Every finding on record at The Health Center at Research Park

Based on interviews, medical record reviews, the facility's policy titled, Abuse Prohibition Plan, the Facility Reported Incident (FRI) received by the Alabama State Survey Agency, and the facility's investigative file, the facility failed to protect Resident Identifier (RI) #334's right to be free from physical abuse by another resident, RI #335. During lunch on 06/23/2023 RI #335 was physical and verbally abusive to staff and expressed suicidal and homicidal ideations. RI #335 was sent to the local hospital's emergency room around 1:00 PM. Upon return from the hospital around 3:00 AM, RI #335 was not supervised and went from his/her room, through the bathroom that connected to RI #334's room. On 06/24/2023 at approximately 4:30 AM, RI #335 was witnessed by a CNA (Certified Nursing Assistant) in RI #334's room, standing over RI #334's bed with a pillow over RI #334's face gripping both sides and pushing with force. It was determined the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect and Exploitation at F 600- Free from Abuse and Neglect. On 06/16/2024 at 6:56 PM, the Administrator, Assistant [NAME] President of Operations, Regional Nurse Manager, and the Director of Nursing (DON) were provided the IJ templates and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Freedom from Abuse, Neglect, and Exploitation at F 600- Free from Abuse and Neglect. The IJ began on 06/24/2023 and continued until 06/18/2024 when the survey team verified onsite that corrective actions had been implemented. On 06/19/2024, the immediate jeopardy was removed, and was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of a Facility Reportable Investigation/Complaint/Report Number AL00044582. This deficient practice affected one of seven residents reviewed for abuse and neglect prevention. Findings Include: Cross Reference F 740 A review of the facility's policy titled, Abuse Prohibition Plan, with an effective date of 04/01/2018, revealed: . Purpose: The facility has a zero-tolerance policy for abuse. Verbal, mental, sexual, or physical abuse, corporal punishment . is prohibited. The resident shall not be subjected to mistreatment, neglect . The Abuse Policy applies to anyone involved with the residents of this facility, including, but not limited to all facility staff, other residents . Definitions: . Abuse means the willful infliction or injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes deprivation by an individual, . of good or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . It includes . physical abuse, and mental abuse . Willful means the individual deliberately, not that the individual must have intended to, inflict injury harm. Physical Abuse includes but not limited to hitting, slapping, pinching, and kicking. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative visitor, another healthcare provider, . if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse . B. TRAINING All employees shall receive training during initial orientation, annually and with ongoing sessions . Training shall include, but is not limited to the following: . 2. Resident Rights 3. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property and exploitation . 6. How to identify residents who are at risk for abuse, neglect, . 8. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms include, but are not limited to: a. Aggressive and/or catastrophic reactions of residents . b. Wandering or elopement type behaviors . c. Resistance to care; d. Outburst or yelling out . C. PREVENTION It is the policy of this facility . To prevent potential abuse, the facility leadership shall assess the needs of residents in the facility and the environment to identify concerns. F. PROTECTION It is the policy of this facility that Residents shall be protected from the alleged offender (s) . RI #335 was admitted to the facility on [DATE] with diagnoses that included Dementia with Agitation and Major Depressive Disorder. A review of RI #335's Admission MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 05/08/2023, indicated RI #335's Brief Interview for Mental Status (BIMS) as five of 15, which indicated that RI #335 was cognitively impaired. RI #334 was admitted to the facility on [DATE] with diagnoses that included Dementia and Weakness. RI #334 Admissions MDS with ARD date of 04/11/2023 indicated RI #334 had a BIMS of seven of 15 which indicated RI #334 was cognitively impaired. A review of RI #335's care plan with a Problem Onset Date of 09/28/2022 documented: Altercation with another resident . (RI #335) has a history of verbal aggressive behavior towards family, . hx (history) of wandering behavior . hx of . Resident has threatened to kill his/her daughter and his/her family . Confusion, alteration in thought process related to (RI #335) has dementia . A review of RI #335's Clinical Notes Report entered by Registered Nurse (RN) #30 and dated 06/23/2023 at 12:00 PM, revealed the following: . Called into the dining room by restorative cna and activities director. Was informed that this resident was going off and had thrown juice all over the staff and floor, saw staff wet clothes, and this resident standing near door. Walked up to resident and resident starting telling activities director that this writer was in on it and then resident grabbed this nurse by the wrist and pulled this nurse toward him/her. This nurse pulled away from resident's grip and then resident began advancing toward this nurse . Was visibly angry and upset, would not leave dining room. Administrator walked in and was able to get him/her to leave . Before leaving, resident said, everyone in this room is going to get killed . A review of RI #335's Clinical Notes Report entered by RN #30 dated 06/23/2023 at 12:16 PM, revealed the following: resident stated he/she knows something is wrong in his/her head and feels that he/she would rather be gone then he/she hurt someone A review of RI #335's Clinical Notes Report entered by RN #30 dated 06/23/2023 at 12:59 PM, revealed the following: Stated that if he/she had a gun in front of him/her he/she would shoot himself/herself. Continue to make comments about get rid of me and I'm gonna do it. A review of RI #335's Clinical Notes Report entered by the Social Services Designee (SSD) dated 06/23/2023 at 1:32 PM, revealed the following: I sent information to (name of Psychiatric Facility) for (RI #335) to go over there due to behavior. I was trying my best to get him/her . next door instead of going to ER . I called (name of Mental Health Center) to see if they could speed up the process of getting him/her over there. No one responded, so they sent him/her to the ER (emergency room ) . A review of RI #335's Clinical Notes Report entered by Registered Nurse (RN) #18 dated 06/24/2023, revealed the following: Resident brought by .to facility at 3 AM . no new orders given . he/she did not know why he/she was sent to hospital. A review of RI #335's Clinical Notes Report entered by RN #18 dated 06/24/2023 at 5:33 AM, revealed the following: . Resident came back from (name of hospital) went into 200 hall being combative going into other resident rooms, brought him/her back to 100 he/she tried to hit CNA with the hole puncher he/she kept saying we are going to hell and CNA is dead and he/she took a statue from his/her room and tried to hit us with it he/she was throwing the snack tray around trying to hit the nurse. He/She tried to hit the CNA with the pill crusher, he/she tried to smother another resident with a pillow the CNA walked in on him/her and he/she tried to run back to his/her room. called the administrator and she said send him/her back to the (name of hospital) . On 06/24/2023 at 8:59 AM the facility submitted a report to The Alabama Department of Public Health Online Incident Reporting System. The report indicated at 4:30 AM RI #334 .was found in bed with another resident over him/her with a pillow in his/her hand. Other resident had pillow over resident face . Residents were immediately separated. Aggressor resident was placed on one on one supervision until ambulance arrived and he/she was sent to the hospital. Other resident was assessed head toe for any signs of injury. None noted. Assessment attempted to see if incident caused any distress to resident. Hard to determine due to resident mental condition . The report indicated the incident was report to the Assistant Director of Nursing (ADON), Director of Nursing (DON) and Administrator (ADM) who then reported to medical director, corporate office, state, adult protective services, and local police. The facility's undated incident summary documented the resident on resident Physical was substantiated. The reports summary documented: .Summary: On 06/24/2023 at approximately 4:30-5:00 a.m. the CNA heard the door slam and went to check on what (RI #335) was doing. He/She wasn't in his/her room and found him/her in (RI #334's) room with a pillow over (RI #334's) face with him/her moving his/her arms and legs. CNA immediately pulled (RI #335) away and moved the pillow, she removed (RI #335) from the room, he/she was placed on one-to-one with the nurse . medical director was notified and (RI #335) was sent to (name of hospital) . The immediate intervention was to separate see if incident cause any distress. Psychosocial assessment difficult due to his/her mental condition . After concluding the investigation which included obtaining statement from all involved staff, interviewing residents with a BIM's of 13 and over to ensure resident that was engaging in behaviors not came into their room on the date of concern . We notified the police of incident and (RI #335) was sent to (name of hospital) by (name of ambulance). Unsuccessful attempts were made to interview CNA #27, the witness of the incident, on the phone several times during the survey. An undated written statement from CNA #27 documented: At approx (approximately) 4:30 AM I heard a door slam down 101 hall I went down the hall and checked in room and resident in room, so I walked through adjoining bathroom and noticed resident (RI #335) standing over . (RI #334) holding a pillow over his/her face/head. Resident was gripping pillow on both sides and pushing with force. (RI #335) was immediately removed from room . and was placed 1 to 1 with the nurse. The other nurse came . The resident (RI #334) . was ok . An undated witness statement from RI #188, a resident who was discharged at the time of the survey documented: (typed) Did any resident wake you up last night? . (handwritten) Yes . Resident stated the aggressor came in his/her room and was yelling and screaming leave him/her alone and don't touch him/her resident said the aggressor was talking to himself/herself. Resident said he/she was afraid because the aggressor was running in and out of his/her room and bathroom . An undated witness statement from another resident, RI #33 documented: (typed) Did any resident come in your room last night? (handwritten) Yes, a female/male resident walked in to my room with a vase in his/her hand, walked in bathroom, and then CNA came and got him/her and walked him/her out. He/She was yelling, leave me alone . On 06/13/2024 at 12:10 PM, a telephone interview was conducted with the Former Assistant Director of Nursing (FADON). The FADON was asked about the incident that occurred on 06/24/2023 with RI #334 and RI #335. She stated, she was told that a CNA was walking past the room and observed RI #335 with a pillow over RI #334's head, the CNA immediately intervened by separating RI #335 from RI #334. FADON said that she considered this incident to be resident to resident physical abuse, she further said that RI #335 had been exhibiting aggressive, impulsive, and combative behaviors prior to this incident. On 06/13/2024 at 1:00 PM during an interview, Registered Nurse (RN) #18 stated on the night of the incident, RI #335 was acting strange and was not acting like himself/herself. RN #18 said RI #335 was uncooperative and would not go to his/her room. RN #18 said when RI #335 was asked to go to his/her room, RI #335 got mad and pushed all the snacks off the table. On 06/13/2024 at 6:20 PM a follow-up interview was conducted with RN #18 who said a nursing assessment was not completed when RI #335 returned from the hospital because he/she was not gone over 24 hours. RN #18 said between 3:00 AM and 4:30 AM, the CNA was walking the halls and saw RI #335 with the pillow over RI #334's face. She further stated, the CNA intervened and stopped RI #335, and RI #335 ran back to his/her room and the CNA followed. RN #18 said RI #335 was placed on one-on-one supervision until discharged to the hospital. On 06/14/2024 at 12:05 PM an interview was conducted with Regional Nurse Manager (RNM). The RNM said incident that occurred on 06/24/2023 regarding RI #335 was substantiated as physical abuse. ********************************************************** On 06/18/2024 at 6:00 PM, the facility submitted an acceptable removal plan, which documented: Safety: 1. Resident's #334 and #335 were separated by the CNA on 6/24/23. Assessment: 2. Resident #334 was assessed by the Charge Nurse on 6/24/23, with no injuries noted. 3. On 06/26/2023 the Psychiatric Nurse Practitioner assessed Resident #334 and documented in a provider note with no negative findings. On 6/26/23 Resident #334 was assessed by the Nurse with no negative findings. 4. Resident #335 was placed on one on one by the Charge Nurse on 6/24/23 until resident transferred to the hospital by HEMSI and ultimately discharged . 5. Resident interviews were conducted by the Social Services Director and Activity Coordinator with a BIMS of 13 or greater regarding physical or verbal abuse by another resident on 06/24/2023 with no negative findings. 6. Residents with a BIMS of 12 or less, a body audit was completed by the Director of Nursing and Charge Nurse on 06/24/2023 with no negative findings. 7. Alabama Department of Health, Adult Protective Services, and law enforcement were notified of the reported events on 06/24/2023 by the Administrator. 8. Resident interviews were conducted by the Social Services Director with a BIMS of 13 or greater regarding abuse by anyone on 06/11/2024 and 06/18/2024 with no negative findings. 9. Residents with a BIMS of 12 or less, a body audit was completed by the Director of Nursing, Staffing Coordinator, and Charge Nurse on 06/11/2024 with no negative findings. Notification: 1. On 06/24/2023 Charge Nurse made notifications to the practitioners and responsible parties for resident #334 and #335. Audits: 2. Clinical Record Review from 03/01/2024 to 06/16/2024 was initiated on 06/16/2024 and completed on 06/17/2024 by the Director of Clinical Education and Regional Nurse Managers to include clinical notes, event notes, and daily skilled notes to identify any potential residents for instances of physical abuse, with no unknown new findings. In-services: 1. On 06/16/2024 Inservice was provided by the Assistant [NAME] President of Operations and the Regional Nurse Manager to the Administrator, DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress and combative behaviors and suicidal/homicidal ideation. Education was also provided regarding staff unavailable to receive education will not be permitted to work until required education is completed. The Staffing Coordinator was designated as responsible for ensuring staff are educated on abuse prohibition plan, behavioral health services policy, and list of interventions for behaviors 2. On 06/16/2024 Inservice was provided by the DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress, and combative behaviors and suicidal/homicidal ideation to all staff. Staff unavailable to receive education will not be permitted to work until the required education is completed. 73 out of 77 employees have been educated. 3. On 06/16/2024 competency and validation questions were answered by staff currently working to ensure competency verbalized from education received. 4. On 06/17/2024 the Regional Nurse Manager placed signage in break rooms, nurses stations, and behavior communication binders that list interventions for behaviors including abuse, aggressive, distress and combative behaviors and suicidal/homicidal ideation. QAPI: 1. Adhoc QAPI was conducted on 06/24/2023 to include Administrator, Director of Nursing, Senior [NAME] President of Operations, Assistant [NAME] President of Operations, Regional Nurse Manager, Assistant [NAME] President of Clinical Operations, Regional Nurse Manager to discuss resident to resident altercation event, education, root cause, and interventions. 2. The Medical Director was notified of the immediate jeopardy citations on 06/16/2024 by the Assistant [NAME] President of Operations. 3. A Root cause analysis was conducted on 06/16/2024 by the Administrator, Regional Director of Operations, Assistant [NAME] President of Clinical Operations, Regional Nurse Manager, Directors of Nursing, Assistant [NAME] President of Quality, Director of Clinical Education. Root cause was identified as ineffective training and education related to behavioral health services. 4. QAPI meeting was conducted on 06/16/2024 to include Administrator, Director of Nursing, Staffing Coordinator, Dietary Manager, Activity Coordinator, Treatment Nurse, Receptionist, MDS Coordinator, Social Service Director, Business Office Manager, Maintenance Director, Regional Nurse Manage, Assistant [NAME] President of Operations, Regional Nurse Manager, Medical Director, Assistant [NAME] President of Clinical Operations, Senior [NAME] President, and Director of Clinical Education regarding Immediate Jeopardy citations, Abuse and Behavior Health Services policy review, education, interventions for immediate removal plan, Medical Director notification, facility assessment updated/reviewed and root cause analysis determined. a. Abuse Prohibition Plan reviewed with no recommendation for changes 06/16/2024 b. On 06/16/2024 the Behavior Health Services Policy reviewed with recommendation made to include suicidal and homicidal ideation's (Section 5, Subset F) under procedures- to include risk factors, triggering events, examples used to harm self. Definition of Suicidal Ideation added to provide clarification of terminology related to behavioral health services. c. On 06/16/2024 Updated Intervention list attachment included in the updated Behavior Health Policy for behaviors to include immediate action steps to implement related to abuse, aggressive, distress, combative, and Suicidal and Homicidal Ideations. d. On 06/16/2024 the facility assessment plan was revised to include suicidal ideations. 5. A Governing Body meeting was held to include the Administrator, Director of Nursing, Assistant [NAME] President of Operations, Assistance [NAME] President for Clinical, Senior [NAME] President of Operations, and Regional Nurse Managers on 6/16/24 at 9 PM to discuss the corrective action plans to address the immediate concerns for F 600 for Resident's #334 and #335 and all current residents have the potential to be affected. The Medical Director agreed with the current action plan and had no new recommendations. Facility implemented all corrective Actions on 6/18/2024. ***************************************************************************** After a review of documentation supporting the above corrective actions, including the facility's investigative file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implement corrective actions including ongoing monitoring on 06/18/2024.

Based on interviews, medical record reviews, and the facility policy titled Behavioral Health Services, the facility failed to ensure interventions were developed and implemented to address Resident Identifier (RI) #335's behaviors which included being physically and verbal aggressive towards staff and homicidal and suicidal ideation. On 06/23/2023, RI #335 was sent to the hospital emergency room after being physical and verbally abusive to staff and expressing homicidal and suicidal ideation. RI #335 returned from the hospital around 3:00 AM on 06/24/2023. The facility had not developed a plan for RI #335's return to ensure residents' safety. No new orders were provided, and no new interventions were developed or implemented. On 06/24/2023 around 4:30 AM, Certified Nursing Assistant (CNA) #27 witnessed RI #335 in RI #334's room. RI #335 was standing over RI #334's bed with a pillow over RI #334's face gripping both sides and pushing with force. It was determined the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 443.40 Behavioral Health Services. On 06/16/2024 at 6:56 PM, the Administrator, Assistant [NAME] President of Operations, Regional Nurse Manager, and the Director of Nursing (DON) were provided the IJ templates and notified of the findings at the immediate jeopardy level in the area of Behavioral Health at F 740- Behavioral Health Services. The IJ began on 06/24/2023 and continued until 06/18/2024 when the survey team verified onsite that corrective actions had been implemented. On 06/19/2024, the immediate jeopardy was removed, and was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of a Facility Reportable Investigation/Complaint/Report Number AL 00044582. This deficient practice affected one of four residents reviewed for behavioral health services. Findings Include: Cross reference F 600 and F 741. A review of a facility's policy titled, Behavioral Health Services, with an effective date of 10/02/2023 revealed: Purpose: To ensure that residents receive necessary behavior health services. Policy: It is the policy of this facility that all residents receive care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning. Definitions: Definitions are provided to clarify terminology related to behavioral health services and the attainment or maintenance of a resident's highest practicable well-being. Highest practicable physical, mental and psychosocial well-being is defined as the highest possible level of functioning and well-being-limited by the individual's recognized pathology and normal aging process. Highest practicable is determined through the comprehensive resident assessment and by recognizing and competently and thoroughly addressing the physical, mental, and psychosocial needs of the individual . Procedure: . 3. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. 4. Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial well-being. 5. Conditions that are frequently seen in nursing home residents and may require the facility to provide specialized services and supports base upon residents' individual needs, include, but are not limited to: . a. Depression- It is not a natural part of aging, however, older adults in the nursing home setting are more at risk than older adults in the community. e. Aggressive Behaviors-defined as behaviors that cause harm, threaten to harm, or put the health and safety of people risk . 6. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-center care . b. Obtaining history from medical records, the family, and the resident regarding mental, psychosocial, and emotional health; c. MDS and care area assessments; d. Ongoing monitoring of mood and behavior; e. Care plan development and implementation, and f. Evaluation. 8. Facility staff shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. Education shall be based on the role of the employee and needs identified through the facility assessment . 9. Interventions shall be evidence-based, culturally competent, trauma-informed . RI #335 was admitted to the facility on [DATE] with diagnoses that included Dementia with Agitation and Major Depressive Disorder. A review of RI #335's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/08/2023, indicated RI #335's Brief Interview for Mental Status (BIMS) as five of 15, which indicated that RI #335 was cognitively impaired. A review of RI #335's care plan effective 09/21/2022 through 01/31/2023 included that RI #335 had wandering behaviors with interventions that included monitor his/her location to ensure safety. RI #335's care plan included the he/she had a history of paranoid statements about family taking items from her in a nursing home, has reported seeing men in living room at home when no home was present/seeing bugs on wall, hearing family members talking when they were not there, resident has threatened to kill his/her daughter and his/her family with interventions that included to remove from the situation. The care plan also included 9/28/22 Altercation with another resident. RI #335's care planned interventions did not indicate the level of supervision required. A review of RI #335's Clinical Notes Report entered by Registered Nurse (RN) #30 and dated 06/23/2023 at 12:00 PM, revealed the following: . Called into the dining room by restorative cna and activities director. Was informed that this resident was going off and had thrown juice all over the staff and floor, saw staff wet clothes, and this resident standing near door. Walked up to resident and resident started telling activities director that this writer was in on it and then resident grabbed this nurse by the wrist and pulled this nurse toward him/her. This nurse pulled away from resident's grip and then resident began advancing toward this nurse . Was visibly angry and upset, would not leave dining room. Administrator walked in and was able to get him/her to leave . Before leaving, resident said, everyone in this room is going to get killed . On 06/13/2024 at 12:38 PM an interview was conducted with Restorative Certified Nursing Assistant (RCNA) #19. She described an incident that occurred during dining on 06/23/2023. She said, RI #335 was sitting at a table with two male residents and RI #335 was fixated on one male at the table. RCNA #19 stated she redirected the resident, and he/she got angry stood up and cursed. Then RI #335 grabbed a cup off another resident's plate and threw the juice cup. The resident threatened to do it again and grabbed another cup, but another staff intervene and was able to redirect him/her. A review of RI #335's Clinical Notes Report entered by RN #30 dated 06/23/2023 at 12:16 PM, revealed the following: resident stated he/she knows something is wrong in his/her head and feels that he/she would rather be gone then he/she hurt someone. A review of RI #335's Clinical Notes Report entered by RN #30 dated 06/23/2023 at 12:59 PM, revealed the following: Stated that if he/she had a gun in front of him/her he/she would shoot himself/herself. Continue to make comments about get rid of me and I'm gonna do it. A review of RI #335's Clinical Notes Report entered by the Social Services Designee (SSD) dated 06/23/2023 at 1:32 PM, revealed the following: I sent information to (name of Psychiatric Facility) for resident's name RI #335 to go over there due to behavior. I was trying my best to get (him/her) next door instead of going to ER . I called (name of Mental Health Center) to see if they could speed up the process of getting him/her over there. No one responded, so they sent him/her to the ER . A review of RI #335's Clinical Notes Report entered by Registered Nurse (RN) #18 dated 06/24/2023, revealed the following: Resident brought by .to facility at 3 AM no new orders given . he/she did not know why he/she was sent to hospital The facility's investigative file included an undated witness statement from RI #188, a resident who was discharged at the time of the survey documented: . Resident stated the aggressor came in his/her room and was yelling and screaming leave him/her alone and don't touch him/her resident said the aggressor was talking to himself/herself. Resident said he/she was afraid because the aggressor was running in and out of his/her room and bathroom, so staff put a chair at the bathroom door to keep the aggressor from coming in through the bathroom. An undated witness statement from another resident, RI #33 documented: (typed) Did any resident come in your room last night? (handwritten) Yes, a female/male resident walked in to my room with a vase in his/her hand, walked in bathroom, and then CNA came and got him/her and walked him/her out. He/She was yelling, leave me alone . A review of RI #335's Clinical Notes Report entered by RN #18 dated 06/24/2023 at 5:33 AM, revealed the following: . Resident came back from (name of hospital) went into 200 hall being combative going into other resident rooms, brought him/her back to 100 he/she tried to hit CNA with the hole puncher he/she kept saying we are going to hell and CNA is dead and he/she took a statue from his/her room and tried to hit us with it he/she was throwing the snack tray around trying to hit the nurse. He/She tried to hit the CNA with the pill crusher, he/she tried to smother another resident with a pillow the CNA walked in on him/her and he/she tried to run back to his/her room. ADON (Assistant Director of Nursing) called the administrator and she said send him/her back to the (name of hospital) . The facility's investigative file included an undated written statement from CNA #27 documented: At approx (approximately) 4:30 AM I heard a door slam down 101 hall I went down the hall and checked in room and resident in room, so I walked through adjoining bathroom and noticed resident (RI #335) standing over . (RI #334) holding a pillow over his/her face/head. Resident was gripping pillow on both sides and pushing with force. (RI #335) was immediately removed from room . and was placed 1 to 1 with the nurse. The other nurse came . The resident (RI #334) . was ok . Unsuccessful attempts were made to interview CNA #27, the witness of the incident, on the phone several times during the survey. On 06/13/2024 at 1:00 PM during an interview, Registered Nurse (RN) #18 stated on the night of the incident, RI #335 was acting strange and was not acting like himself/herself. RN #18 said RI #335 was uncooperative and would not go to his/her room. RN #18 said when RI #335 was asked to go to his/her room, RI #335 got mad and pushed all the snacks off the table. RN #18 said she went to ask for help from another nurse and when she returned to the hall CNA #27 told her what happened. On 06/13/2024 at 6:20 PM a follow-up interview was conducted with RN #18 who said a nursing assessment was not completed when RI #335 returned from the hospital, because he/she was not gone over 24 hours. RN #18 said between 3:00 AM and 4:30 AM, CNA #27 was walking the halls and saw RI #335 with the pillow over RI #334's face. She further stated, the CNA intervened and stopped RI #335, and RI #335 ran back to his/her room and the CNA followed. RN #18 said RI #335 picked up a statue in his/her room and tried to hit the CNA. RN #18 said, they were able to get RI #335 to the nurses' station to sit one to one and made sure RI #335 was away from other residents. The ADM and the DON were notified and the staff were instructed to remain one on one with him/her and he/she was sent back to the hospital. On 06/13/2024 at 10:10 AM an interview was conducted with Social Service Designee (SSD). The SSD stated, RI #335 became fixated on a male resident and began having behaviors, his/her mood would fluctuate, and he/she would really get upset and other times he/she would be calm. The SSD further said, RI #335 was aggressive toward other staff. RI #335 would always say, he/she could not get straight in her/his head and would hold his/her head. The SSD was asked what interventions did the facility implement for RI #335 behaviors. The SSD stated, she would walk RI #335 up to her office, allow RI #335 to sit with her and vent, and she got RI #335 involved in activities. The SSD was asked when did RI #335 start having aggressive behavior. She stated when he/she became attached to the male resident. When asked what interventions were put in place at that time. The SSD stated, RI #335 was moved to a different hall. On 06/15/2024 at 3:54 PM an interview was conducted with Social Services Designee. The SSD said that when RI #335 returned to the facility on Saturday, 06/24/2023, there were no interventions put in place, because the facility's staff did not know the hospital would send him/her back. The SSD said the facility thought the hospital would have kept him/her and they would have discussed his/her behavior and added interventions on Monday, 06/26/2023. On 06/13/2024 at 12:10 PM and interview was conducted with the Former Assistant Director of Nursing (FADON). The FADON was asked what actions/interventions were put in place as a result of the incident involving RI #335 on 06/23/2023. She stated she did not recall exactly. The FADON further stated RI #335 had been exhibiting behavior prior to the incident on 06/23/2023 which was impulsive and combative behavior but did not recall what psychiatric interventions were put in place. On 06/16/2024 at 12:46 PM an interview was conducted with the MDS Coordinator, RN. The MDS Coordinator (MDSC) was asked on 06/23/2024 when RI #335 was having behaviors, what interventions were developed and implemented. She said RI #335 was sent out to the hospital emergency room , but when RI #335 returned to the facility on [DATE], no interventions were added to his/her care plan. On 06/16/2024 at 1:04 PM a follow-up interview was conducted with the MDSC who said when RI #335 returned to the facility on [DATE] a nursing assessment was not done, but most likely should have been. The MDSC was asked, why was a nursing assessment not done on the resident upon return. The MDSC said the nursing notes indicated RI #335 was still combative and aggressive, so the staff might have not been able to do an assessment, but she was not sure. The MDSC said the facility did not put any interventions in place upon RI #335's return from the hospital on 06/24/2023. The MDSC said the facility should have put a plan or intervention in place. The MDSC said the concern with not having a plan or interventions in place was even though the hospital said he/she was cleared to return, the facility should have had a plan in place to try to prevent any further occurrence of aggressive behavior toward other residents for the safety of residents and staff. On 06/16/2024 at 4:13 PM an interview was conducted with the Director of Nursing (DON). The DON stated on 06/23/2023, RI #335 was sent to the hospital for physical aggressive behavior and suicidal ideation. The DON said the facility did not complete a nursing assessment when RI #335 returned to the facility on [DATE]. The DON said if a nursing assessment had been done, it would have triggered interventions such as one to one supervision. The DON was asked, what other interventions would you have expected to have been put in place. The DON said interventions for RI #335 and other residents' safety, so one on one supervision and notification of the supervisor, medical director, and resident's family that the resident was having suicidal ideations. ********************************************************************************************* On 06/18/2024 at 6:00 PM, the facility submitted an acceptable removal plan, which documented: Immediate Action Removal Plan for F 740 Description: The facility failed to ensure interventions were developed and implemented to address RI#335's physical and verbally abusive behaviors towards staff and suicidal ideations. Safety: 1. Resident #335 was redirected from the Dining room by the Administrator on 6/23/23 after yelling, throwing things and grabbing at staff. 2. Social services made referrals for Psych services on 6/23/23 related to physical and verbally abusive behaviors and suicidal ideation. Charge Nurse sent RI #335 to theER on [DATE] and transported by HEMSI. 3. Resident #335 returned from the hospital by HEMSI on at 3 am on 6/24/23 with no new orders. Labs were drawn at the ER. Per ER records resident denied any complaints, denied suicidality and homicidal ideations. 4. Resident's #334 and #335 were separated by the CNA on 6/24/23. Assessments: 1. Resident #334 was assessed by the Charge Nurse on 6/24/23, with no injuries noted. 2. On 6/26/23 the Psychiatric Nurse Practitioner assessed Resident #334 and documented in a provider note with no negative findings. On 6/26/23 Resident #334 was assessed by the Nurse with no negative findings. 3. Resident #335 was placed on one on one by the Charge Nurse on 6/24/23 until resident transferred to the hospital by HEMSI and ultimately discharged . 4. Resident interviews were conducted by the Social Services Director and Activity Coordinator with a BIMS of 13 or greater regarding physical or verbal abuse by another resident on 6/24/23 with no negative findings. 5. Residents with a BIMS of 12 or less, a body audit was completed by the Director of Nursing and Charge Nurse on 6/24/23 with no negative findings. 6. Alabama Department of Health, Adult Protective Services, and law enforcement were notified of the reported events on 6/24/23 by the Administrator. 7. Resident interviews were conducted by the Social Services Director with a BIMS of 13 or greater regarding abuse by anyone on 6/11/24 and 6/18/24 with no negative findings. 8. Residents with a BIMS of 12 or less, a body audit and observation for abuse and behaviors was completed by the Director of Nursing, Staffing Coordinator, and Charge Nurse on 6/11/24 with no negative findings. 9. Resident interviews using a Resident Psychosocial Health Questionnaire were conducted by Social Services Director with BIMS of 13 or greater to determine resident's mood, behaviors, and thoughts such as anxiety, agitation, depression, suicidal and homicidal ideations on 6/18/2024, with no new negative findings. Notification: 1. On 6/24/23 Charge Nurse made notifications to the practitioners and responsible parties for resident #334 and #335. Audits: 1. Clinical Record Review from 3/1/24 to 6/16/24 was initiated on 6/16/24 and completed on 6/17/2024 by the Director of Clinical Education and Regional Nurse Managers to include clinical notes, event notes, and daily skilled notes to identify any potential residents for instances of allegations of potential/actual abuse, aggressive, distress, and combative behaviors, and suicidal and homicidal ideations, with no new unknown findings. In-services: 1. On 6/16/24 Inservice was provided by the Assistant [NAME] President of Operations and the Regional Nurse Manager to the Administrator, DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress and combative behaviors, and suicidal/homicidal ideation. Education was also provided regarding staff unavailable to receive education will not be permitted to work until required education is completed. The Staffing Coordinator was designated as responsible for ensuring staff are educated n abuse prohibition plan, behavioral health services policy, and list of interventions for behaviors 2. On 6/16/24 Inservice was provided by the DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress, and combative behaviors, and suicidal/homicidal ideation to all staff. Staff unavailable to receive education will not be permitted to work until the required education is completed. 73 out of 77 employees have been educated. 3. On 6/16/2024 competency and validation questions were answered by staff currently working to ensure competency verbalized from education received. 4. On 6/17/2024 the Regional Nurse Manager placed signage in break rooms, nurses stations, and behavior communication binders that list interventions for behaviors including abuse, aggressive, distress and combative behaviors, and suicidal/homicidal ideation. This communication binder is used as a communication tool for staff to note resident behaviors, new or changes. This communication binder is brought to morning QA by a member of the Behavior Committee and reviewed during QA to determine appropriate interventions. 5. On 6/18/2024 Regional Nurse Manager inserviced the DON, Staffing Coordinator and Risk Manager that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. 6. On 6/18/2024 the DON, Staffing Coordinator, and Risk Manager in-serviced Nursing Staff that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted using the Resident Return from Transfer Behavior assessment form. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. Nursing Staff unavailable to receive education will not be permitted to work until the required education is completed. 20 out of 22 Nurses have been educated. QAPI: 1. Adhoc QAPI was conducted on 6/24/23 to include Administrator, Director of Nursing, Senior [NAME] President of Operations, Assistant [NAME] President of Operations, Regional Nurse Manager, Assistant [NAME] President of Clinical Operations, Regional Nurse Manager to discuss resident to resident altercation event, education, root cause, and interventions. 2. The Medical Director was notified of the immediate jeopardy citations on 6/16/24 by the Assistant [NAME] President of Operations. 3. A Root cause analysis was conducted on 6/16/24 by the Administrator, Regional Director of Operations, Assistant [NAME] President of Clinical Operations, Regional Nurse Manager, Directors of Nursing, Assistant [NAME] President of Quality, Director of Clinical Education. Root cause was identified as ineffective training and education related to behavioral health services. 4. QAPI meeting was conducted on 6/16/24 to include Administrator, Director of Nursing, Staffing Coordinator, Dietary Manager, Activity Coordinator, Treatment Nurse, Receptionist, MDS Coordinator, Social Service Director, Business Office Manager, Maintenance Director, Regional Nurse Manage, Assistant [NAME] President of Operations, Regional Nurse Manager, Medical Director, Assistant [NAME] President of Clinical Operations, Senior [NAME] President, and Director of Clinical Education regarding Immediate Jeopardy citations, Abuse and Behavior Health Services policy review, education, interventions for immediate removal plan, Medical Director notification, facility assessment updated/reviewed and root cause analysis determined. a. Behavior Health Services Policy reviewed with recommendation made to include suicidal and homicidal ideations (Section 5, Subset F) under procedures- to include risk factors, triggering events, examples used to harm self. Definition of Suicidal Ideation added to provide clarification of terminology related to behavioral health services. b. Updated Intervention list attachment included in the updated Behavior Health Policy for behaviors to include immediate action steps to implement related to abuse, aggressive, distress, and combative behaviors, and Suicidal and Homicidal Ideations. c. The facility assessment plan was revised to include suicidal ideations. 5. A Governing Body meeting was held to include the Administrator, Director of Nursing, Assistant [NAME] President of Operations, Assistance [NAME] President for Clinical, Senior [NAME] President of Operations, and Regional Nurse Managers on 6/16/24 at 9pm to discuss the corrective action plans to address the immediate concerns for F 600, F 740, F 741 and F 867 for Resident's #334 and #335 and all current residents in the facility have the potential to be affected. The Medical Director agreed with the current action plan and had no new recommendations. 6. This Behavior Communication binder is brought to morning QA by a member of the Behavior Committee and reviewed during QA to determine any new or changes in behaviors, intervention implementation and appropriateness and will be revised as necessary. 7. Upon return from a transfer when ER deems resident appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a Resident Return from Transfer Behavior assessment will be conducted. This will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. For any resident discharged and readmitted a readmission assessment is already part of the readmission process and is completed to include an abuse and behavior section. On 6/18/2024 Nursing Staff was educated that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted using the Resident Return from Transfer Behavior assessment form. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. Nursing Staff unavailable to receive education will not be permitted to work until the required education is completed. 20 out of 22 Nurses have been educated. Facility implemented all corrective actions by 6/18/2024. ***************************************************************************** After a review of documentation supporting the above corrective actions, including the facility's investigative file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implement corrective actions including ongoing monitoring on 06/18/2024.

