Every finding on record at Tradewater Pointe

Based on observation, interview, and review of facility policy, it was determined the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks for one of 15 sampled residents (Resident (R) 31).The findings include:Review of the facility policy titled, Concord Health Systems, 03/31/2020, revealed nursing personnel will serve resident trays, checking the information on tray cards with the items on the trays prior to serving, and will help residents who require assistance with eating.Review of the Resident Face Sheet for R31 revealed the facility admitted the resident to the facility on [DATE], with diagnoses to include: chronic obstructive pulmonary disease (COPD), Alzheimer's, and dysphagia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R31 to have a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen, indicating the resident was cognitively intact.Review of the physician order for R31 dated 11/14/2025, revealed an order for the resident to have regular soft and bite size / nectar mildly thick liquids. Continued review of the order revealed R31 was to have a divided plate, nosey cup, weighted utensils, and suction bowls to increase overall self-feeding and increase intake.Review of R31's Comprehensive Care Plan dated 11/14/2025, revealed a focus for nutritional risk related to receiving a mechanically altered diet and a diagnosis of dysphagia and oropharyngeal phase. Continued review revealed interventions dated 11/14/2025, included providing diet as ordered; and providing a divided plate and spouted lid with meals.Observation on 03/26/2026 at 11:36 AM R31 was served a lunch tray by CNA 4. Observation of his meal card revealed the resident was not provided built up utensils. R31 stated during the observation that he was not able to grip utensils easily because the ones provided are not what he is used to. During an interview with Certified Nursing Aide (CNA) 4 on 03/26/2026 at 11:32 AM, she was observed at this time dropping off the lunch tray for R31. She stated the kitchen places the utensils on the tray. She stated she should have double checked the meal card before dropping off the tray to R31. CNA 4 went to the kitchen to retrieve utensils and drop them off to resident. Observation on 03/26/2026 at 12:03 PM, resident was observed using his built-up utensils after they had been dropped off by CNA4. R31stated the built-up utensils are better for him, especially when I am customed on handling the utensils. He stated that they forget his built-up utensils often. He stated the built-up utensils help with his grip, instead of the regular utensil rolling off his fingers. During an interview with the Dietary Manager on 03/27/2026 at 9:22 AM, she stated our dietary aide set up the tray, drinks, condiments, silverware, and desserts. She stated she printed off the meal card. Meal card updates are communicated through a communication slip from the nurses, and the order is updated via tray card system. The updates vary from resident to resident on new orders including resident likes and dislikes. She stated the resident being unable to feed himself with the required utensils is a concern. During an interview with LPN 2 on 03/27/2026 at 9:31 AM, she stated she helped by delivering food trays. Resident name, diet expirations, room numbers, likes and dislikes are always checked before dropping off the food tray to the resident. She stated before picking up the tray from the kitchen, she checked for the correct utensil, plate, and diet. If the resident was missing something from his tray, she stated she went back to the kitchen and kitchen staff swap it out. She stated a resident who required specialized equipment is at risk for a negative outcome if they are not provided. She added, the resident can struggle and it is also a dignity issue. She stated, they can drop their food, and it can be embarrassing for them. During an interview with CNA 5 on 03/27/2026 at 9:43 AM, she stated she assisted with delivering food trays, food carts, and feeding assistance. She stated she verified the meal card for the residents' diet, correct utensils, specialty plates, and cups. She stated she would take the incorrect utensils and replace them. She stated if the residents did not have the right utensils, this would cause a dignity concern and cause embarrassment because they would not be able to feed themselves. During an interview with CNA 6 on 03/27/2026 at 10:09 AM, she stated the meal task is divided up amongst CNAs to assist in the dining room and hallways. She stated she verified the ticket name, verified food items, and checked for the right utensils. She stated that staff that work here usually will know what their residents need. She stated if the resident had the wrong utensils and they were in the dining room; she would go to the kitchen to correct it. If she is working in the hallway, she would grab the charge nurse to help with getting the right utensils. She stated the resident would become frustrated if they didn't have the correct utensils. During an interview with the DON on 03/27/2026 at 10:52 AM, she stated she expected staff to know the mealtimes and verifying all residents have their assistive devices. This would fall under dignity concern if they were not provided what they need. She stated she expected staff to correct the issue immediately. During an interview with the Administrator on 03/27/2026 at 10:54 AM, she stated her expectation was for staff to correctly deliver the food tray by verifying the resident's meal card, and to make sure it was correct before serving. She expected for staff to address any issues with the kitchen if anything is missing off the resident's tray. She also added, the residents would feel undignified if they didn't have the correct utensils.

Based on interview, record review, and review of facility policy, the facility failed to ensure an allegation of suspected abuse was reported in accordance with S42 CFR 483.12 (c)(1), for 1 of 12 sampled residents, (Resident (R)45). In interview, a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) stated they reported to facility leadership an allegation of sexual abuse involving R44 and R45 in mid-December, 2024. However, per the facility's report, the abuse incident allegedly occurred on 12/31/2024, approximately 17 days after the nurses reporting the allegation. The findings include: Review of the facility policy titled, Resident Abuse, Neglect, and Exploitation, revised 11/26/2024, revealed the goal of the facility was to have a process in place to protect the health and welfare of each resident and assure each resident was free from verbal, sexual, physical, and mental abuse. Per policy review, all alleged violations and substantiated incidents were to be reported, and notification must be made to the appropriate reporting agencies within two hours, to include law enforcement. Further review revealed a written report of the investigation was to be prepared by the Administrator or designee and completed within five working days of the incident. Review of a progress note dated 12/14/2024 at 2:25 PM for R45, revealed the resident was being sent to the emergency room (ER) per the Medical Director related to increased agitation and change in mental status. Review revealed R45 had experienced multiple behavioral episodes that shift, and was unaware her actions were wrong. Further review revealed statements were given to administration, with an incident report in progress. Review of the facility's initial report dated 01/01/2025, for an alleged incident on 12/31/2024, revealed it had been reported to the former Administrator by a third party source there were rumors of some type of sexual act that occurred between two residents within the facility. Per review, the third party source communicated via telephone call that a staff member of the facility told them R45 had entered R44's room and performed a sex act on the resident while the door was closed. Continued review revealed the third party source did not identify the staff member who reported the incident to them. Review of the facility's initial investigation findings revealed the facility had determined those acts had not occurred as it was not able to verify the incident. Review of the facility's Final 5-day Report dated 01/09/2025, for a second investigation, revealed the former Administrator had not thoroughly investigated the reported abuse. Per review, the second investigation discovered R44 was the one who went into R45's room and not the reverse as the former Administrator had said. Continued review revealed staff members working that day (the alleged sexual abuse occurred) were never interviewed and noted those staff were never contacted by the former Administrator regarding the alleged sexual abuse incident. In addition, review revealed the former Administrator had not thoroughly investigated, or reported the incident within the mandated time frame. In interview with LPN 1 on 01/16/2025 at 2:53 PM, she stated the alleged abuse incident occurred in mid-December, and she stated it occurred on dayshift. She stated she notified the Administrator by phone immediately to report the alleged incident and to ask her how she wanted her to proceed with the matter. The LPN reported the Administrator told her and the other nurse working with her that day (RN 1) that they were not to document anything about it because it would need to be documented a certain way. She said during the phone call with the Administrator, RN 1 asked the Administrator if they needed to contact the resident's family and the Administrator told her, No, let me handle it. LPN 1 stated she documented the incident anyway and notified the Medical Director who gave orders to send R45 to the hospital that evening. She further stated the Administrator never said anything further regarding the incident and she assumed the matter had been taken care of. In interview with RN 1 on 01/22/2025 at 10:11 AM, she stated she recalled the alleged incident occurred on either 12/14/2024 or 12/15/2024 she could not remember the exact date. She said however, she remembered for sure it happened in the middle of December of 2024 on the weekend that she worked. RN 1 reported LPN 1 had called the Administrator to report the incident immediately after finding R44 and R45 together. Per the RN in interview, the residents were lying on the bed together, with the male resident with no pants on and only wearing his brief, and the female resident fully clothed lying across the male resident. She stated the Administrator advised them both to not document anything and not notify the family because she would handle all of it. RN 1 further stated she never heard any more about the alleged incident after that. In interview with the former Director of Nursing (DON) on 01/15/2025 at 3:28 PM, she stated she had been out on medical leave during the time the alleged abuse event occurred. She further stated she would take action to report any allegations of abuse or neglect to her Administrator immediately. In interview with the former Administrator on 01/14/2025 at 11:46 AM, she stated on 12/31/2024, another Administrator, who worked at their sister facility, reported she had received third party information, regarding an incident between R45 and R44 that allegedly occurred sometime in mid-December of 2024. She stated she had not learned of the alleged abuse incident until 12/31/2024. The former Administrator said she reported the alleged abuse as soon as she was made aware and began an investigation. She further stated she did not recall staff reporting anything to her (regarding the alleged abuse event) and had not been aware of any progress note documented prior to learning of the alleged incident from the third-party source.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.1, the facility failed to ensure Minimum Data Set (MDS) Assessments accurately reflected the resident status for 3 of 12 sampled residents. (Residents (R)43, 31, and 13). Record review revealed R13, R31, and R43 did not have MDS Discharge Assessments completed as required upon being discharged from the facility. The findings include: Review of the CMS RAI 3.0 User's Manual Version 1.19.1, Chapter 2: Assessments for the RAI, revealed discharge assessments must be completed when a resident was discharged from the facility. 1. Review of R13's closed record revealed the facility admitted the resident on 03/27/2020, with diagnoses to include: Unspecified Dementia, Anxiety, and Stage 3 Chronic Kidney Disease. Closed record review further revealed R13 was discharged from the facility on 08/16/2024, with no documented evidence of a MDS Discharge Assessment having been completed as required. 2. Review of R31's closed record revealed the facility admitted the resident on 04/12/2023, with diagnoses to include: Vascular Dementia, Hemiplegia and Hemiparesis post cerebral infarction affecting the left non-dominant side, and Chronic Obstructive Pulmonary Disease (COPD). Closed record review further revealed R31 was discharged from the facility on 08/12/2024, with no documented evidence of a MDS Discharge Assessment having been completed as required. 3. Review of R43's closed record revealed the facility admitted the resident on 11/28/2023, with diagnoses to include: Cerebral Infarction, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and Gastroparesis. Closed record review further revealed R43 was discharged from the facility on 08/14/2024, with no documented evidence of a MDS Discharge Assessment having been completed as required. In interview with the MDS Coordinator on 01/24/2025 at 5:51 PM, he stated MDS Discharge Assessments should be completed on the day a resident discharged from the facility. The MDS Coordinator stated on that day they opened up the MDS Discharge Assessment and had a 14 day window to complete the assessment. He said he had only been the MDS Coordinator since 11/01/2024. The MDS Coordinator reported prior to that dated, the facility had not had a MDS Coordinator. He further stated the MDS tasks had been outsourced to a third party service provider for a couple of months. The MDS Coordinator additionally stated the MDS Discharge Assessments should have been completed for R13, R31, and R43. An interview was attempted with the Third Party MDS Coordinator on 01/24/2025 at 3:25 PM; however, was unsuccessful with no return phone call received. In interview with the Director of Nursing (DON) on 01/24/2025 at 6:13 PM, she stated her expectations were for the MDS Assessments, including the Discharge Assessments, to be performed per the regulatory guidelines. In interview with the Administrator on 01/24/2025 at 5:51 PM, she stated her expectations were for the MDS Assessments (to include the Discharge Assessments) to be completed timely with accuracy. She further stated she also expected the MDS Assessments to be updated to correlate to the nursing assessment of the resident.

Based on observation, interview, record review, and review of facility policy, the facility failed to develop and implement a comprehensive care plan for 2 of 12 sampled residents, (Residents (R)30, and 45). Record review revealed R30 was care planned to have both a bed and chair alarm in place; however, observation on 01/23/2025 at 10:58 AM, revealed the chair and bed alarms were not visualized as in use. Additionally, record review revealed R45 was care planned for having difficulty finding her room and a name plate with a picture with a picture of her favorite animal was to be placed outside her room to make it easier for her to find her room consistently. However, observation on 01/08/2025 at 4:40 PM, and 01/09/2025 at 10:03 AM, revealed no name on R45's nameplate and no picture of a horse (her favorite animal) outside the resident's door as per her care plan. The findings include: Review of the facility policy titled, Comprehensive Care Plan, revised 01/11/2022, revealed it was the facility's policy for residents to receive care and treatment based on an assessment of their needs, the severity of their disease,condition, or impairment of disability. Further review revealed the comprehensive care plan would describe at a minimum resident specific interventions that reflected the resident's needs and preferences. 1. Record review revealed the facility admitted R45 on 11/20/2024, with diagnoses to include: Vascular Dementia, moderate with other behavioral disturbance; Cognitive Communication Deficit; and Type 2 Diabetes Mellitus. Review of R45's Discharge Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 12/18/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status score of 99 indicating the resident was unable to complete the assessment. Review of the Comprehensive Care Plan for R45 dated 12/06/2024, revealed the facility identified a problem for the resident related to disorientation to place, having difficulty finding her room, and wandering from room to room looking for her possessions. Per review, the interventions included R45 having an image of her favorite animal (a horse) and her name placed outside her room to make it easier for her to find the room consistently. Further review revealed additional interventions included staff assisting R45 out of other residents' rooms if she was observed wandering into others' rooms that she had not been invited into or requested to enter. Observation on 01/08/2025 at 4:40 PM and on 01/09/2025 at 10:03 AM, revealed no visual evidence of R45's name/signage or picture of a horse posted outside her door as per the care plan. In interview with Licensed Practical Nurse (LPN) 6 on 01/09/2025 at 10:05 AM, she stated the only reasons she could think of why a resident's name would not be on their room door was because there was either a room change or the room was for a new admission to the facility. She reported she did not know who was responsible for placing the residents' names on the room door nameplates. The LPN further stated she would use the resident's photo located in the facility's Electronic Medical Record (EMR) to identify them if there was not a name displayed on their room door. In interview with the Director of Nursing (DON) on 01/24/2025 at 6:00 PM, she stated the Activities Director made the door signs for R45; however, the resident was known to remove the signs quite frequently. She stated if the Activities Director was not at the facility there was no way to access her computer in order to make another door sign if the resident removed it. 50153 2. Record review revealed the facility admitted on R30 on 09/12/2019, with admission diagnoses that included: history of falling, need for assistance with personal care, Muscle Wasting and Atrophy, Schizophrenia and Bipolar Disorder. Review of the Quarterly MDS Assessment with an ARD of 12/03/2024, revealed the facility assessed R30 to have a BIMS score of 13 out of 15, indicating the resident was cognitively intact. Review of the Physician's orders for R30 revealed a Safety order initiated on 07/29/2024, that included a pressure alarm to bed and chair. Review of Comprehensive Care Plan for R30 revealed the facility identified the resident as at risk for falls related to history of falls, impaired balance, use of psychotropic med, muscle wasting, and abnormal gait, which was initiated 09/12/2019 and last revised 11/22/2021. Per review, the interventions included R30 to have an alarm on the bed and an alarm in place on the wheelchair. Observation on 01/23/2025 at 10:58 AM and 01/24/2025 at 10:40 AM, revealed however, no bed or wheelchair alarms in place as per R30's care plan In interview with LPN 1 on 01/24/2025 at 1:30 PM, she stated she thought R30's alarms had been discontinued since they did not show up on the resident's Treatment Administration Record (TAR). Review of R30's TAR revealed no documented evidence of an active order for the resident to have bed and chair alarms. In interview with the MDS Coordinator on 01/09/2025 at 2:15 PM, he stated his expectations were for care plan interventions to be followed through with by staff. In interview with the DON on 01/24/2025 at 1:45 PM and at 6:00 PM, she stated she expected an intervention on located in a resident's care plan to be in place and for staff to implement the residents' care plan interventions. In interview with the Administrator on 01/24/2025 at 6:40 PM, she stated her expectations were for staff to develop an appropriate care plan for residents' needs and follow the interventions on the residents' care plans.

Based on observation, interview, and review of facility policy, the facility failed to store drugs in accordance with currently accepted professional practices for 1 of 2 medication carts audited out of a total of 2 medication carts and 1 of 1 audited medication rooms. Observation of the East Hall medication cart revealed 12 insulin pens not properly labeled for 8 of 15 residents. (Residents (R)32 32, 36, 17, 23, 15, 20, 35, and 5). Observation of the East Hall medication room revealed a vial of Tubersol solution (an injectable medication used to test for tuberculosis) not properly stored in the medication refrigerator. The findings include: Review of the facility policy titled, Medication Storage, revised 08/18/2017, revealed Medications. treatments, and biologicals are stored safely, securely, and properly following manufacturer's recommendations or facility policy. Further review of the policy revealed, medications would be dated at time of opening as appropriate (ie. insulin, tb solution, etc.). 1. Review of the manufacturer's recommendation for the Tubersol solution revealed once the vial had been entered, it was to be discarded after 30 days. Review further revealed the vial should not be used after the expiration date. Observation on 01/23/2025 at 3:19 PM, of the East Hall medication room revealed one opened, undated vial of Tubersol solution located in the medication refrigerator available for use. In interview with the Director of Nursing (DON) on 01/24/2025 at 1:45 PM, she stated she did not know if facility staff had been educated specifically about dating open medication vials since she became the DON last fall (2024). She verbalized that an opened vial should be dated with the open date and the expiration date on both the vial and the box once opened. 2. Review of the manufacturer's recommendations for insulin storage revealed Lantus, Novalog, and Lispro insulin pens, once opened, were beyond use, 28 days after opening when kept at room temperature. Further review revealed the pens should be replaced after 28 days. Observation of the East Hall medication cart on 01/23/2025 at 3:30 PM, revealed eight insulin pens prescribed for eight of the 15 residents (located on that hall) were not properly stored and labeled. Per observation, one vial of Lantus was not improperly labeled. Continued observation revealed one vial of Lantus and three insulin pens were dated; however, were available for use past the manufacturer's recommendations. Observation revealed the medications were prescribed for R32, R36, R17, R23, R15, R20, R35, and R5 and included the following: (a) One unlabeled pen of Trulicity (injectable diabetes medication), 0.75 milligrams (mg) per 0.5 milliliters (ml), without a cap, resident name label, or opened date lying in the top drawer of the medication cart. (b) One unlabeled Lantus insulin pen, 100 units per ml, opened with no label indicating the resident's name and opened date, that was lying inside the top drawer of the medication cart. (c) R32's Lantus 10 ml vial with an opened date of 12/20/2024, available for use beyond the 28-day storage for Lantus; and a Novolog insulin pen dated with opened date; however, not labeled with the resident's name. (d) R36's Lantus 10 ml vial was not labeled with an opened date. (e) R23's Lantus pen with an opened date of 12/23/2024, available for use after the manufacturer's recommended beyond use date of 28 days when stored at room temperature. (f) A Lantus pen which was dated; however, not labeled with R15's name. (g) A Lispro (short acting insulin) pen, unlabeled, but dated with an opened date of 12/20/2024, available for use past the manufacturer's recommended 28 days from open date when stored at room temperature. (h) A Novolog (short acting insulin) pen labeled with R35's name and dated 12/21/2024, past the beyond use date, and one Novolog pen with an opened date, but not labeled with the resident's name. (i) A Basaglar (long acting) insulin pen opened and dated; however, was not labeled with R5's name. In interview on 01/23/2025 at 2:57 PM, Licensed Practical Nurse (LPN) 7, assigned to the East Hall medication cart, stated that there was risk of transmitting disease if insulin pens were shared between residents. The LPN said sharing pens between residents, even if the needle was changed, was not an acceptable practice. LPN 7 further stated insulin pens should be labeled with the residents' names to prevent cross contamination. In a phone interview on 01/23/2025 at 5:06 PM, the Pharmacist, from the supplying pharmacy, stated the pharmacy dispensed boxes of five insulin pens and labeled the box, but did not open the boxes and label each pen. He stated the beyond use date would depend on the type of insulin and according to the manufacturer's recommendation on the package insert. The Pharmacist reported Levemir could be in use out of the refrigeration for 42 days; Novolog for 28 days; and Lantus for 28 days. He further stated it would not be good practice to use insulin past the beyond use date. The Pharmacist additionally said it would not be acceptable to share insulin pens between residents due to the risk of disease transmission. In continued interview with the DON on 01/24/2025 at 1:45 PM, she stated insulin pens should be labeled and dated once opened with both the opened date and a disposal date that was 28 days after opening. She said it had not been the pharmacy's practice to label each insulin pen with the resident's names. The DON further stated insulin pens were not to be shared due to the risk for potential disease transmission. In interview with the Administrator on 01/24/2025 at 6:38 PM, she stated medications should be stored according to manufacturer's recommendations. She further stated medications should also be refrigerated as appropriate, and labeled accordingly.

