Every finding on record at VillaSpring of Erlanger

Based on observation, interview, and facility policy review, the facility failed to prepare food in accordance with professional standards for food safety. This had the potential to affect 131 of 132 current residents that received food from the kitchen.The findings include:Review of the facility's policy titled, Uniform - Dress Code, revised 01/2024, revealed hair and beard nets must be worn by kitchen staff.1. Observation on 09/09/2025 at 9:28 AM revealed Food Service Worker (FSW) 1 had both sides of her hair, approximately three inches, not contained in the hairnet.During an immediate interview with FSW1 at the time of the observation she stated she received education involving how to wear hairnets and all hair was to be covered.2. Observation on 09/09/2025 at 9:47 AM revealed the Executive Chef had her front bangs, approximately two inches, not contained in the hairnet.During an immediate interview with the Executive Chef at the time of the observation she stated the facility policy was all hair should be covered. She stated her front bangs were not covered because she was rushed.During an interview on 09/11/2025 at 10:38 AM with the Dietitian, she stated all the residents in the facility received food from the kitchen except one, who had an order stating nothing was allowed by mouth and received artificial nutrition.During an interview on 09/11/2025 at 10:18 AM with the Director of Nursing (DON), he stated he expected the kitchen staff to follow facility policies and to wear hairnets when preparing food.During an interview on 09/11/2025 at 10:32 AM with the Administrator, she stated she occasionally went into the kitchen to monitor staff for proper hygiene, and she expected staff to wear hairnets that completely covered all hair.

Based on observation, interview, record review, review of the facility's policies, and review of the Centers for Disease Control and Prevention (CDC) guidlines related to enhanced-barrier precautions (EBP) and transmission-based precautions (TBP), the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases for 4 out of 27 sampled residents (Residents (R) 5, R20, R65, and R86) 1. Observation on 09/09/2025 revealed the Medical Records Supervisor failed to remove her gloves or perform hand hygiene before leaving a resident's room after handling trash and walked through the hallway with gloved hands and opened the dirty utility room door with contaminated personal protective equipment (PPE).2. Observation on 09/09/2025 revealed State Registered Nurse Aide (SRNA) 3 entered room [ROOM NUMBER], an EBP room, then exited the room without performing hand hygiene.3. Observation on 09/09/2025 revealed the Nurse Practitioner (NP) entered the dining room and used a blood pressure cuff, digital thermometer, oxygen saturation monitor, and stethoscope to provide care to R20 in the dining room without disinfecting any of the equipment used.4. Observation on 09/10/2025 revealed Kentucky Medication Aide (KMA) 1 did not remove her gloves or perform hand hygiene prior to exiting room [ROOM NUMBER]. She walked through the hall wearing the gloves and opened the door to the dirty utility room with her contaminated gloved hand.5. Observation on 09/10/2025 revealed Licensed Practical Nurse (LPN) 1 took vital signs on R5, however the LPN did not clean and sanitize the shared equipment before performing a vital sign assessment on patient R65.6. Observation on 9/11/2025 revealed LPN2 entered the dining room holding a glucometer with a test strip inserted and was not wearing gloves and a glucose fingerstick on R86 without performing hand hygiene. LPN2 put on gloves and completed the fingerstick then placed the contaminated glucometer with the test strip in place on top of the medication cart and removed her gloves.The findings include:Review of the CDC Guidelines titled, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately before providing resident care and after care was completed. It stated staff should ensure the proper selection and use of PPE based on the nature of the patient interaction and potential for exposure to blood, body fluids, and/or infectious materials.Review of the facility's policy titled, Standard Precautions, revised 09/2025, revealed standard precautions will be used in the care of all residents regardless of their diagnosis or suspected or confirmed infection status. Further review of the policy revealed hand hygiene is required after removing gloves and other PPE. According to the policy, reusable shared equipment is not used for the care of another resident until it has been appropriately cleaned and disinfected.Review of the facility's policy titled, Nursing Standards of Practice for Bedside Blood Glucose Testing with the EvenCare G3 Blood Glucose Monitor, revised 1/2023, revealed standard precautions are used while providing blood glucose testing. Furthermore, nursing staff should disinfect glucose monitors between patient use.Review of R20's admission Record revealed the facility admitted the resident on 12/07/2022 with diagnoses of Alzheimer's disease, unspecified, anxiety disorder, unspecified, and depression, unspecified.Review of R20's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 09/03/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of five out of 15, indicating R20 was severely cognitively impaired.Review of R5's admission Record revealed the facility admitted the resident on 02/03/2023 with diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus, and congestive heart failure.Review of R5's quarterly MDS, with an ARD of 08/15/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating R5 was cognitively intact.Review R65's admission Record revealed the facility admitted the resident on 04/07/2023 with diagnoses of chronic venous hypertension, type 2 diabetes mellitus, and chronic kidney disease.Review of R65's quarterly MDS, with an ARD of 08/22/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating R65 was cognitively intact.Review of R86's admission Record revealed the facility admitted the resident on 12/30/2023 with diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus, and atherosclerotic heart disease.Review of R86's quarterly MDS, with an ARD of 08/27/2025, revealed the facility assessed the resident to have a BIMS score of 15 out 15, indicating R86 was cognitively intact.1. Observation of the Medical Records Supervisor on 09/09/2025 at 10:10 AM revealed she gathered trash from a resident's room. The supervisor wore gloves but failed to remove her gloves or perform hand hygiene before leaving the resident's room and after handling trash. She walked through the hallway with gloved hands and opened the dirty utility room door with contaminated PPE.During an immediate interview at the time of the observation, the Medical Records Supervisor stated she was unaware she needed to remove her gloves and perform hand hygiene before leaving the room if she needed to carry trash to the dirty utility room. She stated she did not normally assist on the floor other than to monitor as needed. She further stated following infection control practices was important to prevent the spread of infection due to cross-contamination.2. Observation of SRNA3 on 09/09/2025 at 10:29 AM revealed she entered room [ROOM NUMBER], an EBP room, and did not perform hand hygiene upon entry. SRNA3 then exited the room without performing hand hygiene.During an interview with SRNA3 on 09/09/2025 at 10:40 AM, she stated she performed hand hygiene before leaving the room. When questioned further regarding the observation of not following hand hygiene protocols, she stated, I can't say I do it all the time. SRNA 3 stated following infection prevention and control policies (IPCP) was important to prevent the spread of infection due to cross-contamination. 3. Observation of the NP on 09/09/2025 at 1:05 PM revealed she entered the dining room wearing a blood pressure cuff on her right forearm. She approached R20 and applied the cuff to R20's right forearm without first cleaning and disinfecting the shared equipment, then measured the resident's blood pressure. After taking the measurement, she placed the cuff on the dining table. The NP took a digital thermometer out of her pocket to check R20's temperature and returned it to her pocket without disinfecting it. She then used an oxygen saturation monitor on R20's index finger, putting it back in her pocket without cleaning it afterward. Next, she listened to R20's heart and breath sounds using her stethoscope, again without disinfecting the equipment. Finally, the NP returned the blood pressure cuff to her forearm and left the dining room.During an interview with the NP on 09/09/2025 at 1:26 PM, she stated she did not work for the facility but provided services under contract. She stated she did not wipe off the blood pressure cuff after using it on a resident. She stated she usually cleans and disinfects shared equipment after using it a few times on residents. The NP stated there was a possibility of transmission of microorganisms to other residents when staff did not clean and disinfect shared equipment after use. She further stated infection control was important for the safety and well-being of residents.4. Observation of KMA1 on 09/10/2025 at 9:29 AM revealed she did not remove her gloves or perform hand hygiene prior to exiting room [ROOM NUMBER]. She walked through the hall wearing the gloves and opened the door to the dirty utility room with her contaminated gloved hand.During an interview with KMA1 on 09/10/2025 at 9:41AM, she stated she should have doffed (taken off) her gloves and PPE before exiting the resident's room. KMA1 stated she wanted to continue wearing gloves while transporting the heavily soiled trash and linen but stated she should have double bagged the items instead. She stated hand hygiene, and the removal of contaminated PPE was important to prevent cross contamination. 5. Observation of LPN1 on 09/10/2025 at 10:04 AM revealed she conducted a vital sign assessment on patient R5. However, after taking the vital signs, she did not clean and sanitize the shared equipment before performing a vital sign assessment on patient R65. Additionally, instead of cleaning and sanitizing the shared equipment after the second assessment, she pushed the vital sign machine into the hallway and left it there as she walked away.During an interview with LPN1 on 09/10/2025 at 10:24 AM, she stated according to facility policy any shared equipment should be cleaned and disinfected using the appropriate disinfecting wipes immediately after use on a resident. She stated she usually cleaned and disinfected the vital sign machine. She stated it was important to prevent the spread of infection and for the safety and well-being of the residents. 6. Observation of LPN2 on 09/11/2025 at 7:50 AM revealed she entered the dining room holding a glucometer with a test strip inserted and was not wearing gloves. She approached resident R86 and began to perform a glucose fingerstick. Upon noticing the State Survey Agency (SSA) surveyor, she stopped and moved the resident into the hallway near the medication cart. Without performing hand hygiene, she donned gloves and completed the fingerstick. LPN2 placed the contaminated glucometer with the test strip in place on top of the medication cart and removed her gloves. She pulled out the test strip, rolled it into her gloves, and disposed of them. She did not clean or sanitize the glucometer and did not perform hand hygiene immediately after the procedure.During an interview with LPN2 on 09/11/2025 at 10:41 AM, she stated she had never intended to perform R86's fingerstick in the dining room but only took all the supplies in there to get the resident to take her to her room. She stated she did perform hand hygiene when donning and doffing her gloves. She stated further that she cleaned the glucometer before she stored it in the medication cart. LPN2 could not articulate why it was important to use a barrier when placing the contaminated glucometer down on top of the medication cart with other supplies. During an interview with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) on 09/11/2025 at 3:18 PM, she stated it was her expectation for all staff to follow the infection prevention and control practices within the facility. She stated staff were required to follow CDC guidelines as posted on EBP and TBP signs located on resident's doors. She further stated the purpose of these signs was to ensure that staff use the correct PPE and perform hand hygiene to prevent the spread of infection. The ADON/IP stated all vendors, including the providers, are expected to follow facility IPCP policies to prevent the spread of infection and for the safety of all residents, staff, and visitors.During an interview with the Administrator on 09/11/2025 at 3:49 PM, she stated it was her expectation that staff follow all infection prevention and control practices. She stated nursing leadership should make routine observations to ensure staff followed protocol. The Administrator stated the importance of infection prevention and control was to prevent the spread of infection between residents, staff, and visitors, and she further stated infection prevention and control was essential for the safety and well-being of everyone in the facility.

Based on observation, interview, record review, and facility policy review, the facility failed to establish a system of records of receipts and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and failed to determine drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 out of 27 sampled residents (Resident (R) 101). Review of the Controlled Drug Receipt Record/Disposition Form for the 2100 Hall medication cart on 09/11/2025 revealed an incorrect count for R101's pregabalin 50 milligram (mg) capsules.Review of the Narcotic Shift Count sheet for the 2200 Hall medication cart on 09/11/2025 revealed Licensed Practical Nurse (LPN) 4 failed to sign the Narcotic Shift Count sheet as the oncoming nurse. Review of the Narcotic Shift Count sheet for the 2100 Hall medication cart on 09/11/2025 revealed LPN3 failed to sign the Narcotic Shift Count sheet as the oncoming nurse. The findings include:Review of the facility's policy titled Controlled Drug Reconciliation, revised 06/2025, revealed the licensed nurse/medication aide counts all controlled medications at every change of shift and during the hand-off of narcotic keys. According to the policy, a reconciliation is performed by both the outgoing and incoming licensed nurse/medication aide. The outgoing nurse/medication aide reads the quantity of narcotics listed on the proof of use sheet, while the incoming nurse/medication aide verifies the medication packaging to ensure it matches the recorded number of narcotics. A physical count reconciliation of controlled substances, along with the identification of the individuals conducting the medication reconciliation, is documented on the proof of use sheets for every shift-to-shift count.1. Review of R101's admission Record revealed the facility admitted the resident on 07/15/2025 with diagnoses of lumbosacral spondylopathies, chronic pain syndrome, and type 2 diabetes.Review of R101's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 09/05/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating R101 was cognitively intact.Review of R101's Order Summary, dated 09/2025, revealed on 07/15/2025 the physician prescribed pregabalin oral capsule 50 mg, give one capsule by mouth two times a day for pain.Review of the Medication Administration Report [MAR], dated 09/2025, revealed documentation on 09/08/2025 that R101 was given one pregabalin oral capsule 50 mg at 9:00 PM.Review of the 2100 Hall medication cart's Narcotic Count Sheets, on 09/11/2025 at 11:36 AM, revealed the count of R101's scheduled 9:00 PM dose of pregabalin 50 mg (a medication used to treat pain or nerve pain in individuals with diabetes) and classified as a Schedule 5 controlled substance (the lowest category for abuse potential), was inaccurate. The records indicated there were 17 capsules remaining; however, only 16 capsules were counted in the medication card. Furthermore, documentation showed that R101's scheduled 9:00 PM dose of pregabalin 50 mg on 09/08/2025 had not been signed out as administered.Review of the 2100 Hall medication cart's Controlled Drug Receipt Record/Disposition Form, for R101's pregabalin 50 mg capsules, with a received date of 09/03/2025, revealed the resident received one pregabalin 50 mg capsule by mouth twice daily for pain. The quantity received from the pharmacy was 30 capsules. On 09/08/2025, one capsule was signed out at 9:00 AM as given, leaving 22 pills. There was no 9:00 PM dose documented as given. The count on 09/11/2025 was 17.On 09/11/2025 at 11:40 AM, the State Survey Agency (SSA) surveyor requested the name and contact information for the nurse on duty on 09/08/2025, during the evening shift, who was responsible for administering R101's medications. This information was not provided by the facility during the survey.During an interview with Unit Manager (UM)/Registered Nurse (RN) 2 on 09/11/2025 at 11:41 AM, she stated nurses and medication aides were required to sign the narcotic count sheet at the end of the shift reconciliation period and staff must count at the beginning and end of each shift, ensure the count is accurate, and complete documentation. She stated R101's 9:00 PM dose of pregabalin 50 mg on 09/08/2025 was not signed out, however, based on the medication card count, the dose was given. UM/RN2 stated nursing staff should have identified and reported the inconsistency immediately and were expected to follow established narcotic count protocols to prevent incorrect counts and diversion.2. Review of the Narcotic Shift Count sheet for the 2200 Hall medication cart on 09/11/2025 at 11:17 AM revealed LPN4 had not signed the sheet as the oncoming nurse. During an immediate interview, LPN4 stated she completed a narcotic card count with the outgoing nurse at shift change earlier that morning. However, she stated she forgot to sign the Narcotic Shift Count sheet. LPN4 stated it was important to follow the facility's procedures and document correctly to prevent the diversion of scheduled narcotics.3. Review of the Narcotic Shift Count sheet for the 2100 Hall medication cart on 09/11/2025 11:36 AM revealed LPN3 had not signed the sheet as the oncoming nurse. During an immediate interview, LPN3 stated she completed the count with the outgoing nurse at shift change, but stated I must have forgot to sign the sheet. LPN3 stated it was important to follow policy to prevent diversion of narcotic drugs.During an interview with the Assistant Director of Nursing (ADON) on 09/11/2025 at 3:18 PM, she stated licensed nurses/medication aides should follow facility policy related to medication storage and should follow established protocols for counting narcotics. She stated nurses were to maintain the cart according to policy and must follow the process for the cart count. She stated it was her expectation that both the outgoing and incoming nurse/medication aide count the cart together. She further stated they should be counting the medication pack as well as the count sheet. The ADON stated the incorrect count should have been identified immediately during the next shift count. She stated following narcotic count protocols was important to help prevent diversion of narcotics from occurring.During an interview with the Director of Nursing (DON) on 09/11/2025 at 3:42 PM, he stated licensed nurses and medication aides were expected to maintain the medication cart in accordance with facility policy and follow established procedures for completing the narcotic count. The DON stated it was his expectation for both the outgoing and incoming nurse or medication aide to conduct the narcotic medication count together. He further stated the incorrect count should have been identified immediately and the discrepancy should not have taken three days to discover, and the error should have been detected immediately if the counts were performed correctly. The DON stated staff must follow facility policy and protocols for counting narcotics, which included signing the narcotic count sheet and completing counts at the beginning and end of each shift. He stated following proper narcotic count procedures was important to ensure accuracy and to prevent opportunities for diversion.During an interview with the Administrator on 09/11/2025 at 3:49 PM, she stated it was her expectation that staff follow all established protocols for counting narcotics. She stated it was important for the well-being and safety of the residents to ensure accuracy of the narcotic count and to safeguard against potential diversion.

Based on observation, interview, record review, and facility policy review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 27 sampled residents (Resident (R) 2 and R20).Observation during lunch service on 09/09/2025 revealed the Occupational Therapy Assistant (OTA) was standing between R2 and R20 while assisting them with eating lunch.Additional observation during lunch service on 09/09/2025 revealed the Nurse Practitioner (NP) approached R20, who was seated at a table eating lunch with R20, to obtain vital signs from the resident while she was eating. The findings include:Review of facility policy titled, Resident Rights, undated, revealed the resident shall be treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs. 1. Review of R2's admission Record revealed the facility admitted the resident on 03/10/2023 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphasia, pharyngoesophageal phase, and type II diabetes mellitus with hyperglycemia.Review of R2's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 08/28/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 99, indicating R2 was unable to complete the interview.Review of R2's Comprehensive Care Plan, dated 09/10/2025, revealed the resident was identified as having an activities of daily living (ADL) self-care performance deficit. R2 was totally dependent on staff for eating and required a feeding tube related to dysphagia.Observation of lunch service in the dining room on 09/09/2025 at 12:57 PM revealed R20 was sitting in a Broda chair positioned in the back corner of room. R2 was positioned in a Broda chair directly across from R20, and the OTA was standing in between the residents, assisting both residents with eating lunch.During an interview on 09/09/2025 at 1:22 PM with the OTA, she stated she was trying to feed R2 while keeping an eye on the other resident. She was not aware she was supposed to sit with R2 when assisting her with eating, and stated it was hard to sit because R2 was in a Broda chair, and it was hard to reach her mouth.2. Review of R20's admission Record revealed the facility admitted the resident on 12/07/2022 with diagnoses of Alzheimer's disease, unspecified, anxiety disorder, unspecified, and depression, unspecified.Review of R20's quarterly MDS, with an ARD of 09/03/2025, revealed the facility assessed the resident to have a BIMS score of five out of 15, indicating R20 was severely cognitively impaired.Review of R20's Comprehensive Care Plan (CCP), dated 09/10/2025, revealed the resident was identified as having an ADL self-care performance deficit. Interventions included R20 needed assistance with eating in set-up then supervision (helper provides verbal cues and/or touching as resident completes activity). Observation of lunch service in the dining room on 09/09/2025 at 1:05 PM revealed the NP brought a blood pressure cuff wrapped around her wrist into the dining room and proceeded to apply the blood pressure cuff to R20's right wrist, while the resident was eating, and she obtained additional vital signs for R20.During an interview on 09/09/2025 at 1:29 PM with the NP, she stated she was unaware of the requirement allowing residents to eat meals without being interrupted. She stated she was trying to obtain R20's vital signs and knew about infection control, but she was attempting to visit all her patients before leaving to travel to another facility.During an interview on 09/11/2025 at 5:00 PM with the Director of Nursing (DON), he stated it was his expectation that staff assisting residents with eating would sit next to the resident and not stand. He stated it was his expectation for staff or contract employees to respect the privacy of residents and not try to obtain vital signs while residents were eating.During an interview on 09/11/2025 at 4:47 PM with the Administrator, she stated it was her expectation that staff would take a food tray to a resident in the dining room and would expect staff to sit next to the resident when assisting residents with eating. She stated it was her expectation that staff would not interrupt residents to obtain vital signs while residents were dining, and residents should be allowed to dine without being disturbed.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to label and store medications in accordance with currently accepted professional principles for 2 out 27 sampled residents (Resident (R) 94 and R103).During an observation of the 1300 Hall medication cart on 09/11/2025, a medicine cup containing R94's opened medications was found in the drawer. The medications were documented as given.During an observation of the 2100 Hall medication cart on 09/11/2025, a medicine cup containing R103's opened medications was found in the drawer. The medications were documented as given. The findings include:Review of the facility's policy titled, Administration Oral Medication, revised 11/2024, revealed the facility ensured residents were given medications per the physician's orders. The policy stated medications are given at the time ordered.Review of the facility's policy titled, Medication Storage, revised 04/2024, revealed medications and biologicals for each resident are stored in the containers in which they were originally received.1. Review of R94's admission Record revealed the facility admitted the resident on 07/11/2025 with diagnoses of type 2 diabetes mellitus, malignant meal plans, and in chronic pain.Review of R94's admission Minimum Data Set [MDS], with an assessment reference date (ARD) of 07/17/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating R94 was cognitively intact.Review of the Medication Administration Report [MAR], dated 09/2025, revealed on 09/11/2025 all of R94's 9:00 AM medications were documented as given by Licensed Practical Nurse (LPN) 2.Observation of the 1300 Hall medication cart on 09/11/2025 at 10:50 AM revealed an unlabeled medicine cup containing the medications for R94, scheduled for 9:00 AM, was found in a medication drawer. Medications found were cholecalciferol 50 micrograms (mcg) oral tablet, pantoprazole sodium 40 milligrams (mg) oral tablet, pioglitazone HCL 15 mg oral tablet, metformin 1000 mg oral tablet, ferrous sulfate 325 mg oral tablet, and lisinopril 10 mg oral tablet. All the medications had been documented on the MAR as administered to R94.During an immediate interview with LPN2, she stated she prepared the 9:00 AM medications and took them to R94's room; however, the resident did not want to take them at that time and stated she would take them after her physical therapy session. LPN2 stated she marked the medications as given but should have discarded them and marked them as refused. She stated opened and unlabeled medications should not be stored in the medication cart. LPN2 stated following facility policy for medication storage was important for the safety of the residents and she should not have marked the medications as given since they were not actually administered.2. Review of 103's admission Record revealed the facility admitted the resident on 08/13/2025 with diagnoses of pleural effusion, malignant neoplasm of the breast, and anemia.Review of R103's quarterly MDS, with an ARD of 08/17/2025, revealed the facility assessed the resident to have a BIMS score of 13 out of 15, indicating R103 was cognitively intact.Review of the MAR, dated 09/2025, revealed on 09/11/2025 all of R103's 9:00 AM medications were documented as given by LPN3.Observation of the 2100 Hall medication cart on 09/11/2025 at 11:17 AM revealed an unlabeled medicine cup containing the medications for R103, scheduled for 9:00 AM, was found in the medicine drawer. Medications found were Eliquis 2.5 mg oral tablet, doxycycline 100 mg oral tablet, mucus relief D 600 mg oral tablet, oxybutynin extended relief 10 mg oral tablet, pantoprazole sodium 40 mg oral tablet, pravastatin 20 mg oral tablet, probiotic 250 mg oral tablet, and metoprolol extended release 200 mg oral tablet. All the medications had been documented on the MAR as administered to R103. During an immediate interview with LPN3, she stated R103 refused her 9:00 AM medications, but she was going to try to get the resident to take them at a later time. She stated it would be too late to give them to the resident now as it was past the one hour after window. LPN3 marked the medications as given but stated she should have marked them as refused because the resident did not take them. Further interview revealed LPN3 stated opened or unlabeled medication should not be kept in the medication cart. She stated it was important to follow facility protocols for storage to ensure resident safety.During an interview with Unit Manager (UM)/Registered Nurse (RN) 2 on 09/11/2025 at 11:41 AM, she stated staff must follow the facility's policies for medication storage to ensure the safety of residents and to prevent errors. She stated any opened or unlabeled medications pose a safety risk and must be discarded according to policy. She further stated the nurse responsible for the medication pass should not have marked the medications as given when they were not administered but should have instead documented them as refused and discarded the medications.During an interview with the Assistant Director of Nursing (ADON) on 09/11/2025 at 3:18 PM, she stated it was her expectation that nursing staff adhere to the facility policy for proper medication storage as it was important to protect residents from harm. She stated opened or unlabeled medications created a safety risk and must be discarded immediately. The ADON further stated medication should never be documented as given if they were not administered and staff were required to document the dose as refused.During an interview with the Director of Nursing (DON) on 09/11/2025 at 3:42 PM, he stated according to facility policy staff should not keep opened or unlabeled medications in the medication cart as it places residents at risk. The DON stated staff were required to discard such medications immediately. He stated medications must not be signed out as administered if they were not given and staff should instead document the doses as refused in accordance with the policy. The DON stated it was his expectation all nursing staff follow the facility policies and procedures for safe medication storage and administration. He further stated it was important that resistant residents receive their medications as ordered by their physician to ensure safe and effective treatment.During an interview with the Administrator on 09/11/2025 at 3:49 PM, she stated it was her expectation that staff follow all established protocols for medication storage and administration. She stated it was important for the well-being and safety of the residents and to ensure they receive their medication as ordered by the physician.