Based on interviews, record review, and a review of a policy titled, Behavioral Health Services, the facility failed to ensure there were sufficient staff who had the knowledge, training, competencies, and skills sets to address the behavioral health care needs of Resident Identifier (RI) #335 after RI #335 was sent to the hospital for aggressive behaviors and suicidal and homicidal ideations. The facility did not develop and implement interventions to ensure resident's safety or to provide additional supervision. On 06/23/2023 during lunch, RI #335 was physically and verbally abusive to staff and had suicidal and homicidal ideation before being sent to the hospital. Upon return from the hospital on 06/24/2023 around 3:00 AM, the facility did not ensure interventions were developed and implemented to ensure residents' safety or to provide additional supervision. Staff identified that RI #335 was acting strange, she was not being herself, she was not being cooperative, she would not listen to what staff were saying when she was redirected to her room as she previously had done. No actions were taken to ensure residents' safety. Around 4:30 AM, RI #335 was witnessed by a CNA in RI #334's room, standing over RI #334's bed with a pillow over RI # 334's face gripping both sides and pushing with force. It was determined the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.40 Behavioral Health at F 741-Sufficient/Competent Staff-Behavior Health Needs. On 06/16/2024 at 6:56 PM, the Administrator, Assistant [NAME] President of Operations, Regional Nurse Manager, and the Director of Nursing (DON) were provided the IJ templates and notified of the findings at the immediate jeopardy level in the area of Behavioral Health Services at F 741-Sufficient/Competent Staff-Behavior Health Needs. The IJ began on 06/24/2023 and continued until 06/18/2024 when the survey team verified onsite that corrective actions had been implemented. On 06/19/2024, the immediate jeopardy was removed, and was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of a Facility Reportable Investigation complaint/report number AL00044582. This deficient practice affected one of four residents reviewed for behavioral health services. Findings Include: Cross Reference F 600 and F 740. Purpose: To ensure that residents receive necessary behavior health services. Policy: It is the policy of this facility that all residents receive care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning. Definitions: Definitions are provided to clarify terminology related to behavioral health services and the attainment or maintenance of a resident's highest practicable well-being. Highest practicable physical, mental and psychosocial well-being is defined as the highest possible level of functioning and well-being-limited by the individual's recognized pathology and normal aging process. Highest practicable is determined through the comprehensive resident assessment and by recognizing and competently and thoroughly addressing the physical, mental, and psychosocial needs of the individual . Procedure: . 3. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. 4. Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial well-being. 5. Conditions that are frequently seen in nursing home residents and may require the facility to provide specialized services and supports base upon residents' individual needs, include, but are not limited to: . a. Depression- It is not a natural part of aging, however, older adults in the nursing home setting are more at risk than older adults in the community. e. Aggressive Behaviors-defined as behaviors that cause harm, threaten to harm, or put the health and safety of people risk . 6. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-center care . b. Obtaining history from medical records, the family, and the resident regarding mental, psychosocial, and emotional health; c. MDS and care area assessments; d. Ongoing monitoring of mood and behavior; e. Care plan development and implementation, and f. Evaluation. 8. Facility staff shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. Education shall be based on the role of the employee and needs identified through the facility assessment . 9. Interventions shall be evidence-based, culturally competent, trauma-informed . RI #335 was admitted to the facility on [DATE] with diagnoses that included Dementia with Agitation and Major Depressive Disorder. A review of RI #335's Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/08/2023, indicated RI #335's BIMS (Brief Interview for Mental Status) was five of 15 which indicated that RI #335 was cognitively impaired. A review of RI #335's Clinical Notes Report entered by RN #30 dated 06/23/2023 at 12:16 PM, revealed the following: resident stated he/she knows something is wrong in his/her head and feels that would rather be gone then he/she hurt someone A review of RI #335's Clinical Notes Report entered by RN #30 dated 06/23/2023 at 12:59 PM, revealed the following: Stated that if he/she had a gun in front of him/her he/she would shoot himself/herself. Continue to make comments about get rid of me and I'm gonna do it. A review of RI #335's Clinical Notes Report entered by the Social Services Designee (SSD) dated 06/23/2023 at 1:32 PM, revealed the following: I sent information to (name of Psychiatric Facility) for resident's name RI #335 to go over there due to behavior. I was trying my best to get (him/her) next door instead of going to ER .I called (name of Mental Health Center) to see if they could speed up the process of getting him/her over there. No one responded, so they sent him/her to the ER . The local hospital's ED Note Physician documented that RI #335 was admitted on [DATE] at 1:48 PM and discharged on [DATE] at 2:45 AM. RI #335 was seen by the medical doctor at the hospital on 06/23/2023 at 2:29 PM. The note included: . History of Present Illness . . presents for evaluation of aggressive behavior . he/she made some suicidal homicidal thoughts . Medical Decision Making I reached out to staff at Millenium health to discuss the case. They said that his/her behavior is certainly progressing worsening over the last few weeks and is the first time he/she has been physically assaultive with staff at the facility. He/she then also stated that he/she was going to kill everyone and that something was wrong with him/her and the he/she wanted to kill himself/herself. He/She is obviously denying all of this here . likely disposition back to the facility . A review of RI #335's Clinical Notes Report dated 06/24/2023, revealed the following: Resident brought by .to facility at 3 AM no new orders given . A review of RI #335's Clinical Notes Report entered by RN #18 dated 06/24/2023 at 5:33 AM, revealed the following: . Resident came back from (name of hospital) went into 200 hall being combative going into other resident rooms, brought him/her back to 100 he/she tried to hit CNA with the hole puncher he/she kept saying we are going to hell and CNA is dead and he/she took a statue from his/her room and tried to hit us with it he/she was throwing the snack tray around trying to hit the nurse. He/She tried to hit the CNA with the pill crusher, he/she tried to smother another resident with a pillow the CNA walked in on him/her and he/she tried to run back to his/her room . On 06/13/2024 at 1:00 PM during an interview, Registered Nurse (RN) #18 stated on the night of the incident, RI #335 was acting strange and was not acting like himself/herself. RN #18 said RI #335 was uncooperative and would not go to his/her room. RN #18 said when RI #335 was asked to go to his/her room, RI #335 got mad and pushed all the snacks off the table. RN #18 said she went to ask for help from another nurse and when she returned to the hall CNA #27 told her what happened. On 06/13/2024 at 6:20 PM a follow-up interview was conducted with RN #18 who said a nursing assessment was not completed when RI #335 returned from the hospital, because he/she was not gone over 24 hours. On 06/14/2024 at 6:52 PM an interview was conducted with the MDS Coordinator (MDSC). The MDSC was asked what training have staff received about residents with suicidal ideation. She said she did not know exactly when they had education or training on suicidal ideation. On 06/16/2024 at 4:13 PM was conducted with the Director of Nursing (DON). The DON stated when RI #335 returned from the hospital on 06/24/2023 a nursing assessment was not completed on resident. She further stated RI #335, was sent to the hospital for physical aggressive behavior and suicidal ideation should have had an assessment completed when he/she returned to the facility. The DON said if a nursing assessment had been done, it would have triggered interventions such as one to one supervision. The DON was asked, what other interventions would you have expected to have been put in place. The DON said interventions for RI #335 and other residents' safety, so one on one supervision and notification of the supervisor, medical director, and resident's family that the resident was having suicidal ideations. In a follow up interview with the MDSC on 06/16/2024 at 12:46 PM, she was asked, when RI #335 returned from the hospital on 06/24/2023 was a nursing assessment completed. The MDSC said, no there was not a nursing assessment done on RI #335, but a nursing assessment should have been done. According to the RI #335's progress notes, when RI #335 returned from the hospital on 06/24/2023 she was still combative and aggressive, did the facility add any interventions or put a plan in place. The MDSC stated, there were no interventions or plan put in place but interventions or a plan should have been put in place. When asked what would be the concern of not having a plan or interventions in place for a resident with aggressive behavior or suicidal ideation. She said the facility should have had a plan in try to prevent any further occurrence of aggressive behavior toward other residents and for the safety of residents and staff. The MDSC was asked did the facility provide training/education on how to manage resident with aggressive behavior and suicidal thoughts, where was the documentation. The MDSC stated she would have to check. ****************************************************************************** On 06/18/2024 at 6:00 PM, the facility submitted an acceptable removal plan, which document: Description; On 6/24/23 Resident #335 was observed standing over RI #334's bed with pillow over face gripping both sides with force. Safety: 1. Resident #335 was redirected from the Dining room by the Administrator on 6/23/23 after yelling, throwing things and grabbing at staff. 2. Social services made referrals for Psych services on 6/23/23 related to physical and verbally abusive behaviors and suicidal ideation. Charge Nurse sent R1#335 to theER on [DATE] and transported by HEMSI. 3. Resident #335 returned from the hospital by HEMSI on at 3am on 6/24/23 with no new orders. Labs were drawn at the ER. Per ER records resident denied any complaints, denied suicidally and homicidally. 4. Resident's #334 and #335 were separated by the CNA on 6/24/23. Assessment: 1. Resident #334 was assessed by the Charge Nurse on 6/24/23, with no injuries noted. 2. On 6/26/23 the Psychiatric Nurse Practitioner assessed Resident #334 and documented in a provider note with no negative findings. On 6/26/23 Resident #334 was assessed by the Nurse with no negative findings. 3. Resident #335 was placed on one on one by the Charge Nurse on 6/24/23 until resident transferred to the hospital by HEMSI and ultimately discharged . 4. Resident interviews were conducted by the Social Services Director and Activity Coordinator with a BIMS of 13 or greater regarding physical or verbal abuse by another resident on 6/24/23 with no negative findings. 5. Residents with a BIMS of 12 or less, a body audit was completed by the Director of Nursing and Charge Nurse on 6/24/23 with no negative findings. 6. Alabama Department of Health, Adult Protective Services, and law enforcement were notified of the reported events on 6/24/23 by the Administrator. 7. Resident interviews were conducted by the Social Services Director with a BIMS of 13 or greater regarding abuse by anyone on 6/11/24 and 6/18/2024 with no negative findings. 8. Residents with a BIMS of 12 or less, a body audit and observation for abuse and behaviors was completed by the Director of Nursing, Staffing Coordinator, and Charge Nurse on 6/11/24 with no negative findings. 9. Resident interviews using a Resident Psychosocial Health Questionnaire were completed by Social Services Director with BIMS of 13 or greater to determine resident's mood, behaviors and thoughts such as anxiety, agitation, depression, suicidal and homicidal ideation on 6/18/2024, with no new negative findings. Notification: 1. On 6/24/23 Charge Nurse made notifications to the practitioners and responsible parties for resident #334 and #335. Audits: 1. Clinical Record Review from 3/1/24 to 6/16/24 was initiated on 6/16/24 and completed on 6/17/2024 by the Director of Clinical Education and Regional Nurse Managers to include clinical notes, event notes, and daily skilled notes to identify any potential residents for instances of potential/actual abuse, aggressive, distress, and combative behaviors, and suicidal and homicidal ideation that might require Behavioral Health services, with no new unknown findings. In-services: 1. On 6/16/24 Inservice was provided by the Assistant [NAME] President of Operations and the Regional Nurse Manager to the Administrator, DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress, and combative behaviors and suicidal/homicidal ideation. Education was also provided regarding staff unavailable to receive education will not be permitted to work until required education is completed. The Staffing Coordinator was designated as responsible for ensuring staff are educated n abuse prohibition plan, behavioral health services policy, and list of interventions for behaviors 2. On 6/16/24 Inservice was provided by the DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, Behavior Health Services Policy, and interventions related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideation to all staff. Staff unavailable to receive education will not be permitted to work until the required education is completed. 73 out of 77 employees have been educated. 3. On 6/16/2024 competency and validation questions were answered by staff currently working to ensure competency verbalized from education received. 4. On 6/17/24 the Regional Nurse Manager placed signage in break rooms, nurses stations, and behavior communication binders that list interventions for behaviors including abuse, aggressive, distress, and combative behaviors, and suicidal/homicidal ideation. This communication binder is used as a communication tool for staff to note resident behaviors, new or changes. This communication binder is brought to morning QA by a member of the Behavior Committee and reviewed during QA to determine appropriate interventions. 5. On 6/18/2024 Regional Nurse Manager inserviced the DON, Staffing Coordinator and Risk Manager that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideation's a behavioral assessment should be conducted. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideation's. 6. On 6/18/2024 the DON, Staffing Coordinator, and Risk Manager inserviced Nursing Staff that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideation a behavioral assessment should be conducted using the Resident Return from Transfer Behavior assessment form. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideation. Nursing Staff unavailable to receive education will not be permitted to work until the required education is completed. 20 out of 22 Nurses have been educated. QAPI: 1. Adhoc QAPI was conducted on 6/24/23 to include Administrator, Director of Nursing, Senior [NAME] President of Operations, Assistant [NAME] President of Operations, Regional Nurse Manager, Assistant [NAME] President of Clinical Operations, Regional Nurse Manager to discuss resident to resident altercation event, education, root cause, and interventions. 2. The Medical Director was notified of the immediate jeopardy citations on 6/16/24 by the Assistant [NAME] President of Operations. 3. A Root cause analysis was conducted on 6/16/24 by the Administrator, Regional Director of Operations, Assistant [NAME] President of Clinical Operations, Regional Nurse Manager, Directors of Nursing, Assistant [NAME] President of Quality, Director of Clinical Education. Root cause was identified as ineffective training and education related to behavioral health services. 4. QAPI meeting was conducted on 6/16/24 to include Administrator, Director of Nursing, Staffing Coordinator, Dietary Manager, Activity Coordinator, Treatment Nurse, Receptionist, MDS Coordinator, Social Service Director, Business Office Manager, Maintenance Director, Regional Nurse Manage, Assistant [NAME] President of Operations, Regional Nurse Manager, Medical Director, Assistant [NAME] President of Clinical Operations, Senior [NAME] President, and Director of Clinical Education regarding Immediate Jeopardy citations, Abuse and Behavior Health Services policy review, education, interventions for immediate removal plan, Medical Director notification, facility assessment updated/reviewed and root cause analysis determined. a. Abuse Prohibition Plan reviewed with no recommendation for changes 6/16/24 b. Behavior Health Services Policy reviewed with recommendation made to include suicidal and homicidal ideations (Section 5, Subset F) under procedures- to include risk factors, triggering events, examples used to harm self. Definition of Suicidal Ideation added to provide clarification of terminology related to behavioral health services. c. Updated Intervention list attachment included in the updated Behavior Health Policy for behaviors to include immediate action steps to implement related to abuse, aggressive, distress, and combative behavior, and Suicidal and Homicidal Ideations. d. The facility assessment plan was revised to include suicidal ideations. 5. A Governing Body meeting was held to include the Administrator, Director of Nursing, Assistant [NAME] President of Operations, Assistance [NAME] President for Clinical, Senior [NAME] President of Operations, and Regional Nurse Managers on 6/16/24 at 9pm to discuss the corrective action plans to address the immediate concerns for F600, F740, F741, and F867 for Resident's #334 and #335 and all current residents in the facility have the potential to be affected. The Medical Director agreed with the current action plan and had no new recommendations 6. This Behavior Communication binder is brought to morning QA by a member of the Behavior Committee and reviewed during QA to determine any new or changes in behaviors, intervention implementation, and appropriateness and will be revised as necessary. 7. Upon return from a transfer when ER deems resident appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a Resident Return from Transfer Behavior assessment will be conducted. This will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. For any resident discharged and readmitted a readmission assessment already part of the readmission process is completed to include an abuse and behavior section. On 6/18/2024 Nursing Staff educated that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted using the Resident Return from Transfer Behavior assessment form. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. Nursing Staff unavailable to receive education will not be permitted to work until the required education is completed. 20 out of 22 Nurses have been educated. Facility implemented all corrective actions by 6/18/2024. ****************************************************************************** After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff intervention, the survey team verified the facility implemented corrective actions including ongoing monitoring on 06/18/2024.