Based on observation, interview and review of facility policy, the facility failed to establish and maintain an effective infection prevention and control program for 4 of 12 sampled residents (Resident (R)5, R10, R34, and R4). Observation of a cart located by the 100 hall nurse's station revealed no Personal Protective Equipment (PPE) gowns present in the cart. Observation of the cart on the 200 hall revealed no PPE gowns present in that cart. 1 (a). Observation revealed R34 had an indwelling catheter and the resident's room door had signage for enhanced barrier precautions (EBP). However, no Personal Protective Equipment (PPE) observed outside R4's door. R4, in interview, reported having a wound on his sacrum. (b). Observation of R10's room door had a sign for contact precautions; however, there was no PPE visible near the resident's door or in the hallway. R10, in interview, reported having wounds on her leg. (c). Observation of R4's room, revealed a sign on the door that read contact precautions. Observation also revealed two staff in R4's room at the resident's bedside without no PPE in place. An additional observation on another day revealed the Activity Director present in R4's room without any PPE in place. 2, Observation of Certified Medication Technician (CMT) 2 revealed she left the medication cart to go to the medication room to obtain a blood pressure cuff. The CMT was observed to return to the medication cart and continued with medication administration without sanitizing hands. CMT 2 was further observed to fail to disinfect the blood pressure cuff before using it on R5. The findings include: Review of the facility policy titled,Precaution for Managing Infections, revised on [DATE], revealed, all facilities would appropriately use standard precautions, transmission-based precautions, and resident placement to decrease/prevent the spread of infectious disease. Continued review revealed gowns were to be worn to protect the skin and prevent soiling of clothing during procedures and resident care activities that were likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or cause soiling of clothing. Further review revealed that contact precautions were to be used when transmission of disease can occur through direct and indirect contact. Direct contact transmission involves skin-to-skin contact and the physical transfer of microorganisms from a source person to a host. Gowns were to be worn when entering a resident's room if you anticipate substantial contact with the resident environmental services or items in the residents' room. Wear gloves when coming in direct contact with a resident. A red bio-hazard trash bag should be placed in the residents' room for disposal of contaminated material such as gloves, masks, and gowns. Observation on [DATE] at 12:05 PM, a cart sitting at the 100 hall nurse's station. The State Survey Agency (SSA) Surveyor checked the cart for PPE, and when all drawers were opened there were no gowns observed present in the cart. The SSA Surveyor went to the 200 hall and checked the cart located there, and observed no gowns present in that cart. 1(a). Review of the Admission Record for R34 revealed the facility admitted the resident on [DATE], with diagnoses to include: acquired absence of left leg below the knee, acquired absence of right leg, above the knee, and pressure ulcer of right buttock, stage 2. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R34 to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident was cognitively intact. Observation on [DATE] at 1:30 PM, of room [ROOM NUMBER] (R34's room) revealed signage on door for enhanced barrier precautions (EBP); however, no Personal Protective Equipment (PPE) was visible outside the door in the hallway. In interview with R34 on [DATE] at 1:33 PM, he stated staff did not wear gowns when providing care for his indwelling urinary catheter. The resident also stated he had a wound on his sacrum and staff did not wear gowns when providing his wound care. (b). Review of the Admission Record for R10 revealed the facility admitted the resident on [DATE], with diagnoses to include: chronic obstructive pulmonary disease, peripheral vascular disease, and type 2 diabetes mellitus. Review of the Significant Change in Status Assessment (SCSA) dated [DATE], revealed the facility assessed R10 to have a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Observation on [DATE] at 11:55 AM, of room [ROOM NUMBER] (R10's room) revealed a sign on the door for contact precautions. Further observation revealed no PPE visible near R10's room door or nearby in the hallway. In interview with R10 on [DATE] at 11:58 AM, she stated she had wounds on her leg. She said there used to be a door hanger on her door, that contained gowns and masks on it; however, staff had taken it down. R10 said the gowns were now located on a cart in the hallway. R10 further stated staff did not don PPE before entering her room or when they provided her care and wound care. In interview with Licensed Practical Nurse (LPN) 6, an agency nurse, on [DATE] at 10:25 AM, she stated she thought R10 was on contact precautions because she had wounds. The LPN said however, she did not know if there was an infection, and would have to ask someone. (c). Review of the Admission Record for R4 revealed the facility admitted the resident on [DATE], with diagnoses to include: Alzheimer's dementia, heart failure, and renal insufficiency. Review of the SCSA dated [DATE], revealed the facility assessed R4 to have a BIMS score of three out of 15, indicating the resident had severe cognitive impairment. Observation on [DATE] at 12:10 PM, of room [ROOM NUMBER] (R4's room) revealed a sign on the door that read contact precautions. Continued observation revealed two staff in R4's room at the resident's bedside without PPE in place. At the time of observation, the SSA Surveyor asked Certified Nursing Assistant (CNA) 1 to read the sign on R4's door. In interview at the time of observation, CNA 1 stated he was not aware PPE was required when caring for R4. The CNA stated he did not know where PPE was located. CNA 1 asked Certified Medication Technician (CMT) 3 and the CMT told the CNA, PPE was located in the cart in the hall. Observation revealed CNA 1 went to the cart, opened four drawers, and found no gowns present in the cart. Observation on [DATE] at 10:33 AM, R4 remained on contact precautions, and the Activity Director present in R4's room without wearing PPE. In interview, at the time of observation, the Activity Director stated the sign on R4's door said contact precautions. The Activity Director said she should have put on a gown and gloves before entering the resident's room. In interview on [DATE] at 12:17 PM, Licensed Practical Nurse (LPN) 9, an agency nurse, stated it was her first day at the facility. When asked by the SSA Surveyor were PPE was located, LPN 9 stated she did not know the location of PPE. When the SSA Surveyor asked LPN 9 what the difference was in contact precautions and EBP, she stated she did not know the difference. 50153 2. Review of the facility policy titled, Medication Pass with a revision date of [DATE], stated the purpose of the policy is for medications to be administered in an appropriate and timely manner that upholds Nursing Standards of Practice and to always begin by first washing hands and using proper sanitary technique. Review of the policy titled, Infection Control Universal Precautions with a revision date of [DATE] stated that re-useable resident care equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed. Observation on [DATE] at 9:20 AM, revealed Certified Medication Technician (CMT) 2 left the medication cart to go into the medication room to obtain a blood pressure cuff. Per observation, CMT 2 returned to the medication cart and continued with medication administration without sanitizing her hands. Additionally, observation revealed the CMT failed to disinfect the blood pressure cuff before using it on R5. In interview with CMT 2 on [DATE] at 9:45 AM, she stated sanitizing one's hands, and disinfecting equipment was important in preventing the spread of infection. In interview with Licensed Practical Nurse (LPN) 1 on [DATE] at 4:28 PM, she stated disinfecting equipment and hand sanitizing would be indicated if she left the medication cart then returned to the cart, and before restarting medication administration to prevent the spread of infection. Interview with the Director of Nursing (DON) on [DATE] at 6:00 PM she stated the facility currently did not have an Infection Preventionist (IP) as her certification had expired. She stated she was currently taking classes to get it back. She stated the former DON was the last IP that the facility had. She stated she has been the DON at the facility since [DATE]. She stated she does not know of any corporate people who do IP for the facility. She stated she is currently responsible for training staff on infection control. The DON stated contact precautions were required for wounds with drainage or had something growing in the wound, Respiratory Syncytial Virus (RSV) or COVID infections. She stated enhanced barrier precautions (EBP) would be for residents if they had a feeding tube, indwelling catheter, or wounds. She stated she has not done any training on EBP or Contact Precautions with staff since she has been the DON. Stated she does not do onboarding training for new staff stated she doesn't know what the facility's annual training is. Stated she received some training when she came on as DON but not much. Interview with the Administrator on [DATE] at 6:40 PM, she stated that the DON had just informed her yesterday about the status of her IP training but as far as she was concerned she did not believe that the training expires at all. She stated when they facility does not have an in house IP person they will utilize the IP from the sister facility, consult with their in house legal nurse consultant or contact the local epidemiologist. She stated what the facility had been using was not the correct signage and that they corrected it yesterday and that the staff should be well aware.

Based on interview, record review, review of facility investigation, and facility policy review, it was determined the facility failed to protect one (1) of three (3) sampled residents (Resident #1) from verbal abuse and potential neglect. Interviews revealed the facility failed to protect Resident #1 from potential neglect, verbal abuse and psychosocial harm, by allowing Licensed Practical Nurse (LPN) #1 to speak to Resident #1 by cursing and speaking in a negative and demeaning manner. The resident was scooting around in the floor crying out, help me, help me and was told by LPN #1, I don't have time to help you. I'm busy. Once assisted to bed approximately seventeen (17) minutes later, LPN #1 told the resident to stay in the damn bed. In addition, record review and interviews revealed, LPN #1 was terminated previously on 10/20/2020, due to violating resident rights related to restraint and seclusion. She was rehired on 11/28/2020 to work independently without supervision or re-education by this facility, on the COVID unit. The facility's failure to protect Resident #1 from potential neglect, verbal abuse and psychosocial harm has caused or was likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on 12/17/2020 and determined to exist on 11/28/2020. The facility was notified of the Immediate Jeopardy on 12/17/2020. An acceptable Allegation of Compliance (AoC) was received on 12/23/2020. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 12/21/2020. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of facility policy, titled, Abuse, Neglect and Exploitation, updated on 05/17/2019, revealed it was the goal of the facility to have a process in place to protect the health and welfare of each resident. This included ensuring that each resident was free from verbal, sexual, physical and mental abuse; corporal punishment, neglect, involuntary seclusion, exploitation, and injuries of unknown origin including the use of any chemical or physical restraint not required to treat medical symptoms. Record review revealed the facility admitted Resident #1 on 05/31/2017 with diagnoses, which included Altered Mental Status, Delusional Disorders, Anterograde Amnesia, Dementia without behaviors, and [MEDICAL CONDITION]. Review of a Significant Change Minimum Data Set (MDS) assessment, dated 11/25/2020, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident was interviewable. Review of the facility investigation, dated 11/30/2020, revealed State Registered Nurse Aide (SRNA) #1 made the Administrator aware on 11/30/2020 that on 11/28/2020, she observed Resident #1 was scooting around in the floor, yelling out for help. She reported LPN #1 ignored the resident's cries for help and told the resident, I don't have time to help, I'm busy. SRNA #1 further made her aware that when the resident was assisted back to bed, LPN #1 told the resident now stay in the damn bed. Interview with SRNA #1 on 12/10/2020, revealed she was called to work the night shift, on 11/28/2020 on the non-COVID unit. SRNA #1 stated she heard a call light and saw Resident #1 in the floor through the plastic barrier between the two units at 8:40 PM, and she observed LPN #1 and SRNA #2 assist the resident back to bed at 8:52 PM. She revealed she heard Resident #1's call light continue to sound again at 8:54 PM and made Registered Nurse (RN) #1 aware and RN #1 tried to call the nurses station and did not get an answer. She stated she observed SRNA #2 respond to the resident's call light at 9:16 PM. She stated she then observed Resident #1 scooting around on the floor at 9:30 PM and yelling for help. The SRNA stated, When someone falls you should help them from the floor. She stated LPN #1 was passing medications at the time and would not assist the resident to get up and she heard LPN #1 tell the resident, I don't have time to help you. I'm busy, and continued to pass medications. She further revealed when the resident was assisted back to the bed at 9:47 PM by LPN #1 and SRNA #2, she overheard LPN #1 tell Resident #1, Now stay in the damn bed. The SRNA reported that she felt broken-hearted for the resident and she felt helpless. She stated that telling the resident to stay in the damn bed was a horrible thing to say to the resident and that it might have made the resident feel like it was his/ her own fault. SRNA #1 stated she reported what she had seen and overheard to the Charge Nurse, RN #1; and RN #1 called the unit and went to check on them through the plastic barrier. SRNA #1 revealed she reported the incident to the Administrator on 11/30/2020 and she was not aware RN #1 had not reported the allegation. Interview with the SRNA #3, who was working on the non-COVID side of plastic barrier with SRNA #1 and RN #1 the night of the incident, on 12/15/2020 at 5:06 PM, revealed she heard Resident #1 yelling out, help me, help me and she heard LPN #1 tell the resident she didn't have time to help him/her. The SRNA stated she and SRNA #1 reported to RN #1 that the staff were not helping resident out of the floor. She further revealed the resident had pushed the call light and staff did not answer the call light. She stated the LPN was very rude and hateful to the resident. Interview with RN #1, on 12/16/2020 at 5:53 AM, revealed she worked 11/28/2020 on the clean end and she recalled Resident #1 crawling in the floor on two (2) separate occasions. RN #1 stated LPN #1 was doing her medication pass later than usual and she called to check on the staff on the COVID unit but no one answered the phone. She revealed she did not approach the plastic barrier for further evaluation of the situation. She stated SRNA #1 and SRNA #3 told her the resident was in the floor crying for help, that LPN #1 would not help the resident, and that LPN #1 had cursed at the resident. She stated if she thought it was abuse/neglect she would have reported it to the Administrator, but she did not think it was abuse/neglect. RN #1 also reported that the resident was confused at times and had hallucinations and would have full conversations in his/her room with no one there. Interview with SRNA #2, on 12/15/2020 at 12:10 PM, revealed she only worked with LPN #1 for four (4) hours that night on the COVID side of barrier, from 6:00 PM - 10:00 PM. SRNA #2 stated she assisted Resident #1 back to bed on two (2) occasions. She said on the second occasion she was across the hall in another resident's room when she saw Resident #1 on the floor. She revealed she had LPN #1 assist her to get the resident back in the bed and when the resident was asked what he/she was doing, the resident stated, I'm crawling on the floor. She revealed she does not recall hearing LPN #1 say damn bed and she did not hear the LPN speak ugly to the resident. SRNA #2 reported that she did not feel that LPN #1 would abuse a resident but that her tone of voice came across as hateful sometimes. Attempts were made to contact LPN #1, on 12/10/2020 at 11:23 AM, 12/12/2020 at 10:48 AM, 12/13/2020 at 3:03 PM, and 12/15/2020 at 11:28 AM. There was no answer and messages were left but the LPN did not return the calls. Interview with the Administrator, on 12/10/2020 at 12:31 PM, and 12/15/2020 at 9:32 AM, revealed LPN #1 had been terminated on 10/20/2020, after the facility was cited for LPN #1 violating resident rights related to seclusion and restraint; however, LPN #1 went to work at a sister facility where she was also the Administrator. She stated a Performance Improvement Plan was put into place, on 10/24/2020, to address LPN #1's violation of Residents rights. The Administrator stated she rehired LPN #1 at this facility on 11/28/2020, to work the COVID unit due to the critical need of staff. Further interview revealed SRNA #1 reported the incident related to Resident #1 on 11/30/2020, and she started an investigation. The Administrator stated she determined the allegation was substantiated, but not as abuse nor neglect. She revealed she felt like the SRNA's watching should have suited up and helped and she did not think LPN #1 was trying to harm the resident. The Administrator stated LPN #1 was terminated from the building on 11/30/2020 but not from the company and was being used for staffing in a sister facility. Review of the Performance Improvement Plan (PIP) for LPN #1, dated 10/24/2020 revealed the PIP was initiated related to continued employment in a sister facility with the following concerns addressed. 1. Residents have the right of choice in their care and treatment. 2. Care plans must be followed for all residents with specific emphasis to address dementia care plans and treatments given. 3. Conduct should remain professional, even in stressful situations. 4. Employee required to repeat initial training related to behaviors and dementia, abuse and resident rights with ongoing training as specified by the DON. Review of a Post Test, dated 10/24/2020, revealed LPN #1 was educated on Dementia/[MEDICAL CONDITION]/Cognitive Impairments, and Resident Rights. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 is visited and interviewed daily to assure that the resident had no current concerns related to care and was free from abuse. 2. LPN #1 was terminated by the Administrator on 11/30/2020. On 12/01/2020 the Administrator completed notification and termination to the personnel file that stipulates LPN #1 was not eligible for re-hire. 3. On 12/18/2020, a blanket call system was mobilized by the Social Services Director at the direction of the Administrator to solicit concerns and allegations of abuse. The system contacts each resident or legal representative to solicit concerns related to care and allegation of abuse and neglect. 4. On 12/18/2020, Social Services interviewed alert residents to solicit any concerns that may be related to abuse or neglect. Those residents that were not interviewable were observed daily by Social Services for any signs and symptoms of neglect, mistreatment or abuse such as physical or mental evidence. Any concerns were monitored each day by the Administrator and the Social Services Director. 5. On 12/18/2020-12/20/2020, the DON and Charge Nurse completed physical observations of each resident that included visual inspection for outward signs and symptoms of unexplained injury, tearfulness or other psycho-social impairment to assure that residents are free from abuse and neglect. No concerns were noted. 6. On 12/18/2020, the ReachAlert system was mobilized to contact each employee to solicit any resident concerns and to assure that each resident was free from abuse and neglect. No concerns were noted. 7. On 12/17/2020, the facility secured a Long-term Care Consultant (LTCC) to assist the Administrator and the facility with compliance issues to include abuse. 8. On 12/17/2020, the LTCC met with the Administrator to review policies and facility practice on the prevention of abuse to include employee screening of hires and re-hires, reporting of abuse and investigating of abuse. Starting on 12/17/2020, the LTCC reviewed hiring practices and prevention of abuse with the Administrator daily and would continue daily review of education with the Administrator for a minimum of two weeks or until QAC indicates complete compliance. 9. The LTCC provided education to the Administrator on 12/18/2020 regarding the prevention, reporting and investigation of abuse. The Administrator completed a post-test on 12/18/2020. 10. On 12/18/2020, the Administrator and the Social Services Director began reviews of the staff scheduled for duty each day for the following day to assist in assuring that residents were not exposed to employees that may have been involved in a recent allegation of abuse. 11. On 12/18/2020, the Administrator instructed all key staff members and all department supervisors to immediately notify the Social Services Director and the Administrator of any schedule changes. 12. The Administrator made the Human Resources/Payroll Department aware on 12/18/2020, of the required review by the Administrator and Social Services Director of all new hires to include a review of the Nurse Aide Registry check, the Adult Caregiver Misconduct Registry, the Exclusion Database from Office of the Inspector General, Criminal Background checks and education provided to each new employee upon hire that included a review of resident rights and resident abuse policies that address the seven step process and procedure: screening, training, prevention, identification, protection, investigation and reporting. A review by the Administrator and Social Services Director also included the reviewing of audits of present staff by Administrative staff in walking rounds that includes the Administrator, Director of Nursing, Quality Assurance Nurse, MDS Nurse, Social Services, Dietary Director, Charge Nurse or Therapy Director. 13. On 12/18/2020 through 12/20/2020, the Social Services Director, the Director of Nursing and a charge nurse provided education to all employees on abuse policies and practices to include freedom from abuse, reporting of abuse and investigating of abuse. Each employee was post-tested on [DATE] through 12/20/2020 after receiving the education. 14. Employees that were off work and unavailable for any reason would receive this education and post-test before returning to work. 15. On 12/18/2020, the Quality Assurance Committee (QAC) conducted a virtual meeting due to the COVID-19 pandemic. The QAC meets daily seven days a week to review actions taken and compliance with IJ citations issued on 12/17/2020. The QAC members include: Administrator, DON, Assistant Director of Nursing (ADON), Quality Assurance / Infection Preventionist (QA/IP) Nurse, MDS Coordinator, Social Services (SS), Rehabilitation Therapy Director and the Medical Director. Starting on 12/18/2020, the Administrator and Social Services Director were providing the QAC full information related to the Immediate Jeopardy citations on 12/17/2020 to include all actions taken to comply with F600 (Freedom from Abuse), Reporting of abuse (F609), Investigate/Prevent/Correct Alleged Violation (F610), Administration (F835). The Administrator and Social Services Director present all actions, corrections, and reviews to the daily meetings of the QAC on the abuse prevention education that is provided to employees, post testing of abuse education, the employee abuse education attendance roster, a review of all newly hired or re-hired staff, daily staffing schedules as reviewed by the Administrator and Social Services, results from resident and employee inquisitions related to solicitation of resident concerns and allegations of abuse through ReachAlert and resident interviews completed by Social Services. The Quality abuse concerns and allegations obtained through ReachAlert and resident interviews completed by Social Services. The Quality Assurance Committee provides review, recommendations and follow-up to assure that the facility was in compliance with Freedom from Abuse (F600), Reporting of abuse (F609), Investigate/Prevent/Correct Alleged Violation (F610), Administration (F835). 17. On 12/18/2020, the DON provided education to RN #1 regarding reporting of abuse and neglect, investigating abuse, and prevention of abuse. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the interview sheets dated 12/18/2020 through 12/29/2020 revealed staff visited and interviewed Resident #1 daily to assure that the resident had no current concerns related to care and was free from abuse and no concerns were identified. Interviews on 12/29/2020, with the ADON at 9:57 AM, LPN #1 at 10:59 AM, Social Services Director (SSD) at 10:13 AM, and LPN #2 at 10:08 AM revealed daily visits were started on 12/18/2020 with Resident #1 to assure the resident had no current concerns. No concerns were voiced nor noted. 2. Review of an Employee Personnel Action Sheet revealed the Administrator terminated LPN #1 on 12/11/2020 with stipulation that LPN #1 was not eligible for re-hire. Interview with the Administrator on 12/29/2020 at 11:53 AM, revealed the LPN was ineligible for re-hire. 3. Interview with the SSD on 12/29/2020 at 10:13 AM revealed she was directed to mobilize a blanket call system for mass communication to solicit concerns and allegations of abuse. Residents or their legal representatives were contacted as well as staff to solicit any concerns regarding abuse. 4. Review of Audit sheets 12/18/2020 through 12/29/2020, revealed the SSD interviewed interviewable resident and observed non-interviewable residents for any signs and symptoms of neglect, mistreatment or abuse such as physical or mental evidence with no concerns identified Interview with the SSD on 12/29/2020 at 10:13 AM, revealed she interviewed alert residents to solicit any concerns regarding abuse and observed residents with BIMS scores of less than eight (8) daily for any signs and symptoms of neglect, mistreatment or abuse. 5. Review of audit sheets, dated 12/18/2020 through 12/20/2020, revealed the DON and Charge Nurse completed physical observations on each resident with no concerns identified. Interview with the Interim DON, on 12/29/2020 at 9:57 AM, revealed she and the Charge Nurse completed physical observations of each resident that included visual inspection for outward signs and symptoms of unexplained injury, tearfulness or other psychosocial impairment to assure that residents were free from abuse and neglect. No concerns were noted. 6. Interview with the SSD, on 12/29/2020 at 10:13 AM, revealed on 12/18/2020, the ReachAlert system was mobilized to contact each employee to solicit any resident concerns and to assure that each resident was free from abuse and neglect. No concerns were noted. Interviews on 01/08/2021 (Post Survey) with RN #2, at 5:25 AM, NA #1 at 5:26 AM, SRNA #3 at 5:27 AM, NA #2 at 5:28 AM, and SRNA #2 at 5:29 AM, revealed they had received the call through the mobile system and they had no concerns. 7. Interview with the Administrator, on 12/29/2020 at 11:53 AM, revealed on 12/17/2020 that she secured a Long-term Care Consultant (LTCC) to assist the Administrator and the facility with compliance issues to include abuse. 8. Interview with the Administrator, on 12/29/2020 at 11:53 AM revealed the LTCC met with her on 12/17/2020 to review policies and facility practice on the prevention of abuse to include employee screening of hires and re-hires, reporting of abuse and investigating abuse. She stated the LTCC met daily with her from 12/17/2020 through 12/29/2020. 9. Review of education materials/content on abuse and Posttest dated 12/18/2020 revealed the Administrator was educated and provided a posttest on the prevention, reporting and investigation of abuse. Interview with the Administrator, on 12/29/2020 at 11:53 AM, revealed she received education on 12/18/2020, regarding the prevention, reporting and investigation of abuse; and, she completed a post-test. 10. Review of staff schedules and check sheets, dated 12/18/2020 through 12/29/2020, revealed the Administrator and the Social Services Director reviewed the staff scheduled for duty each day for the following day to assist in assuring that residents were not exposed to employees that may have been involved in a recent allegation of abuse. Interviews on 12/29/2020 with the Administrator, at 11:53 AM, and the SSD at 10:13 AM, revealed starting on 12/18/2020, they reviewed the staff scheduled for duty each day for the following day to ensure residents were not exposed to employees that may have been involved in a recent allegation of abuse. She stated no concerns identified. 11. Review of an attendance roster, dated 12/18/2020 revealed the Administrator instructed key staff members and department supervisors to notify the SSD and herself if there were any schedule changes Interview with the Administrator, on 12/29/2020 at 11:53 AM, revealed she instructed key staff members and all department supervisors to notify the SSD and herself immediately of any schedule changes. 12. Review of the new hire review checklist and the daily Administrative round flow sheets revealed the Administrator and SSD reviewed all new hires paperwork to ensure a Nurse Aide Registry check, the Adult Caregiver Misconduct Registry check, the Exclusion Database from Office of the Inspector General was checked, and a Criminal Background check was completed. In addition, they ensured education was provided to each new employee upon hire that included a review of resident rights and resident abuse policies that address the seven-step process and procedure: screening, training, prevention, identification, protection, investigation and reporting. They also reviewed the walking round audits by Demonstrative staff of present staff. Interviews on 12/29/2020, with the Administrator at 11:53 AM, Human Resources/payroll staff at 10:24 AM, and the SSD, at 10:13 AM, revealed all new hires were screened by the Administrator and the SSD for a review of the Nurse Aide Registry check, the Kentucky Adult Caregiver Misconduct Registry, the Exclusion Database from the Office of Inspector General and Criminal background checks and the new hires were being educated on Resident Rights and abuse. 13. Review of a staff roster and posttests, dated 12/18/2020 through 12/20/2020, revealed staff were education on abuse and scored 100% on posttests. Interviews on 12/28/2020, with LPN #2 at 2:24 PM, RN #1 at 2:27 PM, SRNA #4 at 2:40 PM, SRNA #3 at 2:44 PM, Dietary staff member #1 at 2:56 PM, SRNA #2 at 3:01 PM, Medication Technician (MT) #1 at 3:06 PM, and LPN #2 at 10:08 AM; and on 12/29/2020 with SSD at 10:13 AM, HR/Payroll at 10:24 AM, LPN #1 at 10:59 AM, and the MDS Coordinator at 11:14 AM, revealed they were educated on abuse and neglect. 14. Review of the education rosters for abuse dated 12/18/2020 through 12/20/2020 did not have staff that were educated after 12/20/2020. 15. Review of QAC meeting rosters revealed they met daily from 12/18/2020 to 12/29/2020. Interviews on 12/29/2020 with the ADON at 9:57 AM, the QA/IP Nurse at 10:08 AM, the SSD at 10:13 AM, MDS Nurse at 11:14 AM, and the Administrator at 11:53 AM, revealed they have been attending the daily QAC meetings and the topics of discussion included the Immediate Jeopardy's the facility received on 12/17/2020 Interview (Post survey) with the Administrator, on 01/08/2021 at 9:29 AM, revealed during the QAC meetings they discussed the AoC, staff schedules, any concerns brought up and new hires. Interview (Post Survey) with the SSD, on 01/08/2021 at 9:33 AM, revealed during the QAC meetings they would discuss staffing schedules, any resident, family or staff concerns and the AoC. Interview with the facility Medical Director, on 12/29/2020 at 10:40 AM, revealed he was made aware of the recent Jeopardy tags, attended the required QA meeting, and that he has no concerns with the facility. 17. Interview with RN #1 on 12/28/2020 revealed she was re-educated on abuse and neglect and had to sign a form and take a post-test. She was educated to report any allegation of abuse or neglect immediately to her supervisor. Interview with the Administrator on 12/29/2020 at 11:53 AM revealed the DON had provided education and post-testing regarding reporting of abuse and neglect, investigating abuse and prevention of abuse to RN #1.