Based on observation, interview, record review, review of the manufacturer's instructions for use, and review of the facility's policies, the facility failed to maintain infection prevention and control measures to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents sampled for transmission- based precautions (Resident (R) 36 and R107) and 1 of 3 residents reviewed for use of sit-to-stand mechanical lifts (R21). The findings include: Review of the facility's policy titled, Infection Control: Transmission Based Precautions, dated 9/2024, revealed the facility was to implement contact precautions for residents known or suspected to be infected with microorganisms that could be transmitted by direct or indirect contact with the resident or the resident's environment. Further review revealed infections indicating use of contact precautions included multi-drug resistant organisms. Per the policy, staff was to wear gloves and gown for interactions that involved contact with the resident. Review of the facility's policy titled, Standard Precautions, revised 09/2023, revealed reusable equipment used for resident care was not used for the care of another resident until it had been appropriately cleaned and reprocessed. Review of the manufacturer's instruction for use of the Hoyer Ascent lift, not dated, revealed the lift should be cleaned using a damp cloth and to wipe clean with ordinary soap and water and/or using any hard surface disinfectant. 1. a. Review of R36's Admission Record revealed the facility admitted the resident on 09/08/2023 with diagnoses including unspecified dementia and type 2 diabetes. Review of R36's Care Plan, not dated, revealed the facility identified the resident had an infection with a multi-drug resistant organism and included the intervention of placing the resident in contact precautions. Review of R36's Order Details, dated 10/02/2024, revealed the physician ordered the resident to be in contact precautions for extended-spectrum beta-lactamase (ESBL-a multi-drug resistant organism) in her urine. Observation on 10/10/2024 at 10:59 AM revealed the facility posted a sign on the personal protective equipment (PPE) container outside R36's room, indicating the resident was in contact precautions. Further observation revealed the sign indicated staff was to don (put on) a gown and gloves prior to entering R36's room. Continued observation revealed Licensed Practical Nurse (LPN) 6 entered R36's bed space without donning PPE, including a gown and gloves. Per additional observation, LPN6 administered R36's insulin (medication given to reduce blood glucose level with a subcutaneous route) without donning gown or gloves. In an immediate interview, LPN6 stated she never wore PPE for insulin administration. She further stated she believed PPE was only required in contact precaution rooms when aides were providing incontinence care or helping a resident get dressed, and she was not expected to wear PPE when administering insulin. In an interview on 10/10/2024 at 11:14 AM, the 100 Unit Manager stated staff was to don PPE prior to entering a room for a resident in contact precautions, especially if the staff member came into direct contact with the resident. b. Observation on 10/11/2024 at 9:03 AM revealed State tested Nurse Aide (STNA) 18 carried a food tray into R107's room without donning PPE. Per observation, she put the tray on R107's bedside table, exited the room, and applied hand sanitizer. Further observation revealed the sign on the door frame indicated for visitors to check at the nurse's desk. Additional observation revealed a container of PPE located to the right of the doorway had a sign on the top for contact precautions. In an interview on 10/11/2024 at 9:13 AM, STNA18 stated, When residents are in enhanced barrier precautions we do not need to put on PPE. If they are in contact precautions, we should put on PPE before bringing the tray into the room. Did I not do that? After the State Survey Agency (SSA) Surveyor told her she did not wear PPE and R107 was in contact precautions, STNA 18 responded, I am sorry. In an interview on 10/11/2024 at 9:09 AM, the 200 Unit Manager stated if a resident was in contact precautions, staff was required to don PPE for tray delivery and remove PPE before exiting the room. In an interview on 10/10/2024 at 4:12 PM, the Assistant Director of Nursing/Infection Preventionist stated she expected all nurses to don a gown and gloves prior to entering the resident room to administer insulin when the resident was in contact precautions. In an interview on 10/11/2024 at 10:58 AM the Director of Nursing (DON) stated he expected staff to don a gown and gloves prior to coming in contact with a resident in contact precautions, including for insulin administration. In an interview on 10/11/2024 at 9:37 AM, the Administrator stated staff were to don PPE, including gown and gloves, prior to entering a room of a resident in isolation. 44000 2. Observation on 10/09/2024 at 10:22 AM revealed Nurse Aide in Training (NAT) 3 and STNA13 used the Hoyer Ascend lift to assist R21 to the toilet. They secured a cloth sling around R21's back and together assisted her to stand. They then moved R21 to the toilet. The strap to the sling fell on R21's abdomen and upper perineal area. They then assisted R21 to the wheelchair. They removed the sling and put the sling on the lift. STNA13 then took the Hoyer Ascent lift to the shower room on the 1100 Hall. She left the shower room and failed to clean the lift. During interview with STNA13 on 10/09/2024 at 10:42 AM in the hallway after she left the shower room, she stated she forgot to clean the lift. She stated she should have cleaned the lift with disinfectant wipes. Registered Nurse (RN) 1 appeared during the interview with STNA13. He had the Hoyer Ascent lift and stated he was going to clean the lift with disinfectant wipes, which were kept in the locked room adjacent to the shower room. However, when RN1 came out of that room, he stated there were no disinfection wipes in the room, and he was going to get some wipes. He then placed the lift back in the shower room and left to get wipes. During interview with STNA13 on 10/09/2024 at 10:44 AM, she stated she did not have a key to the locked room adjacent to the shower room. During interview with RN1 on 10/09/2024 at 11:02 AM, he stated disinfectant wipes were not kept in the shower room because staff was concerned a resident might use the wipes in an inappropriate way. He stated the disinfectant wipes were always in a locked room. During interview with RN7, the Wound Care/Infection Preventionist, on 10/09/2024 at 12:54 PM, she stated the facility did not audit the cleaning of multiuse resident equipment. She stated staff was educated on cleaning the multiuse equipment with bleach wipes. She stated the multiuse wipes were available on the treatment carts and were usually in the shower room. During interview with the DON on 10/10/2024 at 10:07 AM, he stated staff was to clean the lifts after each use and was to use disinfectant wipes. He stated staff was educated in orientation and yearly on infection control. During interview with the Administrator on 10/11/2024 at 10:11 AM, she stated she relied on the Infection Preventionists and the DON to assure the equipment was cleaned appropriately.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have safeguards and systems in place to control, account for, and reconcile controlled medications to ensure all controlled medications were maintained for two (2) of sixteen (16) sampled residents (Resident #15 and Resident #16). Resident #16 was prescribed [MEDICATION NAME]/APAP 5/325 milligram (mg) tablet (a controlled, Schedule II, narcotic pain medication), to be administered one (1) tablet every four (4) hours PRN (as needed) for severe pain. The Pharmacy documented delivery to the facility of twenty (20) tablets or one (1) skid of the medication, on 10/23/2020 at 12:51 AM, with a signed receipt by Licensed Practical Nurse (LPN) #5. This skid of [MEDICATION NAME]/APAP 5/325 mg tablets was reported missing by the facility, and the facility was unable to determine what happened to the twenty (20) tablets. Resident #15 was prescribed [MEDICATION NAME] Extended Release (ER, a controlled, Schedule II, narcotic pain medication) 10 mg tablet, to be administered one (1) tablet every twelve (12) hours PRN for chronic pain. The Pharmacy documented delivery to the facility of twenty (20) tablets or one (1) skid of the medication, on 02/10/2021 at 11:50 pm, with a signed receipt by LPN #5. This skid of [MEDICATION NAME] ER 10 mg tablets was reported missing by the facility, and the facility was unable to determine what happened to the twenty (20) tablets. The findings include: Review of the facility's policy titled, Controlled Substances-Chain of Custody, revised 02/2019, revealed the facility had an established system of records of receipt and disposition of controlled drugs to enable accurate reconciliation from the time medications were received. In addition, the policy stated controlled medications in Schedules II, III, IV, and V were subject to special handling, storage, disposal, and record keeping. Per policy, when receiving controlled substances, a delivery receipt was given to the nurse from the Pharmacy driver, and the nurse receiving the delivery receipt took responsibility for the medication(s). Per policy, the nurse verified that the quantities of all drugs listed on the delivery receipt were correct, and the integrity of each package was to be examined, with discrepancies noted at the time of receipt. If discrepancies existed, the nurse could decline receipt of the controlled substance at the time of delivery. The policy stated the nurse receiving the delivery took responsibility for the medication reaching the correct medication cart/box. In addition, the proof of use sheet for each controlled substance must be signed and dated, with the quantity written in the area for documentation of receipt of the medication. Further, the policy stated controlled substances were to be locked up immediately upon receipt. Review of the facility's policy titled, Ordering of Drugs-Receiving Drug Orders from Pharmacy, dated 07/2018, revealed when drugs were delivered, the nurse on duty checked the drugs against the pharmacy order sheet and signed the delivery receipt. Review of the facility's policy titled, Medication Storage, dated 08/2018, revealed the facility ensured that only authorized facility staff had possession of the keys which opened medication storage areas. Further review revealed Schedule II Controlled Substances were stored in a separate compartment within the locked medication carts and should have a different key or access device. Review of the facility's policy titled, Controlled Drug Reconciliation, undated, revealed a record of the inventory count was entered on the medication nurse's log. In addition, each completed medication log was forwarded to the Director of Nursing (DON), who, after review, filed the record. 1. Review of Resident #16's medical record revealed the facility admitted the resident, on 10/22/2020, with [DIAGNOSES REDACTED]. Review of Resident #16's Initial Minimum Data Set (MDS) Assessment, dated 10/28/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), indicating mild cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as not having pain during the last five (5) days of the assessment reference period. Review of Resident #16's Monthly physician's orders [REDACTED].#16 was prescribed [MEDICATION NAME]/APAP (narcotic pain medication), 5/325 mg tablet, administer one (1) tablet every four (4) hours PRN (as needed) for severe pain. 2. Review of Resident #15's medical record revealed the facility admitted the resident, on 02/10/2021, with [DIAGNOSES REDACTED]. Review of Resident #15's Admission Minimum Data Set (MDS) Assessment, dated 02/16/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15), indicating moderate cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as not having pain during the last five (5) days of the assessment reference period. Review of Resident #15's Monthly physician's orders [REDACTED].#15 was prescribed [MEDICATION NAME] Extended Release (narcotic pain medication), ten (10) milligram (mg) tablet, one (1) to be administered every twelve (12) hours as needed (PRN) for chronic pain. Telephone interview with the Police Detective, on 04/07/2021 at 10:23 AM, revealed he investigated a report twice involving one (1) nurse, Licensed Practical Nurse (LPN) #5, signing for controlled medications and bringing the medications into the facility. With the first incident, on 10/23/2020, the controlled drug was [MEDICATION NAME], and once the drugs were delivered and signed for, it seemed to be a mystery where the drugs went. He stated the police administered a polygraph test to LPN #5, but nothing was confirmed from the test. The Detective stated, in the second incident, on 02/10/2021, the medication [MEDICATION NAME] ER was involved; the same nurse, LPN #5, picked up the drugs from the delivery person, placed them on a table sitting inside an inside and outside sliding door, took a smoke break, came back in, picked up the drugs, and took them back to the workstation. He added there was video footage of LPN #5 doing this, but one could not see everything going on through the entire transaction. Continued conversation revealed that Detectives interviewed LPN #5 a second time; however, they did not do a second polygraph. Per the Detective, the nurse who received her portion of the controlled drugs from LPN #5 said she signed for the medications given to her, but she could not say she checked them one (1) by one (1) to confirm all were accounted for. The Detective also revealed he talked to the Administrator and the interim DON, who showed him their process of securing controlled drugs. He stated he noticed the narcotic keys were on a key ring with about fifteen (15) other keys. These keys were sometimes given to other staff members to retrieve locked supplies and were not closely monitored to see where they were used. The Detective also revealed that LPN #5 said it was a mutual agreement between her and the facility to leave employment, stating she did not want to work for a facility with her name attached to these two (2) incidents. He said his conversation with the facility revealed they terminated LPN #5 for not following procedural protocol. Continued telephone interview with the Detective, on 04/07/2021 at 10:23 AM, also revealed no other staff member was interviewed regarding this incident; there was only one (1) other common staff member working the day of both incidences, and that staff member worked another unit, so the opportunity was not there for misappropriation. He said the police performed a criminal background check on both the Pharmacy driver and LPN #5 but found no criminal record on either. Per the Detective, someone from the Office of Inspector General (OIG) ran a Casper report on both the driver and the nurse and found no concerns. In addition, the Detective stated he talked to the DON (currently out on medical leave) when the first incident occurred. He revealed the DON told him she believed LPN #5 was a good person; someone did not check the bag good enough; and maybe the medication was thrown away by mistake. The Detective stated the second time he received the report of missing narcotics, he said, We've got to do something about this. Telephone interview with the Manager of Med Care Pharmacy (contracted with the facility), on 04/07/2021 at 11:55 AM, employed nine (9) years with the Pharmacy, revealed she investigated the two (2) incidents of misplaced narcotics, on 10/23/2020 and 02/10/2021. She said the Pharmacy had never had an issue with the facility before the two (2) incidents and had not had an incident since then. Continued interview revealed the delivery driver had been with the company for greater than ten (10) years, and this facility was his usual route. She stated their process for packaging, handling, and delivering controlled medications was: controlled drugs were prepared and packaged in a caged area, surrounded by four (4) cameras, capable of viewing what was happening in the preparation and packaging process at four (4) different angles. She added, We can see precisely when the medication is prepared, toted, the manifest put with it, and the bag sealed, making it tamper-resistant. Each step in the process is time-stamped and videoed. In addition, the Manager stated that after the in-facility processes, the medications were transferred to a driver, who was responsible for the bags and signed for them. She stated the driver delivered the sealed bag to the facility and gave the bag to a specific person; the person receiving the bag opened it; counted and verified all medications listed on the delivery receipt were correct; and signed the receipt. Per interview, for both incidents, the same process occurred with packaging, handling, and delivery; video footage verified this. She stated everything was received and signed as required, and all procedures, from their end, were performed per their protocols. Continued interview revealed the Pharmacy did not hear anything about the delivery until the drugs were reported missing by the facility. The Manager stated neither resident was charged for the drugs, and the Pharmacy charged the facility in both instances. Telephone interview with Registered Nurse #1, on 04/08/2021 at 9:00 AM, employed at the facility for approximately four (4) months, revealed she went with LPN #5 to pick up the medication delivery from the driver for the second incident. She stated LPN #5 signed that she had received all the medications; sat the drugs down and went out to smoke with State Registered Nurse Aide (SRNA) #2; returned to the unit; and laid the medications, including the narcotics, on the counter for nurses from the other units to pick up what belonged to their residents. RN #1 stated she picked up the medications she thought was for her residents, which she believed was four (4) skids of narcotics. She said each skid of narcotics was assigned to an individual resident. After picking up the four (4) skids of medications, she stated she walked around to the medication cart and signed them into the narcotic drawer. After the missing drug event, she said there had been mandatory education and training regarding receiving and disposition of controlled drugs, along with record keeping. Telephone interview with SRNA #2, on 04/08/2021 at 7:00 PM, employed at the facility for about two (2) years, revealed, for the second incident, he met LPN #5 downstairs to have a smoke, stating LPN #5 had gone ahead of him to retrieve medications delivered by the carrier. He revealed he did not observe the medication hand-off between LPN #5 and the pharmacy carrier, as they were completing the transaction when he got there. He said LPN #5 sat the medications on a couch located between the inner and outer front doorway, and he and LPN #5 went to smoke outside in front of the building. He said at no time were they not in view of the medications. Per interview, when they finished smoking, they came back inside; he started counting the green bags (containing non-controlled drugs); and LPN #5 counted the red bags (containing controlled drugs). SRNA #2 stated LPN #5 carried the medications upstairs, gave RN #1 her medications, and RN #1 put up the medications she received. The State Survey Agency (SSA) Surveyor was unable to interview LPN #5, as this nurse had been terminated by the time of the survey. Interview with the Unit Manager (UM), on 04/08/2021 at 10:25 AM, revealed the Pharmacy carrier delivered the facility medications to the front lobby in a sealed bag. She stated the nurse met the carrier in the lobby, opened the bag, verified the count, signed the receipt for the medications, and brought the medications back to the unit. Per interview, the medications were verified again with another nurse, and both nurses then signed the pink narcotic slip. In addition, the UM stated if medications were received for other units, they were taken to that unit's medication cart and verified again with that medication nurse. Per interview, both nurses signed for the medications (the nurse who delivered the medications and the nurse who received the medications). Interview with the Interim Director of Nursing (DON), on 04/08/2021 at 2:14 PM, employed for twelve (12) years in nursing and as Interim DON, since 02/09/2021, because the DON was out on medical leave, revealed the second narcotics event happened during the first week of her Interim DON role. She said the procedure for receiving medications was the nurse got the bags of medicines from the delivery driver, and the nurse cut open the bag (controlled medications were delivered in a red bag and non-controlled medications were delivered in a green bag). The DON stated once the bag was opened, the nurse counted what was inside and reconciled the medications to the count; brought them to their unit; and nurses from other units came and got medications for residents on their units. Per interview, both nurses would go to the medication cart and sign in the number of skids taken, and two (2) signatures were required on the narcotic sign-in sheet. Per the DON, it was her understanding that LPN #5, the nurse who received the medications from the driver, signed for the medications, then placed them on a table between the two (2) front entry doors while she went outside to smoke with a co-worker. She stated, after finishing smoking, LPN #5 re-entered the door, retrieved the medications, and took them back to her unit. Further, the DON stated that these were not the steps to follow when receiving medications from the carrier and delivering the medications to the unit. Continued interview revealed the medications should always be brought directly back to the department or unit after receipt from the carrier, with the nurse receiving them in control of them until the medications were picked up or delivered to the intended department or unit. Interview with the Administrator, on 04/07/2021 at 4:00 PM, and again, on 04/08/2021 at 3:00 PM, employed at the facility since July 2020, revealed she was informed of two (2) incidents of missing narcotics, the first time, on 10/23/2020, and the second time, on 02/10/2021. The first time the facility was alerted of the missing [MEDICATION NAME] was when the Pharmacy called the Director of Nursing (DON) and said they believed their count was off by one (1) pill. She stated when the DON checked the cart to see, she found an entire skid (a card of twenty (20) tablets) of [MEDICATION NAME] was missing, not just one (1) pill. She stated the [MEDICATION NAME] medication for this resident (Resident #16) was only administered PRN (as needed), so there was no opportunity to notice an entire skid was missing, as the resident had not asked for the medication. Per interview, the second time a skid of [MEDICATION NAME] ER was reported missing (Resident #15); it was not noticed at shift change narcotic count because both the skid of [MEDICATION NAME] ER and the associated sign-out sheet were missing, resulting in nothing to count against. She added, she guessed the resident requested something for pain, and when the nurse went to get the pain medication, there was not a skid of [MEDICATION NAME] ER for the resident. She stated she reported both incidents to the police, as she considered it a law enforcement matter. Per interview, the police investigated the incidences, polygraphed the nurse, but nothing was concluded from the investigations. The Administrator stated LPN #5 said she received the medications from the carrier but admitted she did not count the medications as closely as she should have. Further, the Administrator said LPN #5 was terminated for not following proper medication receiving and handling protocol. She stated she expected nurses to follow standards of practice related to handling all drugs, including controlled medications. In addition, the Administrator stated the Pharmacy never charged Resident #15 and Resident #16 for the missing narcotics; therefore, they needed no credit back to their accounts because the Pharmacy charged the facility for those medications.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to protect one (1) of sixteen (16) sampled residents, Resident #2, from physical abuse. On 03/25/2021, a licensed nurse was administering morning medications to Resident #2 when the resident reported to her that a staff member had abused him/her during morning care by grabbing his/her arm. The findings include: Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, revised 11/2016, revealed the facility would not tolerate abuse of a resident and staff would report all allegations immediately to the Administrator and the respective State Survey Agency (SSA). Further review of the policy revealed abuse included, but was not limited to, the willful infliction of injury, intimidation, and mental anguish. Additionally, the policy included verbal, physical, or mental abuse. The policy stated its purpose was to prevent abuse of residents and provide a safe, comfortable environment. Continued review of the policy revealed nursing supervisory staff would monitor the environment of care to identify inappropriate behavioral exchanges with residents, to include rough handling or ignoring residents by staff while providing care. The policy stated incidents would be reported to the Administrator, Director of Nursing (DON), or their designee, and the staff member would be removed from the facility. Review of the facility's policy titled, Resident Rights and Facility Responsibilities, undated, revealed each resident would be treated with respect and dignity regardless of [DIAGNOSES REDACTED]. Review of Resident #2's medical record revealed the facility admitted Resident #2, on 11/14/2015, with [DIAGNOSES REDACTED]. Review of Resident #2's Brief Interview for Mental Status (BIMS) assessment for Cognitive Patterns, in the Minimum Data Set (MDS) Assessment, dated 02/12/2021, revealed the resident had a BIMS score of nine (9), indicating moderately impaired cognition. Review of Resident #2's Comprehensive Care Plan revealed the resident demonstrated an activities of daily living (ADL) self-care deficit related to impaired mobility and impaired balance. Additional review of the care plan revealed the facility had interventions in place for management of the resident's [DIAGNOSES REDACTED]. Observation and interview of Resident #2, on 04/06/2021 at 3:30 PM, revealed the resident was lying in bed and stated he/she believed he/she was getting everything needed and was treated well at the facility. Additional interview revealed the resident was aware State Registered Nurse Aide (SRNA) #3 had been fired. When questioned about the alleged abuse, the resident stated, I don't remember. Per interview, the resident stated SRNA #3 did not hit him/her, and then continued by saying, He's a big guy. Resident #2 stated he/she did not tell anyone about it, and a staff member must have reported it. Additional observation of Resident #2's room, on 04/07/2021 at 3:30 PM, revealed the resident had a semi-private room, and his/her bed was the one closest to the window. Resident #2's roommate, Resident #9, occupied the bed closest to the door. Resident #9 was out of the facility at the time of the observation. Interview with Licensed Practical Nurse (LPN) #3, on 04/08/2021 at 9:14 AM, revealed she was working day shift on the hall when the alleged abuse was reported to her by Resident #2, on 03/25/2021. LPN #3 stated she went into the resident's room to give morning medications, and Resident #2's roommate, Resident #9, told the LPN that his/her roommate was being abused and that SRNA #3 was rough with Resident #2 and a little different with him/her from everyone else. LPN #3 stated Resident #9 told her that SRNA #3 was arguing with Resident #2 because the resident did not want to get out of bed, and SRNA #3 forced Resident #2 to get up. Per interview, an argument had ensued between Resident #2 and SRNA #3, with SRNA #3 cursing at Resident #2. In addition, LPN #3 stated Resident #9 told her he/she heard Resident #2 stating that SRNA #3 was mean and hateful. LPN #3 stated she notified the Director of Nursing (DON), around 5:30 AM to 6:00 AM on 03/25/2021, when it was first reported to her. Per interview, the DON advised LPN #3 to get a written statement from SRNA #3 and escort him out of the facility. Review of Registered Nurse (RN) #1's Facility Statement Form, dated 03/25/2021 at 6:45 AM, revealed RN #1 went with LPN #3 to Resident #2's room as a witness. Resident #2 reported to them that SRNA #3 had abused him/her. Resident #2's roommate, Resident #9, stated no one treated Resident #2 the way SRNA #3 did. Per report, Resident #9 further stated that the SRNA was very rough and hostile and was cursing at Resident #2; he/she did not deserve to be treated in that way, and the SRNA's similar behavior toward Resident #2 had happened several times before. Interview with Registered Nurse (RN) #1, on 04/08/2021 at 9:00 AM, revealed LPN #3 asked her to go with the LPN to Resident #2's room as a witness to the resident's statement. Per interview, the resident was sitting in a chair visibly upset. RN #1 stated the resident's roommate, Resident #9, reported that SRNA #3 did not treat Resident #2 right and that SRNA #3 used the F word a lot, telling the resident to move the [***] over or do it yourself. RN #1 stated Resident #2 had agreed with Resident #9's statements. Review of SRNA #3's Facility Statement Form, dated 03/25/2021 at 6:57 AM, revealed the SRNA went into Resident #2's room and found the resident lying sideways in the bed with the front of his/her brief pulled off. He stated the resident stated he/she wanted to get up. Per interview, the resident had a significant amount of stool on his/her buttocks and became agitated, threatening to hit the SRNA as he was cleaning the resident. SRNA #3 stated Resident #2 dug his/her nails into SRNA #3's elbow and the SRNA stated, If you don't calm down, I'll have to leave you here; then, Resident #2 stated, I don't give a[***] SRNA #3 stated he covered the resident up, then continued with care. In addition, SRNA #3 stated Resident #2 began grabbing the SRNA's arms again, and SRNA #3 told the resident, You absolutely have to stop. Per interview, Resident #2 continued this behavior while the SRNA transferred him/her to a chair; SRNA #3 then reported the incident to RN #1. Review of Resident #2's Facility Statement Form, dated 03/25/2021 at 8:15 AM, revealed SRNA #3 did not like the resident. Resident #2 stated, Nothing really happened, just words, but I don't remember. Review of Resident #9's Facility Statement Form, dated 03/25/2021 at 8:30 AM, revealed the resident had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating Resident #9 was cognitively intact. Resident #9 stated SRNA #3 nagged Resident #2 until the resident got upset. Resident #9 stated if SRNA #3 would just do what he was supposed to, Resident #2 would be fine. In addition, Resident #9 reported SRNA #3 came into the room that morning and said, Jesus [***] ing Christ, then Resident #2 said, [***] You a few times. The Statement Form revealed Resident #9 was unable to see anything because of the drawn curtain separating the beds and his/her [MEDICAL CONDITION]/poor eyesight. Resident #9 further stated SRNA #3 walked over to him/her before leaving the room and showed the resident a scratch that SRNA #3 stated Resident #2 had made on his arm. Review of Facility's Five (5) Day Follow-Up Report, dated 03/29/2021, revealed Resident #2 had reported to Registered Nurse (RN) #1 that SRNA #3 had abused him/her but could not give any specifics. RN #1 assessed the resident and assured the resident's safety. RN #1 then removed SRNA #3 from the floor and notified the Director of Nursing (DON) to report the abuse. The DON notified the Administrator following the call from RN #1, and SRNA #3 gave a written statement (see prior statement) and was escorted from the property. Per report, Resident #2 was interviewed, at approximately 8:30 AM, and showed no signs or symptoms of distress. During the interview, Resident #2 stated that nothing really had happened, just that he/she and SRNA #3 had argued because the resident wanted to get up and the SRNA wanted him/her to stay in bed. Per report, Resident #2 stated the SRNA kept running his mouth and at one point, grabbed the resident's arm. In addition, the report stated there were no signs of bruising on the left arm that Resident #2 indicated SRNA #3 had grabbed. Continued review of the Five (5) Day Follow-Up Report revealed that during a follow-up interview with SRNA #3, the Administrator asked if, at any time, he had grabbed Resident #2's arm, to which SRNA #3 stated, No. Continued review revealed SRNA #3 was questioned concerning the language used in Resident #2's room during this time. The SRNA admitted to using foul language during Resident #2's care but stated it was not directed at the resident; this was part of his every day vocabulary, and he tried not to use this language around residents. In addition, SRNA #3 acknowledged he should have removed himself from the resident's room but was afraid the resident would fall while trying to transfer out of the bed to the chair on his/her own. Per report, the facility assessed Resident #2, and no physical injury was noted; Social Services assessed the resident, and no psycho-social distress was noted. Continued review of the Five (5) Day Follow-Up Report revealed SRNA #3 was re-educated on avoiding unprofessional language, however, the facility report stated the language was not directed toward the resident. On further review, the report stated Resident #2 did not feel threatened with harm in any way and that SRNA's and all direct care staff would be re-educated on updated resident care plans, particularly incontinence care and resistive episodes. In addition, the report stated the facility did not substantiate abuse had occurred. Interview with the Director of Nursing (DON), on 04/08/2021 at 2:14 PM, revealed she was called by RN #1 after Resident #2's allegation of abuse from SRNA #3. Per interview, the DON instructed the RN to pull the SRNA from the unit and have him write a statement regarding the allegation; then he was to leave the facility. She stated Resident #2 was assessed by RN #1, following the removal of SRNA #3, and again by her, when she arrived at the facility. She said no physical injury was found during either assessment. The DON stated she expected staff not to be disrespectful or abusive to residents. She also stated she spoke with SRNA #3 and told him he should have gotten someone else to help with Resident #2. Additionally, the DON stated she did not like the SRNA's bedside manner but did not consider this abuse. She then stated SRNA #3's language could be considered verbal abuse, and it was not appropriate. Per interview, if a resident was agitated, staff was trained to wait until the resident was more accepting of what needed to be done, leave, come back later, and not continue doing what the resident was resisting. Interview with the Administrator, on 04/08/2021 at 2:57 PM, revealed she was notified within two (2) hours of the incident, and appropriate notifications were made, along with other required actions. The Administrator stated Resident #2 and SRNA #3 did not get along, further stating she felt it was more of a personality conflict between the two (2) individuals. During the follow-up interview with Resident #2, the Administrator said the resident's roommate, Resident #9, stated SRNA #3 was not happy that Resident #2 had soiled himself/herself, and while changing the resident, the SRNA stated, Jesus [***] ing Christ, this is all over you. The roommate said this probably made Resident #2 upset. The Administrator stated SRNA #3 tried to explain things to Resident #2 to the degree that appeared confrontational. Per interview, Resident #9 was not a physical witness as the curtain was drawn, but he/she did hear foul language from both resident and staff. The Administrator stated based on the facility's knowledge of Resident #2 and his/her patterns of behavior, there was no intent on the part of SRNA #3 to harm Resident #2. She said the facility did not feel this incident rose to the level of abuse. Continued interview further revealed that SRNA #3 was terminated due to using offensive language in the presence of residents in his care. The Administrator stated after talking with SRNA #3 about the incident, the decision was made to terminate him. The Administrator stated she expected that residents were well cared for and that staff were following proper procedures.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure all reporting of alleged violations involving misappropriation of controlled substances was reported within twenty-four (24) hours to State Agencies and the results of all investigations were reported to State Agencies within five (5) working days. Although the facility identified missing narcotics and notified the police, on 10/23/2020, and again, on 02/10/2021, there was no evidence the facility reported the misappropriation of the medications to State Agencies as per State Law for two (2) of sixteen (16) sampled residents, Resident #15 and Resident #16. The findings include: Review of the facility's policy titled, Abuse/Neglect/Misappropriation of Property, dated November 2016, revealed the facility would investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. Continued review of the policy revealed misappropriation of resident property was defined as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money, without the resident's consent. In addition, the policy stated facility staff should immediately report all such allegations to the Administrator and the respective State Survey Agency (SSA) in accordance with the procedures in this policy. Furthermore, in cases where a crime was suspected, staff should also report the same to local law enforcement. 1. Review of Resident #16's medical record revealed the facility admitted the resident, on 10/22/2020, with [DIAGNOSES REDACTED]. Review of Resident #16's Initial Minimum Data Set (MDS) Assessment, dated 10/28/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), indicating mild cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as not having pain during the last five (5) days of the assessment reference period. Review of Resident #16's Monthly physician's orders [REDACTED].#16 was prescribed [MEDICATION NAME]/APAP (a narcotic pain medication), 5/325 milligram (mg) tablet, administer one (1) tablet every four (4) hours PRN (as needed) for severe pain. 2. Review of Resident #15's medical record revealed the facility admitted the resident, on 02/10/2021, with [DIAGNOSES REDACTED]. Review of Resident #15's Admission Minimum Data Set (MDS) Assessment, dated 02/16/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15), indicating moderate cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as not having pain during the last five (5) days of the assessment reference period. Review of Resident #15's Monthly physician's orders [REDACTED].#15 was prescribed [MEDICATION NAME] Extended Release (a narcotic pain medication), 10 mg tablet, one (1) to be administered every twelve (12) hours as needed (PRN) for chronic pain. Telephone interview with the Police Detective, on 04/07/2021 at 10:23 AM, revealed he investigated a report twice involving one (1) nurse, Licensed Practical Nurse (LPN) #5, signing for controlled medications and bringing the medications into the facility. With the first incident, on 10/23/2020, the controlled drug was [MEDICATION NAME], and once the drugs were delivered and signed for, it seemed to be a mystery where the drugs went. He stated the police administered a polygraph test to LPN #5, but nothing was confirmed from the test. The Detective stated, in the second incident, on 02/10/2021, the medication involved was [MEDICATION NAME] ER; the same nurse, LPN #5, picked up the drugs from the delivery person, placed them on a table sitting inside an inside and outside sliding door, took a smoke break, came back in, picked up the drugs, and took them back to the workstation. He added there was video footage of LPN #5 doing this, but one could not see everything going on through the entire transaction. Continued conversation revealed that Detectives interviewed LPN #5 a second time; however, they did not do a second polygraph. Per the Detective, the nurse who received her portion of the controlled drugs from LPN #5 said she signed for the medications given to her, but she could not say she checked them one (1) by one (1) to confirm all were accounted for. The Detective also revealed that LPN #5 said it was a mutual agreement between her and the facility to leave employment, stating she did not want to work for a facility with her name attached to these two (2) incidents. He said his conversation with the facility revealed they terminated LPN #5 for not following procedural protocol. Continued telephone interview with the Detective, on 04/07/2021 at 10:23 AM, also revealed no other staff member was interviewed regarding this incident; there was only one (1) other common staff member working the day of both incidents, and that staff member worked another unit, so the opportunity was not there for misappropriation. He said the police performed a criminal background check on both the Pharmacy driver and LPN #5 but found no criminal record on either. Per the Detective, someone from the Office of Inspector General (OIG) ran a Casper report on both the driver and the nurse and found no concerns. In addition, the Detective stated he talked to the DON (currently out on medical leave) when the first incident occurred. He revealed the DON told him she believed LPN #5 was a good person; someone did not check the bag good enough; and maybe the medication was thrown away by mistake. The Detective stated the second time he received the report of missing narcotics, he said, We've got to do something about this. Interview with the Administrator, on 04/07/2021 at 4:00 PM, and again, on 04/08/2021 at 3:00 PM, employed at the facility since July 2020, revealed she was informed of two (2) incidents of missing narcotics, the first time, on 10/23/2020, and the second time, on 02/10/2021. The first time the facility was alerted of the missing [MEDICATION NAME] was when the Pharmacy called the Director of Nursing (DON) and said they believed their count was off by one (1) pill. She stated when the DON checked the cart to see, she found an entire skid (a card of twenty (20) tablets) of [MEDICATION NAME] was missing, not just one (1) pill. She stated the [MEDICATION NAME] medication for this resident (Resident #16) was only administered PRN (as needed), so there was no opportunity to notice an entire skid was missing, as the resident had not asked for the medication. Per interview, the second time a skid of [MEDICATION NAME] ER was reported missing (Resident #15); it was not noticed at shift change narcotic count because both the skid of [MEDICATION NAME] ER and the associated sign-out sheet were missing, resulting in nothing to count against. She added, she guessed the resident requested something for pain, and when the nurse went to get the pain medication, there was not a skid of [MEDICATION NAME] ER for the resident. She stated she reported both incidents to the police, as she considered it a law enforcement matter. Per interview, the police investigated the incidents, polygraphed the nurse, but nothing was concluded from the investigations. The Administrator said LPN #5 was terminated for not following proper medication receiving and handling protocol. She said a report was not made to the Office of Inspector General (OIG) because there were no findings, and there was nothing that could substantiate the narcotics loss that happened at the facility. In addition, she stated she did not notify the Drug Enforcement Administration (DEA) or fill out a DEA form, as she did not determine the facility lost the medication, and she thought the police or the Pharmacy would notify the DEA. Continued interview, on 04/08/2021 at 3:00 PM, with the Administrator revealed she and the DON were in constant contact with the Pharmacy and the police when she was made aware of the missing narcotics. She said she was not aware the missing narcotics were considered misappropriation of resident property. As a result, she stated she did not report the missing narcotics to State Agencies. Continued interview revealed she was under the impression that since the facility purchased the medications, they were the property of the facility. The Administrator added, she considered this a law enforcement event and immediately reported it, both times, to the police.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment; to prevent and/or contain COVID-19; and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. Observations of multiple staff from the Environmental Services Department revealed hand hygiene was not performed correctly and masks were either not being worn or being worn incorrectly, with the nose left uncovered. Observations of multiple staff from the Dietary Department revealed masks were being worn incorrectly, with the nose left uncovered. The findings include: Review of the facility's policy titled, Carespring Health Care Management: Hand Hygiene, revision date 03/2020, revealed hand washing was most beneficial for decontaminating hands after known or suspected exposure to an outbreak or with high endemic rates of an infection and after contact with inanimate objects in the immediate vicinity of the patient. Further review revealed to wear gloves when in contact with infectious materials; to remove gloves promptly after use, before touching non-contaminated items and environmental surfaces; and to decontaminate hands after removing gloves. Review of the facility's policy titled, PPE Guidelines to Conserve Supplies and Manage COVID-19 in the Facility, updated revision and not dated, revealed the Dietary Department staff wore N95 masks in the kitchen and kitchenette areas. In addition, the Laundry Department staff wore N95 masks in the laundry and on the units. 1. Observation of the first floor COVID Unit, on 01/26//2021 at 10:54 AM, revealed the housekeeper stood in the hallway near the housekeeping cart, changed gloves without sanitizing or washing her hands, and donned a new pair of gloves. Interview with the Environmental Services Manager, on 01/27/2021 at 11:09 AM, revealed she was the housekeeper for the first floor COVID Unit due to a staff call in. She stated she was trying to cover the unit and was in a hurry. Further, she stated she did not realize she had not sanitized or washed her hands between the glove change. Observation, upon entering the clean Laundry area, on 01/26/2021 at 3:10 PM, revealed Laundry Aide #1 was not wearing an N95 mask, and Laundry Aide #2 was incorrectly wearing an N95 mask around her neck, not covering her nose. Interview with Laundry Aide #1, on 01/26/2021 at 3:10 PM, revealed he got hot in the laundry room and did not wear his mask. He stated there was no other staff in the laundry room except Laundry Aide #2, and they work together often. Interview with Laundry Aide #2, on 01/27/2021 at 11:04 PM, revealed she was hot and needed to cool off. She stated she removed her mask from her nose to cool off due to her asthma; however, Laundry Aide #2 stated it was important to wear the N95 mask correctly to prevent the spread of COVID-19. Continued interview with the Environmental Services Manager, on 01/27/2021 at 11:09 AM, revealed Laundry staff was to wear N95 masks correctly in the Laundry area. The Environmental Services Manager stated it was important to sanitize or wash hands between glove changes and to wear N95 masks correctly and per policy to prevent the spread of germs, bacteria, and the COVID-19 virus between residents. Furthermore, she stated Environmental Services staff had been educated on proper hand hygiene and wearing N95 masks correctly, which included covering the nose. 2. Observation of the first floor Kitchenette, on 01/26/2021 at 12:00 PM, revealed Dietary Aide #1 incorrectly wore an N95 mask, as her nose was not covered and was exposed when she was preparing to serve the lunch meal. Interview with Dietary Aide #1, on 01/27/2021 at 10:45 AM, revealed N95 masks should be worn over the nose in the kitchenette areas. She also stated it was important to wear N95 masks correctly to prevent the spread of COVID-19, and she had been educated on when the N95 mask was required and the correct way to wear it. Observation of the second floor Kitchenette, on 01/26/2021 at 12:05 PM, revealed Dietary Aide #2 incorrectly wore an N95 mask, as her nose was not covered and was exposed when she was preparing to serve the lunch meal. Interview with Dietary Aide #2, on 01/27/2021 at 11:56 AM, revealed she had her mask down so other staff could hear her speak. She also stated staff should wear the N95 mask correctly (over the nose) to protect self and others from the spread of COVID-19, and she had been educated on this. Observation in the Dietary Department Kitchen, on 01/26/2021 at 3:00 PM, revealed the Prep Cook and Kitchen Supervisor with N95 masks worn incorrectly, with the masks not covering their noses. Interview with the Prep Cook, on 01/27/2021 at 10:58 AM, revealed the N95 mask should be worn over the nose in the kitchen because it was important to prevent the spread COVID-19. Interview with the Kitchen Supervisor, on 01/27/2021 at 11:45 AM, revealed he had his mask down to breathe easier. However, he said it was important to wear a mask covering the nose to prevent exposure to COVID, which possibly could spread to other staff and residents when not wearing a mask. Interview with the Chef, on 01/27/2021 at 11:56 AM, revealed Dietary staff was instructed to wear N95 masks correctly at all times, while in the kitchenettes and the kitchen, to prevent the spread of COVID. In addition, he stated he checked staff on a daily basis for compliance, and audited it monthly. The Chef stated it was permissible to remove the N95 mask, during breaks, in the outside break area or in a room, outside of the department or kitchenettes, with no other staff present. Interview with Registered Nurse (RN) Assistant Director of Nursing (ADON)/ Infection Control Preventionist, on 01/27/2021 at 10:00 AM, revealed all staff had been educated to wear N95 masks and face shields in resident areas. She stated the housekeeper should have sanitized her hands between glove changes to prevent cross contamination, and staff had been educated on this. Further, Dietary staff should have worn N95 masks in the kitchen and kitchenettes to prevent the possible spread of [MEDICAL CONDITION] and cross contamination; and Laundry staff should have worn N95 masks in the clean area to prevent the spread of [MEDICAL CONDITION] and cross contamination. Per interview, the ADON stated she, the Administrator, and the Director of Nursing trained department managers on the use of appropriate personal protective equipment (PPE); then, the department managers trained their staff on it. She stated staff was instructed to use the designated areas to remove face masks and take breaks. The ADON stated staff could use the break room, outside, and other locations within the facility, with no staff or residents present, to remove face masks. Interview with the Administrator, on 01/27/2021 at 1:45 PM, revealed she expected staff to follow guidelines, as they had been trained on, for correct personal protective equipment (PPE) use when in contact with residents to prevent the spread of COVID-19. She stated this expectation included staff to wear a face shield and an N95 mask appropriately in resident areas and throughout the facility. Furthermore, she stated hospital grade masks should be worn in department areas and kitchenettes, which pertained to Laundry and Dietary staff.

