Resident #13's quarterly Minimum Data Set (MDS) assessment, completed on 07/31/15, revealed the facility assessed the resident as requiring extensive assistance from staff to toilet, and for all transfers. The resident required one-person supervision for locomotion in the facility. The facility assessed the resident as having been unable to complete a Brief Interview for Mental Status (BIMS) exam due to memory problems and was unable to be understood, with a score of 0, meaning the resident was not interviewable. Review of the Fall Root Cause Investigation Report, dated 07/30/15 at 12:00 PM, revealed the resident sustained [REDACTED]. The facility staff found the resident on the floor in his/her room, but not on the mat provided. The investigation report stated the staff was unsure if the resident fell out of the wheelchair or if the resident transferred him/herself out of the wheelchair. No injuries were noted from this fall. Review of the Care Plan for Resident #13, last updated 07/20/15, revealed the facility added interventions to the care plan on 07/30/15. One intervention included nursing to allow the resident into his/her wheelchair to transfer to and from the dining room and activities only. Additional interventions included nursing staff was to assist the resident to the floor mat or beanbag chair in the resident's room when not in his/her wheelchair. The care plan further stated the resident required an assist of one (1) staff person for transfers and care. On 07/22/15, the facility discontinued an alarming seatbelt when the resident was in the wheelchair. Review of the Nurse Tech Information Kardex, not dated, revealed the facility identified a special need for Resident #13. Nursing staff was to use the wheelchair with the resident only for transferring to and from the dining room or activities. The Kardex also stated the resident was only to be in the wheelchair with supervision. The Kardex discussed safety measures for Resident #13, including a mat to the floor and the beanbag chair in the resident's room. Review of the Fall Root Cause Investigation Report, dated 09/02/15, revealed Resident #13 sustained a fall in the hallway of the facility. Next to Potential Causes, staff stated the resident was reaching for the handrail and slid off the wheelchair and onto the floor. Per the care plan the resident was only to be up in the wheelchair for transport to activities and meals with supervision of staff. Review of the Fall Root Cause Investigation Report, dated 09/10/15, revealed Resident #13 sustained a fall in the resident's room. Nursing staff found the resident on the floor of the room, face down with a bloody nose and a 0.5 cm cut on the inside of his/her lower lip. The facility sent the resident to the hospital. Resident #13 returned from the hospital with no injuries. On the form, staff stated they were unsure what the resident was doing prior to the fall. The staff did not implement the transfer to the mat or bean bag chair as care planned. Interview with CNA #7, on 10/15/15 at 9:47 AM, revealed CNAs provided assistance for transfers for Resident #13. The CNAs also provided supervision for Resident #13 when he/she was in the wheelchair due to a history of falls. Interview with the Unit Manager (UM) #1, on 10/15/15 at 5:50 PM, revealed Resident #13 had a history of [REDACTED]. Due to all of the falls, staff was supposed to supervise the resident whenever he/she was in the wheelchair by keeping him/her in a public area of the facility and staying with him/her when ambulating in the wheelchair. However, the staff did not do this. Interview with the Administrator, 10/15/15 at 6:30 PM, revealed the facility had identified falls as an issue. He stated he expected nursing staff to follow interventions put in place and by not following the interventions could lead to resident injury.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to provide supervision and assistive devices to prevent accidents for three (3) of sixteen (16) sampled residents (Resident #6, #12 and #13). Certified Nursing Assistant (CNA) #5 failed to assist Resident #6 with their meal, and failed to reposition the fall mat next to the bed that resulted in a fall and scapular fracture and subdural hematoma. The resident required hospital intervention. CNA #2 failed to utilize two assistants when providing a bed bath to Resident #12 and he/she fell from the bed onto the floor and sustained a right distal femur fracture. The resident was transported to a local hospital. Resident #13 sustained a fall on 07/30/15 and 09/02/15, without injury. On 09/10/15 the resident was found by staff face down with a bloody nose and a cut inside the lower lip. The resident was transferred to the hospital for evaluation. The findings include: Review of the facility's policy and procedure regarding Accident and Incident Investigations, dated 11/30/14, revealed a Fall Root Cause Investigation must be completed for all falls. The Fall Root Cause Investigation form included the designation of interventions minimizing future occurrences. 1. Review of the clinical record for Resident #6 revealed the facility admitted the resident on 09/22/10 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 02/14/15, revealed the facility assessed Resident #6 as requiring extensive assistance of two (2) persons with bed mobility and limited assistance of one (1) person with toileting and eating. The facility assessed Resident #6 using the Brief Interview for Mental Status (BIMS) and scored a three (3), indicating the resident was not interviewable. Review of the comprehensive care plan for Resident #6, dated 02/27/15 and reviewed on 05/06/15 and 07/11/15, revealed he/she was at risk for falls/injury. The facility set a goal to maintain preventative measures and manage any fall related injuries through next review. Resident #6 was care planned for assistance with turning and repositioning, fall mats to remain at the bedside and for assistance to the toilet before and after meals. Review of the Fall Root Cause Investigation Report Form for Resident #6, revealed he/she experienced a fall on 07/11/15 with no time documented, while pushing the over the bed table away from the bed. The facility changed the fall mat to a beveled mat as the intervention put in place to minimize future fall occurrences. Review of the Situation Background Assessment Recommendation Communication Form, dated 07/11/15, revealed a fall on 07/11/15, resulting in a laceration above the resident's right eye. Review of the Nursing Home to Hospital Transfer Form, dated 07/11/15, revealed the facility obtained vital signs at 10:38 PM for Resident #6, and revealed he/she was transferred to the Emergency Department on 2nd shift. Review of the staffing sheets, dated 07/11/15, revealed CNA #5 and Licensed Practical Nurse (LPN) #3 were assigned to Hall C and Resident #6 when the resident fell . The facility provided an incorrect phone number for CNA #5, according to the individual answering that phone on 10/15/15 at 9:14 AM. No one responded to the two (2) voice mail messages left for CNA #5's emergency contact at 9:45 AM and 1:00 PM on 10/15/15. Interview with LPN #3 by phone, on 10/15/15 at 9:18 AM, revealed he took care of Resident #6 on the 2nd shift on 07/11/15. He stated Resident #6 was in bed prior to his/her fall, but did not recall the time of the incident and was unsure of what paperwork was completed following the incident. LPN #3 stated he heard Resident #6's bed alarm sounding and the sound of the fall, which alerted him to Resident #6's distress. LPN# 6 stated after running to the end of the hall, he found Resident #6 half on and half off the floor mat with his/her head on the tile. Resident #6 had a laceration over his/her right eye and he stabilized his/her neck until emergency personnel could arrive. LPN #3 could not remember when he had last seen Resident #6 before the fall. LPN #3 could not recall which CNA was responsible for Resident #6 on 07/11/15. Interview with CNA #4, on 10/15/15 at 10:00 AM, revealed she cared for Resident #6 for one (1) year on 1st shift and she was aware Resident #6 fell frequently on 2nd shift. CNA #4 stated she always got Resident #6 up and out of bed as soon as Resident #6 woke up, otherwise he/she would try to get up himself/herself and would fall. Telephone interview with the Interim Director of Nursing (DON), on 10/15/15 at 11:49 AM, revealed she investigated Resident #6's 07/11/15 fall. She had concluded CNA #5 brought Resident #6's dinner tray to his/her room, moved the fall mat aside to roll the over the bed table in place, and left the dinner tray on his/her table. CNA #5 did not assist Resident #6 with his/her meal; did not collect the tray after the mea; did not reposition the over the bed table; did not return the fall mat to the bedside; and, CNA #5 did not toilet Resident #6 following his/her meal. Continued interview revealed the Interim DON contacted Human Resources and requested the CNA, who was PRN, be terminated. The Interim DON stated she phoned the family of Resident #6 to let them know that it was her findings the facility was at fault for Resident #6's fall. Review of CNA #5's personnel file revealed CNA #5 resigned and she last worked on 07/11/15. Interview with the Regional Director of Clinical Services, on 10/15/15 at 10:30 AM, revealed she investigated Resident #6's fall on 07/11/15. She stated her findings were Resident #6's fall mat was not at the bedside when the fall occurred. CNA #5 had moved the fall mat aside to place the over the bed table. Resident #6 had fallen while pushing the over the bed table away from the bed when he/she had finished eating. She documented her findings on the Fall Root Cause Investigation Report Form. She stated that changing the fall mat to a beveled mat was the intervention put in place to minimize future fall occurrences. 2. Observation of Resident #12, on 10/14/15 at 4:45 PM, revealed the resident was in bed with his/her eyes closed. The bed had an air mattress with bolsters. There were fall mats on the floor on both sides of bed. The resident's call light was within reach. Review of Resident #12's clinical record, revealed the facility readmitted the resident on 08/02/12 with [DIAGNOSES REDACTED]. Review of Resident #12's Quarterly Minimum Data Set assessment, completed on 06/22/15, revealed the facility assessed Resident #12's Brief Interview for Mental Status (BIMS) as twelve (12) which meant the resident was interviewable. In addition, the resident required extensive assistance of two (2) staff for bed mobility. Review of the Comprehensive Care Plan for Resident #12, dated 01/20/15, with a target date of 10/03/15, revealed the resident had a plan of care in place for self-care deficit related to immobility syndrome and for all care needs to be provided with two (2) staff members. Review of the Kardex for Resident #12, not dated, revealed the resident was an assist of two (2) for bed mobility. Review of the Fall Root Cause Investigation Report, dated 09/01/15, revealed Resident #12 rolled from the bed onto the floor during a bed bath and was sent to the acute hospital for assessment. Review of the radiology report from the acute hospital, dated 09/01/15, revealed Resident #12 sustained an acute fracture of the distal femur to the right leg. Interview with CNA #2, on 10/15/15 at 11:20 AM, revealed she checked the Kardex for Resident #12 and was aware that two (2) staff was to be present when providing care. She stated other CNAs on the unit told her Resident #12 was able to roll himself/herself using the bed rails and did not require the assist of two (2) staff. She stated after she finished giving the resident a bed bath she changed the bed linens. CNA #2 stated when she was walking around to the left side of the bed, the resident rolled to the right side of the bed and kept rolling and fell to the floor. Interview, on 10/15/15 at 2:15 PM, with LPN #1 via telephone, revealed she was unsure how many staff were needed to provide care for Resident #12. She stated she worked as needed and floated to all the units. She stated on the day of the fall, she heard someone yell and when she entered Resident #12's room, the resident was on the floor. She stated there was plenty of staff available for resident care on the day of the fall. Interview with the A and D Hall Unit Manager (UM), on 10/15/15 at 2:25 PM, revealed Resident #12 required the assist of two (2) staff when care was provided. She stated there was plenty of staff on the day of the fall for two (2) staff to provide care to Resident #12. She further stated CNA #2 was new and the day of the fall was CNA #2's second day working alone. Interview with Resident #12, on 10/15/15 at 2:50 PM, revealed there were usually two (2) CNAs present when he/she would get a bath; however, on the day of the fall, only one (1) CNA was in the room. The resident stated when he/she attempted to roll to the right side of the bed, he/she pulled his/her left leg over and the leg kept going and he/she fell off the bed and landed on his/her right knee. 3. Observations of Resident #13's room, on 10/13/15 at 9:00 AM, revealed the facility provided mats and a bean bag chair for the resident to sit on in his/her room. Observations of Resident #13, on 10/13/15 at 9:12 AM, revealed the resident was in the hallway of the facility. The resident was propelling self in the hallway using the handrails. A staff person was standing and walking next to the resident. Review of Resident #13's clinical record revealed the facility admitted the resident on 04/16/14 with [DIAGNOSES REDACTED]. Review of Resident #13's quarterly Minimum Data Set (MDS) assessment, completed on 07/31/15, revealed he/she required extensive assistance from staff to toilet, and for all transfers. The resident required one-person supervision for locomotion in the facility. The facility assessed the resident as having been unable to complete a Brief Interview for Mental Status (BIMS) exam due to memory problems and was unable to be understood, meaning the resident was not interviewable. Review of the Care Plan for Resident #13, last updated 07/20/15, revealed the facility added interventions to the care plan on 07/30/15. One intervention included nursing to allow the resident into his/her wheelchair to transfer to and from the dining room and activities only. Secondly, the interventions revealed the nursing staff was to assist the resident to the floor mat or beanbag chair in the resident's room when not in his/her wheelchair. The care plan further revealed the resident required an assist of one (1) staff person for transfers and care. On 07/22/15, the facility discontinued the alarming seatbelt when the resident was in the wheelchair. Review of the Nurse Tech Information Kardex, not dated, revealed the facility identified a special consideration for Resident #13. Nursing staff was to use the wheelchair with the resident only for transferring to and from the dining room or activities. The Kardex also stated the resident was only to be in the wheelchair with supervision. The Kardex discussed safety measures for Resident #13, including a mat to the floor and the beanbag chair in the resident's room. Review of the Fall Root Cause Investigation Report, dated 07/30/15 at 12:00 PM, revealed the resident sustained [REDACTED]. The facility staff found the resident on the floor in his/her room, but not on the mat provided. The investigation report stated the staff was unsure if the resident fell out of the wheelchair or if the resident transferred him/herself out of the wheelchair; however the resident was unsupervised. No injuries were noted from this fall. The facility added a bean bag chair to transfer the resident into after meals. Review of a second Fall Root Cause Investigation Report, dated 09/02/15, revealed Resident #13 sustained a fall in the hallway of the facility. Next to the Potential Causes, staff stated the resident was reaching for the handrail and slid off the wheelchair and onto the floor. No injuries were documented. The facility added new interventions of replacing the chair alarm. Review of the Fall Root Cause Investigation Report, dated 09/10/15, revealed Resident #13 sustained a fall in the resident's room. Nursing staff found the resident on the floor of the room, face down with a bloody nose and a 0.5 centimeter cut on the inside of his/her lower lip. The facility sent the resident to the hospital. Resident #13 returned from the hospital with no injuries. On the form, staff stated they were unsure what the resident was doing prior to the fall; however was unsupervised at the time. The facility added new interventions of continue bed and chair alarm, consider one on one supervision or put mattress on the floor. Interview with CNA #1, on 10/15/15 at 9:05 AM, revealed CNAs used the Kardex to guide the care they gave each resident. The Kardex told the CNAs what care and what level of assistance each resident required. Interview with CNA #7, on 10/15/15 at 9:47 AM, revealed CNAs provided assistance for transfers for Resident #13. CNAs also provided supervision for Resident #13 when he/she was in the wheelchair due to a history of falls. Interview with Unit Manager #1, on 10/15/15 at 5:50 PM, revealed resident #13 sustained several falls for which the facility introduced interventions. She stated the resident sustained [REDACTED]. The resident was reaching forward to pull him/herself along the wall. The Unit Manager stated one of the interventions put in place was to increase supervision of the resident while he/she was in the wheelchair by keeping him/her in a public area of the facility. However, this was not on the care plan and not implemented. Interview with the Director of Nursing (DON), on 10/15/15 at 6:00 PM, revealed she was unaware of any falls for Resident #13 due to not following the care plan. The DON stated since her employment started less than three (3) weeks ago, she was not aware of any instances of falls and could not speak to instances prior to her employment. Interview with the Administrator, on 10/15/15 at 6:30 PM, revealed the facility had identified falls as an area of concern and had been incorporating a new plan to reduce falls in the past two (2) months. The facility was bringing information pertaining to falls to the morning meeting to discuss each fall. The facility was also tracking and trending the falls to look for any consistencies that may contribute to an individual's fall rate. The Administrator stated he discovered falls that had taken place due to nursing staff not following all care plan interventions. This placed residents at risk for injury if staff did not follow care plan interventions.

Based on interview and review of the facility's Abuse policy and investigations, it was determined the facility's Administration failed to ensure the facility policy and procedures were implemented in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. The facility's Administration failed to have an effective system in place to ensure policy and procedures were implemented to protect residents from abuse; failed to ensure staff was knowledgeable of the facility's policy and procedures related to abuse; and failed to provide guidance and oversight during abuse investigations. The Administration failed to provide guidance to Social Services to ensure assessments of resident behaviors were completed and care plans updated. The Administration further failed to ensure staff were knowledgeable of resident behaviors, monitored and documented the behaviors to ensure communication to Social Services. The Administration also failed to ensure the residents' clinical record was complete and accurate related to verbal, physical, and/or sexual behaviors exhibited by the residents. (Refer to F223, F225, F226, F250, F280, F282, F323, F514). In addition, the facility's Administration failed to ensure the facility maintained substantial compliance per the facility's Plan of Correction as evidenced by repeat deficiencies from the standard survey conducted on 08/01/13 at F203, F280, F323, F514, and F520. (Refer to F520) The facility's failure to ensure the facility policy and procedures were implemented in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident placed residents in a situation that was likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy (IJ) was identified on 01/10/14 and determined to exist on 07/17/13. The facility was notified of the Immediate Jeopardy on 01/10/14. An acceptable Allegation of Compliance (AOC) was received on 01/20/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 01/16/14 as alleged, prior to exit on 01/22/14. The scope and severity was lowered to an "E" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the Administrator's job description, undated, revealed the Administrator was responsible for the resident's condition of health and an essential function and responsibility was to review all accidents and incidents in the facility, maintain all records, funds, and licensing standards and requirements, and participate in on-going quality assurance of the facility. The Administrator through leadership evaluates and recognizes priorities, selects effective team members, and recognizes the need for and provides adequate resources. 1. Review of the facility's policy regarding Resident Abuse, revised 01/01/12, revealed each resident would be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriate of property. Any employee who witnessed or had knowledge of an act of abuse to a resident was obligated to report such information to the Clinical Nurse in charge, Director of Clinical Services (DCS) and the Executive Director. All reported events would be investigated by the DCS. This information would be forwarded to the Executive Director, who would serve as the facility's Abuse Coordinator, and an abuse investigation would be conducted. In the absence of the Executive Director, the DCS will serve as the Abuse Coordinator. The Abuse Coordinator was responsible for reporting to the appropriate officials in accordance with Federal and State Regulation. Immediately upon report of an incident the suspect would be segregated from the resident. An incident report would be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. The Abuse Coordinator and/or DCS would take statements from the victims, the suspects and all possible witnesses including all other employees in the vicinity of the alleged abuse. Once the investigation was completed the report would be reviewed by the DCS, the Abuse Coordinator, and one other Administrative staff member. Interview and record review revealed the facility failed to have an effective system in place to ensure residents were free from abuse for four (4) of twenty-two (22) sampled residents (Resident #1, #2, #3 and #19). Record review revealed Resident #1 had a history of [REDACTED]. The facility's failure to address Resident #1's abusive behavior affected Resident #2 and Resident #3. Resident #19 was victim of verbal abuse by a staff member. (Refer to F223) Interview and record review revealed the facility failed to have an effective system in place to ensure incidents of potential abuse were investigated and reported immediately to the appropriate State Survey Agency (SSA) for fourteen (14) of twenty-two (22) sampled residents (Resident #1, #2, #3, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18 and #19). The facility failed to investigate and report allegations of verbal, physical and sexual abuse by resident to resident and staff to resident. The facility also failed to prevent further potential abuse by failing to conduct investigations. (Refer to F225 and F226) Review of the list of the facility's Key Personnel provided to the state survey agency on 01/06/14 revealed the Social Service Director (SSD) was the facility's Abuse Coordinator. A revised list, provided on 01/16/14 at 8:50 AM, revealed the facility's Abuse Coordinator was the Interim ED. Interview with the Social Service Director on 01/07/14 at 8:57 AM, on 01/09/14 at 1:54 PM, and on 01/10/14 at 1:55 PM revealed she took over reviewing the investigations from a previous Administrator in May 2013. However, the facility incident reports would be turned in to the DCS and she had never seen a facility incident report. Per interview, the SSD was unaware she was identified on the list of Key Personnel as the Abuse Coordinator. Interview with the current Interim ED, on 01/9/14 at 12:29 PM, revealed the SSD was the Abuse Coordinator during some of the allegations discussed and he did not know when he had become the facility's current Abuse Coordinator. He indicated he began at the facility as the Interim ED on 12/06/13, and in that timeframe did not know how many allegations of abuse had been reported to him. The ED stated he did not know what could be verbal or mental abuse and he would need to pull the state law to know what the regulations were for abuse. Interview, on 01/08/14 at 4:15 PM, with the Regional Director of Clinical Services revealed the facility discovered after the state survey agency entered the facility on 01/02/14, that the facility had a problem with abuse. 2. Review of the facility's policy regarding Resident Abuse, revised 01/01/12, under the section titled screening, revealed the facility would screen any persons applying for employment for a history of abuse, neglect or mistreating residents by checking references from previous or current employers, criminal background checks, abuse checks with appropriate licensing board and registries prior to hire, sworn disclosure statements prior to hire, and verification of license or registration prior to hire. Interview and record review revealed the facility failed to have an effective system in place for abuse screening and prevention for eight (8) of eighteen (18) sampled personnel files. The facility failed to verify staff licenses, complete nurse aide abuse registry (NAR) checks, complete reference checks, and/or criminal background checks were conducted or contained negative information regarding theft. (Refer to F225) On 01/07/14 at 12:35 PM, interview with the Interim ED revealed HR was responsible to ensure personnel files were complete. The ED further indicated he would use a checklist to ensure all documents and checks had been completed; however, he had not implemented one. He stated he would also conduct periodic and random checks of employee files; however, he had not done any at the facility in his time employed. 3. Review of the facility's policy regarding Social Services, revised 09/01/11, revealed Social Services as a member of the Interdisciplinary Team, would participate in planning the overall care of the resident including completing periodic reviews of the assessment as necessary, but at least once quarterly and documenting progress in the Social Service Progress Notes and respond to changes in a resident's mental, physical, or emotional status. Interview and record review revealed the facility failed to have an effective system in place to ensure staff communicated the behaviors of the residents to Social Services through the 24 Hour Report, Behavior Sheets, Nurses' Notes, Incident Reports, and access to the Kiosk (State Registered Nurse Aides (SRNA) computer documentation) to enable Social Services to assess and provide medically-related social services to meet the residents' highest practicable physical, mental and psychosocial well being; and, revise the care plans based on the behaviors of fourteen (14) of twenty-two (22) sampled residents. (Residents #1, #2, #3, #9, #10, #11, #13, #14, #15, #16, #17, #18, #19 and #22). (Refer to F250 and F280) Interview with the SSD on 01/09/14 at 2:00 PM revealed she was responsible for the assessment of behaviors for the MDS and was responsible for creating the behavior care plans. She also tracked and trended behaviors for the Psychiatric Behavior Meeting. She obtained information from the morning meetings where incidents were discussed. However, the she did not have access to the Kiosk to view the behavior charting. Interview with the ED, on 01/16/14 at 4:05 PM, revealed he supervised Social Services by talking with her every day. 4. Review of the facility's policy regarding Accident and Incident Investigation, reviewed 12/27/13, revealed certain incidents would be investigated to determine root cause and to provide an opportunity to decrease future occurrences of the event. Any event that was not of the facility's routine operations or care of a resident should have the completion of an incident report. Additionally, certain events would also require the completion of designated investigation forms, including behavior outburst with using the Behavioral Outburst Assault of another Resident or Staff. The Executive Director (ED), Director of Clinical Services (DCS) or designee should begin a documented investigation to include interviews with the resident, staff involved, and others who may be able to help with the investigation. Additionally, results of the investigation would be reviewed by the DCS to ensure it was completed and thorough. Review of the facility's policy regarding Behavior Monitoring, reviewed 01/03/13, revealed any resident that exhibited behaviors would have a "Behavior/ Intervention Monthly Flow Record" (Behavior Sheet) initiated. The Behavior Sheet required documentation every shift as well as a summary in a weekly progress note. Behaviors listed included: violent behavior/striking other residents, sexual, verbal, or physical behavior toward other residents, sexual aggression, verbal or physical abuse toward staff, abusive yelling or screaming, kicking, aggression during walking/wheeling, and any other behavior which posed harm to other residents. The documentation should include the specific type of behavior being monitored, i.e. kicking, hitting, yelling. Additional documentation included: the number of times the behavior was observed during the shift; the code for the first attempted intervention; non-pharmacological interventions; the code for the outcome; and the code for any side effects observed. The Behavior Sheet was to be maintained with the Medication Administration Record [REDACTED]. The policy also revealed any resident that received psychoactive medications would have a Behavior Sheet. The medication being monitored and the specific behavior that indicated the use of the medication should be noted. Interview and record review revealed the facility failed to have an effective system in place to ensure staff adequately supervised residents with behaviors for fifteen (15) of twenty-two (22)sampled residents. The facility failed to identify and monitor all exhibited behaviors by Residents #1, #2, #3, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and #22. Additionally, the facility failed to monitor Resident #1's behavior of physical, sexual, and verbal abuse to provide needed care and treatment in an attempt to maintain a safe environment for other residents in the facility. (Refer to F282, F323, and F514) On 01/08/14 at 4:15 PM, interview with the Regional DCS revealed the facility audited residents' charts and discovered a problem with abusive behaviors. 5. Review of the annual survey dated 08/01/13 revealed the facility had been cited in Admission, Transfer and Discharge (F203 S/S "D"), Resident Assessment (F280 S/S "D"), Quality of Care (F323 S/S "G"), and Administration (F514 S/S "D", F520 S/S "G"). The facility alleged compliance as of 09/13/13. The facility did not provide any evidence the Plan of Correction was monitored for continued compliance after the revisit date of 09/19/13. (Refer to F520) Interview with the Vice President of Clinical Operations, on 01/14/14 at 5:20 PM, revealed the facility was unable to attest that the Plan of Correction was utilized. Further interview with the Executive Director, on 01/19/14 at 11:37 AM, revealed he reviewed the previous Plan of Correction on his own, and as an interim put together a transition binder for the new administrator coming on which included prior surveys. The ED further stated he kept the facility's systems in place when he started because the worst thing an interim could do was change systems around. However, the ED then stated the facility obviously had a broken system, but didn't want to change everything. The facility provided an Allegation of Compliance (AOC) on 01/20/14 alleging the Immediate Jeopardy (IJ) was removed on 01/16/14; the facility took the following immediate steps to remove the IJ: 1. Resident #1 and SRNA #2 were immediately separated on 12/31/13 by staff. 2. The police were notified of the incident on 12/31/13. 3. Resident #1 was discharged to the hospital for a psychiatric evaluation on 01/07/14. 4. SRNA #2 was suspended immediately on 12/31/13. 5. Resident #3 was referred by the DCS, and seen by the Psychiatric ARNP, on 01/15/14. 6. Resident #3 was placed on increased supervision, 1:1 observation, to redirect impulse behaviors on 01/12/14. 7. Resident #3 was reviewed by the Interdisciplinary Team (IDT) (consisting of the Corporate Administrative Nurse, DCS, Activity Director, and Regional Director of Clinical Services) in the Behavior Management Meeting, on 01/12/14, which included a medical record review. 8. Resident #3's care plan was updated by the Corporate Administrative Registered Nurse on 01/13/14. 9. The incident involving Resident #3, on 11/05/13, was reported to the State Survey Agency (SSA), on 01/08/14 via a 24 Hour Report, investigated and a 5 Day report was submitted to the SSA on 01/13/14. 10. Resident #2 was reviewed in the Behavior Management Meeting by the IDT Corporate Administrative Registered Nurse, DCS, Activity Director, and the Regional Director of Clinical Services on 01/12/14 which included a medical record review and a care plan review. 11. The incident on 07/17/13 involving Resident #2 was reported to the SSA on 01/08/14 via a 24 hour report. A 5 day Report was submitted to the SSA on 01/13/14. 12. Resident #2 was interviewed on 01/07/14 by the SSD and the DCS regarding the incident on 07/17/13 and 01/06/14. 13. Current resident chart reviews completed , on 01/07/14 and 01/08/14 by the DCS, ADCS, Unit Manager and RDCS and staff interviews on 01/11/14 and 01/12/14 by Corporate Administrative Registered Nurses to identify residents with behaviors, the facility identified three (3) residents (#3, #13, and #21) as exhibiting sexual or physical behaviors towards others. These three residents were: A. Reviewed in the Behavior Management Meeting by the IDT (Corporate Administrative Registered Nurse, Director of Clinical Services Activity Director, and the Regional Director of Clinical Services) on 01/12/14. B. Increased supervision was initiated on 01/12/14 and the care plans were revised by the Activity Director the Corporate Administrative Registered Nurse and the DCS on 01/13/14. C. Referred to the Psychiatrist for review by the DCS and two (#13 and #21) of three residents were seen on 01/15/14. D. Had documentation of behavior reviewed daily since 01/13/14 by a member of the IDT (to include the DCS, ED, and the Corporate Administrative Registered Nurses). 14. Thirty-nine (39) residents, with a brief interview for mental status (BIMS) of an 8 or above were interviewed by the Social Services on 01/07/14 to ensure they had not been abused or neglected. 15. All residents were assessed by nurses via skin sweeps for suspicious injuries on 01/07/14, 01/08/14, and on 01/15/14 with no injuries found. 16. All Department Heads along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116) were interviewed by the Corporate Administrative Registered Nurse on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 to ensure no one had witnessed any abuse or neglect that had not been previously reported. 17. Current resident charts were reviewed on 01/07 and 01/08/14 by the Director of Clinical Services, Assistant Director of Clinical Services, Staff Educator, Unit Manager, and the Regional Director of Clinical Services to determine if there were any incidents that were reportable and/or needed further investigation. The seven (7) incidents that were identified during the review were reported on 01/08/14. 18. The facility's concern book was reviewed by the Regional Director of Clinical Services on 01/11/14 for allegations that needed to be reported and no allegations were identified. 19. The current staff members' employee personnel files were reviewed by Regional Director of Human Resources and Facility Human Resources/Payroll Coordinator to ensure that the files were completed with the Criminal Background Check, Kentucky State Board of Nursing/Nurse Aide Abuse Registry check, Office of the Inspector General Check, Telephone Reference Checks and Abuse/Neglect Attestation on 01/11/14 and 01/12/14. The six (6) discrepancies identified were corrected with missing Criminal Background Checks and Reference checks by 01/12/14. 20. All current Department Head staff along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116 employees) were educated by the Corporate Administrative Registered Nurses on abuse screening, training, prevention, identification, investigation, protection, reporting and response, F223 and the facility's Policy and Procedure for Resident Abuse, on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 and completed a post test. No staff members worked beyond 01/12/14 without having already been educated prior to the start of their shift. 21. The Human Resource/Payroll Coordinator was reeducated by the Regional Director of Human Resources on 01/12/14 that newly hired employees must have a Criminal Background Check, Kentucky Board of Nursing/Nurse Aide Abuse Registry Screen, Office of the Inspector General Exclusion Check, and Telephone reference checks. 22. The ED and DCS were re-educated by the Vice President of Clinical Services on 01/11/14 and 01/12/14 to ensure newly hired employees must have a Criminal Background Check, Kentucky Board of Nursing/Nurse Aide Abuse Registry Screen, Office of the Inspector General Exclusion Check, and Telephone reference checks. The ED will validate and sign that Newly Hired Employees have had all the required checks. 23. Mock Survey Rounds consisting of care plan review and implementation, behavior documentation, and staff interviews were completed by the IDT on 01/13/14, 01/14/14, and 01/15/14 that included resident interviews regarding potential abuse issues. 24. A Behavior Meeting was conducted by the IDT on 01/12/14 to review the current residents with known behaviors to discuss the behaviors, interventions, and medication. The nine (9) residents identified as having some type of behavior were referred to the physician and interventions were updated on the care plans by the IDT on 01/15/14. 25. Social Service notes were reviewed and Care Plans updated by the Corporate Social Services on 01/15/14. 26. The Social Service Director (SSD) was re-educated by the Corporate Administrative Registered Nurse on F250 and the facility's Policy and Procedures for Abuse and Behaviors on 01/12/14. 27. The Social Service Department consisting of the Corporate Social Services, Corporate Administrative Registered Nurse had daily oversight on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 with review of resident and family concerns daily in the morning meeting to ensure department managers were working towards resolution. 28. All facility staff was educated by the Corporate Administrative Registered Nurse on identification of behaviors to include but not limited to sexual and physical behavior on 01/12/14. Residents with behaviors will be discussed weekly at the Behavior Management Meeting to ensure targeted behaviors are documented, care planned, and appropriate interventions are in place. The Nurse will document the behaviors on the 24 Hour Report to be shared during the morning meeting. 29. All facility staff were educated, on 01/12/14, 01/13/14, 01/14/14, 01/15/14, by the Corporate Administrative Registered Nurses, that revisions are made to the resident's care plan to include interventions for behaviors. The staff was instructed to follow the care plan for specific interventions for resident's interventions. Education was also provided on identification of accidents which can include behaviors, intervene, and report sexual and physical behavior to the resident's nurse for documentation in the medical record and follow up with the Physician. The nurse will also document in the 24 Hour Report to share information in the morning meeting. In addition all staff was educated on F520, the facility's policies for Behaviors, Incidents, Documentation, and Performance Improvement which included the QAPI process, Monitoring of Facility Care Services, Identification of Performance Improvement Opportunities, and the Role of the Performance Team. 30. All resident care plans were reviewed and/or updated by the Regional Case Mix Coordinator on 01/11/14 and 01/12/14 to ensure they were accurate as compared to the Minimum Data Set and physician's orders [REDACTED]. 31. The facility's Administrative staff (ED/Abuse Coordinator and DCS) have been educated by the Corporate Administrative Registered Nurse on 01/12/14 that abuse allegations which are reported to them by employees must be investigated and reported to the appropriate officials in accordance with Federal and State Regulation. 32. The QAPI Committee had an Ad-Hoc QAPI meeting on 01/10/14 to discuss IJ citations and on 01/15/14 to discuss performance improvement opportunities and to review the facility's Abuse policy. The attendees consisted of the Interim Director of Clinical Services, Dietary Manager, Business Office Manager, Director of Admissions, Medical Records, Central Supply, Regional Case Mix Coordinator, Regional Director of Human Resources, Regional Director of Business Services, Regional Director of Clinical Services, Corporate Administrative RN, Director of Rehabilitation Services, Clinical Ambassador, Corporate Director of Education, Regional Vice President of Operations, Vice President of Operations, Vice President of Clinical Services, Vice President of Admissions & Marketing, Corporate Operations Team Member and Executive Director via telephone. 33. The ED and DCS were re-educated by the Corporate Administrative Registered Nurse on 01/12/14, regarding the regulations for F520, the facility's policies for Behaviors, Incidents, Documentation, and Performance Improvement which included the QAPI process, Monitoring of Facility Care Services, Identification of Performance Improvement Opportunities, and the Role of the Performance Team. Through observation, interview, and record review the State Survey Agency (SSA) validated the AOC, on 01/21/14-01/22/14 prior to exit as follows: 1. Review of Resident #1's closed medical record and the facility's investigation revealed Resident #1 and SRNA #2 were immediately separated. 2. Review of the facility's investigation revealed the Police were notified of the incident on 12/31/13. 3. Review of the Resident #1 closed medical record revealed the resident was discharged from the facility and sent to the hospital for a psychiatric evaluation on 01/07/14. 4. Review of the facility's investigation revealed the SRNA was immediately suspended and removed from the facility on 12/31/13. 5. Interview with the Regional Director of Clinical Services (RDCS), on 01/22/14 at 1:08 PM, revealed the audits of resident clinical records which included review of nurse's notes back to 07/17/13 identified three (3) residents with behaviors requiring increased monitoring through 1:1. Review and observation confirmed 1:1 was occurring and documented. The RDCS revealed Resident #3 was identified as one of these residents. Review of the Psychiatric ARNP notes, dated 01/15/14, revealed Resident #3 was listed as one of the residents assessed. 6. Interview with the Vice President of Clinical Operations (VPCO), on 01/22/14 at 2:48 PM, revealed resident's identified with behaviors from the chart audits, on 01/07/14 through 01/08/14 and staff interviews on 01/11/12 through 01/12/14, had interventions put in place during the care plan review. Observation of Resident #3, on 01/21/14 at 4:12 PM, revealed 1:1 supervision was provided with a SRNA #8. 7. Review of the Behavior Meeting notes, on 01/12/14, revealed Resident #3 was listed with identified behaviors, medications, and interventions. 8. Review of Resident #3's Care plan revealed an intervention for 1:1 supervision on 01/13/14. 9. Review of the faxed communication with the SSA from the facility revealed the incident involving Resident #3 and #1, on 11/05/13 was reported on 01/08/14 and a 5 day report was submitted on 01/13/14. 10. Review of the Behavior Meeting notes, on 01/12/14, revealed Resident #2 was reviewed to include a medical record review and care plan review. Interview with the Corporate Administrative Registered Nurse (CARN), on 01/22/14 at 1:27 PM, revealed Resident #2 did not need increased monitoring was not exhibiting behaviors. 11. Review of the faxed communications to the SSA from the Facility revealed the incident on 07/17/13 with Resident #1 and #2 was reported on 01/08/14 and a 5 day follow up was submitted on 01/13/14. 12. Interview with Resident #2, on 01/22/14 at 2:03, revealed he/she did have a conversation with the DCS and SSD regarding the incident on 07/17/13 and 01/06/14. Resident #2 revealed being asked if he/she felt safe and what had occurred. 13. Interview with the Regional Director of Clinical Services (RDCS), on 01/22/14 at 1:08 PM, revealed the audits of resident clinical records which included review of nurse notes back to 07/17/13 identified three (3) residents (#3, #13, and #21) with behaviors requiring increased monitoring. A. Review of the Behavior Management Meeting notes, dated 01/12/14, revealed the three (3) identified were Residents #3, #13, and #21 were included in the meeting. B. Review of the three (3) identified resident's care plan (#3, #13, and #21) revealed interventions to increase supervision using 1:1 was added. C. Review of the Psychiatric ARNP notes, dated 01/15/14, revealed two (2) of the three (3) residents (Residents #13 and #21) had medications and behaviors reviewed. D. Review of the nursing notes and 24 hour report book, revealed the three (3) residents (#3, #13, and #21) were monitored daily with documented behaviors observed. 14. Interview on 01/21/14 with twelve (12) residents, identified as interviewable with a BIMS of 8 or greater, revealed they felt safe at the facility and had been interviewed by the SSD. 15. Review of the facility skin sweeps, dated 01/07/14, 01/08/14, and on 01/15/14, revealed the facility's 89 residents were assessed with [REDACTED]. 16. Interview with sixteen (16) facility staff, Certified Occupational Therapy Assistant (COTA) #1 on 01/20/14 at 2:30 PM; COTA #2 on 01/20/14 at 2:30 PM; LPN #7 on 01/21/14 at 3:25 PM; Maintenance Director on 01/21/14 at 3:30 PM; Dietary Cook on 01/21/14 at 3:35 PM; Dietary Aide on 01/21/14 at 3:37 PM; LPN #8 on 01/21/14 at 3:39 PM; SRNA #10 on 01/21/14 at 4:00 PM; SRNA #8 on 01/21/14 at 4:12 PM; Medical Records on 01/22/14 at 12:58 PM; Payroll/HR on 01/22/14 at 12:50 PM; Business Office Manager on 01/22/14 at 3:11 PM; LPN #5 on 01/22/14 at 1:01 PM; Housekeeper on 01/22/14 at 12:52 PM; SRNA #12 on 01/22/14 at 4:23 PM; and SRNA #11 on 01/22/14 at 4:05 PM, revealed they were asked to identify any residents who exhibited behaviors, abuse and/or neglect that had not been reported. Review of the Behavior Monitoring tool revealed staff was to document who identified a behavior, which resident, and the behavior identified. 17. Review of the faxed communication and facility investigations revealed the seven (7) identified incidents were reported to the SSA on 01/08/14. The expanded sample included five incidents involving Residents #9 and 10, #11 and 12, #13 and 14, #15 and 16, and #17 and 18. 18. Interview with the RDCS, on 01/22/14 at 1:08 PM, revealed the resident's concerns (grievances) were reviewed for potential allegations and none were identified. 19. Interview with RDCS and DCS, on 01/21/14 at 2:30 PM, revealed personnel files were audited on 01/12/14 for: two (2) reference checks, OIG report, Kentucky Board of Nursing Nurse Aide Abuse Registry, Criminal Record Checks, and abuse acknowledgment. RDCS and DCS revealed audits compared to current staff roster and the facility had no new hires for review. Review of two (2) SRNAs, the ED and Activities Assistant personnel files revealed they were accurate. 20. Review of the staff training signature sheets, dated 01/11/14 through 01/15/14, covering the following topics: Identification of Resident Behaviors, Behavior Management, Behavior Reporting, Abuse Education, Facility Policies and Procedures for Behaviors, Emotional and Behavioral Support, Management Problems of Resident with Dementia, Behavior Monitoring, Federal Regulations F223, F225, F226, Physical and Sexual behavior, reporting to Charge nurse and DCS/ED, and documentation contained 116 staff signatures. Interviews with sixteen (16) facility staff members, (See #16) on 01/21/14 and 01/22/14, verified abuse education was completed and followed by an abuse post-test. 21. Interview with the Human Resource/Payroll Coordinator, on 01/22/14 at 12:50 PM, revealed she was educated on required screening components for new hires. Components to include Criminal background checks, two (2) reference checks, OIG report, Kentucky Board of Nursing Nurse Aide Abuse Registry, and abuse acknowledgment. 22. Review of training signature sheets, dated 01/11/14 through 01/15/14, revealed both the ED and DCS signatures as attending the training. A separate training, dated 01/12/14, revealed just the ED and DCS were trained on the facility's Abuse and Neglect Policy and the procedures for reporting investigating. The facility's abuse policy contained new employee hire screening components. 23. Interview with the RDCS and the DCS, on 01/21/14 at 2:20 PM, revealed resident interviews regarding potential abuse issues, and mock surveys consisting of care plan review and implementation, behavior documentation, and staff interviews, were completed on all halls on 01/13/14, the F Hall on 01/14/14, E and F Halls on