Based on interview, record review, review of facility investigation, and facility policy review, it was determined the facility failed to ensure staff reported an allegation of abuse/neglect immediately to the administrator for one (1) of three (3) sampled residents (Resident #1). Interviews revealed on 11/28/2020, a State Register Nurse Aide (SRNA) reported to Registered Nurse (RN) #1 that Licensed Practical Nurse (LPN) #1 told Resident #1, I don't have time to help you. I'm busy while the resident was scooting around on the floor asking for help. In addition, LPN #1 told the resident now stay in the damn bed when she and SRNA #1 placed the resident back in bed. However, staff failed to report the allegation to Administration immediately per facility policy. SRNA #1 reported the incident to the Administrator two (2) days later. The facility's failure to ensure staff reported an allegation of abuse in a timely manner has caused or was likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on 12/17/2020 and determined to exist on 11/28/2020. The facility was notified of the Immediate Jeopardy on 12/17/2020. An acceptable Allegation of Compliance (AoC) was received on 12/23/2020. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 12/21/2020. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of facility policy, titled, Abuse, Neglect and Exploitation, updated 05/17/2019, revealed an alleged violation and all substantiated incidents shall be reported as set forth in paragraph two (2) under the investigation section. Any incidents of suspected abuse, neglect or exploitation involving staff towards a resident(s) shall be immediately reported to the employee's immediate supervisor and the Administrator and/or designee, at which time an investigation will begin. The Charge Nurse shall be immediately notified of the incident who will then contact the physician for necessary medical intervention, if needed. Review of the facility investigation, dated 11/30/2020, revealed the Administrator was made aware on 11/30/2020 by SRNA #1, that Resident #1 was in the floor scooting around and yelling out for help on the COVID unit on 11/28/2020. Further review of the investigation revealed it was reported LPN #1 ignored the resident's cries for help and told the resident, I don't have time to help, I'm busy. In addition, it was reported when the resident was assisted back to bed, LPN #1 told the resident now stay in the damn bed. On 12/10/2020 at 1:34 PM, interview with SRNA #1, revealed she made Registered Nurse (RN) #1 aware Resident #1, who resided on the Covid unit, was in the floor. SRNA #1 stated the staff on the COVID unit were ignoring the residents cries for help and did not immediately assist the resident up off the floor. She also reported to the RN that she heard LPN #1 say to the resident, I don't have time to help, I'm busy. After assisting the resident back to bed LPN #1 told the resident, Now stay in the damn bed. SRNA #1 stated she informed the Administrator of the alleged abuse on the morning of 11/30/2020. She revealed when she spoke with the Administrator, he was very hateful and made her feel like she was in the wrong for reporting. Interviews on 12/10/2020 at 10:56 AM, and on 12/15/2020 at 5:06 PM, with SRNA #3, revealed she worked the night Resident #1 was in the floor. SRNA #3 stated she and SRNA #1 reported to RN #1 that LPN #1 was very rude and hateful to the resident and the LPN told the resident that she did not have time to help him/her while the resident was yelling out, help me, help me. She further revealed they reported LPN #1 told Resident #1 to now stay in the damn bed. Interview with RN #1, on 12/16/2020 at 5:53 AM, and on 01/07/2021 (Post Survey) at 10:18 AM, revealed she was working on the clean end of the building and she observed Resident #1 crawling out into the hallway twice on the COVID unit. The RN stated that she could hear the resident yelling out and SRNA #1 and #3 told her the staff were not assisting the resident back into the bed. She further revealed she did not think there was neglect/or abuse but wished that the staff had taken care of the resident quicker. She stated if she thought it was abuse, she would have reported the incident immediately to the Administrator. The RN stated the SRNA's did not tell her that the LPN had cursed at the resident. She revealed that nothing was ever said about the resident being abused. She stated if she felt it was abuse, she would have removed the LPN from resident care and notified the Administrator. She revealed she was very aware of the abuse policy. However, did not consider the aides report, as possible neglect. Interview with the Administrator, on 12/10/2020 at 12:31 PM, revealed SRNA #1 notified her on 11/30/2020 of the events between Resident #1 and LPN #1. The Administrator stated the SRNA #1 did not inform her until 11/30/2020 of the potential allegation of abuse/neglect. She stated she expected staff to report any suspicion or allegation of abuse immediately, per policy. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 is visited and interviewed daily to assure that the resident had no current concerns related to care and was free from abuse. 2. LPN #1 was terminated by the Administrator on 11/30/2020. On 12/01/2020 the Administrator completed notification and termination to the personnel file that stipulates LPN #1 was not eligible for re-hire. 3. On 12/18/2020, a blanket call system was mobilized by the Social Services Director at the direction of the Administrator to solicit concerns and allegations of abuse. The system contacts each resident or legal representative to solicit concerns related to care and allegation of abuse and neglect. 4. On 12/18/2020, Social Services interviewed alert residents to solicit any concerns that may be related to abuse or neglect. Those residents that were not interviewable were observed daily by Social Services for any signs and symptoms of neglect, mistreatment or abuse such as physical or mental evidence. Any concerns were monitored each day by the Administrator and the Social Services Director. 5. On 12/18/2020-12/20/2020, the DON and Charge Nurse completed physical observations of each resident that included visual inspection for outward signs and symptoms of unexplained injury, tearfulness or other psycho-social impairment to assure that residents are free from abuse and neglect. No concerns were noted. 6. On 12/18/2020, the ReachAlert system was mobilized to contact each employee to solicit any resident concerns and to assure that each resident was free from abuse and neglect. No concerns were noted. 7. On 12/17/2020, the facility secured a Long-term Care Consultant (LTCC) to assist the Administrator and the facility with compliance issues to include abuse. 8. On 12/17/2020, the LTCC met with the Administrator to review policies and facility practice on the prevention of abuse to include employee screening of hires and re-hires, reporting of abuse and investigating of abuse. Starting on 12/17/2020, the LTCC reviewed hiring practices and prevention of abuse with the Administrator daily and would continue daily review of education with the Administrator for a minimum of two weeks or until QAC indicates complete compliance. 9. The LTCC provided education to the Administrator on 12/18/2020 regarding the prevention, reporting and investigation of abuse. The Administrator completed a post-test on 12/18/2020. 10. On 12/18/2020, the Administrator and the Social Services Director began reviews of the staff scheduled for duty each day for the following day to assist in assuring that residents were not exposed to employees that may have been involved in a recent allegation of abuse. 11. On 12/18/2020, the Administrator instructed all key staff members and all department supervisors to immediately notify the Social Services Director and the Administrator of any schedule changes. 12. The Administrator made the Human Resources/Payroll Department aware on 12/18/2020, of the required review by the Administrator and Social Services Director of all new hires to include a review of the Nurse Aide Registry check, the Adult Caregiver Misconduct Registry, the Exclusion Database from Office of the Inspector General, Criminal Background checks and education provided to each new employee upon hire that included a review of resident rights and resident abuse policies that address the seven step process and procedure: screening, training, prevention, identification, protection, investigation and reporting. A review by the Administrator and Social Services Director also included the reviewing of audits of present staff by Administrative staff in walking rounds that includes the Administrator, Director of Nursing, Quality Assurance Nurse, MDS Nurse, Social Services, Dietary Director, Charge Nurse or Therapy Director. 13. On 12/18/2020 through 12/20/2020, the Social Services Director, the Director of Nursing and a charge nurse provided education to all employees on abuse policies and practices to include freedom from abuse, reporting of abuse and investigating of abuse. Each employee was post-tested on [DATE] through 12/20/2020 after receiving the education. 14. Employees that were off work and unavailable for any reason would receive this education and post-test before returning to work. 15. On 12/18/2020, the Quality Assurance Committee (QAC) conducted a virtual meeting due to the COVID-19 pandemic. The QAC meets daily seven days a week to review actions taken and compliance with IJ citations issued on 12/17/2020. The QAC members include: Administrator, DON, Assistant Director of Nursing (ADON), Quality Assurance / Infection Preventionist (QA/IP) Nurse, MDS Coordinator, Social Services (SS), Rehabilitation Therapy Director and the Medical Director. Starting on 12/18/2020, the Administrator and Social Services Director were providing the QAC full information related to the Immediate Jeopardy citations on 12/17/2020 to include all actions taken to comply with F600 (Freedom from Abuse), Reporting of abuse (F609), Investigate/Prevent/Correct Alleged Violation (F610), Administration (F835). The Administrator and Social Services Director present all actions, corrections, and reviews to the daily meetings of the QAC on the abuse prevention education that is provided to employees, post testing of abuse education, the employee abuse education attendance roster, a review of all newly hired or re-hired staff, daily staffing schedules as reviewed by the Administrator and Social Services, results from resident and employee inquisitions related to solicitation of resident concerns and allegations of abuse through ReachAlert and resident interviews completed by Social Services. The Quality abuse concerns and allegations obtained through ReachAlert and resident interviews completed by Social Services. The Quality Assurance Committee provides review, recommendations and follow-up to assure that the facility was in compliance with Freedom from Abuse (F600), Reporting of abuse (F609), Investigate/Prevent/Correct Alleged Violation (F610), Administration (F835). 17. On 12/18/2020, the DON provided education to RN #1 regarding reporting of abuse and neglect, investigating abuse, and prevention of abuse. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the interview sheets dated 12/18/2020 through 12/29/2020 revealed staff visited and interviewed Resident #1 daily to assure that the resident had no current concerns related to care and was free from abuse and no concerns were identified. Interviews on 12/29/2020, with the ADON at 9:57 AM, LPN #1 at 10:59 AM, Social Services Director (SSD) at 10:13 AM, and LPN #2 at 10:08 AM revealed daily visits were started on 12/18/2020 with Resident #1 to assure the resident had no current concerns. No concerns were voiced nor noted. 2. Review of an Employee Personnel Action Sheet revealed the Administrator terminated LPN #1 on 12/11/2020 with stipulation that LPN #1 was not eligible for re-hire. Interview with the Administrator on 12/29/2020 at 11:53 AM, revealed the LPN was ineligible for re-hire. 3. Interview with the SSD on 12/29/2020 at 10:13 AM revealed she was directed to mobilize a blanket call system for mass communication to solicit concerns and allegations of abuse. Residents or their legal representatives were contacted as well as staff to solicit any concerns regarding abuse. 4. Review of Audit sheets 12/18/2020 through 12/29/2020, revealed the SSD interviewed interviewable resident and observed non-interviewable residents for any signs and symptoms of neglect, mistreatment or abuse such as physical or mental evidence with no concerns identified Interview with the SSD on 12/29/2020 at 10:13 AM, revealed she interviewed alert residents to solicit any concerns regarding abuse and observed residents with BIMS scores of less than eight (8) daily for any signs and symptoms of neglect, mistreatment or abuse. 5. Review of audit sheets, dated 12/18/2020 through 12/20/2020, revealed the DON and Charge Nurse completed physical observations on each resident with no concerns identified. Interview with the Interim DON, on 12/29/2020 at 9:57 AM, revealed she and the Charge Nurse completed physical observations of each resident that included visual inspection for outward signs and symptoms of unexplained injury, tearfulness or other psychosocial impairment to assure that residents were free from abuse and neglect. No concerns were noted. 6. Interview with the SSD, on 12/29/2020 at 10:13 AM, revealed on 12/18/2020, the ReachAlert system was mobilized to contact each employee to solicit any resident concerns and to assure that each resident was free from abuse and neglect. No concerns were noted. Interviews on 01/08/2021 (Post Survey) with RN #2, at 5:25 AM, NA #1 at 5:26 AM, SRNA #3 at 5:27 AM, NA #2 at 5:28 AM, and SRNA #2 at 5:29 AM, revealed they had received the call through the mobile system and they had no concerns. 7. Interview with the Administrator, on 12/29/2020 at 11:53 AM, revealed on 12/17/2020 that she secured a Long-term Care Consultant (LTCC) to assist the Administrator and the facility with compliance issues to include abuse. 8. Interview with the Administrator, on 12/29/2020 at 11:53 AM revealed the LTCC met with her on 12/17/2020 to review policies and facility practice on the prevention of abuse to include employee screening of hires and re-hires, reporting of abuse and investigating abuse. She stated the LTCC met daily with her from 12/17/2020 through 12/29/2020. 9. Review of education materials/content on abuse and Posttest dated 12/18/2020 revealed the Administrator was educated and provided a posttest on the prevention, reporting and investigation of abuse. Interview with the Administrator, on 12/29/2020 at 11:53 AM, revealed she received education on 12/18/2020, regarding the prevention, reporting and investigation of abuse; and, she completed a post-test. 10. Review of staff schedules and check sheets, dated 12/18/2020 through 12/29/2020, revealed the Administrator and the Social Services Director reviewed the staff scheduled for duty each day for the following day to assist in assuring that residents were not exposed to employees that may have been involved in a recent allegation of abuse. Interviews on 12/29/2020 with the Administrator, at 11:53 AM, and the SSD at 10:13 AM, revealed starting on 12/18/2020, they reviewed the staff scheduled for duty each day for the following day to ensure residents were not exposed to employees that may have been involved in a recent allegation of abuse. She stated no concerns identified. 11. Review of an attendance roster, dated 12/18/2020 revealed the Administrator instructed key staff members and department supervisors to notify the SSD and herself if there were any schedule changes Interview with the Administrator, on 12/29/2020 at 11:53 AM, revealed she instructed key staff members and all department supervisors to notify the SSD and herself immediately of any schedule changes. 12. Review of the new hire review checklist and the daily Administrative round flow sheets revealed the Administrator and SSD reviewed all new hires paperwork to ensure a Nurse Aide Registry check, the Adult Caregiver Misconduct Registry check, the Exclusion Database from Office of the Inspector General was checked, and a Criminal Background check was completed. In addition, they ensured education was provided to each new employee upon hire that included a review of resident rights and resident abuse policies that address the seven-step process and procedure: screening, training, prevention, identification, protection, investigation and reporting. They also reviewed the walking round audits by Demonstrative staff of present staff. Interviews on 12/29/2020, with the Administrator at 11:53 AM, Human Resources/payroll staff at 10:24 AM, and the SSD, at 10:13 AM, revealed all new hires were screened by the Administrator and the SSD for a review of the Nurse Aide Registry check, the Kentucky Adult Caregiver Misconduct Registry, the Exclusion Database from the Office of Inspector General and Criminal background checks and the new hires were being educated on Resident Rights and abuse. 13. Review of a staff roster and posttests, dated 12/18/2020 through 12/20/2020, revealed staff were education on abuse and scored 100% on posttests. Interviews on 12/28/2020, with LPN #2 at 2:24 PM, RN #1 at 2:27 PM, SRNA #4 at 2:40 PM, SRNA #3 at 2:44 PM, Dietary staff member #1 at 2:56 PM, SRNA #2 at 3:01 PM, Medication Technician (MT) #1 at 3:06 PM, and LPN #2 at 10:08 AM; and on 12/29/2020 with SSD at 10:13 AM, HR/Payroll at 10:24 AM, LPN #1 at 10:59 AM, and the MDS Coordinator at 11:14 AM, revealed they were educated on abuse and neglect. 14. Review of the education rosters for abuse dated 12/18/2020 through 12/20/2020 did not have staff that were educated after 12/20/2020. 15. Review of QAC meeting rosters revealed they met daily from 12/18/2020 to 12/29/2020. Interviews on 12/29/2020 with the ADON at 9:57 AM, the QA/IP Nurse at 10:08 AM, the SSD at 10:13 AM, MDS Nurse at 11:14 AM, and the Administrator at 11:53 AM, revealed they have been attending the daily QAC meetings and the topics of discussion included the Immediate Jeopardy's the facility received on 12/17/2020 Interview (Post survey) with the Administrator, on 01/08/2021 at 9:29 AM, revealed during the QAC meetings they discussed the AoC, staff schedules, any concerns brought up and new hires. Interview (Post Survey) with the SSD, on 01/08/2021 at 9:33 AM, revealed during the QAC meetings they would discuss staffing schedules, any resident, family or staff concerns and the AoC. Interview with the facility Medical Director, on 12/29/2020 at 10:40 AM, revealed he was made aware of the recent Jeopardy tags, attended the required QA meeting, and that he has no concerns with the facility. 17. Interview with RN #1 on 12/28/2020 revealed she was re-educated on abuse and neglect and had to sign a form and take a post-test. She was educated to report any allegation of abuse or neglect immediately to her supervisor. Interview with the Administrator on 12/29/2020 at 11:53 AM revealed the DON had provided education and post-testing regarding reporting of abuse and neglect, investigating abuse and prevention of abuse to RN #1.