Based on observation, interview, and review of facility policy, it was determined the facility failed to prepare and serve food under sanitary conditions. Observation on 08/14/19 of the second floor Unit 2 dining room, revealed Dietary Aide #5 held four (4) saucer plates against her clothing and put her ungloved thumb and other fingers into the middle and over the rim of the saucers prior to placing the saucers into the middle of the table. In addition, observation on 08/14/19, revealed Dietary Staff #4 was wearing gloves while talking on a cell phone and did not wash hands and change gloves after putting the phone away and prior to continuing to work in the kitchenette. Furthermore, observation of the second floor kitchenette on 08/14/19, revealed Dietary Aide #1 was working during tray service from 5:08 PM to 6:15 PM, without wearing a beard net to cover his beard. Dietary #1 was also observed to use gloved hands to pull up and readjust his scrub top; however, failed to wash hands and don new gloves prior to continuing to work in the kitchenette. The findings include: Review of the facility Policy titled Meal Service, dated 02/2017, revealed hands are washed and gloves changed if the Dietary Aide touches any unclean surface. Staff are to serve meals using proper handling techniques while preventing contact of eating surfaces with staff's clothing. Review of the facility Policy, titled Dress Code dated 08/2016, revealed hair and beard nets were to be worn by kitchen staff and serving staff. Review of the facility policy titled Cell Phone Use dated 08/2016; revealed personal cell phones are not to be used while on the clock. Cell phones are used in designated areas, break room or outside the facility. Review of the facility Policy, titled Hand Hygiene dated 04/2017, revealed all team members will follow hand hygiene guidelines to reduce the incidence of health care associated infections. Ensure Hand hygiene after removing gloves. Observation on 08/14/19 at 2:20 PM, of the second floor Unit 2 dining room, revealed Dietary staff was setting up tables for dinner service. Dietary Aide #5 held four (4) saucer plates against her clothing and put her ungloved thumb and other fingers into the middle and over the rim of the saucers prior to placing the saucers into the middle of the table. Observation on 08/14/19 at 5:20 PM, of Dietary staff setting up the second floor kitchenette, revealed Dietary Staff #4 was wearing gloves while talking on a cell phone and did not change his gloves or wash his hands after putting the phone away and prior to continue working in the kitchenette. Also, observation of the second floor kitchenette on 08/14/19 at 5:20 PM, revealed Dietary Aide #1 was working during tray service from 5:08 PM to 6:15 PM, without wearing a beard net to cover his beard. Dietary #1 was also observed to use gloved hands to pull up and readjust his scrub top. However, the Dietary Aide failed to wash hands and don new gloves prior to continuing to work in the kitchenette after adjusting his clothes. Interview on 08/15/19 at 1:40 PM, with Dietary Aide #1, revealed he did not always wear his beard net when working with food or working in the kitchenette. However, he stated beard nets should be worn to prevent hair from getting into residents' food and to prevent cross contamination. Further interview revealed he should have washed his hands after adjusting his clothes while working during tray service. Interview on 08/15/19 at 1:49 PM, with the Chef, revealed cell phones were not allowed during meal service. Per interview, staff hairnets and beard nets were to be worn at all times to prevent cross contamination. The Chef stated Dietary staff should have washed hands after touching their clothes and the cell phone. Further interview revealed dishware should be handled properly and not held against clothing and ungloved fingers should not touch the plates to be served in order to prevent cross contamination. Interview on 08/15/19 at 2:42 PM, with the Director of Nursing (DON), revealed there was an infection control issue if staff used the cell phone and then failed to wash hands and don new gloves prior to continuing to serve food. Further, if staff adjusted their own clothing, they were to wash hands prior to continuing to work with serving food. Continued interview revealed plates or saucers should not be held against clothing and ungloved hands should not touch the plates or saucers. Additional interview revealed staff should wear beard nets when working in the kitchenettes to prevent hair from falling into food. Interview on 08/15/19 at 3:00 PM, with the Administrator, revealed staff was to wear beard nets in the kitchen and kitchenettes to prevent cross contamination. Further, if staff touched objects such as the phone or their own clothing, they should wash hands, and don new gloves before working in the kitchenettes or with food. Continued interview revealed dietary staff should take the cart to each table, instead of carrying saucer or dishware against their clothing to prevent cross contamination.