Based on observation, interview, record review, and review of the facility's policies; Social Services, Resident Abuse, Resident Abuse-Resident to Resident, and Resident to Resident Related Concerns, it was determined the facility failed to have an effective system in place to ensure staff communicated the behaviors of the residents to Social Services through the 24 Hour Report, Behavior Sheets, Nurses' Notes, Incident Reports, and access to the Kiosk (State Registered Nursing Assistant (SRNA) computer documentation) to enable Social Services to assess and provide medically-related social services to meet the residents' highest practicable physical, mental and psychosocial well being; and, revise the care plans based on the behaviors of fourteen (14) of twenty-two (22) sampled residents. (Residents #1, #2, #3, #9, #10, #11, #13, #14, #15, #16, #17, #18, #19 and #22). (Refer to F280 and 323) The facility's failure to have an effective system in place to ensure Social Services received communication from all aspects of behavior monitoring to ensure medically-related social services was provided; and, failure to ensure revision of care plans for residents with a change in mental, physical or emotional status placed residents at risk in a situation that has caused or is likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy was identified on 01/10/14 and determined to exist on 07/17/13. The facility was notified of the Immediate Jeopardy on 01/10/14. An acceptable Allegation of Compliance (AOC) was received on 01/20/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 01/16/14 as alleged, prior to exit on 01/22/14. The scope and severity was lowered to an "E" while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy regarding Social Services, revised 09/01/11, revealed Social Services as a member of the Interdisciplinary Team, would participate in planning the overall care of the resident including completing periodic reviews of the assessment as necessary, but at least once quarterly and documenting progress in the Social Service Progress Notes and respond to changes in a resident's mental, physical, or emotional status. Review of the facility's policy regarding Resident Abuse-Resident to Resident, revised 01/01/09, revealed residents would be closely monitored and behavior documented. Per the policy, the facility must develop measures to prevent reoccurrence and document these measures in the resident's medical record to include revision of the plan of care. Review of the facility's policy regarding Behavior Monitoring, revised 01/03/13, revealed any resident who exhibited any of the following behaviors would have a "Behavior/Intervention Monthly Flow Record" initiated which required documentation every shift, as well as a synopsis on Weekly Nursing Progress Notes: violent behavior; endangering him/herself; sexual, verbal physical behavior toward other residents/others; sexual aggression, verbal physical abuse toward staff; indecent exposure; abusive yelling screaming; slapping/hitting/spitting/biting/kicking; aggression during walking or wheeling; any other behavior which posed a harm to other residents/others; frequent refusal of care and treatment. The type of behavior should be noted along with the time it was observed and attempted interventions. Outcomes and side effects observed should be documented. The form is maintained in the Medication Administration Record of the resident being observed. Any resident receiving psychoactive medications would have a Behavior/Intervention Monthly Flow Record. 1. Review of Resident #1's clinical record revealed the facility admitted the resident on 06/22/11. The Minimum Data Set (MDS), dated [DATE], revealed no behaviors had occurred during the look back period. The facility assessed the resident's behaviors using the MDS, dated [DATE], indicating no behaviors had occurred other than some rejection of care. However, the Nurses' Notes identified behaviors had occurred between these two (2) assessments. Review of the Behavior Chart Detail Report from 07/11/13 to 01/07/14, revealed only one (1) verbal incident. However, the Behavior/Intervention Monthly Flow Record (BOP) was completely blank in the Medication Administration Book for January 2014. Further review revealed no other BOP sheet in the resident's clinical record, except for September 2013 which was also blank. Review of the resident's Comprehensive Plan of Care, revised 11/25/13, revealed the resident displayed flirtatious behavior with male residents and aggressive behavior toward staff including hitting, grabbing, and throwing items. Further review of Resident #1's record revealed a Progress Note from Psychiatric Services, dated 07/13/13, stating the resident had verbally threatening behavior and reported no further aggression, but remained sexually intrusive and made inappropriate comments toward male caregivers. Review of a Nursing Note, written 07/17/13 at 10:25 PM, indicated Resident #1 was assessed with [REDACTED]. Resident #1 was observed in Resident #2's (BIMS score of 1) room with his/her hand under Resident #2's sheet. Resident #2 was telling Resident #1 to "stop". After Resident #1 continued to "play" with Resident #2, the resident got mad and threw a pack of cookies at Resident #1. Resident #1 then started to throw items at Resident #2. Resident #1 was removed from the room and began arguing with staff and refused to leave Resident #2's doorway for twenty (20) minutes while yelling and arguing with staff. (Refer to F223 and F226) Interview with the Social Service Director (SSD), on 01/07/14 at 9:00 AM, revealed she had been told about Resident #1's history of sexually inappropriate behavior, but she was not aware of any incidents since she started at the facility, on 02/18/13. During the interview with the SSD, she stated she had witnessed Resident #1 kiss Resident #2 in the hallway by the shower, on 01/06/14; however, she did not interview Resident #2 as to whether or not the kiss was mutual. The SSD revealed behaviors should be recorded in the 24 Hour Report Book to be discussed in the morning meetings with the Interdisciplinary Team. The SSD stated she was aware the resident had behaviors, but she was not aware of anything specific that had occurred. The SSD revealed she was responsible to assess resident behaviors and revise the care plan. Further interview revealed the lack of documentation indicated there was a lack in communication as well. Resident #1's care plan was not updated to reflect the above behaviors. 2. Review of Resident #2's clinical record revealed the facility admitted the resident, on 03/03/10, with [DIAGNOSES REDACTED]. The facility assessed the resident using the Minimum Data Set (MDS), dated [DATE]. Further review revealed the resident was assessed as having modified independence in cognition, but usually understood, having difficulty with speech and communicating some words or finishing thoughts, but was able if prompted or given time. Review of the Nurse's Notes and Social Service Notes revealed no entries regarding Resident #1's sexual behavior towards Resident #2, nor was the care plan revised to address unwanted sexual behavior from Resident #1. (Refer to F223, 226, 323 and 280) Interview with SSD, on 01/09/14 at 2:00 PM, revealed she did not interview anyone else except Resident #2, who said the kissing was ok and confirmed being touched in the groin, but no sexual relations had occurred. The SSD revealed she did not ask the resident how many times he/she had been touched or if it was consensual. The SSD revealed she was not doing an investigation on the incident and had not been instructed to do so. She stated she didn't have all the facts about the incidents. The SSD and the DCS revealed they were witnesses to the interview with Resident #2. Further interview revealed the SSD did not update either of the resident's care plans, or address these concerns with Resident #2. 3. Interview with the SSD, on 01/07/14 at 9:00 AM, revealed the following incident. On 11/05/13, the incident started with Resident #1 talking about Resident #3's pants sagging down. The SSD revealed Resident #3 fell and Resident #1 put his\her hands up to prevent Resident #3 from falling on Resident #1 and to protect him\her self. The SSD revealed Resident #1 yelled for someone to come help Resident #3. The SSD revealed she spoke with both residents and SRNA #3. The SSD revealed the incident was never reported to her and she found out about it by overhearing conversations from staff. The SSD revealed it was not investigated, but looked into as a behavioral incident through interview with both residents. However, the resident's care plans were not updated Further interview, on 01/09/14 at 2:00 PM, revealed she did not know what happened to the statements written by the supervisor or the SRNA. She stated she did not know they ever existed. The SSD revealed the previous ED #2 told her SRNA #3 was actually in the courtyard by the Therapy Department and was not even in the same courtyard as the residents. The SSD revealed she was aware of the x-ray results, but was told by the previous DCS that subluxation and dislocation were the same thing and they knew she had subluxation of that shoulder. However, earlier interview with the SSD revealed she did in fact talk with SRNA #3. The SSD revealed she did interview Residents #1 and #3, but they stated it was just yelling and denied hitting each other. Further interview with the SSD revealed she did attend the morning meetings where falls and/or incidents were discussed. The SSD revealed Resident #1 had been discussed regarding refusal of care and cussing. The SSD stated the other behaviors she had never been informed of and had not seen any documentation in the charts. The SSD stated she did not have access to the Kiosk to view the behavior charting, even though she was responsible for the assessment of behaviors for the MDS, for tracking and trending behaviors in the Psychiatric Behavior Meeting; and, was responsible for creating the behavior care plans. However, the MDS Director had been creating the behavior care plans when the SSD was overwhelmed. Review of Resident #3's clinical record revealed no information recorded for the incident with Resident #1. Interview with the SSD, on 01/09/14 at 4:24 PM, revealed the incident on 11/05/13 between Resident #1 and #3 should have been investigated and a new behavior plan started. Interview with the current DCS, on 01/09/14, at 3:12 PM, revealed she was not able to find any evidence of an investigation regarding the incident with Residents #1 and #3 on 11/05/13 or that it was ever reported. Interview with the SSD, on 01/14/14 at 10:32 AM, revealed she actually knew the incident on 11/05/13 was a physical altercation and she talked with both residents and documented the conversation in the resident's records as a verbal argument. She stated the Regional DCS was aware of the incident from 11/05/13, because the previous ED #2 called the Regional DCS for advice on that incident involving Residents #1 and #3. (Refer to F223, 226, 280 and 323) 4. Interview with the SSD, on 01/14/14 at 10:32 AM, revealed she was notified of a verbal argument between Resident #19 and the Activities Director by the ARNP on 12/30/13. The SSD stated the ARNP walked to her office and told her someone needed to remove the Activities Director. The SSD revealed the Interim ED completed the investigation, and she had witnesses write statements and turned them in to the ED. However, she did not revise the care plan to address the verbal altercation. Interview with the SSD, on 01/16/14 at 4:33 PM, revealed the Advanced Registered Nurse Practitioner (ARNP) came to her office to inform her of what was going on with the Activities Director (AD), and then she received a phone call from MDS Director #1. The SSD stated she took the information as an allegation of verbal abuse and talked with the AD who said she let her temper get the best of her. The SSD stated she reported the incident to the DCS and ED. The SSD revealed the ED agreed to take over the investigation so she could handle another situation. (Refer to F223, 226, 280 and 323) 5. The facility reported to OIG five (5) incidents that were found during an audit on 01/08/14 of current clinical records involving ten (10) residents. Record review revealed the SSD did not revise the care plans for Residents #9 and #10, Resident #15 and #16, Resident #13 and #14, Resident #11, Resident #17 and 18, after verbal, physical and sexual abuse occurred. (Refer to F226, 280 and F323.) 6. Review of Resident #22's clinical record revealed the resident displayed verbally and physically aggressive behavior, verbal abuse, symptoms of psychosis, and hallucinations/delusions. The resident physically injured a staff member on 01/11/14. Further review of the clinical record revealed the care plan had not been updated since 11/04/13. Further interview with the SSD on 01/09/14 at 2:00 PM revealed she did attend the morning meetings where incidents were discussed. However, the SSD stated she did not have access to the Kiosk to view the behavior charting, even though she was responsible for the assessment of behaviors for the MDS, for tracking and trending behaviors in the Psychiatric Behavior Meeting; and, responsible for creating the behavior care plans. However, the MDS Director had been creating the behavior care plans when the SSD was overwhelmed. The facility provided an Allegation of Compliance (AOC) on 01/20/14 alleging the Immediate Jeopardy (IJ) was removed on 01/16/14; the facility took the following immediate steps to remove the IJ: 1. Resident #1 and SRNA #2 were immediately separated on 12/31/13 by staff. 2. The police were notified of the incident on 12/31/13. 3. Resident #1 was discharged to the hospital for a psychiatric evaluation on 01/07/14. 4. SRNA #2 was suspended immediately on 12/31/13. 5. Resident #3 was referred by the DCS, and seen by the Psychiatric ARNP, on 01/15/14. 6. Resident #3 was placed on increased supervision, 1:1 observation, to redirect impulse behaviors on 01/12/14. 7. Resident #3 was reviewed by the Interdisciplinary Team (IDT) (consisting of the Corporate Administrative Nurse, DCS, Activity Director, and Regional Director of Clinical Services) in the Behavior Management Meeting, on 01/12/14, which included a medical record review. 8. Resident #3's care plan was updated by the Corporate Administrative Registered Nurse on 01/13/14. 9. The incident involving Resident #3, on 11/05/13, was reported to the State Survey Agency (SSA), on 01/08/14 via a 24 Hour Report, investigated and a 5 Day report was submitted to the SSA on 01/13/14. 10. Resident #2 was reviewed in the Behavior Management Meeting by the IDT Corporate Administrative Registered Nurse, DCS, Activity Director, and the Regional Director of Clinical Services on 01/12/14 which included a medical record review and a care plan review. 11. The incident on 07/17/13 involving Resident #2 was reported to the SSA on 01/08/14 via a 24 hour report. A 5 day Report was submitted to the SSA on 01/13/14. 12. Resident #2 was interviewed on 01/07/14 by the SSD and the DCS regarding the incident on 07/17/13 and 01/06/14. 13. Current resident chart reviews completed , on 01/07/14 and 01/08/14 by the DCS, ADCS, Unit Manager and RDCS and staff interviews on 01/11/14 and 01/12/14 by Corporate Administrative Registered Nurses to identify residents with behaviors, the facility identified three (3) residents (#3, #13, and #21) as exhibiting sexual or physical behaviors towards others. These three residents were: A. Reviewed in the Behavior Management Meeting by the IDT (Corporate Administrative Registered Nurse, Director of Clinical Services Activity Director, and the Regional Director of Clinical Services) on 01/12/14. B. Increased supervision was initiated on 01/12/14 and the care plans were revised by the Activity Director the Corporate Administrative Registered Nurse and the DCS on 01/13/14. C. Referred to the Psychiatrist for review by the DCS and two ( #13 and #21) of three residents were seen on 01/15/14. D. Had documentation of behavior reviewed daily since 01/13/14 by a member of the IDT (to include the DCS, ED, and the Corporate Administrative Registered Nurses). 14. Thirty-nine (39) residents, with a brief interview for mental status (BIMS) of an eight or above were interviewed by the Social Services on 01/07/14 to ensure they had not been abused or neglected. 15. All residents were assessed by nurses via skin sweeps for suspicious injuries on 01/07/14, 01/08/14, and on 01/15/14 with no injuries found. 16. All Department Heads along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116) were interviewed by the Corporate Administrative Registered Nurse on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 to ensure no one had witnessed any abuse or neglect that had not been previously reported. 17. Current resident charts were reviewed on 01/07 and 01/08/14 by the Director of Clinical Services, Assistant Director of Clinical Services, Staff Educator, Unit Manager, and the Regional Director of Clinical Services to determine if there were any incidents that were reportable and/or needed further investigation. The seven (7) incidents that were identified during the review were reported on 01/08/14. 18. The facility's concern book was reviewed by the Regional Director of Clinical Services on 01/11/14 for allegations that needed to be reported and no allegations were identified. 19. The current staff members' employee personnel files were reviewed by Regional Director of Human Resources and Facility Human Resources/Payroll Coordinator to ensure that the files were completed with the Criminal Background Check, Kentucky State Board of Nursing/Nurse Aide Abuse Registry check, Office of the Inspector General Check, Telephone Reference Checks and Abuse/Neglect Attestation on 01/11/14 and 01/12/14. The six (6) discrepancies identified were corrected with missing Criminal Background Checks and Reference checks by 01/12/14. 20. All current Department Head staff along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116 employees) were educated by the Corporate Administrative Registered Nurses on abuse screening, training, prevention, identification, investigation, protection, reporting and response, F223 and the facility's Policy and Procedure for Resident Abuse, on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 and completed a post test. No staff members worked beyond 01/12/14 without having already been educated prior to the start of their shift. 21. The Human Resource/Payroll Coordinator was reeducated by the Regional Director of Human Resources on 01/12/14 that newly hired employees must have a Criminal Background Check, Kentucky Board of Nursing/Nurse Aide Abuse Registry Screen, Office of the Inspector General Exclusion Check, and Telephone reference checks. 22. The ED and DCS were re-educated by the Vice President of Clinical Services on 01/11/14 and 01/12/14 to ensure newly hired employees must have a Criminal Background Check, Kentucky Board of Nursing/Nurse Aide Abuse Registry Screen, Office of the Inspector General Exclusion Check, and Telephone reference checks. The ED will validate and sign that Newly Hired Employees have had all the required checks. 23. Mock Survey Rounds consisting of care plan review and implementation, behavior documentation, and staff interviews were completed by the IDT on 01/13/14, 01/14/14, and 01/15/14 that included resident interviews regarding potential abuse issues. 24. A Behavior Meeting was conducted by the IDT on 01/12/14 to review the current residents with known behaviors to discuss the behaviors, interventions, and medication. The nine (9) residents identified as having some type of behavior were referred to the physician and interventions were updated on the care plans by the IDT on 01/15/14. 25. Social Service notes were reviewed and Care Plans updated by the Corporate Social Services on 01/15/14. 26. The Social Service Director (SSD) was re-educated by the Corporate Administrative Registered Nurse on F250 and the facility's Policy and Procedures for Abuse and Behaviors on 01/12/14. 27. The Social Service Department consisting of the Corporate Social Services, Corporate Administrative Registered Nurse had daily oversight on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 with review of resident and family concerns daily in the morning meeting to ensure department managers were working towards resolution. 28. All facility staff was educated by the Corporate Administrative Registered Nurse on identification of behaviors to include but not limited to sexual and physical behavior on 01/12/14. Residents with behaviors will be discussed weekly at the Behavior Management Meeting to ensure targeted behaviors are documented, care planned, and appropriate interventions are in place. The Nurse will document the behaviors on the 24 hour report to be shared during the morning meeting. 29. All facility staff were educated, on 01/12/14, 01/13/14, 01/14/14, 01/15/14, by the Corporate Administrative Registered Nurses, that revisions are made to the resident's care plan to include interventions for behaviors. The staff was instructed to follow the care plan for specific interventions for resident's interventions. Education was also provided on identification of accidents which can include behaviors, intervene, and report sexual and physical behavior to the resident's nurse for documentation in the medical record and follow up with the Physician. The nurse will also document in the 24 hour report to share information in the morning meeting. In addition all staff was educated on F520, the facility's policies for Behaviors, Incidents, Documentation, and Performance Improvement which included the QAPI process, Monitoring of Facility Care Services, Identification of Performance Improvement Opportunities, and the Role of the Performance Team. 30. All resident care plans were reviewed and/or updated by the Regional Case Mix Coordinator on 01/11/14 and 01/12/14 to ensure they were accurate as compared to the Minimum Data Set and physician's orders [REDACTED]. 31. The facility's Administrative staff (ED/Abuse Coordinator and DCS) have been educated by the Corporate Administrative Registered Nurse on 01/12/14 that abuse allegations which are reported to them by employees must be investigated and reported to the appropriate officials in accordance with Federal and State Regulation. 32. The QAPI Committee had an Ad-Hoc QAPI meeting on 01/10/14 to discuss IJ citations and on 01/15/14 to discuss performance improvement opportunities and to review the facility's Abuse policy. The attendees consisted of the Interim Director of Clinical Services, Dietary Manager, Business Office Manager, Director of Admissions, Medical Records, Central Supply, Regional Case Mix Coordinator, Regional Director of Human Resources, Regional Director of Business Services, Regional Director of Clinical Services, Corporate Administrative RN, Director of Rehabilitation Services, Clinical Ambassador, Corporate Director of Education, Regional Vice President of Operations, Vice President of Operations, Vice President of Clinical Services, Vice President of Admissions & Marketing, Corporate Operations Team Member and Executive Director via telephone. 33. The ED and DCS were re-educated by the Corporate Administrative Registered Nurse on 01/12/14, regarding the regulations for F520, the facility's policies for Behaviors, Incidents, Documentation, and Performance Improvement which included the QAPI process, Monitoring of Facility Care Services, Identification of Performance Improvement Opportunities, and the Role of the Performance Team. Through observation, interview, and record review the State Survey Agency (SSA) validated the AOC, on 01/21/14-01/22/14 prior to exit as follows: 1. Review of Resident #1's closed medical record and the facility's investigation revealed Resident #1 and SRNA #2 were immediately separated. 2. Review of the facility's investigation revealed the Police were notified of the incident on 12/31/13. 3. Review of the Resident #1 closed medical record revealed the resident was discharged from the facility and sent to the hospital for a psychiatric evaluation on 01/07/14. 4. Review of the facility's investigation revealed the SRNA was immediately suspended and removed from the facility on 12/31/13. 5. Interview with the Regional Director of Clinical Services (RDCS), on 01/22/14 at 1:08 PM, revealed the audits of resident clinical records which included review of nurse's notes back to 07/17/13 identified three (3) residents with behaviors requiring increased monitoring through 1:1. Review and observation confirmed 1:1 was occurring and documented The RDCS revealed Resident #3 was identified as one of these residents. Review of the Psychiatric ARNP notes, dated 01/15/14, revealed Resident #3 was listed as one of the residents assessed. 6. Interview with the Vice President of Clinical Operations (VPCO), on 01/22/14 at 2:48 PM, revealed resident's identified with behaviors from the chart audits, on 01/07/14 through 01/08/14 and staff interviews on 01/11/12 through 01/12/14, had interventions put in place during the care plan review. Observation of Resident #3, on 01/21/14 at 4:12 PM, revealed 1:1 supervision was provided with a SRNA #8. 7. Review of the Behavior Meeting notes, on 01/12/14, revealed Resident #3 was listed with identified behaviors, medications, and interventions. 8. Review of Resident #3's Care plan revealed an intervention for 1:1 supervision on 01/13/14. 9. Review of the faxed communication with the SSA from the facility revealed the incident involving Resident #3 and #1, on 11/05/13 was reported on 01/08/14 and a 5 day report was submitted on 01/13/14. 10. Review of the Behavior Meeting notes, on 01/12/14, revealed Resident #2 was reviewed to include a medical record review and care plan review. Interview with the Corporate Administrative Registered Nurse (CARN), on 01/22/14 at 1:27 PM, revealed Resident #2 did not need increased monitoring was not exhibiting behaviors. 11. Review of the faxed communications to the SSA from the Facility revealed the incident on 07/17/13 with Resident #1 and #2 was reported on 01/08/14 and a 5 day follow up was submitted on 01/13/14. 12. Interview with Resident #2, on 01/22/14 at 2:03, revealed he/she did have a conversation with the DCS and SSD regarding the incident on 07/17/13 and 01/06/14. Resident #2 revealed being asked if he/she felt safe and what had occurred. 13. Interview with the Regional Director of Clinical Services (RDCS), on 01/22/14 at 1:08 PM, revealed the audits of resident clinical records which included review of nurse notes back to 07/17/13 identified three (3) residents (#3, #13, and #21) with behaviors requiring increased monitoring. A. Review of the Behavior Management Meeting notes, dated 01/12/14, revealed the three (3) identified were Residents #3, #13, and #21 were included in the meeting. B. Review of the three (3) identified resident's care plan (#3, #13, and #21) revealed interventions to increase supervision using 1:1 was added. C. Review of the Psychiatric ARNP notes, dated 01/15/14, revealed two (2) of the three (3) residents (Residents #13 and #21) had medications and behaviors reviewed. D. Review of the nursing notes and 24 hour report book, revealed the three (3) residents (#3, #13, and #21) were monitored daily with documented behaviors observed. 14. Interview on 01/21/14 with twelve (12) residents, identified as interviewable with a BIMS of 8 or greater, revealed they felt safe at the facility and had been interviewed by the SSD. 15. Review of the facility skin sweeps, dated 01/07/14, 01/08/14, and on 01/15/14, revealed the facility's 89 residents were assessed with [REDACTED]. 16. Interview with sixteen (16) facility staff, Certified Occupational Therapy Assistant (COTA) #1 on 01/20/14 at 2:30 PM; COTA #2 on 01/20/14 at 2:30 PM; LPN #7 on 01/21/14 at 3:25 PM; Maintenance Director on 01/21/14 at 3:30 PM; Dietary Cook on 01/21/14 at 3:35 PM; Dietary Aide on 01/21/14 at 3:37 PM; LPN #8 on 01/21/14 at 3:39 PM; SRNA #10 on 01/21/14 at 4:00 PM; SRNA #8 on 01/21/14 at 4:12 PM; Medical Records on 01/22/14 at 12:58 PM; Payroll/HR on 01/22/14 at 12:50 PM; Business Office Manager on 01/22/14 at 3:11 PM; LPN #5 on 01/22/14 at 1:01 PM; Housekeeper on 01/22/14 at 12:52 PM; SRNA #12 on 01/22/14 at 4:23 PM; and SRNA #11 on 01/22/14 at 4:05 PM, revealed they were asked to identify any residents who exhibited behaviors, abuse and/or neglect that had not been reported. Review of the Behavior Monitoring tool revealed staff was to document who identified a behavior, which resident, and the behavior identified. 17. Review of the faxed communication and facility investigations revealed the seven (7) identified incidents were reported to the SSA on 01/08/14. The expanded sample included five incidents involving Residents #9 and 10, #11 and 12, #13 and 14, #15 and 16, and #17 and 18. 18. Interview with the RDCS, on 01/22/14 at 1:08 PM, revealed the resident's concerns (grievances) were reviewed for potential allegations and none were identified. 19. Interview with RDCS and DCS, on 01/21/14 at 2:30 PM, revealed personnel files were audited on 01/12/14 for: two (2) reference checks, OIG report, Kentucky Board of Nursing Nurse Aide Abuse Registry, Criminal Record Checks, and abuse acknowledgment. RDCS and DCS revealed audits compared to current staff roster and the facility had no new hires for review. Review of two (2) SRNAs, the ED and Activities Assistant personnel files revealed they were accurate. 20. Review of the staff training signature sheets, dated 01/11/14 through 01/15/14, covering the following topics: Identification of Resident Behaviors, Behavior Management, Behavior Reporting, Abuse Education, Facility Policies and Procedures for Behaviors, Emotional and Behavioral Support, Management Problems of Resident with Dementia, Behavior Monitoring, Federal Regulations F223, F225, F226, Physical and Sexual behavior, reporting to Charge nurse and DCS/ED, and documentation contained 116 staff signatures. Interviews with sixteen (16) facility staff members, (See #16) on 01/21/14 and 01/22/14, verified abuse education was completed and followed by an abuse post-test. 21. Interview with the Human Resource/Payroll Coordinator, on 01/22/14 at 12:50 PM, revealed she was educated on required screening components for new hires. Components to include Criminal background checks, two (2) reference checks, OIG report, Kentucky Board of Nursing Nurse Aide Abuse Registry, and abuse acknowledgment. 22. Review of training signature sheets, dated 01/11/14 through 01/15/14, revealed both the ED and DCS signatures as attending the training. A separate training, dated 01/12/14, revealed just the ED and DCS were trained on the facility's Abuse and Neglect Policy and the procedures for reporting investigating. The facility's abuse policy contained new employee hire screening components. 23. Interview with the RDCS and the DCS, on 01/21/14 at 2:20 PM, revealed resident interviews regarding potential abuse issues, and mock surveys consisting of care plan review and implementation, behavior documentation, and staff interviews, were completed on all halls on 01/13/14, the F hall on 01/14/14, E and F halls on 01/15/13. Mock surveys continued on 01/16/14 for A, C, E, and F halls, 01/17/14 for E, A, B, F halls, and A hall was done again on 01/18/14. 24. Review of the Behavior Management Meeting, dated 01/12/14, revealed twenty-four (24) residents were reviewed. Review of the psychiatric ARNP notes, dated 01/15/14, revealed nine (9) residents were reviewed which included review of medications. 25. Review of the chart audits, dated 01/15/14, revealed care plans were updated according to concerns noted in SSD notes. Review of 24 resident care plans revealed they had been updated. 26. Review of the facil

Based on observation, interview, record review, review of the facility's 08/01/13 Plan of Correction (POC), review of the facility's investigation reports, facility's policies, Performance Improvement Morning Meetings, Comprehensive 24 Hour Report, Performance Improvement Committee, and Clinical Performance Improvement, it was determined the facility's Quality Assurance Committee failed to operationalize their policies regarding the function and attendance of the committee and failed to monitor the 08/01/13 Plan of Correction to ensure continued compliance. The facility failed to identify quality deficiencies, develop a plan of action, and implement the plan of action to keep residents free from abuse, and identify and address behaviors for fifteen (15) of the twenty-two (22) sampled residents (Resident #1, #2, #3, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #22). (Refer to F223, F225, F226, F250, F280, F282, F323, F490, F493, and F514) The facility's failure to have an effective system in place to ensure the Quality Assurance Program/Committee functioned according to their policy and identified quality deficiencies, develop plans of action, and implement the plans of action placed residents in a situation that has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy (IJ) was identified, on 01/10/14 and determined to exist on 07/17/13. The facility was notified of the Immediate Jeopardy on 01/10/14. An acceptable Allegation of Compliance (AOC) was received, 01/20/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 01/16/14, as alleged, prior to exit on 01/22/14. The scope and severity was lowered to a "E" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes and the plan of correction. The findings include: 1. Review of the facility's policy regarding Performance Improvement Morning Meeting, Revised 09/01/11, revealed the morning meeting would be conducted to provide effective communications to all staff on resident care. The morning meeting consisted of the nursing 24 Hour Report from each Clinical Nurse, report from the mock survey member, reports for previous 24 hours, quality of care status to include decubitus, weights, restraints, resident and/or change in condition or care planning. Review of the facility's policy regarding Comprehensive 24 Hour Report, revised on 09/12/13, revealed clinical services would have a written method for monitoring and communicating clinical information, unusual occurrence information, and administrative matters on a twenty-four (24) hour basis. Examples of additional issues which may be addressed on the report are as follows, but should not be considered all inclusive: residents whose condition required extra attention and supervision; unusual occurrences, resident or facility related; all incidents and accidents; family concerns which have been made know; physician visits and concerns or issues; abnormal labs and x-ray values; IV's; antibiotics; and development of skin issues. The completed reports would be maintained for no more then 30 days in the nursing office for review and use for morning meetings. Review of the facility's policy regarding Performance Improvement Committee, revised on 09/01/11, revealed the Performance Improvement Committee would meet monthly to review, recommend and act upon activities of the facility, performance action teams and/or departmental activities. The committee would direct all activities including approving proposed monitoring, evaluating and review of services. The committee would assure activities had written indicators and standards/thresholds for evaluation, that appropriate actions are implemented, and that such corrections had been evaluated by subsequent monitoring. The committee would assign interdisciplinary performance action teams activities and monitor the teams progress. A Performance Action Team would be developed to collect and evaluate data and to plan and implement needed action under the direction of the Performance Improvement Committee. The Committee would review the results of all evaluating and monitoring activities and make appropriate recommendations. Interview with the DCS, on 01/07/14 at 10:50 AM, revealed all resident behaviors should be documented in social service notes and nursing notes so a behavioral investigation could be completed. The DCS revealed behaviors could also be documented in the Care Tracker system. Further interview with the DCS, on 01/17/14 at 3:58 PM, revealed any time there was an allegation, an initial report needed to be filed. The DCS revealed an allegation was anything that someone stated happened. The DCS revealed all incident reports were discussed in the morning QA meeting, which included the Social Service Director (SSD), which was how the SSD became aware of any issues. The 24 Hour Reports and morning minutes are used as well. However, the DCS revealed she was not sure if the facility still had the 24 Hour Reports or the morning minutes. The DCS revealed the SSD documented all behaviors in a binder, which was what the SSD used in the behavior meetings with the Psychiatrist. The DCS retrieved the behavior binder, and review of the binder revealed a list of residents on [MEDICAL CONDITION] medication; however, no behaviors were documented. Interview with DCS on the behavior binder, on 01/17/14 at 5:15 PM, revealed behaviors were not being monitored and tracked. The DCS revealed she was not monitoring to ensure documentation of behaviors were being completed. All the data gathered through the incident reports, 24 Hour Reports and the behavior binder were to be taken to QA by the appropriate staff. However, this data was inconsistent or non-existent and tracking and trending was not completed. Interview with the ED, on 01/09/14 at 12:29 PM, revealed the morning QA meeting consisted of two (2) parts, the clinical portion and the operations portion. The ED revealed the 24 Hour Report was usually discussed in the clinical portion of the meeting and he did not normally attend that portion of the meeting unless he happened to be available, then he would go over the mock survey rounds, staffing, incidents and [MEDICATION NAME]. 2. Based on the findings of the abbreviated survey, the facility failed to maintain substantial compliance based on repeat deficiencies at 42 CFR 482.12 Admission, Transfer, Discharge (F203), 42 CFR 482.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F514 and F520). Review of the 08/01/13 Health Survey Plan of Correction revealed the facility would (F203) QI monitor monthly all residents prior to issuing discharge notices to ensure documentation and guidelines are followed according to regulation and policy for development of action plans to ensure written notice of discharges include a valid reason for transfer/discharge from the facility. The facility would monitor (F280) any omissions or revision to the care plans would be addressed at time of daily operations audit and reviewed in QI monthly. The facility would (F323) monitor care plans and Kardexs in the daily operations meeting the next business day following an incident. Any variances will result in correction of the care plan and Kardex. The facility would (F514) QI monitor physician orders [REDACTED]. The facility would (F520) hold a monthly QI meeting to discuss deficient practice, develop and implement action plans. QI monitoring for effectiveness, and then discuss QI monthly findings at the next QI monthly meeting, action plan revision would be developed at this time if applicable. The ED would conduct discussions of the status of the plan of correction to ensure continued compliance. Interview with the DCS, on 01/09/13 at 11:07 AM, revealed she was not aware of what the previous deficiencies were or what was written as the facility's POC. The DCS revealed she had not even looked for the survey book, but did request for someone to find it for her. Observation of the facility's front desk, on 01/09/14 at 11:51 AM, revealed the facility's survey binder was on the desk with the most recent survey results in place. Interview with the Interim Executive Director (ED), on 01/09/14 at 12:29 PM, revealed he did look through the facility's POC and noted an audit in the compliance book, but did not use this tool as he preferred to use his own worksheet for the AM meetings. However, interview with the ED, on 01/15/14 at 9:22 AM, revealed the ED's worksheet was his own and not the facility's and he would have to get permission before he could share the information with the surveyors. No worksheets were ever provided as evidence of audit in the morning QA meetings. Interview with the ED, on 01/09/14 at 5:17 PM, revealed the morning QA meeting minutes and the 24 Hour Reports were only kept for two (2) weeks and stated he did not know how that information made it to the quarterly QA meetings since the information was being purged. Continued interview with the ED, on 01/16/14 at 3:11 PM, revealed the facility continued to purge these notes although the state surveyors requested evidence of the forms. Interview with the Vice President of Clinical Operations, on 01/14/14 at 5:20 PM, revealed the facility was unable to attest that the Plan of Correction was completed. The Vice President of Clinical Operations revealed they were unable to find any evidence to verify any of the reviews, audits, or meetings were done as directed in the POC. Interview with the the Regional Vice President of Operations(RVPO), on 01/19/14 at 12:32 PM, revealed he did not do any follow up related to the POC from the previous survey cited with multiple tags at a S/S of a "G". The RVPO revealed he did not follow up from any QA meetings and the facility was not required to send anything regarding QA to him. 3. Review of the facility's policy regarding Performance Improvement-Clinical, revised 09/01/11, revealed the Executive Director would hold the position of chairperson of the QA Committee. The Committee may consist of the Medical Director, Executive Director, Director of Clinical Services, and three (3) other staff persons. Review of the Quality Assurance Meeting signature sheets provided by the facility revealed Quality Assurance meetings were held on the following dates: 08/09/13; 08/16/13; 08/23/13; 09/17/13; 09/27/13; 10/04/13; 10/18/13; and 10/25/13. Further review revealed neither the Medical Director nor any other physician had signed for attendance at any of the meetings listed above. In addition, there was no signature for the DCS to indicate attendance on 08/16/13 or 10/18/13. There was no signature of attendance by the Executive Director on 09/17/13, 10/18/13 or 10/25/13. Interview with the facility's previous Medical Director, on 01/22/14 at 11:06 AM, revealed he was the Medical Director from 11/26/13 to 01/11/14. The previous Medical Director revealed he had never attended a QA meeting, and had never been invited or notified when they were to occur. The previous Medical Director revealed he found out the facility had been notified of the Immediate Jeopardy, on 01/11/14, by the Psychiatrist. The previous Medical Director revealed he had to ask the Vice President of Operations what had caused the IJ status and was told it was no big deal and it concerned some residents from back in July and November. The previous Medical Director revealed he submitted his resignation that day, 01/22/14. The facility provided an Allegation of Compliance (AOC) on 01/20/14 alleging the Immediate Jeopardy (IJ) was removed on 01/16/14; the facility took the following immediate steps to remove the IJ: 1. Resident #1 and SRNA #2 were immediately separated on 12/31/13 by staff. 2. The police were notified of the incident on 12/31/13. 3. Resident #1 was discharged to the hospital for a psychiatric evaluation on 01/07/14. 4. SRNA #2 was suspended immediately on 12/31/13. 5. Resident #3 was referred by the DCS, and seen by the Psychiatric ARNP, on 01/15/14. 6. Resident #3 was placed on increased supervision, 1:1 observation, to redirect impulse behaviors on 01/12/14. 7. Resident #3 was reviewed by the Interdisciplinary Team (IDT) (consisting of the Corporate Administrative Nurse, DCS, Activity Director, and Regional Director of Clinical Services) in the Behavior Management Meeting, on 01/12/14, which included a medical record review. 8. Resident #3's care plan was updated by the Corporate Administrative Registered Nurse on 01/13/14. 9. The incident involving Resident #3, on 11/05/13, was reported to the State Survey Agency (SSA), on 01/08/14 via a 24 Hour Report, investigated and a 5 Day report was submitted to the SSA on 01/13/14. 