Based on interview, record review, and facility policy review it was determined the facility failed to prevent further potential abuse/neglect and to conduct a thorough investigation after an allegation of abuse was reported to Registered Nurse #1 on 11/28/2020, for one (1) of three (3) sampled residents (Resident #1). Interviews revealed on 11/28/2020, State Registered Nursing Aides (SRNA) #1 and #3 reported to Registered Nurse (RN) #1 that Resident #1 was scooting around on the floor hollering, Help me, help me. Staff alleged Licensed Practical Nurse (LPN) #1 told the resident she did not have time to help him/her and when the resident was, assisted back to bed, LPN #1 told the resident to stay in damn bed. The facility failed to remove LPN #1 from resident care until 11/30/2020. Record review revealed the facility failed to conduct a thorough investigation. The facility's failure to protect residents from further potential abuse or neglect and conduct a thorough investigation, has caused or was likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on 12/17/2020 and determined to exist on 11/28/2020. The facility was notified of the Immediate Jeopardy on 12/17/2020. An acceptable Allegation of Compliance (AoC) was received on 12/23/2020. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 12/21/2020. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility policy, titled, Abuse, Neglect and Exploitation, updated 05/17/2019, revealed the Administrator or designee shall take prompt action to protect the individual, including suspension of the suspected staff member, pending outcome of the investigation. The policy also revealed that allegations or suspicions should be thoroughly investigated by the Abuse/Neglect Coordinator, Administrator, and/or their designee. If an employee was involved, he/she may be restricted from further contact with individuals during the investigation process. As outlined in the Resident Abuse/allegation policy, the employee's written statement would be obtained and the employee may be sent off duty, without pay, pending an investigation and final determination. Review of facility investigation, dated 11/30/2020, and interviews with State Registered Nurse Aide (SRNA) #1, on 12/20/2020 at 1:34 PM, and SRNA #3 on 12/15/2020 at 5:06 PM, revealed on the evening of 11/28/2020, SRNA #1 and SRNA #3 were able to see through the plastic barrier to the COVID Unit. SRNA #1 and #3 reported they observed Resident #1 crawling in the floor in the hall and could hear the resident crying out help me, help me on two (2) different occasions. Further review and interviews revealed the first time the resident was on the floor, LPN #1 and SRNA #3 did not assist the resident back to bed for approximately ten (10) minutes and a few minutes later, the resident's call light went off. SRNA #1 stated it sounded for approximately twenty (20) minutes. RN #1 (nurse on non-COVID area with SRNA #1 and #3) tried to call the unit with no answer but then SRNA #2 was observed to answer the call light. Approximately fifteen (15) minutes later SRNA #1 observed the resident crawling on the floor again and crying out help me help me. LPN #1 was observed to continue to pass medications and heard to tell the resident, I don't have time to help you, I'm busy. After the resident was assisted back to bed approximately fifteen (15) minutes later. SRNA #1 heard LPN state, now stay in the damn bed. The SRNA's reported what they had seen and heard to RN #1. Further review revealed no indications on the investigation that skin assessments were completed for the cognitively impaired residents, nor were residents assessed for psychosocial harm. The Administrator did not determine an issue related to LPN #1 continuing to provide care to residents after these incidents. Interview with RN #1, on 12/16/2020 at 5:53 AM, and on 01/07/2021 (Post Survey) at 10:18 AM, revealed SRNA #1 and SRNA #3 reported to her Resident #1 was in the floor and staff were not answering the resident's call light fast enough. RN #1 stated she did not report the incident to the Administrator, as she did not feel that it was abuse and LPN #1 was allowed to continue to work. Interview with the Human Resources/payroll staff, on 12/29/2020 at 10:24 AM, revealed LPN #1 finished her four (4) hour shift, on 11/28/2020 at 10:00 PM, worked twelve (12) hours on 11/29/2020, and a partial shift on 11/30/2020 providing resident care. She stated LPN #1 was relieved, terminated, and escorted out of the building on 11/30/2020, and was available for rehire. Interview with the Administrator, on 12/10/2020 at 12:31 PM, revealed she would have removed the LPN from the building had the incident been reported to her. She stated if the staff suspected abuse, the LPN should have been removed from the building and reported the incident to the Administration. She also revealed that she terminated LPN #1, on 11/30/2020, but she allowed her to work at the sister facility because she had not substantiated abuse with her investigation. The Administrator stated that she felt the investigation was thorough. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 is visited and interviewed daily to assure that the resident had no current concerns related to care and was free from abuse. 2. LPN #1 was terminated by the Administrator on 11/30/2020. On 12/01/2020 the Administrator completed notification and termination to the personnel file that stipulates LPN #1 was not eligible for re-hire. 3. On 12/18/2020, a blanket call system was mobilized by the Social Services Director at the direction of the Administrator to solicit concerns and allegations of abuse. The system contacts each resident or legal representative to solicit concerns related to care and allegation of abuse and neglect. 4. On 12/18/2020, Social Services interviewed alert residents to solicit any concerns that may be related to abuse or neglect. Those residents that were not interviewable were observed daily by Social Services for any signs and symptoms of neglect, mistreatment or abuse such as physical or mental evidence. Any concerns were monitored each day by the Administrator and the Social Services Director. 5. On 12/18/2020-12/20/2020, the DON and Charge Nurse completed physical observations of each resident that included visual inspection for outward signs and symptoms of unexplained injury, tearfulness or other psycho-social impairment to assure that residents are free from abuse and neglect. No concerns were noted. 6. On 12/18/2020, the ReachAlert system was mobilized to contact each employee to solicit any resident concerns and to assure that each resident was free from abuse and neglect. No concerns were noted. 7. On 12/17/2020, the facility secured a Long-term Care Consultant (LTCC) to assist the Administrator and the facility with compliance issues to include abuse. 8. On 12/17/2020, the LTCC met with the Administrator to review policies and facility practice on the prevention of abuse to include employee screening of hires and re-hires, reporting of abuse and investigating of abuse. Starting on 12/17/2020, the LTCC reviewed hiring practices and prevention of abuse with the Administrator daily and would continue daily review of education with the Administrator for a minimum of two weeks or until QAC indicates complete compliance. 9. The LTCC provided education to the Administrator on 12/18/2020 regarding the prevention, reporting and investigation of abuse. The Administrator completed a post-test on 12/18/2020. 10. On 12/18/2020, the Administrator and the Social Services Director began reviews of the staff scheduled for duty each day for the following day to assist in assuring that residents were not exposed to employees that may have been involved in a recent allegation of abuse. 11. On 12/18/2020, the Administrator instructed all key staff members and all department supervisors to immediately notify the Social Services Director and the Administrator of any schedule changes. 12. The Administrator made the Human Resources/Payroll Department aware on 12/18/2020, of the required review by the Administrator and Social Services Director of all new hires to include a review of the Nurse Aide Registry check, the Adult Caregiver Misconduct Registry, the Exclusion Database from Office of the Inspector General, Criminal Background checks and education provided to each new employee upon hire that included a review of resident rights and resident abuse policies that address the seven step process and procedure: screening, training, prevention, identification, protection, investigation and reporting. A review by the Administrator and Social Services Director also included the reviewing of audits of present staff by Administrative staff in walking rounds that includes the Administrator, Director of Nursing, Quality Assurance Nurse, MDS Nurse, Social Services, Dietary Director, Charge Nurse or Therapy Director. 13. On 12/18/2020 through 12/20/2020, the Social Services Director, the Director of Nursing and a charge nurse provided education to all employees on abuse policies and practices to include freedom from abuse, reporting of abuse and investigating of abuse. Each employee was post-tested on [DATE] through 12/20/2020 after receiving the education. 14. Employees that were off work and unavailable for any reason would receive this education and post-test before returning to work. 15. On 12/18/2020, the Quality Assurance Committee (QAC) conducted a virtual meeting due to the COVID-19 pandemic. The QAC meets daily seven days a week to review actions taken and compliance with IJ citations issued on 12/17/2020. The QAC members include: Administrator, DON, Assistant Director of Nursing (ADON), Quality Assurance / Infection Preventionist (QA/IP) Nurse, MDS Coordinator, Social Services (SS), Rehabilitation Therapy Director and the Medical Director. Starting on 12/18/2020, the Administrator and Social Services Director were providing the QAC full information related to the Immediate Jeopardy citations on 12/17/2020 to include all actions taken to comply with F600 (Freedom from Abuse), Reporting of abuse (F609), Investigate/Prevent/Correct Alleged Violation (F610), Administration (F835). The Administrator and Social Services Director present all actions, corrections, and reviews to the daily meetings of the QAC on the abuse prevention education that is provided to employees, post testing of abuse education, the employee abuse education attendance roster, a review of all newly hired or re-hired staff, daily staffing schedules as reviewed by the Administrator and Social Services, results from resident and employee inquisitions related to solicitation of resident concerns and allegations of abuse through ReachAlert and resident interviews completed by Social Services. The Quality abuse concerns and allegations obtained through ReachAlert and resident interviews completed by Social Services. The Quality Assurance Committee provides review, recommendations and follow-up to assure that the facility was in compliance with Freedom from Abuse (F600), Reporting of abuse (F609), Investigate/Prevent/Correct Alleged Violation (F610), Administration (F835). 17. On 12/18/2020, the DON provided education to RN #1 regarding reporting of abuse and neglect, investigating abuse, and prevention of abuse. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the interview sheets dated 12/18/2020 through 12/29/2020 revealed staff visited and interviewed Resident #1 daily to assure that the resident had no current concerns related to care and was free from abuse and no concerns were identified. Interviews on 12/29/2020, with the ADON at 9:57 AM, LPN #1 at 10:59 AM, Social Services Director (SSD) at 10:13 AM, and LPN #2 at 10:08 AM revealed daily visits were started on 12/18/2020 with Resident #1 to assure the resident had no current concerns. No concerns were voiced nor noted. 2. Review of an Employee Personnel Action Sheet revealed the Administrator terminated LPN #1 on 12/11/2020 with stipulation that LPN #1 was not eligible for re-hire. Interview with the Administrator on 12/29/2020 at 11:53 AM, revealed the LPN was ineligible for re-hire. 3. Interview with the SSD on 12/29/2020 at 10:13 AM revealed she was directed to mobilize a blanket call system for mass communication to solicit concerns and allegations of abuse. Residents or their legal representatives were contacted as well as staff to solicit any concerns regarding abuse. 4. Review of Audit sheets 12/18/2020 through 12/29/2020, revealed the SSD interviewed interviewable resident and observed non-interviewable residents for any signs and symptoms of neglect, mistreatment or abuse such as physical or mental evidence with no concerns identified Interview with the SSD on 12/29/2020 at 10:13 AM, revealed she interviewed alert residents to solicit any concerns regarding abuse and observed residents with BIMS scores of less than eight (8) daily for any signs and symptoms of neglect, mistreatment or abuse. 5. Review of audit sheets, dated 12/18/2020 through 12/20/2020, revealed the DON and Charge Nurse completed physical observations on each resident with no concerns identified. Interview with the Interim DON, on 12/29/2020 at 9:57 AM, revealed she and the Charge Nurse completed physical observations of each resident that included visual inspection for outward signs and symptoms of unexplained injury, tearfulness or other psychosocial impairment to assure that residents were free from abuse and neglect. No concerns were noted. 6. Interview with the SSD, on 12/29/2020 at 10:13 AM, revealed on 12/18/2020, the ReachAlert system was mobilized to contact each employee to solicit any resident concerns and to assure that each resident was free from abuse and neglect. No concerns were noted. Interviews on 01/08/2021 (Post Survey) with RN #2, at 5:25 AM, NA #1 at 5:26 AM, SRNA #3 at 5:27 AM, NA #2 at 5:28 AM, and SRNA #2 at 5:29 AM, revealed they had received the call through the mobile system and they had no concerns. 7. Interview with the Administrator, on 12/29/2020 at 11:53 AM, revealed on 12/17/2020 that she secured a Long-term Care Consultant (LTCC) to assist the Administrator and the facility with compliance issues to include abuse. 8. Interview with the Administrator, on 12/29/2020 at 11:53 AM revealed the LTCC met with her on 12/17/2020 to review policies and facility practice on the prevention of abuse to include employee screening of hires and re-hires, reporting of abuse and investigating abuse. She stated the LTCC met daily with her from 12/17/2020 through 12/29/2020. 9. Review of education materials/content on abuse and Posttest dated 12/18/2020 revealed the Administrator was educated and provided a posttest on the prevention, reporting and investigation of abuse. Interview with the Administrator, on 12/29/2020 at 11:53 AM, revealed she received education on 12/18/2020, regarding the prevention, reporting and investigation of abuse; and, she completed a post-test. 10. Review of staff schedules and check sheets, dated 12/18/2020 through 12/29/2020, revealed the Administrator and the Social Services Director reviewed the staff scheduled for duty each day for the following day to assist in assuring that residents were not exposed to employees that may have been involved in a recent allegation of abuse. Interviews on 12/29/2020 with the Administrator, at 11:53 AM, and the SSD at 10:13 AM, revealed starting on 12/18/2020, they reviewed the staff scheduled for duty each day for the following day to ensure residents were not exposed to employees that may have been involved in a recent allegation of abuse. She stated no concerns identified. 11. Review of an attendance roster, dated 12/18/2020 revealed the Administrator instructed key staff members and department supervisors to notify the SSD and herself if there were any schedule changes Interview with the Administrator, on 12/29/2020 at 11:53 AM, revealed she instructed key staff members and all department supervisors to notify the SSD and herself immediately of any schedule changes. 12. Review of the new hire review checklist and the daily Administrative round flow sheets revealed the Administrator and SSD reviewed all new hires paperwork to ensure a Nurse Aide Registry check, the Adult Caregiver Misconduct Registry check, the Exclusion Database from Office of the Inspector General was checked, and a Criminal Background check was completed. In addition, they ensured education was provided to each new employee upon hire that included a review of resident rights and resident abuse policies that address the seven-step process and procedure: screening, training, prevention, identification, protection, investigation and reporting. They also reviewed the walking round audits by Demonstrative staff of present staff. Interviews on 12/29/2020, with the Administrator at 11:53 AM, Human Resources/payroll staff at 10:24 AM, and the SSD, at 10:13 AM, revealed all new hires were screened by the Administrator and the SSD for a review of the Nurse Aide Registry check, the Kentucky Adult Caregiver Misconduct Registry, the Exclusion Database from the Office of Inspector General and Criminal background checks and the new hires were being educated on Resident Rights and abuse. 13. Review of a staff roster and posttests, dated 12/18/2020 through 12/20/2020, revealed staff were education on abuse and scored 100% on posttests. Interviews on 12/28/2020, with LPN #2 at 2:24 PM, RN #1 at 2:27 PM, SRNA #4 at 2:40 PM, SRNA #3 at 2:44 PM, Dietary staff member #1 at 2:56 PM, SRNA #2 at 3:01 PM, Medication Technician (MT) #1 at 3:06 PM, and LPN #2 at 10:08 AM; and on 12/29/2020 with SSD at 10:13 AM, HR/Payroll at 10:24 AM, LPN #1 at 10:59 AM, and the MDS Coordinator at 11:14 AM, revealed they were educated on abuse and neglect. 14. Review of the education rosters for abuse dated 12/18/2020 through 12/20/2020 did not have staff that were educated after 12/20/2020. 15. Review of QAC meeting rosters revealed they met daily from 12/18/2020 to 12/29/2020. Interviews on 12/29/2020 with the ADON at 9:57 AM, the QA/IP Nurse at 10:08 AM, the SSD at 10:13 AM, MDS Nurse at 11:14 AM, and the Administrator at 11:53 AM, revealed they have been attending the daily QAC meetings and the topics of discussion included the Immediate Jeopardy's the facility received on 12/17/2020 Interview (Post survey) with the Administrator, on 01/08/2021 at 9:29 AM, revealed during the QAC meetings they discussed the AoC, staff schedules, any concerns brought up and new hires. Interview (Post Survey) with the SSD, on 01/08/2021 at 9:33 AM, revealed during the QAC meetings they would discuss staffing schedules, any resident, family or staff concerns and the AoC. Interview with the facility Medical Director, on 12/29/2020 at 10:40 AM, revealed he was made aware of the recent Jeopardy tags, attended the required QA meeting, and that he has no concerns with the facility. 17. Interview with RN #1 on 12/28/2020 revealed she was re-educated on abuse and neglect and had to sign a form and take a post-test. She was educated to report any allegation of abuse or neglect immediately to her supervisor. Interview with the Administrator on 12/29/2020 at 11:53 AM revealed the DON had provided education and post-testing regarding reporting of abuse and neglect, investigating abuse and prevention of abuse to RN #1.

Based on interview, record review, facility investigation, and Administrator job description, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Record review and interview revealed the Administrator had terminated Licensed Practical Nurse (LPN) #1, on 10/20/2020, after it was determined LPN #1 violated resident rights related to seclusion and restraint. LPN #1 went to work at the sister facility that the Administer was also the Administrator. On 11/28/2020, the Administrator rehired LPN #1 at this facility to work on the COVID Unit. The LPN was rehired without providing any re-education or training at this facility. She was allowed to work without supervision and an allegation that LPN #1 abused a resident was reported on 11/30/2020. In addition, the Administrator failed to conduct a thorough investigation. Interviews revealed the LPN was terminated on 11/30/2020, and again was available for rehire, because the Administrator did not believe the allegation was abuse or neglect. The facility's failure to be administered in a manner that used its resources has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/17/2020 and determined to exist on 11/28/2020. The facility was notified of the Immediate Jeopardy on 12/17/2020. An acceptable Allegation of Compliance (AoC) was received on 12/23/2020. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 12/21/2020. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the Administrator's job description revealed the nursing home administrator developed, managed, and directed health care programs such as preventive medicine and staff training. Other duties included she was responsible for managing institution employees, maintaining regulatory compliance, overseeing building and/or equipment maintenance, and reviewing budgets and accounting procedures. Review of the personnel file revealed LPN #1 was terminated on 10/20/2020 and rehired on 11/28/2020. However, there was no evidence LPN #1 was reeducated upon rehire or providing resident care at this facility, regarding Resident Rights, Seclusion/Restraints or Abuse. Review of the facility investigation, dated 11/30/2020, revealed State Registered Nurse Aide (SRNA) #1 went to the Administrator and reported LPN #1 failed to provide care in a timely manner and was cursing at Resident #1. Interview with the Administrator, on 12/15/2020 at 9:32 AM, revealed LPN #1 was terminated at this facility on 10/20/2020, due to violating residents rights related to restraints and seclusion; however, was allowed to work at the sister facility, owned by the company, where she was also the Administrator. The Administrator stated when this facility needed a nurse to work the COVID Unit and she was unable to find anyone else, she rehired LPN #1 to work at this facility on 11/28/2020. She stated LPN #1 was placed on a Performance Improvement Plan at the sister facility due to the prior incidence at this facility and had received education on Abuse, Dementia and Resident Rights on 10/24/2020. However, was not reeducated once rehired to work on the COVID unit. Further interview with the Administrator, revealed after she received the complaint about LPN #1 on 11/30/2020, the LPN was called to the Administrator's office and was terminated; however, was still available for rehire, because she did not substantiate abuse. The Administrator stated LPN #1 continued to work for the company, but at the sister facility and it was not until 12/11/2020, was the LPN terminated and not available for rehire. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 is visited and interviewed daily to assure that the resident had no current concerns related to care and was free from abuse. 2. LPN #1 was terminated by the Administrator on 11/30/2020. On 12/01/2020 the Administrator completed notification and termination to the personnel file that stipulates LPN #1 was not eligible for re-hire. 3. On 12/18/2020, a blanket call system was mobilized by the Social Services Director at the direction of the Administrator to solicit concerns and allegations of abuse. The system contacts each resident or legal representative to solicit concerns related to care and allegation of abuse and neglect. 4. On 12/18/2020, Social Services interviewed alert residents to solicit any concerns that may be related to abuse or neglect. Those residents that were not interviewable were observed daily by Social Services for any signs and symptoms of neglect, mistreatment or abuse such as physical or mental evidence. Any concerns were monitored each day by the Administrator and the Social Services Director. 5. On 12/18/2020-12/20/2020, the DON and Charge Nurse completed physical observations of each resident that included visual inspection for outward signs and symptoms of unexplained injury, tearfulness or other psycho-social impairment to assure that residents are free from abuse and neglect. No concerns were noted. 6. On 12/18/2020, the ReachAlert system was mobilized to contact each employee to solicit any resident concerns and to assure that each resident was free from abuse and neglect. No concerns were noted. 7. On 12/17/2020, the facility secured a Long-term Care Consultant (LTCC) to assist the Administrator and the facility with compliance issues to include abuse. 8. On 12/17/2020, the LTCC met with the Administrator to review policies and facility practice on the prevention of abuse to include employee screening of hires and re-hires, reporting of abuse and investigating of abuse. Starting on 12/17/2020, the LTCC reviewed hiring practices and prevention of abuse with the Administrator daily and would continue daily review of education with the Administrator for a minimum of two weeks or until QAC indicates complete compliance. 9. The LTCC provided education to the Administrator on 12/18/2020 regarding the prevention, reporting and investigation of abuse. The Administrator completed a post-test on 12/18/2020. 10. On 12/18/2020, the Administrator and the Social Services Director began reviews of the staff scheduled for duty each day for the following day to assist in assuring that residents were not exposed to employees that may have been involved in a recent allegation of abuse. 11. On 12/18/2020, the Administrator instructed all key staff members and all department supervisors to immediately notify the Social Services Director and the Administrator of any schedule changes. 12. The Administrator made the Human Resources/Payroll Department aware on 12/18/2020, of the required review by the Administrator and Social Services Director of all new hires to include a review of the Nurse Aide Registry check, the Adult Caregiver Misconduct Registry, the Exclusion Database from Office of the Inspector General, Criminal Background checks and education provided to each new employee upon hire that included a review of resident rights and resident abuse policies that address the seven step process and procedure: screening, training, prevention, identification, protection, investigation and reporting. A review by the Administrator and Social Services Director also included the reviewing of audits of present staff by Administrative staff in walking rounds that includes the Administrator, Director of Nursing, Quality Assurance Nurse, MDS Nurse, Social Services, Dietary Director, Charge Nurse or Therapy Director. 13. On 12/18/2020 through 12/20/2020, the Social Services Director, the Director of Nursing and a charge nurse provided education to all employees on abuse policies and practices to include freedom from abuse, reporting of abuse and investigating of abuse. Each employee was post-tested on [DATE] through 12/20/2020 after receiving the education. 14. Employees that were off work and unavailable for any reason would receive this education and post-test before returning to work. 15. On 12/18/2020, the Quality Assurance Committee (QAC) conducted a virtual meeting due to the COVID-19 pandemic. The QAC meets daily seven days a week to review actions taken and compliance with IJ citations issued on 12/17/2020. The QAC members include: Administrator, DON, Assistant Director of Nursing (ADON), Quality Assurance / Infection Preventionist (QA/IP) Nurse, MDS Coordinator, Social Services (SS), Rehabilitation Therapy Director and the Medical Director. Starting on 12/18/2020, the Administrator and Social Services Director were providing the QAC full information related to the Immediate Jeopardy citations on 12/17/2020 to include all actions taken to comply with F600 (Freedom from Abuse), Reporting of abuse (F609), Investigate/Prevent/Correct Alleged Violation (F610), Administration (F835). The Administrator and Social Services Director present all actions, corrections, and reviews to the daily meetings of the QAC on the abuse prevention education that is provided to employees, post testing of abuse education, the employee abuse education attendance roster, a review of all newly hired or re-hired staff, daily staffing schedules as reviewed by the Administrator and Social Services, results from resident and employee inquisitions related to solicitation of resident concerns and allegations of abuse through ReachAlert and resident interviews completed by Social Services. The Quality abuse concerns and allegations obtained through ReachAlert and resident interviews completed by Social Services. The Quality Assurance Committee provides review, recommendations and follow-up to assure that the facility was in compliance with Freedom from Abuse (F600), Reporting of abuse (F609), Investigate/Prevent/Correct Alleged Violation (F610), Administration (F835). 17. On 12/18/2020, the DON provided education to RN #1 regarding reporting of abuse and neglect, investigating abuse, and prevention of abuse. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the interview sheets dated 12/18/2020 through 12/29/2020 revealed staff visited and interviewed Resident #1 daily to assure that the resident had no current concerns related to care and was free from abuse and no concerns were identified. Interviews on 12/29/2020, with the ADON at 9:57 AM, LPN #1 at 10:59 AM, Social Services Director (SSD) at 10:13 AM, and LPN #2 at 10:08 AM revealed daily visits were started on 12/18/2020 with Resident #1 to assure the resident had no current concerns. No concerns were voiced nor noted. 2. Review of an Employee Personnel Action Sheet revealed the Administrator terminated LPN #1 on 12/11/2020 with stipulation that LPN #1 was not eligible for re-hire. Interview with the Administrator on 12/29/2020 at 11:53 AM, revealed the LPN was ineligible for re-hire. 3. Interview with the SSD on 12/29/2020 at 10:13 AM revealed she was directed to mobilize a blanket call system for mass communication to solicit concerns and allegations of abuse. Residents or their legal representatives were contacted as well as staff to solicit any concerns regarding abuse. 4. Review of Audit sheets 12/18/2020 through 12/29/2020, revealed the SSD interviewed interviewable resident and observed non-interviewable residents for any signs and symptoms of neglect, mistreatment or abuse such as physical or mental evidence with no concerns identified Interview with the SSD on 12/29/2020 at 10:13 AM, revealed she interviewed alert residents to solicit any concerns regarding abuse and observed residents with BIMS scores of less than eight (8) daily for any signs and symptoms of neglect, mistreatment or abuse. 5. Review of audit sheets, dated 12/18/2020 through 12/20/2020, revealed the DON and Charge Nurse completed physical observations on each resident with no concerns identified. Interview with the Interim DON, on 12/29/2020 at 9:57 AM, revealed she and the Charge Nurse completed physical observations of each resident that included visual inspection for outward signs and symptoms of unexplained injury, tearfulness or other psychosocial impairment to assure that residents were free from abuse and neglect. No concerns were noted. 6. Interview with the SSD, on 12/29/2020 at 10:13 AM, revealed on 12/18/2020, the ReachAlert system was mobilized to contact each employee to solicit any resident concerns and to assure that each resident was free from abuse and neglect. No concerns were noted. Interviews on 01/08/2021 (Post Survey) with RN #2, at 5:25 AM, NA #1 at 5:26 AM, SRNA #3 at 5:27 AM, NA #2 at 5:28 AM, and SRNA #2 at 5:29 AM, revealed they had received the call through the mobile system and they had no concerns. 7. Interview with the Administrator, on 12/29/2020 at 11:53 AM, revealed on 12/17/2020 that she secured a Long-term Care Consultant (LTCC) to assist the Administrator and the facility with compliance issues to include abuse. 8. Interview with the Administrator, on 12/29/2020 at 11:53 AM revealed the LTCC met with her on 12/17/2020 to review policies and facility practice on the prevention of abuse to include employee screening of hires and re-hires, reporting of abuse and investigating abuse. She stated the LTCC met daily with her from 12/17/2020 through 12/29/2020. 9. Review of education materials/content on abuse and Posttest dated 12/18/2020 revealed the Administrator was educated and provided a posttest on the prevention, reporting and investigation of abuse. Interview with the Administrator, on 12/29/2020 at 11:53 AM, revealed she received education on 12/18/2020, regarding the prevention, reporting and investigation of abuse; and, she completed a post-test. 10. Review of staff schedules and check sheets, dated 12/18/2020 through 12/29/2020, revealed the Administrator and the Social Services Director reviewed the staff scheduled for duty each day for the following day to assist in assuring that residents were not exposed to employees that may have been involved in a recent allegation of abuse. Interviews on 12/29/2020 with the Administrator, at 11:53 AM, and the SSD at 10:13 AM, revealed starting on 12/18/2020, they reviewed the staff scheduled for duty each day for the following day to ensure residents were not exposed to employees that may have been involved in a recent allegation of abuse. She stated no concerns identified. 11. Review of an attendance roster, dated 12/18/2020 revealed the Administrator instructed key staff members and department supervisors to notify the SSD and herself if there were any schedule changes Interview with the Administrator, on 12/29/2020 at 11:53 AM, revealed she instructed key staff members and all department supervisors to notify the SSD and herself immediately of any schedule changes. 12. Review of the new hire review checklist and the daily Administrative round flow sheets revealed the Administrator and SSD reviewed all new hires paperwork to ensure a Nurse Aide Registry check, the Adult Caregiver Misconduct Registry check, the Exclusion Database from Office of the Inspector General was checked, and a Criminal Background check was completed. In addition, they ensured education was provided to each new employee upon hire that included a review of resident rights and resident abuse policies that address the seven-step process and procedure: screening, training, prevention, identification, protection, investigation and reporting. They also reviewed the walking round audits by Demonstrative staff of present staff. Interviews on 12/29/2020, with the Administrator at 11:53 AM, Human Resources/payroll staff at 10:24 AM, and the SSD, at 10:13 AM, revealed all new hires were screened by the Administrator and the SSD for a review of the Nurse Aide Registry check, the Kentucky Adult Caregiver Misconduct Registry, the Exclusion Database from the Office of Inspector General and Criminal background checks and the new hires were being educated on Resident Rights and abuse. 13. Review of a staff roster and posttests, dated 12/18/2020 through 12/20/2020, revealed staff were education on abuse and scored 100% on posttests. Interviews on 12/28/2020, with LPN #2 at 2:24 PM, RN #1 at 2:27 PM, SRNA #4 at 2:40 PM, SRNA #3 at 2:44 PM, Dietary staff member #1 at 2:56 PM, SRNA #2 at 3:01 PM, Medication Technician (MT) #1 at 3:06 PM, and LPN #2 at 10:08 AM; and on 12/29/2020 with SSD at 10:13 AM, HR/Payroll at 10:24 AM, LPN #1 at 10:59 AM, and the MDS Coordinator at 11:14 AM, revealed they were educated on abuse and neglect. 14. Review of the education rosters for abuse dated 12/18/2020 through 12/20/2020 did not have staff that were educated after 12/20/2020. 15. Review of QAC meeting rosters revealed they met daily from 12/18/2020 to 12/29/2020. Interviews on 12/29/2020 with the ADON at 9:57 AM, the QA/IP Nurse at 10:08 AM, the SSD at 10:13 AM, MDS Nurse at 11:14 AM, and the Administrator at 11:53 AM, revealed they have been attending the daily QAC meetings and the topics of discussion included the Immediate Jeopardy's the facility received on 12/17/2020 Interview (Post survey) with the Administrator, on 01/08/2021 at 9:29 AM, revealed during the QAC meetings they discussed the AoC, staff schedules, any concerns brought up and new hires. Interview (Post Survey) with the SSD, on 01/08/2021 at 9:33 AM, revealed during the QAC meetings they would discuss staffing schedules, any resident, family or staff concerns and the AoC. Interview with the facility Medical Director, on 12/29/2020 at 10:40 AM, revealed he was made aware of the recent Jeopardy tags, attended the required QA meeting, and that he has no concerns with the facility. 17. Interview with RN #1 on 12/28/2020 revealed she was re-educated on abuse and neglect and had to sign a form and take a post-test. She was educated to report any allegation of abuse or neglect immediately to her supervisor. Interview with the Administrator on 12/29/2020 at 11:53 AM revealed the DON had provided education and post-testing regarding reporting of abuse and neglect, investigating abuse and prevention of abuse to RN #1.