Based on interview and record review, it was determined the facility failed to ensure PRN (as needed) orders for [MEDICAL CONDITION] drugs were limited to fourteen (14) days, unless the Physician documents the rationale for extending the order and documents the duration of the PRN order for one (1) of twenty-five (25) sampled residents (Resident #94). Resident #94 was prescribed [MEDICATION NAME] (antianxiety medication) PRN on 03/18/19 with no end date; however, there was no documented evidence of the rationale for extending the medication beyond fourteen (14) days nor was there documented evidence of the duration for the PRN order. On 04/19/19, the Physician responded to the Consultation Report from Pharmacy stating the duration was indefinite and the rationale was hospice patient. However, indefinite was not an acceptable duration for the PRN order. There was no further duration for the medication documented after subsequent requests from pharmacy. The physician's orders [REDACTED]. (Refer to F-756) The findings include: Review of the facility's [MEDICAL CONDITION]-Anti-psychotic Medication Management Policy, revised 10/2017, revealed PRN orders for [MEDICAL CONDITION] drugs are limited to fourteen (14) days. Per Policy, except as provided in § 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond the 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Review of Resident #94's medical record revealed the facility admitted the resident on 07/18/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 06/19/19, revealed the facility assessed the resident as having both short and long term memory loss. Review of Section N, Medications, revealed Resident #94 had received one (1) antianxiety medication during the seven (7) day look back period. Review of the physician's orders [REDACTED]. The medication end date was listed at indefinite and there was no documented rationale for extending the medication past fourteen (14) days. Review of Resident #94's Consultation Report from Pharmacy, dated 04/09/19, revealed a comment stating the resident had a PRN order for an anxiolytic, without a stop date: Lorazapem [MEDICATION NAME] 0.5 mg - 1 mg-2 mg every three (3) hours as needed for anxiety. Further review revealed a recommendation stating, Please discontinue PRN [MEDICATION NAME]. If the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy and the extended time period. The Physician replied stating the duration was indefinite and the rationale as hospice patient. The Report was signed and dated by the Physician on 04/19/19. Review of Resident #94's Consultation Report from Pharmacy, dated 06/03/19, revealed a comment stating, the resident has a PRN order for an anxiolytic, without a stop date: [MEDICATION NAME] 0.5 mg - 1 mg-2 mg every three (3) hours as needed for anxiety. Further review revealed a recommendation stating in all CAPITAL letters, SOM (State Operations Manual) requires a duration of therapy even for hospice patients and indefinite is not allowed per CMS guidelines. In the Physician's Response, there were was no indication of the Physician's choice to accept, decline, or modify the recommendations. The Report was not signed or dated by the Physician. Review of the Consultation Report from Pharmacy, dated 08/05/19, revealed a comment stating, Resident #94 has a PRN order for an anxiolytic, without a stop date: [MEDICATION NAME] 0.5 mg - 1 mg-2 mg every three (3) hours as needed for anxiety. Further review revealed a recommendation stating in all CAPITAL letters, SOM requires a duration of therapy even for hospice patients and indefinite is not allowed per CMS guidelines. In the Physician's Response, there were was no indication of the Physician's choice to accept, decline, or modify the recommendations. The Report was not signed or dated by the Physician. Further review of the physician's orders [REDACTED]. Interview on 08/15/19 at 2:52 PM, with the Consultant Pharmacist, revealed he sent a Consultation Report to Resident #94's Physician on 04/09/19 requesting documentation related to the indication for use, the intended duration of therapy and the extended time period for the [MEDICATION NAME] PRN if the medication could not be discontinued. He further stated the Physician replied he wanted the medication ordered indefinitely because the resident was hospice. Further, he informed the Physician through a Consultation Report dated 06/03/19, a duration of indefinite was not allowed per CMS guidelines, but he did not receive a response from the Physician. Per interview, he sent another Consultation Report to Resident #94's Physician on 08/05/19, again reminding the Physician of the need for a duration for the PRN medication. Interview with the Director of Nursing (DON), on 08/15/19 at 5:55 PM, revealed she acknowledged PRN anti-anxiety medications were limited to fourteen (14) days or if the Provider wanted to extend the duration of the medication, the Provider would need to document the rationale in the resident's medical record and indicate the duration for the PRN order as per facility Policy. Per interview, it was her expectation the facility policy be followed related to PRN [MEDICAL CONDITION] medications. Interview with Administrator, on 08/15/19 at 06:11 PM, revealed it was her expectation the facility follow facility Policy and regulations related to PRN [MEDICAL CONDITION] medications.

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident environment remains as free of accident hazards as is possible. Observation on 08/13/19 and 08/14/19, revealed an opened tube of Ammonium [MEDICATION NAME] Cream 12% ( moisturizer for dry itchy skin) and an opened tube of Remedy Antifungal Cream 2% ([MEDICATION NAME]) on the bedside table in Resident #46's room accessible to residents and visitors. In addition, staff interviews revealed Resident #17 was confused and ambulatory and wandered into and out of resident rooms. The findings include: Review of the facility's Medication Storage Policy, dated 08/2018, revealed medications and biologicals, including treatment items, are securely stored in a secured locked cabinet/cart or locked medication room that is inaccessible to residents and visitors. Review of Resident #46's clinical revealed the facility admitted the resident on 05/23/19 with [DIAGNOSES REDACTED]. Review of Resident #13's Annual Minimum Data Set (MDS) Assessment, dated 05/10/19, revealed the facility assessed the resident as having a Brief Interview for mental Status (BIMS) of a thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Observation on 08/13/19 at 11:49 AM, of Resident #46's room, revealed an opened tube of Ammonium [MEDICATION NAME] Cream 12% ( moisturizer for dry itchy skin) and an opened tube of Remedy Antifungal Cream 2% ([MEDICATION NAME]) on the bedside table. Interview with Resident #46, at the time of observation, revealed the tubes were kept on the table and the nurse would put the medication on his/her feet. Observation on 08/14/19 at 8:15 AM, of Resident #46's room revealed the opened tube of Ammonium [MEDICATION NAME] Cream 12% ( moisturizer for dry itchy skin) and the opened tube of Remedy Antifungal Cream 2% ([MEDICATION NAME]) remained ion the resident's bedside table. Review of Resident #46 Monthly (MONTH) Physician's orders, revealed an order with an original date of 05/23/19 for Ammonium [MEDICATION NAME] Cream 12%, apply to feet and legs topically every day and night shift related to congenital [DIAGNOSES REDACTED]; and an order for [REDACTED]. Review of the Safety Data Sheet for Ammonium [MEDICATION NAME] 12% Moisturizing Lotion revealed this was an eye irritant, as well as required contact with a physician or Poison Control Center if the lotion was ingested. Review of the Safety Data Sheet for [MEDICATION NAME] revealed it could be harmful if swallowed, and if ingested contact a physician or Poison Center if ingested. Interview with Licensed Practical Nurse (LPN) #4, on 08/15/19 at 3:32 PM, revealed all topical medications were to be locked in a cabinet or medication/treatment cart including ointments because wandering residents could get hold of the medication which would be a safety issue. Interview with LPN #5, on 08/15/19 3:32 PM, revealed nurses were to ensure medications, creams, and ointments were locked in the medication or treatment carts or locked in the medication room and not accessible to confused residents. Interview with Licensed Practical Nurse (LPN) #4, on 08/15/19 at 3:32 PM, revealed all topical medications were to be locked in a cabinet or medication/treatment cart including ointments because wandering residents could get hold of the medication which would be a safety issue. Interview with LPN #5, on 08/15/19 3:32 PM, revealed nurses were to ensure medications, creams, and ointments were locked in the medication or treatment carts or locked in the medication room and not accessible to confused residents. Interview on 08/15/19 at 3:33 PM, with State Registered Nurse Aide (SRNA #5), revealed Resident #17 wandered into other peoples rooms. When questioned related to medication storage, SRNA #5 stated resident medications should not be kept at bedside, and all medications should be locked up for the safety of the residents. Further interview revealed if she saw any medications including medicated lotions or creams, she would report it to the nurse right away. Interview on 08/15/19 at 3:45 PM, with SRNA #6, revealed she had seen Resident #17 who was confused and could ambulate, wander into and out of other residents' rooms. Further interview revealed medications should be stored in the medication cart or treatment cart, and should only be stored in a resident's room if the medication was locked in a cabinet. She further stated medications should never be sitting out in open, as any confused resident could take the medications. Interview on 08/15/19 at 3:54 PM, with Licensed Practical Nurse (LPN) #3, revealed Unit 1 did have one (1) confused resident who would go into other residents' rooms which was Resident #17. When questioned about medications being left out in a resident's room, she stated medications should be locked in the medication cart, treatment cart, or medication room and should not be stored out in the open at bedside. Per interview, this was because there were wandering residents who may consume the medication. Interview on 08/15/19 at 4:03 PM, with the Director of Nursing (DON), revealed Resident #17 was a wanderer on the first floor and primarily wandered in the hallways; however, sometimes he/she did go into other residents' rooms. She stated all medications should be secured and not left at the bedside. Per interview, any medicated ointments or lotions should be locked in the treatment cart. Further interview revealed it was important to keep all medications secure so that residents did not have access to the medications. Further, it was her expectation staff lock up medications on the treatment cart. Interview with the Administrator, on 08/15/19 6:07 PM, revealed it was her expectation staff follow the policy regarding medication storage for the safety of the residents.

Based on interview and record review, it was determined the facility failed to ensure drug irregularities reported by Pharmacy were acted on for one (1) of twenty-five (25) sampled residents (Resident #94). Resident #94 was prescribed [MEDICATION NAME] (antianxiety medication) PRN (as needed) on 03/18/19 with no end date; however, there was no documented rationale for extending the medication beyond fourteen (14) days nor was there documentation stating the duration for the PRN order. On 04/19/19, the Physician responded to the Consultation Report from Pharmacy documenting the duration was indefinite and the rationale was hospice patient. On 06/03/19, the Consultation Report from the Pharmacist Consultant stated the SOM (State Operations Manual) required a duration of therapy even for hospice patients and indefinite was not allowed per CMS (Centers for Medicare and Medicaid) guidelines. However, there was no indication of the Physician's choice to either accept, decline, or modify the recommendations. This Report was not signed or dated by the Physician and there was no documented evidence the facility acted on this recommendation. Resident #94's physician's orders [REDACTED]. (Refer to F-758) The findings include: Review of the facility Pharmacy-Medical Record and Medication Regimen Review Policy, revised 10/2017, revealed medical record and and Medication Regimen Reviews (MRR) are performed monthly by the Consultant Pharmacist and the Pharmacist provides potential recommendations to the Physician/Prescriber for each resident's medication regimen. The Physician/Prescriber should either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. The MRR recommendations are given to the Director of Nursing (DON) on a monthly basis. The Pharmacist will address copies of resident's MRRs to the Attending Physician and the Medical Director. The DON gives recommendations to the Physician/Prescriber to review. The Physician reviews recommendations completes, signs and dates the form. If Physician/Prescriber rejects recommendations they need to document rationale and return to the DON. If recommendations are not completed within sixty (60) days, the Consultant Pharmacist will re-issue the recommendation or DON/designee will contact Physician for review and completion. The facility should alert the Medical Director where MRRs are not addressed by the Attending Physician in a timely manner. Review of the facility's [MEDICAL CONDITION]-Anti-psychotic Medication Management Policy, revised 10/2017, revealed PRN orders for [MEDICAL CONDITION] drugs are limited to fourteen (14) days. Per Policy, except as provided in § 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond the 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Review of Resident #94's clinical record revealed the facility admitted the resident on 07/18/16 with [DIAGNOSES REDACTED]. Review of Resident #94's physician's orders [REDACTED]. The medication end date was listed at indefinite and there was no documented evidence of a rationale for extending the medication past fourteen (14) days. Review of Resident #94's Consultation Report from the Consultant Pharmacist, dated 04/09/19, revealed the resident had a PRN order for an anxiolytic, without a stop date: [MEDICATION NAME] 0.5 mg - 1 mg-2 mg every three (3) hours as needed for anxiety. Additional review revealed, Please discontinue PRN [MEDICATION NAME]. If the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy and the extended time period. The Physician replied the duration was indefinite and the rationale was hospice patient. This Report was signed and dated by the Physician on 04/19/19. Review of Resident #94's Consultation Report from Pharmacy, dated 06/03/19, revealed the resident had a PRN order for an anxiolytic, without a stop date: [MEDICATION NAME] 0.5 mg - 1 mg-2 mg every three (3) hours as needed for anxiety. Continued review revealed a recommendation stating in all CAPITAL letters, SOM requires a duration of therapy even for hospice patients and indefinite is not allowed per CMS guidelines. In the Physician's Response, there was no indication of the Physician's choice to either accept, decline, or modify the recommendations. This Report was not signed or dated by the Physician. Review of Resident #94's Consultation Report from Pharmacy, dated 08/05/19, revealed the resident had a PRN order for an anxiolytic, without a stop date: [MEDICATION NAME] 0.5 mg - 1 mg-2 mg every three (3) hours PRN for anxiety. Additional review revealed a recommendation stating in all CAPITAL letters, SOM requires a duration of therapy even for hospice patients and indefinite is not allowed per CMS guidelines. Continued review of the physician's orders [REDACTED]. Interview with the Consultant Pharmacist, on 08/15/19 at 2:52 PM, revealed he reissued recommendations that had not been acted upon. He stated he sent a Consultation Report to Resident #94's Physician on 04/09/19 asking for documentation related to the indication for use, the intended duration of therapy and the extended time period for the [MEDICATION NAME] PRN if the medication could not be discontinued. Per interview, the Physician replied he wanted the medication ordered indefinitely because the resident was hospice. Interview further revealed he informed the Physician through a Consultation Report dated 06/03/19, a duration of indefinite was not allowed per CMS guidelines, but he did not receive a response from the Physician. He stated he sent another Consultation Report to Resident #94's Physician on 08/05/19, again reminding the Physician of the need for a duration for the PRN medication. Interview with the Director of Nursing (DON), on 08/15/19 at 5:55 PM, revealed she acknowledged PRN anti-anxiety medications were limited to fourteen (14) days or if the Provider wanted to extend the duration of the medication, the Provider would need to document the rationale in the resident's medical record and also indicate the duration for the PRN order as per the facility Policy. Further, it was her expectation the Physician acknowledge and respond to the Consultation Reports from Pharmacy. Post survey interview with the DON, on 08/29/19 11:47 PM, revealed she received the Pharmacy Consultation Reports and she reviewed the reports before placing them in the Physician's Binder at the nurse's station or in the medical record as per the Prescriber's preference. She stated she checked the Physician's Binder and the medical records three (3) times per week to ensure the Physician/Prescriber had acted on the recommendations. Further interview revealed she was unsure why Resident #94's Pharmacy recommendation dated 06/03/19 related to [MEDICATION NAME] PRN was not acted on by the facility. Interview with the Administrator, on 08/15/19 at 06:11 PM, revealed it was her expectation the facility follow Policy and regulations related to PRN [MEDICAL CONDITION] medications. Further, it was her expectation drug irregularities reported from Pharmacy were acted on by the facility.

Based on observation, interview, and review of facility Policy, it was determined the facility failed to ensure proper storage of drugs and biologicals for one (1) of twenty-five (25) sampled residents (Resident #46). Observation on 08/13/19 and 08/14/19, revealed Resident #46 had an opened tube of Ammonium [MEDICATION NAME] Cream 12% ( moisturizer for dry itchy skin) and an opened tube of Remedy Antifungal Cream 2% ([MEDICATION NAME]) on the bedside table in his/her room. The findings include: Review of the facility's Medication Storage Policy, dated 08/2018, revealed medications and biologicals including treatment items are securely stored in a secured locked cabinet/cart or locked medication room that is inaccessible to residents and visitors. Review of Resident #46's medical record revealed the facility admitted the resident on 05/23/19 with [DIAGNOSES REDACTED]. The facility assessed Resident #13, in an Annual Minimum Data Set (MDS) Assessment, dated 05/10/19, as having a Brief Interview for Mental Status (BIMS) of a thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Observation on 08/13/19 at 11:49 AM, revealed an opened tube of Ammonium [MEDICATION NAME] Cream 12% ( moisturizer for dry itchy skin) and an opened tube of Remedy Antifungal Cream 2% ([MEDICATION NAME])on the bedside table in Resident #46's room. Interview with Resident #46, on 08/13/19 at 11:49 AM, revealed the tubes were kept on the table and the nurse would put the medication on his/her feet. Observation on 08/14/19 at 8:15 AM, of Resident #46's room, revealed the opened tube of Ammonium [MEDICATION NAME] Cream 12% ( moisturizer for dry itchy skin) and the opened tube of Remedy Antifungal Cream 2% ([MEDICATION NAME]) was still on the resident's bedside table. Review of Resident #46 Monthly (MONTH) physician's orders [REDACTED]. Review of the Safety Data Sheet (SDS) for Ammonium [MEDICATION NAME] 12% Moisturizing Lotion, revealed this product was an eye irritant, as well as required contact with a physician or Poison Control Center if the lotion was ingested. Review of the SDS for [MEDICATION NAME], revealed it could be harmful if swallowed, and to contact a physician or Poison Center if ingested. Interview with Licensed Practical Nurse (LPN) #4, on 08/15/19 at 3:32 PM, revealed all topical medications were to be locked in a cabinet or medication/treatment cart including ointments. Per interview, it was important to keep all medications locked and inaccessible to residents and visitors. Interview with LPN #5, on 08/15/19 3:32 PM, revealed nurses were to ensure medications, creams, and ointments were locked in the medication or treatment carts or locked in the medication room. Per interview, leaving topical medications, or any medications accessible to confused residents created the potential for danger as the medications could be ingested. Interview 08/15/19 04:09 PM, with the Director of Nursing (DON), revealed, We wouldn't want opened tubes of medication kept at the bedside. We have kept resident's medication in their locked drawer in the past, but current practice is to lock up the medications in the medication cart. The DON further stated unlocked medication could be hazardous to residents and it was her expectation staff lock up any medication. Interview with the Administrator, on 08/15/19 6:07 PM, revealed if the resident did not have an order to keep medications or medicated creams at the bedside, then the medication should be kept in the medication cart. Per interview, it was her expectation staff follow the facility policy regarding medication storage.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 3.0, it was determined the facility failed to ensure the accuracy and completion of Section K of the Minimum Data Set (MDS) Assessment, for one (1) of twenty-five (25) sampled residents (Resident #94). Review of Resident #94's Quarterly MDS Assessment, dated 06/19/19, Section K0300, revealed the facility assessed the resident as not having a weight loss of ten percent (10%) or more in the last six (6) months; however, record review of the resident's weights revealed the resident sustained [REDACTED]. In addition, review of Resident #94's Significant Change MDS Assessment, dated 07/17/19, Section K0300, revealed the facility assessed the resident as not having a weight loss of ten percent (10%) or more in the last six (6) months; however, record review of the resident's weights revealed the resident sustained [REDACTED]. The findings include: Review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 3.0, dated (MONTH) (YEAR), revealed the purpose of this manual is to offer clear guidance about how to use the Resident Assessment Instrument (RAI) correctly and effectively to help provide appropriate care. Further review under section K, revealed for determining weight loss in 180 days, start with the resident's weight closest to 180 days ago and multiply by .90 (or 90%). The resulting figure represents a 10% loss from the weight 180 days ago. If the resident's current weight is equal to or less then the resulting figure, the resident has lost 10% or more body weight. Review of Resident #94's medical record revealed the facility admitted the resident on 07/18/16 with [DIAGNOSES REDACTED]. Review of the Resident #94's weights reveals the following: 07/02/19- 104.6 pounds 06/04/19- 103.0 pounds 05/03/19- 103.0 pounds 04/07/19- 115.2 pounds 03/18/19- 126.0 pounds 02/03/19- 121.0 pounds 01/11/19- 119.8 pounds 01/02/19- 123.8 pounds 01/01/19- 114.6 pounds 12/06/18- 125.6 pounds 11/02/18- 127.2 pounds Review of Resident #94's Quarterly MDS Assessment, dated 06/19/19, Section K0300, revealed the facility assessed the resident as not having a weight loss of five (5) percent (5%) in the last month or a weight loss of ten percent (10%) or more in the last six (6) months. However, per record review the resident weighed 125.6 pounds on 12/06/18 and weighed 103 pounds on 06/04/19. This would be an 18% weight loss in six (6) months during the 180 day look back period between 12/06/19 and 06/04/19. Review of Resident #94's Significant Change MDS Assessment, dated 07/17/19, Section K0300, revealed the facility assessed the resident as not having a weight loss of five (5) percent (5%) in the last month or a weight loss of ten percent (10%) or more in the last six (6) months. However, per record review the resident weighed 123.8 pounds on 01/02/19 and weighed 104.6 pounds on 07/02/19. This would be a 15.50 % weight loss in the last six (6) months during the 180 day look back period between 01/02/19 and 07/02/19. Interview with the MDS Nurse, on 08/15/19 at 4:15 PM, revealed she did not complete the Nutrition section of the MDS Assessments as the Registered Dietician was responsible for completing section K. Per interview, it was her expectation all sections of the MDS Assessments be completed accurately in order to get a true picture of the residents. Interview with the Registered Dietician (RD), on 08/15/19 04:34 PM, revealed she didn't mark the resident as sustaining a weight loss for the MDS Assessments dated 06/19/19 and 07/17/19. Per interview, this was because the RAI manual was vague in explaining how to complete section K, and therefore she used her clinical judgement when completing the MDS Assessments. The RD admitted to not receiving any formal education related to completing the MDS Assessments. Interview with the Director of Nursing (DON), on 08/15/19 at 5:48 PM, revealed she was not an expert on the MDS Assessments and relied on staff to complete all sections of the MDS Assessments accurately. Interview with the Administrator, on 08/15/19 at 6:18 PM, revealed she thought the RD was completing the MDS Assessments accurately according to the guidelines.

Based on observation, interview, record review, and review of the facility Policy, it was determined the facility failed to ensure it's medication error rates are not five (5) percent or greater. Observation of medication pass on 7/18/18, revealed twenty-eight (28) medication opportunities with eight (8) medication errors resulting in a medication error rate of 28.5 percent. Observation of medication administration for Resident #470, on 07/18/19, revealed medications were given via Percutaneous Endoscopic Gastrostomy Tube (PEG tube) without water flushes in between medications for eight (8) medications. The findings include: Review of the facility Medication Administration Via Gastric/Jejunostomy Tubes Policy, revised 02/2012, revealed tubing was to be flushed before and after medications were given using thirty (30) to sixty (60) milliliters (ml) of water and multiple medications to be given at the same time should be given individually and flushed individually. Review of Resident #470's medical record revealed the facility admitted the resident on 07/09/18, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to be severely cognitively impaired and unable to be interviewed for a Brief Interview for Mental Status Score. Review of Resident #470's Physician's Orders dated (MONTH) (YEAR), revealed orders to crush the resident's medications and to administer medications including [MEDICATION NAME], Duloxetine, [MEDICATION NAME], Folic Acid, [MEDICATION NAME] and Potassium Chloride via Pe[DEVICE]. (A PEG/Percutaneous Endoscopic Gastrostomy is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) Observation on 7/18/18 starting at 10:45 AM, revealed Licensed Practical Nurse (LPN) #1 checked the Medication Administration Record [REDACTED]#470 per PEG tube after checking for placement of the tube. However, the nurse failed to flush the resident's PEG tube with water after administration of the medication. Further observation revealed LPN #1 then went back to the medication cart in the hallway and retrieved Duloxetine 60 milligram capsule (antidepressant medication); brought the medication back into the resident's room; opened the capsule and mixed it with thirty (30) ml's of water; and administered the medication per PEG tube. However, the nurse failed to flush the resident's PEG tube with water after administration of the medication. Continued observation revealed LPN #1 then went back to the medication cart in the hallway and retrieved [MEDICATION NAME] 0.25 mg tablet (medication used to treat [MEDICAL CONDITION] Fibrillation, an abnormal heart rhythm); crushed the medication, and placed it in a cup. The nurse brought the cup of crushed medication back into the resident's room; added thirty (30) mls of water to the cup; and administered the medication via the resident's PEG tube. However, the nurse failed to flush the resident's PEG tube with water after administration of the medication. Additional observation revealed LPN #1 then went back to the medication cart in the hallway and retrieved Folic Acid one (1) mg (a vitamin to treat [MEDICAL CONDITIONS]) two (2) tablets; crushed the tablets; then brought the cup of medication back to the room and dissolved the medication in thirty (30) ml of water. The nurse then administered the medication via the PEG tube. However, the nurse failed to flush the resident's PEG tube with water after administration of the medication. Further observation revealed LPN #1 then went back to the medication cart in the hallway and retrieved [MEDICATION NAME] (antipsychotic) twenty-five (25) milligrams, one (1) tablet and crushed the tablet. She then brought the cup of crushed medication back to the room and dissolved the medication in thirty (30) mls of water and administered the medication via the PEG tube. However, the nurse failed to flush the resident's PEG tube with water after administration of the medication. Interview with LPN #1, on 07/18/18 at 11:00 AM, revealed normal procedure for giving medications through a PEG tube would be to take all crushed medications in the resident room at the same time and then dissolve the medications in individual cups prior to administering the medications. Upon prompts for further procedures related to medication administration, LPN #1 could not name anything else she would do differently related to administration of medication via PEG tube. Continued observation on 7/18/18 at 11:05 AM, revealed LPN #1 retrieved Resident #470's medication from the medication cart including [MEDICATION NAME] (anti-anxiety medication) 0.5 mg - two (2) tablets; [MEDICATION NAME] (antacid) 150 mg; and Potassium chloride (for [DIAGNOSES REDACTED]) 20 mg/15 milliliters (ml) liquid which she measured for a dose of 7.5 ml. The nurse crushed the [MEDICATION NAME] and placed the medication in a cup, then crushed the [MEDICATION NAME] and placed the medication in a separate cup, and then returned to the resident's room. Once in the resident's room, LPN #1 mixed thirty (30) mls of water in the medication cup with the [MEDICATION NAME] and also mixed 30 mls of water in the medication cup with the [MEDICATION NAME]. She then administered the [MEDICATION NAME] and next the [MEDICATION NAME] through the PEG tube, but failed to flush the PEG tube with water between administration of the [MEDICATION NAME] and [MEDICATION NAME] and failed to flush the PEG after administering the medications. LPN #1 then proceeded to dilute the Potassium Chloride with eight (8) ounces of water and administered it through the PEG tube. The PEG tube was flushed with sixty (60) mls of water after the Potassium Chloride. Interview with LPN #1, on 7/18/18 at 3:30 PM, revealed per facility policy and also per standards of practice, when administering medication through a PEG tube, the tube should be flushed with water after each medication unless there was Physician's orders not to flush with water between medications. Continued interview revealed it was important to flush the PEG tube after each medication was administered to make sure the full amount of medication was given and to ensure the tube did not get occluded. Per interview, LPN #1 had been employed by the facility for ten (10) months and had received training on medication administration through a PEG tube. Interview with LPN #1's Unit Manager, on 7/19/19 at 11:20 AM, revealed nursing staff was to flush PEG tubes with water after administration of each individual medication. Per interview, this was important for the absorption of medication and to make sure the medication did not get clumped up in the tube. Per interview, there may be times when there was not as many residents on the unit with PEG tubes and therefore the nurses may not be as familiar with administration of the medication per PEG tube. Continued interview revealed the Corporate Educator was available for any staff member who needed assistance with skills. Interview with Director of Nursing (DON), on 7/19/19 at 11:30 AM, revealed it was her expectation nursing staff performed water flushes after administration of each medication through PEG tubes per policy and nursing standards. Per interview, the flushes were important to ensure the tube was patent and to ensure full administration of the medication. Continued interview revealed this skill was part of the annual competency for nurses. Interview with the Administrator, on 7/19/19 at 11:35 AM, revealed staff was to follow policies and procedures related to administration of medications. Continued interview revealed policies were developed to ensure staff delivered medications through proper procedure. Per interview, this was important for the safety and well being of the resident. Continued interview revealed this skill was an annual competency for the nursing staff.