Based on observation, interview, the facility's policy for Dietary: Menus and Adequate Nutrition, the facility's 2024 S/S (Spring/Summer) Week 2 Menu, the facility's posted Disher Capacity guide, and the facility's recipes for Salisbury Steak, Seasoned [NAME] Beans, Chicken Fettuccini Alfredo, and Buttered Noodles; the facility failed to ensure the residents received nutrition as planned per the facility's menu by allowing the following: hot water was added to puree food items during Lunch service on 06/12/2024 to extend the volume available, the amounts of Chicken [NAME] and of Noodles served for the Regular, Mechanical Soft, Dysphagia II, and Puree/Dysphagia I texture diets were less than the amounts indicated on the menu for Lunch on 06/13/2024, and orange slices were served to most of the residents receiving Consistent Carbohydrate (CCHO) diets, instead of apple slices as indicated by the menu for Lunch on 06/13/2024. This had the potential to affect all residents receiving Regular, Mechanical Soft, Dysphagia II (Dys II), and Puree/Dysphagia I (Dys I) texture diets and residents receiving CCHO diets from the facility's kitchen; 79 of 79 residents. Findings include: The facility's policy for Dietary: Menus and Adequate Nutrition, revised 07/31/2023, included the following: . Purpose: The purpose of this policy is to assure menus are developed and prepared, based on reasonable efforts, to meet resident choices and reflect the resident's nutritional . needs, while using established guidelines . Policy: 1. The community shall ensure that menus: a. Meet the nutritional needs of resident in accordance with established national guidelines . c. Be followed . On 06/12/2024, the facility's 2024 S/S (Spring/Summer) Menu for Week 2, Wednesday, Lunch was observed to have the following change approved by the Registered Dietitian (RD): Salisbury Steak instead of Country Fried Steak. The menu therefore indicated the Pureed/Dys I diet was to receive 3 oz. (ounces) Pureed Salisbury Steak with Gravy and 4 oz. Pureed [NAME] Beans in addition to other items. The facility's recipe for Salisbury Steak - 4102 included the following: . Service portion: 1 (one) 3oz steak patty . Puree Steps: Remove desired number of servings and add nutritive liquid, milk, broth, etc. (to indicate further, similar items are included). Blend until desired consistency. Add approved thickener to achieve desired consistency if needed. The facility's recipe for Seasoned [NAME] Beans - 1038 included the following: . Service portion: 4oz (#8 scoop/disher). Puree Steps: Remove desired number of servings and add nutritive liquid, milk, broth, etc. Blend until desired consistency. Add approved thickener to achieve desired consistency if needed. On 06/12/2024 at 11:07 AM, the facility's trayline was ongoing for lunch with the AM [NAME] serving the residents' meal plates. At 11:20 AM, observed Salisbury Steak on the steamtable (being substituted for the Country Fried Steak and indicated as approved by the RD by her initials on the menu posted at the steamtable). There were two observations of the puree meat scoop not being filled completely for service. Then an observation of hot water being added to the puree meat and stirred in by AM Cook. Then a third observation of the scoop not being fully filled with puree meat. At 11:55 AM, there was an observation of hot water being added to the puree green beans by the AM Cook. There were still not enough puree green beans for a serving and it looked more liquid than puree. The Kitchen Supervisor began preparing additional puree green beans. At 12:02 PM, the Lunch trayline service was finished. On 06/13/2024, the facility's 2024 S/S (Spring/Summer) Menu for Week 2, Thursday, Lunch included the following: Regular and CCHO diets were to receive 6 oz Chicken Fettuccini [NAME] and 4 oz Buttered Noodles, Mechanical Soft diets were to receive 6 oz Gr (Ground) Chicken [NAME] and 4 oz Buttered Noodles, Dys II, and Puree/Dys I texture diets were to receive 6 oz Pur (Pureed) Chicken [NAME] and 4 oz Pur Buttered Noodles, and CCHO diets were to receive 4 oz Apple Slices. The facility's recipe for Chicken Fettuccini [NAME] - 4238 included the following: . Service portion: 6 oz Chicken Fettuccini Alfredo. 3oz (#10 scoop) Pasta & [and] 3oz (3-4 strips) Chicken . The facility's recipe for Buttered Noodles - 2005 included the following: . Service portion: 4 ounces . On 06/13/2024 at 10:33 AM, Diet Aide #16 was observed portioning Apple Pie for the residents' Lunch. Diet Aide #16 said the CCHO were getting fresh orange slices. Diet Aide #16 said the CCHO (diets) do not get a lot of sugar, so they get fresh fruit. Diet Aide #16 further said one person had a sliced fresh apple because the resident cannot eat oranges. Observed servings of fresh orange slices and one serving of fresh apple slices. On 06/13/2024 at 10:47 AM, a Disher [scoop] Capacity chart was observed on the bulletin board in the Kitchen over the Prep Sink, which included the following: [NAME] #6 disher equals 4.66 fluid ounces Grey #8 disher equals 3.64 fluid ounces [NAME] #12 disher equals 2.78 fluid ounces On 06/13/2024 at 10:54 AM, the AM [NAME] began putting pans on the steamtable for lunch service. At 11:33 AM, trayline temperatures were being checked and the following was observed: Two full pans of Chicken (in chunks) and Noodles mixed together with [NAME] Sauce and a 4-ounce serving spoodle, Mechanical Soft Chicken and Noodles mixed together with [NAME] Sauce and a 4-ounce serving spoodle, Chicken and Noodles and [NAME] Sauce pureed together with a #6 scoop/disher. Trayline service was observed until 12:09 PM, when the last serving cart was loaded. On 06/13/2024 at 12:34 PM, the Kitchen Supervisor was interviewed: The Kitchen Supervisor was given the facility's 2024 S/S (Spring/Summer) Menu for Week 2, Thursday, Lunch to review as needed. When asked how much Chicken Fettuccini [NAME] was supposed to be served per the menu, the Kitchen Supervisor said 6 ounces. When asked how much Buttered Noodles was supposed to be served per the menu, the Kitchen Supervisor said 4 ounces. The Kitchen Manager was reminded that the Chicken Fettuccini [NAME] was mixed with the Noodles and a 4 oz. spoodle was used to serve the combined items. When asked how much should have been served per portion since the two menu items were mixed together, the Kitchen Supervisor said 10 ounces. The Kitchen Manager then said there is no 10-ounce ladle or spoodle. When asked what could have been done, the Kitchen Supervisor said, I would use the closest scoop/spoodle size. We have an eight-ounce spoodle, I think. But it still would not be the right amount. When asked if the Mechanical Soft Chicken [NAME] mixed with Noodles and served with the 4 oz. spoodle was enough, the Kitchen Manager said no, it was not enough. The Kitchen Manager further said it should be separated into noodles and the chicken with sauce. When asked if the pureed Chicken [NAME] mixed with Noodles served with the #6 scoop/disher was enough, the Kitchen Manager said no. The Kitchen Manager said not serving the amount as indicated on the menu meant the residents are not getting enough food. When asked why sliced oranges were served to the residents at lunch instead of sliced apples; the Kitchen Manager said we have apples, I do not know why. On 06/13/2024 at 1:08 PM, the AM [NAME] was interviewed: The AM [NAME] was asked why she was adding hot water to the puree food at lunch yesterday (Wednesday, 6/12/2024). The AM [NAME] replied, To stretch it. The AM [NAME] said she asked her manager (the Dietary Manager) this morning if the Chicken [NAME] was to be mixed with the Noodles and she said yes. The AM [NAME] agreed that a 4 oz. spoodle was used to serve the Chicken Fettuccini [NAME] mixed with the Noodles. The AM [NAME] was given the facility's 2024 S/S (Spring/Summer) Menu for Week 2, Thursday, Lunch to review as needed. When asked how much Chicken Fettuccini [NAME] should be served per person according to the menu, the AM [NAME] said 6 ounces. When asked how much Buttered Noodles should be served per person according to the menu, the AM [NAME] said 4 ounces. When asked how much should have been a serving since the Chicken Fettuccini [NAME] and Buttered Noodles were mixed together, the AM [NAME] said 10 ounces. The AM [NAME] then said there was not a 10-ounce spoodle. When asked what could have been done, the AM [NAME] said she did not know. When asked if the 4 oz. spoodle used to serve the Mechanical Soft Chicken [NAME] mixed with Noodles was enough for a serving, the AM [NAME] said it should have been 10 ounces. When asked if the #6 scoop/disher used to serve the pureed Chicken [NAME] mixed with Noodles was enough for a serving, the AM [NAME] said it should have been 10 ounces. On 06/13/2024 at 5:31 PM, the Dietary Manager was interviewed: When asked what instructions were given to food service employees for preparing pureed foods properly and in adequate quantity, the Dietary Manager said they were shown when they were trained for the position. The Dietary Manager said it was not acceptable to add hot water to a pureed food during meal service to stretch it. The Dietary Manager said the problem was diluting the food and reducing the nutrients. When asked how the food service employees knew how much to serve of each food item, the Dietary Manager said they have the menus with portion sizes, spoodles in different ounce capacities, and have color-coordinated scoops/dishers, and a chart. The Dietary Manager said Corporate (the corporate office) developed and approved the menus used at the facility. The Dietary Manager said she had received consultations from the Registered Dietitian two Tuesdays out of the month so far and topics had included temperatures, food dating, cleanliness, organization, portion sizes, and menu items in house. The Dietary Manager was given the facility's 2024 S/S (Spring/Summer) Menu for Week 2, Thursday, Lunch to review as needed. It was noted that the menu listed 6 ounces Chicken Fettuccini [NAME] and 4 ounces Buttered Noodles as separate menu items, but the Chicken Fettuccini [NAME] and the Noodles were mixed together in pans for service on the trayline. When asked if the 4 oz. spoodle used to serve the Chicken Fettuccini [NAME] mixed with Noodles to the Regular Diets was a large enough portion, the Dietary Manager said no. When asked if the Mechanical Soft Chicken [NAME] mixed with Noodles and served with the 4 oz. spoodle was enough, the Dietary Manager said no. When asked if the #6 scoop/disher used to serve the pureed Chicken [NAME] mixed with Noodles was enough for a serving, the Dietary Manager said no. When asked the concern for residents, the Dietary Manager said that the residents were not getting enough food, protein, nutrients. The Dietary Manager said fresh apples were available in the kitchen the night before and that morning. When asked why would staff not serve sliced apples to the CCHO diets per the menu today (Thursday, 06/13/24), the Dietary Manager said they might not have had knowledge of the apples. The Dietary Manager said she did not ask the RD to approve a change from apples to oranges. On 06/13/2024 at 7:20 PM, the Registered Dietitian (RD) was interviewed by phone: When asked what instructions were given to food service employees for preparing pureed foods properly and in adequate quantity, the RD said it should be on the recipe. The RD said it would not be acceptable for the [NAME] to add hot water to a pureed food during meal service to stretch it. When asked the problem; the RD said the calories would not be the same, as there would be fewer calories per serving. The RD further said it could also change the consistency. When asked how the food service employees know how much to serve of each food item, the RD said the portions are on the menus and in the recipes. The RD further said the size of dishers/scoops to use for specific serving sizes (ounces) should be on the recipe. The RD was told that according to the Week 2 menu for Thursday, 6 ounces Chicken Fettuccini [NAME] was supposed to be served over 4 ounces Buttered Noodles, but the Chicken Fettuccini [NAME] and the Noodles were mixed together in a pan for service on the trayline. When told that a 4 oz. spoodle was used to serve the Chicken Fettuccini [NAME] mixed with Noodles to the Regular Diets, the RD said that was not enough. When told a 4 oz. spoodle was used for the serving the Mechanical Soft Chicken [NAME] mixed with Noodles, the RD said that was not enough. When told a #6 scoop/disher was used to serve the pureed Chicken [NAME] mixed with Noodles, the RD said that was not enough. When asked the concern for residents, the RD said the menus were prepared to provide serving sizes to meet the residents' caloric needs. The RD said she was not asked to approve serving oranges to the CCHO diets instead of sliced apples for lunch on Thursday, 06/13/2024.

Based on observation, interview, the facility's Dish Machine Temperatures-Sanitation log for June 2024, the facility's policies for Dietary- Mechanical Dishwashing and Dietary- Hand Washing Techniques, and the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code; the facility failed to prevent cross-contamination on 06/11/2024 by allowing the following to occur: Staff going from handling dirty dishes to handling clean dishes and not washing their hands, Staff using a cloth to dry multiple wet trays instead of air drying, Access to a hand sink was blocked by a plate lowerator and when staff reached over the equipment to use the hand sink, water splashed onto the stored plates, and Staff chewing gum in the kitchen. The facility further failed to ensure sanitizing of dishware by not checking the dish machine temperatures prior to washing breakfast dishes on 06/11/2024, by the dish machine final rinse not reaching the minimum temperature of 180 (degrees) Fahrenheit (F) on 06/11/2024, and by not recording actual temperatures on the dish machine temperature log. This had the potential to affect all residents receiving meals from the facility's kitchen, 79 of 79 residents. Findings include: The 2022 U.S. FDA Food Code included the following: . 2-4 Hygienic Practices 2-401 Food Contamination Prevention 2-401.11 Eating, Drinking, or Using Tobacco Products (A) . an EMPLOYEE shall eat, drink, or use any form of TOBACCO PRODUCTS only in designated areas where the contamination of exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES; or other items needing protection can not result. [Annex 2, page 22: . 2-401.11 Eating, Drinking, or Using Tobacco Products. 2-402.11 Effectiveness. 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) . (8) 'Confining .eating food, chewing gum, drinking beverages or using tobacco.' ] . 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with . clean EQUIPMENT and UTENSILS, . and: . (E) After handling soiled EQUIPMENT or UTENSILS; . 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) . in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 C (194 F), or less than: . (2) For all other machines, 82 C (180 F). 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried . 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) . cleaned EQUIPMENT and UTENSILS, . shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination . 5-204.11 Handwashing Sinks. A HANDWASHING SINK shall be located: (A) To allow convenient use by EMPLOYEES in FOOD preparation, FOOD dispensing, and WAREWASHING areas; . The facility's policy for Dietary- Mechanical Dishwashing, revised and dated effective 10/09/2023, included the following: . Purpose: To ensure dishes and utensils are cleaned under sanitary conditions. Dishes shall be cleaned and sanitized after each use. Policy: . A. Turn on the machine, checking temperatures to assure proper wash and rinse temperatures . 1. High temp machine: Wash- 140 F, . Rinse - 180 F . H. Allow clean dishes to air dry completely before storing or store in a manner that allows for air drying. I. If the same person is loading and unloading the racks, hands must be washed . before touching the clean surfaces of the items in the rack. Documentation: 1. The temperature of the dish machine shall be recorded three (3) times a day. Temperatures out of specified range shall be reported . The facility's policy for Dietary- Hand Washing Techniques, revised and dated effective 10/09/2023, included the following: . Purpose: Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. dietary employees shall clean their hands in a handwashing sink . Policy: . 6. Frequency of Handwashing: Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with . clean equipment and utensils . and also in the following situations: b. After hands have touched anything unsanitary i.e. (that is), garbage, soiled utensils/equipment, dirty dishes . During a kitchen observation on 06/12/2024 at 9:21 AM, Diet Aide #13 was seen pre-rinsing dirty trays and dishware at the dirty side of the dishwashing machine, while wearing gloves. Diet Aide #13 then went to the clean side of the dishwashing machine and removed clean trays from the rack and stacked them on a cart. Diet Aide #13 did not remove her gloves or wash her hands before touching the clean trays. A handwashing sink was observed just a couple of steps behind Diet Aide #13 in the dishwashing area; however, access to the handwashing sink was somewhat blocked by a two-compartment plate lowerator, which was filled with plates. At 9:24 AM, Diet Aide #14 entered the dishwashing area and rolled the cart stacked with trays away. At 9:27 AM, Diet Aide #13 took off her gloves, but did not wash her hands. Diet Aide #13 then pulled a rack of dishes from dishwasher to the clean drying area. At 9:28 AM, Diet Aide #13 was loading dirty dishes into a rack and spraying them with water. At 9:29 AM, Diet Aide #13 opened the dishwasher and moved freshly washed dishes to the clean side. Diet Aide #13 then unloaded other clean dishes from a different rack and stacked them on the clean side. Diet Aide #13 did not wash her hands prior to handing the clean dishes. On 06/12/2024 at 9:33 AM, the Kitchen Supervisor was asked to observe dishwashing with the surveyor. As dishwashing was going on, Diet Aide #14 was seen nearby starting to load trays from the stacked trays on the cart onto the delivery speed racks to be used for lunch service. As Diet Aide #14 removed each tray from the stack, he repeatedly used a white terry cloth square to dry each tray. Diet Aide #13 was again observed going from the dirty side to the clean side of the dishwashing machine without washing her hands. When asked the problem, the Kitchen Supervisor said Diet Aide #13 should have washed her hands. When asked the issue with Diet Aide #14's activity, the Kitchen Supervisor said, Wet trays. When asked if the trays should be air-dried, instead of towel-dried, to reduce the risk of cross-contamination; the Kitchen Supervisor said yes. The Kitchen Manager was then observed to be chewing gum. When asked about restrictions for chewing gum in the kitchen, the Kitchen Supervisor looked surprised and said, I didn't know that. This is the first time anyone told me that. On 06/12/2024 at 9:37 AM, Diet Aide #13 was asked the problem with going from the dirty side of the dishwashing machine to the clean side. Diet Aide #13 thought for a moment and said, I should have washed my hands. I didn't think. On 06/12/2024 at 9:38 AM. Diet Aide #13 was asked if temperatures had been checked on the dishwashing machine. Diet Aide #13 said it was running about 160 to 170 degrees. Diet Aide #13 was asked to run the dishwashing machine to confirm the temperatures. The Wash temperature was 157 F and the Final Rinse was 171 F. The plate on the dishwashing machine documented the minimum Wash temperature as 150 F and the minimum Final Rinse as 180 F. The Dish Machine Temperatures-Sanitation log sheet for June 2024 had the exact same numbers for the temperatures recorded for all three meals from June 1 to June 11; the repeated temperature for Wash was 160 and for Rinse was 180. Diet Aide #13 said the temperatures did vary, but they just recorded those numbers. Diet Aide #13 said if the temperature was 181 degrees F, they would record 180 degrees F. There were no temperatures yet recorded on the log sheet for June 12. The Kitchen Manager contacted Maintenance to come check the dishwashing machine. On 06/12/2024 at 9:43 AM, Diet Aide #14 was observed going to the hand sink in the dishwashing area, but he did not move the two-compartment plate lowerator. Instead, Diet Aide #14 reached over the two-compartment plate lowerator to wash his hands at the sink. Water splash from the sink and his hands hit the dishes in the two-compartment plate lowerator. The Kitchen Manager observed this also and said it was a contamination problem. On 06/12/2024 at 9:45 AM, the Maintenance Supervisor arrived to check the dishwashing machine. The Maintenance Supervisor asked if the Booster Heater was turned on. On 06/12/2024 at 9:55 AM, the Maintenance Supervisor said someone would have to come work on the dishwashing machine. On 06/12/2024 at 11:07 AM, a worn, plastic covered sign was observed above the handwashing sink in Dishwashing area, on which was printed, COMPLETE TEMPERATURE LOG AT THE BEGINNING OF EACH DISH CYCLE. On 06/13/2024 at 10:31 AM, a worn sign in a plastic sleeve was observed above the 3-compartment sink in the Dishwashing area, on which was printed, PLEASE DO NOT LEAVE BOOSTER ON. On 06/13/2024 at 11:47 AM, the Kitchen Manager said the Dishwashing machine repair person came yesterday (06/12/2024) and that a new booster heater needed to be ordered. During an interview on 06/13/2024 at 4:52 PM, the Maintenance Supervisor said the dishwashing machine was not getting to temperature for the Final Rinse. He said the Final Rinse temperature should be 180 to 185 degrees Fahrenheit. The Maintenance Supervisor further said the dishwasher was new, but the booster heater was older. He said they would be getting a new booster heater. When asked about the sign posted in the kitchen about turning off the booster heater, the Maintenance Supervisor said it was probably meant for overnight to save the life of the heating elements. The Maintenance Supervisor additionally said he did not actually know about the sign or its purpose. During an interview on 06/13/2024 at 5:31 PM, the Dietary Manager said she had been working at the facility for about two months. The Dietary Manager said cross contamination was the problem with going from working on the dirty side of the dishwashing machine and then going to the clean side without washing one's hands. The Dietary Manager said staff could not wear gloves on the dirty side of the dishwashing machine and then merely remove them to go to the clean side. The Dietary Manager further said you have to wash your hands. The Dietary Manager said dishwashing machine temperatures should be recorded three times a day, before washing dishes. The Dietary Manager said the problem with recording the expected temperatures and not the actual temperatures for the dishwashing machine was not knowing what the temperature actually was and you cannot guess that. The Dietary Manager further said if the water was not hot, it was not going to clean and sanitize. The Dietary Manager said the dishwashing machine's Final Rinse should reach 180 degrees Fahrenheit to sanitize the dishes or else the residents could get sick. The Dietary Manager said cross contamination was the problem with using a white terry cloth square to repeatedly to dry resident food trays and that they should be air-dried. The Dietary Manager said the problem with the two-compartment plate lowerator or any equipment being placed in front of the handwashing sink was that it blocked access to the sink. The Dietary Manager said cross contamination from splashed water was the concern with the employee leaning over the two-compartment plate lowerator to wash their hands at the handwashing sink. The Dietary Manager said food service employees were not allowed to chew gum in the kitchen. The Dietary Manager further said when chewing gum, spit can come out of the mouth. The Dietary Manager said the booster heater was the problem with the dishwashing machine and a new was being purchased as soon as possible. The Dietary Manager did not know about the sign posted in the kitchen about turning off the booster heater or the reason for it. During a phone interview on 06/13/2024 at 7:20 PM, the Registered Dietitian (RD) said infection control was the concern with staff going from working on the dirty side of the dishwashing machine and then going to the clean side, without washing their hands. The RD further said staff could not wear gloves on the dirty side of the dishwashing machine and then merely remove them to go to the clean side. The RD said the dishwashing machine's Wash and Final Rinse temperatures should be recorded at the beginning of the cycle. When asked the problem with staff recording the expected dishwashing machine temperatures and not the actual temperatures, the RD said they were not the same thing. The RD said the 180 F minimum temperature of the Final Rinse is needed to sanitize. The RD said repeatedly using a white terry cloth square to dry resident food trays was an infection control concern and that they should be air dried. The RD said infection control was the concern with the two-compartment plate lowerator or any equipment being placed in front of the handwashing sink. The RD further said cross contamination and infection control were problems resulting from the employee leaning over the two-compartment plate lowerator, which contained dishes, to wash their hands at the handwashing sink. The RD said food service employees were not allowed to chew gum in the kitchen due to germs. The RD further said if the gum left their mouth, it could get in the food.

Based on record review, interviews, the Facility Reported Incident (FRI) received by the Alabama State Survey Agency, and the facility policy titled Abuse Prohibition Plan, the facility failed to protect Resident Identifier (RI) #40's right to be free from misappropriation of property when Registered Nurse (RN) #6 placed RI #40's temazepam in her pocket and left the facility. This affected RI #40 one of seven residents sampled for abuse prevention. This was cited due to the investigation of facility reported incident/complaint/report number AL00047874. Findings Include: Review of a facility policy titled Abuse Prohibition Plan, with an effective date of 11/02/2023 documented . Purpose: . The resident shall not be subjected to . misappropriation of property . Definitions: . Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. RI #40 was admitted to the facility 12/18/2022. On 05/16/2024 at 3:26 PM the facility reported an incident by way of The Alabama Department of Public Health Online Reporting Incident System. The report indicated that the facility was notified on 05/16/2024 by a Drug Enforcement Agency (DEA) Officer that RN #6 was found with a white substance in her possession during a K-9 search at her other job. The DEA Officer reported that RN #6 told the officer it was a temazepam from RI #40 that was refused and she placed in her pocket to return or destroy later. The report indicated that RN #6 said she forgot it was in her pocket until discovered by the DEA Officer several months later. On 06/12/2024 at 10:46 AM during an interview with DEA Officer, he said routinely the correctional facility performed K-9 search and on 05/16/2024 a search of employees was conducted. The search found a white substance which was in RN #6's wallet in her purse. It was sent to the lab, tested , and returned as temazepam. He said in questioning RN #6 she said it was from the facility. He said RN #6 gave the name of RI #40, said the resident had refused the medication and she put it in her pocket instead of getting the other nurse to destroy with her. He said she was arrested for possession of a controlled substance and theft. Interview with resident RI #40 on 06/12/2024 at 11:27 AM said he/she did not recall refusing sleeping pill but might have. When RI #40 was told it might have been in January he/she said too long ago. On 06/12/2024 at 11:00 AM during an interview with the facility Regional Nurse Manager (RNM) he said he worked on this investigation. He said the DEA officer called and told found white substance on RN #6 during a K-9 search at the correction facility while working. The RNM said RN #6 said RI #40 refused the medication and she put it in her pocket. He said they were notified of the incident on 05/16/2024 and the best they could gather it occurred 01/07/2024. He said it was abuse by misappropriation when RN #6 placed the medication in her pocket. On 06/12/2024 at 3:07 PM during an interview with RN #6, she said she went to give RI #40 the temazepam the last time she worked at the facility January 2024. RN #6 said RI #40 said he/she did not want it. RN #6 said she put it in a plastic bag and in her pocket. She said she did not recall the exact date. She said she forgot to get the other nurse to come destroy it with her, and when she got home, she realized it was still in her pocket, so she put it in her wallet in her purse and forgot about it. She said she worked at the correctional facility and a K-9 search was done and it was found in her car. She said she was arrested and charged with possession and theft. She said she should never have placed the medication in her pocket.

Based on interviews and medical record review the facility failed to ensure Resident Identifer (RI) #335's representative was notifed of an incident and that he/she transfered to the hospital on 06/24/2024. This deficient practice affected RI #335 one of three residents reviewed for transfer and discharge. Finding Include: RI #335 was admitted to the facility on [DATE] with diagnoses of Dementia with Agitation and Major Depressive Disorder. A review of RI #335's Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/08/2023, indicated RI #335's BIMS (Brief Interview for Mental Status) as five of 15, indicating RI #335 was cognitively impaired. A review of RI #335's Clinical Notes Report dated 06/24/2024, revealed RI #335 was transferred to the hospital on 06/24/2023 after an increase in agressive behaviors. There was no documentation in the Clinical Progress Notes that the representative sponsor was notified of the incident and the resident transfer to the hospital on 06/24/2023. On 06/14/2024 at 2:00 PM an intervew was conducted with RI #335's representative/sponsor. She was asked when was she made aware of the incident that happened on 06/23/2023 regarding and RI #335 that resulted in RI #335 being transferred to the hospital. The sponsor stated she was not made aware of the incident by the facility, but by the hospital social worker and then she called the facility. She further stated RI #335 had been in the hospital for a few days before she was aware of the incident and being in the hospital.

Based on observations, interviews, and review of a facility policy Infection Prevention and Control Program, the facility failed to ensure staff washed their hands and stored resident hygiene supplies in a manner to prevent cross-contamination. On 06/12/2024 and 06/13/2024 two unlabeled bath basins were observed on the bathroom of adjoining resident rooms for Resident Identifier (RI) #22 and RI #66. On 06/14/2024 the facility Treatment Nurse failed to perform hand hygiene after cleaning RI #14's wound and before applying the treatment. This affected RI #22, RI #66, and RI #14. Findings include: A facility policy titled, Infection Prevention and Control Program dated 11/20/2023 documented: .Policy: . 5. Hand Hygiene Protocol: a. All staff shall perform hand hygiene when coming on duty, between resident contacts, after handling contaminated objects, after PPE (Personal Protective Equipment) removal . b. Staff shall perform hand hygiene before and after performing resident care procedures. c. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedure. 11. Facilities with communal bathrooms: a. Items such as wash basins, bed pans, etc. shall be placed in a bag that is clearly labeled and stored separately . RI #22 was admitted to the facility on [DATE]. RI #66 was admitted to the facility on [DATE]. On 06/12/2024 at 10:59 AM, a shared bathroom for RI #22 and RI #66 was observed with two gray wash basins on the bathroom floor. On 06/13/2024 at 11:00 AM the adjoining bathroom of RI #22 and RI #66 was observed with two unlabeled wash basins on the floor. On 06/13/2024 at 11:30 AM Certified Nursing Assistant (CNA) #25 reported that each resident should have their own basin, labeled with their name and room number. CNA #25 said, the basins should be covered and in a clear plastic bag. RI #14 was admitted on [DATE] with diagnoses that included Stage Four Sacral Pressure Ulcer. On 06/14/2024 at 08:18 AM the Treatment Nurse, Licensed Practical Nurse (LPN) #26 was observed providing wound care for RI #14. LPN #26 cleaned RI #14's sacral wound and applied the clean treatment to the wound. LPN #26 did not perform hand hygiene or change gloves after removing the soiled dressing and before applying the clean treatment. An interview was conducted on 06/14/2024 at 06:12 PM with the Risk Manager/Infection Preventionist. The Risk Manager/Infection Preventionist reported, according to the facility policy staff should wash their hands after all care and each time they are dirty. The Risk Manager/Infection Preventionist stated, staff should remove soiled gloves before they exit the room or when they finished care. The Risk Manager/Infection Preventionist stated, staff should not be wearing contaminated gloves when touching clean items. The Risk Manager/Infection Preventionist stated, the risk of picking up clean items while wearing dirty/soiled gloves was contamination.