Based on interview, record review, and facility policy review, it was determined the facility failed to review and revise the Comprehensive Care Plan in regards to falls for one (1) of three (3) sampled residents (Resident #1). Resident #1 had a history of [REDACTED]. The findings include: Review of facility policy titled, Fall Management Program, last reviewed on 01/15/2020, revealed it was the policy of the facility to safeguard the residents while promoting the highest possible level of independence and quality of life. The residents care plan and nursing assistant care plan would reflect the risk and intervention for falls. The comprehensive care plan was to include goals and interventions that were resident specific. The nursing assistant care plan would provide interventions determined appropriate. Both care plans would be updated timely removing or adding interventions as necessary. When a fall occurred, immediate action would be taken in accordance with the post-fall protocols that include the Post Falls Assessment and Root Cause Analysis. After a fall, the charge nurse would complete a post falls investigation. Assessment for causative factors, implementation of appropriate interventions and any needed changes would be determined. Record review revealed the facility admitted Resident #1, on 05/31/2017 with diagnoses, which included Altered Mental Status, Unsteady on feet, Delusional Disorders, Dementia without behaviors, and [MEDICAL CONDITION]. Review of a Significant Change Minimum Data Set (MDS) assessment, dated 11/25/2020, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident was interviewable. Review of falls documentation in the nursing notes and/or Post Fall Assessments/Post Fall Risk Assessments, revealed Resident #1 had a history of [REDACTED]. Record review revealed nursing did not revise the care plan. The resident had two (2) falls on 11/27/2020 at 6:24 AM, the first fall was due to ambulating without wearing non-skid socks, another similar fall occurred at 11:46 AM; and nursing did not revise the care plan. Continued revealed there was no evidence the care plan was revised to address Resident #1 being found on the floor two times on 11/28/2020, to prevent another fall. Interview with State Registered Nurse Aide (SRNA) #2, on 12/15/2020 at 12:10 PM, revealed Resident #1 was found crawling on the floor saying Help me, help me two (2) times on 11/28/2020. She stated staff were not aware of how the resident ended up in the floor and the nurse did not instruct her to do anything different to prevent this from occurring again. Attempts to reach Licensed Practical Nurse (LPN) #1 who was the nurse in charge on 11/28/2020, on 12/10/2020 at 11:23 AM, on 12/12/2020 at 10:48 AM, on 12/13/2020 at 3:03 PM, and on 12/15/2020 at 11:28 AM, were unsuccessful. There was no answer when called and a voicemail was left each time requesting a return phone call. Interview with the MDS Nurse, on 12/29/2020 at 11:14 AM, and on 01/08/2021 (Post Survey) at 9:54 AM, revealed the nurse caring for the resident after a fall should update the care plan to ensure care needs were met. Interview with the Interim Director of Nursing (DON), on 12/14/2020 at 10:34 AM, revealed when a resident was found in the floor, it should be treated as a fall and fall assessment and a Fall Risk Assessment should be completed. The DON stated the nurse should also put an intervention in place to try to prevent further falls. She stated this failure could result in another fall. She also stated that all falls were reviewed in the morning Interdisciplinary Team meetings and possible care plan revisions were discussed, at that time. The Interim DON stated Resident #1's Care Plan was discussed in the IDT Meeting but no changes or updates were made.

Based on interview, record review, and facility policy review, it was determined the facility failed to complete Falls investigations for one (1) of three (3) sampled residents (Resident #1). Resident #1 was found scooting self on the floor two (2) times on 11/28/2020. There was no witness to indicate whether the resident self-transferred to the floor or if the resident had fallen. Staff failed to complete a Post Fall Assessment, Fall Risk assessment, and place interventions in place to try to prevent further falls, per facility policy. The findings include: Review of facility policy titled, Fall Management Program, reviewed on 01/15/2020, revealed it was the policy of the facility to safeguard the residents while promoting the highest possible level of independence and quality of life. This should be accomplished through thorough assessment of all residents to establish their risk for falls, care planning to minimize falls and injuries related to falls, and tracking and trending for patterns. The facility provides care in a safe environment. All residents should be assessed utilizing the facility fall risk assessment tool after a fall. The resident's care plan and nursing assistant care plan should reflect the fall risk and interventions to prevent falls. Both care plans should be updated timely removing or adding interventions as necessary. When a fall occurs, immediate action should be taken in accordance with the post-fall protocols that include the Post Falls Assessment and Root Cause Analysis. After a fall, the charge nurse should complete a post falls investigation. Assessment for causative factors, implementation of appropriate interventions and any needed changes should be determined. The DON should review all Post Falls Investigations and decide if other actions were necessary. Record review revealed the facility admitted Resident #1 on 05/31/2017 with diagnoses, which included unsteady on feet, Altered Mental Status, Delusional Disorders, [MEDICAL CONDITION], Anterograde Amnesia, Dementia without behaviors, and [MEDICAL CONDITION]. Review of a Significant Change Minimum Data Set (MDS) assessment, dated 11/25/2020, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident was interviewable. Further review of the MDS assessment revealed the resident required extensive assist of one (1) staff for transfers and ambulation and the resident was not steady when ambulating and transferring; and only able to stabilize with staff assistance. Interviews with State Registered Nurse Aide #1 on 12/10/2020 at 1:34 PM, SRNA #2 on 12/15/2020 at 12:10 PM, SRNA #3 on 12/10/2020 at 10:56 AM, and Registered Nurse (RN) #1 on 12/16/2020 at 5:53 AM, revealed Resident #1 was found crawling on the floor yelling, Help me, help me two (2) times on 11/28/2020. SRNA #1 stated she was not directed to implement additional fall prevention interventions. Review of of the Nursing Notes, dated 11/28/2020 and Electronic Record, revealed there was no evidence Resident #1 was found on the floor and/or Post Fall assessments and Falls Risk assessment were completed, per facility policy. In addition, review of falls documentation in the nursing notes and or Post Fall Assessments, revealed Resident #1 was noted to have falls on 11/02/2020 11:45 PM, during self transfer from the commode to the wheelchair. There was no intervention placed on the care plan. The resident had two (2) falls on 11/27/2020 at 6:24 AM, the first fall was due to ambulating without wearing non-skid socks, another similar fall occurred at 11:46 AM. There were no interventions placed on the care plan. The resident also fell on [DATE] at 7:31 PM, while easing self out of chair at bedside onto floor to scoot towards the doorway. The intervention placed after the 11/30/2020 fall was to review the residents medications, however no other intervention was put in place to prevent another similar fall from occurring. Review of the Comprehensive Care Plan for falls, initially dated 06/01/2017, revealed Resident #1 was at risk for falls related to impaired balance, [MEDICAL CONDITION] Disorder, Use of [MEDICAL CONDITION] Medications, Scoliosis, Muscle Weakness, Lack of Coordination, Repeated fall history, Abnormal Gait and Obesity. Further review revealed interventions to prevent falls were to anticipate needs as necessary, diversional activity using therapy animals for pet therapy, dycem to recliner and wheelchair, instruct resident on safety measures, monitor shoes for proper fit and non skid soles, observe for changes in mood, behavior, psychosocial well being, and cognitive status; occupational therapy as ordered; sensor alarm to wheelchair and bed to notify staff of unassisted transfers, monitor every shift for placement and function, electric hi/low bed in normal position, sign in room to remind resident to call for assistance, encourage to call for assistance, and wheelchair out of room when in bed to decrease unassisted transfers. Further review of the Comprehensive Care Plan for falls, dated 06/01/2017 revealed there was no evidence the care plan was evaluated for effectiveness, nor for additional interventions to address falls on 11/02/2020, 11/27/2020, 11/28/2020 or 11/30/2020. Attempts to reach Licensed Practical Nurse (LPN) #1 who was the nurse who worked with Resident #1 on 11/28/2020, were made on 12/10/2020 at 11:23 AM, on 12/12/ 2020 at 10:48 AM, on 12/13/2020 at 3:03 PM, and on 12/15/2020 at 11:28 AM were unsuccessful. There was no answer when called and a voicemail was left each time requesting a return phone call. Interview with the Interim Director of Nursing (DON), on 12/14/2020 at 10:34 AM, and on 01/07/2021 (Post Survey) at 11:40 AM, revealed when the resident was found in the floor it was not witnessed how he/she got there, staff should have considered it a fall. She further revealed the nurse should have put a new intervention in place if indicated, to prevent further falls. In addition, she stated the nurse should have completed a Post Fall Assessment and the Fall Risk Assessment at that time. The Interim DON stated Resident #1's Care Plan and unwitnessed falls were discussed in the IDT Meeting but no updates were made and no issues identified regarding documentation.

Based on interview and record review, it was determined the facility failed to maintain a medical record that was complete and accurately documented for one (1) of three (3) sampled residents (Resident #1). Resident #1 was found in the floor crawling and hollering out, Help me, help me, on two (2) separate occasions on the evening of 11/28/2020, However, there was no documented evidence (nursing note, and/or Post Fall assessment) in the medical record that these incidents occurred. The findings include: Interview (Post Survey) with the Administrator, on 01/06/2020 at 11:24 AM, revealed the facility does not have a policy on documentation. Record review revealed the facility admitted Resident #1 on 05/31/2017 with diagnoses, which Unsteady on feet, Altered Mental Status, Delusional Disorders, [MEDICAL CONDITION], Anterograde Amnesia, Dementia without behaviors, and [MEDICAL CONDITION]. Interview with State Registered Nurse Aide (SRNA) #2, on 12/15/2020 at 12:10 PM, revealed she and Licensed Practical Nurse (LPN) #1 assisted Resident #1 back to bed on two (2) occasions after finding the resident crawling on the floor stating help me, help me on 11/28/2020. However, review of Resident #1's medical record revealed there was no documented evidence the resident was found on the floor two times on 11/28/2020. Attempts were made to contact LPN #1 who was the nurse on duty, on 11/28/2020, on 12/10/2020 at 11:23 AM, 12/12/2020 at 10:48 AM, 12/13/2020 at 3:03 PM, and 12/15/2020 at 11:28 AM. There was no answer and messages were left but the LPN did not return the calls. Interview with the Interim Director of Nursing (DON) (Post Survey), on 01/07/2020 at 11:40 AM, revealed the incidents of Resident #1 being found on the floor two (2) times on 11/ 0 should have been documented in the resident's record. She stated she would have expected to see nursing notes, and a completed Post Fall assessment for resident #1.

Based on interview, record review, and facility policy review, it was determined the facility failed to thoroughly investigate allegations of abuse for one (1) of seven (7) sampled residents, (Resident #3). On 09/28/2020, Resident #1 entered the nursing station and began throwing papers and other objects while yelling get out of my house. LPN #1 stated she was unable to redirect the resident so she grabbed the resident by his/her wrists and sat the resident in a computer chair and held him/her there until a staff member intervened In addition, on 10/01/2020, Nurse Aide #1 observed the resident on the floor in the nursing station and LPN #1 informed her that she had to take down the resident down. Interview with the Director of Nursing (DON), on 10/12/2020 at 1:30 PM, revealed she did not realize LPN #1 actually took the resident down to the floor. The DON revealed she did not report the incident to the Administrator or investigate the incident due to her misunderstanding of the information about the incident however, she stated either way, I would have expected LPN #1 to document the incident, and there should have been an investigation. The DON revealed she went to the facility on [DATE] at approximately 11 PM after receiving a call indicating LPN #1 held Resident #1 down in a chair against the resident's will. She stated when she got to the facility she spoke with SRNA #1, observed Resident #1 eating a snack and listening to music. However, interview with LPN #1, revealed the DON came to the facility but did not question her regarding the incident. The findings include: Review of the facility's policy titled, Dementia Management and Resident Abuse Prevention Training dated 08/07/18, revealed it was the policy of the facility that all employees would receive adequate, appropriate, and effective training on the prevention of resident abuse and the management of residents with dementia in order to ensure that residents remained free of abuse and maintain the highest practicable physical, mental, and/or psychological well-being. All residents would be assessed and an individualized care plan developed that included non-pharmacological interventions for residents with dementia and/or behaviors. All staff would receive training, including competency validation, on caring for residents with dementia on hire and at least annually thereafter that would include competency's either via Healthcare Academy and/or orientation modules. Routine training would include how to communicate effectively with residents with dementia and behavioral health needs on hire and at least annually thereafter. Review of the facility's policy titled, Abuse, Neglect, Exploitation, updated 05/17/19, revealed allegations or suspicions will be investigated thoroughly by the Abuse/Neglect Coordinator, Administrator and/or their designee. Record review revealed the facility readmitted Resident #1 on 08/07/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment, dated 08/14/2020, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Interview with State Registered Nurse Aide (SRNA) #1, on 10/07/2020 at 3:40 PM, revealed on 09/28/2020 at approximately 10:51 PM, she heard Resident #1 yelling. She stated she checked on the resident and witnessed LPN #1 grab the resident by both wrist, sit him/her down in a chair, and hold the resident down in the chair by his/her wrist. She stated she intervened and took the resident to his/her room. SRNA #1 stated she called the Director of Nursing (DON), informed her of the incident and the DON told her to write a statement of the incident. She further revealed the DON came to the facility however, she did not investigate the incident and LPN #1 remained throughout the shift. Interview with Nurse Aide (NA) #1, on 10/12/2020 at 12:10 PM, revealed Licensed Practical Nurse (LPN) #1 placed Resident #3 in his/her room, slammed the door shut, and yelled, stay in that room and do not come back out on 09/21/2020 during 6:00 PM to 6:00 AM shift. She revealed she notified the Director of Nursing (DON) of the incident, however, she was not sure what the outcome. Interview with LPN #1 on 10/12/2020 at 3:47 PM, revealed on 10/01/2020, during PM shift (6 AM to 6 PM), Resident #1 had been wandering in other resident's room, striking out at staff, and would not follow staff's redirection. LPN #1 stated, I was coming out of the nursing station and the resident grabbed me and started to fight me, I was not able to redirect him/her, so I just sat the resident down on the floor. She stated the resident had been wandering and fighting the staff all night. LPN #1 stated the DON came to the facility but did not question her regarding the incident. Interview with LPN #1, on 10/12/2020 at 11:02 AM, revealed on night of 09/21/2020, Resident #1 was distracted, wandering in other resident's room, striking out at staff, and would not follow staff's redirection. LPN #1 stated she took resident to his/her room and closed the door because the residents were to stay in their room to quarantine related to COVID-19. She revealed she told Resident #1 to stay in the room and shut the resident's room door; however, denied yelling at resident. She revealed she has a loud voice tone and some staff have referred to her as short-tempered. She stated she was not questioned regarding her taking the resident down to the ground due to behaviors. Interview with the Director of Nursing (DON), on 10/12/2020 at 1:30 PM, revealed she received a text during night shift of 10/01/2020 from LPN #1 which indicated Resident #1 went to the floor. The DON stated sometimes, the resident will lay on the floor and play dead or as though passed out, so I just assumed that was the case however, it was a misunderstanding on my behalf because I did not realize she was saying she actually took the resident down to the floor. The DON revealed she did not report the incident to the Administrator or investigate the incident due to her misunderstanding of the information about the incident however, she stated either way, I would have expected LPN #1 to document the incident, and there should have been an investigation. Interview revealed the DON investigated the incident on 09/28/2020 related to LPN #1 holding the resident's arms down. However, interview with LPN #1 revealed the DON did not question her regarding the incident. Interview with the Administrator, on 10/16/2020 at 2:00 PM, revealed she was not informed of LPN #1 taking Resident #1 to the floor until surveyor's interview with the DON about the incident. The Administrator stated LPN #1 was trained in Crisis Prevention Intervention (CPI) although, this was not a practice the facility used to manage behaviors however, LPN #1's intervention used should have been investigated.

Based on interview, record review, and facility's policy review, it was determined the facility failed to ensure one (1) of seven (7) sampled resident was free from involuntary seclusion, Resident #3. On 09/21/2020, Resident #3 was wandering and entering other residents' rooms. Licensed Practical Nurse (LPN) #1 put the resident in his/her room; slammed the door shut, and yelled at the resident stay in that room and do not come back out. Nurse Aide (NA) #1 heard the resident crying and when she entered the resident's room, the resident was crying and stated why do I have to stay in here. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation dated 07/07/2020, revealed it was the facility's process to protect the health and welfare of each resident; to assure each resident is free from verbal, sexual, physical and mental abuse; corporal punishment, neglect, involuntary seclusion, exploitation and injuries of unknown origin including the use of any chemical or physical restraint not required to treat medical symptoms. Record review revealed the facility admitted Resident #3 on 03/03/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/11/2020, revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Interview with Nurse Aide (NA) #1, on 10/12/2020 at 12:10 PM, revealed Licensed Practical Nurse (LPN) #1 placed Resident #3 in his/her room, slammed the door shut, and yelled, stay in that room and do not come back out on 09/21/2020 during 6:00 PM to 6:00 AM shift. NA #1 stated she heard Resident #3 crying behind the closed door and when she entered the room the resident was crying and stated why do I have to stay in here. NA #1 revealed she asked LPN #1 to give the resident a mask earlier in the shift since the resident would not stay in his/her room to quarantine. NA #1 stated the resident did not understand why she had to stay in his/her room, so she stayed with the resident, turned on some music, and sat with the resident until she calmed down. She revealed she notified the Director of Nursing (DON) of the incident, however, she was not sure what the outcome was. Interview with LPN #1, on 10/12/2020 at 11:02 AM, revealed on night of 09/21/2020, Resident #1 was distracted, wandering in other resident's room, striking out at staff, and would not follow staff's redirection. LPN #1 stated she took resident to his/her room and closed the door because the residents were to stay in their room to quarantine related to COVID-19. She further stated, I did not lock the door, the resident was able to come out on their own. LPN #1 revealed she was not aware the resident was crying and did not consider putting the resident in his/her room as involuntary seclusion. She stated other staff on the unit were providing resident care and she did not ask for assistance in caring for the resident prior to taking the resident to bedroom. She revealed she told Resident #1 to stay in the room and shut the resident's room door; however, denied yelling at resident. She revealed she has a loud voice tone and some staff have referred to her as short-tempered. Interview with the Director of Nursing (DON), on 10/12/2020 at 1:30 PM, revealed she was informed of the above incident during the night of 09/21/2020. The DON stated she interviewed the staff working the PM shift (6:00 PM to 6:00 AM) and NA #1 admitted to hearing LPN #1 yelling. The DON stated she asked LPN #1 was her voice louder than usual however, she did not admit to being any louder and replied that's just how I talk. The DON stated I just felt her tone and actions were not socially acceptable due to the task being performed. Interview with the Administrator, on 10/16/2020 at 2:00 PM, revealed Resident #3 was not placed in seclusion (bedroom) during incident on 09/21/2020. She stated Resident #3 was capable of exiting bedroom although instructed not to come out of his/her room. The Administrator stated LPN #1 was encouraging the resident to stay in his/her bedroom although she would not expect LPN #1's loud tone of voice and closing the door to be used for keeping the resident in his/her room.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to implement the Comprehensive Person-Centered Care Plan interventions for two (2) of seven (7) sampled Residents (#1, and #3) to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. On 09/28/2020, Resident #1 entered the nursing station and began throwing papers and other objects while yelling get out of my house. Licensed Practical Nurse (LPN) #1 stated she did not call out for staff assistance to help redirect the resident nor she she try to implement other care plan interventions. Instead she grabbed the resident by his/her wrists and sat the resident in a computer chair and held him/her there until a staff member intervened. On 10/01/2020, Nurse Aide (NA) #1 observed Resident #1 lying on the floor near the nursing station. LPN #1 told the NA she had to take down the resident because the resident was fighting and she was fearful they both were going to fall. On 09/21/2020, LPN #1 took Resident #3 to his/her room. Interview with NA #1 revealed she heard the door slam shut and the nurse was heard yelling stay in that room and do not come back out. Interview revealed Resident #3 was heard crying behind the closed door. NA #1 entered the resident's room and the resident was crying and stated why do I have to stay in here. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, last revised 02/10/15, revealed the purpose of the care plan was to document how each resident's daily care needs were provided by the nursing staff in accordance with the guidelines of the Resident Assessment Instrument (RAI) process and in keeping the Medicare/Medicaid Services requirements. Residents receive care and treatment based on an assessment of their needs, the severity of their diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Review of the medical record revealed the facility readmitted Resident #1 on 08/07/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicates the resident was not interviewable. Review of Resident #1's Progress Note, dated 09/28/2020 and 10/01/2020, revealed no documentation of the resident's behaviors which led to being confined to the chair and being taken to the floor for aggressive behaviors. Review of Resident #1's Comprehensive Care Plan titled, At Risk for Indicators of Mood/Behaviors due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . and prior to bedtime provide quiet, relaxing activity to prepare for sleep. Interview with State Registered Nurse Aide (SRNA) #1, on 10/07/2020 at 3:40 PM, revealed on 09/28/2020 at approximately 10:51 PM, she heard Resident #1 yelling. She stated she checked on the resident and witnessed LPN #1 grab the resident by both wrist, sat him/her down in a chair, and holding the resident down in the chair by his/her wrist. She stated she intervened, told LPN #1 I got the resident, and took the resident to his/her room. Further interview revealed when she got the resident to his/her room, she turned on music, got the resident calm, and provided him/her a snack. SRNA #1 stated she called the Director of Nursing (DON) and informed her of the incident. She stated the DON told her to write a statement of the incident. Interview revealed the DON came to the facility, however, she did not investigate the incident and LPN #1 remained throughout the shift. Interview with Nurse Aide (NA) #1, on 10/12/2020 at 12:10 PM, revealed on 10/01/2020 at approximately 9:57 PM, she noticed Resident #1 lying on the floor near nursing station, NA #1 stated LPN #1 informed her she had to take down the resident because the resident was fighting and she was fearful they (she and resident) were going to fall. NA #1 stated Resident #1 was care planned for behaviors and taking the resident to the floor was not an intervention. Interview revealed the resident was wandering in other resident's room, thinking they were in the resident's house, attempting to fight CNA's initially however, after several attempts at redirection by CNA's the resident would interact appropriately for short time frame and repeat behaviors. Interview with Licensed Practical Nurse (LPN) #1, on 10/12/2020 at 11:02 AM, revealed on 09/28/2020 Resident #1 entered the nursing station and began snatching papers off the printer and yelling get out of my house. She stated the resident was combative and gait was unsteady so she grabbed the resident by his/her wrists and sat him/her in computer chair. LPN #1 stated she confined the resident to the chair until a staff member intervened. Interview revealed LPN #1 did not call out for staff assistance to help redirect the resident. She stated she had to keep the resident from getting hold of the computer and did not consider her intervention as a restraint nor did she document the incident. She stated Resident #1 was care planned for behaviors however, she did not utilize care plan interventions to redirect and/or divert the resident prior to confining the resident to the chair. Interview revealed the Director of Nursing (DON) did come to the facility after the incident, however, she did not question her about the incident. Further interview with LPN #1 on 10/12/2020 at 3:47 PM, revealed on 10/01/2020, during PM shift (6:00 AM to 6:00 PM), Resident #1 had been wandering in other resident's room, striking out at staff, and would not follow staff's redirection. LPN #1 stated, I was coming out of the nursing station and the resident grabbed me and started to fight me, I was not able to redirect him/her, so I just sat the resident down on the floor. LPN #1 stated she did not call for staff's assistance because they were providing care to other residents. LPN #1 stated she failed to implement least restrictive alternatives, to assess the resident for injury when staff assisted the resident off the floor, and did not document the incident. Further interview revealed Resident #1 was care planned for behaviors however, she did not implement care plan interventions to speak calmly, redirect and divert resident's attention because the resident was fighting. Additionally, she stated she did not summon other staff's assistance before she took Resident #1 down to the floor. Interview with the DON, on 10/12/2020 at 1:30 PM, revealed she became aware of the incident at approximately 11:00 PM on 09/28/2020. She stated she initially received a text then a phone call alleging LPN #1 had held the resident down in a chair against his/her will. She stated she went to the facility, interviewed some staff, assessed Resident #1's wrists. She stated the resident was calm, eating a snack, and was in no distress. The DON stated she talked to LPN #1 and was informed the resident came behind the desk slinging papers and the computer was next so she sat the resident down in the chair to allow him/her to regain control. The DON stated she would have expected LPN #1 to document the incident, however, she did not consider the resident being held in the chair as a restraint. Further interview with the DON revealed she received a text during night shift of 10/01/2020, from LPN #1 which indicated Resident #1 went to the floor. The DON stated sometimes, the resident will lay on the floor and play dead or as though passed out, so I just assumed that was the case; however, it was a misunderstanding on my behalf because I did not realize she was saying she actually took the resident down to the floor. However, she stated either way, she would have expected LPN #1 to implement dementia care interventions, assess the resident for injuries when staff got the resident from the floor, and to document the incident. Interview with the Administrator, on 10/16/2020 at 2:00 PM, revealed the facility did not encourage the use of restraints and she did not consider Resident #1 being confined to chair as restraint. The Administrator stated the resident was placed in the chair to prevent harming self or others, and he/she was held less than five (5) minutes before staff intervened. Further revealed she was not informed of LPN #1 taking Resident #1 to the floor until surveyor's interview with the DON about the incident. The Administrator stated LPN #1 was trained in Crisis Prevention Intervention (CPI) although, this was not a practice the facility uses to manage behaviors and she would expect staff to implement dementia based interventions related to behaviors. 2. Record review revealed the facility admitted Resident #3 on 03/03/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/11/2020, revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Review of Resident #3's Comprehensive Care Plan titled, Impaired Communication Related To Alzheimer's Dementia dated 03/04/2020, revealed interventions to allow resident time to discuss/report problems, do not rush, approach in a calm, soothing manner, avoid commands using DON'T or NO, use positive terms such as DO LET'S, offer simple choices allowing sufficient time for decision making. Further review of the resident's care plan titled, Resident Exhibits Aggressive Outburst of Disruptive Behaviors (threats to hit other residents/staff, curses loudly, shoving/hitting, or scratching) related to Dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Nurse Aide (NA) #1, on 10/12/2020 at 12:10 PM, revealed on 09/21/2020 during PM shift, LPN #1 placed Resident #3 in his/her room, slammed the door shut, and yelled, stay in that room and do not come back out. NA #1 stated she heard Resident #3 crying behind the closed door and when she entered the room the resident was crying and stated why do I have to stay in here. NA #1 stated the resident did not understand why she had to stay in his/her room, so she stayed with the resident, turned on some music, and sat with the resident until she calmed down. Interview revealed Resident #3 was care planned for behaviors of fighting and wandering. She revealed she notified the Director of Nursing (DON) of the incident. Interview with LPN #1, on 10/12/2020 at 11:02 AM, revealed on night of 09/21/2020, Resident #3 was distracted and wandering. LPN #1 stated she took resident to his/her room and closed the door because the residents were to stay in their room to quarantine related to COVID-19. She stated other staff on the unit were providing resident care and she did not ask for assistance in caring for the resident prior to taking the resident to bedroom. She revealed she told Resident #3 to stay in the room and shut the resident's room door; however, denied yelling at resident. She revealed Resident #3 was care planned for behaviors however, she did not implement interventions to approach from the front, do things one step at a time and provide an un-hurried pace, to ensure the resident's security and safety. Interview with the DON, on 10/12/2020 at 1:30 PM, revealed she was informed of the above incident during the night of 09/21/2020. The DON stated she interviewed the staff working the PM shift (6 PM to 6 AM) and who admitted to hearing LPN #1 yelling. The DON stated she asked LPN #1 was her voice louder than usual however, she did not admit to being any louder and replied that's just how I talk. She stated LPN #1 was suspended for two (2) nights and placed on a Performance Plan. The DON stated I just felt her tone and actions were not socially acceptable due to the task being performed. The DON stated Resident #1 was care planned for behaviors and would expect staff to implement interventions developed to care for the resident when he/she exhibited aggressive or disruptive behaviors. Interview with the Administrator, on 10/16/2020 at 2:00 PM, revealed Resident #3 was not placed in seclusion (bedroom) during incident on 09/21/2020. The Administrator stated Resident #3 was capable of exiting bedroom although instructed not to come out on his/her room. The Administrator revealed LPN #1 was encouraging the resident to stay in his/her bedroom although she would not expect LPN #1's loud tone of voice and closing the door to be used for keeping the resident in his/her room. Interview with the Administrator, on 10/19/2020 at 3:30, pm revealed all staff were educated on dementia care upon hire and annually through Healthcare Academy Computer Based Training and were required to complete competencies with training. She further stated she expected staff to follow each resident's care plan interventions related to resident care and behaviors. Interview revealed LPN #1 was the only licensed staff in the facility during PM shifts, on 09/28/2020, 10/01/2020 and 10/05/2020, when incidents occurred therefore, she was not monitored to ensure she was implementing residents care plan interventions for identified behaviors.