Based on observation, interview, and review of facility policy, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Observation revealed four (4) Continuous Passive Motion (CPM) machines (machine used to rehabilitate a limb) sitting on resident room floors uncovered in rooms [ROOM NUMBER]. Further observation during the initial tour on 05/10/16, revealed four (4) resident bathrooms with plungers sitting on the bathroom floor uncovered (Rooms #2202, #2206, #2211 and #2301). The findings include: Review of the facility's Standard Precautions, Policy, revised May 2015, section five (5)-Resident-Care Equipment, revealed handle used resident-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of other microorganisms to other residents and environments. Per Policy, ensure reusable equipment is not used for the care of another resident until it has been appropriately cleaned. 1. Review of the facility's Policy, titled, Rehabilitation Services, In Resident Room Treatments-Resident Right Procedures:, revised June 2009, revealed infection control policy and procedures would be adhered to during treatment. Observations, during the initial tour on 05/10/16 at 11:35 AM, revealed three (3) Continuous Passive Motion (CPM) devices in three (3) residential rooms stored directly on the floor of Rooms #2302, #2304, and #2307. Interview with the Director of Nursing (DON), on 05/12/16 at 9:10 PM, revealed the CPM machines were typically stored in the floor, but staff was to be put them on chairs when not in use. She stated it was important not to store the machines on the floor because bacteria could be transferred from the floor to the bed and this was an infection control issue. 2. Observation during initial tour on 05/10/16 at 10:00 AM, revealed plungers which were uncovered sitting on resident's bathroom floors in four (4) rooms (room [ROOM NUMBER], #2206, #2211 and #2301). Further interview on 05/12/16 at 9:10 PM, with the DON, revealed plungers being used, then placed directly onto the floor could be an infection control issue. Interview on 05/12/16 at 9:50 PM, with the Administrator, revealed plungers should be in a bag, prior to sitting the plunger on the floor related to infection control.

Based on observations, interviews and the facility's policy it was determined the facility failed to ensure resident's environment remained free of accident hazards and each resident received adequate supervision to prevent accidents. Observation on 05/10/16, revealed the facility's second (2nd) Floor unlocked Therapy Gym had an unlocked cabinet under the sink, and an unlocked cabinet next to the sink containing hazardous chemicals accessible to residents. The findings include: Review of the facility's Policy, titled, Occupational Safety and Health Administration (OSHA), Maintenance, revised June 2015, revealed the facility would follow all applicable OSHA standards regarding chemical safety and injury reporting. Further review under Procedure 4, Hazards-Physical and Health, revealed harm may be caused by chemicals. Either by touch, smell or ingested. Corrosive chemicals will cause skin burns if the chemical comes in contact with skin. Toxic is a patch chemical and if manufacturer precautions are not followed, may cause rashes or lesions. Review of the facility's Policy, titled, Rehabilitation Services, Resident's Rights and Safety-Therapy Treatment and Maintenance Program Sessions, revised April 2002 and June 2009, revealed when the gym was empty, the door to the gym would be locked to prevent any accidental injury caused by an unattended resident or visitor. Review of the facility's Wandering Resident List, provided by the facility, revealed there were four (4) wandering residents on the second (2nd) floor. Observation on 05/10/16 at 1:10 PM, in the facility's 2nd Floor unlocked Therapy Gym, revealed an unlocked cabinet under the sink, containing one (1) bottle of Comet Disinfecting Sanitizing Bathroom Cleaner, and one (1) bottle of Comet Cleaner with Bleach accessible to residents. Further observation revealed an unlocked cabinet next to the sink with one (1) bottle of Spic and Span Disinfecting All Purpose Spray and Glass Cleaner. Review of the Safety Data Sheet (SDS) for Comet Disinfecting Sanitizing Bathroom Cleaner dated 06/18/15, revealed causes eye irritation; harmful if swallowed; wash hand thoroughly after handling; do not eat, drink or smoke when using this product; if eye contact rinse with plenty of water and get medical help if irritation persists; if skin contact rinse with plenty of water and get medical attention if irritation develops or persists; if ingested rinse mouth and drink one (1) to two (2) glasses of water, do not induce vomiting, get medical attention if symptoms occur; and if inhaled move to fresh air and call physician if symptoms persist. Review of the SDS for Comet Cleaner with Bleach-Ready revised 04/07/15 revealed: Hazard causes eye irritation, rinse eyes for several minutes with water; wash hands thoroughly after handling; drink one (1) to two (2) glasses of water if swallowed and get medical attention if symptoms arise or persist. Continued review, revealed keep out of the reach of children and use appropriate eye protection, protective gloves and suitable protective clothing and in case of insufficient ventilation wear suitable respiratory equipment. Further review, revealed this material contains one (1) or more substances regulated as a hazardous substance under the Comprehensive Environmental Response Compensation and Liability Act. Review of the SDS for Spic and Span Disinfecting All-Purpose Spray and Glass Cleaner, revised 04/07/15, revealed causes severe skin burns and eye damage; combustible liquid; do not breath mist; wash hands thoroughly after handling; wear protective gloves and eye protection; use with ventilation; and keep away from heat/sparks/open flames/hot surfaces. Further review revealed first aid measures included: if eye contact, rinse with water and contact physician immediately; if skin contact rinse with water, ingestion drink one (1) or two (2) glasses of water, do not induce vomiting, get medical attention immediately; and if inhaled remove to fresh air and call physician or poison control center immediately. Interview on 05/12/16 at 5:45 PM, with the Director of Rehabilitation, revealed the therapy gym door should be locked when not in use. Continued interview, revealed residents should never be in the therapy gym alone and the cleaning chemicals should have been behind a locked cabinet or closet. Interview on 05/12/16 at 9:50 PM, with the Administrator, revealed it was his expectation that the facility's policies related to chemical storage should be followed. Continued interview revealed the chemicals should have been secured where confused residents would not have access.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to implement written policies and procedures that would prohibit neglect for one (1) of twenty-four (24) sampled resident's (Resident #8). Staff failed to provide the services necessary to maintain health in order to prevent neglect for Resident #8. Resident #8 was assessed and Care Planned for two (2) staff to transfer the resident, and to walk calmly away and approach later when physically aggressive. However, on 05/09/16 while Resident #8 was agitated and combative, the resident was transferred with the assist of one (1) staff member. This resulted in the resident sustaining large painful bruises and skin tears. The findings include: Review of the facility's Policy titled, Abuse/Neglect/Misappropriation of Property, revised January 2016, revealed it was the facility's intent to prevent abuse, mistreatment and neglect of residents. In this way, the facility would provide an environment that would be comfortable and safe for the facility's long term residents. Further review of the Policy, revealed abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Per Policy, neglect was the failure of the caregiver to provide the goods or services that were necessary to maintain the health or safety of an elder. Review of Resident #8's medical record revealed the facility admitted the resident on 10/29/13 with [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set (MDS) Assessment, dated 02/05/16, revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severe cognitive impairment. Continued review of the MDS, revealed, the resident was assessed to have one (1) episode of behavior which occurred within one (1) to three (3) days of the assessment, related to a rejection of care. Further review of the MDS, revealed, the resident was assessed to require two (2) persons for physical assist for all transfers. Further review of Resident #8's Care Plan initiated 02/08/15, revealed the resident had the potential to be physically aggressive related to Dementia, Poor Impulse Control, Anger, Depression, and History of Harming others. The goal stated the resident would not harm self or others. The interventions included: when resident agitated, staff to intervene before his/her agitation escalated; guide the resident away from the source of the distress; engage calmly in conversation; and if response was aggressive, staff would walk calmly away, and approach later. Continued review of Resident #8's care plan initiated 08/21/14, revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit related to dementia, confusion, and impaired balance. The goal stated all ADL's were to be met. The interventions included extensive assist of two (2) people with transfers. Review of the Nurse Aide Care Plan, undated revealed the resident was to be transferred with the extensive assist of two (2) staff. Review of the Statement Form, dated 05/09/16, completed by State Registered Nurse Aide (SRNA) #4, revealed Resident #8 was restless and trying to take his/her seatbelt off and he/she was being combative with the nurse and SRNA #4. Continued review revealed the SRNA noticed the resident smelled of urine, so she took the resident to his/her room and told the resident he/she needed to be changed. Further review revealed SRNA #4 told Licensed Practical Nurse (LPN) #5 as she was going into Resident #8's room, she was going to change the resident because he/she smelled. Per the statement the nurse asked her if she needed assistance with the resident and SRNA #4 stated she did not need help, but would call her if she did. Continued review of the Statement Form, revealed SRNA #4 never had too much of a problem with Resident #8, so she did not think she needed help, adding the resident was a one (1) person assist. Per the statement, SRNA #4 revealed she started taking the resident's seatbelt off and the resident started scratching her. The resident got his/her arms around her like they were hugging and she transferred the resident to the bed. According to the statement, when SRNA #4 took her arms out from behind him/her, the resident punched her in the face. Further review of the Statement Form, revealed SRNA #4 laid the resident down and the resident was scratching her so she held his/her hands until she got his/her pants down. SRNA #4 had two (2) pairs of gloves on because she knew the resident would scratch, but the resident was getting her everywhere. Per the statement, SRNA #4 changed the resident's brief and put some pajama pants on him/her. She then pulled the residents pants up, and noticed the resident was bleeding so she got the nurse right away. Further review, revealed SRNA #4 was not sure how the resident got the skin tears because she was focused on changing the residents pants and making sure the resident did not fall out of the bed. Attempted interview with State Registered Nurse Aide (SRNA) #4, on 05/12/16 at approximately 11:00 AM; however, SRNA's telephone number was disconnected. The Administrator revealed he attempted to reach out to SRNA #4, as the facility had SRNA #4's same telephone number provided to this surveyor, as well as, attempted to contact her through social media and made a visit to her home. The Administrator reported the facility was unable to reach SRNA #4. Review of Resident #8's Progress Note, dated 05/10/16 at 6:33 AM, revealed LPN #5 documented that at 10:30 PM, it was reported that Resident #8 obtained two (2) skin tears to the left upper arm measuring two (2) centimeters (cm) length x 1.5 cm width and one (1) cm length x one (1) cm width, and the back of the right hand had a two (2) cm length x one (1) cm width skin tear. Per the Note, SRNA #4 stated during resident care, the resident became combative, as evidenced by, scratching and punching her (SRNA #4) in the face, scratches were noted to both arms of SRNA #4. According to the Note, SRNA #4 stated she looked up and saw Resident #8 bleeding and did not know when the actual skin tear occurred, but she was trying to change him/her and prevent him/her from falling. Further review of the Progress Note, revealed LPN #5 she was in the room with a resident when she heard SRNA #4 say let me get the nurse, because you are bleeding. Per the Note, LPN #5 went in the room and noted that Resident #8 was laying in his/her bed with his/her feet off the bed. Per the Progress Note, LPN #5 helped SRNA #4 get the resident up in the bed, assessed, measured, cleaned and covered the skin tears and told SRNA #4 to remain with the resident. Continued review, revealed LPN #5 got the supervisor, LPN #6, who also assessed, measured, and applied steri strips to the skin tears. Interview with Licensed Practical Nurse (LPN) #5, on 05/12/16 at 10:07 AM, revealed she had been assigned to Resident #8 on 05/09/16. She stated the resident had dementia and would become combative and the resident's behaviors included kicking or hitting staff. LPN #5 stated at the time of the incident, SRNA #4 was the only aide on the floor and she was in the middle of medication pass. Per interview, SRNA #4 told LPN she was going to change the resident. LPN #5 stated she knew the resident was a two (2) person assist and asked SRNA #4 if she needed help with the resident and SRNA #4 revealed she did not need any assistance. Continued interview with LPN #5, revealed she heard Resident #8 yell, Don't touch me, and Leave me alone. LPN #5 stated those were words the resident always stated, thus she did not pay much attention to the resident when the resident made these statements. LPN #5 revealed, while she was completing administration of medication to a resident, she heard SRNA #4 state, I got to get the nurse cause you are bleeding. LPN #5 stated she went into the room when she heard that statement, not waiting for SRNA #4 to get her. Upon entering the room, LPN #5 stated she found the resident laying on his/her bed horizontally, as though the resident's transfer was completed. LPN #5 stated she spoke to SRNA #4 who informed her that the resident was combative when she removed the resident's seatbelt and when she proceeded with the transfer, the resident continued to be combative, stating the resident was fighting her. LPN #5 stated she told SRNA #4 to get someone the next time that happened immediately and stop with his/her care, adding this would protect her and the resident. Further interview with LPN #5, revealed SRNA #4 had several scratches and the resident had skin under his/her nails and she believed this to be SRNA #4's skin, who was also bleeding. She stated she left SRNA #4 with the resident and got LPN #6, at around 10:45 PM, after the incident, for a second opinion of the resident's injuries. LPN #5 stated LPN #6 completed the resident's dressing, and LPN #5 did not notice bruising after the incident, only the skin tears which she documented. LPN #5 further stated she had SRNA #4 write a statement of the incident and she documented the incident in the Progress Notes. Further interview with LPN #5, revealed she defined abuse as forcing a resident to do anything against their will. She stated she thought SRNA #4 made a poor decision regarding the resident's care and because SRNA #4 continued to provide care, transferring the resident and continuing with changing the resident's clothing, while the resident was combative, this could be considered abuse. Additionally, she revealed the care plan should have been followed related to transfers and with dealing with the resident's behaviors. She stated she knew the resident was a two (2) assist with his/her transfers and she allowed the SRNA to transfer the resident by herself, and in hindsight should have demanded SRNA #4 wait for her to assist with the resident's care. Observation of Registered Nurse (RN) #1/Unit Manager performing a skin assessment on Resident #8, on 05/12/16 at 2:40 PM, revealed the resident had three (3) linear bruises located on the back of the upper left arm. The top bruise, located near the resident's shoulder blade measured four (4) centimeters (cm) in length and three and a half (3.50) cm in width. The second (2nd) bruise, located in the middle, was eighteen (18) cm in length, The third (3rd) bruise, bottom, was four (4) cm in length and three (3) cm in width. The posterior edge of the upper left arm had a skin tear which was one (1) cm in length and one and a half (1.50) cm in width. Additionally, the resident's left and right hand was observed to be treated with steri-strips, for skin tears. During the skin assessment, Resident #8 complained of pain. Interview with LPN #4, on 05/12/16 at approximately 9:15 AM, revealed she was normally assigned to work with Resident #8. She stated the resident was often resistive to care, making statements like leave me alone, and he/she would push staff away. Further interview with LPN #4 revealed if the resident stated no, staff should make sure the resident was safe, get the nurse, and try to proceed with care later. Continued interview revealed if the resident was still combative after re-approaching, then another aide or nurse would be requested to provide the resident's care. LPN #4 revealed, after several attempts, usually the resident was okay with staff assisting him/her with his/her care. Additionally, she reported the resident would state, you are hurting me, which meant to leave him/her alone. LPN #4 stated the bruising on the resident's arm was not on the resident's arm on Sunday, on 05/08/16, but when she returned to work on Wednesday, on 05/11/16, the resident had a bruise to his/her left arm. LPN #4 stated the resident bruised easily, but never to the extent shown on his/her left arm. LPN #4 stated she was informed in shift report that the bruising came from care that was provided to the resident from SRNA #4. Interview with SRNA #6, on 05/12/16 at approximately 9:30 AM, revealed she was normally assigned to work with Resident #8. SRNA #6 revealed the resident can become aggressive, verbally abusive, and combative and when the resident displayed these behaviors, staff should ensure the resident was safe, walk away, and re-approach the resident at a later time. She stated this was for the safety of the resident, as well as staff. Continued interview with SRNA #6 revealed staff should not try to force care on the resident, which could be seen as abusive. Interview with SRNA #7, on 05/12/16 at 3:04 PM, revealed she was assigned to work with Resident #8 on a regular basis. She stated the resident was extremely combative and aggressive. Continued interview revealed when the resident was resistive to care, staff should leave the resident alone and should come back later to provide any care. SRNA #7 revealed staff should not continue to provide care to the resident if the resident refused, adding this protected the staff member, as well as, the resident. SRNA #7 stated Resident #8 required two (2) assist for transfers and the resident could not stand for long periods of time. Per interview she saw the resident after the incident and the resident stated it hurts and when she asked the resident where it hurts, the resident responded by telling her everywhere. Interview with SRNA #5, on 05/12/16 at 7:30 PM, revealed she worked with Resident #8 often and the resident scratched and hit staff at times. She stated Resident #8 was a two (2) assist with all of his/her transfers. She further stated when the resident had behaviors which included the resident becoming combative, staff should redirect the resident, to try to get the resident to think about something else, or leave the resident for about a minute or so and re-approach. She stated this would often work for the resident. SRNA #5 revealed if the resident stated, Don't touch me, staff should not proceed with the resident's care adding, you can not be forceful with the resident, and this would often make the situation worse. Interview with Licensed Practical Nurse (LPN) #7, on 05/12/16 at 7:35 PM, revealed she worked with Resident #8 often. She stated, when the resident had behaviors, staff was to leave the resident alone and re-approach. Continued interview revealed if the resident did not want staff to do something for him/her, staff should not force the resident. LPN #7 stated staff should leave the resident when he/she refused care and re-approach at a different time, to avoid any physical harm for staff, as well as, the resident. Further interview with LPN #7 revealed Resident #8 required two (2) staff to transfer, adding the resident could stand, but would give out at times, so it was best to have two (2) people for transfers for the safety of the resident and staff. LPN #7 stated she heard about the incident, having worked on the night of 05/09/16 until the morning of 05/10/16. Further interview revealed when she saw SRNA #4 after the incident, she looked like she had been in battle, with all her war wounds and scratches. Interview with Licensed Practical Nurse (LPN) #3, on 05/12/16 at 8:14 PM, revealed Resident #8 should have two (2) staff to assist with his/her transfers and staff should not transfer the resident while the resident was being combative. Additionally she stated, staff should walk away from the resident and re-approach the resident in about 10 (ten) or fifteen (15) minutes, adding this would be for the safety of the resident and staff. Interview with Registered Nurse (RN) #1/Unit Manager, on 05/12/16 at 8:11 PM, revealed she was notified of Resident #8's skin tear on 05/10/16, during the resident's care conference that took place somewhere between 10:30 AM or 11:30 AM. RN #1 stated she was not aware of the resident's bruising on his/her arm until the day of this interview, 05/12/16 during the resident's requested skin assessment by the surveyor. RN #1 stated the resident had bruises in the past, but none to the extent shown on the resident's left arm. RN #1 stated, if the resident was combative before care and was safe, SRNA #4 should not have provided care to the resident. Continued interview with RN #1, revealed SRNA #4 should have left the resident and re-approached the resident at a different time, when the resident was calmer. Further interview with RN #1 stated this would have prevented the resident and SRNA #4 from having physical harm. Interview with the Director of Nursing (DON), on 05/12/16 at 9:10 PM, revealed she was first notified about Resident #8's skin tear on Tuesday morning, 05/10/16, from the Night Supervisor/LPN #6 who informed her, through an email, the resident had skin tears and bruising and the incident involved SRNA #4, if anything came up. Continued interview with the DON revealed the facility provided in-services at least annually on working with residents who had behaviors. She revealed this was important to avoid any physical harm to staff and residents. The DON stated she did not feel as though the incident was abuse; however, after reviewing the definition of abuse and neglect she reported it could have been neglectful with the staff continuing care, though the resident refused, and transferring the resident with one (1) person when the resident was care planned to be a two (2) person assist. Interview with the Administrator, on 05/12/16 at 9:48 PM, revealed he did not feel staff were neglectful with Resident #8's care, and there was just a failure to follow the resident's care plan. Furthermore, he revealed it would have been his expectation that the facility's policy, as well as, the Centers for Medicare and Medicaid (CMS) Regulations be followed.