10. Resident #2 was reviewed in the Behavior Management Meeting by the IDT Corporate Administrative Registered Nurse, DCS, Activity Director, and the Regional Director of Clinical Services on 01/12/14 which included a medical record review and a care plan review. 11. The incident on 07/17/13 involving Resident #2 was reported to the SSA on 01/08/14 via a 24 Hour Report. A 5 day Report was submitted to the SSA on 01/13/14. 12. Resident #2 was interviewed on 01/07/14 by the SSD and the DCS regarding the incident on 07/17/13 and 01/06/14. 13. Current resident chart reviews completed , on 01/07/14 and 01/08/14 by the DCS, ADCS, Unit Manager and RDCS and staff interviews on 01/11/14 and 01/12/14 by Corporate Administrative Registered Nurses to identify residents with behaviors, the facility identified three (3) residents (#3, #13, and #21) as exhibiting sexual or physical behaviors towards others. These three residents were: A. Reviewed in the Behavior Management Meeting by the IDT (Corporate Administrative Registered Nurse, Director of Clinical Services Activity Director, and the Regional Director of Clinical Services) on 01/12/14. B. Increased supervision was initiated on 01/12/14 and the care plans were revised by the Activity Director the Corporate Administrative Registered Nurse and the DCS on 01/13/14. C. Referred to the Psychiatrist for review by the DCS and two (#13 and #21) of three residents were seen on 01/15/14. D. Had documentation of behavior reviewed daily since 01/13/14 by a member of the IDT (to include the DCS, ED, and the Corporate Administrative Registered Nurses). 14. Thirty-nine (39) residents, with a brief interview for mental status (BIMS) of an 8 or above were interviewed by the Social Services on 01/07/14 to ensure they had not been abused or neglected. 15. All residents were assessed by nurses via skin sweeps for suspicious injuries on 01/07/14, 01/08/14, and on 01/15/14 with no injuries found. 16. All Department Heads along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116) were interviewed by the Corporate Administrative Registered Nurse on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 to ensure no one had witnessed any abuse or neglect that had not been previously reported. 17. Current resident charts were reviewed on 01/07 and 01/08/14 by the Director of Clinical Services, Assistant Director of Clinical Services, Staff Educator, Unit Manager, and the Regional Director of Clinical Services to determine if there were any incidents that were reportable and/or needed further investigation. The seven (7) incidents that were identified during the review were reported on 01/08/14. 18. The facility's concern book was reviewed by the Regional Director of Clinical Services on 01/11/14 for allegations that needed to be reported and no allegations were identified. 19. The current staff members' employee personnel files were reviewed by Regional Director of Human Resources and Facility Human Resources/Payroll Coordinator to ensure that the files were completed with the Criminal Background Check, Kentucky State Board of Nursing/Nurse Aide Abuse Registry check, Office of the Inspector General Check, Telephone Reference Checks and Abuse/Neglect Attestation on 01/11/14 and 01/12/14. The six (6) discrepancies identified were corrected with missing Criminal Background Checks and Reference checks by 01/12/14. 20. All current Department Head staff along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116 employees) were educated by the Corporate Administrative Registered Nurses on abuse screening, training, prevention, identification, investigation, protection, reporting and response, F223 and the facility's Policy and Procedure for Resident Abuse, on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 and completed a post test. No staff members worked beyond 01/12/14 without having already been educated prior to the start of their shift. 21. The Human Resource/Payroll Coordinator was reeducated by the Regional Director of Human Resources on 01/12/14 that newly hired employees must have a Criminal Background Check, Kentucky Board of Nursing/Nurse Aide Abuse Registry Screen, Office of the Inspector General Exclusion Check, and Telephone reference checks. 22. The ED and DCS were re-educated by the Vice President of Clinical Services on 01/11/14 and 01/12/14 to ensure newly hired employees must have a Criminal Background Check, Kentucky Board of Nursing/Nurse Aide Abuse Registry Screen, Office of the Inspector General Exclusion Check, and Telephone reference checks. The ED will validate and sign that Newly Hired Employees have had all the required checks. 23. Mock Survey Rounds consisting of care plan review and implementation, behavior documentation, and staff interviews were completed by the IDT on 01/13/14, 01/14/14, and 01/15/14 that included resident interviews regarding potential abuse issues. 24. A Behavior Meeting was conducted by the IDT on 01/12/14 to review the current residents with known behaviors to discuss the behaviors, interventions, and medication. The nine (9) residents identified as having some type of behavior were referred to the physician and interventions were updated on the care plans by the IDT on 01/15/14. 25. Social Service notes were reviewed and Care Plans updated by the Corporate Social Services on 01/15/14. 26. The Social Service Director (SSD) was re-educated by the Corporate Administrative Registered Nurse on F250 and the facility's Policy and Procedures for Abuse and Behaviors on 01/12/14. 27. The Social Service Department consisting of the Corporate Social Services, Corporate Administrative Registered Nurse had daily oversight on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 with review of resident and family concerns daily in the morning meeting to ensure department managers were working towards resolution. 28. All facility staff was educated by the Corporate Administrative Registered Nurse on identification of behaviors to include but not limited to sexual and physical behavior on 01/12/14. Residents with behaviors will be discussed weekly at the Behavior Management Meeting to ensure targeted behaviors are documented, care planned, and appropriate interventions are in place. The Nurse will document the behaviors on the 24 hour report to be shared during the morning meeting. 29. All facility staff were educated, on 01/12/14, 01/13/14, 01/14/14, 01/15/14, by the Corporate Administrative Registered Nurses, that revisions are made to the resident's care plan to include interventions for behaviors. The staff was instructed to follow the care plan for specific interventions for resident's interventions. Education was also provided on identification of accidents which can include behaviors, intervene, and report sexual and physical behavior to the resident's nurse for documentation in the medical record and follow up with the Physician. The nurse will also document in the 24 hour report to share information in the morning meeting. In addition all staff was educated on F520, the facility's policies for Behaviors, Incidents, Documentation, and Performance Improvement which included the QAPI process, Monitoring of Facility Care Services, Identification of Performance Improvement Opportunities, and the Role of the Performance Team. 30. All resident care plans were reviewed and/or updated by the Regional Case Mix Coordinator on 01/11/14 and 01/12/14 to ensure they were accurate as compared to the Minimum Data Set and physician's orders [REDACTED]. 31. The facility's Administrative staff (ED/Abuse Coordinator and DCS) have been educated by the Corporate Administrative Registered Nurse on 01/12/14 that abuse allegations which are reported to them by employees must be investigated and reported to the appropriate officials in accordance with Federal and State Regulation. 32. The QAPI Committee had an Ad-Hoc QAPI meeting on 01/10/14 to discuss IJ citations and on 01/15/14 to discuss performance improvement opportunities and to review the facility's Abuse policy. The attendees consisted of the Interim Director of Clinical Services, Dietary Manager, Business Office Manager, Director of Admissions, Medical Records, Central Supply, Regional Case Mix Coordinator, Regional Director of Human Resources, Regional Director of Business Services, Regional Director of Clinical Services, Corporate Administrative RN, Director of Rehabilitation Services, Clinical Ambassador, Corporate Director of Education, Regional Vice President of Operations, Vice President of Operations, Vice President of Clinical Services, Vice President of Admissions & Marketing, Corporate Operations Team Member and Executive Director via telephone. 33. The ED and DCS were re-educated by the Corporate Administrative Registered Nurse on 01/12/14, regarding the regulations for F520, the facility's policies for Behaviors, Incidents, Documentation, and Performance Improvement which included the QAPI process, Monitoring of Facility Care Services, Identification of Performance Improvement Opportunities, and the Role of the Performance Team. Through observation, interview, and record review the State Survey Agency (SSA) validated the AOC, on 01/21/14-01/22/14 prior to exit as follows: 1. Review of Resident #1's closed medical record and the facility's investigation revealed Resident #1 and SRNA #2 were immediately separated. 2. Review of the facility's investigation revealed the Police were notified of the incident on 12/31/13. 3. Review of the Resident #1 closed medical record revealed the resident was discharged from the facility and sent to the hospital for a psychiatric evaluation on 01/07/14. 4. Review of the facility's investigation revealed the SRNA was immediately suspended and removed from the facility on 12/31/13. 5. Interview with the Regional Director of Clinical Services (RDCS), on 01/22/14 at 1:08 PM, revealed the audits of resident clinical records which included review of nurse's notes back to 07/17/13 identified three (3) residents with behaviors requiring increased monitoring through 1:1. Review and observation confirmed 1:1 was occurring and documented. The RDCS revealed Resident #3 was identified as one of these residents. Review of the Psychiatric ARNP notes, dated 01/15/14, revealed Resident #3 was listed as one of the residents assessed. 6. Interview with the Vice President of Clinical Operations (VPCO), on 01/22/14 at 2:48 PM, revealed resident's identified with behaviors from the chart audits, on 01/07/14 through 01/08/14 and staff interviews on 01/11/12 through 01/12/14, had interventions put in place during the care plan review. Observation of Resident #3, on 01/21/14 at 4:12 PM, revealed 1:1 supervision was provided with a SRNA #8. 7. Review of the Behavior Meeting notes, on 01/12/14, revealed Resident #3 was listed with identified behaviors, medications, and interventions. 8. Review of Resident #3's Care plan revealed an intervention for 1:1 supervision on 01/13/14. 9. Review of the faxed communication with the SSA from the facility revealed the incident involving Resident #3 and #1, on 11/05/13 was reported on 01/08/14 and a 5 day report was submitted on 01/13/14. 10. Review of the Behavior Meeting notes, on 01/12/14, revealed Resident #2 was reviewed to include a medical record review and care plan review. Interview with the Corporate Administrative Registered Nurse (CARN), on 01/22/14 at 1:27 PM, revealed Resident #2 did not need increased monitoring was not exhibiting behaviors. 11. Review of the faxed communications to the SSA from the Facility revealed the incident on 07/17/13 with Resident #1 and #2 was reported on 01/08/14 and a 5 day follow up was submitted on 01/13/14. 12. Interview with Resident #2, on 01/22/14 at 2:03, revealed he/she did have a conversation with the DCS and SSD regarding the incident on 07/17/13 and 01/06/14. Resident #2 revealed being asked if he/she felt safe and what had occurred. 13. Interview with the Regional Director of Clinical Services (RDCS), on 01/22/14 at 1:08 PM, revealed the audits of resident clinical records which included review of nurse notes back to 07/17/13 identified three (3) residents (#3, #13, and #21) with behaviors requiring increased monitoring. A. Review of the Behavior Management Meeting notes, dated 01/12/14, revealed the three (3) identified were Residents #3, #13, and #21 were included in the meeting. B. Review of the three (3) identified resident's care plan (#3, #13, and #21) revealed interventions to increase supervision using 1:1 was added. C. Review of the Psychiatric ARNP notes, dated 01/15/14, revealed two (2) of the three (3) residents (Residents #13 and #21) had medications and behaviors reviewed. D. Review of the nursing notes and 24 hour report book, revealed the three (3) residents (#3, #13, and #21) were monitored daily with documented behaviors observed. 14. Interview on 01/21/14 with twelve (12) residents, identified as interviewable with a BIMS of 8 or greater, revealed they felt safe at the facility and had been interviewed by the SSD. 15. Review of the facility skin sweeps, dated 01/07/14, 01/08/14, and on 01/15/14, revealed the facility's 89 residents were assessed with [REDACTED]. 16. Interview with sixteen (16) facility staff, Certified Occupational Therapy Assistant (COTA) #1 on 01/20/14 at 2:30 PM; COTA #2 on 01/20/14 at 2:30 PM; LPN #7 on 01/21/14 at 3:25 PM; Maintenance Director on 01/21/14 at 3:30 PM; Dietary Cook on 01/21/14 at 3:35 PM; Dietary Aide on 01/21/14 at 3:37 PM; LPN #8 on 01/21/14 at 3:39 PM; SRNA #10 on 01/21/14 at 4:00 PM; SRNA #8 on 01/21/14 at 4:12 PM; Medical Records on 01/22/14 at 12:58 PM; Payroll/HR on 01/22/14 at 12:50 PM; Business Office Manager on 01/22/14 at 3:11 PM; LPN #5 on 01/22/14 at 1:01 PM; Housekeeper on 01/22/14 at 12:52 PM; SRNA #12 on 01/22/14 at 4:23 PM; and SRNA #11 on 01/22/14 at 4:05 PM, revealed they were asked to identify any residents who exhibited behaviors, abuse and/or neglect that had not been reported. Review of the Behavior Monitoring tool revealed staff was to document who identified a behavior, which resident, and the behavior identified. 17. Review of the faxed communication and facility investigations revealed the seven (7) identified incidents were reported to the SSA on 01/08/14. The expanded sample included five incidents involving Residents #9 and 10, #11 and 12, #13 and 14, #15 and 16, and #17 and 18. 18. Interview with the RDCS, on 01/22/14 at 1:08 PM, revealed the resident's concerns (grievances) were reviewed for potential allegations and none were identified. 19. Interview with RDCS and DCS, on 01/21/14 at 2:30 PM, revealed personnel files were audited on 01/12/14 for: two (2) reference checks, OIG report, Kentucky Board of Nursing Nurse Aide Abuse Registry, Criminal Record Checks, and abuse acknowledgment. RDCS and DCS revealed audits compared to current staff roster and the facility had no new hires for review. Review of two (2) SRNAs, the ED and Activities Assistant personnel files revealed they were accurate. 20. Review of the staff training signature sheets, dated 01/11/14 through 01/15/14, covering the following topics: Identification of Resident Behaviors, Behavior Management, Behavior Reporting, Abuse Education, Facility Policies and Procedures for Behaviors, Emotional and Behavioral Support, Management Problems of Resident with Dementia, Behavior Monitoring, Federal Regulations F223, F225, F226, Physical and Sexual behavior, reporting to Charge nurse and DCS/ED, and documentation contained 116 staff signatures. Interviews with sixteen (16) facility staff members, (See #16) on 01/21/14 and 01/22/14, verified abuse education was completed and followed by an abuse post-test. 21. Interview with the Human Resource/Payroll Coordinator, on 01/22/14 at 12:50 PM, revealed she was educated on required screening components for new hires. Components to include Criminal background checks, two (2) reference checks, OIG report, Kentucky Board of Nursing Nurse Aide Abuse Registry, and abuse acknowledgment. 22. Review of training signature sheets, dated 01/11/14 through 01/15/14, revealed both the ED and DCS signatures as attending the training. A separate training, dated 01/12/14, revealed just the ED and DCS were trained on the facility's Abuse and Neglect Policy and the procedures for reporting investigating. The facility's abuse policy contained new employee hire screening components. 23. Interview with the RDCS and the DCS, on 01/21/14 at 2:20 PM, revealed resident interviews regarding potential abuse issues, and mock surveys consisting of care plan review and implementation, behavior documentation, and staff interviews, were completed on all halls on 01/13/14, the F Hall on 01/14/14, E and F Halls on 01/15/13. Mock surveys continued on 01/16/14 for A, C, E, and F Halls, 01/17/14 for E, A, B, F Halls, and A Hall was done again on 01/18/14. 24. Review of the Behavior Management Meeting, dated 01/12/14, revealed twenty-four (24) residents were reviewed. Review of the psychiatric ARNP notes, dated 01/15/14, revealed nine (9) residents were reviewed which included review of medications. 25. Review of the chart audits, dated 01/15/14, revealed care plans were updated according to concerns noted in SSD notes. Review of 24 resident care plans revealed they had been updated. 26. Review of the facility's education, and review of the staff training signature sheets, dated 01/11/14 through 01/15/14, covering the following topics: Identification of Resident Behaviors, Behavior Management, Behavior Reporting, Abuse Education, Facility Policies and Procedures for Behaviors, Performance Improvement Committee, Indicators, Performance Improvement Committee, Emotional and Behavioral Support, Management Problems of Resident with Dementia, Behavior Monitoring, Federal Regulations F223, F226, F250, Physical and Sexual behavior, reporting to Charge nurse and DCS/ED, and documentation contained 116 staff signatures including the SSD. The SSD was not available for interview. 27. Review of the Morning Minute worksheet provided by the facility as the Social Services oversight revealed concerns identified were addressed. Incident report Investigations were completed by Corporate Social Services. No new incident reports were reported; however, seven (7) incidents identified were reviewed and addressed. 28. Review of the staff training signature sheets, dated 01/11/14 through 01/15/14, covering the following topics: Identification of Resident Behaviors, Behavior Management, Behavior Reporting, Abuse Education, Facility Policies and Procedures for Behaviors, Performance Improvement Committee, Indicators, Performance Improvement Committee, Emotional and Behavioral Support, Management Problems of Resident with Dementia, Behavior Monitoring, Federal Regulations F223, F225, F226, F280, F282, F323, F514, Physical and Sexual behavior, reporting to Charge nurse and DCS/ED, and documentation and care plan interventions contained 116 staff signatures. Interviews with sixteen (16) facility staff members, (see #16) on 01/21/14 and 01/22/14, verified education was completed and followed by a post-test. 29. Review of the staff training signature sheets, dated 01/11/14 through 01/15/14, covering the following topics: Identification of Resident Behaviors, Emotional and Behavioral Support, Management Problems of Resident with Dementia, Behavior Monitoring, Federal Regulations F280, F282, F514, P

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure clinical records were accurate and complete for fifteen (15) of twenty-two (22) sampled residents. Residents #1, #2, #3, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and #22. The facility staff failed to document behaviors of verbal, physical, and/or sexual behaviors toward staff and other residents in the clinical record. (Refer to F323) This is a repeat deficiency from the 08/01/13 Standard Health Survey. The facility's failure to have an effective system in place to ensure clinical records were accurate and complete placed residents in a situation that has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy was identified on 01/10/14 and determined to exist on 07/17/13. The facility was notified of the Immediate Jeopardy on 01/10/14. An acceptable Allegation of Compliance (AOC) was received on 01/20/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 01/16/14, as alleged, prior to exit on 01/22/14. The scope and severity was lowered to an "E" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: The facility did not provide a policy regarding accuracy of the clinical record. Review of the facility's policy regarding Behavior Monitoring, reviewed 01/03/13, revealed any resident that exhibited behaviors would have a "Behavior/ Intervention Monthly Flow Record" (Behavior Sheet) initiated. The Behavior Sheet required documentation every shift as well as a summary in a weekly progress note. The documentation should include the specific type of behavior being monitored, i.e. kicking, hitting, yelling. Additional documentation included: the number of times the behavior was observed during the shift, the code for the first attempted intervention, non-pharmacological interventions, the code for the outcome, and the code for any side effects observed. The Behavior Sheet was to be maintained with the Medication Administration Record [REDACTED]. The policy also revealed any resident that received psychoactive medications, would have a Behavior Sheet. The medication being monitored and the specific behavior that indicated the use of the medication should be noted. 1. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 06/22/11 with [DIAGNOSES REDACTED]. The resident was also diagnosed with [REDACTED]. The Comprehensive Care Plan, dated 09/04/13 and revised 11/25/13, revealed the facility's care plan and interventions for Resident #1 included behaviors of verbal abuse and flirtatious behavior with male residents. Continued review of Resident #1's clinical record revealed a MAR for January 2014; however, a Behavior Sheet for January 2014 was not provided by the facility. A Behavior Sheet, dated October 2013, for Resident #1 revealed the form was blank, with no behaviors listed or any other documentation. A Psychiatric Note, dated 04/12/13, revealed Resident #1 had become aggressive with a peer and hit someone "young and stupid". The Nurse's Notes reviewed from 02/07/13 through 05/23/13 revealed no documentation of Resident #1 in an altercation with a peer, or behavior other than refusing [MEDICAL TREATMENT]. Review of a Psych Note, dated 11/08/13, revealed the resident had been in a verbal altercation with a male peer that was misinterpreted as a physical altercation. However; the Nurse's Note, dated 11/05/13, revealed the resident was happy on the day shift, pleasant on the day and evening shift with no behaviors noted. The Nurse's Note did not include documentation of an incident which Resident #1 had become verbally and/or physically aggressive with a peer. There was no other documented evidence of the events with Resident #1 in the clinical record. The Behavior Chart Detail Report from 07/11/13 through 01/07/14, printed from the SRNA Kiosk for Resident #1, revealed standard behaviors that should be documented included: verbal abuse, verbal alterable, physical abuse, physical alterable, social inappropriate, and social inappropriate alterable. The report contained documentation for one (1) day of verbal alterable behavior. Further review revealed no documented evidence of the other behaviors. Review of the A and D Hall MARs, on 01/06/14 at 11:30 AM, revealed all residents had a Behavior Sheet; however, most of the resident sheets were blank. Resident #1's Behavior Sheet for January 2014 was blank. Review of the A and D Hall MARs, on 01/07/14 at 5:16 PM, revealed the blank Behavior Sheets had been pulled from the MARs and the current Behavior Sheet for Resident #1 was no longer in the MAR. Observation, on 01/07/14 at 3:24 PM, of Resident #1 revealed the resident was yelling wanting to go outside to smoke. At 4:04 PM, Resident #1 was yelling "emergency" while self-propelling down the hallway. Continued observation at 4:06 PM revealed Resident #1 was near the nurse's station for the A and D Halls. The resident was yelling at a staff member, cursing, and positioned his/her wheelchair to corner the staff member between the nurse's station and resident rooms without a way to remove herself from the resident. The incident at 4:06 PM was not documented in the medical record. 2. Review of the clinical record for Resident #2 revealed the facility admitted the resident on 03/03/10 with [DIAGNOSES REDACTED]. The facility assessed the resident to have no mood or behavioral indicators and having difficulty with communication. Review of the Comprehensive Care Plan, dated 08/20/13 and revised 11/04/13, revealed the resident had an alteration in communication. Review of Resident #1's clinical record of a Nurse's Note, dated 07/17/14 at 10:25 PM, revealed Resident #1 had been in Resident #2's room with his/her hand under Resident #2's sheet touching and fondling Resident #2. The nurse's note further revealed Resident #2 told Resident #1 to stop; however, Resident #1 continued to touch Resident #2 under the sheet. Continued review of Resident #2's clinical record revealed Nurse's Notes from 07/15/13 through 10/21/13 revealed no documented evidence of the incident with Resident #1 on 07/17/13. There was no other documented evidence of the event in Resident #2's clinical record. Interview with the DCS, on 01/09/14 at 11:06 AM, revealed the incident should have been documented in Resident #2's chart, which was used for the monthly behavior meetings with the Psychiatrist. 3. Review of the clinical record for Resident #3 revealed the facility admitted the resident on 12/03/12 with [DIAGNOSES REDACTED]. The Comprehensive Care Plan, dated 10/04/13, revealed the care plan for behaviors included interventions to not argue with the resident and to ensure safety of the residents and others. A skin assessment of Resident #3, dated 11/05/13, revealed a mark on the left side of the resident's mouth. Continued review of Resident #3's clinical record revealed Daily Skilled Nurse's Notes, dated 11/06/13 and 11/07/13, and narrative notes for November did not identify any aspects of the incident. Additional review of Resident #3's clinical record revealed an Situation, Behavior, Assessment, Recommendation communication form, dated 11/05/13, that revealed the resident was found on the ground in the courtyard due to a fall. A Social Service's Note, dated 11/06/13 by the Social Service Director (SSD), revealed the resident was in a verbal argument with another resident. The SSD indicated Resident #3 stated he/she had become aggravated with the other resident and handled the incident the wrong way. There was no documentation in the Nurse's Notes or clinical record that the event had occurred. The facility did not provide Behavior Sheets for Resident #3. Interview with Medical Records staff, on 01/09/14 at 3:53 PM, revealed the two (2) skilled Nurse's Notes for Resident #3, dated 11/06/13 and 11/07/13, were the only Nurse's Notes for the month of November, and stated "that's all there was". 4. Review of the clinical record for Resident #9 revealed the facility admitted the resident on 02/22/13 with [DIAGNOSES REDACTED]. Care plan interventions included give the resident papers to shuffle, keep safe distance when behaviors occur, and take to a quiet location as necessary. A Nurse's Note, dated 07/28/13 at 7:35 PM, revealed the resident kissed a female resident's hand and after redirection from staff the resident kissed the female resident on the lips and inserted his/her tongue in the resident's mouth. There was no documented evidence of a completed Behavior Sheet in the clinical record. 5. Review of Resident #10's clinical record revealed the facility admitted the resident on 04/27/09 with [DIAGNOSES REDACTED]. and possible injury, and remind resident to use the call light. There was no documented evidence of a completed Behavior Sheet in the clinical record. 6. Review of the clinical record for Resident #11 revealed the facility admitted the resident on 05/24/12 with [DIAGNOSES REDACTED]. The Comprehensive Care Plan, dated 12/02/13, revealed the resident would often use profanity or vulgarity and call people names. A SSD Note, dated 10/25/13, revealed the resident threw a bowl of soup in the direction of Resident #12 and some of the soup hit the resident. There was no evidence of a completed Behavior Sheet in the clinical record. 7. Review of Resident #12's clinical record revealed the facility admitted the resident on 05/07/08 with [DIAGNOSES REDACTED]. A SSD Note, dated 10/25/13, revealed on 10/24/13 another resident who was angry knocked over a bowl of soup which fell into Resident #12's lap and chest area. The SSD note indicated the resident was assessed with [REDACTED].#12. However, there was a skin assessment documented as occurring on 10/26/13. 8. Review of the clinical record for Resident #13 revealed the facility admitted the resident on 06/27/11 with a [DIAGNOSES REDACTED]. A Nurse's Note, dated 09/07/13 at 5:00 PM, revealed the resident was arguing with another resident and threatened to stab him/her with a shoe horn and was asked by staff to leave the shoe horn in his/her room. At 5:20 PM, the Nurse's Note revealed Resident #13 had threatened the other resident again. There was no evidence of a completed Behavior Sheet in the clinical record. 9. Review of Resident #14's clinical record revealed the facility admitted the resident on 12/06/12 with a [DIAGNOSES REDACTED]. Interventions included monitor for alcohol consumption to determine cause, intervene to ensure safety, set limits, and watch for behavioral cues, such as body language and tone of voice. A Nurse's Note, dated 09/07/13 at 3:00 PM, revealed the resident was arguing with another resident and threatened him/her. There was no evidence of a completed Behavior Sheet in the clinical record. 10. Review of the clinical record for Resident #15 revealed the facility admitted the resident on 05/13/11 with [DIAGNOSES REDACTED]. 11. Review of the clinical record for Resident #16 revealed the facility admitted the resident on 07/17/10 with a [DIAGNOSES REDACTED]. A Nurse's Note, dated 11/30/13 at 9:00 PM, revealed the resident's back was assessed for injury from an altercation with another resident. There was no evidence of documentation in the clinical record the incident occurred, no date, or time was noted. There was no evidence of a completed Behavior Sheet in the clinical record. 12. Review of Resident #17's clinical record revealed the facility admitted the resident on 08/20/13 with a [DIAGNOSES REDACTED]. Interventions included observe behavior to assist in determining cause of refusal per behavior flow sheet, intervene to ensure resident safety, and ensure safety of resident and others. A Behavior Sheet, dated 10/13, revealed wandering behavior inconsistently monitored. There was no other evidence in the clinical record for the physically abusive behaviors towards males or any other Behavior Sheets. 13. Review of the clinical record for Resident #18 revealed the facility admitted the resident on 01/08/14 with a [DIAGNOSES REDACTED]. A Comprehensive Care Plan, dated 01/09/14, revealed the resident would wander and enter other resident rooms and would become angry when redirected by staff. Interventions included praise, positive behavior, do not argue with the resident, and re-approach the resident with refusal. A Nurse's Note, dated 01/09/14 at 4:20 AM, revealed the resident had been wandering into other resident rooms. Additionally, the resident was then found in his/her room yelling and standing face-to-face with his/her roommate which required the nurse to step between them. There was no other evidence in the clinical record for other behaviors or other Behavior Sheets. 14. Review of the clinical record for Resident #19 revealed the facility admitted the resident on 09/18/13 with [DIAGNOSES REDACTED]. The Comprehensive Care Plan, dated 12/20/13, revealed the resident displayed verbally aggressive behavior. The care plan interventions included diversional activities by activities staff, do not argue with the resident, and talk to the resident in a calm voice. An incident on 12/30/13 between the Activity Director (AD) and the resident was not documented in the resident's clinical record. 15. Review of Resident #22's clinical record revealed the facility admitted the resident on 10/24/13 with [DIAGNOSES REDACTED]. The Comprehensive Care Plan, dated 11/04/13, revealed the resident would yell out and use profanity. The care plan also indicated the resident displayed verbally and physically aggressive behavior with interventions to reinforce unacceptability of verbal abuse and talk with resident calmly when behavior was disruptive. The care plan also indicated the resident had symptoms of [MEDICAL CONDITION], hallucinations/delusions and document target behaviors. There was no evidence of a completed Behavior Sheet in the clinical record that contained monitoring of targeted behaviors. Interview, on 01/07/14 at 8:57 AM and 01/09/14 at 2:01 PM, with the SSD revealed the nurses did not document resident behaviors on the Behavior Sheet. She stated she used the Behavior Sheets and Nurse's Notes for the residents' MDS assessments. The SSD indicated if the nurses did not document the behaviors then she would not be aware of the behaviors that would need to be captured to complete the MDS assessment. She further indicated she was unaware the aides documented resident behaviors and stated she did not have access to the computer in which the aides document the resident behaviors. The SSD stated, after reviewing the Behavior Chart Detail Report from 07/11/13 through 01/07/14 for Resident #1, from her knowledge one (1) incident was not a correct number and there should have been more behaviors documented. On 01/07/14 at 10:24 AM, interview with the Interim Director of Clinical Services (DCS) revealed Resident #1's specific behaviors were not documented anywhere. She stated resident behaviors should be documented by the nurses in the chart for the SSD. She indicated the aides would document in the care tracker. The DCS stated she had told nurses to make sure resident behaviors were documented in the Nurse's Note. She also stated residents would have Behavior Sheets if they had certain medications. Continued interview, on 01/09/14 at 11:06 AM, revealed resident charts and care plans were taken to the monthly behavior meeting that occurred with the Psychiatrist. The DCS stated the behavior meeting with the Psychiatrist did not get a full picture of the resident's behavior when the behaviors were not documented in the resident's chart. Interview, on 01/19/14 at 10:36 AM, with the DCS revealed the Unit Manager (UM) was responsible to check resident charts to ensure everything was being captured that needed to be. She stated, she sometimes would go back and check records as well as the Assistant DCS (ADCS). The DCS did not say when she had last checked the charts. Interview with LPN #5, on 01/09/14 at 9:01 AM, revealed she was unaware if resident behaviors should be documented anywhere other than the 24 Hour Report. She stated if there was no documentation in the resident's charts then it was possible resident issues were not being addressed and the events could happen again. She indicated resident charts were used in resident care plan meetings to update the care plans. Interview, on 01/09/14 at 12:40 PM and 01/10/14 at 2:28 PM, with the Psychiatrist revealed nurses' charting was reviewed during the monthly behavior meetings. The physician stated in addition to medications and dose reduction reviews, behavior interventions were also reviewed. However, interview with the Advanced Registered Nurse Practitioner (ARNP), on 01/18/14 at 10:19 AM, revealed she had told the facility staff continuously to document behaviors and it was just not followed. Interview with the Interim ED, on 01/16/14 at 10:22 AM, revealed he was unaware of what was contained in the facility's records and needed to refer to the records; however, he stated records were either missing or could not be located. Further interview with the ED revealed he could not answer how he administered the facility without records, he reported they were missing and replied "that is a good question". On 01/19/14 at 12:32 PM, interview with the Regional Vice President (VP) of Operations revealed he was the Interim ED's direct supervisor and he would take on a consultative role when the ED would ask for guidance. The VP stated there were no real checks and balances in place. He stated the ED was employed to run the business and the facility was not required to send any information directly to him. The facility provided an Allegation of Compliance (AOC) on 01/20/14 alleging the Immediate Jeopardy (IJ) was removed on 01/16/14; the facility took the following immediate steps to remove the IJ: 1. Resident #1 and SRNA #2 were immediately separated on 12/31/13 by staff. 2. The police were notified of the incident on 12/31/13. 3. Resident #1 was discharged to the hospital for a psychiatric evaluation on 01/07/14. 4. SRNA #2 was suspended immediately on 12/31/13. 5. Resident #3 was referred by the DCS, and seen by the Psychiatric ARNP, on 01/15/14. 6. Resident #3 was placed on increased supervision, 1:1 observation, to redirect impulse behaviors on 01/12/14. 7. Resident #3 was reviewed by the Interdisciplinary Team (IDT) (consisting of the Corporate Administrative Nurse, DCS, Activity Director, and Regional Director of Clinical Services) in the Behavior Management Meeting, on 01/12/14, which included a medical record review. 8. Resident #3's care plan was updated by the Corporate Administrative Registered Nurse on 01/13/14. 9. The incident involving Resident #3, on 11/05/13, was reported to the State Survey Agency (SSA), on 01/08/14 via a 24 Hour Report, investigated and a 5 Day report was submitted to the SSA on 01/13/14. 10. Resident #2 was reviewed in the Behavior Management Meeting by the IDT Corporate Administrative Registered Nurse, DCS, Activity Director, and the Regional Director of Clinical Services on 01/12/14 which included a medical record review and a care plan review. 11. The incident on 07/17/13 involving Resident #2 was reported to the SSA on 01/08/14 via a 24 hour report. A 5 day Report was submitted to the SSA on 01/13/14. 12. Resident #2 was interviewed on 01/07/14 by the SSD and the DCS regarding the incident on 07/17/13 and 01/06/14. 13. Current resident chart reviews completed , on 01/07/14 and 01/08/14 by the DCS, ADCS, Unit Manager and RDCS and staff interviews on 01/11/14 and 01/12/14 by Corporate Administrative Registered Nurses to identify residents with behaviors, the facility identified three (3) residents (#3, #13, and #21) as exhibiting sexual or physical behaviors towards others. These three residents were: A. Reviewed in the Behavior Management Meeting by the IDT (Corporate Administrative Registered Nurse, Director of Clinical Services Activity Director, and the Regional Director of Clinical Services) on 01/12/14. B. Increased supervision was initiated on 01/12/14 and the care plans were revised by the Activity Director the Corporate Administrative Registered Nurse and the DCS on 01/13/14. C. Referred to the Psychiatrist for review by the DCS and two (#13 and #21) of three residents were seen on 01/15/14. D. Had documentation of behavior reviewed daily since 01/13/14 by a member of the IDT (to include the DCS, ED, and the Corporate Administrative Registered Nurses). 14. Thirty-nine (39) residents, with a brief interview for mental status (BIMS) of an 8 or above were interviewed by the Social Services on 01/07/14 to ensure they had not been abused or neglected. 15. All residents were assessed by nurses via skin sweeps for suspicious injuries on 01/07/14, 01/08/14, and on 01/15/14 with no injuries found. 16. All Department Heads along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116) were interviewed by the Corporate Administrative Registered Nurse on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 to ensure no one had witnessed any abuse or neglect that had not been previously reported. 17. Current resident charts were reviewed on 01/07 and 01/08/14 by the Director of Clinical Services, Assistant Director of Clinical Services, Staff Educator, Unit Manager, and the Regional Director of Clinical Services to determine if there were any incidents that were reportable and/or needed further investigation. The seven (7) incidents that were identified during the review were reported on 01/08/14. 18. The facility's concern book was reviewed by the Regional Director of Clinical Services on 01/11/14 for allegations that needed to be reported and no allegations were identified. 19. The current staff members' employee personnel files were reviewed by Regional Director of Human Resources and Facility Human Resources/Payroll Coordinator to ensure that the files were completed with the Criminal Background Check, Kentucky State Board of Nursing/Nurse Aide Abuse Registry check, Office of the Inspector General Check, Telephone Reference Checks and Abuse/Neglect Attestation on 01/11/14 and 01/12/14. The six (6) discrepancies identified were corrected with missing Criminal Background Checks and Reference checks by 01/12/14. 20. All current Department Head staff along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116 employees) were educated by the Corporate Administrative Registered Nurses on abuse screening, training, prevention, identification, investigation, protection, reporting and response, F223 and the facility's Policy and Procedure for Resident Abuse, on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 and completed a post test. No staff members worked beyond 01/12/14 without having already been educated prior to the start of their shift. 21. The Human Resource/Payroll Coordinator was reeducated by the Regional Director of Human Resources on 01/12/14 that newly hired employees must have a Criminal Background Check, Kentucky Board of Nursing/Nurse Aide Abuse Registry Screen, Office of the Inspector General Exclusion Check, and Telephone reference checks. 22. The ED and DCS were re-educated by the Vice President of Clinical Services on 01/11/14 and 01/12/14 to ensure newly hired employees must have a Criminal Background Check, Kentucky Board of Nursing/Nurse Aide Abuse Registry Screen, Office of the Inspector General Exclusion Check, and Telephone reference checks. The ED will validate and sign that Newly Hired Employees have had all the required checks. 23. Mock Survey Rounds consisting of care plan review and implementation, behavior documentation, and staff interviews were completed by the IDT on 01/13/14, 01/14/14, and 01/15/14 that included resident interviews regarding potential abuse issues. 24. A Behavior Meeting was conducted by the IDT on 01/12/14 to review the current residents with known behaviors to discuss the behaviors, interventions, and medication. The nine (9) residents identified as having some type of behavior were referred to the physician and interventions were updated on the care plans by the IDT on 01/15/14. 25. Social Service notes were reviewed and Care Plans updated by the Corporate Social Services on 01/15/14. 26. The Social Service Director (SSD) was re-educated by the Corporate Administrative Registered Nurse on F250 and the facility's Policy and Procedures for Abuse and Behaviors on 01/12/14. 27. The Social Service Department consisting of the Corporate Social Services, Corporate Administrative Registered Nurse had daily oversight on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 with review of resident and family concerns daily in the morning meeting to ensure department managers were working towards resolution. 28. All facility staff was educated by the Corporate Administrative Registered Nurse on identification of behaviors to include but not limited to sexual and physical behavior on 01/12/14. Residents with behaviors will be discussed weekly at the Behavior Management Meeting to ensure targeted behaviors are documented, care planned, and appropriate interventions are in place. The Nurse will document the behaviors on the 24 Hour Report to be shared during the morning meeting. 29. All facility staff were educated, on 01/12/14, 01/13/14, 01/14/14, 01/15/14, by the Corporate Administrative Registered Nurses, that revisions are made to the resident's care plan to include interventions for behaviors. The staff was instructed to follow the care plan for specific interventions for resident's interventions. Education was also provided on identification of accidents which can include behaviors, intervene, and report sexual and physical behavior to the resident's nurse for documentation in the medical record and follow up with the Physician. The nurse will also document in the 24 hour report to share information in the morning meeting. In addition all staff was educated on F520, the facility's policies for Behaviors, Incidents, Documentation, and Performance Improvement which included the QAPI process, Monitoring of Facility Care Services, Identification of Performance Improvement Opportunities, and the Role of the Performance Team. 30. All resident care plans were reviewed and/or updated by the Regional Case Mix Coordinator on 01/11/14 and 01/12/14 to ensure they were accurate as compared to the Minimum Data Set and physician's orders [REDACTED]. 31. The facility's Administrative staff (ED/Abuse Coordinator and DCS) have been educated by the Corporate Administrative Registered Nurse on 01/12/14 that abuse allegations which are reported to them by employees must be investigated and reported to the appropriate officials in accordance with Federal and State Regulation. 32. The QAPI Committee had an Ad-Hoc QAPI meeting on 01/10/14 to discuss IJ citations and on 01/15/14 to discuss performance improvement opportunities and to review the facility's Abuse policy. The attendees consisted of the Interim Director of Clinical Services, Dietary Manager, Business Office Manager, Director of Admissions, Medical Records, Central Supply, Regional Case Mix Coordinator, Regional Director of Human Resources, Regional Director of Business Services, Regional Director of Clinical Services, Corporate Administrative RN, Director of Rehabilitation Services, Clinical Ambassador, Corporate Director of Education, Regional Vice President of Operations, Vice President of Operations, Vice President of Clinical Services, Vice President of Admissions & Marketing, Corporate Operations Team Member and Executive Director via telephone. 33. The ED and DCS were re-educated by the Corporate Administrative Registered Nurse on 01/12/14, regarding the regulations for F520, the facility's policies for Behaviors, Incidents, Documentation, and Performance Improvement which included the QAPI process, Monitoring of Facility Care Services, Identification of Performance Improvement Opportunities, and the Role of the Performance Team. Through observation, interview, and record review the State Survey Agency (SSA) validated the AOC, on 01/21/14-01/22/14 prior to exit as follows: 1. Review of Resident #1's closed medical record and the facility's investigation revealed Resident #1 and SRNA #2 were immediately separated. 2. Review of the facility's investigation revealed the Police were notified of the incident on 12/31/13. 3. Review of the Resident #1 closed medical record revealed the resident was discharged from the facility and sent to the hospital for a psychiatric evaluation on 01/07/14. 4. Review of the facility's investigation revealed the SRNA was immediately suspended and removed from the facility on 12/31/13. 5. Interview with the Regional Director of Clinical Services (RDCS), on 01/22/14 at 1:08 PM, revealed the audits of resident clinical records which included review of nurse's notes back to 07/17/13 identified three (3) residents with behaviors requiring increased monitoring through 1:1. Review and observation confirmed 1:1 was occurring and documented. The RDCS revealed Resident #3 was identified as one of these residents. Review of the Psychiatric ARNP notes, dated 01/15/14, revealed Resident #3 was listed as one of the residents assessed. 6. Interview with the Vice President of Clinical Operations (VPCO), on 01/22/14 at 2:48 PM, revealed resident's identified with behaviors from the chart audits, on 01/07/14 through 01/08/14 and staff interviews on 01/11/12 through 01/12/14, had interventions put in place during the care plan review. Observation of Resident #3, on 01/21/14 at 4:12 PM, revealed 1:1 supervision was provided with a SRNA #8. 7. Review of the Behavior Meeting notes, on 01/12/14, revealed Resident #3 was listed with identified behaviors, medications, and interventions. 8. Review of Resident #3's Care plan revealed an intervention for 1:1 supervision on 01/13/14. 9. Review of the faxed communication with the SSA from the facility revealed the incident involving Resident #3 and #1, on 11/05/13 was reported on 01/08/14 and a 5 day report was submitted on 01/13/14. 10. Review of the Behavior Meeting notes, on 01/12/14, revealed Resident #2 was reviewed to include a medical record review and care plan review. Interview with the Corporate Administrative Registered Nurse (CARN), on 01/22/1