Based on observation, interview, record review, and facility's policy review, it was determined the facility failed to ensure two (2) of five (5) sampled residents (Residents #1 and #3) who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Resident #3 was diagnosed with Dementia with Behavioral Disturbance and was assessed and care planned for aggressive outbursts and disruptive behaviors of threats to hit other residents/staff, curses loudly, shoving/hitting, or scratching. On 09/21/2020, Resident #3 was wandering in other resident's room, striking out at staff, and would not follow staff's redirection. Licensed Practical Nurse (LPN) #1 placed Resident #3 in his/her room slamming door shut and hollering stay in room and do not come back out. A Nurse Aide (NA) heard the resident crying and when she entered the resident's room the resident stated, why do I have to stay in here. Continued interview with LPN #1 revealed did she provide the resident a face mask as the resident's cognition did not allow the resident to understand the need to stay in the room nor other dementia care related interventions. Resident #1 was diagnosed with Alzheimer;s Disease and was assessed and care planned for behaviors of wandering. On 09/28/2020, Resident #1 entered the nursing station and began throwing papers and other objects while yelling get out of my house. LPN #1 stated she was unable to redirect the resident so she grabbed the resident by his/her wrists and sat the resident in a computer chair and held him/her there until a staff member intervened In addition, on 10/01/2020, Nurse Aide #1 observed the resident on the floor in the nursing station and LPN #1 informed her that she had to take down the resident down because the resident was fighting and she was fearful they (she and resident) were going to fall. Interviews revealed LPN #1 failed to implement behavior care plan interventions to provide supportive listening and redirect to positive activity and to use soothing voice/touch to calm/relax the resident. The findings include: Review of the facility's policy titled, Dementia Management and Resident Abuse Prevention Training dated 08/07/18, revealed it was the policy of the facility that all employees would receive adequate, appropriate, and effective training on the prevention of resident abuse and the management of residents with dementia in order to ensure that residents remained free of abuse and maintain the highest practicable physical, mental, and/or psychological well-being. All residents would be assessed and an individualized care plan developed that included non-pharmacological interventions for residents with dementia and/or behaviors. All staff would receive training, including competency validation, on caring for residents with dementia on hire and at least annually thereafter that would include competency's either via Healthcare Academy and/or orientation modules. Routine training would include how to communicate effectively with residents with dementia and behavioral health needs on hire and at least annually thereafter. 1. Record review revealed the facility readmitted Resident #1 on 08/07/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment, dated 08/14/2020, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Review of the MDS and Comprehensive Care Plan revealed the facility identified the resident to exhibit behaviors of wandering, going into other residents room, and fighting with staff. Review of Resident #1's Comprehensive Care Plan titled, At Risk for Indicators of Mood/Behaviors due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Remove irritant not related to care or treatment. Prior to bedtime provide quiet, relaxing activity to prepare for sleep. Interview with State Registered Nurse Aide (SRNA) #1, on 10/07/2020 at 3:40 PM, revealed on 09/28/2020 at approximately 10:51 PM, she heard Resident #1 yelling. She stated she checked on the resident and witnessed LPN #1 grab the resident by both wrists, sit him/her down in a chair, and hold the resident down in the chair by his/her wrist. She revealed she intervened, and told LPN #1 I got the resident, and assisted the resident to his/her room. SRNA #1 stated she called the Director of Nursing (DON) and informed her of the incident. She stated the DON told her to write a statement of the incident and the DON came to the facility; however, she did not investigate the incident and LPN #1 remained in the facility throughout the shift. Interview with Nurse Aide (NA) #1, on 10/12/2020 at 12:10 PM revealed on 10/01/2020 at approximately 9:57 PM, NA #1 noted Resident #1 lying on the floor near nursing station, NA #1 stated LPN #1 informed her she had to take down the resident because the resident was fighting and she was fearful they (she and resident) were going to fall. Review of Resident #1's Progress Note, dated 09/28/2020 through 10/01/2020, revealed there was no documentation of the resident's behaviors and of the resident being confined to the chair for aggressive behaviors on 09/28/2020; or the resident's mood and behaviors and LPN #1 taking the resident to the floor when he/she became combative. Interview with Licensed Practical Nurse (LPN) #1, on 10/12/2020 at 11:02 AM, revealed on 09/28/2020, Resident #1 entered the nursing station and began snatching papers off the printer and yelling get out of my house. She stated the resident was combative and gait was unsteady so she grabbed the resident by his/her wrists and sat him/her in computer chair. LPN #1 stated she confined the resident to the chair until a staff member intervened. She further revealed she failed to call for assistance and/or implement interventions of the resident's care plan developed for the resident's behaviors. She stated she had to keep the resident from getting hold of the computer and did not consider her intervention as a restraint nor did she document the incident. She revealed the Director of Nursing (DON) came to the facility after the incident, however, she did not question her about the incident. Further interview with LPN #1, on 10/19/2020 at 11:35 AM, revealed she had received Dementia Care training through Healthcare Academy Computer Based Training and in-service training provided through Murray Behavioral Health. However, dementia focused care plan interventions do not always work. Further interview with LPN #1, on 10/12/2020 at 3:47 PM, revealed on 10/01/2020, during PM shift (6:00 AM to 6:00 PM), Resident #1 had been wandering in other resident's room, striking out at staff, and would not follow staff's redirection. LPN #1 stated, I was coming out of the nursing station and the resident grabbed me and started to fight me, I was not able to redirect him/her, so I just sat the resident down on the floor. She stated the resident had been wandering and fighting the staff all night. LPN #1 stated she did not call for staff's assistance because they were providing care to other residents. LPN #1 stated she failed to implement least restrictive alternatives, dementia care plan intervention, or to assess the resident for injury when staff assisted the resident off the floor, and/or document the incident. Interview with the Director of Nursing (DON), on 10/12/2020 at 1:30 PM, revealed at approximately 11:00 PM on 09/28/2020, she received a text then a phone call that LPN #1 had held the resident down in a chair against his/her will. She stated she went to the facility, interviewed some staff, assessed Resident #1's wrists, and the resident was calm, eating a snack, and was in no distress. The DON stated she talked to LPN #1 and was informed the resident came behind the desk slinging papers and the computer was next so she sat the resident down in the chair to allow him/her to regain control. The DON stated she would have expected LPN #1 to document the incident, however, she did not consider the resident being held in the chair as a restraint. Further interview with the DON revealed she received a text during night shift of 10/01/2020, from LPN #1 which indicated Resident #1 went to the floor. The DON stated sometimes, the resident will lay on the floor and play dead or as though passed out, so I just assumed that was the case; however, it was a misunderstanding on my behalf because I did not realize she was saying she actually took the resident down to the floor. The DON revealed she did not report the incident to the Administrator or investigate the incident due to her misunderstanding of the information about the incident however, she stated either way, she would have expected LPN #1 to implement dementia care interventions, and document the incident. She stated there should have been an investigation conducted. Interview by phone with the Administrator, DON, and Assistant DON, on 10/19/2020 at 3:30 PM, revealed all staff received Dementia Care Management in orientation and annually through Healthcare Academy Computer Based Training. Interview revealed staff was also inserviced by Murray Behavioral Health Consultants. Interview with the Administrator, on 10/16/2020 at 2:00 PM, revealed the facility did not encourage the use of restraints and she did not consider Resident #1 being confined to the chair as a restraint. The administrator stated the resident was care planned for behaviors due to a dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator stated the resident was placed in the chair to prevent harming self or others, and he/she was held less than five (5) minutes before staff intervened. She further revealed she was not informed of LPN #1 taking Resident #1 to the floor until surveyor's interview with the DON about the incident. The Administrator stated LPN #1 was trained in Crisis Prevention Intervention (CPI) although, this was not a practice the facility uses to manage behaviors. 2. Record review revealed the facility admitted Resident #3 on 03/03/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/11/2020, revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Review of Resident #3's Comprehensive Care Plan titled, Impaired Communication Related To Alzheimer's Dementia dated 03/04/2020, revealed interventions to allow resident time to discuss/report problems, do not rush, approach in a calm, soothing manner, avoid commands using DON'T or NO. use positive terms such as DO LET'S, offer simple choices allowing sufficient time for decision making. Further review of the resident's care plan titled, Resident Exhibits Aggressive Outburst of Disruptive Behaviors (threats to hit other residents/staff, curses loudly, shoving/hitting, or scratching) related to Dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Nurse Aide (NA) #1, on 10/12/2020 at 12:10 PM, revealed Resident #3 was placed in his/her room on 09/21/2020 during 6:00 PM to 6:00 AM shift by LPN #1. NA #1 stated she heard the door slam shut and the nurse yell stay in that room and do not come back out. She revealed she heard the resident crying behind the closed door and when she entered the resident's room, the resident was crying and stated why do I have to stay in here. She stated she asked LPN #1 to give the resident a mask earlier in the shift since the resident would not stay in his/her room to quarantine. Interview with LPN #1, on 10/12/2020 at 11:02 AM, revealed Resident #3 had been distracted, wandering in other resident's room, striking out at staff, and would not follow staff's redirection during the night shift on 10/01/2020. LPN #1 stated she assisted the resident to his/her room and closed the door because the residents were to stay in their room due to quarantine related to COVID-19. LPN #1 revealed she was not aware the resident was crying when she left the closed the door and left the room. She stated dementia focused care plan interventions do not always work and she did not utilize the interventions in Resident #3's dementia-focused care plan to speak to the resident in a calm tone of voice and provide an un-hurried pace. She stated other staff on the unit were providing resident care and she did not ask for assistance in caring for the resident prior to taking the resident to his/her bedroom. LPN #1 revealed she told Resident #3 to stay in the room and she shut the resident's room door; however, she denied yelling at resident. LPN #1 stated she has a loud voice tone and some staff have referred to her as short-tempered. LPN #1 stated on 09/22/2020 she was placed on suspension for two (2) days related to the incident. She revealed she failed to implement any of the care plan interventions developed for Resident #3's episodes of aggressive outburst and/or disruptive behaviors prior to escorting the resident to his/her room, closing the door, and telling the resident not to come out. Interview with the Director of Nursing (DON), on 10/12/2020 at 1:30 PM, revealed she was informed of LPN #1 yelling at Resident #3 during the night of 09/21/2020. The DON stated she interviewed the staff working the PM shift (6:00 PM to 6:00 AM) and NA #1 admitted to hearing LPN #1 yelling. The DON stated she asked LPN #1 was her voice louder than usual however, she did not admit to being any louder and replied that's just how I talk. The DON stated I just felt her tone and actions were not socially acceptable due to the task being performed. Further interview with the Director of Nursing (DON), on 10/12/2020 at 1:30 PM, revealed she received a text message from NA #1 informing her LPN #1 had taken Resident #1 down to the floor. The DON revealed she followed up with staff working the PM shift (6 PM to 6 AM) on 09/22/2020 and with those that heard LPN #1 yelling. The DON further revealed she asked LPN #1 was her voice louder than usual; however, she did not admit to being any louder and replied that's just how I talk. The DON stated I just felt her tone and actions were not socially acceptable due to the task being performed. Interview with the Administrator, on 10/16/2020 at 2:00 PM, revealed Resident #3 was not placed in seclusion (bedroom) during incident on 09/21/2020. The Administrator stated Resident #3 was capable of exiting bedroom although instructed not to come out on his/her room. The Administrator revealed LPN #1 was encouraging the resident to stay in his/her bedroom although she would not expect LPN #1's loud tone of voice and closing the door to be used for keeping the resident in his/her room. She stated all staff were educated on dementia care upon hire and annually through Healthcare Academy Computer Based Training and were required to complete competencies with training. She further stated she expected staff to follow each resident's care plan interventions related to resident care and behaviors.

Based on interview, record review, facility policy review, and review of Facility Reported Incident (FRI), Allegation Report and Investigationit it was determined the facility failed to ensure each resident rights to a dignified existence, self-determination, and exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility for one (1) of seven (7) sampled residents, (Resident #2). On 10/05/2020 at approximately 9:00 PM, Licensed Practical Nurse (LPN) #1 requested Resident #2 be put to bed to apply his/her ordered medicated ointment. However, the resident stated he/she did not want to go to bed until 11:00 PM, so LPN #1 told the resident she would document he/she refused the treatment. The findings include: Review of the facility's policy titled, Resident Rights, dated 11/28/16, revealed the resident has a right to a dignified existence, self-determination, and communication. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Record review revealed the facility admitted Resident #2 on 04/26/17, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment, dated 08/26/2020, revealed the facility assessed Resident #2's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of Resident #2's Physician Orders, dated 07/21/2020, revealed order for [MEDICATION(S)] Ointment 0.44-20.6% (Menthol-[MEDICATION(S)] Oxide) to be applied to back of bilateral legs topically every day and night shift for wound healing. Review of Resident #2's Comprehensive Care Plan titled, Actual Skin Impairment Related to Wound Back of Bilateral Lower Legs, last revised 07/21/2020, revealed treatment as ordered of [MEDICATION(S)]. Review of the Facility Reported Incident (FRI), Allegation Report and Investigation, dated 10/06/2020, revealed on 10/05/2020 PM between 9:00 and 10:00 PM, LPN #1 asked Certified Nurse Aides (CNA's) to put Resident #2 to bed so she could perform treatment to back of both lower legs. FRI revealed resident refused to lie down and LPN #1 commented in loud voice that she was [NAME] to write resident down as refusing his/her treatment. Resident stated he/she was not refusing, he/she just did not want to go to bed until 11 PM and that was his/her right, LPN documented refusal of treatment. Interview with Resident #2, on 10/08/2020 at 1:50 PM, revealed LPN #1 wanted him/her to go to bed early and always wanted him/her to go to bed early. Resident #2 stated, I do not like to go to bed before 11 PM but LPN #1 did not agree with him/her staying up until 11 PM. Resident #2 further revealed LPN #1 sometimes tells him/her she wanted him/her to go to bed to treat his/her legs and other times she had no specific reason. Resident #2 stated he/she knew he/she had the right to stay up and was aware of his/her rights. Interview with State Registered Nurse Aide (SRNA) #1, on 10/07/2020 at 3:40 PM, revealed on 10/05/2020 at approximately 9:00 PM she heard LPN #1 attempt to force Resident #1 to go to bed. SRNA #1 stated, I could hear the nurse yelling, I went to see what was going on and the nurse was in Resident #1's face screaming he/she needed to go to bed. The nurse yelled to the resident, I'll just write down you were having behaviors and refused your treatment. She further revealed she recorded the nurse yelling at the resident on her phone and sent the recorded message to the Director of Nursing (DON) however, the DON sent a text that she could not understand what was being said. Interview with SRNA #2, on 10/07/2020 at 4:47 PM, revealed on night of 10/05/2020 she heard LPN #1 tell Resident #1 that the resident refused his/her her treatment since the resident refused to go to bed. SRNA #2 stated the resident told the nurse, I didn't refuse, I just wanted to stay up another hour. Interview with Licensed Practical Nurse (LPN) #1, on 10/12/2020 at 11:02 AM, revealed she wanted Resident #2 to go to bed so she could perform the resident's treatment. LPN #1 stated the resident did not go to bed, when she, asked so she took it as he/she was refusing the treatment. LPN #1 further revealed she documented Resident #2 refused to have the [MEDICATION(S)] Ointment applied to back of both lower legs. LPN #1 stated she did not yell at Resident #1. Interview with the Director of Nursing (DON), on 10/12/2020 at 1:30 PM, revealed she received a voice recording via text from SRNA #1 on night of 10/05/2020; however, she was unable to understand the message. The DON stated on 10/06/2020 when she arrived to work she spoke with SRNA #1, regarding recording and investigated the incident. She stated she determined LPN #1 wanted Resident #1 to go to bed so she could perform the ordered treatment; however, the resident was not ready to go to bed so LPN #1 documented the resident refused the treatment. The DON stated I would have expected the nurse to approach the resident when she went to bed and offer treatment then. The resident did not refuse the treatment, the nurse just refused to accommodate the resident's preference. I would expect the nurse to acknowledge the resident's preference because it was the resident's right. Interview with the Administrator, on 10/08/2020 at 3:30 PM, revealed the DON informed her of the incident 10/06/202. She stated Resident #2 was interviewed and an investigation was initiated. Interview revealed after investigation was completed, it was determined LPN #1 failed to offer the resident treatment after he/she went to bed and documented the resident refused. Interview revealed it was Resident #1's right stay up until 11:00 PM.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure each resident had a right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for one (1) of seven (7) sampled residents (Resident #1). On 09/28/2020, Resident #1 entered the nursing station and began throwing papers and other objects while yelling get out of my house. Licensed Practical Nurse (LPN) #1 stated she was unable to redirect the resident so she grabbed the resident by his/her wrists and sat the resident in a computer chair and held him/her there until a staff member intervened. However, record review revealed there was no documented evidence of the resident's behaviors or other alternatives used prior to the restraint, a physician's was obtained, the type of restraint used, length of time used, effectiveness of the restraint, and name of the individual applying such measures per facility policy. The findings include: Review of the facility's policy titled, Restraint Protocol, dated 11/01/11, revealed chemical and physical restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Physical restraints for behavior control shall only be used with an order from the physician, except in an emergency that threatens to bring immediate injury to the resident or others. In such an emergency, an order may be given by the Director of Nursing Services. Such order may be counter-signed by the attending physician. Full documentation of the episode leading to the use of physical restraint, type of restraint used, length of time used, effectiveness of the restraint, and name of the individual applying such measures shall be entered in the resident's medical record with a Restraint Form. Assess resident for lease restrictive device prior to implementation. Record review revealed the facility admitted Resident #1 on 08/07/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment, dated 08/14/2020, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Observation of Resident #1, on 10/08/2020 at 2:05 PM, revealed the resident lying in bed, alert to name, smiling, with hand extended to greet surveyor, although unable to carry out reality based conversation. Interview with State Registered Nurse Aide (SRNA) #1, on 10/07/2020 at 3:40 PM, revealed on 09/28/2020 at approximately 10:51 PM, she heard Resident #1 yelling. She stated she checked on the resident and witnessed LPN #1 grab the resident by both wrist, sit him/her down in a chair, and hold the resident down in the chair by his/her wrist. She stated she intervened, told LPN #1 I got the resident, and took the resident to his/her room. Further interview revealed when she got the resident to his/her room, she turned on music, got the resident calm, and provided him/her a snack. SRNA #1 stated she called the Director of Nursing (DON), informed her of the incident and the DON told her to write a statement of the incident. She further revealed the DON came to the facility however, she did not investigate the incident and LPN #1 remained throughout the shift. Review of Resident #1's Progress Note, dated 09/28/2020, revealed there was no documented evidence of the resident's behaviors or other alternatives used prior to the restraint, no physician's order for the restraint, type of restraint used, length of time used, effectiveness of the restraint, and name of the individual applying such measures per facility policy. Interview with Licensed Practical Nurse (LPN) #1, on 10/12/2020 at 11:02 AM, revealed on 09/28/2020 Resident #1 entered the nursing station and began snatching papers off the printer and yelling get out of my house. She stated the resident was combative and gait was unsteady so she grabbed the resident by his/her wrists and sat him/her in computer chair. LPN #1 revealed she confined the resident to the chair until a staff member intervened. Further interview revealed LPN #1 did not call out for staff assistance to help redirect the resident. She stated she had to keep the resident from getting hold of the computer and did not consider her intervention as a restraint nor did she document the incident. She revealed the DON came to the facility after the incident, however, she did not question her about the incident. Interview with the DON, on 10/12/2020 at 1:30 PM, revealed she became aware of the incident at approximately 11:00 PM on 09/28/2020. She stated she initially received a text then a phone call alleging LPN #1 had held the resident down in a chair against his/her will. She stated she went to the facility, interviewed some staff, and assessed Resident #1's wrists. She stated the resident was calm, eating a snack, and was in no distress. The DON stated she talked to LPN #1 and was informed the resident came behind the desk slinging papers and the computer was next so she sat the resident down in the chair to allow him/her to regain control. The DON stated she would have expected LPN #1 to document the incident, however, she did not consider the resident being held in the chair as a restraint. Interview with the Administrator, on 10/16/2020 at 2:00 PM, revealed the facility did not encourage the use of restraints and she did not consider Resident #1 being confined to chair as a restraint. The Administrator stated the resident was placed in the chair to prevent harming self or others, and he/she was held less than five (5) minutes before staff intervened.