Based on record review, interview, a review of Facility Reported Incidents, the facility's investigative files, and review of a facility policies Medication Administration, and AMPharm Delivery Service, the facility failed to ensure controlled medications records were maintained and able to be reconciled when licensed staff failed to add medication to the control sheets and failed to place the controlled medications in the narcotic drawer after receiving from the pharmacy for Resident Identifier (RI) #57 and RI #47. This affected RI #47 and RI #57 and was cited as a result of the investigation of complaint/report AL00045923. Findings Include: A review of a facility policy AMPharm Delivery Services with an effective date of 11/2021 documented Policy: Nightly delivery is provided to each facility on a preset schedule. Procedure: . c. The delivery person shall present the nurse with a delivery manifest for signature . For narcotic deliveries, the receiving nurse shall verify the medications and counts with the delivery person prior to signing the manifest. 1. Immediately upon receipt scheduled medications shall be secured in the medication cart . RI #47 was admitted to the facility on [DATE]. RI #57 was admitted to the facility on [DATE]. The Facility Reported Incident submitted on 10/18/2023 at 7:06 PM indicated Registered Nurse (RN) #5 identified RI #47 and RI #57 had missing oxycodone tablets. The facility's investigative summary indicated . Incident type: Misappropriation of resident property Suspected Offender: Unknown 10/18/23 it was found that (RI #47) had Oxycodone/APAP 5/325 tablets 60 pills were unaccounted for. 10/18/23 it was found that (RI #57) had Oxycodone 5 milligram tablets 30 pills were unaccounted for. It is substantiated that the pills are missing. But we don't know for sure what happened to them at this point. On October 18th at approximately 12:45 PM 100 hall charge nurse (RN #5) reported to the DON (Former Director of Nursing (FDON)) that she called the pharmacy . to inquire about oxycodone for (RI #57's room number). The (pharmacy) reported that the medication had been delivered the night before and was signed off by two individuals. Nurse managers initiated search . No Oxycodone was found that belonged to (RI #57). On October 18th at approximately 4:30 PM . (RN #5) notified (pharmacy) that (RI #47) was completely out of oxycodone despite (RN #5) faxing the script (prescription) to (pharmacy) the previous day. (Pharmacy) informed (RN #5) the last oxycodone script was filled and delivered . on 10/13/23 of 60 tablets.After a thorough search of the building no medications were found. An order to (pharmacy) was called in requesting to replace the residents missing medications - replacement provided by Millennium. Multiple attempts via phone calls and text messages to contact (RN #7) the charge nurse that signed for both cards of oxycodone were left unanswered. (RN #7) was scheduled to work night shift on October 18th . She arrived late . stated her phone was dead . (RN #7) provided a statement . but denied any involvement in the missing medications. However, she did agree that she was the only nurse that signed for the medications that were delivered . During an interview with RN #5 on 06/12/2024 at 11:58 AM, she said she had ordered RI #57's oxycodone on 10/17/2023. RN #5 said on 10/18/2023 she checked the cart to confirm delivery and did not find it. RN #5 said she called the pharmacy and was told it had been delivered the night before and signed by RN #7. She said she and other nurses searched and did not find the medication, so she reported to the Director of Nursing (DON). She said she told the DON she counted with the RN #18, because RN #7 had left early. RN #5 said the counts were accurate. She said later the same day when RI #47 asked for pain medication, she went to the cart for oxycodone and there was none there, she again called the pharmacy and was told the medication delivered on 10/13/2023 and was also signed by RN #7. RN #5 said the facility was unsure about what happened to the medications and that neither resident missed a dose of the pain medication. An unsuccessful attempt was made to contact RN #7 on 06/12/2024 at 12:15 PM. On 06/12/2024 at 12:20 PM an interview was conducted with RN #18. RN #18 said she worked the same night as RN #7 but worked the other side of facility. RN #18 said when medications were delivered RN #7 received them and signed for them. RN #18 said she went over and got the medications for her hall later in the shift. RN #18 said RN #7 left before her shift was over and RN #7 and herself counted the medications and the count was accurate. RN #18 said she became aware of the missing medications when she did her statement. On 06/14/2024 at 6:44 PM during an interview with the Regional Nurse Manager (RNM), he said RN #5 identified that RI #47 and RI #57's oxycodone was missing. The RNM said RI #47's was delivered and signed by RN #7 on 10/13/2023 and RI #57's was delivered and signed also by RN #7 on 10/17/2023. When asked what happened to the medications, he said they did not have evidence other than RN #7 signed the delivery sheet. The RNM said RN #7 failed to follow the pharmacy processes of documenting and recording the medication when received. The RNM said RN #7 said she left the medications unattended and was terminated.

Based on interviews, record review and a review of a facility's policy titled, Oxygen Concentrator and Oxygen Storage, the facility failed to ensure: Resident Identifier (RI) #5 had a physician order for his/her oxygen and his/her oxygen tubing was labeled/dated. The facility further failed to ensure RI #52's nebulizer mask was stored in a plastic bag when not in use. This deficient practice affect RI #5 and RI #52, two of three residents sampled for respiratory care. Findings Include: A review of a facility's policy titled, Oxygen Concentrator . with an effective date of 12/01/2023 documented: . Purpose: To administer oxygen for the treatment of certain diseases or conditions . Policy: . Oxygen should be administered only under orders of the attending physician . Procedure: . 1. Care of the Resident . a. Obtain physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc.). Cannulas and masks should be change weekly . A review of RI #5's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 04/29/2024 Section O did not indicate oxygen therapy. A review of RI #5's Care Plan Report Effective 08/01/2023 indicated RI #5 required supplemental oxygen at times . change tubing one (1) times weekly starting 08/01/2023 . check/record oxygen saturation three times daily and check/fill humidifier one time daily . On 06/11/2024 at 4:00 PM, the surveyor observed RI #5's oxygen infusing via nasal cannula at three liters per minute. There was no date on the oxygen tubing. On 06/12/2024 at 5:54 PM, the surveyor observed RI #5's oxygen infusing via nasal cannula at 3 liters per minute. The tubing remained undated. On 06/13/2024 at 12:17 PM, the surveyor observed RI #5's oxygen was infusing via nasal cannula at 3 liters per minute. The tubing remained undated. On 06/13/2024 at 12:17 PM, Licensed Practical Nurse (LPN) #22 escorted the surveyor to RI #5's room. The surveyor asked LPN #22 did he see a date on RI #5's oxygen tubing. LPN #22 said no. LPN #22 said there should be a date on the tubing and a dated bag to store it in. When asked the rational for labeling the tubing and bag, LPN #22 said to let other staff know how long the tubing had been on the resident and when it was to be changed. On 06/13/2024 at 6:30 PM, the surveyor conducted an interview with Registered Nurse (RN) #23, a nurse supervisor. When asked if RI #5 had a physician's order for the oxygen, RN #23 looked at RI #5's Physician Orders and said yes. Surveyor asked RN #23 when the orders were initiated, she stated she helped LPN #22 input the orders earlier today. RN #23 stated nasal cannulas, nebulizer tubing and humidified water bottles should be changed weekly normally by the nurse on night shift. RN #23 said the tubing for the nasal cannula should be labeled with a date when changed. RI #52 was admitted to the facility on [DATE] with a diagnosis of Encounter For Screening for Respiratory Tuberculosis. RI #52's orders dated for 01/11/2024 documented, . Duoneb treatment tid, (three times a day) . On 06/11/2024 at 3:38 PM, RI #52's nebulizer machine was observed on the bedside table, the mask was uncovered, not in a plastic bag. On 06/12/2024 at 8:56 AM, RI #52's nebulizer machine was observed on the bedside table. The mask lying on bed side table, was uncovered, not in use, not in plastic bag. On 06/13/2024 at 11:28 AM, RI #52's mask was connected to nebulizer machine. The mask was uncovered, not in use, not stored in a plastic bag. On 06/13/2024 an interview was conducted with RN #15. RN #15 said the nebulizer mask should be stored in a zip locked bag when not in use. RN #15 stated the nurses who provide the treatment should make sure after they gave the treatment, the mask was stored in a plastic bag. When asked what was the concern with the nebulizer mask not being stored in a plastics bag, she stated an infection control issue. 47408

Based on interviews, record reviews and a facility policy titled Baseline Careplan, the facility failed to ensure Resident Identifier (RI) #72 received a copy of his/her Baseline Care plan Summary within 48 hours of admission. The facility further failed to ensure RI #72's Baseline Care Plan was developed within 48 hours of admission. This deficient practice affected one out three sampled residents whose baseline care plans were reviewed. Findings Include: RI #72 was admitted to the facility on [DATE] with admitting Diagnoses of Pleural Effusion, Pneumonia, Chronic Respiratory Failure with Hypoxia. A review of a facility policy titled, Baseline Careplan, dated 11/2016, Revised 10/25/2023: .Purpose: The facility shall develop and implement a baseline care plan for each resident that meet professional standards of quality care. Policy: 1. ''The baseline careplan shall a. Be developed within upon a resident's admission . 2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment .and discuss with the resident and resident representative . b. Interventions shall be initiated that address the residents current needs .c. Once established, goals and interventions shall be documented . 3. A supervising nurse shall verify that a baseline care plan has been developed . On 06/13/2024 at 09:47 AM an interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC reviewed the medical records and stated that she did not see a baseline care plan for RI #72. The MDSC was asked should RI #72 have had care plans within 48 hours and she replied, yes. The MDSC was asked who was responsible for initiating baseline care plans and the MDSC stated the Director of Nursing (DON) was responsible for initiating baseline care plans and MDSC initiated the complete Care Plans. On 06/13/2024 at 01:03 PM an interview was conducted with the DON. The DON was unable to locate RI #72's baseline care plan. The DON said admitting nurse was responsible for initiating a baseline care plan. The DON was asked why should a resident have baseline care plans and she stated to work in conjunction with the plan of care and for the health and well-being of the patient. The DON was asked should RI #72 have had baseline care plans and she replied yes.

Based on interviews, medical record review, review of the facility reported incident and a review a of the facility policy titled, Abuse Prohibition, the facility failed to report an allegation of abuse within the time frame of two hours to the state Agency on 06/24/2023. On 06/24/2023 at 4:30 AM, the facility staff reported an allegation of physical abuse by RI #335. The facility reported the allegation of physical abuse at 8:59 AM on 06/24/2023 to ADPH (Alabama Department of Public Health) State Agency. This deficient practice affected one out of three sampled residents reviewed for abuse concerns. Finding Include: A review of the facility's policy titled, Abuse Prohibition Plan, with an effective date of 04/01/2018, revealed: . EXTERNAL REPORTING . All alleged violations are reported immediately, but not later than 2 hours after the allegations is made . On 06/24/2023 at 8:59 AM the facility submitted a report to The Alabama Department of Public Health Online Incident Reporting System. The report indicated staff became aware of an incident of physical abuse at on 06/24/2023 at 4:30 AM. An interview was conducted on 06/26/2026 at 9:39 AM with the Administrator (ADM). The ADM stated he was the Abuse Coordinator for the facility, and that all allegations of abuse should reported to our office (ADPH). When asked what was the time frame for reporting alleged physical, he said within two hours of discovery.

Based on observations and review of the facility documents, the facility failed to ensure dishware was completed dried before storage; expired items were discarded; and the can opener and microwave were cleaned after use. These deficient practices had the potential to affect all residents who received food from the kitchen. Findings include: The facility's policy titled, Dietary - Mechanical Dish Washing dated [DATE], indicated, allow clean dishes to air dry completely before storing. Review of the Weekly Kitchen Cleaning Schedule revealed the can opener should be cleaned after each use by the cook. The PM Aide should check the dates of items in the Reach-In Cooler. On [DATE] beginning at 9:48 AM, a brief tour of the kitchen was conducted with Employee Identifier (EI) #7, the Certified Dietary Manager (CDM). The following was observed: three steam table pans were stacked together by the stove with water between them; the can opener blade had dried debris; there were seven boxes of Thickened Dairy Drinks in the reach-in cooler with an expiration date of [DATE]; there was one box of Thickened Cranberry Juice with an expiration date of [DATE] in the reach-in cooler; two rack of dishware (bowls, divided plates, steam table plans and coffee cups) were stored in the dish room with water between them. Also noted during the tour, the microwave had dried food debris. A dietary staff member was observed to use a rag from the sanitization bucket to clean the microwave. When the solution in the bucket was checked for the level of sanitizer in the bucket, the sanitization level could not be obtained, the CDM instructed the staff to change out the water and sanitizer in the bucket;

Based on observation, record review, interviews, and review of facility policy, the facility failed to serve food in a form designed to meet the individual needs for seven residents on a mechanically altered diet out of 80 total residents that received food from the kitchen. Findings include: The facility's policy titled, Dietary: Therapeutic Diets dated October 2020, revealed the intent was to assure that residents received and consumed foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician. The Diet Master dated 4/20/2021, revealed the facility had seven residents that received a mechanical soft diet. During the lunch meal tray line observation on 4/21/2021 beginning at 11:00 AM, Employee Identifier (EI) #5, a dietary cook served regular baked beans to the residents that were on a mechanically altered soft diet. Further observation revealed the kitchen did not have mashed baked beans to serve to the residents. The Menu Spreadsheet dated 4/20/2021, revealed residents that received a mechanical soft diet should receive mashed baked beans In an interview on 4/21/2021 at 11:59 AM, EI #8, a dietary cook stated she did not realize the menu called for mashed baked beans and did not make any. In an interview on 4/21/2021 at 12:00 PM, EI #7, the Certified Dietary Manager stated the facility did not provide mashed baked beans for the residents that received a mechanical soft diet.

Based on observation, record review, interviews, and review of facility policy, the facility failed to follow the menu for scoop size of the pureed entrees for four of four residents that received a pureed diet of 80 residents that received food from the kitchen. Findings include: The facility's policy titled, Dietary: Menus and Adequate Nutrition, dated October 2020, revealed the menus should be followed. The undated facility's policy titled, Portion Control revealed the food should be portioned according to the current menus and portion control was achieved through using the appropriate serving utensils. Review of the Diet Master revealed the facility had four residents that received a pureed diet. On 4/21/2021 beginning at 11:00 AM, the lunch meal tray line was observed. Employee Identifier (EI) 5, a dietary cook, placed on the residents that received a pureed diet plate, 2-2/3 ounces of pureed pork barbeque, pureed baked beans and pureed coleslaw. Review of the Menu Spreadsheet revealed the residents should receive three ounces of the pureed pork barbeque and four ounces of the pureed baked beans and the pureed coleslaw. In an interview on 4/21/2021 at 12:00 PM, EI #7, the Certified Dietary Manager (CDM) stated the kitchen used three 2-2/3 ounce scoops to serve the pureed pork, baked beans and coleslaw instead of the required scoop sizes.

Based on observation, record review, interviews, and review of the facility policy, the facility failed to follow the recipes for pureed diets for four residents on pureed diets out of 80 residents that received food from the kitchen. Findings include: The facility's policy titled, Dietary: Therapeutic Diets, dated October 2020, revealed the intent was to assure that residents received and consumed foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician. Review of the Diet Master dated 4/20/2021, revealed the facility had four residents that received a pureed diet. On 4/21/2021 at 2:40 PM, Employee Identifier (EI) #5, a dietary cook was observed to preparing the pureed entrees for the evening meal. EI #5 obtained a pan of chicken salad, which he stated had four to five servings of chicken salad in it. EI #5 poured the chicken salad into the Robot Coupe (industrialized food processor) then added an unmeasured amount of thickener and unmeasured amount of water and mixed the mixture. EI #5 added an unmeasured amount of water on three different occasions after adding the thickener. EI #5 then placed the pureed chicken salad into a pan. On 4/21/2021 at 2:59 PM, EI #5 poured the pasta salad into the Robot Coupe, added an unmeasured amount of thickener, and then mixed the mixture. EI #5 then added an unmeasured amount of water to the mixture then blended it. EI #5 then placed the pureed pasta salad into a pan. Review of the recipe for the chicken salad under the puree steps documented to remove the desired number of servings and add nutritive liquid, milk, broth etc. Blend until desired consistency. Add approved thickener to achieve desired consistency if needed. Review of the recipe for the pasta salad under the puree steps documented to remove the desired number of servings, and add nutritive liquid, milk, broth, etc. Blend until desired consistency. Add approved thickener to achieve desired consistency if needed. On 4/21/2021 at 4:10 PM, EI #6, the Registered Dietician (RD) stated EI #5 should mix the entrée then add thickener as needed. EI #6 stated adding water would decrease the nutrients per serving.

Based on interview, review of Resident Identifier (RI) #38's medical records and an undated document titled Use of dashes, the facility failed to ensure RI #38's Admission and Quarterly Minimum Data Set (MDS) were complete. This deficient practice affected RI #38, one of 23 sampled residents. Findings include: RI #38 was admitted to the facility on [DATE]. RI #38's Admission MDS with an assessment reference date of 11/24/2020, indicated the following sections were not complete; a dash was present: Section C, Cognitive Patterns; Section D, Mood; Section G, Functional Status; Section GG, Functional Abilities and Goals; and the Influenza and Pneumococcal portion of Section O. RI #38's Quarterly MDS with an assessment reference date of 2/21/2021, indicated the following sections were not complete; a dash was present: Section C, Cognitive Patterns; Section D, Mood, Section G, Functional Status; and the reason why the Influenza and Pneumococcal vaccine were not administered within Section O. On 4/22/2021 beginning at 10:06 AM, an interview was conducted with Employee Identifier (EI) #3 and EI #4, both MDS Coordinators. Both staff acknowledged the areas of MDS were not assessed but offered no explanation other than the staff responsible did not complete it. On 4/22/2021 at 11:40 AM, EI #4, MDS Coordinator presented the survey team with a undated documented titled, Use of dashes, which documented . A dash value indicates that an item was not assessed .

Based on observations, interviews, review of Resident Identifier (RI) #58's medical record and the facility's policy titled Restraint Policy the facility failed to provide medical justification of a physical restraint for RI #58, one of one sampled residents reviewed for physical restraints. RI #58, who is assessed as requiring limited assistance with transfers and mobility was observed in a locked, reclined Geri-chair that prevented the resident from getting up and walking. Findings include: The facility's policy titled, Restraint Policy last reviewed May 2020, documented Definitions: Physical Restraints refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body . Policy: Each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints . Physical restraints may include, but are not limited to: . d. Using devices in conjunction with a chair or merry walker, such as trays, bars or belts, that the resident cannot remove easily, that prevent the resident from rising or leaving the chair/walker. d. Placing a resident in a chair that prevents a resident from rising . RI #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #58's Admission Minimum Data Set (MDS) with an assessment reference date of 3/19/2021 indicated the resident was severely impaired in cognitive skills with a Brief Interview for Mental Status (BIMS) score of seven. RI #58 was assessed as required limited assistance with transfers and mobility. A review of RI #58's care plan did not indicate the use of reclined Geri-chair. Further review of Resident #58's clinical record revealed there was no documented evidence the resident was assessed for the use of the Geri-chair. On 4/20/2021 at 10:44 AM, RI #58 was observed sitting in front of the nurse's station in a reclined Geri-chair. On 4/21/2021 at 12:18 PM, RI #58 was observed sitting in front of the nurse's station in a reclined Geri-chair. On 4/21/2021 at 1:44 PM, RI #58 was observed sitting in front of the nurse's station in a reclined Geri-chair. On 4/21/2021 at 2:03 PM, Employee Identifier (EI) #1, a Registered Nurse (RN) was asked to observe RI #58 seated in a reclined Geri-chair. EI #1 verified that RI #58 was seated in the Geri-chair in front of the nurse's station in the reclined position. EI #1 stated RI #58 was placed there in the reclined Geri-chair because the resident kept getting out of the chair and walking around the facility. EI #1 stated RI #58 was a fall risk and not stable when walking. When asked if the reclined Geri-chair was a restraint, EI #1 stated in a way the Geri-chair is a restraint. On 4/21/2021 at 2:13 PM, EI #2, the Director of Nursing (DON) was asked to observe RI #58 in the reclined Geri-chair. EI #2 acknowledged the resident was seated in a reclined Geri-chair. Upon approaching RI #58, the resident was heard saying, Please help me to get out of this chair. RI #58 was observed to place his/her hands on the armrest in an attempt to push the Geri-chair forward. EI #2 stated the Geri-chair could not be moved because it was locked in the back. EI #2 acknowledged the locked, reclined Geri-chair was a restraint.

Based on observation, medical record review, interviews, and review of a facility polity titled Enteral (Tube) Nutrition, the facility failed to ensure Resident Identifier (RI) #73's tube feeding water flush was infusing at 55 ml (milliliters) /(an) hr( hour) as ordered by the physician. This was observed on 3/26/2019 and affected one of one resident sampled to receive a feeding tube water flush. Findings Include: A review of a facility policy titled, Enteral (Tube) Nutrition, with a revised date of 11/2018, revealed, .Policy Explanations and Compliance Guidelines . 8. The nurse will . 4. Verify that . flushes are administered per the . physician's orders [REDACTED]. RI # 73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #73's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/14/2019 revealed RI #73 had a Brief Interview for Mental Status (BIMS) of moderate cognitive impairment for daily decision Swallowing/Nutritional Status indicate RI #73 had a feeding tube and received tube feeding fluid intake daily. A review of RI #73's (MONTH) 2019 Physician Order's revealed .55 ml/hr water auto flush . On 3/26/19 at 11:54 a.m., the surveyor observed with Employee Identifier (EI) #3, a Registered Nurse, and EI #2, Director of Nursing/Registered Nurse, RI # 73's Tube Feeding Pole. The following was observed hanging: a tube feeding water bag hanging with a date of 3/26/2019 and a time hung listed as 12:00 a.m There were 1000 ml left in the bag. The surveyor observed Resident #73's feeding pump was set to infuse as follows: water flush at 0 ml/hour every 1 hours. The surveyor conducted an interview on 3/26/19 at 12:00 p.m. with EI #3, a Registered Nurse. EI #3 was asked if the water flush on RI #73's tube feeding pump was set at the correct rate on 3/26/2019 at 11:54 a.m EI #3 stated no. EI #3 was asked what should RI #73's tube feeding water flush be set at on the tube feeding pump. EI # 3 stated it should be set at 55/ml an hour. EI #3 was asked what was RI #73's tube feeding water bag dated/timed and volume left in tube feeding water bag,when observed on 3/26/2019 at 11:54 a.m EI #3 stated it was dated 3/26/2019 at 12:00 a.m., with about 1000 ml in the water bag and the water was still full in the bag. EI #3 was asked how long had RI #73's tube feeding water bag been hanging at the rate of 0 ml an hour according to the label dated/timed of 3/26/2019 at 12:00 a.m., when observed with the surveyor on 3/26/2019 at 11:54 a.m EI #3 stated about twelve hours. EI #3 was asked if the tube feeding water flush on RI # 73's feeding pump set to be given to RI #73 with the water bag dated/time 3/26/2019 at 12 a.m. given as the physician order [REDACTED]. EI #3 stated no. EI #3 was asked if RI #73 received the correct amount of water flush since 12:00 a.m., on 3/26/2019, according to the label date/time on the water bag. EI #3 stated no. EI #3 was asked what was the potential harm when a resident does not get the correct amount of water flush through the feeding tube. EI #3 stated the resident could become dehydrated. On 3/26/19 at 12:10 p.m., the surveyor conducted an interview with EI #2, Director of Nursing/Registered Nurse. EI #2 was asked if RI #73's tube feeding water flush was set at the correct rate on RI #7's feeding pump. EI #2 stated no. EI #2 was asked what should the water flush on RI #73's tube feeding pump be set on as the physician order. EI #2 stated it should be set at 55/ml an hour. EI #2 was asked what date/time and volume of RI #73's tube feeding water bag when observed with the surveyor. EI #2 stated it was dated 3/26/2019 at 12:00 AM with about 1000 ml left in the bag. EI #2 was asked according to the date/time on RI #73's tube feeding water bag, how long had the bag been hanging 0 ml an hour. EI #2 stated about 12 hours. EI #2 was asked had the water flush on RI #73's feeding pump set to be given to RI #73 with the water bag dated/time 3/26/2019 at 12:00 a.m., and the feeding pump water flush set at 0 ml/every 1 hour, been given as the physician order [REDACTED]. EI #2 stated no. EI #2 was asked what was the potential harm when a resident does not get the correct amount of water flush through the feeding tube. RI #2 stated the resident could become dehydrated.

Based on interviews and review of a facility policy titled, Resident Rights, the facility failed to ensure the residents' mail was delivered on Saturdays. This had a potential to affect all seventy-eight residents residing in the facility. Findings Include: A facility policy titled, Resident Rights, with a revision date of 11/28/2017, revealed the following: .7. Information and communication . i. The resident has the right to .receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service . On 3/27/19 at 10:39 a.m., four of four residents present for the Resident Council meeting stated they were unsure if the facility was delivering their mail on Saturdays. None of them could recall receiving any mail on a Saturday. On 3/27/19 at 12:04 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, Administrator. EI #1 was asked if the Postal Service delivered mail on Saturdays to the facility. EI #1 stated yes. EI #1 was asked if the the resident's mail was being delivered to the residents on Saturday. EI #1 stated no, she could not say it was being delivered consistently. EI #1 was asked why the residents' mail was not being delivered on Saturdays. EI #1 stated that she did not have a designated staff to deliver the residents' mail on Saturdays. EI #1 was asked what could be the negative outcome to the residents if their were not getting their mail delivered on Saturdays. EI #1 stated the residents could not get their personal cards, magazines, and/or presents, and it could cause them to feel sad. EI #1 further stated that this was the residents' right to receive their mail on any day that the postal service delivers mail to the facility for the resident.