Based on interview and review of the facility's policies, it was determined the facility failed to have an established Governing Body or designated persons functioning as the Governing Body of the facility. Based on the findings of the abbreviated and partial extended survey conducted 01/02/14 - 01/22/14, which identified Immediate Jeopardy in Resident Behavior & Facility Practice, Quality of Life, Resident Assessment, Quality of Care, and Administration and Substandard Quality of Care identified at Resident Behavior & Facility Practice, Quality of Life, and Quality of Care it was determined the Governing Body failed to assure the facility was administered in a manner that promoted the health and safety of each resident. The facility failed to have a Governing Body to monitor and implement policies and procedures related to abuse investigations, staff treatment of [REDACTED]. The facility's failure to implement abuse policies regarding identifying, investigating, reporting, and protection of resident's from abuse placed residents at risk in a situation that was likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy (IJ) was identified on 01/10/14 and determined to exist on 07/17/13. The facility was notified of the Immediate Jeopardy on 01/10/14. The findings include: (Refer to F223, F225, F226, F250, F280, F282, F323, F490, F514, and F520) The facility did not provide a policy related to Governing Body. Interview, with one of the facility's Corporate Executive Directors, on 01/16/14 at 4:04 PM, revealed the facility had no policy in writing related to Governing Body. Review of facility's administrative staffing changes provided by the Corporate Human Resources Director, on 01/19/14, revealed between 05/29/13 to 01/22/14 the facility had six (6) different Directors of Clinical Services (DCS's) and from 01/19/13 to 01/22/14 seven (7) different Executive Directors. Further interview with the Executive Director, on 01/19/14 at 11:37 AM, revealed he did not know the definition of "Governing Body", but he and the Director of Clinical Services report to the Regional Vice President of Operations and they communicate with the regional consultants. He stated he would need to get a list of the Governing Body members from the Regional Vice President of Operations. Interview with the Regional Vice President of Operations, on 01/16/14 at 1:37 PM, revealed the facility's administrator (Executive Director) was to provide oversight to the building and the final word regarding the operations of the building was the Executive Director's with support from the regional team. On 01/19/14 at 12:32 PM, interview with the Regional Vice President (VP) of Operations revealed he was the Interim ED's direct supervisor and he would take on a consultative role when the ED would ask for guidance. The VP stated there were no real checks and balances in place. He stated the ED was employed to run the business and the facility was not required to send any information directly to him. Additional interview with the Regional Vice President of Operations, on 01/19/14 at 12:32 PM, revealed the management company fulfills the role of the Governing Body and the Executive Director ultimately reports to them. The management company was in charge of the corporation to ensure the Executive Director does what was needed there as an Executive. He further stated there was no real check and balance of forms, they hire the people to do the right thing. When the Executive Director of the facility can't be reached, they contact the Regional Vice President of Operations. Further interview with the Executive Director, on 01/19/14 at 11:37 AM, revealed he kept the facility's systems in place when he started; however, the facility obviously had broken systems, but he didn't want to change everything. The facility provided an Allegation of Compliance (AOC) on 01/20/14 alleging the Immediate Jeopardy (IJ) was removed on 01/16/14; the facility took the following immediate steps to remove the IJ: 1. Resident #1 and SRNA #2 were immediately separated on 12/31/13 by staff. 2. The police were notified of the incident on 12/31/13. 3. Resident #1 was discharged to the hospital for a psychiatric evaluation on 01/07/14. 4. SRNA #2 was suspended immediately on 12/31/13. 5. Resident #3 was referred by the DCS, and seen by the Psychiatric ARNP, on 01/15/14. 6. Resident #3 was placed on increased supervision, 1:1 observation, to redirect impulse behaviors on 01/12/14. 7. Resident #3 was reviewed by the Interdisciplinary Team (IDT) (consisting of the Corporate Administrative Nurse, DCS, Activity Director, and Regional Director of Clinical Services) in the Behavior Management Meeting, on 01/12/14, which included a medical record review. 8. Resident #3's care plan was updated by the Corporate Administrative Registered Nurse on 01/13/14. 9. The incident involving Resident #3, on 11/05/13, was reported to the State Survey Agency (SSA), on 01/08/14 via a 24 Hour Report, investigated and a 5 Day report was submitted to the SSA on 01/13/14. 10. Resident #2 was reviewed in the Behavior Management Meeting by the IDT Corporate Administrative Registered Nurse, DCS, Activity Director, and the Regional Director of Clinical Services on 01/12/14 which included a medical record review and a care plan review. 11. The incident on 07/17/13 involving Resident #2 was reported to the SSA on 01/08/14 via a 24 Hour Report. A 5 day Report was submitted to the SSA on 01/13/14. 12. Resident #2 was interviewed on 01/07/14 by the SSD and the DCS regarding the incident on 07/17/13 and 01/06/14. 13. Current resident chart reviews completed , on 01/07/14 and 01/08/14 by the DCS, ADCS, Unit Manager and RDCS and staff interviews on 01/11/14 and 01/12/14 by Corporate Administrative Registered Nurses to identify residents with behaviors, the facility identified three (3) residents (#3, #13, and #21) as exhibiting sexual or physical behaviors towards others. These three residents were: A. Reviewed in the Behavior Management Meeting by the IDT (Corporate Administrative Registered Nurse, Director of Clinical Services Activity Director, and the Regional Director of Clinical Services) on 01/12/14. B. Increased supervision was initiated on 01/12/14 and the care plans were revised by the Activity Director the Corporate Administrative Registered Nurse and the DCS on 01/13/14. C. Referred to the Psychiatrist for review by the DCS and two (#13 and #21) of three residents were seen on 01/15/14. D. Had documentation of behavior reviewed daily since 01/13/14 by a member of the IDT (to include the DCS, ED, and the Corporate Administrative Registered Nurses). 14. Thirty-nine (39) residents, with a brief interview for mental status (BIMS) of an eight or above were interviewed by the Social Services on 01/07/14 to ensure they had not been abused or neglected. 15. All residents were assessed by nurses via skin sweeps for suspicious injuries on 01/07/14, 01/08/14, and on 01/15/14 with no injuries found. 16. All Department Heads along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116) were interviewed by the Corporate Administrative Registered Nurse on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 to ensure no one had witnessed any abuse or neglect that had not been previously reported. 17. Current resident charts were reviewed on 01/07 and 01/08/14 by the Director of Clinical Services, Assistant Director of Clinical Services, Staff Educator, Unit Manager, and the Regional Director of Clinical Services to determine if there were any incidents that were reportable and/or needed further investigation. The seven (7) incidents that were identified during the review were reported on 01/08/14. 18. The facility's concern book was reviewed by the Regional Director of Clinical Services on 01/11/14 for allegations that needed to be reported and no allegations were identified. 19. The current staff members' employee personnel files were reviewed by Regional Director of Human Resources and Facility Human Resources/Payroll Coordinator to ensure that the files were completed with the Criminal Background Check, Kentucky State Board of Nursing/Nurse Aide Abuse Registry check, Office of the Inspector General Check, Telephone Reference Checks and Abuse/Neglect Attestation on 01/11/14 and 01/12/14. The six (6) discrepancies identified were corrected with missing Criminal Background Checks and Reference checks by 01/12/14. 20. All current Department Head staff along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116 employees) were educated by the Corporate Administrative Registered Nurses on abuse screening, training, prevention, identification, investigation, protection, reporting and response, F223 and the facility's Policy and Procedure for Resident Abuse, on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 and completed a post test. No staff members worked beyond 01/12/14 without having already been educated prior to the start of their shift. 21. The Human Resource/Payroll Coordinator was reeducated by the Regional Director of Human Resources on 01/12/14 that newly hired employees must have a Criminal Background Check, Kentucky Board of Nursing/Nurse Aide Abuse Registry Screen, Office of the Inspector General Exclusion Check, and Telephone reference checks. 22. The ED and DCS were re-educated by the Vice President of Clinical Services on 01/11/14 and 01/12/14 to ensure newly hired employees must have a Criminal Background Check, Kentucky Board of Nursing/Nurse Aide Abuse Registry Screen, Office of the Inspector General Exclusion Check, and Telephone reference checks. The ED will validate and sign that Newly Hired Employees have had all the required checks. 23. Mock Survey Rounds consisting of care plan review and implementation, behavior documentation, and staff interviews were completed by the IDT on 01/13/14, 01/14/14, and 01/15/14 that included resident interviews regarding potential abuse issues. 24. A Behavior Meeting was conducted by the IDT on 01/12/14 to review the current residents with known behaviors to discuss the behaviors, interventions, and medication. The nine (9) residents identified as having some type of behavior were referred to the physician and interventions were updated on the care plans by the IDT on 01/15/14. 25. Social Service notes were reviewed and Care Plans updated by the Corporate Social Services on 01/15/14. 26. The Social Service Director (SSD) was re-educated by the Corporate Administrative Registered Nurse on F250 and the facility's Policy and Procedures for Abuse and Behaviors on 01/12/14. 27. The Social Service Department consisting of the Corporate Social Services, Corporate Administrative Registered Nurse had daily oversight on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 with review of resident and family concerns daily in the morning meeting to ensure department managers were working towards resolution. 28. All facility staff was educated by the Corporate Administrative Registered Nurse on identification of behaviors to include but not limited to sexual and physical behavior on 01/12/14. Residents with behaviors will be discussed weekly at the Behavior Management Meeting to ensure targeted behaviors are documented, care planned, and appropriate interventions are in place. The Nurse will document the behaviors on the 24 hour report to be shared during the morning meeting. 29. All facility staff were educated, on 01/12/14, 01/13/14, 01/14/14, 01/15/14, by the Corporate Administrative Registered Nurses, that revisions are made to the resident's care plan to include interventions for behaviors. The staff was instructed to follow the care plan for specific interventions for resident's interventions. Education was also provided on identification of accidents which can include behaviors, intervene, and report sexual and physical behavior to the resident's nurse for documentation in the medical record and follow up with the Physician. The nurse will also document in the 24 hour report to share information in the morning meeting. In addition all staff was educated on F520, the facility's policies for Behaviors, Incidents, Documentation, and Performance Improvement which included the QAPI process, Monitoring of Facility Care Services, Identification of Performance Improvement Opportunities, and the Role of the Performance Team. 30. All resident care plans were reviewed and/or updated by the Regional Case Mix Coordinator on 01/11/14 and 01/12/14 to ensure they were accurate as compared to the Minimum Data Set and physician's orders [REDACTED]. 31. The facility's Administrative staff (ED/Abuse Coordinator and DCS) have been educated by the Corporate Administrative Registered Nurse on 01/12/14 that abuse allegations which are reported to them by employees must be investigated and reported to the appropriate officials in accordance with Federal and State Regulation. 32. The QAPI Committee had an Ad-Hoc QAPI meeting on 01/10/14 to discuss IJ citations and on 01/15/14 to discuss performance improvement opportunities and to review the facility's Abuse policy. The attendees consisted of the Interim Director of Clinical Services, Dietary Manager, Business Office Manager, Director of Admissions, Medical Records, Central Supply, Regional Case Mix Coordinator, Regional Director of Human Resources, Regional Director of Business Services, Regional Director of Clinical Services, Corporate Administrative RN, Director of Rehabilitation Services, Clinical Ambassador, Corporate Director of Education, Regional Vice President of Operations, Vice President of Operations, Vice President of Clinical Services, Vice President of Admissions & Marketing, Corporate Operations Team Member and Executive Director via telephone. 33. The ED and DCS were re-educated by the Corporate Administrative Registered Nurse on 01/12/14, regarding the regulations for F520, the facility's policies for Behaviors, Incidents, Documentation, and Performance Improvement which included the QAPI process, Monitoring of Facility Care Services, Identification of Performance Improvement Opportunities, and the Role of the Performance Team. Through observation, interview, and record review the State Survey Agency (SSA) validated the AOC, on 01/21/14-01/22/14 prior to exit as follows: 1. Review of Resident #1's closed medical record and the facility's investigation revealed Resident #1 and SRNA #2 were immediately separated. 2. Review of the facility's investigation revealed the Police were notified of the incident on 12/31/13. 3. Review of the Resident #1 closed medical record revealed the resident was discharged from the facility and sent to the hospital for a psychiatric evaluation on 01/07/14. 4. Review of the facility's investigation revealed the SRNA was immediately suspended and removed from the facility on 12/31/13. 5. Interview with the Regional Director of Clinical Services (RDCS), on 01/22/14 at 1:08 PM, revealed the audits of resident clinical records which included review of nurse's notes back to 07/17/13 identified three (3) residents with behaviors requiring increased monitoring through 1:1. Review and observation confirmed 1:1 was occurring and documented. The RDCS revealed Resident #3 was identified as one of these residents. Review of the Psychiatric ARNP notes, dated 01/15/14, revealed Resident #3 was listed as one of the residents assessed. 6. Interview with the Vice President of Clinical Operations (VPCO), on 01/22/14 at 2:48 PM, revealed resident's identified with behaviors from the chart audits, on 01/07/14 through 01/08/14 and staff interviews on 01/11/12 through 01/12/14, had interventions put in place during the care plan review. Observation of Resident #3, on 01/21/14 at 4:12 PM, revealed 1:1 supervision was provided with a SRNA #8. 7. Review of the Behavior Meeting notes, on 01/12/14, revealed Resident #3 was listed with identified behaviors, medications, and interventions. 8. Review of Resident #3's Care plan revealed an intervention for 1:1 supervision on 01/13/14. 9. Review of the faxed communication with the SSA from the facility revealed the incident involving Resident #3 and #1, on 11/05/13 was reported on 01/08/14 and a 5 day report was submitted on 01/13/14. 10. Review of the Behavior Meeting notes, on 01/12/14, revealed Resident #2 was reviewed to include a medical record review and care plan review. Interview with the Corporate Administrative Registered Nurse (CARN), on 01/22/14 at 1:27 PM, revealed Resident #2 did not need increased monitoring was not exhibiting behaviors. 11. Review of the faxed communications to the SSA from the Facility revealed the incident on 07/17/13 with Resident #1 and #2 was reported on 01/08/14 and a 5 day follow up was submitted on 01/13/14. 12. Interview with Resident #2, on 01/22/14 at 2:03, revealed he/she did have a conversation with the DCS and SSD regarding the incident on 07/17/13 and 01/06/14. Resident #2 revealed being asked if he/she felt safe and what had occurred. 13. Interview with the Regional Director of Clinical Services (RDCS), on 01/22/14 at 1:08 PM, revealed the audits of resident clinical records which included review of nurse notes back to 07/17/13 identified three (3) residents (#3, #13, and #21) with behaviors requiring increased monitoring. A. Review of the Behavior Management Meeting notes, dated 01/12/14, revealed the three (3) identified were Residents #3, #13, and #21 were included in the meeting. B. Review of the three (3) identified resident's care plan (#3, #13, and #21) revealed interventions to increase supervision using 1:1 was added. C. Review of the Psychiatric ARNP notes, dated 01/15/14, revealed two (2) of the three (3) residents (Residents #13 and #21) had medications and behaviors reviewed. D. Review of the nursing notes and 24 hour report book, revealed the three (3) residents (#3, #13, and #21) were monitored daily with documented behaviors observed. 14. Interview on 01/21/14 with twelve (12) residents, identified as interviewable with a BIMS of 8 or greater, revealed they felt safe at the facility and had been interviewed by the SSD. 15. Review of the facility skin sweeps, dated 01/07/14, 01/08/14, and on 01/15/14, revealed the facility's 89 residents were assessed with [REDACTED]. 16. Interview with sixteen (16) facility staff, Certified Occupational Therapy Assistant (COTA) #1 on 01/20/14 at 2:30 PM; COTA #2 on 01/20/14 at 2:30 PM; LPN #7 on 01/21/14 at 3:25 PM; Maintenance Director on 01/21/14 at 3:30 PM; Dietary Cook on 01/21/14 at 3:35 PM; Dietary Aide on 01/21/14 at 3:37 PM; LPN #8 on 01/21/14 at 3:39 PM; SRNA #10 on 01/21/14 at 4:00 PM; SRNA #8 on 01/21/14 at 4:12 PM; Medical Records on 01/22/14 at 12:58 PM; Payroll/HR on 01/22/14 at 12:50 PM; Business Office Manager on 01/22/14 at 3:11 PM; LPN #5 on 01/22/14 at 1:01 PM; Housekeeper on 01/22/14 at 12:52 PM; SRNA #12 on 01/22/14 at 4:23 PM; and SRNA #11 on 01/22/14 at 4:05 PM, revealed they were asked to identify any residents who exhibited behaviors, abuse and/or neglect that had not been reported. Review of the Behavior Monitoring tool revealed staff was to document who identified a behavior, which resident, and the behavior identified. 17. Review of the faxed communication and facility investigations revealed the seven (7) identified incidents were reported to the SSA on 01/08/14. The expanded sample included five incidents involving Residents #9 and 10, #11 and 12, #13 and 14, #15 and 16, and #17 and 18. 18. Interview with the RDCS, on 01/22/14 at 1:08 PM, revealed the resident's concerns (grievances) were reviewed for potential allegations and none were identified. 19. Interview with RDCS and DCS, on 01/21/14 at 2:30 PM, revealed personnel files were audited on 01/12/14 for: two (2) reference checks, OIG report, Kentucky Board of Nursing Nurse Aide Abuse Registry, Criminal Record Checks, and abuse acknowledgment. RDCS and DCS revealed audits compared to current staff roster and the facility had no new hires for review. Review of two (2) SRNAs, the ED and Activities Assistant personnel files revealed they were accurate. 20. Review of the staff training signature sheets, dated 01/11/14 through 01/15/14, covering the following topics: Identification of Resident Behaviors, Behavior Management, Behavior Reporting, Abuse Education, Facility Policies and Procedures for Behaviors, Emotional and Behavioral Support, Management Problems of Resident with Dementia, Behavior Monitoring, Federal Regulations F223, F225, F226, Physical and Sexual behavior, reporting to Charge nurse and DCS/ED, and documentation contained 116 staff signatures. Interviews with sixteen (16) facility staff members, (See #16) on 01/21/14 and 01/22/14, verified abuse education was completed and followed by an abuse post-test. 21. Interview with the Human Resource/Payroll Coordinator, on 01/22/14 at 12:50 PM, revealed she was educated on required screening components for new hires. Components to include Criminal background checks, two (2) reference checks, OIG report, Kentucky Board of Nursing Nurse Aide Abuse Registry, and abuse acknowledgment. 22. Review of training signature sheets, dated 01/11/14 through 01/15/14, revealed both the ED and DCS signatures as attending the training. A separate training, dated 01/12/14, revealed just the ED and DCS were trained on the facility's Abuse and Neglect Policy and the procedures for reporting investigating. The facility's abuse policy contained new employee hire screening components. 23. Interview with the RDCS and the DCS, on 01/21/14 at 2:20 PM, revealed resident interviews regarding potential abuse issues, and mock surveys consisting of care plan review and implementation, behavior documentation, and staff interviews, were completed on all halls on 01/13/14, the F Hall on 01/14/14, E and F Halls on 01/15/13. Mock surveys continued on 01/16/14 for A, C, E, and F Halls, 01/17/14 for E, A, B, F Halls, and A Hall was done again on 01/18/14. 24. Review of the Behavior Management Meeting, dated 01/12/14, revealed twenty-four (24) residents were reviewed. Review of the psychiatric ARNP notes, dated 01/15/14, revealed nine (9) residents were reviewed which included review of medications. 25. Review of the chart audits, dated 01/15/14, revealed care plans were updated according to concerns noted in SSD notes. Review of 24 resident care plans revealed they had been updated. 26. Review of the facility's education, and review of the staff training signature sheets, dated 01/11/14 through 01/15/14, covering the following topics: Identification of Resident Behaviors, Behavior Management, Behavior Reporting, Abuse Education, Facility Policies and Procedures for Behaviors, Performance Improvement Committee, Indicators, Performance Improvement Committee, Emotional and Behavioral Support, Management Problems of Resident with Dementia, Behavior Monitoring, Federal Regulations F223, F226, F250, Physical and Sexual behavior, reporting to Charge nurse and DCS/ED, and documentation contained 116 staff signatures including the SSD. The SSD was not available for interview. 27. Review of the Morning Minute worksheet provided by the facility as the Social Services oversight revealed concerns identified were addressed. Incident report Investigations were completed by Corporate Social Services. No new incident reports were reported; however, seven (7) incidents identified were reviewed and addressed. 28. Review of the staff training signature sheets, dated 01/11/14 through 01/15/14, covering the following topics: Identification of Resident Behaviors, Behavior Management, Behavior Reporting, Abuse Education, Facility Policies and Procedures for Behaviors, Performance Improvement Committee, Indicators, Performance Improvement Committee, Emotional and Behavioral Support, Management Problems of Resident with Dementia, Behavior Monitoring, Federal Regulations F223, F225, F226, F280, F282, F323, F514, Physical and Sexual behavior, reporting to Charge nurse and DCS/ED, and documentation and care plan interventions contained 116 staff signatures. Interviews with sixteen (16) facility staff members, (see #16) on 01/21/14 and 01/22/14, verified education was completed and followed by a post-test. 29. Review of the staff training signature sheets, dated 01/11/14 through 01/15/14, covering the following topics: Identification of Resident Behaviors, Emotional and Behavioral Support, Management Problems of Resident with Dementia, Behavior Monitoring, Federal Regulations F280, F282, F514, Physical and Sexual behavior, reporting to Charge nurse and DCS/ED, documentation and care plan interventions contained 116 staff signatures. Interviews with sixteen (16) facility staff members, on 01/21/14 and 01/22/14, verified education was completed and followed by a post-test. Education did include following interventions on the care plan for resident behaviors. 30. Review of the signed census, dated 01/11/14 and 01/12/14, indicated residents had reviews and revisions of their care plan. Care plans for Residents #3, #19 and #21 were reviewed with revisions. 31. Review of training signature sheets, dated 01/11/14 through 01/15/14, revealed both the ED and DCS signatures as attending the training. A separate training, dated 01/12/14, revealed just the ED and DCS were trained on the facility's Abuse and Neglect Policy and the procedures for reporting investigating. The facility's abuse policy contained new employee hire screening components. 32. Interview with the Vice President of Operations, on 01/22/14 at 12:45 PM, revealed an AD-Hoc QA meeting occurred on 01/10/14 to discuss the IJ citations. Interview with the Regional DCS and the DCS, on 01/21/14 at 2:30 PM, revealed the facility's abuse policy and procedure was reviewed and discussed on 01/15/14 in the QA meeting. The Regional DCS revealed no changes were made to the policy as it was determined the facility had a system problem and changes were made in the facility's system to follow the abuse policy. Review of the QA signature sheets and agenda, on 01/15/14, revealed twenty-three (23) people were in attendance and all IJ citations were reviewed and discussed. The QA committee reviewed the facilities policies for Abuse, Resident to Resident Abuse, Behavior Monitoring, Behavior Management, Incidents and Accidents, Performance Improvement, and Morning Meeting. Review of the QA sign in sheet and agenda, on 01/20/14, revealed seven (7) members were in attendance including the Medical Director, the Interim ED, Interim DCS, Regional DCS, and Regional Vice President of Operation. The recent survey findings and recommendations were discussed. Interview on 01/21/13 at 2:30 PM, with the Interim DCS revealed there were no changes to the policy and procedure; however, there was a system change to follow the policy. 33. Review of training signature sheets, dated 01/11/14 through 01/15/14, revealed both the ED and DCS signatures as attending the Training. A separate Training, dated 01/12/14, revealed just the ED and DCS were trained on the facility's Abuse and Neglect Policy and the procedures for reporting investigating. The facility's abuse policy contained new employee hire screening components. Interview with the DCS on 01/21/14 at 2:30 PM, revealed she was knowledgeable of the regulations requirements for identifying and reporting abuse. Interview with the ED on 01/22/14 at 12:50 PM, revealed training was received and could voice understanding of the regulation, types of abuse, and identification of abuse and reporting abuse requirements.

Based on observation, interview, record review, and review of the facility's policy, Accident and Incident Investigation, Behavior Monitoring, and education materials, it was determined the facility failed to have an effective system in place to ensure staff adequately supervised residents with behaviors for fifteen (15) of twenty-two (22) sampled residents. The facility failed to identify and monitor all exhibited behaviors by Residents #1, #2, #3, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and #22. Additionally, the facility failed to monitor Resident #1's behavior of physical, sexual, and verbal abuse to provide needed care and treatment in an attempt to maintain a safe environment for other residents in the facility. This is a repeat deficiency from the Standard Health Survey of 08/01/13 cited at a "G" level. On 07/17/13, Resident #1 was found in Resident #2's room with his/her hand under Resident #2's sheet. Resident #2 was telling Resident #1 to stop, after Resident #1 continued to "play" with Resident #2, the resident got mad and threw a pack of cookies at Resident #1. Resident #1 then started to throw items at Resident #2. Attempts by staff to remove Resident #1 from the room resulted in Resident #1 refusing to leave Resident #2's doorway for twenty (20) minutes while yelling and arguing with staff. On 11/08/13, a verbal exchange occurred between Resident #1 and Resident #3, that escalated in to a physical altercation. Resident #1 was verbally assaulting Resident #3. Resident #3 hit Resident #1 with the walker and fell to the ground. Resident #1 then kicked Resident #3 in the head multiple times. On 11/06/13, Resident #1 complained of arm pain and an x-ray revealed a dislocated shoulder. On 12/31/13, State Registered Nurse Aide (SRNA) #2 and Resident #1 were overheard yelling and screaming at each other by Licensed Practical Nurse (LPN) #2, LPN #3, and LPN #4. LPN #3 revealed he approached SRNA #2 and Resident #1 and stood between them in an attempt to separate them. When Resident #1 touched SRNA #2 on the arm, both the SRNA and the resident began hitting each other in the A/D Hall Television room. LPN #3 revealed he was unable to separate SRNA #2 and the resident and it took him, LPN #2 and LPN #4 to separate the two. The SRNA was taken outside to the courtyard, but continued to try to get inside the building while the resident was cursing at the SRNA and hitting the staff trying to get to SRNA #2 in the courtyard. On 12/30/13, the facility's Activities Director was observed, by the Adult Psychiatric Advanced Registered Nurse Practitioner (ARNP), yelling and screaming at Resident #19. On 07/28/13, Resident #10 received an unwelcomed kiss from Resident #9. On 11/30/13, Resident #15 and Resident #16 were in a physical altercation. On 09/07/13, Resident #13 made verbally threatening remarks to Resident #14. On 10/24/13, Resident #11 threw a bowl of soup that landed on Resident #12. On 01/09/14, Resident #17 and Resident #18 were involved in an altercation. The facility's failure to have an effective system in place to ensure residents were free from abuse, were adequately supervised and monitored for behaviors placed residents at risk in a situation that has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/10/14 and determined to exist on 07/17/13. The facility was notified of the Immediate Jeopardy on 01/10/14. An acceptable Allegation of Compliance (AOC) was received on 01/20/14 and the State Survey Agency (SSA) validated the Immediate Jeopardy was removed on 01/16/14, as alleged, prior to exit on 01/22/14. The scope and severity was lowered to an "E" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy regarding Accident and Incident Investigation, reviewed 12/27/13, revealed certain incidents would be investigated to determine root cause and to provide an opportunity to decrease future occurrences of the event. Any event that was not of the facility's routine operations or care of a resident should have the completion of an incident report. Additionally, certain events would also require the completion of designated investigation forms, including behavior outburst with using the Behavioral Outburst Assault of another Resident or Staff. The Executive Director (ED), Director of Clinical Services (DCS) or designee should begin a documented investigation to include interviews with the resident, staff involved, and others who may be able to help with the investigation. Additionally, results of the investigation would be reviewed by the DCS to ensure it was completed and thorough. Review of the facility's policy regarding Behavior Monitoring, reviewed 01/03/13, revealed any resident that exhibited behaviors would have a "Behavior/ Intervention Monthly Flow Record" (Behavior Sheet) initiated. The Behavior Sheet required documentation every shift as well as a summary in a weekly progress note. Behaviors listed included: violent behavior/striking other residents, sexual, verbal, or physical behavior toward other residents, sexual aggression, verbal or physical abuse toward staff, abusive yelling or screaming, kicking, aggression during walking/wheeling, and any other behavior which posed harm to other residents. The documentation should include the specific type of behavior being monitored, i.e. kicking, hitting, yelling. Additional documentation included: the number of times the behavior was observed during the shift; the code for the first attempted intervention; non-pharmacological interventions; the code for the outcome; and the code for any side effects observed. The Behavior Sheet was to be maintained with the Medication Administration Record (MAR) for the resident. Behavior monitoring may be discontinued when the resident's behavior was no longer necessary to be observed, or the resident was no longer on medication requiring behavior monitoring. The policy also revealed any resident that received psychoactive medications, would have a Behavior Sheet. The medication being monitored and the specific behavior that indicated the use of the medication should be noted. Review of the facility's abuse education materials describing abuse prevention techniques, included: identification of residents at risk would include those with behaviors and communication deficits. Interventions included knowledge of care plan approaches for each resident, avoid arguing, distractions, and to be mindful of tone of voice and other body language. Interview with the Staff Development Coordinator (SDC), on 01/06/14 at 2:28 PM and 3:20 PM, revealed orientation was conducted for new employees as well as annual competencies. She stated these trainings included resident behaviors as part of the facility's abuse training. 1. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 06/22/11, with [DIAGNOSES REDACTED]. The resident was also diagnosed with [REDACTED]. The facility completed a Quarterly Minimum Data Set (MDS) assessment for Resident #1 on 11/25/13, and assessed the resident to have a Brief Interview Mental Status (BIMS) score of 11, indicating the resident was interviewable. Review of the Comprehensive Care Plan, dated 09/04/13 and revised 11/25/13, revealed the care plan for Resident #1 included behaviors of verbal abuse and flirtatious behavior with male residents. Interventions included talking to the resident in a calm manner, not arguing with the resident, and re-direct the resident when the resident was being verbally abusive or using inappropriate language/profanity. Continued review of Resident #1's clinical record revealed a Medication Administration Record (MAR) for January 2014; however, a Behavior Sheet for January 2014 was not provided by the facility. Review of a Behavior Sheet, dated October 2013, for Resident #1 revealed the form was blank, with no behaviors listed or any other documentation. Review of a Psychiatric Note, dated 01/02/14, revealed the resident had been aggressive with staff. Additionally, it stated the resident baited staff to get them to react and the resident found some pleasure in the fact that the staff member reacted. A Psychiatric Note, dated 04/12/13, revealed Resident #1 had become aggressive with a peer and hit someone "young and stupid". A Nurse's Note, dated 07/17/13, revealed the resident had been in Resident #2's room with his/her hand under Resident #2's sheet. Resident #2 threw cookies at Resident #1 when the resident would not stop fondling him/her. Resident #1 was removed from the room by staff. A Psychiatric Note, dated 11/08/13, revealed the resident had been in a verbal altercation with Resident #3, which the facility determined was misinterpreted as a physical altercation. On 01/09/14 at 9:01 AM and 10:12 AM, interview with LPN #5 revealed it was sexually inappropriate behavior for Resident #1 to kiss Resident #2, and it was usually unwelcomed behavior. She stated Resident #2 could not push Resident #1 away as Resident #2 only had the use of one (1) arm; however, the resident could say "no". The Nurse stated she had told Resident #1 to back off and leave the room. She indicated when Resident #1 left the room, Resident #2 would say "thank you". LPN #5 further indicated she did not think Resident #2 liked it when Resident #1 would become affectionate, as Resident #2 would make a face at Resident #1. She indicated she was unaware of the incident between the residents on 07/17/13; however, after review of Resident #1's Nurse's Note it appeared to be sexual abuse. The Nurse stated if she had known about the incident on 07/17/13, then when she had seen Resident #1 touch Resident #2 she would have handled it differently and reported the interaction to the SSD. The LPN indicated the facility used behavior sheets if the resident was prescribed psychiatric medications and there was no other place in the record to document resident behaviors. She further indicated the resident had behaviors which included yelling and screaming. The Nurse stated the resident's care plan had not been updated to reflect physical aggression, which could lead to another similar incident that occurred on 12/31/13. Observation, of Resident #1, on 01/07/14 at 3:24 PM, revealed the resident was yelling, wanting to go outside to smoke. At 4:04 PM, Resident #1 was yelling "emergency" while self-propelling down the hallway. Continued observation at 4:06 PM revealed Resident #1 was near the nurse's station for the A and D Halls. The resident was yelling at a staff member, cursing. The resident positioned his/her wheelchair to corner the staff member between the nurse's station and the resident rooms, not leaving the staff a way to remove herself from the resident. The DCS placed the resident on 1:1 supervision with LPN #9, the resident asked LPN #9 what are you looking at? At 4:17 PM, the resident propelled self into Unsampled Resident B's room with the resident in the room and closed the door. LPN #9 yelled down the hall to get someone now. LPN #9 continued to stand in the hall and not attempt to remove Resident #1. At 4:19 PM, the resident removed him/her self from the room and no staff person entered Unsampled Resident B's room to ensure his/her safety. Interview with State Registered Nurse Aide (SRNA) #1, on 01/03/14 at 12:00 PM, revealed Resident #1 was uncooperative with his/her care and was difficult when working with him/her. She stated the resident had been verbally aggressive and had called her names. She stated she did not take behaviors too seriously. Interview, on 01/03/14 at 2:19 PM, with Licensed Practical Nurse (LPN) #2 revealed he had worked with Resident #1. LPN #2 stated at times the resident was difficult. On 01/06/14 at 8:52 AM, interview with the Unit Manager (UM) revealed she had also worked with Resident #1 while a floor nurse. She stated the resident at times would argue and yell at her. She stated the resident had never been physically aggressive with her or anyone at the facility. She stated the resident liked to smoke at times other than the supervised scheduled smoke breaks. The UM indicated when she would redirect the resident, Resident #1 would yell and scream and she would just walk away. Further interview revealed she did not do chart checks to see if behaviors were being monitored even though interview, on 01/19/13 at 10:36 AM, with the DCS revealed the Unit Manager was responsible for chart checks. Interview with the House Supervisor, on 01/10/14 at 1:35 PM, revealed she over heard staff talking about the incident with Residents #1 and #2 and told them to report it. However, she did not report this information to anyone else and she did not follow up to ensure it was reported. Interview with the Social Service Director (SSD), on 01/06/14 at 9:04 AM, revealed Resident #1 had a history of [REDACTED]. She stated the resident had been physically and verbally aggressive with an aide on 12/31/13. In addition, she was aware Resident #1 had behaviors, but staff never reported to her when they occurred. Continued interview on 01/07/14 at 8:57 AM, revealed the SSD indicated she was unaware of an incident noted in a Psychiatric Note, dated 04/12/13, in which the resident was aggressive with a peer and hit someone young and stupid. She indicated she was unaware of the incident on 07/17/13 of the sexual behavior of Resident #1 toward Resident #2. She further indicated an incident between Resident #1 and Resident #3, on 11/05/13, was a verbal altercation that had been misinterpreted as a physical altercation. The SSD stated the nurses should be documenting resident behaviors; however, they do not and she did not provide an explanation as to why. On 01/06/14 at 10:37 AM, interview with LPN #4 revealed Resident #1 at times was verbally abusive. She stated she was aware the resident had been physically abusive in the past; however, she had never witnessed the resident become physically aggressive. Interview, on 01/07/14 with the Interim Director of Clinical Services (DCS) revealed she had witnessed Resident #1 antagonize staff, and was aware the resident had been combative at times. She stated the resident's behaviors were not documented anywhere in the facility. She further stated she was not monitoring the documentation of behaviors because she assumed the UM was doing this and she should have been. The DCS stated resident behaviors should be documented in the chart and the aides should document behaviors in the kiosk (computer for staff to document resident care). She indicated behavior sheets should be in some resident Medication Administration Records (MAR) if certain medications were triggered for the use of the behavior sheet. The DCS stated the resident had been physically and verbally aggressive toward an aide on 12/31/13. She indicated she began employment on 11/05/13 and was unaware of an incident referred in a Psych Note dated 04/12/13. She stated she was surprised the resident had been physically aggressive as no physical aggression had been reported by staff. Additionally, the DCS indicated the sexual aggression on 07/17/13 with Resident #2 should also have been "written and dealt with" as an incident. She further indicated the incident with Resident #3 on 11/05/13 was not a physical altercation, it was a verbal exchange. Interview, on 01/09/14 at 11:06 AM, with the current DCS revealed a resident's complete chart and the resident's care plans were taken to care plan meetings as well as monthly behavior meetings with the Psychiatrist. She stated if behaviors were not documented in the clinical record, then the Psychiatrist would not have a full picture of the resident. Continued interview, on 01/19/14 at 10:36 AM, with current DCS revealed the Unit Manager was responsible for chart checks to ensure behaviors were documented. The DCS revealed she attended the morning meeting where incidents and behaviors would have been discussed, if they were documented. Further interview revealed the SSD documents the resident's behavior in a binder which is used to schedule meetings with the Psychiatrist. However, review of the SSD's binder revealed a list of residents on psychotropic medications and no behaviors had been documented, as well as no tracking of residents with behaviors, who were not receiving psychotropic medications. Continued interview revealed the behavior list was used in QA to monitor behaviors. However, after review of the actual binder content, she stated that was the only tool used and no behavior monitoring was being done. She further stated if residents were not on psychotropic medications, the staff should still have oversight, documenting and monitoring of behaviors. The DCS stated the system to monitor behaviors was not a very effective system. Interview with the Psychiatrist, on 01/09/14 at 1:54 PM, and on 01/10/14 at 2:28 PM, revealed he had spoken to Resident #1 on 01/02/14. He stated the resident had anti-social traits and limited impulse control. The Psychiatrist indicated the resident had been threatening to others and could be belligerent and hostile. He further indicated Resident #1 reported to him he/she knew he/she was getting under the aide's skin, baited the aide, and was pleased the aide was angry enough to fight the resident. The Psychiatrist stated he had also spoken to the resident about an incident when the resident hit someone young and stupid in reference to a Psych Note dated 04/12/13. He stated he was unaware of the incident on 07/17/13; therefore, had not been able to try and intervene. The Psychiatrist indicated the charting completed by the nurses was used in the monthly behavior meetings. On 01/14/14 at 10:08 AM, interview with MDS Coordinator #1 revealed she had not seen an increase in behavior for Resident #1 as it was the resident's normal behavior. Interview with the Advanced Registered Nurse Practitioner (ARNP), on 01/14/14 at 12:01 PM, revealed she had provided the facility information on how to best deal with certain behaviors, but that was not always followed. In addition, she stated there were more psychosocial problems than psychiatric. She had told the facility to not tolerate the cursing, yelling and bullying or it would end up like a prison yard. She further told them to document well and then issue a thirty (30) day notice of discharge if the behaviors continued. However, this too was not being done. The ARNP continued, stating she had to continuously bring up what to do, how to approach and document, but this still was not done. 2. Record review for Resident #1 and Resident #2 revealed no documented evidence of the incident when Resident #1 kissed Resident #2. Observation of Resident #1, on 01/06/14 at 1:48 PM, revealed the resident propelled him/her self with the right arm and foot, the resident was also able to travel backwards. The resident was observed to propel down the hallway to the Payroll office and asked staff where Resident #2 was and if she had seen the resident. The Payroll/ Human Resources Coordinator told Resident #1 that Resident #2 was with a staff member. Interview with SRNA #1, on 01/03/14 at 10:20 AM, revealed she had observed Resident #1 kissing and touching Resident #2, and stated Resident #1 entices him/her; however, she had not reported this behavior to the nurse. Interview with LPN #5, on 01/09/14 at 10:12 AM, revealed she stated around 12/31/13, or within a couple of days, Resident #1 was seen by a staff member to enter Resident #2's room and was observed kissing him/her. Interview with the SSD, on 01/06/14 at 9:04 AM, revealed she had seen Resident #1 and Resident #2 kissing each other recently. Interview with Resident #2, on 01/07/13 at 5:12 PM, revealed they were not girlfriend/boyfriend and the kissing was not reciprocal. 