Based on observation, interview, and facility policy review, it was determined the facility failed to properly label drugs tow (2) medications in the facility in accordance with currently accepted professional principles. Observation of medication refrigerator revealed staff failed to date a vial of [MEDICATION NAME] solution when opened and observation of the West Hall Medication Cart revealed a white pill in a medication cup not labeled. The findings include: The facility policy, Medication Storage revised on 08/17/17, revealed the purpose is to ensure safe and secure storage of all medication per pharmacy and manufacturer's recommendations. Medications that are unlabeled should be immediately removed. Observations of a medication room refrigerator on 06/06/19 at 9:53 AM, revealed a [MEDICATION NAME] vial was opened and there was no date or initials on the vial or package. Licensed Practical Nurse (LPN) #1 revealed the vial should have been dated and initialed when opened. Observation of the West Hall Medicatication Cart, on 06/06/19 at 10:00 AM, revealed a white tablet oblong in shape sitting in a medication cup inside of the first drawer without any notation of what the medication was. Certified Medication Technician (CMT) #3 picked up cup and said, Oh I'm sorry, that was my [MEDICATION NAME]. She revealed she should not have put the [MEDICATION NAME] in the medication cart and knew she was not following the facility policy. Interview with Director of Nursing (DON) on 06/06/19 at 10:15 AM revealed she expected the CMT's and Licensed nursing staff to not put their personal medications in the medication carts in no uncertain terms. She revealed all nursing staff administering medications should never place medications in the carts that are personal medications or do not belong to the residents. She further revealed that all medications of multi-dose vials should be dated and initialed upon opening.

Based on record review, interview and review of the facility's policy/procedure, it was determined the facility failed to ensure that an allegation of sexual abuse/exploitation was reported immediately to officials in accordance with State law through established procedures (including State survey and certification agency). The facility failed to ensure a thorough investigation was conducted with results reported timely, timely reporting of sexual abuse/exploitation allegation to officials, and failed to prevent further potential abuse involving one resident (#4), in the selected sample of fifteen residents. On 09/14/11, facility staff observed Resident #4 in his/her roommates' bed, naked and "humping" the roommate. Based on the facility's failure to follow their own policy, this presented the potential for abuse to recur for Resident #4 and to occur with other residents in the facility. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/10/12 and determined to exist on 09/14/11 through 02/13/12. An acceptable Allegation of Compliance (AoC) was received on 02/13/12. Immediate Jeopardy was removed, effective 02/14/12, as alleged in the AoC with the scope and severity lowered to a "D" based on the need of the facility to continue to evaluate the implementation of changes and quality assurance activities. Substandard Quality of Care was identified at 483.13 Resident Behavior and Facility Practices and 483.25 Quality of Care. (Refer to F323 and F490) Findings include: A review of the facility's policy/procedure, "Resident Abuse, Neglect and Exploitation," dated 04/12/10, revealed it is the goal of the facility to have a process in place to protect the health and welfare of each resident; to assure that each resident is free from verbal, sexual, physical and mental abuse; corporal punishment, neglect, involuntary seclusion, exploitation an injuries of unknown origin. If a resident to resident altercation occurs, the resident's safety and protection will first be assured. The residents shall be separated from each other and the families and physician shall be notified. An investigation will be performed to determine if abuse has occurred. If it is determined that abuse has occurred, an evaluation of the abusing resident shall be completed to determine if there is a problem that would require medical intervention. The incident will be viewed as a reportable incident with proper protocol followed and the appropriate agencies will be notified. A record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was severely cognitively impaired and rarely made decisions. A review of the Mood and Behavior Patterns, dated 09/11, revealed staff documented on 09/01/11, 09/08/11, 09/14/11 (6 AM-2 PM shift and 2 PM-10 PM shift), 09/17/11, and 09/22/11, that Resident #4 displayed inappropriate sexual behavior. An interview with the psychiatrist, on 02/13/12 at 11:22 AM, revealed he was familiar with Resident #4 since admission to the facility and had treated him/her afterwards. Resident #4 had documented episodes of walking into the dayroom of the facility naked in full view of female residents and visitors in the room. There were also documented episodes of the resident asking other residents and visitors sexually inappropriate questions in 5/4/10. The resident had a history of [REDACTED]. their behavior and acted on impulse. The resident had cognitive deficits and had previously been on Depo-[MEDICATION NAME] injections for sexually inappropriate behavior. The injections were discontinued in July 2011 related to not seeing any effectiveness of the medication. At the time he completed a review of his/her medications, he was urged to reduce the number of medications the resident was taking. He revealed those medications identified as not helping Resident #4 were discontinued. There was clear evidence of sexually inappropriate behavior and some type of intervention was warranted to reduce or minimize the sexually inappropriate behavior. The staff would call and a medication was prescribed; however, the staff would call back stating the resident was lethargic and having increased falls. He revealed the staff were his eyes and ears but he was not aware Resident #4 was started back on the Depo-[MEDICATION NAME] injections for sexual aggression. An interview with the DON, on 02/09/12 at 7:41 PM, revealed Resident #4 made comments to the staff like "give me a kiss" or tried to put his/her arm around the staff. He/she came into the halls wearing his/her hipsters and the staff redirected him/her. She stated there were not interviews with any other staff other than SRNA #2, nor did she talk to the residents in the facility because SRNA #2 was the only witness to the incident. They did not determine there was willful intent but rather confusion on Resident #4's behalf. The investigation report was completed after the interview with the witness. She determined the incident was not abuse, but rather the resident was confused and wanted to lay down. There was no reporting to other agencies because it was determined not to be abuse. The abuse/neglect policy/procedure revealed "separate the residents" and that meant to move them apart. An interview with SRNA #4, on 02/10/12 at 12:34 PM, revealed Resident #4 was very sexual and tried to grab staff inappropriately, such as between the legs and breast. Whenever it happened, she informed the charge nurse about the incident. They spoke to the resident and told him/her not to act like that. A review of the nurse's notes, dated 09/14/11 at 10:00 PM, and an interview with SRNA #2, on 02/09/12 at 5:10 PM, revealed she observed Resident #4 "humping" on his/her roommate (Resident #21). Resident #4 was laying in the bed behind the roommate without any clothes on and the roommate was wearing a pair of hipsters. There was no blanket between the residents and he/she was "humping" on the roommate. SRNA #2 called the resident's name and asked what he/she was doing. Resident #4 got up from the victim's bed, ambulated back to his/her bed and got dressed again. She left the room and the residents were left unsupervised. SRNA #2 reported the incident to the charge nurse on duty (RN #2). Registered Nurse (RN) #2 documented an SRNA reported to her she witnessed Resident #4 naked and in the bed with the roommate "humping" up on him/her. The roommate was dressed and under the covers with his/her eyes closed. Resident #4 was redirected and dressed. She could not recall for certain if she had received reports of Resident #4 getting into bed with other residents but it was common knowledge. The Assistant Director of Nursing (ADON) was notified and advised to place the resident on every fifteen (15) minute checks for safety. Staff was directed to check on Resident #4 every fifteen (15) minutes. Additionally, she reported staff caught the resident in bed with other residents in the past, but he/she was not "humping" on them. The staff redirected Resident #4 and he/she got up from the bed. The resident cursed at the staff but he/she was compliant. The staff has caught the resident in the bed with a resident of the same gender. The staff intervened with redirection and they documented the behavior continued with no other approach implemented. During the month of 10/11, staff documented one incident on the 12th of the resident displaying inappropriate sexual behavior. The staff responded with redirection and it was effective. During the month of 11/11, staff documented on the 16th, 18th and 23rd, Resident #4 displayed inappropriate sexual behavior. The staff responded with redirection; however, they documented the behavior continued with no other approach implemented. During the month of 12/11, staff documented on the 5th and 6th that Resident #4 displayed inappropriate sexual behavior. The staff intervened with redirection and they documented the behavior continued with no other interventions implemented. An interview with Certified Medication Technician (CMT) #1 on 02/09/12 at 6:14 PM and 02/10/12 at 10:21 AM, revealed she and an aide walked into the room and observed Resident #4 trying to perform a sex act with his/her roommate (Resident #21). Resident #4 acted like he/she was trying to have sex with the roommate (Resident #21). The room was dark and she was unable to recall if Resident #4 had clothes on or if there were covers between the residents. They intervened, she guided Resident #4 back to his/her bed and left the room. SRNA #2 informed the charge nurse and the CMT documented the behavior on the resident's behavior sheet. A review of the facility's investigation, dated 09/15/11, revealed Resident #4 crawled in bed with his/her roommate (Resident #21), on 09/14/11 at 10:50 PM. Registered Nurse (RN) #2 reported this incident to the Assistant Director of Nursing (ADON), who was the Administrative nurse. The ADON advised RN #2 to place Resident #4 on fifteen (15) minute checks at that time. There was no evidence the facility separated the residents per their policy/procedure for the protection of the resident related to resident to resident abuse. Rather the facility continued to allow the resident to reside in the same room with only every fifteen minute checks performed by the staff. The DON interviewed SRNA #2 who reported seeing Resident #4 close his/her bedroom door. SRNA #2 went to the resident's room and upon entrance to the room, she noticed Resident #4 was in Resident #21's bed with him/her. Resident #21 was facing the wall and Resident #4 was facing Resident #21. Resident #4 appeared to be moving the middle of his/her body in the direction Resident #21 was laying. SRNA #2 asked Resident #4 what he/she was doing and Resident #4 got out of the bed. Resident #21 remained quiet with his/her eyes closed. Resident #4 had a [DIAGNOSES REDACTED]. Prior to Resident #21's admission to that room, Resident #4 resided in the room alone and he/she frequently got into the empty bed. Resident #4 had a history of [REDACTED]. The day prior to this incident, the ADON walked by the room and noticed Resident #4 sitting on Resident #21's empty bed. The incident appeared to be a "sexual advance" as reported by SRNA #2; however, interview with SRNA #2 revealed she thought the incident could be thought of as abuse with Resident #4's history of sleeping in that bed, and being observed in the empty bed the day before, it was more of a habit. With the [DIAGNOSES REDACTED]. Resident #4 was positioning himself/herself in the bed, which would explain any movement coming from him/her. Additionally, the facility provided no evidence of interviewing alert and oriented residents in the facility to determine if Resident #4 attempted to get in the bed with other residents or display sexually inappropriate behavior. There were no interviews with other staff working in the facility to determine if they observed the resident getting into bed with other residents. An interview with RN #2, on 02/09/12 at 5:56 PM, revealed SRNA #2 reported to her Resident #4 was observed "humping" on his/her roommate (Resident #21). When an incident related to abuse occurred, then she was supposed to notify the Director of Nursing (DON). RN #2 assessed both of the residents and did not observe any injury. An interview with the ADON, on 02/09/12 at 7:00 PM, revealed she did not recall being notified on the night of 09/14/11,when the incident with Resident #4 occurred; however, it was documented that the staff called her. She advised the staff to start the resident on fifteen (15) minute checks. She recalled she was told the next day there was potential inappropriate behavior by Resident #4 directed toward his/her roommate (Resident #21). She stated Resident #4 did not have a history of sexually inappropriate behavior and was demented. The resident previously resided in the first bed of the bedroom and got turned around often. He/she got in the empty bed in his/her room and staff redirected him/her to the other bed in the room. The incident was discussed in the morning meeting, on 09/15/11, and they came to the conclusion no abuse occurred. The resident was confused and got into the wrong bed. An interview with the Administrator, on 02/09/12 at 8:10 PM, revealed she was the Abuse Coordinator and completed the investigations in the facility; however, she did not complete the investigation for the incident, on 09/14/11, involving Resident #4. The DON completed the investigation, but she reviewed it and identified no problem with the investigation. No other individuals were interviewed related to the incident because there was only one witness to the incident. We determined there was no abuse identified because Resident #4 was confused and he/she was trying to get in the bed. There was nothing sexual in nature about the incident. The staff moved Resident #4 back to his/her bed and they put him/her on 15 minute checks. The facility determined the resident thought it was his/her bed but as a precaution, they put him/her on extra supervision. An acceptable Allegation of Compliance was received on 02/13/12 and detailed the following: On 02/10/12, the Administrator was trained by the Corporate Compliance Nurse all alleged violation involving mistreatment, neglect, or abuse (specific F225) must be reported to other officials such as the Department of Community Based Services (DCBS) and Office of Inspector General (OIG). There must be evidence that all alleged violation are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. The Administrator is to ensure there is sufficient and adequate investigation and reporting. On 02/10/12, all Charge Nurses, Administrative Nurses, Social Services Director, Administrator and Department Leaders was inserviced on the Abuse, Neglect and Exploitation Policy. Additionally, nurse aide rounds were established and conducted every hour to view the residents, know their whereabouts and assure their environment was free of accident hazards. All residents were assessed by Licensed Nursing staff utilizing the Residents at Risk for Abuse Assessment form, observation and interview. On 02/10/12, Resident #4 was placed on one to one supervision and remained on continuous monitoring. Verification of the removal of Immediate Jeopardy was completed as follows: Review of the Residents at Risk for Abuse Assessment revealed all residents within the facility had an assessment completed on 02/13/12. Investigation and reporting information along with supervision information was relayed to the Charge Nurses, Administrative Nurses, Social Services Director and Department Leaders by the Administrator after being inserviced by the Corporate Compliance Nurse. A review of the inservicing form, dated 02/10/12, and interview with the Administrator, revealed she was re-educated on 02/10/12 related to ensuring all allegations were thoroughly investigated and reported to the other officials. Interview with Licensed Staff and aides, on 02/13/12, revealed they had received inservicing on 02/10/12 related to abuse, separating the residents, placing the aggressor on one to one supervision and notifying the Administrative Nurse on-call. Additionally, the nurses would start the investigation and get statements from all staff working at the time of the incident. They would also interview the residents to see if they had any knowledge of the incident. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Based on interview and record review, it was determined Immediate Jeopardy was identified on 02/10/12 and determined to exist on 09/14/11 through 02/13/12. An acceptable Allegation of Compliance (AoC) was received on 02/13/12. Immediate Jeopardy was removed, effective 02/14/12, as alleged in the AoC with the scope and severity lowered to a "D" based on the need of the facility to continue to evaluate the implementation of changes and quality assurance activities. Substandard Quality of Care was identified at 483.13 Resident Behavior and Facility Practices and 483.25 Quality of Care. (Refer to F323 and F490)

Based on observation, interview, record review and review of the facility's policy/procedure, it was determined the facility failed to ensure one resident (#4), in the selected sample of fifteen residents, received adequate supervision to prevent accidents. On 09/14/11, Resident #4, who the facility had assessed and identified as having a history of sexually inappropriate behaviors, was observed naked in the bed with his/her roommate (Resident #21) "humping" on him/her. Resident #4 was unclothed and there was no cover separating him/her from Resident #21. Resident #21 was observed with his/her hipsters on and was laying in bed with his /her eyes closed. SRNA #2 intervened and the resident returned to his/her bed. Registered Nurse (RN) #2 was informed about the incident and she notified the Assistant Director of Nursing (ADON). RN #2 started every fifteen (15) minute checks on Resident #4. There was no evidence the facility followed their "Abuse" policy/procedure to ensure the resident's safety and protection was first assured and the residents were separated, as the State Registered Nurse Aide (SRNA) and the Certified Medication Technician (CMT) left both Resident #4 and Resident #21 alone in the room together. The facility only initiated every fifteen minute checks, thus leaving the perpetrator (Resident #4) access to Resident #21 and all residents of the unit without supervision. Furthermore, the facility implemented pharmacological interventions to reduce sexual desire even though the psychiatrist had determined this drug ineffective. Additionally, the facility's investigation failed to identify Resident #4's behavior on 09/14/11 as an allegation of abuse and failed to determine that the resident's actions were of sexual nature which prevented the facility from taking actions to protect residents from abuse. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Based on interview and record review, it was determined Immediate Jeopardy was identified on 02/10/12 and determined to exist on 09/14/11 through 02/13/12. An acceptable Allegation of Compliance (AoC) was received on 02/13/12. Immediate Jeopardy was removed, effective 02/14/12, as alleged in the AoC with the scope and severity lowered to a "D" based on the need of the facility to continue to evaluate the implementation of changes and quality assurance activities. Substandard Quality of Care was identified at 483.13 Resident Behavior and Facility Practices and 483.25 Quality of Care. (Refer to F225 and F490) Findings include: A review of the facility's policy/procedure, "Resident Abuse, Neglect and Exploitation" dated 04/12/10, revealed it is the goal of the facility to have a process in place to protect the health and welfare of each resident; to assure that each resident is free from verbal, sexual, physical and mental abuse; corporal punishment, neglect, involuntary seclusion, exploitation an injuries of unknown origin. If a resident to resident altercation occurs, the resident's safety and protection will first be assured. The residents shall be separated from each other and the families and physician shall be notified. An investigation will be performed to determine if abuse has occurred. If it is determined that abuse has occurred, an evaluation of the abusing resident shall be completed to determine if there is a problem that would require medical intervention. The incident will be viewed as a reportable incident with proper protocol followed and the appropriate agencies will be notified. A record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was severely cognitively impaired and rarely made decisions. A review of the Mood and Behavior Patterns, dated 09/11, revealed staff documented on 09/01/11, 09/08/11, 09/14/11 (6 AM-2 PM shift and 2 PM-10 PM shift), 09/17/11, and 09/22/11, that Resident #4 displayed inappropriate sexual behavior. An interview with Licensed Practical Nurse (LPN) #6, on 02/10/12 at 9:38 AM, revealed Resident #4 would frequently try to put his/her arm around staff and if he/she had stayed up late during the night, he/she might ask the staff to give him/her a kiss. Resident #4 at times would be aware of what he/she was doing and other times he/she would not. The staff would redirect the resident when the behavior was displayed. She had observed Resident #4 sitting on the bed of Resident #21 in the past. Resident #4 was sitting at the foot of the bed and Resident #21 would be in the bed lying at the top. The staff would redirect Resident #4 and help him/her get back to his/her bed. An interview with the psychiatrist, on 02/13/12 at 11:22 AM, revealed he was familiar with Resident #4 since admission to the facility and had treated him/her afterwards. Resident #4 had documented episodes of walking into the dayroom of the facility naked in full view of female residents and visitors in the room. There were also documented episodes of the resident asking other residents and visitors sexually inappropriate questions in 5/4/10. The resident had a history of [REDACTED]. their behavior and acted on impulse. The resident had cognitive deficits and had previously been on Depo-Provera injections for sexually inappropriate behavior. The injections were discontinued in July 2011 related to not seeing any effectiveness of the medication. At the time he completed a review of his/her medications, he was urged to reduce the number of medications the resident was taking. He revealed those medications identified as not helping Resident #4 were discontinued. There was clear evidence of sexually inappropriate behavior and some type of intervention was warranted to reduce or minimize the sexually inappropriate behavior. The staff would call and a medication was prescribed; however, the staff would call back stating the resident was lethargic and having increased falls. He revealed the staff were his eyes and ears but he was not aware Resident #4 was started back on the Depo-Provera injections for sexual aggression. A review of the nurse's notes, dated 09/14/11 at 10:00 PM, and an interview with SRNA #2, on 02/09/12 at 5:10 PM, revealed she observed Resident #4 "humping" on his/her roommate (Resident #21). Resident #4 was laying in the bed behind the roommate without any clothes on and the roommate was wearing a pair of hipsters. There was no blanket between the residents and he/she was "humping" on the roommate. SRNA #2 called the resident's name and asked what he/she was doing. Resident #4 got up from the victim's bed, ambulated back to his/her bed and got dressed again. She left the room and the residents were left unsupervised. SRNA #2 reported the incident to the charge nurse on duty (RN #2). Registered Nurse (RN) #2 documented an SRNA reported to her she witnessed Resident #4 naked and in the bed with the roommate "humping" up on him/her. The roommate was dressed and under the covers with his/her eyes closed. Resident #4 was redirected and dressed. She could not recall for certain if she had received reports of Resident #4 getting into bed with other residents but it was common knowledge. The Assistant Director of Nursing (ADON) was notified and advised to place the resident on every fifteen (15) minute checks for safety. Staff was directed to check on Resident #4 every fifteen (15) minutes. Additionally, she reported staff caught the resident in bed with other residents in the past, but he/she was not "humping" on them. The staff redirected Resident #4 and he/she got up from the bed. The resident cursed at the staff but he/she was compliant. The staff has caught the resident in the bed with a resident of the same gender. The staff intervened with redirection and they documented the behavior continued with no other approach implemented. During the month of 10/11, staff documented one incident on the 12th of the resident displaying inappropriate sexual behavior. The staff responded with redirection and it was effective. During the month of 11/11, staff documented on the 16th, 18th and 23rd Resident #4 displayed inappropriate sexual behavior. The staff responded with redirection; however, they documented the behavior continued with no other approach implemented. During the month of 12/11, staff documented on the 5th and 6th Resident #4 displayed inappropriate sexual behavior. The staff intervened with redirection and they documented the behavior continued with no other interventions implemented. An interview with Certified Medication Technician (CMT) #1 on 02/9/12 at 6:14 PM and 2/10/12 at 10:21 AM, revealed she and an aide walked into the room and observed Resident #4 trying to perform a sex act with his/her roommate (Resident #21). Resident #4 acted like he/she was trying to have sex with the roommate (Resident #21). The room was dark and she was unable to recall if Resident #4 had clothes on or if there were covers between the residents. They intervened, she guided Resident #4 back to his/her bed and left the room. SRNA #2 informed the charge nurse and the CMT documented the behavior on the resident's behavior sheet. An interview with Registered Nurse (RN) #2, on 02/09/12 at 5:56 PM, revealed SRNA #2 reported to her Resident #4 was observed "humping" on his/her roommate (Resident #21). RN #2 checked both of the residents and did not observe any injury. They were told by other staff on the other shifts to keep an eye on him/her. She notified the ADON and was advised to put Resident #4 on every 15 minute checks. A review of the close observation or 1:1 supervision revealed every 15 minute checks were initiated on 09/14/11 at 10:00 PM and discontinued on 09/17/11 at 6:45 AM. The facility initiated close observations on 09/14/11 but did not separate Resident #4 and Resident #21 per their policy. Staff did not implement any other monitoring of the resident except for the routine checks and staff documented Resident #4 displayed sexually inappropriate behavior during October, November and December of 2011. An interview with Resident #4's primary care physician, on 02/13/12 at 10:57 AM, revealed he was informed the incident on 09/14/11 was not sexual in nature. The ADON informed him the resident was confused and got into the wrong bed. It was documented in the resident's history of sexually aggressive behavior but he was not aware of any sexually inappropriate behaviors. Resident #4 was demented and was unsure if he/she knew what they were doing. A review of the medication administration record (MAR), dated September 2011, revealed on 09/16/11, Depo-Provera 150 milligrams (mg) was administered via intramuscular (IM) injection by RN #2. An interview with the DON, on 02/09/11 at 7:41 PM, revealed she received the report of the incident the next morning (09/15/11) in their daily meeting with the department heads. She stated the incident was reported to the ADON and she advised the staff to put Resident #4 on every fifteen (15) minute checks. The resident continued to be monitored by the staff and behaviors were recorded on his/her Behavior Observation/Mood and Behavior Pattern. An interview with the Administrator, on 02/09/12 at 8:10 PM, revealed she was the Abuse Coordinator and completed the investigations in the facility; however, she did not complete the investigation for the incident on 09/14/11 involving Resident #4. The DON completed the investigation. The team determined there was no abuse identified because Resident #4 was confused and he/she was trying to get in the bed and detailed there was nothing sexual in nature about the incident, despite the observations made by SRNA #2 and CMT #1 both reporting that Resident #4 was "humping" Resident #21 and trying to perform a sexual act. The Administrator maintained that Resident #4 was not trying to attack the other residents and did not put the other residents at risk, but rather he/she was trying to get in a bed. He/she thought it was his/her bed but as a precaution staff put Resident #4 on extra supervision. While the 15 minute checks were initiated for staff to check on Resident #4, it would be possible in those other 14 minutes for the resident to get up and get in bed with a resident but the staff would have responded to the alarms as well. The Administrator stated she had no problem with the investigation determination. An acceptable Allegation of Compliance was received on 02/13/12 and detailed the following: On 02/10/12, the Administrator was trained by the Corporate Compliance Nurse that all alleged violation involving mistreatment, neglect, or abuse (specific F225) must be reported to other officials such as the Department of Community Based Services (DCBS) and Office of Inspector General (OIG). There must be evidence that all alleged violation are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. The Administrator is to ensure there is sufficient and adequate investigation and reporting. On 02/10/12, all Charge Nurses, Administrative Nurses, Social Services Director, Administrator and Department Leaders was inserviced on the Abuse, Neglect and Exploitation Policy. Additionally, nurse aide rounds were established and conducted every hour to view the residents, know their whereabouts and assure their environment was free of accident hazards. All residents were assessed by Licensed Nursing staff utilizing the Residents at Risk for Abuse Assessment form, observation and interview. On 02/10/12, Resident #4 was placed on one to one supervision and remained on continuous monitoring. Verification of the removal of Immediate Jeopardy was completed as follows: Review of the Residents at Risk for Abuse Assessment revealed all residents within the facility had an assessment completed on 02/13/12. Nurse aide rounds are conducted every hour to view residents frequently, know their whereabouts, assure that the environment remains free of accident hazards (including looking for any signs pertaining to abuse or any hazard conducive to abuse) and assure that a safe environment is being maintained. Charge Nurses trained the Nurse Aides at the beginning of each shift beginning the evening of 02/10/12. Daily monitoring of incident reports that include investigation and supervision information implemented this date 02/10/12, by Administrative Nurse 7 days per week for three months. Any problems will be reported immediately to Corporate Compliance Nurse for action. A review of the inservicing form, dated 02/10/12, and interview with the Administrator, revealed she was re-educated on 02/10/12 related to ensuring all allegations were thoroughly investigated and reported to the other officials. A review of the nurse aide rounds sheets revealed the residents within the facility were monitored hourly and documented they had checked on each residents. Each CNA revealed they had been trained by the Charge Nurses about conducting the hourly rounds. Interview with Licensed Staff and aides, on 02/13/12, revealed they had received inservicing on 02/10/12 related to abuse, separating the residents, placing the aggressor on one to one supervision and notifying the Administrative Nurse on-call. Additionally, the nurses would start the investigation and get statements from all staff working at the time of the incident. They would also interview the residents to see if they had any knowledge of the incident. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Based on interview and record review, it was determined Immediate Jeopardy was identified on 02/10/12 and determined to exist on 09/14/11 through 02/13/12. An acceptable Allegation of Compliance (AoC) was received on 02/13/12. Immediate Jeopardy was removed, effective 02/14/12, as alleged in the AoC with the scope and severity lowered to a "D" based on the need of the facility to continue to evaluate the implementation of changes and quality assurance activities. Substandard Quality of Care was identified at 483.13 Resident Behavior and Facility Practices and 483.25 Quality of Care. (Refer to F225 and F490)