Based on interview, record review and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure residents' Comprehensive Care Plan interventions were implemented to ensure the resident's safety from abuse for one (1) of five (5)sampled residents (Resident #1). The facility assessed Resident #1 to be potentially verbally aggressive with staff for which the resident was care planned and interventions were in place. The care plan interventions stated if he/she became agitated, staff was to guide the resident away from the source of distress and if he/she became aggressive to walk calmly away and approach the resident at a later time. On 11/25/14, interviews with Certified Nursing Assistant (CNA) #1 and CNA #2 revealed the resident was "agitated" before and during his/her shower; however, they were not familiar with Resident #1's care plan interventions and proceeded with the shower anyway. CNA #2 and Nurse Aide in Training (NAT) #1, who were in the shower room with CNA #1, witnessed CNA #1 intentionally spray Resident #1 in the face with hot and cold water after the resident called her a name. CNA #2 and NAT #1 also heard the resident yelling for CNA #1 to "stop" she was "burning" him/her. (Refer to F223) The facility's failure to have an effective system in place to ensure the Comprehensive Care Plan was implemented to ensure residents' safety from abuse was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 12/18/14, and determined to exist on 11/25/14. The facility was notified of the Immediate Jeopardy on 12/18/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 12/23/14, with the facility alleging removal of the Immediate Jeopardy on 12/23/14. The Immediate Jeopardy was verified to be removed on 12/23/14, as alleged, with remaining non-compliance in the area of 42 CFR 483.20, Resident Assessment, F-282 Qualified Professionals, with a Scope and Severity of a "D" while the facility develops and implements a Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Interview, on 12/18/14 at 2:06 PM, with the Administrator revealed the facility had no policy regarding residents' care plans; however, the facility used the Resident Assessment Instrument (RAI) User Manual Version 3.0 as a guideline for Comprehensive Care plans. Review of the RAI User Manual Version 3.0, dated May 2013, revealed the Comprehensive Care Plan was an interdisciplinary communication tool which must include measurable objectives and time frames, and must describe the services to be furnished to attain or maintain a resident's highest practicable, physical, mental, and psychosocial well-being. Additionally, per the Manual, the services provided or arranged must be consistent with each resident's written plan of care. Review of Resident #1's medical record revealed the facility admitted him/her on 01/21/13, with [DIAGNOSES REDACTED]. Review of the resident's Annual Minimum Data Set (MDS) Assessment, dated 10/21/14, revealed the facility assessed the resident to be moderately cognitively impaired, and was not assessed to have behaviors. However review of Resident #1's Comprehensive Care Plan revealed a care plan for the resident which stated he/she had the potential to be verbally aggressive with staff and his/her spouse which was initiated on 08/01/14 and revised on 08/28/14. Review of the behavior care plan revealed the interventions included CNAs were responsible: when the resident became agitated they should intervene before the agitation escalated; guide the resident away from the source of distress; engage the resident calmly in conversation; if the resident's response was aggressive, staff should walk calmly away and approach later; give the resident as many choices as possible about care and activities; and, monitor his/her behaviors as needed. However, review of Resident #1's Kardex (the CNA care plan), undated, revealed no documented evidence Resident #1's behavior/mood interventions were added to the CNAs' Kardex/Care Plan to ensure they were aware of the interventions. Interview with Resident #1, on 12/17/14 at 4:58 PM, revealed he/she believed staff did not know how to care for him/her. Resident #1 stated he/she received showers twice a week, but did not enjoy showers. Per interview, his/her showers were a "joke", and he/she had experienced "better showers in Korea". Interview with CNA #1, on 12/17/14 at 2:35 PM, revealed the resident was always combative when she gave him/her a shower. Per interview, on 11/25/14 when she was escorting Resident #1 to the shower, the resident was grabbing at her clothes, and indicated he/she was agitated. CNA #1 stated she asked NAT #1 to assist her with getting Resident #1 in the shower chair. She stated once Resident #1 was in the shower she could not de-escalate the resident's behaviors. Continued interview revealed she did not know for certain if Resident #1 was care planned for behaviors or what interventions were in place for the resident. CNA #1 reported Resident #1 would often have behaviors and she would report it to the nurses. She stated, however, she believed the nurses would "shrug off" Resident #1's behaviors and would tell her the behavior was normal and to just "do her job". According to CNA #1, residents' Kardex/CNA Care Plan only informed CNAs how to assist residents with their Activities of Daily Living (ADL's), but did not address residents' behaviors. Further interview revealed she was not aware there was a concern regarding the care she provided Resident #1 on 11/25/14, until the Director of Nursing (DON) approached her and asked her to write a statement concerning the shower room allegations. CNA #1 reported she did not return to work with caring for residents and was terminated on 11/28/14. Interview with CNA #2, on 12/17/14 at 3:30 PM, revealed she was unaware Resident #1 was care planned for behaviors, and she thought only a resident's family or the nurses had access to residents' care plans. Per interview, she stated she had observed CNA #1 being "stern" with residents before. If a resident refused a shower, CNA #1 would say, "you know you really should take a shower". According to CNA #2, this was what happened on 11/25/14, and what escalated the situation for Resident #1 that day, as the resident told CNA #1 he/she did not want to take a shower. CNA #2 stated Resident #1 then became "agitated" and remained that way during his/her shower. Continued interview revealed during the shower Resident #1 called CNA #1 a "nasty" name and CNA #1 "squirted" the resident in the face with water. She stated Resident #1 did not become violent until that happened. Per CNA#2, she and CNA #1 should have stopped Resident #1's shower, taken the loss of giving him/her a shower that day or tried approaching the resident to take it later on that day. Interview with NAT #1, on 12/17/14 at 1:09 PM, revealed Resident #1 had behaviors at times which included loud screams, calling staff names, and he/she would "fight" a bit when staff were transferring him/her. NAT #1 stated staff could de-escalate Resident #1's behaviors however, by talking calmly to the resident, and his/her behaviors could be prevented in this way before behaviors started. Per NAT #1, he was provided very little training from the facility, and did not know what the Kardex/CNA Care Plan was, and had "never used it" before. NAT #1 revealed on 11/25/14 around 3:00 PM, he had assisted CNA #1 per her request to get Resident #1 into the shower. He stated he, CNA #1 and CNA #2 were present when CNA #1 began Resident #1's shower. NAT #1 stated he heard Resident #1 yell over and over again during the shower, "stop you're burning me", and saw CNA #1 spray the resident in the face with water. According to NAT #1, CNA #1 told Resident #1 if he/she would listen to her, she "wouldn't have to do this." NAT #1 revealed he told CNA #1 to stop, and she told him to take over which he did. He stated he adjusted the water temperature and gave the shower hose to Resident #1, and CNA #1 then told him to "get the [***] out of here". NAT #1 reported he told CNA #1 to "be good to" Resident #1, and he then left the shower room to return to work on his hall. Further interview revealed NAT #1 indicated that if CNA #1 had spoken calmly to Resident #1 prior to and during the shower it might have prevented the incident. NAT #1 stated he did not tell anyone what he had witnessed in the shower room until around 5:30 PM. Interview with CNA #4, on 12/17/14 at 11:20 AM, revealed she had cared for Resident #1 before, and he/she had behaviors which included cursing at staff. She stated Resident #1 had not been combative with her recently, but had been in the past. CNA #4 revealed she learned how to de-escalate Resident #1 by talking calmly with him/her which would calm the resident. Continued interview revealed she was not certain if Resident #1 was care planned for behaviors, but knew the resident's behaviors were not on his/her Kardex/CNA Care Plan. She stated the Kardex only contained information on how to assist residents with their daily care. Interview, on 12/17/14 at 4:34 PM, with CNA #7 revealed she had cared for Resident #1 before, and was aware he/she had behaviors of screaming and hollering at times. Per interview, the Kardex gave the CNAs some information, but it was only related to residents' ADLs. She stated the Kardex did not contain information regarding residents' behaviors or what to do about behaviors. Further interview revealed she was "not for sure" if CNAs had access to residents' care plans. Interview, on 12/17/14 at 5:26 PM, with CNA #8 revealed CNA #1 never really ever gave residents an option when it came to their care, and CNA #1 was "kind of rough with" residents. Per interview, CNAs could use the Kardex, but she was "not sure" if it listed behavioral interventions on it. She stated the nurses were supposed to make copies of the Kardex for CNAs to carry with them; however, this was not done. CNA #8 stated the nurses had never really talked to the CNAs about Resident #1's behaviors or what to do if he/she had them. She stated CNAs did not have access to residents' care plans. Interview, on 12/17/14 at 6:30 PM, with CNA #6 revealed she had cared for Resident #1 before, and was aware he/she had behaviors of screaming out when he/she was changed; however, she stated Resident #1 was "in pain a lot". She stated she did not know what interventions CNAs were supposed to use with Resident #1 when this occurred, she just tried to talk calmly to him/her. CNA #6 revealed she had observed CNA #1 "yell" at residents before, including Resident #1, which she reported to the nurses who reported it to the DON. CNA #6 stated nothing was done though; however, if the DON had done something the 11/25/14 shower room incident might not have occurred. She stated CNAs used to have sheets which noted residents' care needs; however, CNAs hadn't had these sheets "for about two (2) months now". According to CNA #6, the computerized system gave CNAs information on the residents' "physical care needs", such as how to transfer, whether they were continent or incontinent or dietary status. CNA #6 stated it was hard to know what kind of care residents needed as nurses "never" gave CNAs report. She revealed the nurses "should do that though" so CNAs would know what the residents needed. Further interview revealed CNAs did not have access to residents' care plans; and, therefore, did not know what interventions were in place. Interview, on 12/17/14 at 5:41 PM and at 6:25 PM with Licensed Practical Nurse (LPN) #4 revealed CNAs had a Kardex to use for residents' care which they were supposed to "carry" with them at all times. She stated residents' Kardex's were printed out each night by the night shift nurses, and copies were stored in a drawer at the nurse's station. The LPN stated the CNAs got a copy of the Kardex at the beginning of their shift. LPN #4 stated however, the Kardex did not have interventions on them for the CNAs to know what to do for residents. Interview, on 12/17/14 at 9:25 PM with Registered Nurse (RN) #2 revealed CNAs had an "online" care plan to use for residents' care which the CNAs were supposed to "check" each day after they received their resident assignment. According to RN #2, she had cared for Resident #1 and he/she had behaviors of calling CNAs "foul" names at times. Per interview, CNAs did not "normally" get report from the nurses, but she did try to give them report if a resident was more confused than normal or if a urine or stool specimen needed to be obtained. She stated she didn't think the "online" care plan addressed residents' behaviors "specifically" and didn't know if the CNAs had access to interventions for residents with behaviors. However, she stated CNAs were trained on behaviors in their nurse aide training program, so they should know how to deal with residents' behaviors. Interview with the Minimum Data Set (MDS) Coordinator, on 12/18/14 at 11:44 AM, revealed upon admission nursing staff assessed residents and a basic care plan was developed after the assessment. The MDS Coordinator stated after twenty-one (21) days, the residents had a Comprehensive Care Plan developed with interventions to be implemented. Per interview, CNAs should follow their Kardex, which was their care plan for residents' care needs. She stated Resident #1 did not trigger for behaviors on the MDS Assessment; however, he/she was care planned for behaviors due to a past history of verbal behaviors. According to the MDS Coordinator, if a resident triggered for behaviors a care plan would be "active" for the behaviors and would be on the CNAs Kardex. However, as Resident #1 did not trigger for behaviors and his/her care plan was based on a history of behaviors, the nurses should have opened a User Defined Assessment (UDA) in the facility's computerized charting system which was "kind of" a short term care plan. She stated it was important for staff to know residents' care plan and follow the interventions, and CNAs should follow the Kardex for their residents. Further interview revealed Resident #1's behavior care plan interventions should have been on the Kardex because if he/she was "agitated" it was important staff know what to do. Interview with the Director of Nursing (DON), on 12/18/14 at 1:00 PM, revealed items triggered on the Comprehensive Care Plan might not always be on the CNAs Kardex, such as "behavior/mood". Continued interview revealed she reported she went over residents' care plans and interventions with nurses; however, she did not go over care plans and interventions with CNAs. The DON stated nurses reviewed residents' care plans with CNAs; however, this was not done every day. She revealed the CNAs could pull up residents' care plans through the facility's computerized charting system, Point Click Care (PCC). Per interview, she would expect CNAs would carry out interventions as they pertained to their residents' behaviors, as this was "common sense", and CNAs received training on how to deal with residents with behaviors. The DON stated residents' care plans were accessible to anyone as all they had to do was get on PCC to pull it up. She stated she did not believe CNA #1 followed Resident #1's care plan, but she should have done this. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 12/23/14 which alleged removal of the IJ effective 12/23/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was assessed by the DON on 11/26/14, regarding the occurrence in the shower. An RN performed a full skin assessment of Resident #1 on 11/26/14 with no findings related to the occurrence of 11/25/14. A Social Worker (SW) assessed Resident #1 on 11/26/14 and on 12/18/14 and provided support to the resident who voiced no concerns with the staff/shower incident and had no concerns of any other staff member abuse. A MDS Nurse completed a comprehensive assessment of Resident #1 on 12/19/14 and noted no concerns, nor any difficulties with late effects of the occurrence of 11/25/14. Resident #1's Comprehensive Care Plans and Kardex (CNA Care Plan), were verified on 12/20/14 by the DON to reflect individualized approaches to manage his/her behaviors. 2. On 12/19/14, each cognitively intact resident with a Brief Interview of Mental Status (BIMS) greater than or equal to eight (8) was observed and interviewed by the SW, Registered Dietician (RD), Activity Director and/or Director of Rehabilitation for resident concerns of any potential abuse, neglect or misappropriation. The findings of the interviews and observations were reported to the Administrator on 12/19/14. Any allegation/concern was immediately followed up on by the Administrator, with investigations completed, and notifications made, if indicated, by the Administrator. The findings were to be reported at the 12/22/14 Quality Assurance (QA) Committee meeting by the Business Office Coordinator. The SW was to continue to perform interviewable resident abuse observations and interviews weekly and report the findings to the QA team. 3. On 12/18/14 through 12/19/14, licensed nursing staff conducted head to toe assessments of each cognitively impaired resident, who had a BIMS less than eight (8) or was non-interviewable, for any new or unusual bruises, skin tears etc., or other signs of potential abuse. There were no findings that would trigger an allegation of abuse. The results of the head to toe assessments were reviewed by the DON and Administrator, and the findings reported at the 12/22/14 QA meeting by the DON. The Nursing Management Team which included the DON, ADON, Unit Managers and Team Leads would perform head to toe assessments of each cognitively impaired resident weekly for any new/unusual bruises, skin tears etc., or other signs of potential abuse, with no findings that required action at the time. 4. On 12/18/14 the facility's electronic charting system was modified by the Corporate Nurse to list/show interventions for residents' behaviors on the Kardex (nurse aide care plan). Each residents' Kardex was updated automatically. By 12/19/14 the Registered Nurse (RN)/MDS/Resident Assessment Instrument (RAI) Coordinator reviewed all residents care plans to ensure Behavior Comprehensive Care Plans were in place for each resident assessed to require one. 5. On 12/19/14, the Administrator, Corporate Compliance Officer (CCO) and Corporate Risk Manager (CRM) reviewed each file of resident allegations of abuse or facility self reports of potential abuse in the past thirty (30) days to assure completeness and thoroughness of the investigation. If there were any concerns/gaps identified, they were followed up accordingly by the Administrator. On 12/21/14, the Administrator, CCO and CRM reviewed additional investigation files which were generated by the facility's observations and interviews completed on 12/19/14 through 12/20/14. This included, but was not limited to: immediate removal of any alleged or perpetrating staff from any care area; immediate reporting to the Administrator; interview of resident and staff; assessment of the alleged victim; and review of the investigation action ensuring it met the policy and federal requirements. The Administrator took action, if any required. The alleged perpetrator, CNA #1 was terminated on 11/28/14 after the completion of the facility's investigation. 6. On 12/19/14 all personnel files were audited by the Business Officer Coordinator and Medical Records Director for completion of pre-hire components used by the facility as part of screening and prevention of abuse. The files were found to be one hundred percent (100%) compliant, with evidence of: current License verification; Abuse Registry Check Registration; Criminal Background Check; and Kentucky Caregiver Misconduct Registry check. The findings of the audit were reported to the Administrator on 12/19/14 and were to be reported to the QA Committee on 12/22/14, by the Business Office Coordinator. The Business Office Coordinator and Administrator would review each new hire personnel file to assure verifications and background checks were completed prior to beginning work. 7. The facility's Abuse/Neglect/Misappropriation of Property Policy was reviewed on 12/19/14, which was in place at the time of the survey, addressing concerns identified by surveyors, by comparing it to federal regulations and interpretive guidelines and the contents of the facility's policy. The facility's Abuse/Neglect/Misappropriation of Property Policy was revised on 12/19/14 by the Chief Operating Officer (COO), Vice President (VP) of Risk Management, and CCO. 8. On 12/19/14 the CCO inserviced the Administrator, DON, ADON, Unit Managers and each Department Head on the results of the survey, the facility's root-cause analysis of the deficiencies and the newly revised abuse policy and procedure. Additionally, on 12/19/14 the CCO inserviced each Department Head, in a "Train the Trainer" fashion, on the "Team Member" education which covered Abuse Prevention, Abuse Reporting, Investigations, Comprehensive Care Plans, Kardex (Nurse Aide Care Plans) and the revised policy. On 12/21/14 the CRM and CCO each provided additional education to the Administrator, DON, and Nursing Leadership Team on: review of federal regulations and interpretive guidelines for F223, F225, F226; additional review of the revision of the facility's policy on Abuse/Neglect/Misappropriation of Property; and root cause analysis of the survey findings related to systematic response to allegations. Evidence of the learning was measured via meaningful Question and Answer (Q & A) and discussion of cause examples and a repeat verbalization of understanding of definitions and the facility's system. 9. On 12/19/14 through 12/22/14 all staff including licensed Nurses, CNAs, licensed Therapists, Social Services, Activity, Dietary, Housekeeping, Business Office and Maintenance was provided inservice education, "Team Member" Education, by the CCO, Administrator, DON or Trained Department Head which covered Abuse Prevention, Abuse Reporting, Investigations, Comprehensive Care Plans, Kardex (Nurse Aide Care Plans) and reporting concerns immediately. The updated abuse policy was reviewed and referred to in all staff "Team Member" education in-services, performed from 12/19/14 through 12/22/14. Evidence of the staff member's learning was measured via a written post-test, with a 100% accuracy required. Any staff member who had not been at work, or was on leave or vacation would complete all education and training prior to working their next shift. No staff member would work without first being inserviced. All newly hired staff members would be provided inservice education on abuse prevention, identification and reporting during their orientation prior to working in the facility through the Interactive Computer Program with a post-test and review of the abuse policy signed for verification. The Business Office Coordinator would track completion. Annual mandatory inservice of abuse, including but not limited to prevention, would continue to be monitored by the Business Office Coordinator; additionally, as indicated by concerns or observations, impromptu inservices for staff would be held as decided by the Administrator, DON, and/or Ombudsman. Also, besides being directly taught to staff, the revised policy was placed in areas staff/team members typically congregate, take breaks and eat lunch. 10. Beginning on 12/20/14, a random observation and interview of staff members was begun by the Administrator, Corporate support staff and Department Heads. The observations and interviews were designed to detect if staff members were knowledgeable about prevention, reporting, investigation of abuse and how to locate and review the revised abuse policy. The facility was to perform interviews of at least twenty (20) staff members weekly until substantial compliance was obtained to ensure each allegation of abuse would be reported immediately by the staff to the DON or Administrator. If the DON or Administrator was not in the facility, staff would contact the DON or Administrator via phone for thorough/timely investigation and reporting. The Administrator would be notified immediately of any allegations. After substantial compliance was obtained, the QA team would determine the frequency of the staff interviews. The findings of each observation and interview developed for this Allegation of Compliance (AOC) were evidence of the operationalization of the facility's policy on abuse/neglect/misappropriation of property. All findings of observations and interviews would be reviewed by the QA Committee to ensure team members understood, implemented and operationalized the policy. 11. The QA team consists of the Medical Director, DON, Administrator and Department Heads. A QA meeting was held on 12/19/14 with the Medical Director, DON, Administrator and other members of the QA Committee. The findings of the State Survey Agency's findings, as well as, deficiencies, including the Scope and Severity, were discussed in the meeting. Action plans to address each deficiency, as well as, the overall system were developed and approved by the QA Committee. On 12/22/14, a second full QA Committee meeting was held to review the action plans to remove the Immediate Jeopardy. Findings of all observations and interviews, compliance with inservicing and results of monitoring were analyzed and discussed. The findings would be reported by the DON, Administrator or Social Service Director and followed by each with Committee recommendations. QA meetings would take place weekly, until the facility was in substantial compliance, and when that occurred the QA Committee would decide on the frequency of meetings with a minimum of quarterly, in order to keep the facility in substantial compliance. 12. From 12/19/14 through 12/22/14, the DON, ADON, Corporate RN, RN Managers and/or Team Lead Nurses provided additional inservice/education to the Nursing staff and Interdisciplinary Team (IDT) on the Comprehensive Care Plan and communication of interventions to the Kardex/Nurse Aide Care Plan for implementation. Included in this training was the importance of accessing the Kardex, communicating changes needed to maintain an accurate and updated Plan of Care, including the Kardex, for each of the facility's residents. 13. On 12/19/14 through 12/22/14, the RN/MDS/RAI Coordinator, MDS Licensed Nurses, the Corporate RN, and/or Social Service Director reviewed each residents' care plan for Behavior to assure interventions were appropriate and flowed automatically to the Kardex (nurse aide care plan) based on feedback and assessment by the direct care staff which included the CNAs, licensed Nurses, Unit Managers and Social Service Director. The care plans were updated as indicated. The findings were reviewed with the DON and Administrator on 12/22/14 and would be reported to the QA Committee on 12/22/14 by the DON. The Kardex's were to be reviewed and updated daily by the Charge Nurses, Unit Managers, MDS Nurses, Team Lead Nurses and/or Therapists to assure they were current and provided appropriate interventions for each resident. The Kardex was to be printed off each day by the Charge Nurse and a copy of the Kardex given to the CNAs. The Kardex copy and verbal report from the nurse was given to each CNA to ensure the direct care staff was aware of the interventions in place for each of the facility's residents. If the Kardex was not current, licensed staff would update it and assure the CNA had the updated copy. CNAs were made aware they were to communicate verbally or via the Kardex to the nurses any concerns or need for further assessment or update of the resident's care plan/Kardex. Resident #1's Kardex was reviewed by the Charge Nurse for changes of the Plan of Care for the resident. Observation and interview rounds will be completed by the Administrator, DON, Unit Manager, Team Lead Nurses and/or licensed Clinical Department Heads to ensure each direct care staff person had the Kardex copy on their person and was able to use it. Results of the observations and interviews would be reported to the DON. The DON would report the findings at the 12/22/14 QA meeting. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of Resident #1's skin assessment, dated 11/26/14, revealed no open areas or bruising noted. Review of the Social Services Note, dated 12/19/14 revealed a late entry from the Social Worker to address her interview with the resident on 11/26/14 to discuss the incident/alleged abuse on 11/25/14. Continued review of the Social Service Notes, dated 12/18/14 and 12/19/14, revealed the Social Service Director followed up with the resident to assess Resident #1's psychosocial well-being. Review of Resident #1's Comprehensive Assessment, dated 12/19/14, revealed the resident was assessed by Licensed Practical Nurse (LPN) #7/MDS Nurse with no concerns identified. Review of Resident #1's Kardex revealed a Behavior/Mood care plan was added to the Kardex. Review of Resident #1's Comprehensive Care Plan revealed the resident's care plan was revised on 12/19/14 for staff to analyze key times, places, circumstances, triggers, and what de-escalated his/her behavior and document the information, as the resident was noted to have increased anxiety with showers and when his/her spouse had left for the day. Interview with the DON, on 12/24/14 at 10:23 AM, revealed Resident #1 was assessed "that night" (11/25/14) and Social Services continued to follow up with the resident. She stated Resident #1 resident was assessed again on 12/18/14 and his/her care plan was updated/revised. She reported she reviewed the resident's updated/revised care plan and verified it was complete regarding the changes that needed to be reflected on his/her care plan. She further stated the CNAs' Kardex had been updated with the changes. Continued interview with the DON revealed the SSD also assessed the resident on 12/18/14 and had been following up with the resident by reviewing his/her care plan. Interview with the SSD, on 12/24/14 at 10:05 AM, revealed she talked to Resident #1 on 12/18/14, and had followed up with him/her since. Continued interview revealed Resident #1's care plan was updated related to his/her behavior and bathing. 2. Review of the facility's Resident Rights/Abuse Prevention/Comprehensive Care Plans Audit Worksheets, dated 12/18/14 and 12/19/14, revealed residents with a BIMS score of eight (8) or higher were interviewed by the Director of Social Service, RD, Activity Director and/or Director of Rehabilitation. Two (2) residents, Unsampled Resident A and Unsampled Resident B, who also resided on Resident #1's unit expressed concerns on 12/21/14, regarding staff, these concerns were not abuse related. The residents' concerns were related to staff not being able to work together to provide care, and staff not taking the time to talk to them. Continued review of the audit revealed the Administrator followed up with the two (2) residents on 12/22/14. Interview on 12/24/14, with Unsampled Resident A at 9:30 AM and Unsampled Resident B at 9:40 AM, revealed they were questioned by staff regarding any concerns they had of abuse by staff; however, neither resident expressed concerns regarding abuse. Interview with the Social Services Director, on 12/24/14 at 10:05 AM, revealed she interviewed all of the interviewable residents with a BIMS score of eight (8) or higher on all the facility's units. She reported there were no concerns of abuse given. The Social Services Director stated the Administrator followed up on some residents' concerns which were not related to abuse. Per interview, the interviewable residents would continue to be interviewed regarding any abuse concerns, and observations performed at the time of interview to ensure the residents had no signs or symptoms of abuse. Interview, on 12/23/14 at 3:19 PM, with the Business Office Coordinator revealed the findings of the audits were reported