3. Review of the clinical record for Resident #3 revealed the facility admitted the resident on 12/03/12 with [DIAGNOSES REDACTED]. The facility completed a Significant Change MDS, on 10/14/13, which indicated the resident was assessed to have a BIMS score of two (2), and as being cognitively moderately impaired. Review of the Comprehensive Care Plan, dated 10/04/13, revealed the care plan for behaviors included interventions to not argue with the resident and to ensure safety of other resident and others. A Psychiatric Note, dated 11/08/13, revealed the resident had been in a verbal altercation with another resident, which had been misinterpreted as physical aggression. Interview with the Social Services Director, on 10/07/14 at 8:57 AM, revealed the altercation between Resident #1 and Resident #3 was a verbal exchange that the facility determined had been misinterpreted as a physical altercation. She further stated on 11/08/13, Resident #1 was verbally abusing Resident #3. Resident #3 hit Resident #1 with the walker and fell to the ground. Resident #1 then kicked Resident #3 in the head multiple times. On 11/06/13, Resident #1 complained of arm pain and an x-ray revealed a dislocated shoulder. Interview, on 01/09/14 at 3:08 PM, with SRNA #3 revealed she witnessed the incident between Resident #1 and Resident #3 on 11/05/13. She stated she heard Resident #1 verbally aggravating Resident #3, who then became physically aggressive toward Resident #1, who then became physically aggressive toward Resident #3. The aide indicated Resident #1 often picked at Resident #3 and felt Resident #3 had enough that evening. Continued interview with SRNA #2, on 01/07/14 at 12:41 PM, revealed she indicated Resident #1 had been in an altercation with Resident #3 in the past in which Resident #1 had kicked Resident #3. Observation, on 01/06/14 at 10:42 AM, of Resident #3 revealed the resident was approachable, sitting in the Television Room on the A and D Unit. Interview, on 01/07/14 at 8:57 AM, with the SSD revealed the altercation between Resident #1 and Resident #3 was a verbal exchange that the facility determined had been misinterpreted as a physical altercation. On 01/07/14 at 10:24 AM, interview with the Interim DCS revealed at the time of the incident on 11/05/13 between Resident #3 and Resident #1, she was the ADCS at the facility and was unaware of the circumstances of the incident. She stated physical abuse was physical contact between two (2) people and verbal abuse could be anything said that was demeaning to another person. During interview, on 01/08/14 at 11:06 AM, the DCS stated the Psychiatrist attended behavior meetings for residents; however, the Psychiatrist could not get a full picture of residents in the behavior meetings when the residents' behaviors were not documented. Interview with the Interim ED, on 01/07/14 at 12:35 PM, revealed he had been in this role and with the facility since 12/06/13. The ED stated the incident on 11/05/13 was a verbal altercation misinterpreted as a physical altercation between Resident #1 and Resident #3. He stated the incident would warrant further looking into. Continued interview, on 01/18/14 at 10:59 AM, revealed the ED indicated abuse would include an altercation between residents. Interview with the Advanced Registered Nurse Practitioner (ARNP), on 01/14/14 at 12:01 PM revealed she was aware of a physical altercation between Resident #1 and Resident #3. She stated the facility later informed her it was not physical but a verbal altercation. On 01/15/14 at 4:51 PM, interview with the Vice President (VP) of Clinical Operations revealed while reviewing the facility's QA Binder, she reviewed a Note, dated 11/05/13, that contained documentation that Resident #1 hit and was hit by another resident. In addition, there was another Note, not dated, that indicated Resident #3 hit another resident and was hit by another resident on 11/05/13. There was no documented evidence of any action taken by the QA Committee. 4. Review of the OIG Long Term Care self reported incident form, dated 01/01/14, revealed on 12/31/13, State Registered Nurse Aide (SRNA) #2 and Resident #1 were overheard yelling and screaming at each other by Licensed Practical Nurse (LPN) #2, LPN #3, and LPN #4. LPN #3 revealed he approached SRNA #2 and Resident #1 and stood between them in an attempt to separate them. When Resident #1 touched SRNA #2 on the arm, both the SRNA and the Resident began hitting each other in the A/D Hall Television room. LPN #3 revealed he was unable to separate SRNA #2 and the resident and it took him, LPN #2 and LPN #4 to separate the two. The SRNA was taken outside to the courtyard, but continued to try to get inside the building while the resident was cursing at the SRNA and hitting the staff trying to get to SRNA #2 in the courtyard. Review of the clinical record for Resident #1 revealed no documented evidence of this incident. Interview with SRNA #2, on 01/07/14 at 12:41 PM, revealed the Aide had been involved in a physical and verbal altercation with Resident #1 on 12/31/13. She stated the resident was physically and verbally aggressive with her. Additionally, the aide stated she had witnessed Resident #1 cursing at people, but nothing physical. The SRNA stated she should have reported it to the nurse, but she did not. The SRNA stated the whole fight could have been avoided if she had told the nurse about the resident's behaviors. 5. Review of Resident #9's clinical record revealed the facility admitted the resident on 02/22/13 with [DIAGNOSES REDACTED]. Review of the Comprehensive Behavior Care Plan, dated 02/22/13, and revised 07/23/13, revealed the resident's behaviors included removing clothing and grabbing at staff which had improved. Care plan interventions included giving the resident papers to shuffle, keep safe distance when behaviors occur, and take the resident to a quiet location as necessary. Review of a Nurse's Note, dated 07/28/13 at 7:35 PM, revealed the resident kissed a female resident's hand and after redirection from staff the resident kissed the female resident on the lips and inserted his/her tongue in his/her mouth. There was no documented evidence in the clinical record that the facility completed a Behavior Sheet. 6. Review of Resident #10's clinical record revealed the facility admitted the resident on 04/27/09 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 10/07/13 and revised 01/02/14, revealed the resident would place him/herself on the floor to get attention from staff. Interventions included re-educate resident to appropriate behaviors to get staff's attention and possible injury and remind resident to use call light. There was no documented evidence the facility completed a Behavior Sheet in the clinical record. 7. Review of the clinical record for Resident #11 revealed the facility admitted the resident on 05/24/12 with [DIAGNOSES REDACTED]. The facility completed a Quarterly MDS assessment, on 09/03/13, and assessed the resident with a BIMS score of 8, and as being oriented with confusion. Review of the Comprehensive Care Plan, dated 12/02/13, revealed the resident would often use profanity or vulgarity and call people names. Interventions included remind the resident calling people offensive names was inappropriate, provide a supportive environment, and redirect inappropriate decisions. A SSD note, dated 10/25/13, revealed the resident threw a bowl of soup in the dining room during the meal and some of the soup hit the resident sitting next to him/her. There was no documented evidence the facility completed a Behavior Sheet in the clinical record. 8. Review of the clinical record for Resident #12 revealed the facility did not assess for injury until a skin assessment, dated 10/26/13, that stated no areas noted. However, the incident occurred on 10/24/13 when the soup was thrown on the resident. 9. Review of the clinical record for Resident #13 revealed the facility admitted the resident on 06/27/11 with a [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 12/17/12, and revised 10/29/13, revealed the resident exhibited sexually inappropriate behavior and suggestive/ inappropriate comments to female staff. The Care Plan interventions included explain when behavior was inappropriate, praise positive behavior, and set limits in behavior. Review of a Nurse's Note, dated 09/07/13 at 5:00 PM, revealed the resident was arguing with another resident and threatened to stab him/her with a shoe horn. The resident was asked by staff to leave the shoe horn in his/her room. At 5:20 PM, the Nurse's Note revealed Resident #13 had again threatened the other resident. There was no documented evidence the facility completed a Behavior Sheet in the clinical record. 10. Review of Resident #14's clinical record revealed the facility admitted the resident on 12/06/12 with a [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 08/05/13 and revised 08/23/13, revealed the resident would consume alcohol without staff awareness. Interventions included to monitor for alcohol consumption to determine cause, intervene to ensure safety, set limits, and watch for behavioral cues, such as body language and tone of voice. Review of a Nurse's Note, dated 09/07/13 at 3:00 PM, revealed the resident was arguing with another resident and threatened him/her. There was no documented evidence the facility completed a Behavior Sheet in the clinical record. 11. Review of the clinical record for Resident #15 revealed the facility admitted the resident on 05/13/11, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 02/21/13 and revised 10/22/13, revealed the facility did not care plan the resident for behaviors or have evidence of a completed Behavior Sheet. The facility care planned behaviors of self-removal of stool. 12. Review of the clinical record for Resident #16 revealed the facility admitted the resident on 07/17/10 with a [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 11/25/13, revealed the resident would hide clothing and state the clothes were missing, claimed he/she was being physically abused, and throw him/herself on the floor. Review of a Nurse's Note, dated 11/30/13 at 9:00 PM, revealed the resident's back was assessed for injury from an altercation with another resident. There was no documented evidence in the clinical record the that the incident had occurred, no date, or time. There was no documented evidence the facility completed a Behavior Sheet in the clinical record. 13. Review of Resident #17's clinical record revealed the facility admitted the resident on 08/20/13, with a [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 09/03/13 and revised 11/14/13, revealed the resident had a history of [REDACTED]. Interventions included to observe resident's behavior to assist in determining cause of refusal per behavior f

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure staff followed the Comprehensive Care Plan for four (4) of twenty-two (22) sampled residents, Resident #1, #3, #5 and #19. State Registered Nurse Aide (SRNA) #2 failed to follow Resident #1's Comprehensive Care Plan for verbal aggression that led to the SRNA becoming physically and verbally abusive toward Resident #1. The facility staff failed to follow the plan of care for Resident #3 when a physical altercation occurred with Resident #1. The facility staff failed to follow the care plan for Resident #19 when a verbal altercation occurred with the Activites Director (AD). Additionally, the staff failed to provide showers to Resident #5 according to the Comprehensive Care Plan for hygiene and bathing resulting in nine (9) missed showers. The facility's failure to ensure an effective system was implemented to ensure a resident's comprehensive care plan was followed placed residents at risk in a situation that has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy was identified on 01/10/14 and determined to exist on 07/17/13. The facility was notified of the Immediate Jeopardy on 01/10/14. An acceptable Allegation of Compliance (AOC) was received on 01/20/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 01/16/14, as alleged, prior to exit on 01/22/14. The scope and severity was lowered to an "E" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy regarding Care Plans, reviewed 09/01/11, revealed all staff must be familiar with each resident's care plan and all approaches must be implemented. Additionally, all direct care staff must always know, understand, and follow a resident's care plan. If a staff member was unable to implement any part of a resident's care plan, the staff member was to notify the Clinical Nurse or Care Planning Coordinator. 1. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 06/22/11 with [DIAGNOSES REDACTED]. The resident was also diagnosed with [REDACTED]. The facility completed a quarterly MDS assessment for Resident #1 on 11/25/13 and assessed the resident to have a Brief Interview Mental Status (BIMS) score of 11. Review of the Comprehensive Care Plan, dated 09/04/13 and revised 11/25/13, revealed the facility's care plan for Resident #1 included behaviors of verbal abuse and interventions included: talk to the resident in a calm manner; do not argue with the resident; and re-direct the resident when the resident is being verbally abusive or using inappropriate language/profanity. Interview with the Social Services Director, on 01/09/14 at 4:04 PM, revealed she had determined the cause of the incident to be how the aide reacted to the resident. She further stated if the aide had intervened appropriately, the incident could have turned out differently. Interview with the Interim Director of Clinical Services, on 01/07/14 at 10:24 AM and on 01/09/14 at 11:06 AM, revealed the care plan for Resident #1, which stated, "flirtatious behavior" was a broad term and she could not define it. She indicated it was possible for staff to misinterpret what flirtatious behavior could mean in relation to Resident #1 and staff with different backgrounds/views would have difficulty knowing how to follow the care plan. Observation of Resident #1, on 01/03/14 at 10:29 AM, revealed the resident in his/her room, sitting in a wheelchair. Continued observation, on 01/06/14 at 1:54 PM, revealed the resident was seated in a wheelchair and able to self-propel backwards down the hallway using only the right foot. Observation, on 01/07/14 at 3:24 PM, of Resident #1 revealed the resident was yelling about wanting to go outside to smoke. At 4:04 PM, Resident #1 was yelling "emergency" while self-propelling down the hallway. Continued observation at 4:06 PM revealed Resident #1 was near the nurse's station for the A and D Halls. The resident was yelling at a staff member and cursing. The resident positioned his/her wheelchair to corner the staff member between the nurse's station and resident rooms, not giving the staff a way to remove herself from the resident. Interview with LPN #4, on 01/06/14 at 10:37 AM, revealed when Resident #1 would become verbally abusive she would walk away. She stated if a resident was combative or aggressive, staff should not escalate the situation or engage the resident. She stated the aides would have information about residents' behaviors on the kardex, which was maintained by the nurses. Additionally, LPN #4 stated the MDS Coordinators maintained the resident care plans; however, the nurses updated the care plans as needed. On 01/07/14 at 12:41 PM, interview with SRNA #2 revealed she could have handled the situation better. The aide stated she should have informed Resident #1's nurse and it all could have been avoided. The aide indicated she had been trained how to work with combative residents and to tell the resident's nurse if a resident becomes aggressive. The aide further indicated the aides have access to the resident care plans at the nurse's station. She stated she was unaware of Resident #1's care plan and interventions and would have to look at the resident's care plan to know what to do for the resident when he/she was exhibiting behaviors. Interview with Licensed Practical Nurse (LPN) #5, on 01/09/14 at 9:01 AM, revealed resident care plans were maintained in a book at the nurse's station. She stated she had been trained to follow a resident's care plan and how to handle resident behaviors. Preliminary care plans were completed by the admitting nurse, then the MDS staff completed the Comprehensive Care Plan which was kept in the care plan book at the desk. However, after the LPN reviewed the care plan and her knowledge of what happened on 07/17/13, she stated she should have known what was on there to prevent it from happening again. The LPN stated the floor nurses do not go to the care plan meetings to share information that witnessed, but not documented. The LPN stated she did not know who even went to care plan meetings that represented the nursing department. 2. Review of Resident #3's medical record revealed the facility admitted the resident on 12/03/12, with [DIAGNOSES REDACTED]. The facility assessed the resident using the Minimum Data Set, dated dated [DATE], revealed the resident was assessed as having verbal and other behaviors directed towards others. Review of the resident's medications revealed an antipsychotic medication of [MEDICATION NAME] given twice a day. The resident's comprehensive care plan revealed problems with behaviors and psychosocial well-being. The care plan revealed the resident was noted to be physically combative and socially inappropriate. Interventions included: warm approach; do not argue; keep safe distance ensure safety of others; consult with psychiatric services; talk calmly and divert attention. Observation and interview with Resident #3, on 01/06/14 at 10:42 AM, revealed the resident sitting in a chair in the A/D Hall television room. The resident revealed getting into a fight with Resident #1, who the resident frequently refers to Resident #1 as being the opposite gender. Resident #3 revealed they were outside and they started "swinging at each other". The resident revealed both of them were yelling and screaming at each other. 3. Review of the clinical record for Resident #19 revealed the facility admitted the resident on 09/18/13 with [DIAGNOSES REDACTED]. The comprehensive care plan, dated 12/20/13, revealed the resident displayed verbally aggressive behavior. The care plan interventions included diversional activities by activities staff, do not argue with the resident, and talk to the resident in a calm voice. Interview with the Activities Director (AD), on 01/14/14 at 3:56 PM, revealed she had been involved in a verbal altercation with Resident #19 on 12/30/13. She stated they had been talking and she was unable to meet the resident's request related to withdrawing money from the bank. The AD indicated the resident had become angry and began to yell. She indicated she had raised her voice to the resident and spoke with a forceful tone. The AD stated she was aware the resident had a history of [REDACTED]. The AD further indicated she had no knowledge of Resident #19's care plan. Additionally, she stated if she had known what interventions the resident was care planned for, it may have helped her in this situation. The AD stated she was part of the morning meetings; however, she was unaware if the incident with Resident #19 was discussed and documented. The AD further stated she had been trained at other facilities regarding how to handle behaviors, but not there. The AD stated she did not know how the resident was care planned regarding behaviors and none of the nursing staff had ever educated her on how to handle Resident #19's behaviors. The AD stated she did not document the incident in the medical record. Continued interview on, 01/15/14 at 11:56 AM, with the AD revealed she raised her voice, it was loud and with a forceful tone, she wanted Resident #19 to know she not going to allow him/her to speak to her that way. Interview, on 01/07/14 at 10:24 AM and 01/09/14 at 11:06 AM, with the Interim Director of Clinical Services (DCS) revealed the care plan for Resident #1 regarding "flirtatious behavior" was a broad term and she could not define it. She indicated it was possible for staff to misinterpret what flirtatious behavior could mean in relation to Resident #1 and with different views/ backgrounds the staff would have difficulty knowing how to follow the care plan. She further indicated she began employment at the facility on 11/05/13 as the Assistant DCS (ADCS) and became the Interim DCS on 11/12/13 or 11/13/13. The DCS stated she had not completed any monitoring or follow up to the POC from the standard survey on 08/01/13. She also stated she had never reviewed the POC and was unable to locate the information. The DCS indicated she had last requested the POC for review prior to the Thanksgiving holiday; however, no one was able to locate the State Survey Book. She further indicated she should have been aware of previous issues and felt she could not do her job effectively with the information she had been given. Interview with the interim Executive Director (ED), on 01/16/14 at 9:25 AM, revealed Resident #19 had become very loud with the AD during their conversation, and the AD's tone matched the resident's. He stated when the AD returned to work a few days later he educated her on personal space. Continued interview, on 01/16/14 at 10:22 AM, the ED stated he viewed and investigated the incident as a customer service issue and not a resident care problem, which would require interventions. The ED further stated he was unaware the reason, when, or by whom the incident with the AD and Resident #19 had become a care concern and reported to the State Survey Agency. He indicated the record should speak for itself. 4. Review of Resident #5's medical record revealed the facility admitted the resident, on 10/21/05, with the [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's Range of Motion was impaired on both sides of the upper and lower extremities and the resident required total assistance with bathing. Review of the facility's Nurse Tech Information Kardex for Resident #5 revealed the resident was to receive showers on Tuesdays and Fridays. Review of the resident's comprehensive care plan revealed the resident was to receive showers per the schedule. Observation and interview with Resident #5, on 01/02/14 at 11:17 AM, revealed he/she was having problems receiving baths and showers as scheduled. Review of the Resident Bathing Type by Day Chart, for 10/17/13 to 01/02/14, revealed the resident had only received twelve (12) showers with no showers recorded as given from 12/04/13 to 01/02/14. Review of the facility's shower schedule revealed the resident should have received two (2) showers a week for a total of nine (9) showers that were missed. Interview with State Registered Nursing Assistant (SRNA) #6, on 01/03/14 at 2:35 PM, revealed that Resident #5 was supposed to receive showers on day shift twice a week and could only remember a few instances when it was not done. The SRNA revealed Nurse Tech Information Kardex and the shower schedule kept in the shower binder, directed when and how often the showers were to be done. The SRNA revealed the procedure when showers were not completed, was to notify the nurse and pass the information on to the next shift to be done. The SRNA revealed she did not follow up to ensure showers were completed and did not always have time to document in the Care Tracker system when they are done. The SRNA revealed the shower book was to be signed and complete the Skin Sweep paper, which was kept in the shower book and done at the time of the shower, and then turned in to the nurse. Interview with Licensed Practical Nurse (LPN) #6, on 01/03/14 at 2:50 PM, revealed she did not check to ensure SRNA charting was complete or ensure bathing was done as care planned. The LPN revealed she signed off on the Skin Sweep forms and turned them in to the Unit Manager. However, the LPN was unable to find the Skin Sweeps or any evidence the showers were done. Further interview with the LPN, on 01/03/14 at 3:00 PM, revealed she had not reviewed Resident #5's care plan or ensured it was followed as care planned for shower needs. Interview with the Unit Manager, on 01/03/14 at 4:05 PM, revealed she was not aware Resident #5 voiced a concern about not receiving showers and had not been monitoring to ensure showers were being completed per the resident's plan of care. Interview with the Director of Clinical Services (DCS), on 01/03/14 at 4:15 PM, revealed the purpose of the care plan was to direct the residents care and she relied on the Unit Manager to monitor showers. The DCS revealed she completed random audits of the care plans. However, she stated she was not aware the Unit Manager was not monitoring showers and did not complete chart reviews to ensure showers were being done or care plans followed. Further interview with the DCS, on 01/09/14 at 11:06 AM, revealed all nurses have been trained to update the care plan and the Kardex to reflect any changes. The facility provided an Allegation of Compliance (AOC) on 01/20/14 alleging the Immediate Jeopardy (IJ) was removed on 01/16/14; the facility took the following immediate steps to remove the IJ: 1. Resident #1 and SRNA #2 were immediately separated on 12/31/13 by staff. 2. The police were notified of the incident on 12/31/13. 3. Resident #1 was discharged to the hospital for a psychiatric evaluation on 01/07/14. 4. SRNA #2 was suspended immediately on 12/31/13. 5. Resident #3 was referred by the DCS, and seen by the Psychiatric ARNP, on 01/15/14. 6. Resident #3 was placed on increased supervision, 1:1 observation, to redirect impulse behaviors on 01/12/14. 7. Resident #3 was reviewed by the Interdisciplinary Team (IDT) (consisting of the Corporate Administrative Nurse, DCS, Activity Director, and Regional Director of Clinical Services) in the Behavior Management Meeting, on 01/12/14, which included a medical record review. 8. Resident #3's care plan was updated by the Corporate Administrative Registered Nurse on 01/13/14. 9. The incident involving Resident #3, on 11/05/13, was reported to the State Survey Agency (SSA), on 01/08/14 via a 24 Hour Report, investigated and a 5 Day report was submitted to the SSA on 01/13/14. 10. Resident #2 was reviewed in the Behavior Management Meeting by the IDT Corporate Administrative Registered Nurse, DCS, Activity Director, and the Regional Director of Clinical Services on 01/12/14 which included a medical record review and a care plan review. 11. The incident on 07/17/13 involving Resident #2 was reported to the SSA on 01/08/14 via a 24 hour report. A 5 day Report was submitted to the SSA on 01/13/14. 12. Resident #2 was interviewed on 01/07/14 by the SSD and the DCS regarding the incident on 07/17/13 and 01/06/14. 13. Current resident chart reviews completed , on 01/07/14 and 01/08/14 by the DCS, ADCS, Unit Manager and RDCS and staff interviews on 01/11/14 and 01/12/14 by Corporate Administrative Registered Nurses to identify residents with behaviors, the facility identified three (3) residents (#3, #13, and #21) as exhibiting sexual or physical behaviors towards others. These three residents were: A. Reviewed in the Behavior Management Meeting by the IDT (Corporate Administrative Registered Nurse, Director of Clinical Services Activity Director, and the Regional Director of Clinical Services) on 01/12/14. B. Increased supervision was initiated on 01/12/14 and the care plans were revised by the Activity Director the Corporate Administrative Registered Nurse and the DCS on 01/13/14. C. Referred to the Psychiatrist for review by the DCS and two ( #13 and #21) of three residents were seen on 01/15/14. D. Had documentation of behavior reviewed daily since 01/13/14 by a member of the IDT (to include the DCS, ED, and the Corporate Administrative Registered Nurses). 14. Thirty-nine (39) residents, with a brief interview for mental status (BIMS) of an eight or above were interviewed by the Social Services on 01/07/14 to ensure they had not been abused or neglected. 15. All residents were assessed by nurses via skin sweeps for suspicious injuries on 01/07/14, 01/08/14, and on 01/15/14 with no injuries found. 16. All Department Heads along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116) were interviewed by the Corporate Administrative Registered Nurse on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 to ensure no one had witnessed any abuse or neglect that had not been previously reported. 17. Current resident charts were reviewed on 01/07 and 01/08/14 by the Director of Clinical Services, Assistant Director of Clinical Services, Staff Educator, Unit Manager, and the Regional Director of Clinical Services to determine if there were any incidents that were reportable and/or needed further investigation. The seven (7) incidents that were identified during the review were reported on 01/08/14. 18. The facility's concern book was reviewed by the Regional Director of Clinical Services on 01/11/14 for allegations that needed to be reported and no allegations were identified. 19. The current staff members' employee personnel files were reviewed by Regional Director of Human Resources and Facility Human Resources/Payroll Coordinator to ensure that the files were completed with the Criminal Background Check, Kentucky State Board of Nursing/Nurse Aide Abuse Registry check, Office of the Inspector General Check, Telephone Reference Checks and Abuse/Neglect Attestation on 01/11/14 and 01/12/14. The six (6) discrepancies identified were corrected with missing Criminal Background Checks and Reference checks by 01/12/14. 20. All current Department Head staff along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116 employees) were educated by the Corporate Administrative Registered Nurses on abuse screening, training, prevention, identification, investigation, protection, reporting and response, F223 and the facility's Policy and Procedure for Resident Abuse, on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 and completed a post test. No staff members worked beyond 01/12/14 without having already been educated prior to the start of their shift. 21. The Human Resource/Payroll Coordinator was reeducated by the Regional Director of Human Resources on 01/12/14 that newly hired employees must have a Criminal Background Check, Kentucky Board of Nursing/Nurse Aide Abuse Registry Screen, Office of the Inspector General Exclusion Check, and Telephone reference checks. 22. The ED and DCS were re-educated by the Vice President of Clinical Services on 01/11/14 and 01/12/14 to ensure newly hired employees must have a Criminal Background Check, Kentucky Board of Nursing/Nurse Aide Abuse Registry Screen, Office of the Inspector General Exclusion Check, and Telephone reference checks. The ED will validate and sign that Newly Hired Employees have had all the required checks. 23. Mock Survey Rounds consisting of care plan review and implementation, behavior documentation, and staff interviews were completed by the IDT on 01/13/14, 01/14/14, and 01/15/14 that included resident interviews regarding potential abuse issues. 24. A Behavior Meeting was conducted by the IDT on 01/12/14 to review the current residents with known behaviors to discuss the behaviors, interventions, and medication. The nine (9) residents identified as having some type of behavior were referred to the physician and interventions were updated on the care plans by the IDT on 01/15/14. 25. Social Service notes were reviewed and Care Plans updated by the Corporate Social Services on 01/15/14. 26. The Social Service Director (SSD) was re-educated by the Corporate Administrative Registered Nurse on F250 and the facility's Policy and Procedures for Abuse and Behaviors on 01/12/14. 27. The Social Service Department consisting of the Corporate Social Services, Corporate Administrative Registered Nurse had daily oversight on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 with review of resident and family concerns daily in the morning meeting to ensure department managers were working towards resolution. 28. All facility staff was educated by the Corporate Administrative Registered Nurse on identification of behaviors to include but not limited to sexual and physical behavior on 01/12/14. Residents with behaviors will be discussed weekly at the Behavior Management Meeting to ensure targeted behaviors are documented, care planned, and appropriate interventions are in place. The Nurse will document the behaviors on the 24 hour report to be shared during the morning meeting. 29. All facility staff were educated, on 01/12/14, 01/13/14, 01/14/14, 01/15/14, by the Corporate Administrative Registered Nurses, that revisions are made to the resident's care plan to include interventions for behaviors. The staff was instructed to follow the care plan for specific interventions for resident's interventions. Education was also provided on identification of accidents which can include behaviors, intervene, and report sexual and physical behavior to the resident's nurse for documentation in the medical record and follow up with the Physician. The nurse will also document in the 24 hour report to share information in the morning meeting. In addition all staff was educated on F520, the facility's policies for Behaviors, Incidents, Documentation, and Performance Improvement which included the QAPI process, Monitoring of Facility Care Services, Identification of Performance Improvement Opportunities, and the Role of the Performance Team. 30. All resident care plans were reviewed and/or updated by the Regional Case Mix Coordinator on 01/11/14 and 01/12/14 to ensure they were accurate as compared to the Minimum Data Set and physician's orders [REDACTED]. 31. The facility's Administrative staff (ED/Abuse Coordinator and DCS) have been educated by the Corporate Administrative Registered Nurse on 01/12/14 that abuse allegations which are reported to them by employees must be investigated and reported to the appropriate officials in accordance with Federal and State Regulation. 32. The QAPI Committee had an Ad-Hoc QAPI meeting on 01/10/14 to discuss IJ citations and on 01/15/14 to discuss performance improvement opportunities and to review the facility's Abuse policy. The attendees consisted of the Interim Director of Clinical Services, Dietary Manager, Business Office Manager, Director of Admissions, Medical Records, Central Supply, Regional Case Mix Coordinator, Regional Director of Human Resources, Regional Director of Business Services, Regional Director of Clinical Services, Corporate Administrative RN, Director of Rehabilitation Services, Clinical Ambassador, Corporate Director of Education, Regional Vice President of Operations, Vice President of Operations, Vice President of Clinical Services, Vice President of Admissions & Marketing, Corporate Operations Team Member and Executive Director via telephone. 33. The ED and DCS were re-educated by the Corporate Administrative Registered Nurse on 01/12/14, regarding the regulations for F520, the facility's policies for Behaviors, Incidents, Documentation, and Performance Improvement which included the QAPI process, Monitoring of Facility Care Services, Identification of Performance Improvement Opportunities, and the Role of the Performance Team. Through observation, interview, and record review the State Survey Agency (SSA) validated the AOC, on 01/21/14-01/22/14 prior to exit as follows: 1. Review of Resident #1's closed medical record and the facility's investigation revealed Resident #1 and SRNA #2 were immediately separated. 2. Review of the facility's investigation revealed the Police were notified of the incident on 12/31/13. 3. Review of the Resident #1 closed medical record revealed the resident was discharged from the facility and sent to the hospital for a psychiatric evaluation on 01/07/14. 4. Review of the facility's investigation revealed the SRNA was immediately suspended and removed from the facility on 12/31/13. 5. Interview with the Regional Director of Clinical Services (RDCS), on 01/22/14 at 1:08 PM, revealed the audits of resident clinical records which included review of nurse's notes back to 07/17/13 identified three (3) residents with behaviors requiring increased monitoring through 1:1. Review and observation confirmed 1:1 was occurring and documented. The RDCS revealed Resident #3 was identified as one of these residents. Review of the Psychiatric ARNP notes, dated 01/15/14, revealed Resident #3 was listed as one of the residents assessed. 6. Interview with the Vice President of Clinical Operations (VPCO), on 01/22/14 at 2:48 PM, revealed resident's identified with behaviors from the chart audits, on 01/07/14 through 01/08/14 and staff interviews on 01/11/12 through 01/12/14, had interventions put in place during the care plan review. Observation of Resident #3, on 01/21/14 at 4:12 PM, revealed 1:1 supervision was provided with a SRNA #8. 7. Review of the Behavior Meeting notes, on 01/12/14, revealed Resident #3 was listed with identified behaviors, medications, and interventions. 8. Review of Resident #3's Care plan revealed an intervention for 1:1 supervision on 01/13/14. 9. Review of the faxed communication with the SSA from the facility revealed the incident involving Resident #3 and #1, on 11/05/13 was reported on 01/08/14 and a 5 day report was submitted on 01/13/14. 10. Review of the Behavior Meeting notes, on 01/12/14, revealed Resident #2 was reviewed to include a medical record review and care plan review. Interview with the Corporate Administrative Registered Nurse (CARN), on 01/22/14 at 1:27 PM, revealed Resident #2 did not need increased monitoring was not exhibiting behaviors. 11. Review of the faxed communications to the SSA from the Facility revealed the incident on 07/17/13 with Resident #1 and #2 was reported on 01/08/14 and a 5 day follow up was submitted on 01/13/14. 12. Interview with Resident #2, on 01/22/14 at 2:03, revealed he/she did have a conversation with the DCS and SSD regarding the incident on 07/17/13 and 01/06/14. Resident #2 revealed being asked if he/she felt safe and what had occurred. 13. Interview with the Regional Director of Clinical Services (RDCS), on 01/22/14 at 1:08 PM, revealed the audits of resident clinical records which included review of nurse notes back to 07/17/13 identified three (3) residents (#3, #13, and #21) with behaviors requiring increased monitoring. A. Review of the Behavior Management Meeting notes, dated 01/12/14, revealed the three (3) identified were Residents #3, #13, and #21 were included in the meeting. B. Review of the three (3) identified resident's care plan (#3, #13, and #21) revealed interventions to increase supervision using 1:1 was added. C. Review of the Psychiatric ARNP notes, dated 01/15/14, revealed two (2) of the three (3) residents (Residents #13 and #21) had medications and behaviors reviewed. D. Review of the nursing notes and 24 hour report book, revealed the three (3) residents (#3, #13, and #21) were monitored daily with documented behaviors observed. 14. Interview on 01/21/14 with twelve (12) residents, identified as interviewable with a BIMS of 8 or greater, revealed they felt safe at the facility and had been interviewed by the SSD. 15. Review of the facility skin sweeps, dated 01/07/14, 01/08/14, and on 01/15/14, revealed the facility's 89 residents were assessed with [REDACTED]. 16. Interview with sixteen (16) facility staff, Certified Occupational Therapy Assistant (COTA) #1 on 01/20/14 at 2:30 PM; COTA #2 on 01/20/14 at 2:30 PM; LPN #7 on 01/21/14 at 3:25 PM; Maintenance Director on 01/21/14 at 3:30 PM; Dietary Cook on 01/21/14 at 3:35 PM; Dietary Aide on 01/21/14 at 3:37 PM; LPN #8 on 01/21/14 at 3:39 PM; SRNA #10 on 01/21/14 at 4:00 PM; SRNA #8 on 01/21/14 at 4:12 PM; Medical Records on 01/22/14 at 12:58 PM; Payroll/HR on 01/22/14 at 12:50 PM; Business Office Manager on 01/22/14 at 3:11 PM; LPN #5 on 01/22/14 at 1:01 PM; Housekeeper on 01/22/14 at 12:52 PM; SRNA #12 on 01/22/14 at 4:23 PM; and SRNA #11 on 01/22/14 at 4:05 PM, revealed they were asked to identify any residents who exhibited behaviors, abuse and/or neglect that had not been reported. Review of the Behavior Monitoring tool revealed staff was to document who identified a behavior, which resident, and the behavior identified. 17. Review of the faxed communication and facility investigations revealed the seven (7) identified incidents were reported to the SSA on 01/08/14. The expanded sample included five incidents involving Residents #9 and 10, #11 and 12, #13 and 14, #15 and 16, and #17 and 18. 18. Interview with the RDCS, on 01/22/14 at 1:08 PM, revealed the resident's concerns (grievances) were reviewed for potential allegations and none were identified. 19. Interview with RDCS and DCS, on 01/21/14 at 2:30 PM, revealed personnel files were audited on 01/12/14 for: two (2) reference checks, OIG report, Kentucky Board of Nursing Nurse Aide Abuse Registry, Criminal Record Checks, and abuse acknowledgment. RDCS and DCS revealed audits compared to current staff roster and the facility had no new hires for review. Review of two (2) SRNAs, the ED and Activities Assistant personnel files revealed they were accurate. 20. Review of the staff training signature sheets, dated 01/11/14 through 01/15/14, covering the following topics: Identification of Resident Behaviors, Behavior Management, Behavior Reporting, Abuse Education, Facility Policies and Procedures for Behaviors, Emotional and Behavioral Support, Management Problems of Resident with Dementia, Behavior Monitoring, Federal Regulations F223, F225, F226, Physical and Sexual behavior, reporting to Charge nurse and DCS/ED, and documentation contained 116 staff signatures. Interviews with sixteen (16) facility staff members, (See #16) on 01/21/14 and 01/22/14, verified abuse education was completed and followed by an abuse post-test. 21. Interview with the Human Resource/Payroll Coordinator, on 01/22/14 at 12:50 PM, revealed she was educated on required screening components for new hires. Components to include Criminal background checks, two (2) reference checks, OIG report, Kentucky Board of Nursing Nurse Aide Abuse Registry, and abuse acknowledgment. 22. Rev