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to be administered in a manner that enabled it to use it resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for one resident (#4) in the selected sample of fifteen residents. The facility failed to thoroughly investigate an allegation of abuse which prevented the facility from taking appropriate action to protect the other residents from further abuse. On 09/14/11, Resident #4 was observed unclothed in the bed of his/her roommate (Resident #21) "humping" on him/her. There were no covers between the residents and Resident #21 was asleep. State Registered Nurse Aide (SRNA) #2 and Certified Medication Technician (CMT) #1 called Resident #4's name and he/she got up from the roommate's bed, redressed and returned to bed. SRNA #2 and CMT #1 left the room and left the residents unsupervised while it was reported to the charge nurse. The Administrator's failure to administer the facility in a manner that enabled it to use its resources to ensure policy and procedures were implemented to ensure allegations of abuse were thoroughly investigated, provide supervision to protect the residents and report the results of the investigation to the appropriate agencies, caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was determined to exist on 09/14/11. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/10/12 and determined to exist on 09/14/11 through 02/13/12. An acceptable Allegation of Compliance (AoC) was received on 02/13/12. Immediate Jeopardy was removed, effective 02/14/12, as alleged in the AoC with the scope and severity lowered to a "D" based on the need of the facility to continue to evaluate the implementation of changes and quality assurance activities. Substandard Quality of Care was identified at 483.13 Resident Behavior and Facility Practices and 483.25 Quality of Care. (Refer to F225 and F323) Findings include: A review of the facility's policy and procedure, "Resident Abuse, Neglect and Exploitation," dated 04/12/10, revealed it is the goal of the facility to have a process in place to protect the health and welfare of each resident; to assure that each resident is free from verbal, sexual, physical and mental abuse; corporal punishment, neglect, involuntary seclusion, exploitation and injuries of unknown origin. If a resident to resident altercation occurs, the resident's safety and protection will first be assured. The residents shall be separated from each other and the families and physician shall be notified. An investigation will be performed to determine if abuse has occurred. If it is determined that abuse has occurred, an evaluation of the abusing resident shall be completed to determine if there is a problem that would require medical intervention. The incident will be viewed as a reportable incident with proper protocol followed and the appropriate agencies will be notified. A record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was severely cognitively impaired and rarely made decisions. A review of the Mood and Behavior Patterns, dated 09/11, revealed staff documented on 09/01/11, 09/08/11, 09/14/11 (6 AM-2 PM shift and 2 PM-10 PM shift), 09/17/11, and 09/22/11, that Resident #4 displayed inappropriate sexual behavior. An interview with the psychiatrist, on 02/13/12 at 11:22 AM, revealed he was familiar with Resident #4 since admission to the facility and had treated him/her afterwards. Resident #4 had documented episodes of walking into the dayroom of the facility naked in full view of female residents and visitors in the room. There were also documented episodes of the resident asking other residents and visitors sexually inappropriate questions in 5/4/10. The resident had a history of [REDACTED]. their behavior and acted on impulse. The resident had cognitive deficits and had previously been on Depo-[MEDICATION NAME] injections for sexually inappropriate behavior. The injections were discontinued in July 2011 related to not seeing any effectiveness of the medication. At the time he completed a review of his/her medications, he was urged to reduce the number of medications the resident was taking. He revealed those medications identified as not helping Resident #4 were discontinued. There was clear evidence of sexually inappropriate behavior and some type of intervention was warranted to reduce or minimize the sexually inappropriate behavior. The staff would call and a medication was prescribed; however, the staff would call back stating the resident was lethargic and having increased falls. He revealed the staff were his eyes and ears but he was not aware Resident #4 was started back on the Depo-[MEDICATION NAME] injections for sexual aggression. A review of the nurse's notes, dated 09/14/11 at 10:00 PM, and an interview with SRNA #2, on 02/09/12 at 5:10 PM, revealed she observed Resident #4 "humping" on his/her roommate (Resident #21). Resident #4 was laying in the bed behind the roommate without any clothes on and the roommate was wearing a pair of hipsters. There was no blanket between the residents and he/she was "humping" on the roommate. SRNA #2 called the resident's name and asked what he/she was doing. Resident #4 got up from the victim's bed, ambulated back to his/her bed and got dressed again. She left the room and the residents were left unsupervised. SRNA #2 reported the incident to the charge nurse on duty (RN #2). Registered Nurse (RN) #2 documented an SRNA reported to her she witnessed Resident #4 naked and in the bed with the roommate "humping" up on him/her. The roommate was dressed and under the covers with his/her eyes closed. Resident #4 was redirected and dressed. She could not recall for certain if she had received reports of Resident #4 getting into bed with other residents but it was common knowledge. The Assistant Director of Nursing (ADON) was notified and advised to place the resident on every fifteen (15) minute checks for safety. Staff was directed to check on Resident #4 every fifteen (15) minutes. Additionally, she reported staff caught the resident in bed with other residents in the past, but he/she was not "humping" on them. The staff redirected Resident #4 and he/she got up from the bed. The resident cursed at the staff but he/she was compliant. The staff has caught the resident in the bed with a resident of the same gender. The staff intervened with redirection and they documented the behavior continued with no other approach implemented. During the month of 10/11, staff documented one incident on the 12th of the resident displaying inappropriate sexual behavior. The staff responded with redirection and it was effective. During the month of 11/11, staff documented on the 16th, 18th and 23rd Resident #4 displayed inappropriate sexual behavior. The staff responded with redirection; however, they documented the behavior continued with no other approach implemented. During the month of 12/11, staff documented on the 5th and 6th Resident #4 displayed inappropriate sexual behavior. The staff intervened with redirection and they documented the behavior continued with no other interventions implemented. An interview with Certified Medication Technician (CMT) #1 on 02/9/12 at 6:14 PM and 2/10/12 at 10:21 AM, revealed she and an aide walked into the room and observed Resident #4 trying to perform a sex act with his/her roommate (Resident #21). Resident #4 acted like he/she was trying to have sex with the roommate (Resident #21). The room was dark and she was unable to recall if Resident #4 had clothes on or if there were covers between the residents. They intervened, she guided Resident #4 back to his/her bed and left the room. SRNA #2 informed the charge nurse and the CMT documented the behavior on the resident's behavior sheet. An interview with the Director of Nursing (DON), on 02/10/12 at 1:24 PM, revealed she completed the investigation of the incident on 09/14/11 involving Resident #4 and his/her roommate (Resident #21). She revealed there was one witness to the incident and she did not interview any cognitively intact residents or staff. She determined, along with the department heads in their daily meeting, the resident was confused and got in the wrong bed. An interview with the Administrator, on 02/09/12 at 8:10 PM, 02/10/12 at 1:15 PM, and 02/13/12 at 8:30 AM, revealed she was responsible for the operation of the facility. She revealed the incident that occurred on 09/14/11 was discussed by the team the next day in the morning meeting. The staff moved Resident #4 back to his/her bed and they put him/her on 15 minute checks. The facility determined the resident thought it was his/her bed but as a precaution, they put him/her on extra supervision. She usually did the investigations in the facility and would interview staff as well as other residents related to the incident; however, she found no concerns with this investigation completed by the DON, who did not conduct interviews with other staff or residents and despite the resident's history of sexually inappropriate behaviors and two staff alleging Resident #4 was "humping" and trying to perform a sexual act, determined it was not sexual in nature. The facility maintained Resident #4 was confused and the movement was related to him/her trying to get in the bed. If she would have determined there was abuse then she would have certainly contacted all the appropriate agencies, but it was not identified. A review of the record revealed the facility initiated fifteen minute checks on 09/14/11 at 10:00 PM. On 09/16/11, the facility administered Depo [MEDICATION NAME] to reduce sexual desire even though their investigation determined the resident's movement was just trying to get into the bed. Furthermore, this intervention had been determined ineffective for this resident in July 2011 by the psychiatrist. The facility discontinued every fifteen minute checks on 09/17/11 at 6:45 AM. The resident continued to display inappropriate sexual behavior according to the behavior monitoring forms for the month of October, November and December of 2011. Redirection was the intervention implemented and staff documented the behavior continued afterwards. The facility continued to allow Resident #4 (the perpetrator) to reside with Resident #21 (the victim) as roommates without supervision and no additional interventions to protect Resident #21 and other residents from potential further abuse by Resident #4. Thus the Administration did not identify failures in the staff not following the policy/procedure, not conducting a thorough investigation and failure to protect residents from further abuse. An acceptable Allegation of Compliance was received on 02/13/12 and detailed the following: On 02/10/12, the Administrator was trained by the Corporate Compliance Nurse all alleged violation involving mistreatment, neglect, or abuse (specific F225) must be reported to other officials such as the Department of Community Based Services (DCBS) and Office of Inspector General (OIG). There must be evidence that all alleged violation are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. The Administrator is to ensure there is sufficient and adequate investigation and reporting. On 02/10/12, all Charge Nurses, Administrative Nurses, Social Services Director, Administrator and Department Leaders was inserviced on the Abuse, Neglect and Exploitation Policy. Additionally, nurse aide rounds were established and conducted every hour to view the residents, know their whereabouts and assure their environment was free of accident hazards. All residents were assessed by Licensed Nursing staff utilizing the Residents at Risk for Abuse Assessment form, observation and interview. On 02/10/12, Resident #4 was placed on one to one supervision and remained on continuous monitoring. Verification of the removal of Immediate Jeopardy was completed as follows: Review of the Residents at Risk for Abuse Assessment revealed all residents within the facility had an assessment completed on 02/13/12. A review of the inservicing form, dated 02/10/12, and interview with the Administrator, revealed she was re-educated on 02/10/12 related to ensuring all allegations were thoroughly investigated and reported to the other officials. Interview with Licensed Staff and aides, on 02/13/12, revealed they had received inservicing on 02/10/12 related to abuse, separating the residents, placing the aggressor on one to one supervision and notifying the Administrative Nurse on-call. Additionally, the nurses would start the investigation and get statements from all staff working at the time of the incident. They would also interview the residents to see if they had any knowledge of the incident. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Based on interview and record review, it was determined Immediate Jeopardy was identified on 02/10/12 and determined to exist on 09/14/11 through 02/13/12. An acceptable Allegation of Compliance (AoC) was received on 02/13/12. Immediate Jeopardy was removed, effective 02/14/12, as alleged in the AoC with the scope and severity lowered to a "D" based on the need of the facility to continue to evaluate the implementation of changes and quality assurance activities. Substandard Quality of Care was identified at 483.13 Resident Behavior and Facility Practices and 483.25 Quality of Care. (Refer to F225 and F323)

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to immediately consult with the resident's physician a need to alter treatment significantly for one resident (#6), in the selected sample of fifteen residents, related to complications of the resident's Percutaneous Endoscopic Gastrostomy (peg) tube site. The facility failed to follow their change in resident condition/status policy and the Enteral Nutrition policy. The facility staff was knowledgeable regarding Resident #6's history of peg tube complications; however, on 01/13/12 and 01/15/12, the facility staff reinserted Resident #6's peg tube without notification of the physician. Additionally, on 01/26/12 the facility staff failed to notify the physician at 4:15 AM when there was yellow drainage from the peg site. At 4:15 PM, the facility transferred the resident to the hospital, who was experiencing severe abdominal pain with excessive amounts of greenish/brown drainage from the tube site. Findings include: A review of the facility's policy/procedure, "Enteral Nutrition," revised 10/21/10, revealed the procedure for gastrostomy tube placement included to obtain a physician's orders [REDACTED]. A review of the facility's policy/procedure, "Change in Resident Condition or Status," revised 03/26/10, revealed the facility should timely notify the attending physician of changes in the resident's medical condition. The nurse supervisor/charge nurse would notify the resident's attending physician or on-call physician when there was a need to alter the resident's medical treatment significantly. A record review revealed Resident #6 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident received a tube feeding. A review of the Nurse's Notes, dated 01/10/12, revealed the resident's peg tube was dislodged. A review of the physician's orders [REDACTED]." Further review of the Nurse's Notes, dated 01/13/12 and 01/15/12, revealed the peg tube was dislodged again, with reinsertion of the tube completed on both days; however, there was no evidence of a physician's orders [REDACTED]. An interview with Registered Nurse (RN) #1, on 02/08/12 at 7:00 PM, revealed she reinserted the resident's peg tube, on 01/13/12; however, she did not notify the physician. An interview with Licensed Practical Nurse (LPN) #3, on 02/09/12 at 10:40 AM, revealed she was the resident's nurse, on 01/15/12. The resident's peg tube was dislodged while administering medications, and RN #1 reinserted the peg tube. She revealed the physician was not notified about the reinsertion, due to an order being received on 01/10/12. She revealed it was her understanding that the order was written to replace the peg tube as needed. An interview with Resident #1's Primary Physician, on 02/08/12 at 2:45 PM, revealed nursing staff should have notified her if the resident's peg tube was dislodged. An interview with the Director of Nursing (DON), on 02/09/12 at 7:15 PM, revealed she expected the staff to reinsert the peg tube to ensure the site did not close, but they should also notify the physician. Further review of the Nurse's Notes, dated 01/25/12 at 12:45 PM, revealed Resident #6 returned to the facility after being examined by the endoscopy department (at the hospital) related to peg tube complications. It was determined by endoscopy the resident's peg tube was functioning properly and orders were resumed. A review of the Nurse's Notes, dated 01/26/12 at 4:15 AM, revealed the resident's peg tube was assessed at that time with a moderate amount of yellow drainage noted around the tube. There was no documented evidence of physician notification. Additional record review revealed, on 01/26/12 At 4:15 PM, the resident was in severe abdominal pain with excessive amounts of greenish/brown drainage around the peg tube. The resident was sent to the emergency room at that time, and admitted with peg tube complications. A review of the Consultation report, dated 01/27/12, revealed treatment during hospitalization consisted of repositioning of the peg tube due to obstruction. An interview with RN #1, on 02/08/12 at 7:00 PM, revealed, on 01/26/12 at 4:15 AM, there was drainage around the resident's peg tube with a slow leakage, but not "major drainage." She revealed drainage was not "normal," but the resident had a history of [REDACTED]. She revealed the physician was not notified regarding the peg tube drainage. An interview with Resident #1's Primary Physician, on 02/08/12 at 2:45 PM, revealed she should have been notified about the moderate yellow drainage, on 01/26/12 at 4:15 AM, as she would have sent the resident to the emergency room at that time. An interview with the DON, on 02/09/12 at 7:15 PM, revealed the physician should have been notified about the drainage around the resident's peg tube, on 01/26/12 at 4:15 AM.

Based on interview, record review, and review of the facility's policies/procedures, it was determined the facility failed to ensure residents received proper treatment and care for gastrostomy tubes for one resident (#6), in the selected sample of fifteen residents, related to complications of the resident's Percutaneous Endoscopic Gastrostomy (peg) tube site. The facility failed to follow their policies/procedures for Enteral Nutrition and Verifying Tube Placement related to gastrostomy tube placement. The facility staff was knowledgeable regarding Resident #6's history of peg tube complications; however, on 01/13/12 and 01/15/12, the facility staff reinserted Resident #6's peg tube without first attaining a physician's orders [REDACTED]. Additionally, on 01/26/12, the facility staff observed at 4:15 AM, yellow drainage coming from the resident's peg tube site. After a period of twelve hours, at 4:15 PM, the facility notified the physician and transferred the resident to hospital #2 after experiencing severe abdominal pain with excessive amounts of greenish/brown drainage coming from the peg tube site. Hospital consultation detailed the resident's peg tube required repositioning due to obstruction. Findings include: A review of the facility's policy/procedure, "Enteral Nutrition - Gastrostomy Tube Placement," revised 10/21/10, revealed the licensed nurse will insert the gastrostomy tube per physician's orders [REDACTED]. A review of the facility's policy/procedure "Verifying Tube Placement," dated 12/13/11, revealed the licensed nurse is responsible for ensuring the tube is positioned in the desired site and for ensuring the tube has remained in the intended position before administering formula or medications through the tube. Verification of correct tube placement is performed before each intermittent feeding, at least once every twelve hours when continuous feedings are given, and before medications are administered through the tube. A record review revealed the facility admitted Resident #6 on 03/16/09 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident received a tube feeding. A review of the comprehensive care plan, "At Risk for Aspiration related to Tube Feeding, Dysphagia," dated 01/11/12, revealed to monitor the tube feeding site for signs/symptoms of infection, drainage, and excoriation. A review of the Nurse's Notes, dated 01/10/12 at 6:45 AM, revealed the resident's peg tube was dislodged and the physician was notified. A review of the physician's orders [REDACTED]." Further review of the Nurse's Notes, dated 01/13/12 at 6:30 AM, revealed "resident's feeding tube dislodged. Re-inserted #16 fr catheter using sterile technique with a 30 cc balloon. Placement checked and verified by two licensed nurses. Resident tolerated well. Denies complaints." Additional record review revealed there was no documented evidence of a physician's orders [REDACTED]. An interview with Registered Nurse (RN) #1, on 02/08/12 at 7:00 PM, revealed she reinserted a new foley catheter in the resident's peg tube site, on 01/13/12, using clean technique. She stated there was no way to keep it sterile. Furthermore, RN #1 revealed she did not notify the physician regarding the reinsertion of the peg tube. A review of the Nurse's Notes, dated 01/15/12 at 8:30 AM, revealed "while doing A.M. flush, peg tube came out. Placement was verified before and it was flushing slower at the time it came out/dislodged. Reinserted #18 fr catheter using 30 cc normal saline. Resident was in slight discomfort during, but no irritation after. Placement verified upon insertion by two licensed nurses. Flushing well and no discomfort voiced at this time. No adverse side effects related to Vitamin D for Vitamin D deficiency observed." Further record review revealed there was no evidence of a physician's orders [REDACTED]. An interview with Licensed Practical Nurse (LPN) #3, on 02/09/12 at 10:40 AM, revealed she was the resident's nurse, on 01/15/12. The resident's peg tube was dislodged while administering medications, and she informed RN #1, who reinserted the peg tube. Placement of the peg tube was verified by both RN #1 and LPN #3. LPN #3 revealed the physician was not notified about the reinsertion of the peg tube, because it was her understanding that the initial physician's orders [REDACTED]. An interview with Resident #6's Primary Physician, on 02/08/12 at 2:45 PM, revealed she expected the nursing staff to notify her each time the resident's peg tube became dislodged. An interview with the Director of Nursing (DON), on 02/09/12 at 7:15 PM, revealed she expected the nurse to reinsert the peg tube to ensure the resident's site did not close; however, the physician should have been notified promptly. Further review of the Nurse's Notes, dated 01/17/12 at 9:17 AM, revealed an "appointment at (hospital #1) Endoscopy to replace peg tube at 2:00 PM today." Additional review revealed the ambulance was to arrive at the facility, at 1:15 PM, to transport the resident to hospital #1. A review of the Nurse's Notes, dated 01/25/12 at 8:00 AM, revealed "abdomen soft, round and non-distended upon palpation. Bowel sounds present (times) four quadrants. Clear fluid seeping from peg site, complaint of headache and nausea," "complaint of tenderness in abdomen near peg," "will call to set up ambulance for treatment per MD orders." A review of the Nurse's Notes, dated 01/25/12 at 8:10 AM, revealed "spoke with Endoscopy - prepared to see resident at 9:00 AM," "resident continues to be NPO (nothing by mouth) with no use of peg per MD orders." A review of the Nurse's Notes, dated 01/25/12 at 8:40 AM, revealed the resident was transported to hospital #1 via ambulance for an endoscopy procedure, and at 12:45 PM, Resident #6 returned to the facility after being examined by the endoscopy department (at hospital #1) related to peg tube complications. It was determined by endoscopy the resident's peg tube was functioning properly and orders were resumed. A review of the Nurse's Notes, dated 01/26/12 at 4:15 AM, revealed the resident's peg tube was assessed at that time with a moderate amount of yellow drainage noted around the tube. There was no documented evidence of physician notification. An interview with RN #1, on 02/08/12 at 7:00 PM, revealed, on 01/26/12 at 4:15 AM, there was drainage around the resident's peg tube with a slow leakage, but not "major drainage." She revealed drainage was not "normal," but the resident had a history of [REDACTED]. She revealed the physician was not notified regarding the peg tube drainage. Additional record review revealed, on 01/26/12 at 4:15 PM, the resident was in severe abdominal pain with excessive amounts of greenish/brown drainage around the peg tube site. On 01/26/12 at 4:30 PM, the physician was notified. On 01/26/12 at approximately 5:40 PM, the resident was transported to the emergency room per ambulance, and was admitted to hospital #2 with peg tube complications. A review of the Consultation report, dated 01/27/12, revealed treatment during hospitalization consisted of repositioning of the peg tube due to obstruction. An interview with the DON, on 02/09/12 at 7:15 PM, revealed the physician should have been notified about the drainage around the resident's peg tube, on 01/26/12 at 4:15 AM. An interview with Resident #6's Primary Physician (#1), on 02/08/12 at 2:45 PM, revealed she should have been notified about the moderate yellow drainage, on 01/26/12 at 4:15 AM, as she would have sent the resident to the emergency room at that time. An interview with Physician #2, on 02/26/12 at 4:00 PM, revealed when he examined the resident in hospital #2's intensive care unit (ICU), the resident was not communicating and appeared sleepy and confused. He stated while he was uncertain about the resident's pain level at that time, the resident had [MEDICAL CONDITION] (or redness) around the peg tube site which could be indicative of an infection at the site, and the blockage of the stomach content (or stomach acid) could have contributed to the discharge at the site.