Based on interviews and record review, the facility failed to remove the alleged perpetrator from the facility during the investigation of Resident Identifier (RI) #5's allegation of property misappropriation. The alleged perpetrator, Employee Identifier (EI) #8 was allowed to remain on the schedule and continue working in the building (on the hall of RI #5, on 04/22/16). This affected one of eight sampled residents for whom abuse allegations were reviewed. Findings include: The facility's Abuse Protection Policy dated November 2011, revealed: .ANY report of actual or suspected abuse MUST be acted upon immediately . All reports are treated in the same fashion. The first and most important step is ensuring the safety of the patients. The next step is to conduct a THOROUGH investigation that is well documented. Abuse protection policy I. Purpose To provide policies and procedures which prohibit mistreatment, neglect and abuse of patients and/or misappropriation of patient property . . SUMMARIZATION & DEFINITIONS . 6. Protection a. The patient will be protected from harm during the investigation process. b. Evaluation and appropriate intervention will be taken to ensure patient safety . . SUSPENSION/TERMINATION OF EMPLOYEES Per (according to) the Abuse Protection Policy, any employee who is accused of abuse is immediately suspended, pending the results of the investigation . the investigation must start immediately . RI #5 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an assessment reference date of 01/15/16 identified RI #5 as cognitively intact and able to make independent decisions. The resident's current care plan with a goal date of 05/02/16, identified the following problem: Resident does not want staff to pick up items in .room, room is cluttered.Goals (with a goal date of 05/02/16), revealed the resident's wishes will be honored over the next 90 days. Interventions included: encourage resident to assist with organizing . room, ask if . would like sheets on . bed. Clean and pick up items in room as resident will allow per . wishes. During the initial tour on 04/19/16 at 10:00 AM, RI #5 was asked how the staff treated residents. RI #5 responded that one staff member was exceptionally ugly to me and it happened on 04/15/16, tax day. RI #5 explained the CNA, Employee Identifier (EI) #8, stated RI #5's room was filthy and threw the resident's things away. RI #5 stated he/she kept stuff in a bag on the bed. The resident stated EI #8 threw away popcorn and the papers he/she writes to give his/her daughter. The resident stated he/she asked EI #8 not to throw his/her things away without asking. On 04/20/16 at 3:30 PM, RI #5 repeated the same scenario and identified EI #8 as the girl that was throwing all my stuff away. When asked what the CNA did, RI #5 revealed she just started throwing things away: things out of my purse (the resident used a Longhorn plastic bag to store his/her purse and other personal items) on the bed. When asked how that made him/her feel, RI #5 stated, awful, terrible. The resident informed the surveyor he/she had reported this incident to the oncoming CNA (EI #9) the following (04/16/16) morning. The resident stated EI #9 immediately went to the Administrator (EI #1). RI #5 stated the Administrator did come to the resident to address this concern. RI #5 explained he/she reported the occurrence to the Administrator, just as he/she had to the surveyor. On 04/21/16 at 7:35 AM, the oncoming CNA (EI #9) to whom RI #5 reported the allegation, was interviewed by the surveyor. EI #9 confirmed that RI #5 had told him the resident's popcorn and personal stuff was thrown away. EI #9 stated the resident reported he/she was tired of the CNA mistreating him/her; the resident was upset. EI #9 stated he immediately went to the Administrator to get help after he identified this incident as abuse. On 04/21/16 at 9:30 AM, EI #8 (the CNA who allegedly misappropriated the resident's property) was asked to relate the occurrences of the evening of 04/15/16, between herself and RI #5. EI #8 stated the resident (RI #5) was nervous I was throwing away his/her important things. The surveyor asked if the resident had asked EI #8 to leave it. EI #8 replied, (He/she) wanted me to leave his/her purse alone. EI #8 stated she knew the resident had little papers on which he/she wrote. The surveyor asked EI #8 if she had thrown out the resident's papers. EI #8 replied she threw out RI #5's trash. When asked if the resident had the right to keep his/her stuff, EI #8 stated yes. When asked if the resident had said anything, EI #8 replied, I could tell she was nervous. When asked if she should have thrown away the stuff EI #8 stated, Then, I didn't think there was any harm; next time I will just have to leave it. He/She wanted it. I should have left it. On 04/21/16 at 3:00 PM, the Administrator/Abuse Coordinator (EI #1) was asked to explain the occurrence involving RI #5 on 04/15/16. EI #1 stated the resident reported he/she did not like the way the CNA (EI #8) had treated him/her and did not like the CNA calling him/her messy. When asked what the CNA (EI #8) said to RI #5, the Administrator said EI #8 stated the resident was messy. When asked how did RI #5 respond, EI #1 stated the resident said he/she did not like to be called messy and did not like to be talked to like that. When asked if that was considered abuse, EI #1 stated, If that's exactly what was said. EI #1 was asked was there any mention of things being disturbed. EI #1 stated something was said about a bag. The facility's CNA schedule sheet for the month of April 2016 revealed EI #8 had worked 04/15/16 through 04/17/16 and was scheduled to work again on 04/20/16 through 04/22/16. On 04/22/16, EI #8 was scheduled to work a double shift, the second shift of which was on RI #5's hall. EI #8 had not been removed from the schedule. The facility was unable to provide documentation of an abuse investigation related to RI #5's allegation, to verify the implementation of their abuse policy. On 04/16/16 the Administrator, Employee Identifier (EI) #1 received knowledge of a resident who alleged mistreatment by a Certified Nursing Assistant on 04/15/16 during the evening shift. After the resident had confided in her usual caregiver (EI#9) on the morning of 04/16/16, EI #1 went to the resident's room and interviewed RI #5. After the interview, EI #1 filed a Grievance Record that documented RI #5 did not like the way EI #8 had spoken to him/her. RI #5 stated EI #8 was short and told resident she/he was messy. In three separate interviews, RI #5 stated EI #8 had thrown away her stuff. When asked what she had told EI #1, she replied the same as he/she told the surveyor. The facility provided no documentation of an allegation of property misappropriation.

Based on interviews and record review, the facility failed to investigate and report an allegation of misappropriation of property to the State Agency within 24 hours of notification. This affected Resident Identifier (RI #5), one of eight sampled residents for whom abuse allegations were reviewed. Findings include: The facility's Abuse Protection Policy dated November 2011, revealed: This facility practices the concept of zero tolerance for patient abuse. Misappropriation of Patient Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's belongings or money without the patient's consent. . 5. a. Complete an investigation on all occurrences to include appropriate information. . 7. Reporting/Response a. report all alleged violations and all substantiated incidents to the State agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation. RI #5 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an assessment reference date of 01/15/16 identified RI #5 as cognitively intact and able to make independent decisions. During the initial tour on 04/19/16 at 10:00 AM, a surveyor asked RI #5 how the staff treated residents. RI #5 replied, I had one that was exceptionally ugly to me. RI #5 explained this had occurred on 04/15/16, tax day. RI #5 stated the Certified Nursing Assistant (CNA) Employee Identifier (EI) #8 had said RI #5's room was filthy, and threw the resident's things away. RI #5 stated he/she kept stuff in a bag on the bed. RI #5 stated EI #8 threw away the popcorn and papers RI #5 wrote on to give to the daughter. RI #5 said EI #8 was told not to throw things away without asking. The surveyor asked RI #5 who was the first person that was told about the incident. RI #5 stated he/she reported it to the oncoming CNA (EI #9) on the following morning (Saturday 04/16/16). RI #5 stated, I told him it made me feel real bad . RI #5 stated EI #9 immediately went to get the Administrator, who happened to be in the facility. When asked what had been told to the Administrator, RI #5 stated: The same as I told you (surveyor). EI #9 (the oncoming CNA to whom the allegation was reported) was interviewed on 04/21/16 at 7:30 AM. He stated RI #5 told him the CNA (EI #8) threw away the resident's stuff. When asked what was thrown away, EI #9 stated it was popcorn and RI #5's personal things. EI #9 further explained he reported this to the Administrator and the Administrator immediately went to see the resident. On 04/21/16 at 3:00 PM, the Surveyor asked the Administrator/Abuse Coordinator (EI #1) what had been reported to her from RI #5 on 04/15/16. EI #1 stated the resident had reported he/she did not like the way the CNA (EI #8) had treated him/her. EI #1 also stated the resident reported something about a bag. EI #1 was asked if she considered this occurrence as possible abuse. EI #1 said, If that was exactly what was said. The surveyor asked if she had investigated this occurrence as abuse. EI #1 replied yes. When asked if she had reported this to the State Agency, EI #1 replied, no. The surveyor asked if she should have reported the incident. EI #1 responded, she didn't know. The surveyors requested a copy of the investigation of RI #5's allegation. The facility was unable to provide documentation of an investigation, or documentation of a report to the State Agency. The facility did provide a Grievance Record, which EI #1 had completed on 04/16/16. This record revealed EI #8 had stated RI #5 was messy. The Grievance Record did not address the discarding of RI #5's personal items.

Based on interviews and record review, the facility failed to investigate a resident's allegation of misappropriation of property. Resident Identifier (RI) #5, alleged a Certified Nursing Assistant (CNA), Employee Identifier (EI) #8 threw away her personal items on 04/15/16, after RI #5 specifically requested EI #8 not to throw away these personal items. This affected RI #5, one of eight sampled residents for whom abuse allegations were reviewed. Findings include: The facility's Abuse Protection Policy dated November 2011, revealed: . ANY report of actual or suspected abuse MUST be acted upon immediately. . SUMMARIZATION & DEFINITIONS Misappropriation of Patient Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's belongings or money without the patient's consent. RI #5 was admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an assessment reference date of 01/15/16, identified RI #5 as cognitively intact and able to make independent decisions. The resident's current care plan with a goal date of 05/02/16, identified the following problem: Resident does not want staff to pick up items in . room, room is cluttered. Resident will not keep linen on bed, has pads on it. Resident keeps . personal items stacked around him/her. Resident has blankets on the floor. Goals (with a goal date of 05/02/16), revealed: resident's wishes will be honored over the next 90 days. Interventions included: encourage resident to assist with organizing . room, ask if . would like sheets on . bed. Clean and pick up items in room as resident will allow per . wishes. During the initial tour on 04/19/16 at 10:00 AM, the surveyor asked RI #5 how the staff treated residents. RI #5 responded that one staff member was exceptionally ugly to me and it happened on 04/15/16, tax day. RI #5 explained the CNA, EI #8, stated RI #5's room was filthy and threw the resident's things away. RI #5 stated he/she kept stuff in a bag on the bed. The resident stated EI #8 threw away popcorn and the papers he/she writes to give his/her daughter. The resident said EI #8 was asked not to throw his/her things away without permission. On 04/20/16 at 3:30 PM, RI #5 repeated the same scenario and identified EI #8 as the girl that was throwing all my stuff away. When asked what the CNA did, RI #5 revealed she just started throwing things away: things out of my purse (the resident used a Longhorn plastic bag to store his/her purse and other personal items) on the bed. When asked how that made him/her feel, RI #5 stated, awful, terrible. On 04/21/16 at 9:30 AM, EI #8 (the CNA who allegedly misappropriated the resident's property) was asked to relate the occurrences of the evening of 04/15/16, between herself and RI #5. EI #8 stated the resident (RI #5) was nervous I was throwing away his/her important things. The surveyor asked if the resident had asked EI #8 to leave it. EI #8 replied, (He/she) wanted me to leave his/her purse alone. EI #8 stated she knew the resident had little papers on which he/she wrote. The surveyor asked EI #8 if she had thrown out the resident's papers. EI #8 replied she threw out trash. When asked if the resident had the right to keep his/her stuff, EI #8 stated yes. When asked if the resident had said anything, EI #8 replied, I could tell she was nervous. When asked if she should have thrown away the stuff EI #8 stated, Then, I didn't think there was any harm; next time I will just have to leave it. He/She wanted it. I should have left it. The surveyor asked if anyone had discussed this incident with her, EI #8 explained, I spoke to the Administrator (EI #1) yesterday (04/20/16); I did not speak to anyone before yesterday. The facility's investigative information revealed the incident had been documented on a facility form titled, Grievance Record dated 04/16/16. The report indicated the resident did not like the way EI #8 spoke to him/her or changed him/her. The resident reported when EI #8 was performing peri-care, EI #8 did not raise the half-rails and it frightened the resident. The patient stated he/she was not harmed or felt threatened. EI #8 also stated the nurse spoke with the CNA and peri-care was better the next time. The results of the investigation specified unable to confirm that events transpired as described by resident. Nurse was present in room during care and stated CNA didn't make that comment and CNA was in front of resident blocking her as she turned her for peri-care. Corrective action: Inservice CNA on reviewing care needs and understanding communication through body language. No further follow-up (resolution) was documented. On 04/21/16 at 3:00 PM, the surveyor interviewed the Abuse Coordinator/Administrator (EI #1). EI #1 explained that EI #9 (another CNA) informed her on the morning of 04/16/16, that RI #5 wanted EI #1 to speak with him/her. The surveyor asked EI #1 what the resident had told her about his/her items. EI #1 explained the resident said EI #8 called him/her messy--that RI #5 had stuff on the bedside table that he/she liked to leave there. The surveyor asked EI #1 what the resident said EI #8 had done with his/her items. EI #1 said the CNA (EI #8) took the resident's tissues and threw them away . and something about a bag. The surveyor asked if the resident had told her whether anything else had been disturbed. EI #1 could not recall. The surveyor asked EI #1 if the CNA should have moved (EI #5's) stuff. EI #1 responded, the CNA should have asked for permission to throw it away. The surveyor asked if this could be considered abuse. EI #1 responded, It could be considered abuse, misappropriation of property. When asked if she should have investigated this incident as potential abuse, EI #1 responded, Yes, I guess. I don't think there was any intent. I think she (EI #8) mishandled the situation. After I spoke with EI #8 yesterday (04/20/16), I wrote it up. On 04/22/16 at 5:35 PM, the Administrator (EI #1) and Corporate Consultant (EI #15) met with the survey staff. EI #15 stated as a result of the surveyors' findings related to RI #5's allegation, the facility had done some follow-up investigation with RI #5. EI #15 explained that after having spoken with RI #5 on 04/22/16, the facility re-opened the investigation. EI #15 stated their investigation revealed they had an allegation of abuse and they had a duty to ensure the safety of their residents.

Based on interviews and record review, the facility's Quality Assurance & Assessment (QA&A) Committee failed to develop and implement a corrective action plan after Resident Identifier (RI) #2 was found unresponsive by Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN) on [DATE]. On [DATE], EI #1, a LPN, who was not certified to perform Cardiopulmonary Resuscitation (CPR), initiated and stopped CPR without calling a code in the facility, activating Emergency Medical Services (EMS) or notification from the physician. Without a corrective action plan, on [DATE], EI #1, who still remained uncertified in CPR, initiated and stopped CPR on RI #1 without calling a code, activating EMS or notification from the physician. These deficient practices affected RI #1 and RI #2, two of two sampled residents reviewed for emergency response, with the potential to affect the remaining 63 Full Code status residents who reside in the facility. These deficient practices placed RI #1 and RI #2 in immediate jeopardy because it was likely to cause serious injury, harm or death. On [DATE] at 6:15 PM, the facility's Administrator, Director of Nursing, and two Regional Nurse Consultants were notified of the findings of immediate jeopardy in the area Quality Assurance and Assessment, F 520. Findings include: Page 11 of the Director of Nursing Training Manual titled QUALITY PROGRAM dated [DATE], documented GENERAL INFORMATION This facility follow the evidence-based path to quality as outlined in the Quality Program Manual. The programs's systems provide easy tracking of quality measures along with the ability to review comparisons and trends within your facility. The methodology is designed to assess the quality of services provided. The program utilizes quality indicators to monitor and evaluate the quality of services provided. It must be a continuous process of identification, evaluation, implement of corrective action plans and monitoring. RI #1 was admitted to the facility on [DATE]. RI #1's electronic nurses' note written by EI #1 dated [DATE] entered at 4:39 AM (written 21 minutes before the physician called back to inform the staff to stop CPR) documented . 0400 (4:00 AM) unable to palpate vital signs, skin cool to touch finger tips purple. CPR attempted without success. (The physician) paged, order given to stop code and release body to funeral home of family's choice, daughter notified, stated they are on their way. (Refer to F 309). RI #2 was admitted to the facility on [DATE]. RI #2's electronic nurses' note written by EI #1 dated [DATE] entered at 8:22 AM documented . 0600 (6:00 AM) Resident found in bed unresponsive, unable to palpate pulse or B/P (blood pressure) chest not rising and falling; skin cool to touch . CPR attempted but unsuccessful . In a telephone interview on [DATE] at 10:40 AM, EI #1 was asked if she had performed CPR on other residents. EI #1 said yes. When asked about the incident, EI #1 stated it was similar to RI #1, that an unidentified Certified Nursing Assistant (CNA) found the resident unresponsive. EI #1 stated she performed CPR, but was unable to resuscitate the resident. When asked if she called a code, EI #1 said no. EI #1 stated no one assisted her, that she was all alone. EI #1 also acknowledged that she did not use the crash cart. When asked, who the resident was, EI #1 said it was RI #2. In a follow-up interview on [DATE] at 9:00 AM, EI #1 was asked if she called 911 when she found RI #2 unresponsive on [DATE]. EI #1 said no. According to EI #1, her CPR certification expired April or [DATE]. In an interview on [DATE] at 10:45 PM, EI #2, the Director of Nursing, stated she was not aware that EI #1 did not call a code or activate the emergency response system when EI #1 found RI #2 without a pulse. In an interview on [DATE] at 8:15 AM, EI #6, the Administrator was asked if the facility reviewed the events surrounding RI #1's and RI #2's death in the facility. EI #6 replied, We did not review in QA. According to the QUARTERLY LEADERSHIP TEAM QA/QI (Quality Improvement) Agenda and Minutes on [DATE] (five days after a LPN, EI #1, who was not CPR certified, performed CPR on RI #2) at 4:00 PM, the concerns identified by the committee were: infection control, food temperatures and resident trust funds. ************************* On [DATE] at 10:40 AM, the facility submitted an acceptable Allegation of Credible Compliance, which documented . F520 . A special session of the QA committee was held on [DATE] by the Administrator. The committee discussed and reviewed the results of the complaint survey as expressed during the exit with review of the immediate jeopardy deficiencies that included: Failure to honor advance directives; to follow American Heart Association guidelines for providing CPR; management failure to ensure that a system was in place so that all staff could readily identify code status; failure to ensure licensed nurses maintain current CPR certification; DON (Director of Nurses) failure to provide oversight to licensed nurses to respond appropriately to residents without a pulse or respirations; Regional Nurse Consultants failed to ensure the facility had a system in place which directed the staff on how to respond if they found a resident without a pulse and respirations; failure of the QA committee to develop and implement corrective action for RI #1 and RI #2 who were a full code and the nurse initiated and ceased CPR without activating the emergency medical service and the physician. The QA committee will discuss survey results and modify systems as needed to maintain compliance. The QA committee received in-service training by the Administrator and Regional Nurse Consultant on [DATE] and [DATE]. The in-service included but was not limited to: Facility QA policies and procedures; Daily QA morning meetings; monthly QA meetings (Leadership team; Customer Service; Patient Care and Services; Behavior and Pain Management) Quarterly QA (goal setting, brainstorming, root cause analysis). The QA committee was instructed to call a meeting to address concerns identified as they arise as well as during the above meetings as needed with assistance from the Medical Director to resolve, reduce, or eliminate concerns identified. The EI #1 received in-service training on [DATE] and [DATE] by the Director of Nursing and Regional Nurse Consultant. The in-service covered areas but not limited to: Advance Directives, Code Status, CPR, (The facility will follow The American Heart Association), Code Blue, and activation of Emergency Medical Services. On [DATE] EI #1 was removed from the schedule indefinitely by the DON. On [DATE] EI #1 employment was terminated. The Administrator has reached out to AQAF on [DATE] and enrolled in the quality improvement program. The Administrator and Regional Director of Operations have contacted an outside independent consultant on [DATE] to oversee facility compliance. AOC [DATE]. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 520 was lowered to F level on [DATE] at 6:15 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 869.

Based on interviews and record review, Employee Identifier (EI) #6, the Administrator, who is responsible for directing the overall day-to-day operations of the facility and EI #2, the Director for Nursing, who is responsible for managing the nursing department, failed to ensure a system was in place for staff to readily identify a resident's code status. The resident's code status was documented in the computer, located at the nurses' station. Furthermore, EI #5, the Staffing Coordinator, who is responsible for directing the overall operation of education programs, failed to ensure licensed nurses maintained current Cardiopulmonary Resuscitation (CPR) certification. These deficient practices affected RI #1 and RI #2, two of two sampled residents reviewed for emergency response, with the potential to affect the remaining 63 Full Code status residents who reside in the facility. These deficient practices placed RI #1 and RI #2 in immediate jeopardy because it was likely to cause serious injury, harm or death. The facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated [DATE], indicated the facility has a total of 78 residents. A typed statement on facility letterhead, signed by the Administrator (EI #6) documented [DATE] Millennium Nursing and Rehab has 63 residents that are a Fullcode status . On [DATE] at 6:15 PM, the facility's Administrator, Director of Nursing, and two Regional Nurse Consultants were notified of the findings of immediate jeopardy in the area of Administration, F 490. Findings include: 1) The Administrator, EI #6's undated JOB DESCRIPTION documented . Summary: The purpose of this position is to establish and direct the facility's overall day-to-day operation, both internal and external, and coordinate these operations in accordance with current existing federal, state and local standards . ESSENTIAL DUTIES AND RESPONSIBILITIES: . *Develop, maintain and periodically update policies and procedures that govern that day-to-day functions of the facility . *Monitor procedures to assure compliance with the guidelines of state and federal regulations and facility policies . The Director of Nursing, EI #2's undated JOB DESCRIPTION documented . Summary: The purpose of this position is to manage the nursing department and administer the nursing programs in compliance with state and federal regulations as well as company policy and procedures. ESSENTIAL DUTIES AND RESPONSIBILITIES: *Plan, develop, organize, implement, evaluate and direct the Nursing Services Department . *Develop, maintain and periodically update written policies and procedures that govern the day-to-day functions of the nursing department . Cross reference F 309 In a telephone interview on [DATE] at 2:55 PM, EI #8, the Certified Nursing Assistant (CNA) who was assigned to care for RI #1 and alerted the nurse (EI #1) of RI #1's change in condition on [DATE], stated they (nursing staff) were running around like chickens with their heads cut off trying to find out the code status of RI #1. In a telephone interview on [DATE] at 10:40 AM, EI #1, the Licensed Practical Nurse (LPN) assigned to care for RI #1 on [DATE], was asked how she knew the code status of RI #1. EI #1 stated she looked for it in the computer but could not find it. In a follow-up interview on [DATE] at 8:10 AM, EI #1 stated while she was talking with RI #1's daughter, she asked for verification purposes, what the resident's code status was. When asked if she knew the resident's code status, EI #1 said no, it was confusing. I was trying to pull it up on (the) system. In a telephone interview on [DATE] at 2:45 PM, EI #3, the Registered Nurse (RN) who EI #1 called for assistance, stated when she arrived to the 200 hall nurses' station, she found EI #1 at the nurses' station. EI #3 said she asked EI #1 if RI #1 was a Full Code. According to EI #3, EI #1 told her she didn't know, that she had looked everywhere and couldn't find it. EI #3 stated she and EI #1 looked in the chart. EI #3 further stated that she looked also and couldn't find it. When asked, how she determined who was a Full Code, EI #3 stated, Most of the time it is in the computer, sometimes it's there, sometimes it's not. The nurse is hindered to know what to do - I just go ahead (and) do the CPR (and) will look later - But right now, since (RI #1) died , they have made a book now that's all the names of the residents on each wing that is full code or DNR. The way we have it now - we just look in the book (and) check - it is much easier. In a telephone interview on [DATE] at 4:30 PM, EI #4, a RN was asked how she determined who was a Full Code. EI #4 stated At that time (when RI #1 died ) we had to look up in the computer but it was difficult to find, but (after) that incident they have a better system. Now we have a binder that is on top (of) the crash cart itself. In an interview on [DATE] at 10:45 AM, EI #2, the Director of Nursing was asked, prior to [DATE] how did the staff determine a resident's code status. EI #2 stated they would go into the computer. When asked about the code status book, EI #1 stated I put the code status book in place because of the confusion surrounding the (RI #1's) case, so they could have a backup to easily find full code or DNR . In an interview on [DATE] at 8:15 AM, EI #6, the Administrator was asked, what corrective measures the facility put in place since the incident involving RI #1 on [DATE]. EI #6 stated, a new policy was developed, the staff was in-serviced and they put together an easily identifiable book for reference. EI #6 explained this book will help the staff to readily identify the code status of a resident. 2) The Staffing Coordinator, EI #5's undated JOB DESCRIPTION documented . Summary: The purpose of this position is to plan, organize, develop and direct the overall operation of education programs for facility staff in accordance with current existing federal, state and local standards, and established policies and procedures of the facility. ESSENTIAL DUTIES AND RESPONSIBILITIES: . *Maintain accurate inservice attendance and other relevant records such as license/certificate renewal dates . MARGINAL DUTIES AND RESPONSIBILITIES: . *Review and determine validity of licensed and/or certified personnel for meeting the requirements of state and/or federal requirements . Cross reference F 309 In a telephone interview on [DATE] at 10:40 AM, EI #1, the Licensed Practical Nurse (LPN) who performed CPR on RI #1 on [DATE], was asked if she was CPR certified. EI #1 answered no and explained that her certification expired [DATE]. EI #1 was asked if she had performed CPR on other residents. EI #1 said yes. When asked about the incident, EI #1 stated it was similar to RI #1, that an unidentified Certified Nursing Assistant (CNA) found the resident unresponsive. EI #1 stated she performed CPR, but was unable to resuscitate the resident. When asked if she called a code, EI #1 said no. EI #1 stated no one assisted her, that she was all alone. EI #1 also acknowledged that she did not use the crash cart. When asked, who the resident was, EI #1 said it was RI #2. RI #2 was admitted to the facility on [DATE]. RI #2's electronic nurses' note written by EI #1 dated [DATE] entered at 8:22 AM documented . 0600 (6:00 AM) Resident found in bed unresponsive, unable to palpate pulse or B/P (blood pressure) chest not rising and falling; skin cool to touch . CPR attempted but unsuccessful . In a follow-up interview on [DATE] at 9:00 AM, EI #1 was asked if she called 911 when she found RI #2 unresponsive on [DATE]. EI #1 said no. According to EI #1, her CPR certification expired April or [DATE]. A review of EI #1's personnel file indicated EI #1's hire date with the facility was [DATE]. In an interview on [DATE] at 11:20 AM, EI #5, who has been employed for two years as the Staffing Coordinator, was asked who was responsible for monitoring CPR certification. EI #5 stated she was. When asked about EI #1's lack of CPR certification, EI #5 stated when she interviewed EI #1, she asked for a copy but EI #1 stated it was in her other wallet and that she (EI #1) would bring it in. EI #1 then came to EI #5 later and said she couldn't find her CPR certification card. EI #5 told EI #1 to sign up for the next class, which was being held [DATE]. According to EI #5, EI #1 signed up for the class, but did not show up. EI #5 was asked if she reported EI #1's lack of CPR certification to anyone and she said no. When asked if she had a policy or some sort of guideline to check new hire credentials, EI #5 said, No, it's pretty much in my head. In an interview on [DATE] at 10:45 AM, EI #2, the DON stated she was not aware that EI #1 was not CPR certified. EI #2 stated she found out yesterday ([DATE]) that EI #1's CPR certification was not current. EI #2 stated she was not aware that EI #1 did not call a code or activate the emergency response system when EI #1 found RI #2 without a pulse. In an interview on [DATE] at 3:10 PM, EI #9, the Medical Director was asked if he expected the nurse to be certified that performed CPR. EI #9 said yes. When asked, if he was aware that the nurse (EI #1) who performed CPR on RI #1 was not CPR certified, EI #9 said No I was not aware. ************************* On [DATE] at 10:40 AM, the facility submitted an acceptable Allegation of Credible Compliance which documented . F 490 . #1 Regional Nurse Consultants initiated the new CPR policy on [DATE] and CPR Directive to licensed staff and Admission Coordinator or designee to be initiated by the Admission Coordinator upon review with the resident and/or Responsible party in the admission packet. Once Directive is obtained then the Admission Coordinator is to notify the Charge Nurse for MD notification and orders as directed. If the MD gives an order for [REDACTED]. When the process is completed it automatically updates to the Nurse Manager Role to do list in Vision that the Advance directive has been updated so that review can occur in morning QA daily Monday through Friday. RNC in-serviced the SDC, DON and Administrator on the adopted CPR policy and CPR Directive procedure put in place on [DATE]. The Administrator and Regional Director of Operations have contacted an outside independent consultant on [DATE] to oversee facility compliance. #2 The SDC was in-serviced on [DATE] by Regional Nurse Consultant on ensuring that licensed nurses maintain current CPR certification for duration of employment. An audit was completed on [DATE] of all licensed nurses to determine current status of CPR certification. CPR certification classes were conducted on [DATE] and [DATE] with completion of all licensed nurses certification. The CPR classes were conducted by the Respiratory Therapist through the American Heart Association. #3 DON or designee initiated in-service to CPR certified staff on proper code procedures for patients who are without a pulse or respirations on [DATE]. DON will conduct mock codes to observe clinical staff's response and to ensure CPR policy is being followed; every shift, every week for 3 weeks and randomly thereafter and report findings to QA committee. DON will audit documentation of every resident who expires in the facility to ensure appropriate procedures were followed and notifications made. AOC [DATE]. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 490 was lowered to F level on [DATE] at 6:15 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 869.