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to revise the Comprehensive Care Plan to include aggressive behaviors for ten (10) of twenty-two (22) sampled residents. Residents #1, #3, #9, #11, #13, #14, #15, #16, #17 and #19 after aggressive incidents occurred. The facility failed to revise the plan of care for Resident #1 to include physical or sexual behaviors towards other residents and/or staff; failed to revise Resident #3's care plan to include physical aggression toward peers; and, failed to revise the care plan for Resident #19 to include updated interventions for verbal aggression. In addition, the facility failed to revise the plan of care for Residents #9, #11, #13, #14, #15, #16, and #17 for behaviors. This is repeat deficiency from the 08/01/13 Standard Health Survey. On 07/17/13, Resident #1 was found in Resident #2's room with his/her hand under Resident #2's sheet. Resident #2 was telling Resident #1 to stop, after Resident #1 continued to "play" with Resident #2, the resident got mad and threw a pack of cookies at Resident #1. Resident #1 then started to throw items at Resident #2. Attempts by staff to remove Resident #1 from the room resulted in Resident #1 refusing to leave Resident #2's doorway for twenty (20) minutes while yelling and arguing with staff. On 11/08/13, revealed a verbal exchange occurred between Resident #1 and Resident #3, that escalated to a physical altercation. Resident #1 was verbally assaulting Resident #3. Resident #3 hit Resident #1 with the walker and fell to the ground. Resident #1 then kicked Resident #3 in the head multiple times. On 11/06/13, Resident #1 complained of arm pain and an x-ray revealed a dislocated shoulder. On 12/31/13, State Registered Nurse Aide (SRNA) #2 and Resident #1 were overheard yelling and screaming at each other by Licensed Practical Nurse (LPN) #2, LPN #3 and LPN #4. LPN #3 revealed he approached the SRNA #2 and Resident #1 and stood between them in an attempt to separate the two. When Resident #1 touched SRNA #2 on the arm, both the SRNA and the Resident began hitting each other in the A/D Hall Television room. LPN #3 revealed it took him, LPN #2 and LPN #4 to separate the two. The SRNA was taken outside to the courtyard, but continued to try and get inside the building while the resident was cursing at the SRNA and hitting the staff trying to get to the SRNA in the courtyard. On 12/30/13, the facility's Activities Director was observed, by the Adult Psychiatric Advanced Registered Nurse Practitioner (ARNP), yelling and screaming at Resident #19. Resident #10 received an unwelcomed kiss from Resident #9, on 07/28/13. Resident #9's care plan was not updated to reflect unwanted kissing of residents. Resident #15 and Resident #16 were in a physical altercation on 11/30/13. Neither of their care plans were updated to reflect the incident. Resident #13 made verbally threatening remarks to Resident #14, on 09/07/13. Neither care plan was updated to reflect the incident. Resident #11 threw a bowl of soup that landed on Resident #12, on 10/24/13. Neither of the residents' care plans were updated to reflect the incident. On 01/09/14 a physical altercation between Resident #17 and Resident #18 occurred and the care plan was not revised to prevent reoccurrence. The facility's failure to have an effective system in place to revise the comprehensive care plans placed residents at risk in a situation that has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy was identified on 01/10/14 and determined to exist on 07/17/13. The facility was notified of the Immediate Jeopardy on 01/10/14. An acceptable Allegation of Compliance (AOC) was received on 01/20/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 01/16/14, as alleged, prior to exit on 01/22/14. The scope and severity was lowered to an "E" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy regarding Care Plans, reviewed 09/01/11, revealed an interdisciplinary care plan would be established for every resident of the facility and updated in accordance to state and federal regulatory requirements, and as needed. The Director of Clinical Services (DCS) would review and update for events that occurred and would sign off on the added interventions to a problem identified in the care plan. A facility Resident Care Plan Coordinator must be a nurse and was responsible for the resident care plan. The Resident Care Plan Coordinator would be responsible to develop the current care plan by addressing all unresolved problems from the previous care plan and noting any new problems and approaches with target dates. Additionally, the Resident Care Plan Coordinator should review the Twenty-four (24) Hour Report daily for significant changes and add minor changes to the existing care plan on a daily basis. Note: the corporation and the facility identified the MDS staff as the MDS Coordinators. 1. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 06/22/11 with [DIAGNOSES REDACTED]. The resident was also diagnosed with [REDACTED]. The facility completed a Quarterly MDS assessment for Resident #1 on 11/25/13 and assessed the resident to have a Brief Interview Mental Status (BIMS) score of 11. The Comprehensive Care Plan, dated 09/04/13 and revised 11/25/13, revealed the facility's care plan for Resident #1 included behaviors of verbal abuse and flirtatious behavior with male residents. Interventions included: talk to the resident in a calm manner; do not argue with the resident; and, re-direct the resident when the resident was being verbally abusive or using inappropriate language/profanity. The care plan was updated 12/31/13 to include the resident had been in an altercation with a tendency for aggressive behaviors. Added interventions included Social Services notified and involved, one (1) on one (1) with decreased supervision to every fifteen (15) minutes, and psych services to follow. The facility completed a behavior care plan, dated 10/16/12 and revised 03/16/13, which revealed the same Comprehensive Care Plan and interventions. However, on 03/16/13 an added problem of aggressive behavior toward staff, hitting, grabbing at staff, and throwing items was added with no additional interventions added. Continued review of Resident #1's clinical record revealed four (4) incidents of aggression between the resident and three (3) other residents and one (1) staff member. A Psychiatric Progress Note, dated 01/02/14, revealed the resident had been aggressive with a staff member. The Psychiatrist noted the resident baited the staff member to get her to react. Additionally, the resident found pleasure when the incident occurred. Review of a Psychiatric Note, dated 11/08/13 by the Advanced Registered Nurse Practitioner (ARNP), revealed the resident had been in a verbal altercation, which had been misinterpreted as physical, with another resident of the facility. A Nurse's Note, dated 07/17/13 at 10:25 PM, revealed Resident #1 was in Resident #2's room with his/her hand under Resident #2's sheet. Additionally, Resident #2 indicated to Resident #1 to stop handling him/her and threw cookies at Resident #1. Staff intervened to attempt to remove Resident #1 from Resident #2's room. A Psychiatric Note, dated 04/12/13, revealed Resident #1 had been aggressive with a peer and hit someone "young and stupid". Observation of Resident #1, on 01/03/14 at 10:29 AM, revealed the resident was in his/her room, sitting in a wheelchair. Observation, on 01/06/14 at 1:48 PM, revealed the resident propelled him/her self with the right arm and foot. The resident was observed to propel down the hallway to the Payroll office and asked staff where Resident #2 was and if she had seen the resident. The Payroll/ Human Resources Coordinator told Resident #1 that Resident #2 was with a staff member. Continued observation, on 01/06/14 at 1:54 PM, revealed the resident seated in a wheelchair and able to self-propel backwards down the hallway using only the right foot. Observation, on 01/07/14 at 3:24 PM, of Resident #1 revealed the resident was yelling wanting to go outside to smoke. At 4:04 PM, Resident #1 was yelling "emergency" while self-propelling down the hallway. Continued observation at 4:06 PM revealed Resident #1 was near the nurse's station for the A and D Halls. The resident was yelling at a staff member, cursing, and had positioned his/her wheelchair to corner the staff member between the nurse's station and resident rooms without a way to remove herself from the resident. Interview with Resident #1, on 01/03/14 at 10:29 AM and on 01/06/14 at 1:54 PM, revealed he/she had been involved in a verbal and physical altercation with an aide at the facility on New Year's Eve. The resident stated the aide hit him/her in the face and made a motion of an open claw. Interviews with Licensed Practical Nurse (LPN) #1, on 01/03/14 at 1:56 PM, with LPN #2, on 01/03/14 at 2:19 PM, with LPN #3, on 01/03/14 at 2:37 PM, and LPN #4, on 01/06/14 at 10:37 PM, all revealed they had each witnessed State Registered Nurse Aide (SRNA) #2 and Resident #1 in a verbal and physical altercation with each other that had occurred at the facility on 12/31/13. Interview with LPN #5, on 01/09/14 at 9:01 AM, revealed Resident #1 was very unpredictable and had outbursts of yelling and screaming. She stated the resident had been sexually inappropriate with Resident #2, trying to kiss him/her. She indicated she was unaware of the incident related to the 04/12/13 Psych Note. The nurse stated she vaguely remembered Resident #1 and the incident with Resident #2, where Resident #1 had his/her hand under Resident #2's sheet. She stated the floor nurse would complete an initial care plan on admission and the MDS Coordinator would complete a resident's Comprehensive Care Plan. The nurse indicated as changes in a resident's care occurred, the floor nurses were responsible to update the care plan so MDS would be aware when the Comprehensive Care Plan was updated during the resident's review. The LPN stated she did not attend resident care plan meetings and did not know who represented nursing in those meetings. She indicated after the care plan meeting was conducted, the resident's care plan was updated by the MDS Coordinators. She stated Resident #1's current care plan, dated 11/25/13, revealed the care plan did not have interventions for physical altercation and this should have been added. The LPN indicated if a care plan was not updated to reflect physical behaviors, then an incident like what had happened between the aide and Resident #1 could occur again. Additionally, the nurse stated if she had known about the incident on 07/17/13 where Resident #1 had his/her hand under Resident #2's sheet that was unwelcomed, she would have handled Resident #1's encounters with Resident #2 differently. She indicated she had been trained by the facility to update resident care plans. On 01/06/14 at 9:04 AM, interview with the Social Services Director (SSD) revealed she had been the SSD when she was hired on 02/08/13. The SSD stated Resident #1 had previous verbal aggression and yelling at other residents. The SSD stated she conducted the facility's investigations for the verbal and physical aggression between SRNA #2 and Resident #1 that occurred, on 12/31/13. She indicated the resident touched the aide and the aide then became physically and verbally aggressive. She further indicated Resident #1 stated he/she had also been physically and verbally involved with the aide. Continued interview, on 01/07/14 at 8:57 AM, revealed she had no knowledge of the incident referenced in a Psych Note, dated 04/12/13. The SSD stated she was unaware of the incident on 07/17/13 with Resident #1's hand under Resident #2's sheet. She indicated she had previously seen Resident #1 and Resident #2 kissing in the hallway. Additionally, the SSD stated the Psych Note, dated 11/08/13, was a verbal altercation between Resident #1 and Resident #3, which had been misinterpreted as a physical altercation in which Resident #3 lost his/her balance and fell . Interview, on 01/10/14 at 1:55 PM, revealed the SSD began to create resident behavior care plans about three (3) weeks prior. She stated the behavior care plans were previously completed by the MDS Coordinators. She indicated the care plans were updated during the MDS assessments for annual, significant changes, and as needed in the morning meetings. The SSD stated Resident #1's care plan was updated on 03/16/13 for aggressive behaviors; however, the interventions were not updated to reflect hitting behaviors by the resident. Additionally, when Resident #1's care plan was revised 11/25/13 the physical behaviors were no longer on the care plan. She indicated the care plan was updated 12/31/13 with interventions added including one (1) to one (1) every fifteen (15) minute checks, and psych services following. She stated additional interventions should have been included for physical behaviors. Further interview with the SSD, revealed she attended the morning meeting on 01/12/14 and Resident #1's care plan was not revised during the meeting and it should have been. The SSD indicated flirtatious behavior was not specific to know what the resident was doing to be flirtatious. She further indicated Resident #1's care plan should say what the resident was doing in order to know what boundaries the resident had crossed. She stated the MDS Coordinators were responsible to indicate the specifics. Interview, on 01/06/14 at 10:37 AM, with LPN #4 revealed Resident #1 would become verbally aggressive when the resident felt challenged or if staff could not do as the resident wanted. The nurse stated the resident's care plans were maintained by the MDS Coordinators; however, the nurses should update the care plan through the process of care of the resident. On 01/07/14 at 10:24 AM, interview with the Interim Director of Clinical Services (DCS) revealed she had been employed at the facility on 11/05/13 as the Assistant DCS (ADCS) and became the facility's Interim DCS on 11/2013. The DCS stated Resident #1 would often antagonize staff; however, she was unsure if the resident would antagonize other residents. She indicated SRNA #2 had been terminated due to the verbal and physical aggression with Resident #1, who was also verbally and physically aggressive with the aide. She indicated the Psych Note, dated 04/12/13, indicated physical aggression; however, she was unaware of Resident #1 being physically aggressive. The DCS further indicated the Nurse's Note, dated 07/17/13, should have been treated as sexual aggression by Resident #1 and reported on the 24 Hour Report and discussed in the morning meeting. She stated the incident in the Psych Note, dated 11/08/13, that a verbal altercation was misinterpreted as physical would warrant further looking into by the facility. The DCS indicated she was unaware of any incidents involving Resident #1 prior to her employment at the facility. Continued interview with the DCS, on 01/09/14 at 11:06 AM, revealed she was unable to locate any information in the facility related to the Psych Note on 04/12/13. She stated she attended care plan meetings at times. She indicated the reference to flirtatious behavior in Resident #1's care plan was a broad term and she could not define what it meant in the care plan. She further indicated staff could misinterpret what inappropriate behavior could be. The DCS stated in the morning meetings resident care plans would be updated as needed if the nurse had not already updated the care plan. She stated the nurses had been trained to update care plans and the kardex for the aides. On 01/13/14 at 8:29 AM, interview with the MDS Director #1 revealed she had been employed with the facility since August 2013. She stated the MDS Coordinators were responsible for resident care plans, other than what the SSD would complete. However, the MDS Director stated she would complete the SSD portion of the care plan when the SSD would become overwhelmed. She indicated the SSD portion of the care plan included behaviors. She stated care plans were updated annually and quarterly. Additionally, she indicated she attended the morning meetings and would discuss if a resident had new behaviors and update the care plan for new interventions. The MDS Director stated she had written Resident #1's 12/31/13 updates to the care plan. She indicated the morning meeting did discuss the 12/31/13 incident. She further indicated written interventions listed did not specify when the resident would advance from one (1) to one (1) to fifteen (15) minute checks. She also stated there were no additional interventions put into place after the incident occurred. The MDS Director stated if care plan interventions were not updated then it was not possible to know if interventions worked and needed to be put into place. Continued interview at 9:30 AM revealed the MDS Director indicated the nurses were not updating the care plans. Interview, on 01/14/14 at 10:08 AM, revealed Resident #1's current care plan with flirtatious behavior was carried over from the previous care plan. She stated she did not know what flirtatious behavior meant. 2. Review of the clinical record for Resident #3 revealed the facility admitted the resident on 12/03/12 with [DIAGNOSES REDACTED]. The facility completed a Significant Change MDS, on 10/14/13 with a Brief Interview for Mental Status (BIMS) score of 2 by staff, as moderately impaired. The Comprehensive Care Plan, dated 10/04/13, revealed the behavior care plan included interventions to not argue with the resident, to keep a safe distance when behaviors occurred, and to ensure safety of other resident and others. The Comprehensive Care Plan for falls, dated 10/04/13 and revised 11/12/13, revealed the resident had a history of [REDACTED]. Observation, on 01/06/14 at 10:42 AM, of Resident #3 revealed the resident sitting in a chair. The resident was approachable, sitting in the TV room on the A and D Unit. Interview with Resident #3, on 01/06/14 at 10:42 AM and on 01/08/14 at 5:17 PM, revealed he/she was in a fight with someone a couple of months ago. The resident stated they both swung at each other and yelled at each other; however, there had not been any other problems since. Resident #3 indicated he/she and Resident #1 were arguing in the courtyard and Resident #1 hit him/her. The resident further indicated he/she did not remember if he/she fell . Resident #3 stated Resident #1 had not ever touched him/her before. Interview, on 01/07/14 at 8:57 AM, with the SSD revealed Resident #3 had been involved in a verbal altercation with Resident #1 about the time a Psych Note, dated 11/08/13 was written. The SSD stated it was misinterpreted as a physical altercation, but it was a verbal incident. She indicated Resident #1 was being verbally aggressive toward Resident #3, who attempted to sit on a bench in the courtyard and fell when attempting to sit. The care plans were not updated for either resident. On 01/07/14 at 10:24 AM, interview with the Interim DCS revealed she began employment at the facility on 11/05/13 as the Assistant DCS (ADCS) and was unaware of the incident between Resident #3 and Resident #1 on 11/05/13. Interview with the Interim ED, on 01/07/14 at 12:35 PM, revealed the incident on 11/05/13 between Resident #3 and Resident #1 was a verbal altercation misinterpreted as a physical altercation. He stated the incident would require further looking into. He indicated he was unaware of any resident behaviors prior to his employment at the facility on 12/06/13. 3. Review of the clinical record for Resident #19 revealed the facility admitted the resident on 09/18/13 with [DIAGNOSES REDACTED]. The Comprehensive Care Plan, dated 12/20/13, revealed the resident displayed verbally aggressive behavior. The care plan interventions included diversional activities by activities staff, do not argue with the resident, talk to the resident in a calm voice when behavior is disruptive and remove resident from public area when behavior is disruptive or unacceptable. Interview with Resident #19, on 01/17/14 at 4:20 PM, revealed he/she had been in an argument with a female staff member in activities about three (3) weeks ago. Interview with the DCS, on 01/14/14 at 4:22 PM, revealed she was not present when the incident between Resident #19 and the AD occurred. She stated she was unaware of the outcome of the incident. Interview, on 01/19/14 at 10:36 AM, revealed they did a one month look back on 01/12/14 of Resident #19's behaviors and it was determined the behaviors were stable. The care plan was not revised until 01/14/14, although the incident occurred 12/30/13. Review of the care plan for Resident #19, dated 12/20/13, revealed an addendum (dated 01/14/14) for Behavior Management Meeting on 01/12/14. "Resident history of verbalizations but none recently. Resident has been stable". An additional Note, dated 01/15/14, revealed "the resident became upset and spoke inappropriately to the Activities Director on 12/30/13". Two interventions were added to the care plan in hand writing and dated 01/12/14. However, these were copies of interventions already in place and no new interventions had been added. Talk to resident in a calm voice and remove from public when disruptive or behavior is unacceptable. These interventions were not effective as they were not followed by staff. 4. Review of the clinical record for Resident #9 revealed the facility admitted the resident on 02/22/13 with [DIAGNOSES REDACTED]. The Comprehensive Behavior Care Plan, dated 02/22/13 and revised 07/23/13, revealed the resident's behaviors included removing clothing and grabbing at staff which had improved. Care plan interventions included to give the resident papers to shuffle, keep at safe distance when behaviors occur, and take to a quiet location as necessary. Review of a Nurse's Note, dated 07/28/13 at 7:35 PM, revealed Resident #9 kissed Resident #10's hand. After redirection from staff, Resident #9 kissed Resident #10 on the lips and inserted his/her tongue in the resident's mouth. There was no evidence of a revised care plan that addressed the aggressive behavior towards the female resident. 5. Review of the clinical record for Resident #11 revealed the facility admitted the resident on 05/24/12 with [DIAGNOSES REDACTED]. The facility completed a Quarterly MDS assessment, on 09/03/13, and assessed the resident with a BIMS score of 8, as oriented with confusion. The Comprehensive Care Plan, dated 12/02/13, revealed the resident would often use profanity or vulgarity and call people names. Interventions included remind the resident calling people offensive names was inappropriate, provide a supportive environment, and redirect inappropriate decisions. A SSD Note, dated 10/25/13, revealed the resident threw a bowl of soup in the dining room during the meal and some of the soup hit the resident sitting next to him/her. There was no evidence of a revised care plan to address the aggressive behavior towards another resident. 6. Review of the clinical record for Resident #13 revealed the facility admitted the resident on 06/27/11 with a [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 12/17/12 and revised 10/29/13, revealed the resident exhibited sexually inappropriate behavior and suggestive/ inappropriate comments to female staff. The care plan interventions included explain when behavior was inappropriate, praise positive behavior, and set limits in behavior. A Nurse's Note, dated 09/07/13 at 5:00 PM, revealed the resident was arguing with another resident and threatened to stab him/her with a shoe horn and was asked by staff to leave the shoe horn in his/her room. At 5:20 PM, the Nurse's Note revealed Resident #13 had threatened the other resident. There was no evidence of a revised care plan to address the threatening behavior towards another resident. 7. Review of Resident #14's clinical record revealed the facility admitted the resident on 12/06/12 with a [DIAGNOSES REDACTED]. The Comprehensive Care Plan, dated 08/05/13 and revised 08/23/13, revealed the resident would consume alcohol without staff awareness. Interventions included monitor for alcohol consumption to determine cause, intervene to ensure safety, set limits, and watch for behavioral cues, such as body language and tone of voice. Review of a Nurse's Note, dated 09/07/13 at 3:00 PM, revealed the resident was arguing with another resident and threatened him/her. There was no evidence of a revised care plan to address the threatening behavior towards another resident. 8. Review of the clinical record for Resident #15 revealed the facility admitted the resident on 05/13/11 with [DIAGNOSES REDACTED]. The Comprehensive Care Plan, dated 02/21/13 and revised 10/22/13, revealed the facility did not care plan the resident for behaviors. 9. Review of the clinical record for Resident #16 revealed the facility admitted the resident on 07/17/10 with a [DIAGNOSES REDACTED]. The Comprehensive Care Plan, dated 11/25/13, revealed the resident would hide clothing and state the clothes were missing; claim being physically abused, and throw him/herself on the floor. A Nurse's Note, dated 11/30/13 at 9:00 PM, revealed the resident's back was assessed for injury from an altercation with another resident. There was no evidence of documentation in the clinical record the incident occurred, no date, or time. There was no evidence of a revised care plan to address the altercation with another resident. 10. Review of Resident #17's clinical record revealed the facility admitted the resident on 08/20/13 with a [DIAGNOSES REDACTED]. The Comprehensive Care Plan, dated 09/03/13 and revised 11/14/13, revealed the resident had a history of [REDACTED]. Interventions included to observe the resident's behavior to assist in determining cause of refusal per behavior flow sheet, intervene to ensure resident safety, and ensure safety of resident and others. Review of a Behavior Sheet, dated October 2013, revealed the resident had wandering behavior which was noted to be monitored. There was no evidence of a revised care plan to address the incident of wandering behaviors. The facility provided an Allegation of Compliance (AOC) on 01/20/14 alleging the Immediate Jeopardy (IJ) was removed on 01/16/14; the facility took the following immediate steps to remove the IJ: 1. Resident #1 and SRNA #2 were immediately separated on 12/31/13 by staff. 2. The police were notified of the incident on 12/31/13. 3. Resident #1 was discharged to the hospital for a psychiatric evaluation on 01/07/14. 4. SRNA #2 was suspended immediately on 12/31/13. 5. Resident #3 was referred by the DCS, and seen by the Psychiatric ARNP, on 01/15/14. 6. Resident #3 was placed on increased supervision, 1:1 observation, to redirect impulse behaviors on 01/12/14. 7. Resident #3 was reviewed by the Interdisciplinary Team (IDT) (consisting of the Corporate Administrative Nurse, DCS, Activity Director, and Regional Director of Clinical Services) in the Behavior Management Meeting, on 01/12/14, which included a medical record review. 8. Resident #3's care plan was updated by the Corporate Administrative Registered Nurse on 01/13/14. 9. The incident involving Resident #3, on 11/05/13, was reported to the State Survey Agency (SSA), on 01/08/14 via a 24 Hour Report, investigated and a 5 Day report was submitted to the SSA on 01/13/14. 10. Resident #2 was reviewed in the Behavior Management Meeting by the IDT Corporate Administrative Registered Nurse, DCS, Activity Director, and the Regional Director of Clinical Services on 01/12/14 which included a medical record review and a care plan review. 11. The incident on 07/17/13 involving Resident #2 was reported to the SSA on 01/08/14 via a 24 hour report. A 5 day Report was submitted to the SSA on 01/13/14. 12. Resident #2 was interviewed on 01/07/14 by the SSD and the DCS regarding the incident on 07/17/13 and 01/06/14. 13. Current resident chart reviews completed , on 01/07/14 and 01/08/14 by the DCS, ADCS, Unit Manager and RDCS and staff interviews on 01/11/14 and 01/12/14 by Corporate Administrative Registered Nurses to identify residents with behaviors, the facility identified three (3) residents (#3, #13, and #21) as exhibiting sexual or physical behaviors towards others. These three residents were: A. Reviewed in the Behavior Management Meeting by the IDT (Corporate Administrative Registered Nurse, Director of Clinical Services Activity Director, and the Regional Director of Clinical Services) on 01/12/14. B. Increased supervision was initiated on 01/12/14 and the care plans were revised by the Activity Director the Corporate Administrative Registered Nurse and the DCS on 01/13/14. C. Referred to the Psychiatrist for review by the DCS and two ( #13 and #21) of three residents were seen on 01/15/14. D. Had documentation of behavior reviewed daily since 01/13/14 by a member of the IDT (to include the DCS, ED, and the Corporate Administrative Registered Nurses). 14. Thirty-nine (39) residents, with a brief interview for mental status (BIMS) of an eight or above were interviewed by the Social Services on 01/07/14 to ensure they had not been abused or neglected. 15. All residents were assessed by nurses via skin sweeps for suspicious injuries on 01/07/14, 01/08/14, and on 01/15/14 with no injuries found. 16. All Department Heads along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116) were interviewed by the Corporate Administrative Registered Nurse on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 to ensure no one had witnessed any abuse or neglect that had not been previously reported. 17. Current resident charts were reviewed on 01/07 and 01/08/14 by the Director of Clinical Services, Assistant Director of Clinical Services, Staff Educator, Unit Manager, and the Regional Director of Clinical Services to determine if there were any incidents that were reportable and/or needed further investigation. The seven (7) incidents that were identified during the review were reported on 01/08/14. 18. The facility's concern book was reviewed by the Regional Director of Clinical Services on 01/11/14 for allegations that needed to be reported and no allegations were identified. 19. The current staff members' employee personnel files were reviewed by Regional Director of Human Resources and Facility Human Resources/Payroll Coordinator to ensure that the files were completed with the Criminal Background Check, Kentucky State Board of Nursing/Nurse Aide Abuse Registry check, Office of the Inspector General Check, Telephone Reference Checks and Abuse/Neglect Attestation o

Based on observation, interview, record review, and review of the facility's policy and procedures, and investigations, it was determined the facility failed to have an effective system in place to ensure residents were free from abuse for four (4) of twenty-two (22) sampled residents (Resident #1, #2, #3 and #19). Record review revealed Resident #1 had a history of [REDACTED]. However, staff accepted the resident's behavior as the norm and there was no documented evidence the facility recognized this behavior as abuse. The facility's failure to address Resident #1's abusive behavior affected Resident #2 and Resident #3. On 07/17/13, Resident #1 was found in Resident #2's room with his/her hand under Resident #2's sheet. Resident #2 was telling Resident #1 to stop, after Resident #1 continued to "play" with Resident #2, the resident got mad and threw a pack of cookies at Resident #1. Resident #1 then started to throw items at Resident #2. Attempts by staff to remove Resident #1 from the room resulted in Resident #1 refusing to leave Resident #2's doorway for twenty (20) minutes while yelling and arguing with staff. On 11/08/13, a verbal exchange occurred between Resident #1 and Resident #3, that escalated in to a physical altercation. Resident #1 was verbally assaulting Resident #3. Resident #3 hit Resident #1 with the walker and fell to the ground. Resident #1 then kicked Resident #3 in the head multiple times while the resident was on the ground. Interview and record review also revealed Resident #1 verbally and physically abused staff and was the victim of abuse after an altercation with staff. On 12/31/13, State Registered Nurse Aide (SRNA) #2 and Resident #1 were overheard yelling and screaming at each other by Licensed Practical Nurse (LPN) #2, LPN #3, and LPN #4. LPN #3 stood between Resident #1 and SRNA #2 in an attempt to separate the two. When Resident #1 touched SRNA #2 on the arm, both the SRNA and the resident began hitting each other in the A/D Hall Television room. LPN #3 was unable to separate the SRNA and the resident and it took LPN #3, LPN #2 and LPN #4 to separate them. The SRNA was taken outside to the courtyard, but continued to try and get inside the building while the resident was cursing at the SRNA and hitting the staff while trying to get to the SRNA in the courtyard. In addition, Resident #19 was victim of verbal abuse by a staff member. On 12/30/13, the facility's Activities Director was observed, by staff, yelling and screaming at Resident #19. The facility's failure to have an effective system in place to ensure residents were free from abuse placed residents in a situation that has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/10/14 and determined to exist on 07/17/13. The facility was notified of the Immediate Jeopardy on 01/10/14. An acceptable Allegation of Compliance (AOC) was received on 01/20/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 01/16/14 as alleged, prior to exit on 01/22/14. The scope and severity was lowered to an "E" with continued noncompliance while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: 1. Review of the facility's policy regarding Resident Abuse-Resident to Resident, reviewed 01/01/09, revealed residents must not be subjected to abuse by anyone, including facility staff or other residents. Abuse included physical, sexual, and verbal abuse. The staff were to remove the resident from danger immediately. Closely monitor and document the behavior and condition of the residents to evaluate for any injury and to prevent reoccurrence of the incident. The facility must develop measures to prevent reoccurrence and document these measures in the resident's medical record to include revision of the plan of care. Other measures to consider were obtaining orders for a psych consult. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 06/22/11 with [DIAGNOSES REDACTED]. The resident was also diagnosed with [REDACTED]. The facility completed a quarterly MDS assessment for Resident #1 on 11/25/13 and assessed the Resident to have a Brief Interview Mental Status (BIMS) score of 11. The comprehensive care plan, dated 09/04/13 and revised 11/25/13, revealed the facility's care plan for Resident #1 included behaviors of verbal abuse and flirtatious behavior with male residents. Interventions included talk to the resident in a calm manner, do not argue with the resident, and re-direct the resident when the resident is being verbally abusive or using inappropriate language/profanity. Review of Resident #1's Psychiatric Services notes revealed the resident had a history of [REDACTED]. Continued review revealed a Psychiatric Services note, dated 02/08/13, stating the reason for the visit was aggression, yelling, lability, severe mood swings, and verbal outbursts. In addition, on 04/12/13 a Psychiatric Services note stated the chief complaint was anger and irritability, with an incident of aggression with a peer. On 07/13/13 a Psychiatric Services note stated the staff reported no further aggression, but remained sexually intrusive and made inappropriate comments toward male caregivers. However, record review revealed no documented evidence the facility implemented interventions to address this potential abusive behavior to protect residents. Review of a nurse's note, dated 07/17/13 at 10:25 PM, revealed Resident #1 had been in Resident #2's room with his/her hand under Resident #2's sheet touching and fondling Resident #2. The nurse's note further revealed Resident #2 told Resident #1 to stop; however, Resident #1 continued to touch Resident #2 under the sheet. Interview with the House Supervisor, on 01/09/14 at 12:59 PM, revealed she was working the evening of 07/17/13 and was told by the nurse that Resident #1 was bothering Resident #2 and was trying to get Resident #1 to leave Resident #2's room. The House Supervisor stated she instructed the nurse to document the incident. The House Supervisor revealed the next day she overheard staff talking about what really happened and she told the staff to make sure they reported what they had heard, but did not follow up to ensure it was done. The facility reported the nurse who wrote the 07/17/13 nurse's note no longer worked at the facility. Attempts to interview the nurse were made; however, the nurse did not return phone messages as of 01/22/14. During an interview with LPN #5 on 01/09/14 at 9:01 AM and 10:12 AM, LPN #5 reviewed the nurse's note for 07/17/13, and indicated Resident #1 was in Resident #2's room with his/her hand under Resident #2's sheet. She stated she vaguely remembered the incident and would not have seen the 11-7 entry on the 24 hour report as it was removed from the nurses station before she came on duty. However, it was something she should have received in report and didn't and would not have known to ask about it. She thought the note indicated Resident #2 did not want Resident #1 in his/her room. The nurse stated Resident #2 was not capable to say stop. LPN #5 stated Resident #2 was aware of what goes on around him/her and she indicated the incident on 07/17/13 was sexual abuse. She further indicated Resident #1 should not have been in Resident #2's room and should not have had his/her hand under Resident #2's sheet. Review of the clinical record for Resident #2 revealed the facility admitted the resident on 03/03/10 with [DIAGNOSES REDACTED]. The facility completed a quarterly MDS assessment on 11/01/13 and assessed the resident with a Staff Assessment for Mental Status with a score of 1, meaning the resident was moderately independent. The facility assessed the resident to have no mood or behavioral indicators and having communication with difficulty. The comprehensive care plan, dated 08/20/13 and revised 11/04/13, revealed the resident had an alteration in communication and interventions included asking yes or no questions, and use alternate means to communicate, such as gestures. Interview with Resident #2, on 01/07/14 at 5:12 PM, revealed the resident was able to speak a few words. The resident stated yes, when asked if he/she was friends with Resident #1; however, the resident stated "no friends" when asked if they were boyfriend and girlfriend. The resident began to twist his/her hands when asked if he/she had been touched inappropriately. Resident #2 indicated they were just friends and at times the touch of Resident #1 went beyond friendly, which was always initiated by Resident #1. The resident further indicated Resident #1 would sometimes stop when asked and that Resident #1 had a hard time taking no for an answer. The resident indicated Resident #1 tried to push him/her into touching in a way that was more than friends. The resident further indicated a hug, or touch on the arm were okay touches. Resident #2 also indicated touch that was not okay included the thigh, knee, chest, and the resident pointed to the groin area. The resident stated Resident #1 tried to touch him/her two (2) times in the groin area. The resident looked down when he/she was asked about the incident in his/her room when Resident #1 was in the room and Resident #2 threw cookies at him/her. Resident #2 indicated the second time Resident #1 tried to touch him/her was after the incident with the cookies. The resident indicated the touching by Resident #1 made him/her feel uncomfortable and he/she just wanted to be friends. Interview with the Social Services Director (SSD), on 01/07/14 at 8:57 AM, revealed she was unaware of the incident on 07/17/13 of Resident #1's behavior toward Resident #2. She stated she should have been made aware of the incident by the staff member(s) who were present when the incident occurred. The SSD stated resident behaviors should be documented on the facility's twenty-four (24) hour report by the nurses and the 24 hour report would be discussed in the morning meeting the following day. However, she did not remember this incident being discussed. On 01/07/14 at 10:24 AM, interview with Interim Director of Clinical Services (DCS) revealed she began employment on 11/05/13 as the Assistant DCS (ADCS) and became the facility's Interim DCS on 11/12/13 or 11/13/13. She stated she was unaware of the incident between Resident #1 and Resident #2; however, based on the nurse's note on 07/17/13 it appeared Resident #1 invaded another resident's privacy and was possible sexual abuse. She stated although Resident #2 had episodes of confusion, he/she was aware of what goes on around him/her. The DCS further indicated Resident #2 had difficulty with speech; however, the resident can make his/her needs known through gestures and throwing things like cookies at Resident #1 was Resident #2's way of communicating. Further interview with the SSD, on 01/07/14 at 8:57 AM revealed she had observed Resident #1 and Resident #2 kissing each other in the hallway on 01/06/14, but never interviewed to determined if it was consensual and she assumed they were girlfriend and boyfriend. Interview with SRNA #1, on 01/09/14 at 10:20 AM, revealed Resident #1 and Resident #2 kiss often, and she had personally seen them kiss on two (2) to three (3) occasions. She stated Resident #1 always initiated the contact. She stated Resident #2 was moody and the resident did not want the attention of Resident #1, even if they were seen kissing. The aide stated she had seen Resident #2 look like he/she did not want to be bothered by Resident #1. She indicated she had never asked Resident #2 if it was okay for Resident #1 to kiss him/her. The SRNA indicated Resident #1 had sexually abused Resident #2. On 01/09/14 at 9:01 AM and 10:12 AM, interview with LPN #5 revealed it was sexually inappropriate behavior for Resident #1 to try and kiss Resident #2. She stated Resident #2 could not push Resident #1 away as Resident #2 only had use of one (1) arm; however, the resident could say "no". The nurse stated she had told Resident #1 on two or three occasions to back off and leave the room. She indicated when Resident #1 left the room, Resident #2 would say "thank you". LPN #5 further indicated she did not think Resident #2 liked it when Resident #1 would become affectionate, as Resident #2 would make a face at Resident #1. The nurse stated around 12/31/13, or within a couple of days, Resident #1 was seen by a staff member to enter Resident #2's room and was kissing him/her. LPN #5 further stated if she had known about the incident on 07/17/13, she would have reported Resident #1 touching/kissing Resident #2 to the SSD. Continued interview with the DCS, on 01/08/14 at 11:06 AM, revealed she was not aware of any reported behaviors of Resident #1 toward Resident #2, and was unaware of the two (2) residents kissing in the hallway recently. She stated staff could misinterpret inappropriate behavior as staff come from different backgrounds and views. She indicated Resident #1's behaviors were not documented on the 24 hour report, which was used for the morning meetings. If the behaviors were not documented, she stated she would not know the behaviors had occurred and therefore Resident #1's behaviors could not be addressed. The DCS further indicated if two (2) residents had contact with each other, the facility would need to look at whether both persons were able to give consent. The DCS further stated someone from the facility should speak to Resident #2 to find out what the resident feels is or is not okay to touch. Continued interview with the SSD and the DCS on 01/09/14 at 1:54 PM, revealed they spoke to Resident #2 who reported he/she and Resident #1 had kissed earlier on that day outside the SSD's office. The DCS stated Resident #2 reported a friendly relationship with Resident #1; however, when asked if Resident #1 had ever been in his/her room unwelcomed, the DCS stated Resident #2 reported the incident in July. The SSD stated Resident #2 said he/she did not want sexual contact with Resident #1. However, by the time of this interview with Resident #2, Resident #1 had already been transferred from the facility. Interview, on 01/07/14 at 12:35 PM, with the Interim Executive Director (ED) revealed he began employment at the facility as the Interim ED on 12/06/13 and was unaware of the incident on 07/17/13 between Resident #1 and Resident #2. Upon review of the nurse's note, dated 07/17/13, the ED stated Resident #1 was inappropriate with Resident #2 and the SSD, DCS and the ED should have been notified and an investigation completed. Interview, on 01/16/14 at 3:07 PM, revealed the ED could not give an example of abuse, and stated he would need to review the law. After obtaining a copy of the regulations, the ED indicated, on 01/16/14 at 4:05 PM, that a resident had the right to be free from sexual abuse. He further stated he would need to refer to the law for more information and did not know what the law stated in relation to abuse. On 01/09/14 at 12:40 PM, interview with the Psychiatrist for Resident #1 revealed he had not been notified of the incident noted in the 07/17/13 nurse's note. He stated he should have been called so that he could have tried to intervene. 2. Continued review of Resident #1's clinical record revealed a psychiatrist's note, dated 11/08/13, which stated the resident had a recent verbal altercation with a male peer witnessed by staff, and misinterpreted as a physical altercation. Review of Resident #1's nurse's noted, dated 11/06/13 at 4:20 PM, revealed Resident #1 complained of pain to the left shoulder and side with a physician order [REDACTED]. Interview, on 01/07/14 at 8:57 AM, with the SSD revealed the altercation between Resident #1 and Resident #3 was a verbal exchange that had been misinterpreted as a physical altercation. She stated Resident #3 was walking in the courtyard and his/her pants were sagging. The SSD indicated Resident #1 was following behind Resident #3 and told Resident #3 to pull up his/her pants, that no one wanted to see his/her ass. The SSD further indicated when Resident #3 turned to sit down on a bench, the resident lost his/her balance and accidentally fell forward toward Resident #1 with his/her walker hitting Resident #1's wheelchair. She stated neither resident touched the other. She also stated she had talked with both Resident #1 and Resident #3, as well as SRNA #3. Interview, on 01/09/14 at 3:08 PM, with SRNA #3 revealed she had been outside in the courtyard on 11/05/13 and witnessed the incident between Resident #1 and Resident #3. She stated she heard Resident #1 tell Resident #3 to pull up his/her pants. The aide stated she redirected Resident #1 who continued to aggravate Resident #3. She indicated Resident #3 had become aggravated and raised his/her walker and hit Resident #1 with the walker two (2) to three (3) times, possibly on the arm. She further indicated Resident #3 then lost his/her balance and fell , and Resident #1 attempted to move his/her wheelchair away from Resident #3. The SRNA stated Resident #3 fell with his/her head falling into Resident #1's lower legs. Additionally, she stated Resident #1 then kicked Resident #3 in the head about three (3) times. The aide stated she reported the incident to the House Supervisor. The aide indicated Resident #1 often picked at Resident #3 and felt Resident #3 had enough that evening. Interview with the House Supervisor, on 01/09/14 at 12:59 PM, revealed the incident happened on 11/05/13 involving Resident #1 and #3 and was brought to her attention by SRNA #3. The residents were arguing in the courtyard and Resident #3 fell , they completed an incident report and turned in written statements. The report and the statements were given to the ED by SRNA #3. Review of the clinical record for Resident #3 revealed the facility admitted the resident on 12/03/12 with [DIAGNOSES REDACTED]. The facility completed a Significant Change MDS, on 10/14/13, and utilized the Staff Assessment for Mental Status and determined the resident was moderately impaired. The comprehensive care plan, dated 10/04/13, revealed the care plan for behaviors included interventions to not argue with the resident and to ensure the safety of the resident and others. A skin assessment of Resident #3, dated 11/05/13, revealed a mark on the left side of the resident's mouth. Interview with Resident #3, on 01/06/14 and on 01/08/14 at 5:17 PM, revealed he/she was in a fight with someone a couple of months ago. The resident stated they both swung at each other and yelled at each other; however, there had not been any other problems since. Resident #3 indicated he/she and Resident #1 were arguing in the courtyard and Resident #1 hit him/her. The resident further indicated he/she did not remember if he/she fell . Resident #3 stated Resident #1 had not ever touched him/her before. Resident #1 was not available to interview regarding the incident with Resident #3. The resident was transferred out of the facility before an interview could be obtained. On 01/07/14 at 10:24 AM, interview with the Interim DCS revealed the SSD had reported to her that she (the SSD) overheard staff talking about an incident involving Resident #1 and Resident #3 and began an investigation. The DCS stated at the time of the incident, she was the ADCS at the facility and was unaware if the investigation by the SSD was completed. She stated physical abuse was physical contact between two (2) people and verbal abuse could be anything said that was demeaning to another person. Interview with the Interim ED, on 01/07/14 at 12:35 PM, revealed he had been in this role and with the facility since 12/06/13. The ED stated the incident on 11/05/13 was a verbal altercation misinterpreted as a physical altercation between Resident #1 and Resident #3. He stated the incident would warrant further looking into. The ED stated physical abuse was physically harming another person and emotion/mental abuse was words or actions that create a significant emotional impact on another person. Interview with the Advanced Registered Nurse Practitioner (ARNP), on 01/14/14 at 12:01 PM, revealed she was aware of the incident between Resident #1 and Resident #3. She stated the facility had notified her of the incident in which Resident #3 had fallen and Resident #1 had hit him/her. She indicated the facility later called her to report that Resident #3 had fallen and was not hit. The ARNP stated the SSD had stated to her that the incident had been blown out of proportion and was not a physical altercation. On 01/15/14 at 4:51 PM, interview with the Vice President (VP) of Clinical Operations revealed while reviewing the facility QA binder, a note, under the November tab, contained documentation that Resident #1 hit, and was hit by another resident, and that Resident #3 hit, and was hit by another resident on 11/05/13. However, no other information regarding the incident was available. Observation of Resident #1, on 01/03/14 at 10:29 AM, revealed the resident was in his/her room, sitting in a wheelchair. Continued observation on 01/06/14 at 1:54 PM revealed the resident seated in a wheelchair and able to self-propel backwards down the hallway using only the right foot. Observation, on 01/07/14 at 3:24 PM, of Resident #1 revealed the resident was yelling wanting to go outside to smoke. At 4:04 PM, Resident #1 was yelling "emergency" while self-propelling down the hallway. Continued observation at 4:06 PM revealed Resident #1 was near the nurse's station for the A/D Halls. The resident was yelling at a staff member, cursing, and positioned his/her wheelchair to corner the staff member between the nurse's station and resident rooms without a way to remove herself from the resident. 