Based on interview, record review and review of the facility's Incident Reports/Investigation documents, Resident Rights document and facility policy and procedures, it was determined the facility failed to have an effective system to ensure each resident remained free from abuse for one (1) of three (3) sampled residents (Resident #1). On 11/25/14 between 3:30 PM and 4:00 PM, Certified Nursing Assistant (CNA) #1 was assisting Resident #1 with his/her shower, and was observed by CNA #2 and Nurse Aide in Training (NAT) #1 to intentionally spray the resident in the face with hot and cold water. Although, both staff observed the alleged abuse, neither staff reported it immediately. Therefore, CNA #1 continued working caring for Resident #1 and other residents on the unit. At approximately 6:00 PM, NAT #1 told CNA #4 about the alleged abuse of Resident #1 in the shower, and CNA #4 reported the incident to Licensed Practical Nurse (LPN) #1. LPN #1 informed the Director of Nursing (DON) and CNA #1 was removed from resident care, interviewed and escorted to clock out from work at 7:05 PM, approximately three (3) to three and a half (3.5) hours after the incident occurred. The facility's failure to ensure an effective system in place to ensure each resident remained free from abuse, was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 12/18/14, and determined to exist on 11/25/14. The facility was notified of the Immediate Jeopardy on 12/18/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/23/14, with the facility alleging removal of the Immediate Jeopardy on 12/23/14. The Immediate Jeopardy was verified to be removed on 12/23/14, as alleged, with remaining non-compliance in the area of 42 CFR 483.13 Resident Behavior and Facility Practice, F 223 at a Scope and Severity of a "D" while the facility develops and implements a Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, "Abuse/Neglect/Misappropriation of Property", revised October 2014, revealed the definition of "abuse" was the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. "Physical abuse" was defined to include controlling behavior through corporal punishment. Review of the facility's "Nursing Home Residents Bill of Rights and Responsibilities", undated, revealed all residents would be free from mental and physical abuse. Review of the facility's "Self-Reported Incident Form, Initial Report" dated 11/25/14, completed by the DON, revealed a staff member reported CNA #1 sprayed Resident #1 "in the face with water" while giving the resident a shower. Per the Initial Report, Resident #1 was alert and oriented with occasional forgetfulness/confusion, and the resident was assessed with [REDACTED]. Further review of the Initial Report revealed CNA #1 was "sent home and removed from the schedule pending investigation". Review of the facility's "Self-Reported Incident Form, 5 Day Follow-up/Final Report" document, dated 11/28/14, revealed CNA #1 was "clocked out" after two (2) other staff members "reported the issue". Per the 5 Day Follow-up/Final Report document, CNA #1 and two (2) other "witnesses" submitted statements regarding the incident. The two (2) "witnesses" had the "same general statement" that CNA #1 "intentionally" sprayed water in Resident #1's face. Further review revealed nursing performed a skin assessment of Resident #1 with "no ill effects from the water being sprayed" in his/her face. Per the report, the Administrator and DON met with the two (2) witnesses (NAT #1 and CNA #2) again and both "felt" CNA #1 "intentionally sprayed" Resident #1 in the face. CNA #1 was terminated "upon final investigation on 11/28/14". Record review revealed the facility admitted Resident #1 on 01/21/13, with [DIAGNOSES REDACTED]. Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 10/21/14, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated moderate cognitive impairment. Review of Resident #1's statement, documented by the Social Worker (SW), dated 11/26/14, revealed the resident reported to the SW that two (2) aides, one (1) male and one (1) female took him/her to the shower room for his/her scheduled shower. Per the statement, Resident #1 reported the aide took the shower head and sprayed him/her "directly" in the face. Review revealed when Resident #1 asked her (the aide) to stop, the resident reported the female aide laughed at him/her and continued to spray him/her. Further review revealed once "she stopped", the aide proceeded with the shower and then returned Resident #1 to his/her room. Interview with Resident #1 on 12/17/14 at 4:58 PM, revealed he/she recalled the shower incident on 11/25/14. Resident #1 stated CNA #1 was spraying him/her in the face with "ice cold" water with a shower hose. Per interview, CNA #1 said something "not nice" to him/her during the shower which made him/her "feel bad"; however, he/she could not recall what was said. Resident #1 stated he/she told CNA #1 he/she would not put up with that "shit", and he/she fought back. According to Resident #1, the shower incident made him feel "terrible", and he/she believed he/she told the "head nurse" about the incident, but was not certain of the nurse's name. Review of CNA #2's written statement dated 11/25/14 at 6:15 PM, revealed CNA #1 "intentionally" sprayed Resident #1 in the face with water from the shower hose. Continued review of the statement revealed the incident/alleged abuse occurred on 11/25/14 at "4:30ish" PM. CNA #2 revealed CNA #1 was giving Resident #1 a shower and she was assisting as the resident sometimes had behaviors. CNA #2 reported CNA #1 was not paying attention and accidentally sprayed Resident #1 in the face again. The resident then started to call her names and swung his/her fist at her so she sprayed him/her in the face again. CNA #2 reported CNA #1 did this until the shower was finished. Interview with CNA #2 on 12/16/14 at 5:25 PM and on 12/17/14 at approximately 3:30 PM, revealed she worked the 3:00 PM to 11: 00 PM shift, and had worked on 11/25/14. She stated on 11/25/14, she was assisting CNA #1 in giving Resident #1 his/her shower, and the resident was agitated prior to the shower. Per interview, Resident #1 called CNA #1 a "nasty name", and CNA #1 then turned the shower water on cold. CNA #2 stated Resident #1 yelled, "stop, I don't like that....it's cold". According to CNA #2, NAT #1 told CNA #1 "that was not okay", and then left the shower room. CNA #2 revealed Registered Nurse (RN) #1, who was her immediate supervisor, completed a skin assessment on Resident #1 after the shower was completed, sometime between 3:30 PM to 4:30 PM. She revealed even though she thought the incident was abusive she did not report it to her supervisor, RN #1, because she was "non-confrontational". She stated she later realized she should have reported it. CNA #2 reported Resident #1 was taken back to his/her room where she remained with the resident while CNA #1 continued to answer call lights on the unit. Review of CNA #1's written statement dated 11/25/14 at 6:59 PM, revealed the alleged abuse occurred on 11/25/14 at 4:00 PM. Per CNA #1's written statement Resident #1 was yelling and hitting her and grabbed at the shower head continually causing it to fall and get everything wet. Continued review of the statement revealed CNA #1 and CNA #2 washed Resident #1, rinsed him/her and the "skin nurse" (RN #1) performed a routine skin assessment. Continued review of the statement revealed that once the resident was washed and rinsed off me, CNA #2, and the skin nurse (RN #1) dried him/her off, put on his/her clothes and assisted him/her back to his/her wheelchair. After that, he/she was pushed to in the hallway by CNA #2. Interview with CNA #1, on 12/17/14 at 2:35 PM revealed on 11/25/14 she had given Resident #1 a shower; however, was not certain of the time. She revealed Resident #1 becomes combative when being given a shower, and was combative that day when staff put him/her into the wheelchair to take him/her to the shower room. CNA #1 revealed she asked NAT #1 to assist her with putting Resident #1 in the shower chair. She stated the water in the shower room was always too hot or too cold. Per interview, as she was giving Resident #1 his/her shower water got all over her and NAT #1 thought it was funny. She stated NAT #1 then gave Resident #1 the shower head and the resident started spraying her. Continued interview revealed she told NAT #1 to leave the shower room because he was not being helpful. CNA #1 revealed after Resident #1's shower, RN #1 assessed his/her skin, and then she and CNA #2 assisted the resident in getting dressed and pushed him/her to the dining area for dinner. CNA #1 reported she was assigned to work with CNA #2 on the same hall that day. CNA #1 revealed she worked from 11:00 AM to 7:00 PM on 11/25/14, and was not aware there was a concern regarding her care of Resident #1 until the DON approached her when she was getting ready to leave for the day. She stated she thought it was "almost 7:00 PM" when this happened, and the DON told her a report had been made against her. According to CNA #1, the DON had her write a statement concerning the allegations, and she did not return to work as she was terminated on 11/28/14. Review of CNA #1's timecard revealed on 11/25/14: she clocked in to work at 10:56 AM; clocked out at 3:17 PM; clocked back in at 3:47 PM; clocked out from work at 7:05 PM. Review of Registered Nurse (RN) #1's written statement dated 11/26/14 at 1:00 PM, revealed the alleged abuse occurred on 11/25/14 at approximately 4:30 PM. Review revealed RN #1 spoke with Resident #1 regarding the shower he/she received on 11/25/14, and the resident reported it was "terrible". Continued review revealed Resident #1 told RN #1 the aide giving him/her the shower, squirted him/her in the face with the water hose, then laughed after doing so. Per RN #1's written statement, Resident #1 stated there were three (3) aides assisting him/her with the shower, but did not know their names. Interview with RN #1, on 12/16/14 at 4:27 PM, revealed she worked 11/25/14 until about 5:30 or 6:00 PM. RN #1 stated she conducted a routine skin assessment of Resident #1 after his/her shower that day. Per interview, CNA #1 and CNA #2 were in the shower room with Resident #1 when she entered to perform the routine skin assessment. RN #1 stated CNA #2 did not report the alleged abusive incident to her that day, and neither did NAT #1. She stated she was not aware of the shower incident until the next day, 11/26/14, when it was requested she conduct another skin assessment on Resident #1 to ensure he/she was free from any bruising. Continued interview with RN #1 revealed she would have expected CNA #2 and NAT #1 to have reported the alleged abuse when they witnessed it. Review of NAT #1's written statement dated 11/25/14 at 7:15 PM, revealed the incident/alleged abuse occurred on 11/25/14 at 4:00 PM. Review revealed he felt Resident #1 was sprayed in the face with hot water by CNA #1 because he/she would not comply with her. Per NAT #1's written statement, he heard Resident #1 scream, "stop spraying my face, you are burning me", and when he turned around CNA #1 was spraying the resident with hot water in the face. NAT #1's written statement revealed he heard CNA #1 tell Resident #1 to "stop fighting me and this wouldn't happen", and then CNA #1 turned the water in the shower to warm. Continued review revealed he told CNA #1 to not do that and to "be good" to Resident #1, and he gave the resident control of the shower. Per NAT #1's written statement, CNA #1 told him to "get the [***] out of here", and he left the shower room. Interview, on 12/17/14 at 1:09 PM, with NAT #1 revealed he worked on 11/25/14, and was assigned on the rehabilitation (rehab) hall of the unit. He stated CNA #1 came and asked him to assist with getting Resident #1 into the shower, not too long after he clocked in around 3:00 PM. NAT #1 revealed he assisted with getting Resident #1 into the shower and stayed in the shower room to assist with transferring the resident back into the wheelchair after the shower. Per interview, CNA #1, CNA #2 and himself were in the room during the resident's shower, and he saw CNA #1 spraying water into Resident #1's face. NAT #1 reported he heard Resident #1 yell over and over again, "stop you're burning me". According to NAT #1, CNA #1 stated to Resident #1 if he/she "would just listen to" her, she "wouldn't have to do this." NAT #1 revealed he told CNA #1 to "stop" spraying Resident #1 in the face with the water, and CNA #1 stopped and told him to come and "do it" (shower the resident). The NAT stated he turned the water to a comfortable temperature which was not "so" hot, and handed the shower head to the resident to use. He stated CNA #1 then told him to get the "[***] " out of the shower room. Continued interview revealed he told CNA #1 to "be good to Resident #1", and left the shower room to return to work on the rehab hall. Per interview, at "around 5:30 PM" he told CNA #4 what had occurred in the shower room, and she told him the incident was "unacceptable" and should be reported. He stated he went to lunch and when he returned to the unit CNA #4 had already reported the incident to the DON. NAT #1 stated he felt the shower room incident involving Resident #1 was abuse now; however, the facility had not given him much training on abuse prior to the incident. Review of CNA #4's written statement dated 11/25/14 at 6:59 PM, revealed the incident/alleged abuse occurred earlier that day at 4:00 PM. Review revealed NAT #1 told her another "team member" (CNA #1) sprayed hot water in Resident #1's face. Continued review revealed NAT #1 told her CNA #1 was giving Resident #1 a shower and sprayed water in the resident's face. Interview with CNA #4, on 12/17/14 at 11:20 AM, revealed NAT #1 came to her after she clocked in for work at about 5:30 PM to 5:45 PM. Per interview, NAT #1 told her what had occurred in the shower during Resident #1's shower. She stated NAT #1 told her CNA #1 squirted cold and hot water in Resident #1's face. CNA #4 she told NAT #1 "that was called abuse", and he needed to tell the nurse, LPN #1. Continued interview revealed NAT #1 told her he would tell the Administrator and left to go on his lunch break. She revealed she reported the incident to LPN #1 herself because she didn't want it on her "conscience". Additional interview with CNA #4 revealed she had observed CNA #1 yell at a resident before which she thought was abusive; however, she did not report it, but should have. Interview with LPN #1, on 12/16/14 at 5:43 PM, revealed she worked on 11/25/14, and thought CNA #4 reported the alleged abuse to her somewhere between 5:30 PM and 6:00 PM, when she was administering evening medications. Continued interview revealed CNA #4 told her NAT #1 was upset over observing CNA #1 spraying Resident #1 in the face with water from the shower hose. LPN #1 stated she went immediately and reported the incident to the DON. Per interview, the DON asked her if she had removed CNA #1 from resident care and she told the DON she had not. LPN #1 stated the DON pulled CNA #1 from resident care to discuss the allegations with her. Interview with the DON on 12/18/14 at 1:00 PM, revealed on 11/25/14, LPN #1 came to her office "around 6ish", and reported NAT #1 told CNA #4 about an alleged abuse involving Resident #1 and CNA #4 had informed her. Per interview, LPN #1 stated CNA #4 told her she told NAT #1 he needed to report the alleged abuse incident to the DON. Continued interview revealed the DON removed CNA #1 from resident care, and asked her if she had given Resident #1 a shower earlier that day and if so, had anything unusual had happened. She stated CNA #1 denied intentionally spraying Resident #1 in the face with water during the shower. Per interview, she spoke to Resident #1 later on that day to ensure he/she was okay. According to the DON, in this case, CNA #2 stayed with Resident #1 to ensure his/her safety. She revealed however, she did not have an answer regarding how all other residents, receiving care from CNA #1, were protected from abuse. Interview with the Administrator, on 12/18/14 at approximately 2:06 PM, revealed the DON called him somewhere between 6:00 PM and 7:00 PM, after he had left the facility, and informed him of the alleged abuse. He stated on 11/26/14, he had CNA #1 come to his office to verify her statement and told her she was suspended pending the investigation results. Continued interview revealed he then followed up with NAT #1 and CNA #2, who both believed CNA #1's actions were intentional when she sprayed water in Resident #1's face. Per interview, CNA #1 was terminated on 11/28/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 12/23/14 which alleged removal of the IJ effective 12/23/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was assessed by the DON on 11/26/14, regarding the occurrence in the shower. An RN performed a full skin assessment of Resident #1 on 11/26/14 with no findings related to the occurrence of 11/25/14. A Social Worker (SW) assessed Resident #1 on 11/26/14 and on 12/18/14 and provided support to the resident who voiced no concerns with the staff/shower incident and had no concerns of any other staff member abuse. A MDS Nurse completed a comprehensive assessment of Resident #1 on 12/19/14 and noted no concerns, nor any difficulties with late effects of the occurrence of 11/25/14. Resident #1's Comprehensive Care Plans and Kardex (CNA Care Plan), were verified on 12/20/14 by the DON to reflect individualized approaches to manage his/her behaviors. 2. On 12/19/14, each cognitively intact resident with a Brief Interview of Mental Status (BIMS) greater than or equal to eight (8) was observed and interviewed by the SW, Registered Dietician (RD), Activity Director and/or Director of Rehabilitation for resident concerns of any potential abuse, neglect or misappropriation. The findings of the interviews and observations were reported to the Administrator on 12/19/14. Any allegation/concern was immediately followed up on by the Administrator, with investigations completed, and notifications made, if indicated, by the Administrator. The findings were to be reported at the 12/22/14 Quality Assurance (QA) Committee meeting by the Business Office Coordinator. The SW was to continue to perform interviewable resident abuse observations and interviews weekly and report the findings to the QA team. 3. On 12/18/14 through 12/19/14, licensed nursing staff conducted head to toe assessments of each cognitively impaired resident, who had a BIMS less than eight (8) or was non-interviewable, for any new or unusual bruises, skin tears etc., or other signs of potential abuse. There were no findings that would trigger an allegation of abuse. The results of the head to toe assessments were reviewed by the DON and Administrator, and the findings reported at the 12/22/14 QA meeting by the DON. The Nursing Management Team which included the DON, ADON, Unit Managers and Team Leads would perform head to toe assessments of each cognitively impaired resident weekly for any new/unusual bruises, skin tears etc., or other signs of potential abuse, with no findings that required action at the time. 4. On 12/18/14 the facility's electronic charting system was modified by the Corporate Nurse to list/show interventions for residents' behaviors on the Kardex (nurse aide care plan). Each residents' Kardex was updated automatically. By 12/19/14 the Registered Nurse (RN)/MDS/Resident Assessment Instrument (RAI) Coordinator reviewed all residents care plans to ensure Behavior Comprehensive Care Plans were in place for each resident assessed to require one. 5. On 12/19/14, the Administrator, Corporate Compliance Officer (CCO) and Corporate Risk Manager (CRM) reviewed each file of resident allegations of abuse or facility self reports of potential abuse in the past thirty (30) days to assure completeness and thoroughness of the investigation. If there were any concerns/gaps identified, they were followed up accordingly by the Administrator. On 12/21/14, the Administrator, CCO and CRM reviewed additional investigation files which were generated by the facility's observations and interviews completed on 12/19/14 through 12/20/14. This included, but was not limited to: immediate removal of any alleged or perpetrating staff from any care area; immediate reporting to the Administrator; interview of resident and staff; assessment of the alleged victim; and review of the investigation action ensuring it met the policy and federal requirements. The Administrator took action, if any required. The alleged perpetrator, CNA #1 was terminated on 11/28/14 after the completion of the facility's investigation. 6. On 12/19/14 all personnel files were audited by the Business Officer Coordinator and Medical Records Director for completion of pre-hire components used by the facility as part of screening and prevention of abuse. The files were found to be one hundred percent (100%) compliant, with evidence of: current License verification; Abuse Registry Check Registration; Criminal Background Check; and Kentucky Caregiver Misconduct Registry check. The findings of the audit were reported to the Administrator on 12/19/14 and were to be reported to the QA Committee on 12/22/14, by the Business Office Coordinator. The Business Office Coordinator and Administrator would review each new hire personnel file to assure verifications and background checks were completed prior to beginning work. 7. The facility's Abuse/Neglect/Misappropriation of Property Policy was reviewed on 12/19/14, which was in place at the time of the survey, addressing concerns identified by surveyors, by comparing it to federal regulations and interpretive guidelines and the contents of the facility's policy. The facility's Abuse/Neglect/Misappropriation of Property Policy was revised on 12/19/14 by the Chief Operating Officer (COO), Vice President (VP) of Risk Management, and CCO. 8. On 12/19/14 the CCO inserviced the Administrator, DON, ADON, Unit Managers and each Department Head on the results of the survey, the facility's root-cause analysis of the deficiencies and the newly revised abuse policy and procedure. Additionally, on 12/19/14 the CCO inserviced each Department Head, in a "Train the Trainer" fashion, on the "Team Member" education which covered Abuse Prevention, Abuse Reporting, Investigations, Comprehensive Care Plans, Kardex (Nurse Aide Care Plans) and the revised policy. On 12/21/14 the CRM and CCO each provided additional education to the Administrator, DON, and Nursing Leadership Team on: review of federal regulations and interpretive guidelines for F223, F225, F226; additional review of the revision of the facility's policy on Abuse/Neglect/Misappropriation of Property; and root cause analysis of the survey findings related to systematic response to allegations. Evidence of the learning was measured via meaningful Question and Answer (Q & A) and discussion of cause examples and a repeat verbalization of understanding of definitions and the facility's system. 9. On 12/19/14 through 12/22/14 all staff including licensed Nurses, CNAs, licensed Therapists, Social Services, Activity, Dietary, Housekeeping, Business Office and Maintenance was provided inservice education, "Team Member" Education, by the CCO, Administrator, DON or Trained Department Head which covered Abuse Prevention, Abuse Reporting, Investigations, Comprehensive Care Plans, Kardex (Nurse Aide Care Plans) and reporting concerns immediately. The updated abuse policy was reviewed and referred to in all staff "Team Member" education in-services, performed from 12/19/14 through 12/22/14. Evidence of the staff member's learning was measured via a written post-test, with a 100% accuracy required. Any staff member who had not been at work, or was on leave or vacation would complete all education and training prior to working their next shift. No staff member would work without first being inserviced. All newly hired staff members would be provided inservice education on abuse prevention, identification and reporting during their orientation prior to working in the facility through the Interactive Computer Program with a post-test and review of the abuse policy signed for verification. The Business Office Coordinator would track completion. Annual mandatory inservice of abuse, including but not limited to prevention, would continue to be monitored by the Business Office Coordinator; additionally, as indicated by concerns or observations, impromptu inservices for staff would be held as decided by the Administrator, DON, and/or Ombudsman. Also, besides being directly taught to staff, the revised policy was placed in areas staff/team members typically congregate, take breaks and eat lunch. 10. Beginning on 12/20/14, a random observation and interview of staff members was begun by the Administrator, Corporate support staff and Department Heads. The observations and interviews were designed to detect if staff members were knowledgeable about prevention, reporting, investigation of abuse and how to locate and review the revised abuse policy. The facility was to perform interviews of at least twenty (20) staff members weekly until substantial compliance was obtained to ensure each allegation of abuse would be reported immediately by the staff to the DON or Administrator. If the DON or Administrator was not in the facility, staff would contact the DON or Administrator via phone for thorough/timely investigation and reporting. The Administrator would be notified immediately of any allegations. After substantial compliance was obtained, the QA team would determine the frequency of the staff interviews. The findings of each observation and interview developed for this Allegation of Compliance (AOC) were evidence of the operationalization of the facility's policy on abuse/neglect/misappropriation of property. All findings of observations and interviews would be reviewed by the QA Committee to ensure team members understood, implemented and operationalized the policy. 11. The QA team consists of the Medical Director, DON, Administrator and Department Heads. A QA meeting was held on 12/19/14 with the Medical Director, DON, Administrator and other members of the QA Committee. The findings of the State Survey Agency's findings, as well as, deficiencies, including the Scope and Severity, were discussed in the meeting. Action plans to address each deficiency, as well as, the overall system were developed and approved by the QA Committee. On 12/22/14, a second full QA Committee meeting was held to review the action plans to remove the Immediate Jeopardy. Findings of all observations and interviews, compliance with inservicing and results of monitoring were analyzed and discussed. The findings would be reported by the DON, Administrator or Social Service Director and followed by each with Committee recommendations. QA meetings would take place weekly, until the facility was in substantial compliance, and when that occurred the QA Committee would decide on the frequency of meetings with a minimum of quarterly, in order to keep the facility in substantial compliance. 12. From 12/19/14 through 12/22/14, the DON, ADON, Corporate RN, RN Managers and/or Team Lead Nurses provided additional inservice/education to the Nursing staff and Interdisciplinary Team (IDT) on the Comprehensive Care Plan and communication of interventions to the Kardex/Nurse Aide Care Plan for implementation. Included in this training was the importance of accessing the Kardex, communicating changes needed to maintain an accurate and updated Plan of Care, including the Kardex, for each of the facility's residents. 13. On 12/19/14 through 12/22/14, the RN/MDS/RAI Coordinator, MDS Licensed Nurses, the Corporate RN, and/or Social Service Director reviewed each residents' care plan for Behavior to assure interventions were appropriate and flowed automatically to the Kardex (nurse aide care plan) based on feedback and assessment by the direct care staff which included the CNAs, licensed Nurses, Unit Managers and Social Service Director. The care plans were updated as indicated. The findings were reviewed with the DON and Administrator on 12/22/14 and would be reported to the QA Committee on 12/22/14 by the DON. The Kardex's were to be reviewed and updated daily by the Charge Nurses, Unit Managers, MDS Nurses, Team Lead Nurses and/or Therapists to assure they were current and provided appropriate interventions for each resident. The Kardex was to be printed off each day by the Charge Nurse and a copy of the Kardex given to the CNAs. The Kardex copy and verbal report from the nurse was given to each CNA to ensure the direct care staff was aware of the interventions in place for each of the facility's residents. If the Kardex was not current, licensed staff would update it and assure the CNA had the updated copy. CNAs were made aware they were to communicate verbally or via the Kardex to the nurses any concerns or need for further assessment or update of the resident's care plan/Kardex. Resident #1's Kardex was reviewed by the Charge Nurse for changes of the Plan of Care for the resident. Observation and interview rounds will be completed by the Administrator, DON, Unit Manager, Team Lead Nurses and/or licensed Clinical Department Heads to ensure each direct care staff person had the Kardex copy on their person and was able to use it. Results of the observations and interviews would be reported to the DON. The DON would report the findings at the 12/22/14 QA meeting. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of Resident #1's skin assessment, dated 11/26/14, revealed no open areas or bruising noted. Review of the Social Services Note, dated 12/19/14 revealed a late entry from the Social Worker to address her interview with the resident on 11/26/14 to discuss the incident/alleged abuse on 11/25/14. Continued review of the Social Service Notes, dated 12/18/14 and 12/19/14, revealed the Social Service Director followed up with the resident to assess Resident #1's psychosocial well-being. Review of Resident #1's Comprehensive Assessment, dated 12/19/14, revealed the resident was assessed by Licensed Practical Nurse (LPN) #7/MDS Nurse with no concerns identified. Review of Resident #1's Kardex revealed a Behavior/Mood care plan was added to the Kardex. Review of Resident #1's Comprehensive Care Plan revealed the resident's care plan was revised on 12/19/14 for staff to analyze key times, places, circumstances, triggers, and what de-escalated his/her behavior and document the information, as the resident was noted to have increased anxiety with showers and when his/her spouse had left for the day. Interview with the DON, on 12/24/14 at 10:23 AM, revealed Resident #1 was assessed "that night" (11/25/14) and Social Services continued to follow up with the resident. She stated Resident #1 resident was assessed again on 12/18/14 and his/her care plan was updated/revised. She reported she reviewed the resident's updated/revised care plan and verified it was complete regarding the changes that needed to be reflected on his/her care plan. She further stated the CNAs' Kardex had been updated with the changes. Continued interview with the DON revealed the SSD also assessed the resident on 12/18/14 and had been following up with the resident by reviewing his/her care plan. Interview with the SSD, on 12/24/14 at 10:05 AM, revealed she talked to Resident #1 on 12/18/14, and had followed up with him/her since. Continued interview revealed Resident #1's care plan was updated related to his/her behavior and bathing. 2. Review of the facility's Resident Rights/Abuse