Based on interviews, review of Resident Identifier (RI) #1's and RI #2's medical record, handwritten statements from licensed nurses and the 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, the facility failed to ensure Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN) followed the AHA guidelines for providing cardiopulmonary resuscitation to RI #1, a resident with Full Code status. Code status describes what type of intervention a health care facility will conduct should a resident stop breathing and/or their heart stops beating. Full Code status means when a resident stops breathing and/or their heart stops beating, staff are to immediately initiate emergency medical services, Cardiopulmonary Resuscitation (CPR), in an attempt to revive the resident. According to the AHA, the lone rescuer should immediately activate the emergency response system, get an AED (Automated External Defibrillator)/defibrillator, if available, and start CPR with chest compressions. CPR should be continued without interruptions until more experienced rescuers assume care. On [DATE] between 3:00 AM and 4:00 AM, EI #8, a Certified Nursing Assistant (CNA) alerted EI #1, the LPN that she should come and check on RI #1. EI #1 went into the resident's room and found RI #1 with a faint pulse. EI #1 left the resident's room to call the physician, the resident's family and EI #3, a Registered Nurse on another hall. When EI #1 returned to RI #1's room, she could not detect RI #1's pulse. EI #1 lowered RI #1's bed and started to perform chest compressions. After 30 chest compressions, EI #1 checked for a pulse. When no pulse was found, EI #1 stopped CPR and returned to the nurses' station to complete paperwork. Without calling a code, activating emergency medical services (EMS) or notification from the physician, EI #1 told RI #1's daughter, the resident had expired when she arrived at the facility at 4:50 AM. Furthermore, it was revealed, this same LPN, EI #1, who was not CPR certified, failed to call a code and activate the emergency response system, when she found RI #2 unresponsive on [DATE]. These deficient practices affected RI #1 and RI #2; two of two sampled residents reviewed for emergency response, and placed RI #1 and RI #2 in immediate jeopardy because it was likely to cause serious injury, harm or death. On [DATE] at 6:15 PM, the facility's Administrator, Director of Nursing (DON), and two Regional Nurse Consultants were notified of the findings of substandard quality of care at immediate jeopardy in the area of Quality of Care, F 309. Findings include: The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care with a copyright date of 2010 documented . Part 4: CPR Overview . The Universal Adult Basic Life Support (BLS) Algorithm is a conceptual framework for all levels of rescuers in all settings. It emphasizes the key components that any rescuer can and should perform. When encountering a victim of sudden adult [MEDICAL CONDITION], the lone rescuer must first recognize that the victim has experienced a [MEDICAL CONDITION], based on unresponsiveness and lack of normal breathing. After recognition, the rescuer should immediately activate the emergency response system, get an AED/defibrillator, if available, and start CPR with chest compressions. If an AED is not close by, the rescuer should proceed directly to CPR. If other rescuers are present, the first rescuer should direct them to activate the emergency response system and get the AED/defibrillator; the first rescuer should start CPR immediately . If an AED/defibrillator is not available, continue CPR without interruptions until more experienced rescuers assume care . rescuers should start CPR immediately if the adult victim is unresponsive and not breathing or not breathing normally . CPR improves the victim's chance of survival by providing heart and brain circulation. Rescuers should perform chest compressions for all victims in [MEDICAL CONDITION], regardless of rescuer skill level, victim characteristics, or available resources . On [DATE], the State Agency received a complaint alleging the facility failed to initiate and continue CPR on RI #1, a resident with Full Code status. The ambulance was not called and there was no crash cart in the resident's room or hallway. According to the complainant, the Director of Nursing (EI #2) stated the nurse (later identified as EI #1) got into trouble for not calling the ambulance. RI #1 was admitted to the facility on [DATE]. RI #1's ADVANCE DIRECTIVE ACKNOWLEDGEMENT form signed by RI #1's daughter dated [DATE] indicated RI #1 had not executed an Advance Directive; therefore, RI #1 was a Full Code. In a telephone interview on [DATE] at 5:30 PM, RI #1's daughter stated she received a phone call on [DATE] at 4:17 PM from EI #1 (LPN), who stated RI #1 was barely breathing and that CPR had been attempted. According to RI #1's daughter, when she arrived at the facility at 4:50 AM, she did not see a crash cart in RI #1's room nor did she see any staff. RI #1's daughter stated the Director of Nursing (EI #2) told her the ambulance was not called and the nurse, EI #1, got into trouble for not calling the ambulance. In a telephone interview on [DATE] at 2:55 PM, EI #8, a CNA stated a little after 3:00 AM (on [DATE]) she notified the nurse, EI #1, who was at the nurses' station, that she might want to come and check on RI #1. In a telephone interview on [DATE] at 10:40 AM, EI #1, a LPN, acknowledged she provided care to RI #1 on [DATE]. When asked about the events that took place with RI #1 on [DATE], EI #1 stated EI #8 (CNA) told her to come and check RI #1's vital signs. EI #1 stated when she went to RI #1's room to check the resident's vital signs, the resident's pulse was very faint. EI #1 left RI #1's room to call EI #3, a Registered Nurse, the physician and RI #1's family. EI #1 stated she returned to RI #1's room and began CPR by doing chest compressions for as long as she could. EI #1 was asked, how long she performed CPR and she stated she was not sure. When asked if she called a code, EI #1 said No, I did not. When asked if she called an ambulance (activate EMS), EI #1 said no ma'am. EI #1 was asked, what the facility's policy directed her to do when she found a resident unresponsive. EI #1 replied, to call a code, call (activate) the emergency response system and continue CPR until EMS arrives. When asked if she followed the facility's policy, EI #1 said no. When asked if she used the crash cart, EI #1 said no. EI #1 was asked if she was CPR certified and she said no, her certification expired in [DATE]. EI #1 stated a couple of days later after RI #1 expired in the facility, the DON (EI #2) re-educated her about calling a code and the ambulance. When asked, why she did not call 911, EI #1 stated she was trying to get RI #1 back and she didn't think to call 911. EI #1 further stated, In hindsight, I should have called 911. When asked, how she knew RI #1 was dead, EI #1 stated she could not get a pulse or vital signs on RI #1; RI #1's nails were starting to turn purple and the resident was unresponsive. EI #1 acknowledged the facility has an AED; however, she did not use it. EI #1 was asked if she had performed CPR on other residents in the facility. EI #1 said yes. When asked about the incident, EI #1 stated it was similar to RI #1, that an unidentified Certified Nursing Assistant (CNA) found the resident unresponsive. EI #1 stated she performed CPR but was unable to resuscitate the resident. When asked if she called a code, EI #1 said no. EI #1 stated no one assisted her, that she was all alone. EI #1 also acknowledged that she did not use the crash cart. When asked, who the resident was, EI #1 said it was RI #2. RI #2 was admitted to the facility on [DATE]. RI #2's electronic nurses' note written by EI #1 dated [DATE] entered at 8:22 AM documented . 0600 (6:00 AM) Resident found in bed unresponsive, unable to palpate pulse or B/P (blood pressure) chest not rising and falling; skin cool to touch . CPR attempted but unsuccessful . In an interview on [DATE] at 9:00 AM, EI #1 was asked if she called 911 when she found RI #2 unresponsive on [DATE]. EI #1 said no. According to EI #1, her CPR certification expired April or [DATE]. In an interview on [DATE] at 11:20 AM, EI #5, who has been employed for two years as the Staffing Coordinator, was asked who was responsible for monitoring CPR certification. EI #5 stated she was. When asked about EI #1's lack of CPR certification, EI #5 stated when she interviewed EI #1, she asked for a copy but EI #1 stated it was in her other wallet and that she (EI #1) would bring it in. EI #1 then came to EI #5 later and said she couldn't find her CPR certification card. EI #5 told EI #1 to sign up for the next class, which was being held [DATE]. According to EI #5, EI #1 signed up for the class but did not show up. EI #5 was asked if she reported EI #1's lack of CPR certification to anyone and she said no. In a follow-up interview on [DATE] at 8:10 AM, EI #1 stated when she entered RI #1's room, the resident had very shallow movements and a faint radial pulse. After noticing this, EI #1 left the resident's room to call the physician, RI #1's daughter and the Registered Nurse (RN), EI #3. When asked if she spoke with the physician, EI #1 stated no, it went to a pager and she left the facility's number for the physician to call back. EI #1 stated while she was talking with RI #1's daughter, she asked for verification purposes, what the resident's code status was. When asked if she knew the resident's code status, EI #1 said no, it was confusing. I was trying to pull it up on system. EI #1 was asked, how she called for RN (EI #3). EI #1 called from station to station on the intercom system. When asked, what she told EI #3, EI #1 said she told EI #3, the RN, that RI #1's vitals were faint. According to EI #1, she went back to RI #1's room and tried to arouse the resident but she could not feel a pulse or anything. Then, EI #1 lowered the resident's bed and started chest compressions. EI #1 stated she did 30 chest compressions, then check for a pulse. When asked, if any staff member was in RI #1's room with her, EI #1 stated not that I can remember. EI #1 was asked, if the physician called her back. EI #1 explained, as she was on her way back to the nurses' station, someone (name unknown) said the physician was on the phone. When asked, what the physician said, EI #1 said the physician said stop CPR and release RI #1's body to the funeral home. EI #1 acknowledged that she had already stopped CPR by the time the physician called back to tell her to stop CPR. When asked, if a nurse can just stop CPR when she wants to, EI #1 said no. EI #1 was asked, approximately what time did this event occur and she said somewhere between 3:00 AM - 4:00 AM. EI #1's handwritten statement dated [DATE] documented On [DATE] I was told by the CNA that I needed to come check (RI #1) because (he/she) was unresponsive and said CNA could not get vital signs on (him/her). The time was 0400 (4:00 AM). I went in and tried to palpate a pulse (radial & carotid). I found a faint pulse and shallow rise and fall of the chest. I then called for assistance of a RN on duty at that time. I called the daughter and the doctor to inform them of the situation. I returned to the room and couldn't palpate a pulse and didn't see any movement of the chest or abdominal region. I called again to let the RN know what was happening and returned to (RI #1) and attempted CPR . (RI #1's) nail beds were purple in color and (his/her) hands were cool to touch. (The physician) called after 0500 (5:00 AM) and said to stop CPR and gave order to release body to the funeral home. The RN did not come down to assist me with what to do. RI #1's electronic nurses' note written by EI #1 dated [DATE] entered at 4:39 AM (written 21 minutes before the physician called back to inform the staff to stop CPR) documented . 0400 (4:00 AM) unable to palpate vital signs, skin cool to touch finger tips purple. CPR attempted without success. (The physician) paged, order given to stop code and release body to funeral home of family's choice, daughter notified, stated they are on their way. EI #3's handwritten statement dated [DATE] documented On [DATE]th, 2015, at about 4:10am, I was working at 100 hall with another nurse. Phone rang and the other nurse answered the call. When I asked what the call was all about, she told me the nurse at 200 hall stated that a resident was found dead. Then I decided to go over there to help out. I met the nurse at nursing station, she stated the resident had a weak pulse so she started CPR. So I went to the resident's room with the nurse and listened to the resident and no vital signs heard, no BP (blood pressure), no respiration, and no apical pulse heard. So I asked her to call (the physician), she said she had already called and waiting for him to call back. While we were at the nursing station the family members started coming in, so we went there with them, by then post morten (mortem) care has already been done and resident was laying on (his/her) back. We expressed our sympathy and I went back to the nursing station. Helped (with) the paperwork and went back to 100 hall. In a telephone interview on [DATE] at 2:45 PM, EI #3, a Registered Nurse (RN) acknowledged she was working in the facility on the morning RI #1 expired ([DATE]). According to EI #3, she and another RN (EI #4), were working on the 100 hall, when EI #4 answered the phone and was told by EI #1 that RI #1 had expired. EI #3 stated about five minutes had passed when she went over to the 100 hall, where she saw EI #1 at the nurses' station. According to EI #3, EI #1 told her she had already done CPR. After finding out the resident's code status, EI #3 stated she went to RI #1's room, where she found the CNAs already performing post mortem care. EI #3 stated she listened with a stethoscope for vital signs and there were none; the resident had expired. EI #3 stated she told EI #1 to call the doctor and the family but EI #1 stated she had already done that. When asked, what the facility's process was for calling a code, EI #3 stated overhead page, code blue to the resident's room. EI #1 further stated That was not done that night. She (EI #1) just called us (EI #3 and EI #4) on the phone (and) said she needed help. When asked, how long should the code be done, EI #3 stated until EMS comes, but they didn't come because no one called them. EI #4's handwritten statement dated [DATE] documented On [DATE]th, 2015 around 0410 (4:10 AM) I was working on the 100 Hall with another RN and I received a call from the LPN working on the 200 Hall stating she has a patient that died . I informed the RN working with me about the situation on the 200 Hall. The RN then left for the 200 Hall to assist the LPN. In a telephone interview on [DATE] at 4:30 PM, EI #4, the other RN, stated she was working on the 100 hall with EI #3 when EI #1 called and said RI #1 had passed. EI #4 stated she did not go over to 200 hall but EI #3 did. EI #4 stated there was no overhead code called. When asked, what the facility's process was for calling a code, EI #4 stated overhead code blue to whatever room and everyone will come to offer assistance. When asked, how long should the code be done, EI #4 stated until we get assistance from EMS. In an interview on [DATE] at 2:40 PM, EI #2, the Director of Nursing stated EI #1 (LPN) told her she did not call a code or EMS when RI #1 expired on [DATE]. EI #2 acknowledged that she did tell RI #1's daughter this information. EI #1's PERSONNEL ACTION dated [DATE] indicated on [DATE] EI #1's employment with the facility was separated (terminated) on [DATE] for failure to follow nursing procedure. ************************* On [DATE] at 10:40 AM, the facility submitted an acceptable Allegation of Credible Compliance, which documented . F309 . The Physician for each Resident effected (RI# 1&2) was notified on [DATE] by the DON that the facility failed to follow the American Heart Association guidelines for providing CPR for residents with full code status. On [DATE] the Facility implemented a CPR policy that follows the recommendation of the American Heart Association that was reviewed and approved by the Medical Director and the Quality Assurance Team. On [DATE] the facility Nursing Department was in-serviced on the CPR policy. As of [DATE] there are 7 nursing staff members that were unable to attend the in-service. Those staff members were notified by phone that they were removed from the schedule until the in-service was complete. On [DATE] the CPR policy was added to the new hire orientation process. AOC [DATE]. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 309 was lowered to F level on [DATE] at 6:15 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 869.

Based on interviews, review of Resident Identifier (RI) #1's medical record, a handwritten statement from a licensed nurse and the 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN) failed to honor the resident rights of Resident Identifier (RI) #1, a resident with Full Code status. On [DATE] between 3:00 AM and 4:00 AM, EI #1, the lone rescuer, could not detect RI #1's pulse. EI #1 lowered RI #1's bed and started to perform chest compressions. After 30 chest compressions, EI #1 checked for a pulse. When no pulse was found, EI #1, the lone rescuer, stopped CPR and returned to the nurses' station to complete paperwork. EI #1 did not call a code, activate emergency medical services (EMS) or receive orders from the physician, before she informed RI #1's daughter, the resident had passed away. According to the AHA, the lone rescuer should immediately activate the emergency response system, get an AED (Automated External Defibrillator)/defibrillator, if available, and start CPR with chest compressions. CPR should be continued without interruptions until more experienced rescuers assume care. This deficient practice affected RI #1; one of two sampled residents reviewed for emergency response, and placed RI #1 in immediate jeopardy because it was likely to cause serious injury, harm or death. On [DATE] at 6:15 PM, the facility's Administrator, Director of Nursing (DON), and two Regional Nurse Consultants were notified of the findings of immediate jeopardy in the area of Resident Rights, F 155. Findings include: Cross reference F 309. According to page 25 of the facility's Director of Nursing Training Manual dated [DATE] titled ADVANCE DIRECTIVES,POLICY Adult patients are informed and written information provided regarding the right to accept or refuse medical or surgical treatment and, at the individual's option, formulates an advance directive . On [DATE], the State Agency received a complaint alleging the facility failed to initiate and continue CPR on RI #1, a resident with Full Code status. The ambulance was not called and there was no crash cart in the resident's room or hallway. According to the complainant, the Director of Nursing (EI #2) stated the nurse (later identified as EI #1) got into trouble for not calling the ambulance. RI #1 was admitted to the facility on [DATE]. RI #1's ADVANCE DIRECTIVE ACKNOWLEDGEMENT form signed by RI #1's daughter dated [DATE] indicated RI #1 had not executed an Advance Directive; therefore, RI #1 was a Full Code. In a telephone interview on [DATE] at 5:30 PM, RI #1's daughter stated she received a phone call on [DATE] at 4:17 AM from EI #1 (LPN), who stated RI #1 was barely breathing and that CPR had been attempted. RI #1's daughter stated she arrived at the facility at 4:50 AM. According to RI #1's daughter, the Director of Nursing (EI #2) told her the ambulance was not called and the nurse, EI #1, got into trouble for not calling the ambulance. In a telephone interview on [DATE] at 10:40 AM, EI #1, a LPN, acknowledged that she provided care to RI #1 on [DATE]. When asked about the events that took place with RI #1 on [DATE], EI #1 stated EI #8,a Certified Nursing Assistant (CNA), told her to come and check RI #1's vital signs. EI #1 stated when she went to RI #1's room to check the resident's vital signs, the resident's pulse was very faint. EI #1 left RI #1's room to call EI #3, a Registered Nurse, the physician and RI #1's family. EI #1 stated she returned to RI #1's room and began CPR by doing chest compressions for as long as she could. EI #1 was asked, how long she performed CPR and she stated she was not sure. When asked if she called a code, EI #1 said No, I did not. When asked if she called an ambulance (activate EMS), EI #1 said no ma'am. EI #1 was asked, what the facility's policy directed her to do when she found a resident unresponsive. EI #1 replied, to call a code, call (activate) the emergency response system and continue CPR until EMS arrives. When asked if she followed the facility's policy, EI #1 said no. EI #1 revealed a couple of days later, after RI #1 expired in the facility, the DON (EI #2) re-educated her about calling a code and the ambulance. When asked, why she did not call 911, EI #1 stated she was trying to get RI #1 back and she didn't think to call 911. EI #1 further stated, In hindsight, I should have called 911. In a follow-up interview on [DATE] at 8:10 AM, EI #1 stated when she entered RI #1's room, the resident had very shallow movements and a faint radial pulse. After noticing this, EI #1 left the resident's room to call the physician, RI #1's daughter and the Registered Nurse (RN), EI #3. EI #1 stated while she was talking with RI #1's daughter, she asked for verification purposes, what the resident's code status was. EI #1 stated RI #1 was not a DNR (Do Not Resuscitate); therefore, the resident was a Full Code. When asked if she spoke with the physician, EI #1 stated no, it went to a pager and she left the facility's number for the physician to call back. According to EI #1, she went back to RI #1's room and tried to arouse the resident but she could not feel a pulse or anything. At that point, EI #1 stated she lowered the resident's bed and started chest compressions. EI #1 stated she did 30 chest compressions, then checked for a pulse. When asked, if any staff member was in RI #1's room with her, EI #1 stated not that I can remember. EI #1 was asked, if the physician called her back. EI #1 replied, as she was on her way back to the nurses' station, someone (name unknown) said the physician was on the phone. When asked, what the physician said, EI #1 said the physician said stop CPR and release RI #1's body to the funeral home. EI #1 acknowledged she had already stopped CPR by the time the physician called back and gave the order to stop CPR. When asked, if a nurse can just stop CPR when she wants to, EI #1 said no. EI #1 was asked, approximately what time did this event occur, she answered somewhere between 3:00 AM - 4:00 AM. EI #1's handwritten statement dated [DATE] documented On [DATE] I was told by the CNA that I needed to come check (RI #1) because (he/she) was unresponsive and said CNA could not get vital signs on (him/her). The time was 0400 (4:00 AM). I went in and tried to palpate a pulse (radial & carotid). I found a faint pulse and shallow rise and fall of the chest. I then called for assistance of a RN on duty at that time. I called the daughter and the doctor to inform them of the situation. I returned to the room and couldn't palpate a pulse and didn't see any movement of the chest or abdominal region. I called again to let the RN know what was happening and returned to (RI #1) and attempted CPR . (RI #1's) nail beds were purple in color and (his/her) hands were cool to touch. (The physician) called after 0500 (5:00 AM) and said stop CPR and gave order to release body to the funeral home . RI #1's electronic nurses' note entered by EI #1 dated and timed [DATE] at 4:39 AM (timed 21 minutes before the physician called back to inform the staff to stop CPR) documented . 0400 (4:00 AM) unable to palpate vital signs, skin cool to touch finger tips purple. CPR attempted without success. (The physician) paged, order given to stop code and release body to funeral home of family's choice, daughter notified, stated they are on their way. In a telephone interview on [DATE] at 2:45 PM, EI #3, a Registered Nurse (RN) acknowledged she was working in the facility on the morning RI #1 expired ([DATE]). According to EI #3, she and another RN (EI #4), were working on the 100 hall, when EI #4 answered the phone and was informed by EI #1 that RI #1 had expired. EI #3 stated about five minutes had passed when she went over to the 100 hall, where she saw EI #1 at the nurses' station. According to EI #3, EI #1 told her she had already done CPR. After finding out the resident's code status, EI #3 stated she went to RI #1's room, where she found the CNAs already performing post mortem care. EI #3 listened with a stethoscope for vital signs and there were none; the resident had expired. EI #3 stated she told EI #1 to call the doctor and the family, but EI #1 stated she had already done that. When asked, what the facility's process was for calling a code, EI #3 stated overhead page, code blue to the resident's room. EI #1 further stated That was not done that night. She (EI #1) just called us (EI #3 and EI #4) on the phone (and) said she needed help. When asked, how long should the code be performed, EI #3 stated until EMS comes, but they didn't come because no one called them. ************************* On [DATE] at 10:40 AM, the facility submitted an acceptable Allegation of Credible Compliance, which documented . F155 . Resident Identifier #1 . - The Medical Director/physician was notified on [DATE] by the DON that the facility failed to honor the advanced directive of cardiopulmonary resuscitation (CPR) status for two residents with full code status. The EI #1 received in-service training on [DATE] and [DATE] by the Director of Nursing and Regional Nurse Consultant. The in-service covered areas but not limited to: Advance Directive, Code Status, CPR, (The facility will follow The American Heart Association), Code Blue, and activation of Emergency Medical Services On [DATE] EI #1 was removed from the schedule indefinitely by the DON. On [DATE] EI #1 employment was terminated. Members of the Interdisciplinary Team (Social Service, Staffing, Coordinator, Medical Records, Treatment Nurse and MDS Coordinators) audited all residents' medical records, conducted resident and responsible party interviews for residents' choice of Advance Directives to include cardiopulmonary resuscitation (CPR) on [DATE], and [DATE]. Orders were obtained from the resident's physician to reflect each choices regarding Advance Directives including code status. All licensed nurses were in-serviced on [DATE] and on [DATE] to follow the American Heart Association CPR guidelines. On [DATE] The CPR policy was added to all new hire orientation process. AOC [DATE]. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 155 was lowered to D level on [DATE] at 6:15 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 869.

Based on interviews, record review, and review of the facility's policy titled "Abuse, Neglect and Exploitation", the facility failed to report an allegation of abuse to State Agency in 24 hours after facility had knowledge of the alleged incident of abuse and the completed investigation within five working days. This affected Resident Identifier (RI) #1, one of four sampled residents for abuse. Findings include: 1. The facility's policy and procedure titled, "Abuse, Neglect and Exploitation", without a date, documented, "Policy Interpretation and Implementation" under the heading "Process ...3. Responses and Reporting of Abuse, Neglect and Exploitation ...When abuse, neglect or exploitation is suspected, the licensed Nurse should: a. Respond to the needs of the Resident and protect them from further incident. b. Notify the Director of Nursing or Administrator. c. Complete an incident report and initiate an investigation immediately. d. Notify the attending physician, Resident's family/legal representative and Medical Director. e. Obtain witness statements. Suspend the accused employee pending completion of the investigation. Remove the employee from Resident care areas immediately. f. Contact the State Agency and the local Ombudsman office to report the alleged abuse. g. Monitor and document the Resident's condition, including the response to medical treatment or nursing interventions. h. Document actions taken in steps a), b), d), and g), above, in the medical record ... 6. Abuse Investigations Policy Statement All suspicion of resident abuse, neglect, exploitation, misappropriation of resident property and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation a. Should an incident of suspected resident abuse, neglect or injury of an unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. b. The individual conducting the investigation will, as a minimum: 1. Review the resident ' s medical record to determine events leading up to the incident 2. Obtain a statement from person(s) reporting the incident 3. Obtain a statement from any witness to the incident 4. Obtain a statement from the resident ... 5. Obtain a statement form (from) staff members (on all shifts) who have had contact with the resident during the time of the alleged incident. 6. Obtain a statement from the Resident's roommate, family members, and visitors if applicable. 7. Obtain a statement from other residents to whom the accused employee provides care or services 8. Review all events leading up to the alleged incident ...d. The Administrator or his/her designee will notify the Department of Public Health that an abuse investigation is being conducted. 2. RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Scheduled 30-day Assessment MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/20/2011 revealed RI #1 had a Brief Interview for Mental Status of 15 which indicated she was cognitively intact. According to "CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual" page C-14, a score of 13-15, indicates the resident is cognitively intact. 3. A complaint "Intake Information" form from the Division of Health Care Facilities (DHCF), with a received / start date of 11/03/11, documents: "The complainant reports on 11/01/11 around 10:00 p.m., resident (RI #1) felt a little warm and asked for her blood pressure to be taken. CNA (Certified Nursing Assistant), (EI #5) reportedly jerked the resident's arm to take the resident's blood pressure, but the cuff was too small..." A facility's form titled, "GRIEVANCE RECORD" dated 11/3/11, documented the following: "Information Received From: (RI #1)...Resident voiced concern about aide, CNA had went to take her blood pressure and resident told her to go get another cuff. CNA told her cuff was ok and she knew how to take B/P (blood pressure) "I don't want her for a CNA anymore." The document was signed by the ADON, EI #4, and the Administrator, EI #2. EI (Employee Identifier) #5's, a Certified Nursing Assistant (CNA) "Counseling Form Personnel Action" dated 11/03/2011 signed by the Administrator (EI #2), documented "...speaking in a rude tone and manner. This is considered violation 1.18 pg. (page) 55 of employee handbook. Employee will improve manner and disposition when residents request assistance. Will monitor tone of voice and answer appropriately..." 4. "EMPLOYEE HANDBOOK ...EMPLOYEE CONDUCT AND DISCIPLINARY ACTION 701 STANDARDS OF CONDUCT ... A. Serious Infractions ...1.18 Behaving in a disorderly, indecent, or immoral manner, or acting in a manner which discredits the Facility's reputation in the community." 5. According to the "Evening Shift CNA ASSIGNMENT SHEET" on 11/06/2011, EI #5, a CNA, was assigned to "Section #2" which included rooms 119 - 133, one of which was RI #1's room. On 11/7/11 at 6:40 p.m., during the entrance conference, the Administrator, Employee Identifier (EI) #2, identified herself as the person designated to answer questions about what the facility does to prevent abuse. EI #2 is the facility's Abuse Coordinator. The surveyor asked EI #2 if the facility were currently investigating any allegations of abuse or neglect and EI #2 said no sir. The surveyor asked EI #2 if the facilty investigated any allegations of abuse or neglect in the past 30 - 90 days that was sent to the Division of Health Care Facilities? EI #2 said, no sir. 6. On 11/08/2011 at 12:10 PM the Assistant Director of Nurses (ADON), (EI #4), was asked to describe the process used for grievances issued by residents. The ADON, (EI #4), stated the person that receives a complaint starts writing up the incident on the grievance form. The Administrator, DON, ADON and Social Worker are made aware of the problem and an investigation is started. The ADON (EI #4), was asked what was involved in investigating a complaint/grievance. The ADON, (EI #4), replied first you speak to the resident issuing the complaint. Then you speak with the department involved and the your findings are communicated to the Administrator. The ADON, (EI #4), was asked to identify what is or might be considered, abuse. The ADON,(EI #4), answered the following: Verbal abuse - cursing, yelling. Physical abuse- making physical contact. Mental abuse- belittling a patient down-grading. The ADON, (EI #4), was asked if verbal abuse could be something other than cursing and yelling. The ADON, (EI #4), stated harshness or mannerisms could be considered abuse. The ADON, (EI #4), was then asked when are you required to report an allegation of abuse to the State Agency. The ADON, (EI #4), replied when you get an allegation of abuse you report it within 24 hours. The ADON, (EI #4), was asked if during the investigation or before the completion of the investigation was any staff members interviewed or was RI #1's family contacted. The ADON, (EI #4), replied "No ma'am, I didn't." A review of the Alabama Department of Public Health/Division of Health Care Facilities (State Agency) form titled "Report of Abuse, Neglect, Misappropriation of Resident Property and Injury of Unknown Origin" with an effective date of 01/16/05, documents: "WHAT TO REPORT: The facility must ensure all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source, and misappropriation of resident property are reported immediately (as soon as possible but not to exceed 24 hours) to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency. Alleged violations that would constitute violations of criminal statues, such as murders, rapes, and assaults must also be reported to the appropriate local law enforcement agency ... WHEN TO REPORT: All alleged violations involving abuse, neglect, mistreatment, misappropriation of resident property, and injuries of an unknown source (described above) are reported immediately (as soon as possible but not to exceed 24 hours) to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident ... Within 5 working days, send a copy of the ENTIRE investigative file to the Division of Health Care Facilities' Complaint Unit ... All incidents (whether reportable to the State or not), ... must be thoroughly investigated within five working days to determined the cause of the injury/incident. The outcome of the investigation must determine whether or not the incident was abusive or neglectful. All investigations must be documented in a written report, contained within the facility, and be made available upon request to the Division Of Health Care Facilities."