3. Review of the facility's policy regarding Resident Abuse, revised 01/01/12, revealed staff would treat residents so they were free from abuse, neglect, and mistreatment. No employee would, at any time, commit an act of physical, psychological, or emotional abuse or mistreatment against any resident. The policy indicated physical abuse as striking the resident with a part of the body, or an object, kicking, non-therapeutic shoving, pushing the resident's body, or physical contact intentionally or through carelessness that resulted in or was likely to result in physical injury, pain, or psychological harm to the resident. Additionally, physical abuse included acts of physical retaliation, even in response to a physical attack. Verbal Abuse was identified as statements made to a resident which resulted in ridicule or humiliation of a resident, cursing, disparaging and derogatory terms. Psychological/Emotional abuse included humiliation and harassment. The policy stated all actions in which employees engage with residents must have a healthful, proper, and humane care and treatment of [REDACTED]. Review of the completed facility investigation, dated 01/06/14, revealed SRNA #2 verbally and physically abused Resident #1 on 12/31/13. The facility investigation substantiated abuse by the aide against Resident #1. Interview with Resident #1, on 01/03/14 at 10:29 AM and 01/06/14 at 1:54 PM, revealed the resident wanted to go outside to smoke and SRNA #2 stated it was not the time to smoke. The resident stated he/she playfully told the aide to shut up. He/she indicated the aide said not to tell her to shut up. Resident #1 further indicated he/she asked the aide what she, the aide, would do and touched the aide's arm. The resident stated SRNA #2 then tried to pull his/her hair, and hit the resident on the right side of the face, with a motion of an open claw; however, he/she could not remember how many times. Resident #1 stated two (2) nurses, one of whom was LPN #3, had to pull the aide off of him/her. The resident denied having any injuries from the altercation. He/she indicated he/she had not had any problems with the aide previously and the aide's behavior was unexpected. He/she indicated SRNA #2's behavior was abusive. On 01/03/14 at 1:56 PM, interview with LPN #1 revealed she heard screaming down the hall and when she arrived she saw Resident #1 and SRNA #2 separated from the other with the aide outside in the courtyard. She stated both the resident and aide were yelling at each other; however, as the aide was outside, LPN #1 stated she could not hear what the aide was saying. Interview, on 01/03/14 at 2:19 PM, with LPN #2 revealed he heard yelling coming from the TV room at the A and D Hallways and found Resident #1 and SRNA #2 in a physical altercation. The LPN stated Resident #1 was in a wheelchair and the aide was standing over and bent down to the resident. He stated he witnessed both the resident and the aide grabbed each other. He stated he assisted to pull the aide off of the resident and had to hold the aide back. The LPN stated both the resident and aide continued to yell at each other. He indicated he took the aide outside to calm her down, while the aide continued to try to get to the resident. The LPN stated LPN #4 stayed with the aide outside. He further indicated Resident #1 had taken a fork off the dinner tray cart in the hallway; however, was able to get the fork from the resident. LPN #2 stated he felt the altercation between SRNA #2 and Resident #1 was abusive as the aide made physical contact with the resident. He indicated it was unacceptable for the aide to hit the resident back. Interview with LPN #3, on 01/03/14 at 2:37 PM, revealed he was the nurse assigned to the A Hall and heard screaming and yelling. He stated he called for another nurse to assist. The LPN stated when he reached the TV room at the A and D Hall he found Resident #1 in the wheelchair and SRNA #2 was standing over the resident, both verbally insulting each other and making motions of fighting. The nurse stated the resident and aide were not fighting when he arrived; however, they were face to face. He indicated when he stepped between them both the resident and aide made threatening statements to each other; I am going to get "you"; I am going to find "you"; and both were cursing at the other. He indicated he stood between the resident and the aide and they both immediately tried to hit each other, however he could not recall who hit the other person first. The nurse further indicated both the aide and the resident were hitting and grabbing the other. He further indicated he could not separate them and required the assistance of two (2) other nurses. The LPN stated it took a total of three (3) nurses between five (5) to ten (10) minutes to separate the aide from the resident and move the aide to the outside of the building. He stated SRNA #2 said "I am going to get you" to Resident #1 while he and other nurses were attempting to remove the aide from Resident #1. LPN #3 indicated after the aide was taken outside, he went back to check on the resident while the other two (2) nurses stayed with the aide outside. He stated he took Resident #1 to his/her room to try to calm the resident down. The LPN indicated when he left the resident's room the aide was still outside with one (1) nurse, the resident self-propelled him/herself out of the room and began to insult the aide. He further indicated the aide then began again to attempt to get at the resident. LPN #3 stated it took about fifteen (15) to twenty (20) minutes for SRNA #2 to calm down and control herself. The nurse stated the aide wrote a statement about what happened and left the building. The LPN stated he felt the aide's behavior was abusive, regardless of what the resident may have done. He stated the aide should not have engaged in abusive language, and especially should not have become physical with the resident. Interview with LPN #4, on 01/06/14 at 10:37 AM, revealed she heard screaming, yelling, and cussing down the hallway. The nurse stated she, LPN #2, and LPN #3 all responded, and when she arrived SRNA #2 and Resident #1 were in a fist fight with LPN #3 standing between them. She indicated both the aide and the resident were trying to get at each other, around LPN #3, and were throwing fists at each other. The nurse further indicated it took her and LPN #2 several minutes to get the aide separated from Resident #1 and took the aide outside. She further indicated LPN #2 and LPN #3 went to the resident while she, LPN #4 stayed outside with SRNA #2. The nurse stated even after removing the aide to the outside, SRNA #2 continued to yell and cuss at the resident, saying she did not care if the resident was in a wheelchair. Additionally, LPN #4 stated while outside, the aide attempted two (2) to three (3) times to go back into the building, saying she was going to "F... you up". The nurse stated after the aide calmed down, she wrote a statement and left the building. The LPN indicated she completed Resident #1's physical assessment after the incident occurred. She stated the resident had slight bruising to the right cheek and the resident denied any other injuries. LPN #4 stated she felt SRNA #2's behavior was abusive toward Resident #1. On 01/07/14 at 12:41 PM, interview with SRNA #2 revealed she worked with Resident #1 every day. The aide stated she was telling another resident that it was not time to go outside for the smoke break. The aide indicated Resident #1 then cussed at her and told her to shut up. She further indicated she told the resident she was not speaking to him/her and that was when Resident #1 began to yell and scream. She stated the resident was in the wheelchair and touched her and she told the resident not to touch her. The aide stated LPN #3 had then arrived and stepped between them. The aide indicated LPN #3 had grabbed for her, not the resident and felt the nurse was afraid she would do something to Resident #1. She indicated at that point Resident #1 grabbed her and had hold of her, and she began to cuss at the resident. She further indicated it took three (3) nurses to move her away from Resident #1, as she was holding the handrail at the time, and out the door. The aide stated as mad as she was, if LPN #3 had not moved her away from the resident, she would have hit the resident. She indicated she would have hurt the resident; however, she did not have a chance to hit Resident #1. Additionally, SRNA #2 further indicated after being pulled outside by the nurses, she had attempted to get back into the building. She indicated the resident had taken a fork and both of them continued to scream and yell at each other. The aide stated when she had calmed down she re-entered the building to write a statement and then left. She further indicated she had told the resident at some time during the incident she was going to "kick (the resident's) ass". She stated she could have handled the situation better. The aide stated she should have informed Resident #1's nurse and it all could have been avoided. Additionally, SRNA #2 stated her behavior could be interpreted as abusive toward Resident #1. She denied touching the resident; however, she stated she did cuss and threaten the resident. On 01/06/14 at 9:04 AM, interview with the SSD revealed she was called in on 12/31/13 and spoke to Resident #1 about the incident. She stated the resident reported to her that he/she wanted to go outside to smoke and the aide told him/her it was not time. The SSD stated the resident told her he/she rubbed the aide's arm, and the aide began to curse and flail her arms at the resident. She indicated Resident #1 reported three (3) nurses came to assist the resident, including LPN #2, LPN #3, and LPN #4. She further indicated the three (3) nurses took the aide outside to the courtyard and the resident was taken to his/her room. The SSD stated she and Resident #1 spoke to a police officer about the incident and the resident declined to press charges of battery against the aide. She indicated the facility substantiated abuse by the aide to the resident. Additionally, the SSD

Based on interview, record review, review of facility policy and procedures, review of the facility's personnel files, it was determined the facility failed to have an effective system to ensure incidents of potential abuse were investigated and reported immediately to the appropriate State Survey Agency (SSA) for fourteen (14) of twenty-two (22) sampled residents (Resident #1, #2, #3, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18 and #19). The facility failed to investigate and report allegations of verbal, physical and sexual abuse by resident to resident and staff to resident. The facility also failed to prevent further potential abuse by failing to conduct investigations. On [DATE], Resident #1 was found in Resident #2's room with his/her hand under Resident #2's sheet. Resident #2 was telling Resident #1 to stop, after Resident #1 continued to "play" with Resident #2, the resident got mad and threw a pack of cookies at Resident #1. Resident #1 then started to throw items at Resident #2. Attempts by staff to remove Resident #1 from the room resulted in Resident #1 refusing to leave Resident #2's doorway for twenty (20) minutes while yelling and arguing with staff. The incident was not reported to the Abuse Coordinator or the State Survey Agency (SSA), and no investigation was completed. On [DATE], revealed a verbal exchange occurred between Resident #1 and Resident #3, that escalated in to a physical altercation. Resident #1 was verbally assaulting Resident #3. Resident #3 hit Resident #1 with the walker and fell to the ground. Resident #1 then kicked Resident #3 in the head multiple times. On [DATE], Resident #1 complained of arm pain and an X-ray revealed a dislocated shoulder. This incident was never reported to the SSA or investigated as potential abuse. On [DATE], the facility's Activities Director was observed, by the adult Psychiatric Advanced Registered Nurse Practitioner (ARNP), yelling and screaming at Resident #19. The ARNP reported an allegation of verbal abuse to the Social Service Director; however, the facility failed to report the allegation to the SSA or complete an abuse investigation. (Refer to F223) Record review and interview revealed incidents of physical and/or verbal altercations between residents with no documented evidence the incidents were investigated to identify potential abuse and no documented evidence actions were taken to protect residents from further potential abuse. This failure affected ten (10) residents. On [DATE] Resident #10 received and unwelcomed kiss from Resident #9. On [DATE], Resident #13 made verbally threatening remarks to Resident #14. On [DATE], Resident #11 threw a bowl of soup that landed on Resident #12. On [DATE] Resident #15 and Resident #16 were in a physical altercation. On [DATE], there was a physical altercation between Resident #17 and Resident #18. In addition, the facility failed to have an effective system for abuse screening and prevention for eight (8) of eighteen (18) sampled personnel files. The facility failed to verify staff licenses, complete nurse aide abuse registry (NAR) checks, complete reference checks, and/or criminal background checks were conducted or contained negative information regarding theft. The facility's failure to have an effective system for abuse investigation, reporting, prevention and protection of residents at risk placed residents in a situation that has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AOC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit on [DATE]. The scope and severity was lowered to an "E" with continued noncompliance while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy regarding Resident Abuse, revised [DATE], revealed each resident would be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriate of property. Any employee who witnessed or had knowledge of an act of abuse to a resident was obligated to report such information to the Clinical Nurse in charge, Director of Clinical Services (DCS) and the Executive Director. All reported events would be investigated by the DCS. This information would be forwarded to the Executive Director, who would serve as the facility's Abuse Coordinator, and an abuse investigation would be conducted. In the absence of the Executive Director, the DCS will serve as the Abuse Coordinator. All incidents of abuse were to be reported immediately and the prescribed forms were to be completed and delivered to the Abuse Coordinator. The Abuse Coordinator was responsible for reporting to the appropriate officials in accordance with Federal and State Regulation. The Abuse Coordinator or designee would investigate all reports of suspected abuse. Immediately upon report of an incident the suspect would be segregated from the resident. An incident report would be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. The Abuse Coordinator and/or DCS would take statements from the victims, the suspects and all possible witnesses including all other employees in the vicinity of the alleged abuse. Once the investigation was completed the report would be reviewed by the DCS, the Abuse Coordinator, and one other Administrative staff member. Review of the facility's policy Resident Abuse-Resident to Resident, revised [DATE], revealed residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals. If applicable, the staff was to move the resident causing the danger to another room or unit, pending investigation of the incident. Closely monitor and document the behavior and condition of the residents involved to evaluate for any injury and to prevent recurrence of the incident. A documented investigation by the Executive Director, DCS, or designee must be initiated within twenty-four (24) hours of knowledge of the alleged incident. The investigation included talking to all involved (directly or indirectly), any family involved, all residents involved, and any visitors or volunteers involved. The Executive Director, DCS, or their designee must notify Adult Protective Services, the local Ombudsman, and law enforcement (if criminal act) of any alleged abuse. The facility must develop measures to prevent reoccurrence and document these measures in the resident's medical record to include revision of the plan of care. Review of the list of the facility's Key Personnel provided to the State Survey Agency on [DATE] revealed the SSD was also the facility's Abuse Coordinator. However, a revised list provided on [DATE] at 8:50 AM, revealed the facility's Abuse Coordinator was the Interim Executive Director (ED). 1. Interview and record review revealed Resident #1 had a history of [REDACTED]. However, there was no documented evidence the facility had conducted investigations to identify this behavior as potential abuse. Review of Resident #1's Psychiatric Services notes revealed the resident's behaviors toward peers and staff dated back to 2012. Per the Psychiatric Services notes, Resident #1 displayed aggression, yelling, lability, severe mood swings, verbal outbursts, had increased flirtation and poor boundaries with male peers, was sexually intrusive, and made inappropriate comments toward male caregivers. Record review revealed on [DATE] Resident #1 was discovered in Resident #2's room with his/her hand under Resident #2's sheet touching and fondling Resident #2. Interview with Resident #2 revealed the touching by Resident #1 made him/her feel uncomfortable. Interview with the Social Service Director (SSD), on [DATE] at 9:00 AM, revealed she had been told about Resident #1's history of sexually inappropriate behavior, but was not aware of any incidents since she started, on [DATE], and was unaware of the incident on [DATE] of Resident #1's behavior toward Resident #2. On [DATE] at 10:24 AM, interview with Interim DCS revealed Resident #1's behaviors were not documented on the 24 hour report, which was used for the morning meetings. If the behaviors were not documented, she stated she would not know the behaviors had occurred and therefore Resident #1's behaviors would not be addressed. Interview, on [DATE] at 12:35 PM, with the Interim ED revealed the SSD, DCS and the ED should have been notified and an investigation completed regarding the incident on [DATE]. Continued interview, on [DATE] at 2:58 PM, revealed the Quality Assurance (QA) committee met on [DATE] and there was no evidence abuse by Resident #1 toward Resident #2 was discussed. Further interview with the SSD, on [DATE] at 9:00 AM, revealed she had witnessed Resident #1 kiss Resident #2 in the hallway by the shower on [DATE], but did not intervene or interview Resident #2 as to whether or not it was mutual. Interview with Licensed Practical Nurse (LPN) #5, on [DATE] at 9:01 AM, revealed she knew of two (2) or three (3) incidents of kissing/touching in the last six (6) months. However, LPN #5 stated she had not reported it because she had not actually witnessed the incidents. Per interview, she saw Resident #1 touch Resident #2's arm, which caused Resident #2 to grimace. However, she did not think it was something to put on an incident report. LPN #5 stated all the incidents should have been charted. Review of Resident #1's and #2's medical record revealed the incidents the LPN was discussing were not charted. Further review of Resident #1's chart revealed a Psychiatrist note, dated [DATE], indicating a verbal exchange occurred between Resident #1 and Resident #3. No further information was recorded. However, review of Resident #1's medical record revealed the resident began complaining of arm pain on [DATE] and an X-ray revealed a right shoulder dislocation with inferior subluxation. Interview with the House Supervisor, on [DATE] at 12:59 PM, revealed she was working as House Supervisor the night of [DATE] and was notified of a verbal and physical altercation between Resident #1 and Resident #3 outside in the courtyard. The House Supervisor revealed an incident report was completed, the previous ED #2 was notified and statements were written. Interview with the SSD, on [DATE] at 9:00 AM, revealed the incident on [DATE] was not reported to her and she found out about it by overhearing conversation from staff. The SSD revealed it was not investigated, but looked into as a behavioral incident. Further interview, on [DATE] at 2:00 PM, revealed she did not know what happened to the statements written by the Supervisor or the SRNA and did not know they ever existed. The SSD revealed ED #2 did the abuse investigations at that time and would have interviewed the staff. The SSD revealed she did interview Residents #1 and #3, but they stated it was just yelling and denied hitting each other. The SSD revealed she did attend the morning meetings where incidents were discussed. The SSD revealed Resident #1 had been discussed regarding refusal of care and cussing, but she had never been informed of the other behaviors and had not seen any documentation in the charts. Interview with the current DCS, on [DATE], at 3:12 PM, revealed she was not able to find any investigations regarding the incident with Residents #1 and #3 on [DATE]. Further interview with the SSD, on [DATE] at 10:32 AM, revealed the Regional DCS was aware of the incident from [DATE] because the previous ED #2 called the Regional DCS for advice on that incident involving Resident #1 and #3. Interview with previous Regional DCS, on [DATE] at 3:22 PM, revealed the current Regional DCS was training with her, on [DATE], and they received a call from a previous DCS about a reportable involving an altercation with actual body contact between Resident #1 and #3, and #1 actually had to go out for an evaluation due to an injury. The previous Regional DCS revealed she told the facility to report it, write up a plan, and send a copy for review. The previous Regional DCS revealed they received a call from previous ED #2 later that day to discuss this, because he did not want to report the incident, and that he had done his own investigation and did not feel it needed to be reported. The previous Regional DCS revealed the previous ED #2 was told it fell under the guidelines and needed to be reported, and it was always better to error on the side of caution. The previous Regional DCS revealed that was the last she heard from the facility as it was given to another person. The previous Regional DCS confirmed the current Regional DCS was present at the time of the conversation, which was on speaker so both could hear the conversation, and was knowledgeable of what had occurred. Interview with the current Interim ED, on [DATE] at 3:00 PM, revealed the morning meeting QA minutes from [DATE] had the incident with Resident #1 and #3 listed as a reportable incident. The ED revealed he was told by Corporate staff to report to the State Survey Agency that the previous ED #2 was told to report the incident to the SSA, but he had chosen not to. The Regional DCS read the notes listed on the minutes stating it read resident hit another resident. The ED revealed there were no other [MEDICATION NAME] listed or evidence of any tracking on Resident #1's behaviors. 3. Interview with MDS Director #1, on [DATE] at 10:09 AM, revealed another incident had occurred involving Resident #19 and the Activities Director. The MDS Director revealed she overheard the verbal altercation and reported the incident to the SSD by phone as an allegation of verbal abuse and never heard back from anyone regarding the investigation or that it had been reported. Interview with the SSD, on [DATE] at 10:32 AM, revealed she was notified on a verbal argument between Resident #19 and the Activities Director by the Psychiatric Advanced Registered Nurse (ARNP). The SSD revealed she had witnesses write statements and turned them in to the ED and the current Interim ED completed the investigation. The SSD revealed the Incident occurred [DATE] and the Activities Director was suspended until the State Survey Agency entered the building on [DATE]. The SSD revealed the ED had the Activities Director come in and retrieve the requested Resident Council Minutes and told her the incident was not substantiated. Interview with the Activities Director (AD), on [DATE] at 3:56 PM, revealed she was put on suspension until [DATE] and received education at that time to not argue back with the residents. Interview with the current Interim ED, on [DATE] at 9:22 AM, revealed he was responsible for the investigation from the incident on [DATE]. The ED revealed they were speaking loudly because of the distance between the two (2) and this was based on the statements that were turned in from the witnesses. He stated his investigation consisted of the statements from the witnesses, and he did not talk to any of the witness. Per interview, he was not aware the MDS Director and the ARNP reported the incident as an allegation of verbal abuse, and did not interview any of the residents to ensure they had not been affected or victim to any type of abuse from the AD. The ED reported he would have to refer to the SSD's notes because he could not speculate as to who he talked to or what he looked at to base a decision on as to the outcome of his investigation. The ED indicated he was not familiar with the reporting requirements and would have to "let the law speak for itself". The ED further revealed the incident was not investigated as an abuse allegation because it was seen more as a customer service issue and therefore the incident was not reported. 4. Interview on [DATE] at 4:32 PM, with the current Regional DCS revealed that on [DATE], the Assistant Director of Nurses, Unit Manager, Director of Clinical Services, Staff Development Coordinator and the third shift Supervisor conducted audits of resident records, conducted interviews with residents and staff, and discovered there was a problem with abuse in the facility. Per interview, there was no evidence the incidents discovered in the audit had been investigated for potential abuse. Based on this audit, the facility reported some concerns to the State Survey Agency on [DATE]. Review of the concerns from the audit provided by the facility revealed the following: Resident #10 received and unwelcomed kiss from Resident #9, on [DATE]. There was no documented evidence the incident was investigated by the facility and there was no evidence the facility implemented interventions to prevent reoccurrence and to protect residents from potential abuse. Resident #15 and Resident #16 were in a physical altercation (as defined by the OIG report) and a altercation as identified in the nurses note on [DATE]. There was no harm alleged. Resident #15 thrust his/her arm into the back of Resident #16's wheelchair. The incident was not investigated by the facility as potential abuse towards Resident #16 and no evidence the facility implemented interventions to prevent reoccurrence. Resident #13 made verbally threatening remarks to Resident #14, on [DATE]. Resident #13 was cursing and arguing with Resident #14 then threatened Resident #14 that he/she would stab him/her with a long handled shoe horn. Resident #14 yelled to Resident #13 he/she was going to knock his/her M----- F------ ass out that wheelchair. The incident was not investigated by the facility as potential abuse and no evidence the facility implemented interventions to prevent reoccurrence between Resident #13 and Resident #14 or to protect other residents from potential abuse. Resident #11 threw a bowl of soup that landed on Resident #12, on [DATE]. Social Services documented Resident #11 was angry and continued to be angry in the dining room. Resident #11 was upset with the meal and picked up the soup and threw it at Resident #12 and yelled shut up, when it landed on Resident #12. The staff did not assess Resident #12 for any injury until a skin assessment was completed on [DATE], two (2) days later. The incident was not investigated by the facility and there was no evidence the facility took action to address Resident #11's physical abuse towards Resident #12. The facility also reported a physical altercation that occurred on [DATE] between Resident #17 and Resident #18. The nurse turned the TV off and Resident #17 stated he/she was watching the TV. Approximately ten (10) minutes later the nurse overheard yelling "that does not belong to you". When the nurse entered the room she found both residents standing breast to breast. The residents were separated and no injury was alleged. However, the facility did not complete an investigation to determine a root cause to prevent an altercation from occurring again. Review of the facility's list of key personnel listed the SSD as the Abuse Coordinator. However, interview with the SSD, on [DATE] at 2:06 PM, revealed she was not aware she was the Abuse Coordinator. The SSD revealed she was never appointed to that position; however, the SSD stated she had been completing investigations since May of 2013 when the previous ED #1 left. Interview with the current interim ED, on [DATE] at 10:22 AM, revealed the SSD handled all the investigations when he became the ED on [DATE] and assumed since that was the system in place she was the Abuse Coordinator. The ED revealed it was obvious the system was broken. The ED reported there were a lot of offices and a lot of paper in the building and he would have to go through all of them to find out how many had been reported, otherwise he would have to speculate on the accuracy of his memory as to how many abuse allegation there had been and he would have to let the record speak for itself. 5. Review of the facility's policy regarding Resident Abuse, revised [DATE], under the section titled screening, revealed the facility would screen any persons applying for employment for a history of abuse, neglect or mistreating residents by checking references from previous or current employers, criminal background checks, abuse checks with appropriate licensing board and registries prior to hire, sworn disclosure statements prior to hire, and verification of license or registration prior to hire. Review of the facility's policy regarding Licensure and Certification Verification, reviewed [DATE], revealed all staff requiring licensure or certification would produce a current license, certification, or other authorization to practice in the state they are employed. A designated facility representative would be responsible to ensure the policy was followed. Additionally, a copy of the electronic version of an individual's current license/certification would be maintained in the personnel file. Review of the facility's policy regarding Eligibility for Employment, reviewed [DATE], revealed any individual who had been convicted of any offense involving theft may not be eligible for hire. Review of the personnel file for State Registered Nurse Aide (SRNA) #10 revealed the facility hired the SRNA on [DATE]. The facility completed a Nurse Aide Abuse Registry check on [DATE], seven (7) days after date of hire. Review of the personnel file for the Activities Assistant revealed the facility hired her on [DATE]. A Nurse Aide Abuse Registry check and reference checks were not completed until [DATE], or sixty-eight (68) days late. Review of SRNA #5's personnel file revealed the facility hired the SRNA on [DATE]. Reference checks for the aide were not completed by the facility as of [DATE], or one hundred seventy-six (176) days. Review of the personnel file for the previous Director of Clinical Services (DCS) #1 revealed the facility hired the previous DCS on [DATE] and the first day of work was on [DATE]. The facility verified the DCS nursing license and Nurse Aide Abuse Registry check on [DATE], thirty-four (34) days late. Review of previous Interim Executive Director (ED) #3's personnel file revealed the facility hired the ED on [DATE]. The facility conducted the criminal background check on [DATE], fourteen (14) late. A Nurse Aide Abuse Registry check was not completed by the facility as of [DATE], or three hundred and ten (310) days. Review of previous ED #2's personnel file revealed the facility hired him on [DATE] and was present during the incident of physical abuse between Resident #1 and #3. The facility did not complete a Nurse Aide Abuse Registry check as of [DATE], or two hundred and six (206) days. Review of the personnel file for the current Interim ED revealed the facility hired him on [DATE] and was present during the incident of verbal abuse between the Activities Director and Resident #19. A Nurse Aide Abuse Registry check was not completed as of [DATE]. Review of the personnel file for the previous Interim DCS revealed the facility hired the DCS on [DATE] and present during the incident of sexual abuse between Resident #1 and #2. The facility completed a criminal background check on [DATE] that revealed a charge of Theft by Unlawful Taking, disposed as Indictment by Grand Jury. Interview, on [DATE] at 10:24 AM, with the current Interim DCS revealed the nurse aide abuse registry checks for new personnel should be completed prior to new hires entering the building; however, the Activities Assistant did not need to be a SRNA, and therefore would not need an abuse registry check. However, review of the facility's policy revealed "any persons" applying for employment would be screened for a history of abuse, neglect, and mistreating residents. She stated the Staff Development Coordinator (SDC) was responsible to complete the nurse aide abuse registry checks for nursing, and Human Resources (HR) would complete the checks for non-nursing staff. The DCS indicated she directly supervised the SDC. The DCS stated criminal background checks and references should also be completed. She further stated the Activities Assistant had only worked at the facility for a couple of hours in classroom orientation and had never returned. The DCS indicated if the facility did not verify an individual's license then it was possible to have unlicensed personnel in a licensed position. She stated this was a safety issue and not completing the required checks allowed the potential for residents to be unsafe in the facility. Interview with the Staff Development Coordinator (SDC), on [DATE] at 1:25 PM, revealed she was responsible to complete license and NAR checks for nurses and aides, and background checks were completed by HR. The SDC stated she began to complete the license and NAR checks in the previous month. She indicated if the required checks were not completed, a new staff member could have an expired license. She further indicated she was supervised by the DCS; however, did not submit staff checks to the DCS for review prior to submittal to the HR. The DCS stated she began to conduct reference checks in the last couple of weeks as the checks were not being conducted timely by the receptionist. Interview, on [DATE] on 2:35 PM, with the Payroll/HR Coordinator revealed she was responsible for Payroll/ HR from [DATE] to [DATE], and again from [DATE] to present. The Payroll/HR Coordinator stated during the month of [DATE] the HR position was vacant and someone from another facility completed only the payroll. She indicated to her knowledge, no one completed the required personnel checks during that time. She further indicated if the Kentucky Board of Nursing (KBN) checks were not completed, the staff member could be a danger to residents as the staff could potentially be unlicensed and not have the required education. She stated the KBN would verify the KY abuse registry. The HR Coordinator stated she was responsible to ensure SRNA #9's KBN check was completed. Interview with SRNA #4, on [DATE] at 1:01 PM, revealed she was the previous SDC for the facility from ,[DATE] to [DATE]. She stated she was responsible to complete reference checks on staff applicants and the previous HR Coordinator was responsible to complete all of the required checks. She indicated the purpose of conducting the required checks was to ensure the staff member had no reported background of abuse, neglect, drug charges, and theft. On [DATE] at 1:55 PM, interview with the previous Accounts Payable/Payroll Coordinator (PC) revealed she left the faciity on [DATE]. She stated she conducted background and KBN checks for every employee of the facility. She stated each department conducted their own reference checks. She stated she conducted monthly audits and when she left the facility everything was up to date. The PC stated when she left the facility in October, no one had replaced her; however, someone from another facility filled in to complete payroll. She further indicated all of the required checks should be completed prior to a new employee entering the building for new employee orientation. She stated if the background check listed theft, the applicant could not be hired. The PC stated the purpose of the checks was to ensure employees hired would not abuse and neglect residents. On [DATE] at 12:35 PM, interview with the Interim ED revealed HR was responsible to ensure personnel files were complete. He stated if reference checks or abuse registry checks were conducted after the new employee had started working at the facility on [DATE], then it could mean those documents were lost or they were not completed. The ED stated the personnel checks, which included background checks, license verification, and abuse registry checks, should be completed prior to a new employee's hire to keep residents of the facility safe. He indicated the facility should ensure staff were not listed on the abuse registry. The ED further indicated he would use a checklist to ensure all documents and checks had been completed; however, he had not implemented one. He stated he would also conduct periodic and random checks of employee files; however, he had not done any at the facility in his time employed. Interview with the Corporate Human Resources, on [DATE] at 2:24 PM, revealed 360 staffing was contracted to supply interim EDs and DCSs. 360 does all screening and these screenings specify a yes or a no for eligibility for hire. The form does not specify any details of the background search or who the information is obtained from. She further stated she would have to call 360 to obtain the actual hire dates of the EDs. The facility provided an Allegation of Compliance (AOC) on [DATE] alleging the Immediate Jeopardy (IJ) was removed on [DATE]; the facility took the following immediate steps to remove the IJ: 1. Resident #1 was discharged to the hospital for a psychiatric evaluation on [DATE]. 2. Resident #3 was referred by the DCS, and seen by the Psychiatric ARNP, on [DATE]. 3. Resident #3 was placed on increased supervision, 1:1 observation, to redirect impulse behaviors on [DATE]. 4. Resident #3 was reviewed by the Interdisciplinary Team (IDT) (consisting of the Corporate Administrative Nurse, DCS, Activity Director, and Regional Director of Clinical Services) in the Behavior Management Meeting, on [DATE], which included a medical record review. 5. Resident #3's care plan was updated by the Corporate Administrative Registered Nurse on [DATE]. 6. The incident involving Resident #3, on [DATE], was reported to the State Survey Agency (SSA), on [DATE] via a 24 Hour Report, investigated and a 5 Day report was submitted to the SSA on [DATE]. 7. Resident #2 was reviewed in the Behavior Management Meeting by the IDT Corporate Administrative Registered Nurse, DCS, Activity Director, and the Regional Director of Clinical Services on [DATE] which included a medical record review and a care plan review. 8. The incident on [DATE] involving Resident #2 was reported to the SSA on [DATE] via a 24 hour report. A 5 day Report was submitted to the SSA on [DATE]. 9. Resident #2 was interviewed on [DATE] by the SSD and the DCS regarding the incident on [DATE] and [DATE]. 10. Current resident chart reviews completed , on [DATE] and [DATE] by the DCS, ADCS, Unit Manager and RDCS and staff interviews on [DATE] and [DATE] by Corporate Administrative Registered Nurses to identify residents with behaviors, the facility identified three (3) residents (#3, #13, and #21) as exhibiting sexual or physical behaviors towards others. These three residents were: A. Reviewed in the Behavior Management Meeting by the IDT (Corporate Administrative Registered Nurse, Director of Clinical Services Activity Director, and the Regional Director of Clinical Services) on [DATE]. B. Increased supervision was initiated on [DATE] and the care plans were revised by the Activity Director the Corporate Administrative Registered Nurse and the DCS on [DATE]. C. Referred to the Psychiatrist for review by the DCS and two ( #13 and #21) of three residents were seen on [DATE]. D. Had documentation of behavior reviewed daily since [DATE] by a member of the IDT (to include the DCS, ED, and the Corporate Administrative Registered Nurses). 11. Thirty-nine (39) residents, with a brief interview for mental status (BIMS) of an 8 or above were interviewed by the Social Services on [DATE] to ensure they had not been abused or neglected. 12. All residents were assessed by nurses via skin sweeps for suspicious injuries on [DATE], [DATE], and on [DATE] with no injuries found. 13. All Department Heads along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116) were interviewed by the Corporate Administrative Registered Nurse on

Based on observation, interview, review of the facility's investigation, and policies regarding Resident Abuse and Resident Abuse-Resident to Resident, it was determined the facility failed to have an effective system to ensure policies and procedures were implemented related to abuse for fourteen (14) of the twenty-two (22) sampled residents (Resident's #1, #2, #3, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19). The facility failed to ensure staff reported allegations of abuse, failed to investigate allegations of abuse, failed to prevent the potential for further abuse, and failed to report allegations to the appropriate State Agencies per the facility's policy and procedures. (Refer to F223 and F225) On 07/17/13, Resident #1 was found in Resident #2's room with his/her hand under Resident #2's sheet. Resident #2 was telling Resident #1 to stop, after Resident #1 continued to "play" with Resident #2, the resident got mad and threw a pack of cookies at Resident #1. Resident #1 then started to throw items at Resident #2. Attempts by staff to remove Resident #1 from the room resulted in Resident #1 refusing to leave Resident #2's doorway for twenty (20) minutes while yelling and arguing with staff. The incident was not reported to the Abuse Coordinator or the State Survey Agency (SSA), and no investigation was completed. On 11/08/13, revealed a verbal exchange occurred between Resident #1 and Resident #3, that escalated in to a physical altercation. Resident #1 was verbally assaulting Resident #3. Resident #3 hit Resident #1 with the walker and fell to the ground. Resident #1 then kicked Resident #3 in the head multiple times. On 11/06/13, Resident #1 complained of arm pain and an X-ray revealed a dislocated shoulder. This incident was never reported to the SSA or investigated as abuse. On 12/30/13, the facility's Activities Director was observed, by the adult Psychiatric Advanced Registered Nurse Practitioner (ARNP), yelling and screaming at Resident #19. The ARNP reported an allegation of verbal abuse to the Social Service Director; however, the facility failed to report the allegation to the SSA or complete an abuse investigation. Record review and interview revealed incidents of physical and/or verbal altercations between residents which were not reported to the State Agencies, with no documented evidence the incidents were investigated to identify potential abuse and no documented evidence actions were taken to protect residents from further potential abuse. This failure affected ten (10) residents (Residents #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18). In addition, review of eighteen (18) employee records revealed eight (8) employees files did not contain the required registry checks, criminal back ground checks, and/or references for abuse prohibition. The facility's failure to implement abuse policies regarding identifying, investigating, reporting, and protection of residents from abuse placed residents in a situation that has caused, or was likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy (IJ) was identified on 01/10/14 and determined to exist on 07/17/13. The facility was notified of the Immediate Jeopardy on 01/10/14. An acceptable Allegation of Compliance (AOC) was received on 01/20/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 01/16/14 as alleged, prior to exit on 01/22/14. The scope and severity was lowered to an "E" with continued noncompliance while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy regarding Resident Abuse, revised 01/01/12, revealed each resident would be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. Any employee who witnessed or had knowledge of an act of abuse to a resident was obligated to report such information to the Clinical Nurse in charge, Director of Clinical Services (DCS) and the Executive Director. All reported events would be investigated by the DCS. Patterns or trends would be identified that might constitute abuse. This information would be forwarded to the Executive Director, who would serve as the facility's Abuse Coordinator, and an abuse investigation would be conducted. In the absence of the Executive Director, the DCS will serve as the Abuse Coordinator. All incidents of abuse were to be reported immediately and the prescribed forms were to be completed and delivered to the Abuse Coordinator. The Abuse Coordinator was responsible for reporting to the appropriate officials in accordance with Federal and State Regulation. The Abuse Coordinator or designee would investigate all reports of suspected abuse. Immediately upon report of an incident the suspect would be segregated from the resident. The DCS would perform and document a thorough nursing assessment and notify the physician. An incident report would be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. The Abuse Coordinator and/or DCS would take statements from the victims, the suspects and all possible witnesses including all other employees in the vicinity of the alleged abuse. Once the investigation was completed the report would be reviewed by the DCS, the Abuse Coordinator, and one other Administrative staff member. Review of the facility's policy Resident Abuse-Resident to Resident, revised 01/01/09, revealed residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals. If applicable, the staff was to move the resident causing the danger to another room or unit, pending investigation of the incident. Closely monitor and document the behavior and condition of the residents involved to evaluate for any injury and to prevent recurrence of the incident. Notification to the doctor and responsible party must be made to the following of all residents involved in the incident. A documented investigation by the Executive Director, DCS, or designee must be initiated within twenty-four (24) hours of knowledge of the alleged incident. The investigation included talking to all involved (directly or indirectly), any family involved, all residents involved, and any visitors or volunteers involved. The Executive Director, DCS, or their designee must notify Adult Protective Services, the local Ombudsman, and law enforcement (if criminal act) of any alleged abuse. The facility must develop measures to prevent reoccurrence and document these measures in the resident's medical record to include revision of the plan of care. 1. Interview and record review revealed physical altercations involving Resident #1 and two other residents. On 07/17/13, Resident #1 was observed in Resident #2's room with his/her hand under Resident #2's sheet. Resident #2 was telling Resident #1 to "stop", after Resident #1 continued to "play" with Resident #2. On 11/05/13, Resident #1 and Resident #3 were in a verbal and physical altercation in which Resident #1 kicked Resident #3 in the head multiple times. On 01/06/14, the Social Services Director (SSD) witnessed Resident #1 kiss Resident #2 in the hallway by the shower on 01/06/14, but did not intervene or interview Resident #2 as to whether or not it was mutual. There was no evidence the facility completed an incident report, or investigated the incidents as potential abuse per the facility's policy. Interview with the current DCS, on 01/09/14, at 3:12 PM, revealed she was not able to find any investigations regarding the incidents with Resident #1. However, the facility's policy and procedures stated all incidents of abuse were to be reported immediately, and Abuse Coordinator or designee would investigate all reports of suspected abuse. Interview with the current Interim ED, on 01/10/14 at 3:00 PM, revealed the morning meeting QA minutes from 11/06/13 had the incident with Resident #1 and #3 listed as a reportable incident. The ED revealed the previous ED #2 was told to report the incident to the SSA, but he had chosen not to, even though the facility's policy stated all incidents of abuse would be reported to the appropriate officials in accordance with Federal and State Regulation. 2. Interview and record review revealed a verbal altercation between the Activities Director and Resident #19 on 12/30/13. Interview with the with MDS Director #1, on 01/14/14 at 10:09 AM, revealed she reported the incident to the SSD by phone as an allegation of verbal abuse, but never heard back from anyone regarding the investigation or that it had been reported. Interview with the adult Psychiatric Advanced Registered Nurse Practitioner (ARNP), on 01/14/14 at 12:01 PM, revealed she witnessed the Activities Director and Resident #19 yelling at each other. The ARNP revealed she told the Activities Director to walk away and not engage the resident, but she didn't, and the Unit Manager ended up intervening and removed the resident. The ARNP revealed she reported it to the SSD. Interview with the SSD, on 01/14/14 at 10:32 AM, revealed she was notified of a verbal argument between Resident #19 and the Activities Director. However, she stated the current Interim ED completed the investigation. Interview with the current Interim ED, on 01/15/14 at 9:22 AM, revealed he was responsible for the investigation from the incident on 12/30/13. The ED stated his investigation consisted of the statements from the witnesses; however, he did not talk to any of the witness, and was not aware the MDS Director and the ARNP reported the incident as an allegation of verbal abuse to the SSD. In addition, he did not interview any of the residents to ensure they had not been affected or victim to any type of abuse from the AD. The ED revealed the incident was not investigated as an abuse allegation because it was seen more as a customer service issue; and therefore it was not reported. 3. Interview on 010/14/14 at 4:32 PM, with the current Regional DCS revealed that on 01/08/14, and audit of resident records revealed several incidents of resident to resident abuse with no evidence the incidents had been reported to the State Agencies or investigated. However, the facility's policy on Resident to Resident abuse revealed the staff was to move the resident causing the danger to another room or unit, pending investigation of the incident. Closely monitor and document the behavior and condition of the residents involved to evaluate for any injury and to prevent recurrence of the incident. A documented investigation by the Executive Director, DCS, or designee must be initiated within twenty-four (24) hours of knowledge of the alleged incident. The investigation included talking to all involved (directly or indirectly), any family involved, all residents involved, and any visitors or volunteers involved. The Executive Director, DCS, or their designee must notify Adult Protective Services, the local Ombudsman, and law enforcement (if criminal act) of any alleged abuse. The facility must develop measures to prevent reoccurrence and document these measures in the resident's medical record to include revision of the plan of care. The facility reported concerns from the audit which affected ten (10) residents (Residents #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18). Interview with LPN #5, on 01/15/14 at 1:52 PM, revealed there was no set system for reporting allegations of abuse; some nurses had access via computer to the corporate lawyer; and, some nurses just wrote it on the Accident/Incident Report Form (Attorney/Client Worksheet). Review of the facility's list of key personnel listed the SSD as the Abuse Coordinator. However, interview with the SSD, on 01/10/14 at 2:06 PM, revealed she was not aware she was the Abuse Coordinator. The SSD revealed she was never appointed to the position. Interview with the current DCS, on 01/10/14 at 2:17 PM, revealed she was unaware the policy stated the DCS was one of the responsible persons to report abuse allegations. Interview with the current interim ED, on 01/19/14 at 10:22 AM, revealed he could not speak to the corporations formal policy regarding abuse procedures. He further could not verbalize the types of abuse and reporting requirements. He stated the policies were in the manual; however, there was no manual, and all policies were found on the Internet. The ED revealed it was obvious the system was broken. 4. Review of the facility's policy regarding Resident Abuse, revised 01/01/12, under the section titled screening, revealed the facility would screen any persons applying for employment for a history of abuse, neglect or mistreating residents by checking references from previous or current employers, criminal background checks, abuse checks with appropriate licensing board and registries prior to hire, sworn disclosure statements prior to hire, and verification of license or registration prior to hire. Review of the facility's policy regarding Licensure and Certification Verification, reviewed 08/16/13, revealed all staff requiring licensure or certification would produce a current license, certification, or other authorization to practice in the state they are employed. A designated facility representative would be responsible to ensure the policy was followed. Additionally, a copy of the electronic version of an individual's current license/certification would be maintained in the personnel file. Review of the facility's policy regarding Eligibility for Employment, reviewed 03/01/11, revealed any individual who had been convicted of any offense involving theft may not be eligible for hire. Review of eight (8) of eighteen (18) sampled personnel files revealed the facility failed to verify staff licenses, complete nurse aide abuse registry (NAR) checks, complete reference checks, and/or ensure criminal background checks per facility policy. Interview, on 01/07/14 at 10:24 AM, with the current Interim DCS revealed the nurse aide abuse registry checks for new personnel should be completed prior to new hires entering the building. She stated the Staff Development Coordinator (SDC) was responsible to complete the nurse aide abuse registry checks for nursing, and Human Resources (HR) would complete the checks for non-nursing staff. However, there was no documented evidence the facility had a process in place to ensure this background checks were completed prior to hire. On 01/07/14 at 12:35 PM, interview with the Interim ED revealed background checks, license verification, and abuse registry checks should be completed prior to a new employee's hire to keep residents of the facility safe. The ED further indicated a system had not been implemented to ensure all documents and checks had been completed. The facility provided an Allegation of Compliance (AOC) on 01/20/14 alleging the Immediate Jeopardy (IJ) was removed on 01/16/14; the facility took the following immediate steps to remove the IJ: 1. Resident #1 was discharged to the hospital for a psychiatric evaluation on 01/07/14. 2. Resident #3 was referred by the DCS, and seen by the Psychiatric ARNP, on 01/15/14. 3. Resident #3 was placed on increased supervision, 1:1 observation, to redirect impulse behaviors on 01/12/14. 4. Resident #3 was reviewed by the Interdisciplinary Team (IDT) (consisting of the Corporate Administrative Nurse, DCS, Activity Director, and Regional Director of Clinical Services) in the Behavior Management Meeting, on 01/12/14, which included a medical record review. 5. Resident #3's care plan was updated by the Corporate Administrative Registered Nurse on 01/13/14. 6. The incident involving Resident #3, on 11/05/13, was reported to the State Survey Agency (SSA), on 01/08/14 via a 24 Hour Report, investigated and a 5 Day report was submitted to the SSA on 01/13/14. 7. Resident #2 was reviewed in the Behavior Management Meeting by the IDT Corporate Administrative Registered Nurse, DCS, Activity Director, and the Regional Director of Clinical Services on 01/12/14 which included a medical record review and a care plan review. 8. The incident on 07/17/13 involving Resident #2 was reported to the SSA on 01/08/14 via a 24 Hour Report. A 5 day Report was submitted to the SSA on 01/13/14. 9. Resident #2 was interviewed on 01/07/14 by the SSD and the DCS regarding the incident on 07/17/13 and 01/06/14. 10. Current resident chart reviews completed , on 01/07/14 and 01/08/14 by the DCS, ADCS, Unit Manager and RDCS and staff interviews on 01/11/14 and 01/12/14 by Corporate Administrative Registered Nurses to identify residents with behaviors, the facility identified three (3) residents (#3, #13, and #21) as exhibiting sexual or physical behaviors towards others. These three residents were: A. Reviewed in the Behavior Management Meeting by the IDT (Corporate Administrative Registered Nurse, Director of Clinical Services Activity Director, and the Regional Director of Clinical Services) on 01/12/14. B. Increased supervision was initiated on 01/12/14 and the care plans were revised by the Activity Director the Corporate Administrative Registered Nurse and the DCS on 01/13/14. C. Referred to the Psychiatrist for review by the DCS and two (#13 and #21) of three residents were seen on 01/15/14. D. Had documentation of behavior reviewed daily since 01/13/14 by a member of the IDT (to include the DCS, ED, and the Corporate Administrative Registered Nurses). 11. Thirty-nine (39) residents, with a brief interview for mental status (BIMS) of an eight or above were interviewed by the Social Services on 01/07/14 to ensure they had not been abused or neglected. 12. All residents were assessed by nurses via skin sweeps for suspicious injuries on 01/07/14, 01/08/14, and on 01/15/14 with no injuries found. 13. All Department Heads along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116) were interviewed by the Corporate Administrative Registered Nurse on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 to ensure no one had witnessed any abuse or neglect that had not been previously reported. 14. Current resident charts were reviewed on 01/07 and 01/08/14 by the Director of Clinical Services, Assistant Director of Clinical Services, Staff Educator, Unit Manager, and the Regional Director of Clinical Services to determine if there were any incidents that were reportable and/or needed further investigation. The seven (7) incidents that were identified during the review were reported on 01/08/14. 15. The facility's concern book was reviewed by the Regional Director of Clinical Services on 01/11/14 for allegations that needed to be reported and no allegations were identified. 16. The current staff members' employee personnel files were reviewed by Regional Director of Human Resources and Facility Human Resources/Payroll Coordinator to ensure that the files were completed with the Criminal Background Check, Kentucky State Board of Nursing/Nurse Aide Abuse Registry check, Office of the Inspector General Check, Telephone Reference Checks and Abuse/Neglect Attestation on 01/11/14 and 01/12/14. The six (6) discrepancies identified were corrected with missing Criminal Background Checks and Reference checks by 01/12/14. 17. All current Department Head staff along with Nursing, Dietary, Housekeeping/Laundry, and Therapy (totaling 116 employees) were educated by the Corporate Administrative Registered Nurses on abuse screening, training, prevention, identification, investigation, protection, reporting and response, F223 and the facility's Policy and Procedure for Resident Abuse, on 01/11/14, 01/12/14, 01/13/14, 01/14/14, and 01/15/14 and completed a post test. No staff members worked beyond 01/12/14 without having already been educated prior to the start of their shift. 18. The Human Resource/Payroll Coordinator was reeducated by the Regional Director of Human Resources on 01/12/14 that newly hired employees must have a Criminal Background Check, Kentucky Board of Nursing/Nurse Aide Abuse Registry Screen, Office of the Inspector General Exclusion Check, and Telephone reference checks. 19. The ED and DCS were re-educated by the Vice President of Clinical Services on 01/11/14 and 01/12/14 to ensure newly hired employees must have a Criminal Background Check, Kentucky Board of Nursing/Nurse Aide Abuse Registry Screen, Office of the Inspector General Exclusion Check, and Telephone reference checks. The ED will validate and sign that Newly Hired Employees have had all the required checks. 20. Mock Survey Rounds consisting of care plan review and implementation, behavior documentation, and staff interviews were completed by the IDT on 01/13/14, 01/14/14, and 01/15/14 that included resident interviews regarding potential abuse issues. 21. All facility staff was educated by the Corporate Administrative Registered Nurse on identification of behaviors to include but not limited to sexual and physical behavior on 01/12/14. Residents with behaviors will be discussed weekly at the Behavior Management Meeting to ensure targeted behaviors are documented, care planned, and appropriate interventions are in place. The Nurse will document the behaviors on the 24 Hour Report to be shared during the morning meeting. 22. The facility's Administrative staff (ED/Abuse Coordinator and DCS) have been educated by the Corporate Administrative Registered Nurse on 01/12/14 that abuse allegations which are reported to them by employees must be investigated and reported to the appropriate officials in accordance with Federal and State Regulation. 23. The QAPI Committee had an Ad-Hoc QAPI meeting on 01/10/14 to discuss IJ citations and on 01/15/14 to discuss performance improvement opportunities and to review the facility's Abuse policy. The attendees consisted of the Interim Director of Clinical Services, Dietary Manager, Business Office Manager, Director of Admissions, Medical Records, Central Supply, Regional Case Mix Coordinator, Regional Director of Human Resources, Regional Director of Business Services, Regional Director of Clinical Services, Corporate Administrative RN, Director of Rehabilitation Services, Clinical Ambassador, Corporate Director of Education, Regional Vice President of Operations, Vice President of Operations, Vice President of Clinical Services, Vice President of Admissions & Marketing, Corporate Operations Team Member and Executive Director via telephone. Through observation, interview, and record review the State Survey Agency (SSA) validated the AOC, on 01/21/14-01/22/14 prior to exit as follows: 1. Review of the Resident #1 closed medical record revealed the resident was discharged from the facility and sent to the hospital for a psychiatric evaluation on 01/07/14. 2. Interview with the Regional Director of Clinical Services (RDCS), on 01/22/14 at 1:08 PM, revealed the audits of resident clinical records which included review of nurse's notes back to 07/17/13 identified three (3) residents with behaviors requiring increased monitoring through 1:1. Review and observation confirmed 1:1 was occurring and documented The RDCS revealed Resident #3 was identified as one of these residents. Review of the Psychiatric ARNP notes, dated 01/15/14, revealed Resident #3 was listed as one of the residents assessed. 3. Interview with the Vice President of Clinical Operations (VPCO), on 01/22/14 at 2:48 PM, revealed resident's identified with behaviors from the chart audits, on 01/07/14 through 01/08/14 and staff interviews on 01/11/12 through 01/12/14, had interventions put in place during the care plan review. Observation of Resident #3, on 01/21/14 at 4:12 PM, revealed 1:1 supervision was provided with a SRNA #8. 4. Review of the Behavior Meeting notes, on 01/12/14, revealed Resident #3 was listed with identified behaviors, medications, and interventions. 5. Review of Resident #3's Care plan revealed an intervention for 1:1 supervision on 01/13/14. 6. Review of the faxed communication with the SSA from the facility revealed the incident involving Resident #3 and #1, on 11/05/13 was reported on 01/08/14 and a 5 day report was submitted on 01/13/14. 7. Review of the Behavior Meeting notes, on 01/12/14, revealed Resident #2 was reviewed to include a medical record review and care plan review. Interview with the Corporate Administrative Registered Nurse (CARN), on 01/22/14 at 1:27 PM, revealed Resident #2 did not need increased monitoring was not exhibiting behaviors. 8. Review of the faxed communications to the SSA from the Facility revealed the incident on 07/17/13 with Resident #1 and #2 was reported on 01/08/14 and a 5 day follow up was submitted on 01/13/14. 9. Interview with Resident #2, on 01/22/14 at 2:03, revealed he/she did have a conversation with the DCS and SSD regarding the incident on 07/17/13 and 01/06/14. Resident #2 revealed being asked if he/she felt safe and what had occurred. 10. Interview with the Regional Director of Clinical Services (RDCS), on 01/22/14 at 1:08 PM, revealed the audits of resident clinical records which included review of nurse notes back to 07/17/13 identified three (3) residents (#3, #13, and #21) with behaviors requiring increased monitoring. A. Review of the Behavior Management Meeting notes, dated 01/12/14, revealed the three (3) identified were Residents #3, #13, and #21 were included in the meeting. B. Review of the three (3) identified resident's care plan (#3, #13, and #21) revealed interventions to increase supervision using 1:1 was added. C. Review of the Psychiatric ARNP notes, dated 01/15/14, revealed two (2) of the three (3) residents (Residents #13 and #21) had medications and behaviors reviewed. D. Review of the nursing notes and 24 hour report book, revealed the three (3) residents (#3, #13, and #21) were monitored daily with documented behaviors observed. 11. Interview on 01/21/14 with twelve (12) residents, identified as interviewable with a BIMS of 8 or greater, revealed they felt safe at the facility and had been interviewed by the SSD. 12. Review of the facility skin sweeps, dated 01/07/14, 01/08/14, and on 01/15/14, revealed the facility's 89 residents were assessed with [REDACTED]. 13. Interview with sixteen (16) facility staff, Certified Occupational Therapy Assistant (COTA) #1 on 01/20/14 at 2:30 PM; COTA #2 on 01/20/14 at 2:30 PM; LPN #7 on 01/21/14 at 3:25 PM; Maintenance Director on 01/21/14 at 3:30 PM; Dietary Cook on 01/21/14 at 3:35 PM; Dietary Aide on 01/21/14 at 3:37 PM; LPN #8 on 01/21/14 at 3:39 PM; SRNA #10 on 01/21/14 at 4:00 PM; SRNA #8 on 01/21/14 at 4:12 PM; Medical Records on 01/22/14 at 12:58 PM; Payroll/HR on 01/22/14 at 12:50 PM; Business Office Manager on 01/22/14 at 3:11 PM; LPN #5 on 01/22/14 at 1:01 PM; Housekeeper on 01/22/14 at 12:52 PM; SRNA #12 on 01/22/14 at 4:23 PM; and SRNA #11 on 01/22/14 at 4:05 PM, revealed they were asked to identify any residents who exhibited behaviors, abuse and/or neglect that had not been reported. Review of the Behavior Monitoring tool revealed staff was to document who identified a behavior, which resident, and the behavior identified. 14. Review of the faxed communication and facility investigations revealed the seven (7) identified incidents were reported to the SSA on 01/08/14. The expanded sample included five incidents involving Residents #9 and 10, #11 and 12, #13 and 14, #15 and 16, and #17 and 18. 15. Interview with the RDCS, on 01/22/14 at 1:08 PM, revealed the resident's concerns (grievances) were reviewed for potential allegations and none were identified. 16. Interview with RDCS and DCS, on 01/21/14 at 2:30 PM, revealed personnel files were audited on 01/12/14 for: two (2) reference checks, OIG report, Kentucky Board of Nursing Nurse Aide Abuse Registry, Criminal Record Checks, and abuse acknowledgment. RDCS and DCS revealed audits compared to current staff roster and the facility had no new hires for review. Review of two (2) SRNAs, the ED and Activities Assistant personnel files revealed they were accurate. 17. Review of the staff training signature sheets, dated 01/11/14 through 01/15/14, covering the following topics: Identification of Resident Behaviors, Behavior Management, Behavior Reporting, Abuse Education, Facility Policies and Procedures for Behaviors, Emotional and Behavioral Support, Management Problems of Resident with Dementia, Behavior Monitoring, Federal Regulations F223, F225, F226, Physical and Sexual behavior, reporting to Charge nurse and DCS/ED, and documentation contained 116 staff signatures. Interviews with sixteen (16) facility staff members, (See #16) on 01/21/14 and 01/22/14, verified abuse education was completed and followed by an abuse post-test. 18. Interview with the Human Resource/Payroll Coordinator, on 01/22/14 at 12:50 PM, revealed she was educated on required screening components for new hires. Components to include Criminal background checks, two (2) reference checks, OIG report, Kentucky Board of Nursing Nurse Aide Abuse Registry, and abuse acknowledgment. 19. Review of training signature sheets, dated 01/11/14 through 01/15/14, revealed both the ED and DCS signatures as attending the training. A separate training, dated 01/12/14, revealed just the ED and DCS were trained on the facility's Abuse and Neglect Policy and the procedures for reporting investigating. The facility's abuse policy contained new employee hire screening components. 20. Interview with the RDCS and the DCS, on 01/21/14 at 2:20 PM, revealed resident interviews regarding potential abuse issues, and mock surveys consisting of care plan review and implementation, behavior documentation, and staff interviews, were completed on all halls on 01/13/14, the F Hall on 01/14/14, E and F Halls on 01/15/13. Mock surveys continued on 01/16/14 for A, C, E, and F Halls, 01/17/14 for E, A, B, F Halls, and A Hall was done again on 01/18/14. 21. Review of the staff training signature sheets, dated 01/11/14 through 01/15/14, covering the following topics: Identification of Resident Behaviors, Behavior Management, Behavior Reporting, Abuse Education, Facility Policies and Procedures for Behaviors, Performance Improvement Committee, Indicators, Performance Improvement Committee, Emotional and Behavioral Support, Management Problems of Resident with Dementia, Behavior Monitoring, Federal Regulations F223, F225, F226, F280, F282, F323, F514, Physical and Sexual behavior, reporting to Charge nurse and DCS/ED, and documentation and care plan interventions contained 116 staff signatures. Interviews with sixteen (16) facility staff members, (see #16) on 01/21/14 and 01/22/14, verified education was completed and followed by a post-test. 22. Review of training signature sheets, dated 01/11/14 through 01/15/14, revealed both the ED and DCS signatures as attending the training. A separate training, dated 01/12/14, revealed just the ED and DCS were trained on the facility's Abuse and Neglect Policy and the procedures for reporting investigating. The facility's abuse policy contained new employee hire screening components. 23. Interview with the Vice President of Operations, on 01/22/14 at 12:45 PM, revealed an AD-Hoc QA meeting occurred on 01/10/14 to discuss the IJ citations. Interview with the Regional DCS and the DCS, on 01/21/14 at 2:30 PM, revealed the facility's abuse policy and procedure was reviewed and discussed on 01/15/14 in the QA meeting. The Regional DCS revealed no changes were made to the policy as it was determined the facility had a system problem and changes were made in the facility's system to follow the abuse policy. Review of the QA signature sheets and agenda, on 01/15/14, revealed twenty-three (23) people were in attendance and all IJ citations were reviewed and discussed. The QA committee reviewed the facilities policies for Abuse, Resident to Resident Abuse, Behavior Monitoring, Behavior Management, Incidents and Accidents, Performance Improvement, and Morning Meeting. Review of the QA sign in sheet and agenda, on 01/20/14, revealed seven (7) members were in attendance including the Medical D

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure resident's received adequate supervision and assistive devices to prevent accidents for three (3) of seventeen (17) sampled resident's (Resident's #12, #10 and #3). The facility staff failed to provide adequate supervision with bed mobility and repositioning which resulted in the Resident #12 rolling out of bed and sustaining an Acute Distal Ulnar Fracture. In addition, the facility failed to to complete a thorough investigation and root cause analysis following falls sustained by Residents #10 and #3. The findings include: Review of the facility's policy and procedure regarding Procedure for Incidents, effective 01/23/13, revealed the following must be completed prior to completing an incident report: assess the resident; complete the SBAR (Situation, Background, Assessment, Request) placing the original in the chart and sending a copy to the Director of Nursing (DON); call the on call supervisor and the on call would notify the DON; complete a Root Cause Analysis Form and send a copy to the DON; complete the appropriate investigation (Fall, Bruise, Skin Tear or Behavior) and send to the DON; update the Care Plan; call the Physician; and if sending the resident out, complete the QI (Quality Improvement) Tool. A review of the facility policy titled Nurse Tech Information Kardex, with revised date of 09/01/11, revealed Nurse Tech's would utilize the Kardex as a resource when care was provided to the residents. 1. Review of the medical record for Resident #12 revealed the facility readmitted the resident on 08/02/12 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility staff had assessed Resident #12 as extensive assistance of two (2) persons with bed mobility and toileting. Review of Resident #12's comprehensive care plan, dated 12/04/12 and reviewed on 03/04/13, revealed a problem listed as at risk for falls/injury with a goal that the resident would not sustain any significant injuries related to falls. The care plan revealed the resident required assistance with turning and repositioning; however, the care plan failed to indicate extensive assistance of two (2) persons. In addition, Review of Resident #12's Nurse Tech Information Kardex, not dated, revealed the resident required assistance of one (1) staff member for bed mobility and incontinent care not two (2) person assist as assessed by the facility. Review of the SBAR Communication Form for Resident #12 revealed the resident experienced a fall out of bed on 04/25/13. Further review of the fall incident documentation revealed the Root Cause Analysis form or a complete investigation related to the fall had not been completed. Interview with Certified Nursing Assistant CNA #1, on 08/01/13 at 11:30 AM, revealed she had independently provided incontinent care and turned the resident when the resident "tipped" out of bed on 04/25/13. The CNA stated the resident required assistance of one (1) staff member with bed mobility at the time of the fall and had obtained this information from another CNA. However, CNA #1 was unable to recall which CNA provided her training. Per interview, CNA #1 did not refer to Resident #12's Kardex to obtain care information. Interview with CNA #6, on 08/01/13 at 2:00 PM, who has also provided care to Resident #12, revealed Resident #12 required assistance of one (1) staff member when incontinent care was provided and when being turned and repositioned. She further stated this was reported to her by another CNA and she had not reviewed Resident #12's Kardex. Interview with Licensed Practical Nurse (LPN) #1, on 08/01/13 at 1:00 PM, revealed she had assessed Resident #12 after the fall occurred on 04/25/13. The LPN stated the resident complained of generalized pain, had a few abrasions and a physician's order was obtained to transfer the resident to the hospital for further evaluation. The LPN stated she was frequently assigned to care for Resident #12; however, she was not sure what level of assistance the resident required for bed mobility. The LPN stated she was responsible to conduct the root cause analysis of an incident when it occurred on her shift. The LPN indicated she was unsure if she had completed the root cause analysis for the resident's fall on 04/25/13 and stated she couldn't recall if she had identified a causative factor for the fall or not. Review of Resident #12's fall investigation revealed the root cause analysis had not been completed. Interview with the Director of Nursing (DON), on 08/01/13 at 10:45 AM, revealed she had completed the information provided on the Nurse Tech Information Kardex for Resident #12; however, she had not reviewed the resident's MDS assessment and was not aware the resident was a two (2) person assist for bed mobility. The DON further stated she had investigated Resident #12's fall on 04/25/13; however, she had not identified Resident #12 required the assistance of two (2) staff members with bed mobility and incontinent care and that adequate supervision was not provided. Review of Resident #12's fall investigation a thorough investigation had not been completed. 2. Review of the clinical record for Resident #3 revealed the facility admitted the resident on 01/04/13 with [DIAGNOSES REDACTED]. Review of the 06/24/13 Quarterly Assessment revealed the resident had received two injuries from falls since the 01/11/13 Admission Assessment, one with minor injury on 03/25/13 and one with major injury on 06/15/13. In addition, review of the admission assessment revealed the resident was coded as requiring minimal assist with bed mobility. The resident was assessed with [REDACTED]. Observation of Resident #3, on 07/30/13 at 12:40 PM, revealed the resident was lying in his/her bed with his/her eyes closed. Observation, on 07/31/13 at 2:00 PM, revealed the resident was sitting up on the side of the bed watching TV. Interview with the resident revealed he/she did not like to go out of the room very much, and had a fall last month from having low blood sugar; however, stated he/she felt much better now. Review of the Fall Investigation, dated 03/25/13, revealed the resident fell at 12:00 AM, with interventions post fall for vital signs, accuchecks, and neuro checks. The Fall Committee Review/Recommendations were to assist the resident to lie down after meals; however, there was no evidence a root cause analysis had been documented on the Root Cause Analysis Form to reflect why the resident had fallen. In addition, Resident #3 sustained a second fall on 06/15/13, which was placed on the SBAR Communication Form and Progress Note. Review of the SBAR form under the section Situation revealed the fall was due to a drop in blood sugar; however, there was no documentation on the form as to what the blood sugar reading was at the time of the fall. Review of the Quality Improvement Tool, dated 06/16/13, revealed the resident was found on the floor with a cut to the bridge of the nose and mid forehead. Review of the Quality Improvement Tool revealed the resident's blood sugar was 58, and was given Glucogel, with a post Blood Sugar reading of 157. The resident was sent to the hospital for evaluation and treatment. However, review of the Root Cause Analysis for Fall's Form, revealed the 06/15/13 fall had not been evaluated for the root cause, and most of the form was noted to be blank. Interview with LPN #6, on 08/01/13 at 10:00 AM, revealed Resident #3's fall, on 06/15/13, was due to low blood sugar, and stated all falls must have an incident report and SBAR completed with root cause analysis form completed. The LPN stated there had been a lot of turnover with staff, especially administrative staff over the past few months, and the paperwork may not always be completed. 3. Review of Resident #10's medical record revealed [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 05/07/13, revealed the facility assessed the resident as having a Brief Interview of Mental Status (BIMS) of eight (8) indicating cognitive impairment. Further review revealed the facility assessed the resident as requiring the extensive assistance of one (1) staff for bed mobility, limited assistance of two (2) staff for transfers, as ambulation did not occur and as having no falls since admission, reentry, or prior assessment. Review of the Comprehensive Plan of Care with an onset date of 02/16/13 revealed the resident was at risk for injury related to falls, tried to roll out of bed, and was restless at times. The interventions included providing needed devices for locomotion, transfer, wheelchair, walker, assist with transfers, and 1/2 side rails as ordered. Review of a Skilled Nursing Progress Note, dated 07/02/13 at 3:00 AM, revealed the resident was awake, yelling and rolled out of bed to get his/her girlfriends attention. No complaint of pain or discomfort, resident just wanted to get in bed with the girlfriend. Vital Signs were documented as Blood Pressure 126/78, Respirations 18, pulse 88. Oxygen saturation 99 percent on room air. The resident was incontinent of bowel/bladder and required assist of two (2) with transfers, and assist of one (1) with Activities of Daily Living (ADL's). The nurse would continue to monitor. The Note was signed by Licensed Practical Nurse (LPN) #2. Further review of the record revealed no evidence the physician was notified of the fall and no evidence a SBAR was completed, that the Supervisor was notified, the Root Cause Analysis Form was completed, or that the Investigation was completed. Further review revealed there was no evidence the Care Plan was revised as per the procedure or that the facility procedure for incidents was followed. Interview, on 08/01/13 at 5:30 PM, with LPN #2 revealed she had assessed Resident #10 after the fall and there did not appear to be any injury. She stated she checked for range of motion of extremities as well as obtained vital signs. Continued interview revealed there was a binder at the desk which contained the forms needed to complete after a fall including the SBAR, Incident Report, and Root Cause Analysis. She stated it was up to the nurse to decide which forms to complete depending on the severity of the fall. She further stated a fall was also to be transcribed to the Twenty-four (24) Hour Report. Continued interview revealed she could not remember if she had completed these forms after the fall or transcribed the information related to the fall on to the 24 Hour Report. Further interview revealed she did not remember calling the on-call supervisor or notifying the physician of the fall. She stated the girlfriend was on an air mattress on the floor beside the bed when the resident rolled out on top of the girlfriend. Further interview revealed she should have updated the care plan after the fall to indicate a fall had occurred with interventions to prevent further falls. Interview, on 08/01/13 at 11:00 AM, with the Director of Nursing (DON), revealed she had worked at the facility since November 2012, in different roles and had been in the DON position since 04/13. She stated she was unaware of Resident #10 sustaining a fall. She further stated, after a fall, the nurse was to complete the SBAR which included information regarding notification to the physician and family, complete a Fall Investigation which indicated which part of the body was injured, complete a Root Cause Analysis Form, to determine the reason for the fall, then update the care plan. Continued interview revealed the initial revision of the care plan was to be completed by the nurse who assessed the resident after a fall. She stated the fall was also to be noted on the 24 Hour Report. Further interview, revealed the day after a fall she and the MDS nurse were to check the Care Plans to ensure they were updated. The DON stated she had delegated the Unit Manager to update the kardex. The DON stated, there was a morning meeting Monday through Friday in which incidents such as falls was discussed. She stated, an Interdisciplinary Team Meeting (IDT) was held each Tuesday which consisted of the DON, Social Services, Activities, and Dietary and they checked to see if the interventions were working that were placed after the fall. Interview with the DON also revealed there had been several administrative staff members who were no longer there, and they had identified several system problems, one of them being falls. The DON stated this had been identified as a concern in the last QA meeting, where it was identified that several nurses were not thoroughly completing all the forms required by policy after a fall.

Based on interview and a review of the facility's policies, it was determined the facility failed to maintain a Quality Assessment and Assurance Committee that developed and implemented appropriate plans of action to correct identified quality deficiencies related to falls. Administrative staff and the Regional Director of Clinical Services failed to implement action plans after audits identified deficiencies related to the fall investigative process. Based on this failure Resident #12 sustained a fall on 04/25/13 which resulted in actual harm of a fracture and hospital intervention. Refer to F323 The findings include: A review of the facility's policy regarding Performance Improvement Committee (Quality Assurance), dated 09/01/11, revealed the Performance Improvement Committee would meet monthly to review, recommend and act upon activities of the facility. The policy further stated an action team would be developed to collect and evaluate data and would implement needed action, under the direction of the Performance Improvement Committee. Interview with the Director of Nursing (DON), on 08/01/13 at 7:00 PM, revealed the facility had identified several system problems, in the last Quality Assurance (QA) meeting conducted on 06/28/13, and one of those areas was falls. She stated in the last QA meeting they had identified that several nurses were not completing all the forms needed after a fall, and many of the forms were not thoroughly completed. However, no corrective plan of action had been implemented to correct the identified concerns related to falls. An interview with the Regional Director of Clinical Services, on 08/01/13 at 6:54 PM, revealed she had conducted a fall audit at the facility approximately six (6) weeks ago. She stated she identified root cause analysis had not been completed for facility residents who had experienced falls. The Regional Director stated approximately six (6) weeks ago when her audit was completed, she discussed the results with the DON and the Administrator (no longer employed at the facility) about the concerns she identified related to falls. However, there was no evidence corrective action was implemented. The Regional Director stated she developed a four point system, same as a plan of correction, related to the concerns she had identified and emailed it to the current Administrator, during the week of July 29, 2013 (unable to recall exact date). She stated she had requested this Administrator to conduct a QA meeting to discuss identified concerns. An interview with the current Administrator, on 08/01/13 at 6:00 PM, revealed she had been the facility's Administrator since 07/08/13. The Administrator acknowledged concerns related to fall investigations as being incomplete for the facility's residents. The Administrator stated she had not conducted a QA meeting since she had been Administrator; however, she held a "mini" QA meeting with the DON on 07/26/13 and had discussed fall concerns. The Administrator stated she had not implemented any action plans to correct identified concerns related to falls.

Based on interview, record review and a review of the facility's policy, it was determined the facility failed to ensure a comprehensive care plan was developed for one (1) of seventeen (17) sampled residents (Resident #12) to reflect the required assistance needed for bed mobility as assessed on the resident's Minimum Data Set Assessment (MDS). The facility had identified Resident #12 required extensive assistance of two (2) people with bed mobility. However, the resident's care plan did not indicate any level of assistance. In addition, the Nurse Tech Information Kardex, to be utilized by staff as a resource to provide care to residents, stated Resident #12 was a one (1) person assist for bed mobility versus two (2) persons. On 04/25/13, Certified Nursing Assistant (CNA) #1 independently provided incontinent care to Resident #12. When she turned the resident, the resident rolled out of the bed and sustained an Acute Distal Ulnar Fracture. The findings include: Review of the facility's Care Plan Policy, revised 09/11, revealed an Interdisciplinary Plan of Care would be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis. Review of the facility's policy titled Nurse Tech Information Kardex, revised 09/01/11, revealed Nurse Techs (CNAs) would utilize the Kardex as a resource when care was provided to the residents. Review of Resident #12's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #12 as requiring extensive assistance of two (2) persons with bed mobility and toileting. Review of Resident #12's comprehensive care plan, dated 12/04/12, revealed a problem listed as at risk for falls/injury with a goal that the resident would not sustain any significant injuries related to falls. The care plan revealed the resident required assistance with turning and repositioning; however, the care plan failed to indicate extensive assistance of two (2) persons. Review of the Nurse Tech Information Kardex for Resident #12 indicated the resident was a one person assist for bed mobility and incontinent care, not a two (2) person assist as assessed by the facility. Interview, on 08/01/13 at 11:00 AM, with the Director of Nursing (DON) revealed she had completed the information provided on the Nurse Tech Information Kardex for Resident #12, which directed staff to assist the resident with one (1) staff member for bed mobility and incontinent care. However, she stated she obtained the information from the chart in various places and had not reviewed the resident's MDS assessment which identified Resident #12 as a two (2) assist. Review of the SBAR Communication Form for Resident #12 revealed the resident experienced a fall out of bed on 04/25/13. Interview, on 08/01/13 at 11:30 AM, with CNA #1 revealed she had provided incontinent care to the resident on 04/25/13, and turned Resident #12 when the resident "tipped" out of bed, which resulted in injury. The CNA stated at the time of the fall, the resident required one (1) staff member assistance with bed mobility and incontinent care. However, the CNA stated she was informed of the level of staff assistance Resident #12 required by another CNA and had not reviewed Resident #12's Nurse Tech Information Kardex. Interview with CNA #6, on 08/01/13 at 2:00 PM, revealed she was told by the CNA who trained her that the resident required assistance of one (1) staff member with incontinent care and when being turned and repositioned. Per interview, she had not reviewed Resident #12's Kardex. Interview, on 08/01/13 at 1:00 PM, with Licensed Practical Nurse (LPN) #1, revealed she had assessed Resident #12 after the fall occurred, on 04/25/13. The LPN stated she had been assigned to care for Resident #12 frequently; however, the LPN was not sure what level of assistance the resident required for incontinent care or bed mobility. Further interview, on 08/01/13 at 11:00 AM, with the Director of Nursing (DON) revealed staff know what to do for the residents because they look at the Kardex. She acknowledged Resident #12's information was inaccurate on the Kardex and she should have reviewed the resident's MDS information related to the level of assistance required. The DON continued to state if there had been two staff members, it would have prevented the resident from falling out of bed and sustaining a fracture. Interview with the Regional Case Mix Consultant, on 08/01/13 at 6:30 PM, revealed resident care plans and Nurse Tech Information Kardexs, were required to be developed, reviewed and revised with information obtained through the MDS assessment. The Consultant stated care plans and Nurse Tech Information Kardex, should be updated when incidents or significant changes in the resident's condition occurred. She stated information on the residents care plans/kardexs, should be specific to the resident's needs, and the number of staff required to provide care should be included and accurate based on the MDS assessment. However, interviews with CNA #1 and CNA #6 revealed they did not refer to Resident #12's Nurse Tech Information Kardex to obtain information on how care was to be provided to the resident. The MDS Coordinator who had completed Resident #12's assessment and comprehensive plan of care was no longer employed at the facility.