Based on interviews, record review, and review of the facility's policy entitled, "Abuse, Neglect and Exploitation" the facility failed to implement the protection and reporting components of their abuse policy / procedure when RI #1, an alert a oriented resident, reported to the Director of Nursing (DON), Employee Identifier (EI) #3, and the Assistant Director of Nursing (ADON), EI #4, that on 11/02/2011, a Certified Nursing Assistant (CNA), EI #5, had spoken to her in a rude tone and jerked her arm while taking her blood pressure. The facility allowed the accused employee, EI #5 to continue to work the 3 p.m. - 11 p.m. shift on 11/03/2011, 11/4/11 and 11/5/11, the same hall where RI #1 resided. Also, the facility allowed EI #5 to continue to have contact with RI #1 after the facility's Administrative staff had knowledge of the alleged allegation of abuse exhibited by EI #5 on RI #1. As of 11/11/2011 at 4:49 PM, the facility had not reported this incident to the State Agency. This deficient practice affected RI #1, one of four sampled residents for abuse investigation, and placed the health and safety of RI #1 in immediate jeopardy, as it was likely to cause serious injury, harm or death. On 11/10/2011 at 4:59 PM, the facility's Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified of the findings of immediate jeopardy in the area of Resident Behaviors and Facility Practices, F 226 at a "J" Level. Findings include: The facility's undated policy entitled, "Abuse, Neglect and Exploitation", documented, "Policy Statement All Millennium Health and Rehabilitation Nursing Home Residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. All Residents have the right to be free from mistreatment, neglect and misappropriation of property. All reports of Resident abuse, neglect, misappropriation of resident property, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. ...Standard: The Abuse Coordinator in the facility is the Director of Nursing or Administrator. Report allegations of suspected abuse, neglect or exploitation immediately to: Director of Nursing or Administrator.... Process: The components of the facility Abuse Prohibition/Prevention plan are discussed herein: ...3. Responses and Reporting of Abuse, Neglect and Exploitation Anyone in the facility can report suspected abuse...... When abuse, neglect or exploitation is suspected, the licensed Nurse should: a. Respond to the needs of the Resident and protect them from further incident. b. Notify the Director of Nursing or Administrator. c. Complete an incident report and initiate an investigation immediately. ...e. Obtain witness statements. Suspend the accused employee pending completion of the investigation. Romove (remove) the employee from Resident care areas immediately. f. Contact the State Agency and the local Ombudsman office to report the alleged abuse. g. Monitor and document the Resident's condition, including the response to medical treatment or nursing interventions. h. Document actions taken in steps a), b), d), and g), above, in the medical record. The Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies. ...6. Abuse Investigations ...Policy Interpretation and Implementation a. Should an incident of suspected resident abuse, neglect or injury of an unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. b. The individual conducting the investigation will, as a minimum: 1. Review the resident's medical record to determine events leading up to the incident 2. Obtain a statement from person(s) reporting the incident 3. Obtain a statement from any witness to the incident 4. Obtain a statement from the resident ... 5. Obtain a statement form (from) staff members (on all shifts) who have had contact with the resident during the time of the alleged incident. 6. Obtain a statement from the Resident's roommate, family members, and visitors if applicable. 7. Obtain a statement from other residents to whom the accused employee provides care or services 8. Review all events leading up to the alleged incident ...d. The Administrator or his/her designee will notify the Department of Public Health that an abuse investigation is being conducted. ...f. Employees of this facility who have been accused of resident abuse will be suspended from duty (without pay) until the Administrator has reviewed the results of the investigation. g. ...Continued employment of suspended employee will be determined based upon the results of the facility's investigation. The suspended employ (employee) shall be notified of the final decision and continued employment...." The Division of Health Care Facilities' (DHCF's) complaint "Intake Information" form, with a received / start date of 11/03/11, documents: "...The complainant reports on 11/01/11 around 10:00 p.m., resident (RI #1) felt a little warm and asked for her blood pressure to be taken. CNA (Certified Nursing Assistant), (EI #5), reportedly jerked the resident's arm to take the resident's blood pressure, but the cuff was too small. CNA (EI #5) told the resident her arm was too fat. The resident asked if there was a bigger cuff and CNA (EI #5) told the resident that she was "not going to get one," in a rude tone of voice. The complainant reports resident (RI #1) has reported CNA (EI #5) to EI #4 (the ADON), however (EI #4) always takes up for CNA (EI #5)." RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A 30-day Scheduled Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/20/2011 revealed RI #1 had a total score of 15 on the Brief Interview for Mental Status (BIMS). According to "CMS's (Centers for Medicare and Medicaid Services') RAI (Resident Assessment Instrument) Version 3.0 Manual" page C-14, a score of 13-15, indicates the resident is cognitively intact. The facility's document entitled, "GRIEVANCE RECORD," dated 11/03/11, listed RI #1 as the person filing the grievance and is signed by the Assistant Director of Nursing (ADON), EI #4, and the Administrator, EI #2. This record documented RI #1's grievance as, "...Resident voiced concern about aide, CNA had went to take her blood pressure and resident told her to go get another cuff. CNA told her cuff was ok and she knew how to take B/P (blood pressure) "I don't want her for a CNA anymore...." During the entrance conference on 11/07/11 at 6:40 p.m., the Administrator, Employee Identifier (EI) #2, identified herself as the person designated to answer questions about what the facility does to prevent abuse. The surveyor asked EI #2 if the facility was currently investigating any allegations of abuse or neglect. EI #2 (Administrator) answered that the facility was not. The surveyor asked EI #2 if the facilty investigated any allegations of abuse or neglect in the past 30 - 90 days which were sent to the Division of Health Care Facilities. The Administrator (EI #2) responded, no the facility had not. On 11/08/11 at 10:45 a.m., the surveyor conducted a face-to-face interview with RI #1. The surveyor asked RI #1 how things were going for her at the nursing home. RI #1 answered that things were not good. The resident added that she had a lot of problems and asked where should she began. RI #1 identified EI #5, a Certified Nursing Assistant (CNA), as the person causing the problem. RI #1 explained that on November 2, (2011), the CNA (EI #5) took her blood pressure, but the cuff was too small. RI #1 told EI #5 (CNA) that she need to get a larger blood pressure cuff. According to RI #1, the CNA (EI #5) responded in an offensive, rude tone about knowing how to take a blood pressure, and the CNA (EI #5) said that she was not going to get another cuff. RI #1 recalled being scared to say anything else to the CNA (EI #5), and reported that the CNA (EI #5) had jerked her arm that night. The surveyor asked RI #1 the reason for being scared. RI #1 said because of the CNA's (EI #5's) voice and tone. RI #1 clarified that EI #5 (CNA) looks like a man and talks like a man. The surveyor asked RI #1 if the CNA (EI #5) sounded angry. RI #1 responded no, just rude, and repeated that the CNA (EI #5) had jerked her (RI #1's) arm. RI #1 said that she reported the CNA (EI #5) to the Licensed Practical Nurse (LPN) charge nurse (EI #6), the ADON (EI #4), the Director of Nursing (DON), EI #3, and the Administrator (EI #2). The surveyor asked RI #1 if she liked EI #5. RI #1 replied that EI #5 (CNA) was alright, but she (RI #1) didn't want EI #5 as her aide anymore. The surveyor asked RI #1 why she said in the complaint that EI #4 (ADON) takes up for EI #5 (CNA). RI #1 said because nothing was done. According to RI #1, the ADON (EI #4) said that EI #5 (CNA) would not come back in her room, but the CNA (EI #5) has been in her room twice since then, on November 3, and November 4 (2011). The surveyor asked RI #1 if EI #5 was a threat to her. RI #1 answered that she was scared of EI #5 (CNA), and affirmed that EI #5 was a threat. RI #1 commented that the CNA (EI #5) still works on the 100 hall where she resides, and that she (RI #1) didn't know why. RI #1 said she just didn't feel comfortable around EI #5 (CNA), especially whenever she (the resident) saw EI #5 on her hall. The surveyor asked RI #1 what it would take to resolve her complaint. RI #1 responded, for the nurses to do their job and make sure that EI #5 (CNA) stays off the hall where the resident resides. The surveyor asked RI #1 why would she say that she is afraid of EI #5 (CNA) if the CNA had worked in her home as a home health aide. RI #1 replied, because she (RI #1) didn't know what the CNA (EI #5) might do to her (RI #1). Again, RI #1 expressed that she was afraid of EI #5 (CNA), since she (RI #1) had seen the real side of the CNA. RI #1 described EI #5 as not being a pleasant person, and said that the CNA (EI #5) was mad. The surveyor asked RI #1 if she thought that EI #5 would hurt her physically. RI #1 responded by saying it was a possibility, and that she didn't know what EI #5 (CNA) would do to her. RI #1 commented that she had heard that EI #5 (CNA) got wrote up for talking to her in a rude tone of voice and jerking her arm. RI #1 added that she didn't appreciate that from EI #5, and that maybe the CNA (EI #5) was still mad with her (RI #1)about that. The surveyor asked RI #1 if she talked to anyone from Administration about it. RI #1 answered that she had, and said that they (the Administrative staff) came to her room November 3, 2011. They (the Administrative staff) said EI #5 would not be able to come back in her room or on the hall where she resides. RI #1 said she told EI #4 (ADON), and EI #3 (DON), how the CNA (EI #5) jerked her arm. RI #1 said that EI #4 (ADON) and EI #3 (DON) acted like they (EI #4 and EI #3) were siding with EI #5 (CNA) and not her (the resident). RI #1 mentioned that she had called her granddaughter and reported that EI #5 (CNA) had jerked her arm the same night it happened (11/02/11), and that she informed EI #4 (ADON) and EI #3 (DON) that her granddaughter called up to the facility and spoke with the charge nurse (EI #6) about the incident on 11/02/11. According to RI #1, nothing had been done to EI #5(CNA). RI #1 explained that the CNA (EI #5) still comes in her room. RI #1 reported that EI #5 worked the rest of the week and the weekend (November 2, 3, 4, and 5, 2011). On 11/10/2011 at 12:44 PM, the State Surveyor conducted a phone interview with EI #6, a Licensed Practical Nurse (LPN). The surveyor asked if RI #1 had requested that EI #5 not be assigned as the resident's CNA, and had reported that EI #5 jerked her arm on November 2, 3, or 4, 2011. The LPN, EI #6, answered that she could not remember the date, but acknowledged that RI #1 had requested that EI #5 not be assigned to care for her anymore. According to EI #6 (LPN), RI#1 mentioned that she had made the same request to the ADON (EI #4), and that EI #5 (CNA) made her (RI #1) feel intimidated. When asked if EI #5 (CNA) was in RI #1's room on November 3 or 4, 2011, the LPN (EI #6) answered that EI #5 was assigned to RI #1 at the beginning of the shift, but she (EI #6) told EI #5 (CNA) not to go into RI #1's room, and to go work list 3 instead of list 2. EI #6 (LPN) said that around 3:30 PM, the ADON (EI #4) had called her into the office and informed her that EI #5 couldn't work list 2, which included RI #1's room. On 11/08/2011 at 11:25 AM, the ADON, (EI #4), was asked to describe the process used for handling a grievance or an allegation of abuse. The ADON (EI #4) explained that the facility has a grievance form, and once completed, the form goes to herself (EI #4), the DON (EI #3), the Administrator (EI #2), and the Social Worker. The ADON (EI #4) said that then, all department heads are made aware of the problem and an investigation is started immediately. The ADON (EI #4), was asked what was involved in investigating a complaint/grievance. EI #4 (ADON) said that the resident involved is questioned about the problem. Then, the department involved is included, then their findings are communicated to the Administrator (EI #2) and DON (EI #3) to determine what plan of action will be implemented. The ADON, (EI #4), was asked to identify what is or might be considered, abuse. The ADON,(EI #4), answered the following: Verbal abuse - cursing, yelling. Physical abuse- making physical contact. Mental abuse- belittling a patient down-grading. The surveyor asked EI #4 if an employee accused of abuse should be gotten out of the building / suspended pending the results of the investigation. The ADON (EI #4) answered that she would remove the employee from the resident care area. The ADON commented the rudeness was not abuse. Later at 1:40 PM, the surveyor asked the the ADON (EI #4) the reason she wrote the grievance related to RI #1. The ADON (EI #4) answered that RI #1 reported to her (EI #4) that the CNA (EI #5) was rude and told the resident that she (CNA) knew how to take a blood pressure. The ADON (EI #4) said that RI #1 reported this to her (EI #4) on 11/03/11, and referred to the information documented on the 11/03/11 "Grievance Record." After speaking with RI #1, EI #4 (ADON) recalled notifying the DON (EI #3) and the Administrator (EI #2) of the resident's grievance on 11/03/11. When asked what corrective action had been taken to prevent reoccurrence, EI #4 (ADON) responded that EI #5 (CNA) was removed from RI #1's section because the resident did not like the CNA at all. EI #4 said that the CNA (EI #5) was counseled and could not take care of RI #1 anymore. EI #4 was asked if EI #5 (CNA) works on the hall where RI #1 resides. The ADON (EI #4) answered that the CNA (EI #5) may work the opposite side of the hall where RI #1 resides. According to EI #4 (ADON), the facility's investigation began on 11/03/11, and was finished on 11/03/11. The ADON acknowledged that EI #5 (CNA) was never suspended during the investigation, and was reassigned to another section of the hall. In an interview on 11/11/11 from 5:30 PM until 6:25 PM, the DON, (EI #3), was asked when had she become aware of the situation with (RI #1) and the CNA, (EI #5). The DON, (EI #3), responded that she was not certain of the date, but believed that she and the Administrator, (EI #2), became aware of the situation on 11/02/2011 when the ADON, (EI #4), told them about it. The DON, (EI #3), said the ADON, (EI #4), told them that RI #1 wanted to speak with them. The DON, (EI #3,) stated the three of them (the Administrator, (EI #2) the DON, (EI #3), and the ADON, (EI #4) went to RI #1's room and asked her if there was anything going on that RI #1 wanted to tell them. According to the DON, (EI #3), RI #1 reported to them that she (RI #1) had tried to tell the CNA, (EI #5), that the B/P cuff was too small. RI #1 reported to them (the Administrator, (EI #2), the DON, (EI #3) and the ADON,(EI #4)), that EI #5 (CNA) responded that the cuff was the biggest one that she had, and that she (EI #5) knew how to take a blood pressure. The DON, (EI #3), was asked when was the determination made to talk to the CNA, (EI #5). The DON, (EI #3), replied after they had talked to RI #1 they decided they needed to talk to the CNA, (EI #5). The DON, (EI #3), was asked who spoke with the CNA (EI #5), and what was said. The DON, (EI #3), said she and the ADON,(EI #4), spoke with the CNA, (EI #5) and presented her with the counseling form. The DON, (EI #3), said she told the CNA, (EI #5),there was a complaint from a resident about her tone of voice and that she (CNA, EI #5), needed to be careful when speaking to the patients. The DON, (EI #3), was then asked if she had done any other investigation after talking with RI #1 and the CNA, (EI #5). The DON, (EI #3), replied that she did not. The DON (EI #3) was asked if EI #5 worked the evening shift on 11/03/2011. DON could not locate the "CNA Assignment Sheet for 11/03/2011, but referred to a copy of the working schedule and stated that according to the assignment sheet, EI #5 (CNA) did not work on 11/03/11. On 11/08/11 at 2:50 PM, the surveyor conducted an interview with the Administrator (EI #2), who is also the abuse coordinator for the facility. The surveyor asked EI #2 if she interviewed any of the staff who worked with EI #5 on the 3 p.m. - 11 p.m. shift on November 3, 2011. EI #2 answered that she did not. The surveyor asked EI #2 if she or anyone got any statements from staff. EI #2 said they talked to staff, but didn't get any written statements. The surveyor asked EI #2 if EI #5 was suspended from her duties during the investigation on 11/3/11. EI #2 (Administrator) said that EI #5 (CNA) came to work later that evening after they had talked to her earlier that morning on November 3, 2011. The surveyor asked EI #2 was EI #5 scheduled to work the 3 p.m. - 11 p.m. shift today, 11/8/11? EI #2 said yes, she was (scheduled to work on 11/8/11). The surveyor asked EI #2 (Administrator) who reported the incident to her that RI #1 had concerns with one of the CNA's who had spoken to her in a rude tone of voice and jerked her arm. The Administrator (EI #2) identified the ADON (EI #4) as the person who reported the incident. The surveyor asked EI #2, is speaking to a resident in a rude tone of voice considered verbal abuse? EI #2 said, she would have to hear it and she didn't think the statement was rude. The surveyor asked EI #2 did she ask RI #1 to repeat in her voice the manner in which EI #5 (CNA) had spoken to her on 11/3/11, and how the CNA had jerked her arm? EI #2 (Administrator) replied that she asked RI #1 what happened, and RI #1 reported that EI #5 (CNA) told her (the resident) the blood pressure cuff was too small. Then, EI #5 (CNA) said that the blood pressure cuff was the biggest one that she had, and she (EI #5/CNA) knew how to take a blood pressure. EI #2 said she did not ask RI #1 to repeat what was said in a particular voice. The surveyor asked EI #2 if she or her staff asked RI #1 how it made her feel what the CNA (EI #5) said and did to her. The Administrator (EI #2) answered that she did not, and that the staff did not ask the questions in her (EI #2's) presence. The surveyor asked EI #2 what would she call the actions of EI #5's behavior toward RI #1? EI #2 said that the CNA (EI #5) made a statement. The surveyor asked EI #2 if it was appropriate for EI #5 (CNA) to make a statement in a rude tone of voice to a resident. The Administrator (EI #2) responded that if the CNA (EI #5) made it, then, it was not. EI #2 commented that if EI #5 (CNA) was rude to the patient (RI #1), then no, it's not appropriate. The surveyor asked EI #2 how she would know if the statement was rude to the resident if she didn't ask the resident (RI #1) how it made her feel. EI #2 (Administrator) responded that she didn't ask RI #1 that. According to the "Evening Shift CNA ASSIGNMENT SHEET" dated 11/06/2011, EI #5, a CNA, was assigned to "Section #2" which included rooms 119 - 133, one of which was RI #1's room. In a phone conversation with the CNA, (EI #5), on 11/11/2011 at 9:30 AM, the CNA, (EI #5) confirmed she had worked the evening shift on 11/03/2011 and was assigned to RI #1's hall. The CNA, (EI #5), stated that later on in the shift, the LPN Charge Nurse, (EI #6), swapped her (EI #5's) hall assignment with another CNA, EI #7. In an interview on 11/11/2011 at 5:00 PM, a CNA, (EI #7), was asked if she worked the evening shift on the 100 hall, Thursday, 11/03/2011. The CNA, (EI #7), answered, "Yes." The CNA, (EI #7), was asked if she swapped halls with (EI #5) on that day. The CNA, (EI #7), stated there had been more than one incident of her having to swap assignments with CNA, (EI #5), due to a conflict of interest. The CNA, (EI #7), was asked what she meant by a conflict of interest. EI #7 replied, "Couple of residents and families don't want (CNA, EI #5)." The CNA, (EI #7), stated that on 11/03/2011, the LPN Charge Nurse, (EI #6), asked her to swap halls with the CNA, EI #5. EI #7 was asked what time the change in the hall assignment took place. The CNA, (EI #7), answered that it took place around 4:30 to 5:00 PM. The CNA was asked if she had ever noticed EI #5 being overly zealous with a resident. EI #7 (CNA) responded that she had. When asked if she had ever observed EI #5 (CNA) being rude or disrespectful to a resident, EI #7 (CNA) replied that EI #5 (CNA) has been observed being loud, and may come across as aggressive or may be perceived by the resident as yelling. EI #7 (CNA) explained that EI #5 (CNA)would be making statements about being tired, and acting / moving quickly. When asked would she want EI #5 to take care of a member of her family, EI #7 (CNA) answered that she would not. EI #7 was asked why not. The CNA (EI #7) explained that she moves slow when she approaches a resident and said that she gives more of the one-on-one personal care. EI #7 (CNA) said that she didn't she EI #5 (CNA)doing that when taking care of a resident. On 11/08/2011 at 4:45 PM, a CNA, (EI #5), was asked to explain what had happened between her (EI #5) and RI #1. The CNA, (EI #5), replied that RI #1 told her, "(EI #5) this Blood Pressure (B/P) cuff is too little. " So, the CNA, (EI #5), said she got another cuff and told (RI #1) both cuffs read the same. The CNA, (EI #5), stated that since both cuffs had read the same the day before she went ahead and used the smaller cuff the next time she took RI #1's B/P. The CNA, (EI #5), stated RI #1 didn't verbalize a complaint. The CNA, (EI #5), said that when she came in the next day, the Director of Nurses (DON), (EI #3), told the CNA, (EI #5), she had gotten a report saying the CNA, (EI #5), had snatched RI #1's arm. The CNA, (EI #5), stated, "I told the (DON, EI #3), I didn't snatch her (RI #1's) arm." The CNA, (EI #5), said she was then told by the DON, (EI #3), that the CNA, (EI #5), was going to be taken off RI #1's hall to avoid any more confusion. The surveyor asked the CNA, (EI #5), if she had signed the "counseling paper" dated 11/03/2011. The CNA, (EI #5) replied, "Yes, ma'am I did, but I wasn't agreeing I had done anything wrong. I was agreeing with their solution to take me off that hall." The CNA, (EI #5), stated she worked the evening shift that day and had also worked the following weekend but was called (11/08/2011) by the DON, (EI #3), and was told she (the CNA) was being suspended. The CNA, (EI #5), said the DON, (EI #3), did not say what she (CNA) was being suspended for or for how long. The CNA, (EI #5), was asked if she had been questioned by anyone else besides the DON (EI #3) and the ADON (EI #4). The CNA (EI #5) stated, "No, just DON (EI #3), and ADON (EI #4)." A Counseling / Personnel Action form for EI #5 (CNA), dated 11/03/2011 and signed by the Administrator (EI #2), documented: " ...speaking in a rude tone and manner. This is considered violation 1.18 pg. (page) 55 of employee handbook. Employee will improve manner and disposition when residents request assistance. Will monitor tone of voice and answer appropriately.... " The "EMPLOYEE HANDBOOK" pages 53 - 55, documented, " ...EMPLOYEE CONDUCT AND DISCIPLINARY ACTION 701 STANDARDS OF CONDUCT ... A. Serious Infractions ...1.18 Behaving in a disorderly, indecent, or immoral manner, or acting in a manner which discredits the Facility's reputation in the community. " On 11/10/2011 at 9:00 AM, RI #1 was asked to tell the surveyor what took place on 11/02/2011 and 11/03/2011 that prompted her granddaughter to call in a complaint to the Alabama Department of Public Health. RI #1 stated, "I wrote my grievances, you can read it." RI #1 was asked if she had turned in her grievances to anyone at the facility. RI #1 stated she had not turned in her written grievances because she was going to wait until she left the facility. When asked why she was going to wait, RI #1 responded, "I was afraid of repercussions and retaliations." RI #1 was asked to explain what she meant by "repercussions and retaliations" . RI #1 replied, " I'm afraid. She (the CNA, EI #5) scares me." RI #1 was asked how the CNA, (EI #5) scared her. RI #1 stated it was the CNA's (EI #5's) body language that scared her. RI #1 further stated, "She crowds me, gets in my space. She stands over me." RI #1 then demonstrated the CNA's, (EI #5's) body language. In demonstrating, RI #1 stuck out her chest and threw her shoulders back. This deficiency was cited as a result of the investigation of complaint/report number (#)AL 404. *********************************************** On 11/11/2011 at 4:33 PM, the facility submitted an acceptable allegation of credible compliance for the immediate jeopardy cited at F 226 which documents: 1. The staff member accused of an allegation of abuse was suspended on 11/09/11, by the Administrator, with further investigation being completed on 11/11/11, by the Regional Nurse Consultant Team. RI #1 was interviewed by the Regional Nurse Consultant on 11/11/11, @ (at) 6:45 am with no other witnesses present in the room to determine the psychosocial affects related to the alleged incident of verbal and physical abuse that occurred on 11/02/11. RI #1 (11/11/11 @ 6:45 am) and other residents (deemed interviewable per the Minimum Data Set Brief Interview for Mental Status -BIMS C 0500scoring 13-15) interviewed by the Regional Nurse Consultant Team on 11/11/11, were reassured by the Regional Nurse Consultant that it is not the facility policy that care and services be delivered by that is perceived as physical abuse (list not all inclusive: hitting, slapping, pinching, pushing, pulling, corporal punishment) and or verbal abuse (list not all inclusive: hateful, rude, humiliating), by the RI #1 and/or other residents. RI #1 and other residents were ensured by the Regional Nurse Consultant on 11/11/11, that this treatment would not be tolerated and routine visits by the Social Worker would be conducted to see RI #1 and other residents are treated with dignity and respect. The Medical Director contacted the Administrator to discuss the alleged incident on 11/10/11, to review findings that led to the Immediate Jeopardy referenced F 226, 490. RI #1 and other residents will receive care and services in a manner to prevent physical and verbal abuse, and/or psychological harm. All staff will listen closely and communicate with RI #1 and other residents during care and services to ensure RI #1 and other residents are comfortable, safe, and understand treatment or services before they are delivered, and to ensure delivery of needed services to prevent inception of fear and frustration. All staff will respond to RI #1 and other residents concerns in a calm and respectful manner including providing social support during care and services, speaking in a calm voice. The incident for RI #1 will be reported to the Alabama Department of Public Health via electronic submission on the Online Incident Reporting System on 11/11/11 by the Regional Nurse Consultant. 2. The Regional Nurse Consultants will make rounds on 11/11/11, to interview random residents (deemed interviewable per the Minimum Data Set Brief Interview for Mental Status -BIMS C 0500scoring 13-15) to determine if other residents were affected by verbal and physical abuse or indignant acts by staff, family, visitors, residents, and/or vendors. If residents are identified during the interview performed by the Regional Nurse Consultant to have been effected by verbal and/or physical abuse or indignant acts, an investigation will immediately be conducted by the Regional Nurse Consultant, and staff members responsible will be in-serviced, disciplined, suspended, or discharged from service by the Regional Nurse Consultants. 3. The Regional Nurse Consultant will in-service all staff prior their acceptance of resident assignments on 11/10/11 (11-7 shift), and 11/11/11, regarding identification of abuse coordinator, resident abuse (list not all inclusive: verbal and physical), how to handle residents safely, and the company policy that it will not tolerate abuse and complaints will be investigated thoroughly by the Social Worker, LGSW. All facility staff will be in-serviced on 11/15/11, by the Regional Nurse Consultant on how to respond to patient comments and needs (i.e.: video training (Resident Abuse Prevention and Protection & Dementia more than words), how to handle resident safely, courtesy, including tone of voice and choice of words when speaking with residents, respect of personal property, examples of verbal and physical abuse, along with open communication to ensure patients understanding of care and services provided with the opportunity to participate in their care. Residents will be treated with dignity and respect. The Regional Nurse Consultant in-serviced charge nurses on 11/10/11 (11-7 shift) & 11/11/11, regarding their responsibility for supervising, monitoring for signs of abuse, and how to handle allegations of abuse. The Regional Nurse Consultant will perform ongoing in-services on physical and verbal abuse on 11/11/11, to charge nurses prior to taking resident assignment. Established staff was in-serviced by the Regional Nurse Consultant 11/11/11, and reinstructed on facility's strong commitment to provide care in a dignified manner including review of the facility's abuse policy. New hires will be in-serviced during orientation prior to providing patient care by the Social Worker, LGSW. 4. The Social Worker will monitor for compliance daily ( Monday-Friday) starting 11/11/11, during delivery of routine care and services by visual observation, conducting confidential interviews with patients asking specific questions regarding concerns of inappropriate treatment, documenting findings on the " Resident Abuse Interview Tool " that will be kept in the Social Workers office. The Social Worker will discuss all concerns during the daily Quality Assurance meeting and carried to other appropriate committees. The facility findings will be communicated to the Quality Assurance Committee, consisting of Medical Director, Administrator, Director of Nursing, and Assistant Director of Nursing, MDS Coordinator, Staffing Coordinator, Medical Records, Bookkeepers, Food Service Supervisor, Social Worker, Admissions Coordinator, Housekeeping Supervisor, Maintenance Supervisor, and Activities Coordinator. Different members of the committee will participate depending on the nature of the audit. 5. A Resident Council Meeting will be held on 11/11/11, with the Social Worker, LGSW to identify the New Abuse Coordinator (Social Worker, LGSW). Any change in the designated Abuse Coordinator will be communicated to the Resident Counsel Members immediately by the Regional Nurse Consultant. Resident family members will be notified in writing on 11/11/11, by the Social Worker of the change in the Abuse C

Based on interviews with the facility's Administrator, who is the Abuse Coordinator for the facility and responsible for the overall management of the facility and interview with the Director of Nursing (DON), and Assistant Director Of Nursing (ADON) who are responsible for the overall direction, coordination and evaluation of nursing care and services, record reviews and review of the facility's policy titled "Abuse, Neglect and Exploitation" the facility Administrative leaders failed to enforce protection and reporting requirements of the facility's policy entitled, "Abuse, Neglect and Exploitation., upon becoming aware of RI #1's allegation that Employee Identifier (EI) #5, a CNA, had spoken in a rude tone and jerked her arm while taking the resident's blood pressure on the evening of 11/02/11. The ADON, EI #4, misrepresented RI #1's verbal complaint by omitting the resident's allegation of EI #5 (CNA) jerking her arm from the "Grievance record" dated 11/03/11; however, in an interview, EI #5 admitted that the ADON and the DON had informed her that RI #1 alleged that the CNA (EI #5) had jerked her arm. EI #5 reported that she was counseled about speaking rude to RI #1, and agreed to not be assigned to RI #1 anymore. The facility leaders allowed the accused employee, EI #5 to continue to work the 3 p.m. - 11 p.m. shift on 11/03/2011, 11/4/11 and 11/5/11, the same hall where RI #1 resided. Also, the facility allowed EI #5 to continue to have contact with RI #1 after the facility's Administrative staff had knowledge of the alleged allegation of abuse exhibited by EI #5 on RI #1. As of 11/11/2011 at 4:49 PM, the facility had not reported this incident to the State Agency. This deficient practice affected RI #1, one of four sampled residents for abuse investigation, and placed the health and safety of RI #1 in immediate jeopardy, as it was likely to cause serious injury, harm or death. On 11/11/11 at 4:49 p.m., the facility's Administrator, Director of Nursing and Assistant Director Of Nursing were notified of the findings of Immediate Jeopardy at a "J" level, in the area of Administration, F 490. Findings include: A review of the Alabama Department of Public Health/Division of Health Care Facilities (State Agency) form titled "Report of Abuse, Neglect, Misappropriation of Resident Property and Injury of Unknown Origin" with an effective date of 01/16/05, documents: "WHAT TO REPORT: The facility must ensure all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source, and misappropriation of resident property are reported immediately (as soon as possible but not to exceed 24 hours) to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency. Alleged violations that would constitute violations of criminal statues, such as murders, rapes, and assaults must also be reported to the appropriate local law enforcement agency ... WHEN TO REPORT: All alleged violations involving abuse, neglect, mistreatment, misappropriation of resident property, and injuries of an unknown source (described above) are reported immediately (as soon as possible but not to exceed 24 hours) to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident ... Within 5 working days, send a copy of the ENTIRE investigative file to the Division of Health Care Facilities' Complaint Unit ... All incidents (whether reportable to the State or not), ... must be thoroughly investigated within five working days to determined the cause of the injury/incident. The outcome of the investigation must determine whether or not the incident was abusive or neglectful. All investigations must be documented in a written report, contained within the facility, and be made available upon request to the Division Of Health Care Facilities." The facility's undated policy entitled, "Abuse, Neglect and Exploitation", documented, "Policy Statement All Millennium Health and Rehabilitation Nursing Home Residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. All Residents have the right to be free from mistreatment, neglect and misappropriation of property. All reports of Resident abuse, neglect, misappropriation of resident property, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. ...Standard: The Abuse Coordinator in the facility is the Director of Nursing or Administrator. Report allegations of suspected abuse, neglect or exploitation immediately to: Director of Nursing or Administrator.... Process: The components of the facility Abuse Prohibition/Prevention plan are discussed herein: ...3. Responses and Reporting of Abuse, Neglect and Exploitation Anyone in the facility can report suspected abuse...... When abuse, neglect or exploitation is suspected, the licensed Nurse should: a. Respond to the needs of the Resident and protect them from further incident. b. Notify the Director of Nursing or Administrator. c. Complete an incident report and initiate an investigation immediately. ...e. Obtain witness statements. Suspend the accused employee pending completion of the investigation. Romove (remove) the employee from Resident care areas immediately. f. Contact the State Agency and the local Ombudsman office to report the alleged abuse. g. Monitor and document the Resident's condition, including the response to medical treatment or nursing interventions. h. Document actions taken in steps a), b), d), and g), above, in the medical record. The Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies. ...6. Abuse Investigations ...Policy Interpretation and Implementation a. Should an incident of suspected resident abuse, neglect or injury of an unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. b. The individual conducting the investigation will, as a minimum: 1. Review the resident's medical record to determine events leading up to the incident 2. Obtain a statement from person(s) reporting the incident 3. Obtain a statement from any witness to the incident 4. Obtain a statement from the resident ... 5. Obtain a statement form (from) staff members (on all shifts) who have had contact with the resident during the time of the alleged incident. 6. Obtain a statement from the Resident's roommate, family members, and visitors if applicable. 7. Obtain a statement from other residents to whom the accused employee provides care or services 8. Review all events leading up to the alleged incident ...d. The Administrator or his/her designee will notify the Department of Public Health that an abuse investigation is being conducted. ...f. Employees of this facility who have been accused of resident abuse will be suspended from duty (without pay) until the Administrator has reviewed the results of the investigation. g. ...Continued employment of suspended employee will be determined based upon the results of the facility's investigation. The suspended employ (employee) shall be notified of the final decision and continued employment...." A complaint "Intake Information" form from the Division of Health Care Facilities (DHCF), with a received / start date of 11/3/11, documents: "The complainant reports on 11/01/11 around 10:00 p.m., resident (RI #1) felt a little warm and asked for her blood pressure to be taken. CNA (Certified Nursing Assistant), (EI #5) reportedly jerked the resident's arm to take the resident's blood pressure, but the cuff was too small. CNA (EI #5) told the resident her arm was too fat. The resident asked if there was a bigger cuff and CNA (EI #5) told the resident that she was "not going to get one," in a rude tone of voice. The complainant reports resident (RI #1) has reported CNA (EI #5) to EI #4 (the ADON), however (EI #4) always takes up for CNA (EI #5)." On 11/08/11 at 10:45 a.m., the surveyor conducted a face-to-face interview with RI #1. The surveyor asked RI #1 how things were going for her at the nursing home. RI #1 answered that things were not good. The resident added that she had a lot of problems and asked where should she began. RI #1 identified EI #5, a Certified Nursing Assistant (CNA), as the person causing the problem. RI #1 explained that on November 2, (2011), the CNA (EI #5) took her blood pressure, but the cuff was too small. RI #1 told EI #5 (CNA) that she need to get a larger blood pressure cuff. According to RI #1, the CNA (EI #5) responded in an offensive, rude tone about knowing how to take a blood pressure, and the CNA (EI #5) said that she was not going to get another cuff. RI #1 recalled being scared to say anything else to the CNA (EI #5), and reported that the CNA (EI #5) had jerked her arm that night. The surveyor asked RI #1 the reason for being scared. RI #1 said because of the CNA's (EI #5's) voice and tone. RI #1 clarified that EI #5 (CNA) looks like a man and talks like a man. The surveyor asked RI #1 if the CNA (EI #5) sounded angry. RI #1 responded no, just rude, and repeated that the CNA (EI #5) had jerked her (RI #1's) arm. RI #1 said that she reported the CNA (EI #5) to the Licensed Practical Nurse (LPN) charge nurse (EI #6), the ADON (EI #4), the Director of Nursing (DON), EI #3, and the Administrator (EI #2). The surveyor asked RI #1 if she liked EI #5. RI #1 replied that EI #5 (CNA) was alright, but she (RI #1) didn't want EI #5 as her aide anymore. The surveyor asked RI #1 why she said in the complaint that EI #4 (ADON) takes up for EI #5 (CNA). RI #1 said because nothing was done. According to RI #1, the ADON (EI #4) said that EI #5 (CNA) would not come back in her room, but the CNA (EI #5) has been in her room twice since then, on November 3, and November 4 (2011). The surveyor asked RI #1 if EI #5 was a threat to her. RI #1 answered that she was scared of EI #5 (CNA), and affirmed that EI #5 was a threat. RI #1 commented that the CNA (EI #5) still works on the 100 hall where she resides, and that she (RI #1) didn't know why. RI #1 said she just didn't feel comfortable around EI #5 (CNA), especially whenever she (the resident) saw EI #5 on her hall. The surveyor asked RI #1 what it would take to resolve her complaint. RI #1 responded, for the nurses to do their job and make sure that EI #5 (CNA) stays off the hall where the resident resides. The surveyor asked RI #1 why would she say that she is afraid of EI #5 (CNA) if the CNA had worked in her home as a home health aide. RI #1 replied, because she (RI #1) didn't know what the CNA (EI #5) might do to her (RI #1). Again, RI #1 expressed that she was afraid of EI #5 (CNA), since she (RI #1) had seen the real side of the CNA. RI #1 described EI #5 as not being a pleasant person, and said that the CNA (EI #5) was mad. The surveyor asked RI #1 if she thought that EI #5 would hurt her physically. RI #1 responded by saying it was a possibility, and that she didn't know what EI #5 (CNA) would do to her. RI #1 commented that she had heard that EI #5 (CNA) got wrote up for talking to her in a rude tone of voice and jerking her arm. RI #1 added that she didn't appreciate that from EI #5, and that maybe the CNA (EI #5) was still mad with her (RI #1)about that. The surveyor asked RI #1 if she talked to anyone from Administration about it. RI #1 answered that she had, and said that they (the Administrative staff) came to her room November 3, 2011. They (the Administrative staff) said EI #5 would not be able to come back in her room or on the hall where she resides. RI #1 said she told EI #4 (ADON), and EI #3 (DON), how the CNA (EI #5) jerked her arm. RI #1 said that EI #4 (ADON) and EI #3 (DON) acted like they (EI #4 and EI #3) were siding with EI #5 (CNA) and not her (the resident). RI #1 mentioned that she had called her granddaughter and reported that EI #5 (CNA) had jerked her arm the same night it happened (11/02/11), and that she informed EI #4 (ADON) and EI #3 (DON) that her granddaughter called up to the facility and spoke with the charge nurse (EI #6) about the incident on 11/02/11. According to RI #1, nothing had been done to EI #5(CNA). RI #1 explained that the CNA (EI #5) still comes in her room. RI #1 reported that EI #5 worked the rest of the week and the weekend (November 2, 3, 4, and 5, 2011). On 11/08/2011 at 11:25 AM, the ADON, (EI #4), was asked to describe the process used for handling a grievance or an allegation of abuse. The ADON (EI #4) explained that the facility has a grievance form, and once completed, the form goes to herself (EI #4), the DON (EI #3), the Administrator (EI #2), and the Social Worker. The ADON (EI #4) said that then, all department heads are made aware of the problem and an investigation is started immediately. The ADON (EI #4), was asked what was involved in investigating a complaint/grievance. EI #4 (ADON) said that the resident involved is questioned about the problem. Then, the department involved is included, then their findings are communicated to the Administrator (EI #2) and DON (EI #3) to determine what plan of action will be implemented. The ADON, (EI #4), was asked to identify what is or might be considered, abuse. The ADON,(EI #4), answered the following: Verbal abuse - cursing, yelling. Physical abuse- making physical contact. Mental abuse- belittling a patient down-grading. The surveyor asked EI #4 if an employee accused of abuse should be gotten out of the building / suspended pending the results of the investigation. The ADON (EI #4) answered that she would remove the employee from the resident care area. The ADON commented the rudeness was not abuse. Later at 1:40 PM, the surveyor asked the the ADON (EI #4) the reason she wrote the grievance related to RI #1. The ADON (EI #4) answered that RI #1 reported to her (EI #4) that the CNA (EI #5) was rude and told the resident that she (CNA) knew how to take a blood pressure. The ADON (EI #4) said that RI #1 reported this to her (EI #4) on 11/03/11, and referred to the information documented on the 11/03/11 "Grievance Record." After speaking with RI #1, EI #4 (ADON) recalled notifying the DON (EI #3) and the Administrator (EI #2) of the resident's grievance on 11/03/11. When asked what corrective action had been taken to prevent reoccurrence, EI #4 (ADON) responded that EI #5 (CNA) was removed from RI #1's section because the resident did not like the CNA at all. EI #4 said that the CNA (EI #5) was counseled and could not take care of RI #1 anymore. EI #4 was asked if EI #5 (CNA) works on the hall where RI #1 resides. The ADON (EI #4) answered that the CNA (EI #5) may work the opposite side of the hall where RI #1 resides. According to EI #4 (ADON), the facility's investigation began on 11/03/11, and was finished on 11/03/11. The ADON acknowledged that EI #5 (CNA) was never suspended during the investigation, and was reassigned to another section of the hall. The facility's document entitled, "GRIEVANCE RECORD," dated 11/03/11, listed RI #1 as the person filing the grievance and is signed by the Assistant Director of Nursing (ADON), EI #4, and the Administrator, EI #2. This record documented RI #1's grievance as, "...Resident voiced concern about aide, CNA had went to take her blood pressure and resident told her to go get another cuff. CNA told her cuff was ok and she knew how to take B/P (blood pressure) "I don't want her for a CNA anymore...." In an interview on 11/11/11 from 5:30 PM until 6:25 PM, the DON, (EI #3), was asked when had she become aware of the situation with (RI #1) and the CNA, (EI #5). The DON, (EI #3), responded that she was not certain of the date, but believed that she and the Administrator, (EI #2), became aware of the situation on 11/02/2011 when the ADON, (EI #4), told them about it. The DON, (EI #3), said the ADON, (EI #4), told them that RI #1 wanted to speak with them. The DON, (EI #3,) stated the three of them (the Administrator, (EI #2) the DON, (EI #3), and the ADON, (EI #4) went to RI #1's room and asked her if there was anything going on that RI #1 wanted to tell them. According to the DON, (EI #3), RI #1 reported to them that she (RI #1) had tried to tell the CNA, (EI #5), that the B/P cuff was too small. RI #1 reported to them (the Administrator, (EI #2), the DON, (EI #3) and the ADON,(EI #4)), that EI #5 (CNA) responded that the cuff was the biggest one that she had, and that she (EI #5) knew how to take a blood pressure. The DON, (EI #3), was asked when was the determination made to talk to the CNA, (EI #5). The DON, (EI #3), replied after they had talked to RI #1 they decided they needed to talk to the CNA, (EI #5). The DON, (EI #3), was asked who spoke with the CNA (EI #5), and what was said. The DON, (EI #3), said she and the ADON,(EI #4), spoke with the CNA, (EI #5) and presented her with the counseling form. The DON, (EI #3), said she told the CNA, (EI #5),there was a complaint from a resident about her tone of voice and that she (CNA, EI #5), needed to be careful when speaking to the patients. The DON, (EI #3), was then asked if she had done any other investigation after talking with RI #1 and the CNA, (EI #5). The DON, (EI #3), replied that she did not. The DON (EI #3) was asked if EI #5 worked the evening shift on 11/03/2011. DON could not locate the "CNA Assignment Sheet for 11/03/2011, but referred to a copy of the working schedule and stated that according to the assignment sheet, EI #5 (CNA) did not work on 11/03/11. On 11/08/11 at 2:50 PM, the surveyor conducted an interview with the Administrator (EI #2), who is also the abuse coordinator for the facility. The surveyor asked EI #2 if she interviewed any of the staff who worked with EI #5 on the 3 p.m. - 11 p.m. shift on November 3, 2011. EI #2 answered that she did not. The surveyor asked EI #2 if she or anyone got any statements from staff. EI #2 said they talked to staff, but didn't get any written statements. The surveyor asked EI #2 if EI #5 was suspended from her duties during the investigation on 11/3/11. EI #2 (Administrator) said that EI #5 (CNA) came to work later that evening after they had talked to her earlier that morning on November 3, 2011. The surveyor asked EI #2 was EI #5 scheduled to work the 3 p.m. - 11 p.m. shift today, 11/8/11? EI #2 said yes, she was (scheduled to work on 11/8/11). The surveyor asked EI #2 (Administrator) who reported the incident to her that RI #1 had concerns with one of the CNA's who had spoken to her in a rude tone of voice and jerked her arm. The Administrator (EI #2) identified the ADON (EI #4) as the person who reported the incident. The surveyor asked EI #2, is speaking to a resident in a rude tone of voice considered verbal abuse? EI #2 said, she would have to hear it and she didn't think the statement was rude. The surveyor asked EI #2 did she ask RI #1 to repeat in her voice the manner in which EI #5 (CNA) had spoken to her on 11/3/11, and how the CNA had jerked her arm? EI #2 (Administrator) replied that she asked RI #1 what happened, and RI #1 reported that EI #5 (CNA) told her (the resident) the blood pressure cuff was too small. Then, EI #5 (CNA) said that the blood pressure cuff was the biggest one that she had, and she (EI #5/CNA) knew how to take a blood pressure. EI #2 said she did not ask RI #1 to repeat what was said in a particular voice. The surveyor asked EI #2 if she or her staff asked RI #1 how it made her feel what the CNA (EI #5) said and did to her. The Administrator (EI #2) answered that she did not, and that the staff did not ask the questions in her (EI #2's) presence. The surveyor asked EI #2 what would she call the actions of EI #5's behavior toward RI #1? EI #2 said that the CNA (EI #5) made a statement. The surveyor asked EI #2 if it was appropriate for EI #5 (CNA) to make a statement in a rude tone of voice to a resident. The Administrator (EI #2) responded that if the CNA (EI #5) made it, then, it was not. EI #2 commented that if EI #5 (CNA) was rude to the patient (RI #1), then no, it's not appropriate. The surveyor asked EI #2 how she would know if the statement was rude to the resident if she didn't ask the resident (RI #1) how it made her feel. EI #2 (Administrator) responded that she didn't ask RI #1 that. On 11/08/2011 at 4:45 PM, a CNA, (EI #5), was asked to explain what had happened between her (EI #5) and RI #1. The CNA, (EI #5), replied that RI #1 told her, "(EI #5) this Blood Pressure (B/P) cuff is too little. " So, the CNA, (EI #5), said she got another cuff and told (RI #1) both cuffs read the same. The CNA, (EI #5), stated that since both cuffs had read the same the day before she went ahead and used the smaller cuff the next time she took RI #1's B/P. The CNA, (EI #5), stated RI #1 didn't verbalize a complaint. The CNA, (EI #5), said that when she came in the next day, the Director of Nurses (DON), (EI #3), told the CNA, (EI #5), she had gotten a report saying the CNA, (EI #5), had snatched RI #1's arm. The CNA, (EI #5), stated, "I told the (DON, EI #3), I didn't snatch her (RI #1's) arm." The CNA, (EI #5), said she was then told by the DON, (EI #3), that the CNA, (EI #5), was going to be taken off RI #1's hall to avoid any more confusion. The surveyor asked the CNA, (EI #5), if she had signed the "counseling paper" dated 11/03/2011. The CNA, (EI #5) replied, "Yes, ma'am I did, but I wasn't agreeing I had done anything wrong. I was agreeing with their solution to take me off that hall." The CNA, (EI #5), stated she worked the evening shift that day and had also worked the following weekend but was called (11/08/2011) by the DON, (EI #3), and was told she (the CNA) was being suspended. The CNA, (EI #5), said the DON, (EI #3), did not say what she (CNA) was being suspended for or for how long. The CNA, (EI #5), was asked if she had been questioned by anyone else besides the DON (EI #3) and the ADON (EI #4). The CNA (EI #5) stated, "No, just DON (EI #3), and ADON (EI #4)." In a phone conversation with the CNA, (EI #5), on 11/11/2011 at 9:30 AM, the CNA, (EI #5) confirmed she had worked the evening shift on 11/03/2011 and was assigned to RI #1's hall. The CNA, (EI #5), stated that later on in the shift, the LPN Charge Nurse, (EI #6), swapped her (EI #5's) hall assignment with another CNA, EI #7. In an interview on 11/11/2011 at 5:00 PM, a CNA, (EI #7), was asked if she worked the evening shift on the 100 hall, Thursday, 11/03/2011. The CNA, (EI #7), answered, "Yes." The CNA, (EI #7), was asked if she swapped halls with (EI #5) on that day. The CNA, (EI #7), stated there had been more than one incident of her having to swap assignments with CNA, (EI #5), due to a conflict of interest. The CNA, (EI #7), was asked what she meant by a conflict of interest. EI #7 replied, "Couple of residents and families don't want (CNA, EI #5)." The CNA, (EI #7), stated that on 11/03/2011, the LPN Charge Nurse, (EI #6), asked her to swap halls with the CNA, EI #5. EI #7 was asked what time the change in the hall assignment took place. The CNA, (EI #7), answered that it took place around 4:30 to 5:00 PM. On 11/10/2011 at 12:44 PM, the State Surveyor conducted a phone interview with EI #6, a Licensed Practical Nurse (LPN). The surveyor asked if RI #1 had requested that EI #5 not be assigned as the resident's CNA, and had reported that EI #5 jerked her arm on November 2, 3, or 4, 2011. The LPN, EI #6, answered that she could not remember the date, but acknowledged that RI #1 had requested that EI #5 not be assigned to care for her anymore. According to EI #6 (LPN), RI#1 mentioned that she had made the same request to the ADON (EI #4), and that EI #5 (CNA) made her (RI #1) feel intimidated. When asked if EI #5 (CNA) was in RI #1's room on November 3 or 4, 2011, the LPN (EI #6) answered that EI #5 was assigned to RI #1 at the beginning of the shift, but she (EI #6) told EI #5 (CNA) not to go into RI #1's room, and to go work list 3 instead of list 2. EI #6 (LPN) said that around 3:30 PM, the ADON (EI #4) had called her into the office and informed her that EI #5 couldn't work list 2, which included RI #1's room. According to the "Evening Shift CNA ASSIGNMENT SHEET" dated 11/06/2011, EI #5, a CNA, was assigned to "Section #2" which included rooms 119 - 133, one of which was RI #1's room. This deficiency was cited as a result of the investigation of complaint/report number AL 404. ****************************************** Allegation of Compliance 11/11/11 F 490 483.75 Facility Administration Resident Identifier (RI) # 1 The Administrator, Director of Nursing, Assistant Director of Nursing received in-service training on 11/10/11, by the Regional Nurse Consultant. The in-service covered areas but not limited to: abuse protocol, prevention and monitoring, investigations of allegations of abuse, regarding the process of reporting allegations of abuse, the procedure for investigations (how to conduct interviews to include specific details of the alleged incident, determine the psychological effect the incident had on the patient, protecting the patient by suspending employees suspected of abuse and providing patient/family education on abuse), and procedure of what constitutes abuse. The Social Worker will maintain a folder in Social Services Office for each allegation of abuse with all pertinent information (patient, family, staff, or other witness interviews, investigation statements, follow-up and conclusion of investigation) to be reviewed by the Regional Nurse Consultant and Regional Director of Operations (initialed and dated that the file has been reviewed for compliance) upon scheduled visits. The Regional Director of Operations will conduct a follow-up visit to evaluate performance and the facilities compliance regarding abuse procedures 11/12/11. All allegations of abuse will be discussed in the morning (Monday-Friday) Quality Assurance and reported to the Medical Director by the Social Worker as alleged incidents are received. Quality Assurance Committee consisting of: Administrator, Director of Nursing, and Assistant Director of Nursing, Minimum Data Set (MDS) Coordinator, Staffing Coordinator, Medical Records, Bookkeepers, Food Service Supervisor, Social Worker, Admissions Coordinator, Housekeeping Supervisor, Maintenance Supervisor, and Activities Coordinator. Different members of the committee will participate depending on the nature of the audit. After reviewing the facility's information provided in their allegation of credible compliance (i.e. resident interviews, in-service records, staff interviews) completed as of 11/11/2011, the immediate jeopardy was relieved and the scope and severity was lowered to a "D" level on 11/11/2011 at 4:33 PM, to allow the facility time to monitor/revise their corrective actions to sustain substantial compliance.