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure after an allegation of abuse was immediately reported and a thorough investigation was conducted to include interviewing all interviewable residents on the unit, interviewing all staff working on the unit at the time of the allegation and ensuring assessment of all non-interviewable residents on the unit for one (1) of four (4) sampled residents (Resident #1). On 11/25/14, Resident #1 was taken to the shower somewhere between 3:30 PM and 4:00 PM. Three (3) staff were present in the shower room with Resident #1, who included Certified Nursing Assistant (CNA) #1, Nurse Aide in Training (NAT) #1 and CNA #2. CNA #2 and NAT #1 witnessed CNA #1 intentionally spray Resident #1 in the face with hot and cold water. However, CNA #2 and NAT #1 did not report the alleged abuse until approximately 6:00 PM which allowed CNA #1 to continue caring for Resident #1 and other residents on the unit. NAT #1 informed CNA #4 of what he had witnessed and CNA #4 reported the alleged abuse to Licensed Practical Nurse (LPN) 1, who then reported it to the Director of Nursing (DON). The DON initiated an investigation which included assessment of Resident #1 and interviews with the resident, NAT #1, CNA #2 and CNA #1. However, the facility's investigation did not include: assessment of all non-interviewable residents for potential harm or injuries of unknown origin; interviews with all interviewable residents; and interviews with all staff working on the unit at the time of the alleged abuse. CNA #1 was removed from resident care after the DON became aware of the alleged abuse. CNA #1 clocked out of work from the facility at 7:05 PM. (Refer to F223 and F226) The facility's failure to ensure an effective system was in place to ensure a thorough investigation was conducted to include interviewing all interviewable residents on the unit, interviewing all staff working on the unit at the time of the allegation and ensuring assessment of all non-interviewable residents on the unit was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 12/18/14, and determined to exist on 11/25/14. The facility was notified of the Immediate Jeopardy on 12/18/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/23/14, with the facility alleging removal of the Immediate Jeopardy on 12/23/14. The Immediate Jeopardy was verified to be removed on 12/23/14, as alleged, with remaining non-compliance in the area of 42 CFR 483.13 Resident Behavior and Facility Practice at a Scope and Severity of a "D" while the facility develops and implements a Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, "Abuse/Neglect/Misappropriation of Property", revised October 2014, revealed when an incident or occurrence had been identified as abuse, neglect or misappropriation and investigation would immediately follow. Review of the "Identification" section of the Policy revealed when a staff member suspected abuse had occurred against a resident they must report the incident to their immediate supervisor an investigation would be immediately initiated. The Policy revealed the investigation was to include interviews with all appropriate staff, residents, family or visitors who might have information concerning the incident. However, further review of the Policy revealed it did not address specific measures to ensure a thorough investigation was conducted, e.g. conducting physical assessments of all vulnerable non-interviewable residents. Review of the facility's Self-Reported Initial Report Incident form dated 11/25/14, revealed a staff member reported CNA #1 sprayed Resident #1 in the face with water while giving him/her a shower. Review of the facility's "5 Day Follow-up/Final Report" form dated 11/28/14, revealed two (2) staff witnessed the alleged abuse of Resident #1, and "had the same general statement" that CNA #1 "intentionally sprayed water in the resident's face". Review of the facility's investigation of the incident, attached to the "5 Day Follow-up/Final Report" form, revealed Resident #1's statement dated 11/26/14 at 10:03 AM, which noted the resident reported a female aide took the shower head and sprayed him/her directly in the face with water. Per Resident #1's statement, when he/she asked the female aide to stop, she laughed at him/her and continued to spray him/her. Review of NAT #1's written statement dated 11/25/14 at 7:15 PM, revealed on 11/25/14 at 4:00 PM, Resident #1 was being given a shower and was sprayed in the face with hot water by CNA #1, and the resident screamed "stop spraying my face, you are burning me". Review of CNA #2's written statement dated 11/25/14 at 6:15 PM, revealed CNA #1 "intentionally" sprayed Resident #1 in the face with water at approximately 4:30 PM. In addition, the 5 Day Follow-up/Final Report form revealed the Administrator and DON met with the two (2) witnesses (NAT #1 and CNA #2) again and both "felt" CNA #1 "intentionally sprayed" Resident #1 in the face. Per the 5 Day Follow up/Final Report CNA #1 was terminated "upon final investigation on 11/28/14". However, further review of the facility's investigation of the incident on 11/25/14, involving Resident #1, revealed no documented evidence: all interviewable residents residing on the same unit on which Resident #1 resided were interviewed regarding CNA #1's care or possible knowledge of the alleged abuse; all staff working on the unit at the time of the alleged abuse were interviewed; and all non-interviewable residents were physically assessed for signs of possible abuse by the alleged perpetrator, CNA #1. Interview, on 12/17/14 at 4:58 PM, with Resident #1 revealed on 11/25/14, the resident recalled CNA #1 spraying him/her in the face with "ice cold" water and he/she fought back. Resident #1 revealed the incident made him/her feel "terrible", and the resident thought he/she reported the incident to the head nurse; however, could not recall her name. Interview, on 12/16/14 at 5:25 PM and on 12/17/14 at approximately 3:30 PM, with CNA #2 revealed on 11/25/14 around 3:00 PM to 3:30 PM, she was assisting CNA #1 with giving Resident #1 a shower. She stated Resident #1 was agitated before the shower and during the shower the resident called CNA #1 a "nasty" name. CNA #2 revealed CNA #1 turned the water on cold, sprayed Resident #1 in the face and the resident yelled, "stop, I don't like that....it's cold". Per interview, CNA #2 revealed even though she thought the incident was abusive, she did not report the incident as she was "non-confrontational". Continued interview revealed she realized later she should have reported the incident as possible abuse. Interview, on 12/17/14 at 1:09 PM, with NAT #1 revealed around 3:00 PM on 11/25/14, during the shower he heard Resident #1 yell over and over again, "stop you're burning me", and reported he saw CNA #1 spraying water into the resident's face. NAT #1 revealed CNA #1 told Resident #1 "if you would just listen to me, I wouldn't have to do this." According to NAT #1, he went back to work on his hall and did not tell anyone what he had witnessed until around 5:30 PM, when he told CNA #4. NAT #1 stated CNA #4 told him the incident involving Resident #1 was "unacceptable" and should have been reported; however he stated he clocked out and went to lunch. The NAT reported he had previously observed CNA #1 being a little "rough" with residents, being a "bit aggressive" with getting residents to roll over and had heard CNA #1 yell at residents. He stated he thought these behaviors could be abusive and stated he would never have talked to a resident the way CNA #1 did. However, NAT #1 indicated he had never reported CNA #1 behaviors to his supervisor. Interview with CNA #4, on 12/17/14 at 11:20 AM, revealed NAT #1 told her CNA #1 squirted cold and hot water in Resident #1's face. CNA #4 she told NAT #1 "that was called abuse", and he needed to tell the nurse, LPN #1. She revealed she reported the incident to LPN #1 herself because she didn't want it on her "conscience". Additional interview with CNA #4 revealed she had observed CNA #1 yell at a resident before which she thought was abusive; however, she did not report it, but should have. Interview with LPN #1, on 12/16/14 at 5:43 PM, revealed on 11/25/14, CNA #4 told her NAT #1 was upset over observing CNA #1 spraying Resident #1 in the face with water from the shower hose. LPN #1 stated she went immediately and reported the incident to the DON, but did not remove CNA #1 from resident care per the facility's policy and procedure. LPN #1 stated the DON pulled CNA #1 from resident care to discuss the allegations with her. Further interview with LPN #1 revealed NAT #1 was questioned regarding the allegations when he returned from his break. However, review of the facility's 5 Day Follow-up/Final Report and investigation documentation revealed no documented evidence LPN #1 was interviewed or gave a written statement regarding the alleged abuse. Interview with Registered Nurse (RN) #1, on 12/16/14 at 4:27 PM, revealed revealed neither NAT #1 or CNA #2 reported the incident/alleged abuse to her on 11/25/14 after the incident occurred. RN #1 reported she was not made aware of the alleged abuse of Resident #1 by CNA #1, until the next day. Further interview with RN #1 revealed she would have expected CNA #2 and/or NAT #1 to have reported the abuse to their supervisor after witnessing it. Interview, on 12/17/14 at 2:35 PM, with CNA #1 revealed she was not aware of a concern with her care of Resident #1 until the DON approached her later on after dinner. CNA #1 stated the DON asked her to write a statement concerning the alleged abuse of Resident #1, and reported she was suspended. Per interview, she was terminated on 11/28/14. Interview, on 12/17/14 at 5:26 PM, with CNA #8 revealed she asked to work on a different hall of the unit when CNA #1 was working because she didn't like the way CNA #1 "talked to the residents". Per interview, CNA #1 was very "stern" with residents, never "really ever gave the residents an option" and was "kind of rough with them". She stated she had never witnessed physical abuse by CNA #1, but had heard of verbal abuse by CNA #1 from other CNAs, who included CNA #2 and CNA #6. Interview, on 12/17/14 at 6:30 PM, with CNA #6 revealed she had worked on 11/25/14; however, had not been questioned by the DON about CNA #1's care of residents. Per interview, she had witnessed CNA #1 being verbally abusive "a couple of times" before that day. She stated CNA #1 would "yell" at Resident #1 and other residents, and she had reported this to the nurses. CNA #6 stated the nurses she reported her allegations to included RN #2 and LPN #2. Per interview, the nurses reported her allegations of verbal abuse by CNA #1 towards residents to the DON; however, the DON didn't do anything about it. According to CNA #6, if the DON had done something about the alleged verbal abuse, the shower incident involving Resident #1 might not have occurred. Interview, on 12/17/14 at 8:04 PM, with RN #2 revealed CNA #1 had a "bit of attitude", was "mouthy" and "confrontational" with the nurses. However, she stated she had never had any allegations of verbal or physical abuse by CNA #1 towards residents reported to her. Interview, on 12/17/14 at 9:25 PM, with LPN #2 revealed nothing had been reported to her about CNA #1's behavior towards residents. Interview with the DON on 12/18/14 at 1:00 PM, revealed no one had ever reported anything regarding allegations of verbal abuse or any other form of abuse of residents by CNA #1 to her until 11/25/14. Per interview, LPN #1 came to her office and reported NAT #1 had told CNA #4 about the shower incident involving Resident #1 and CNA #1. She reported she removed CNA #1 from resident care and questioned her about the shower incident, and had the CNA write a statement and had the CNA leave the facility. According to the DON, she talked to NAT #1 and CNA #2 later and asked them to provide written statements regarding the alleged abuse. She stated Resident #1 was assessed by RN #1 during the facility's "skin rounds" which occurred weekly. However, per interview all other non-interviewable residents' were not physically assessed after she was informed of the alleged abuse on 11/25/14. The DON stated she believed all non-interviewable residents' should have been physically assessed after the incident thorough. She stated she interviewed some of the alert and oriented residents on the unit on 11/25/14, after the incident was reported to her. However, all interviewable residents were not interviewed until 11/26/14, when she asked the Social Worker (SW) to interview all alert and oriented residents which the SW determined as residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or above. The DON stated she had "informally" interviewed other staff working that night; however, she had not documented these interviews. The facility's investigation included no documented evidence of these interviews. Interview, on 12/18/14 at 2:06 PM, with the Administrator revealed the DON notified him of the incident involving Resident #1 and CNA #1 on 11/25/14 "between 6:00 PM and 7:00 PM". Continued interview with the Administrator revealed he verified CNA #1's written statement with her on 11/26/14 when he had her come to the facility, and she told him she hadn't done what was reported. He stated he followed up with NAT #1 and CNA #2 regarding the incident and they felt CNA #1 had intentionally sprayed Resident #1 in the face with water. According to the Administrator, he supported what NAT #1 had done, because once the NAT thought the incident was abuse, he reported it. He stated "initially" NAT #1 did not think the shower incident was intentional on the part of CNA #1, but after he thought about it he reported it. However, per interview, the facility's expectation was if staff viewed an incident as abuse, then they should report it as soon as possible. The Administrator revealed if NAT #1 and CNA #2 thought the incident was alleged abuse when it happened, they should have reported the incident, and once they felt the incident was potentially abuse they had reported it. According to the Administrator, staff should "report as soon as reasonably possible"; however, the facility's policy intent was for staff to report incidents involving possible abuse immediately. He stated all non-interviewable residents were physically assessed as it was "around the time of our skin rounds", but stated "not that night necessarily". However, no documented evidence was provided to ensure the skin assessments were performed on 11/25/14 after the alleged incident. Further interview revealed the SW interviewed all interviewable residents on 11/26/14. The Administrator stated the facility did what they were supposed to do related to this incident. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 12/23/14 which alleged removal of the IJ effective 12/23/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was assessed by the DON on 11/26/14, regarding the occurrence in the shower. An RN performed a full skin assessment of Resident #1 on 11/26/14 with no findings related to the occurrence of 11/25/14. A Social Worker (SW) assessed Resident #1 on 11/26/14 and on 12/18/14 and provided support to the resident who voiced no concerns with the staff/shower incident and had no concerns of any other staff member abuse. A MDS Nurse completed a comprehensive assessment of Resident #1 on 12/19/14 and noted no concerns, nor any difficulties with late effects of the occurrence of 11/25/14. Resident #1's Comprehensive Care Plans and Kardex (CNA Care Plan), were verified on 12/20/14 by the DON to reflect individualized approaches to manage his/her behaviors. 2. On 12/19/14, each cognitively intact resident with a Brief Interview of Mental Status (BIMS) greater than or equal to eight (8) was observed and interviewed by the SW, Registered Dietician (RD), Activity Director and/or Director of Rehabilitation for resident concerns of any potential abuse, neglect or misappropriation. The findings of the interviews and observations were reported to the Administrator on 12/19/14. Any allegation/concern was immediately followed up on by the Administrator, with investigations completed, and notifications made, if indicated, by the Administrator. The findings were to be reported at the 12/22/14 Quality Assurance (QA) Committee meeting by the Business Office Coordinator. The SW was to continue to perform interviewable resident abuse observations and interviews weekly and report the findings to the QA team. 3. On 12/18/14 through 12/19/14, licensed nursing staff conducted head to toe assessments of each cognitively impaired resident, who had a BIMS less than eight (8) or was non-interviewable, for any new or unusual bruises, skin tears etc., or other signs of potential abuse. There were no findings that would trigger an allegation of abuse. The results of the head to toe assessments were reviewed by the DON and Administrator, and the findings reported at the 12/22/14 QA meeting by the DON. The Nursing Management Team which included the DON, ADON, Unit Managers and Team Leads would perform head to toe assessments of each cognitively impaired resident weekly for any new/unusual bruises, skin tears etc., or other signs of potential abuse, with no findings that required action at the time. 4. On 12/18/14 the facility's electronic charting system was modified by the Corporate Nurse to list/show interventions for residents' behaviors on the Kardex (nurse aide care plan). Each residents' Kardex was updated automatically. By 12/19/14 the Registered Nurse (RN)/MDS/Resident Assessment Instrument (RAI) Coordinator reviewed all residents care plans to ensure Behavior Comprehensive Care Plans were in place for each resident assessed to require one. 5. On 12/19/14, the Administrator, Corporate Compliance Officer (CCO) and Corporate Risk Manager (CRM) reviewed each file of resident allegations of abuse or facility self reports of potential abuse in the past thirty (30) days to assure completeness and thoroughness of the investigation. If there were any concerns/gaps identified, they were followed up accordingly by the Administrator. On 12/21/14, the Administrator, CCO and CRM reviewed additional investigation files which were generated by the facility's observations and interviews completed on 12/19/14 through 12/20/14. This included, but was not limited to: immediate removal of any alleged or perpetrating staff from any care area; immediate reporting to the Administrator; interview of resident and staff; assessment of the alleged victim; and review of the investigation action ensuring it met the policy and federal requirements. The Administrator took action, if any required. The alleged perpetrator, CNA #1 was terminated on 11/28/14 after the completion of the facility's investigation. 6. On 12/19/14 all personnel files were audited by the Business Officer Coordinator and Medical Records Director for completion of pre-hire components used by the facility as part of screening and prevention of abuse. The files were found to be one hundred percent (100%) compliant, with evidence of: current License verification; Abuse Registry Check Registration; Criminal Background Check; and Kentucky Caregiver Misconduct Registry check. The findings of the audit were reported to the Administrator on 12/19/14 and were to be reported to the QA Committee on 12/22/14, by the Business Office Coordinator. The Business Office Coordinator and Administrator would review each new hire personnel file to assure verifications and background checks were completed prior to beginning work. 7. The facility's Abuse/Neglect/Misappropriation of Property Policy was reviewed on 12/19/14, which was in place at the time of the survey, addressing concerns identified by surveyors, by comparing it to federal regulations and interpretive guidelines and the contents of the facility's policy. The facility's Abuse/Neglect/Misappropriation of Property Policy was revised on 12/19/14 by the Chief Operating Officer (COO), Vice President (VP) of Risk Management, and CCO. 8. On 12/19/14 the CCO inserviced the Administrator, DON, ADON, Unit Managers and each Department Head on the results of the survey, the facility's root-cause analysis of the deficiencies and the newly revised abuse policy and procedure. Additionally, on 12/19/14 the CCO inserviced each Department Head, in a "Train the Trainer" fashion, on the "Team Member" education which covered Abuse Prevention, Abuse Reporting, Investigations, Comprehensive Care Plans, Kardex (Nurse Aide Care Plans) and the revised policy. On 12/21/14 the CRM and CCO each provided additional education to the Administrator, DON, and Nursing Leadership Team on: review of federal regulations and interpretive guidelines for F223, F225, F226; additional review of the revision of the facility's policy on Abuse/Neglect/Misappropriation of Property; and root cause analysis of the survey findings related to systematic response to allegations. Evidence of the learning was measured via meaningful Question and Answer (Q & A) and discussion of cause examples and a repeat verbalization of understanding of definitions and the facility's system. 9. On 12/19/14 through 12/22/14 all staff including licensed Nurses, CNAs, licensed Therapists, Social Services, Activity, Dietary, Housekeeping, Business Office and Maintenance was provided inservice education, "Team Member" Education, by the CCO, Administrator, DON or Trained Department Head which covered Abuse Prevention, Abuse Reporting, Investigations, Comprehensive Care Plans, Kardex (Nurse Aide Care Plans) and reporting concerns immediately. The updated abuse policy was reviewed and referred to in all staff "Team Member" education in-services, performed from 12/19/14 through 12/22/14. Evidence of the staff member's learning was measured via a written post-test, with a 100% accuracy required. Any staff member who had not been at work, or was on leave or vacation would complete all education and training prior to working their next shift. No staff member would work without first being inserviced. All newly hired staff members would be provided inservice education on abuse prevention, identification and reporting during their orientation prior to working in the facility through the Interactive Computer Program with a post-test and review of the abuse policy signed for verification. The Business Office Coordinator would track completion. Annual mandatory inservice of abuse, including but not limited to prevention, would continue to be monitored by the Business Office Coordinator; additionally, as indicated by concerns or observations, impromptu inservices for staff would be held as decided by the Administrator, DON, and/or Ombudsman. Also, besides being directly taught to staff, the revised policy was placed in areas staff/team members typically congregate, take breaks and eat lunch. 10. Beginning on 12/20/14, a random observation and interview of staff members was begun by the Administrator, Corporate support staff and Department Heads. The observations and interviews were designed to detect if staff members were knowledgeable about prevention, reporting, investigation of abuse and how to locate and review the revised abuse policy. The facility was to perform interviews of at least twenty (20) staff members weekly until substantial compliance was obtained to ensure each allegation of abuse would be reported immediately by the staff to the DON or Administrator. If the DON or Administrator was not in the facility, staff would contact the DON or Administrator via phone for thorough/timely investigation and reporting. The Administrator would be notified immediately of any allegations. After substantial compliance was obtained, the QA team would determine the frequency of the staff interviews. The findings of each observation and interview developed for this Allegation of Compliance (AOC) were evidence of the operationalization of the facility's policy on abuse/neglect/misappropriation of property. All findings of observations and interviews would be reviewed by the QA Committee to ensure team members understood, implemented and operationalized the policy. 11. The QA team consists of the Medical Director, DON, Administrator and Department Heads. A QA meeting was held on 12/19/14 with the Medical Director, DON, Administrator and other members of the QA Committee. The findings of the State Survey Agency's findings, as well as, deficiencies, including the Scope and Severity, were discussed in the meeting. Action plans to address each deficiency, as well as, the overall system were developed and approved by the QA Committee. On 12/22/14, a second full QA Committee meeting was held to review the action plans to remove the Immediate Jeopardy. Findings of all observations and interviews, compliance with inservicing and results of monitoring were analyzed and discussed. The findings would be reported by the DON, Administrator or Social Service Director and followed by each with Committee recommendations. QA meetings would take place weekly, until the facility was in substantial compliance, and when that occurred the QA Committee would decide on the frequency of meetings with a minimum of quarterly, in order to keep the facility in substantial compliance. 12. From 12/19/14 through 12/22/14, the DON, ADON, Corporate RN, RN Managers and/or Team Lead Nurses provided additional inservice/education to the Nursing staff and Interdisciplinary Team (IDT) on the Comprehensive Care Plan and communication of interventions to the Kardex/Nurse Aide Care Plan for implementation. Included in this training was the importance of accessing the Kardex, communicating changes needed to maintain an accurate and updated Plan of Care, including the Kardex, for each of the facility's residents. 13. On 12/19/14 through 12/22/14, the RN/MDS/RAI Coordinator, MDS Licensed Nurses, the Corporate RN, and/or Social Service Director reviewed each residents' care plan for Behavior to assure interventions were appropriate and flowed automatically to the Kardex (nurse aide care plan) based on feedback and assessment by the direct care staff which included the CNAs, licensed Nurses, Unit Managers and Social Service Director. The care plans were updated as indicated. The findings were reviewed with the DON and Administrator on 12/22/14 and would be reported to the QA Committee on 12/22/14 by the DON. The Kardex's were to be reviewed and updated daily by the Charge Nurses, Unit Managers, MDS Nurses, Team Lead Nurses and/or Therapists to assure they were current and provided appropriate interventions for each resident. The Kardex was to be printed off each day by the Charge Nurse and a copy of the Kardex given to the CNAs. The Kardex copy and verbal report from the nurse was given to each CNA to ensure the direct care staff was aware of the interventions in place for each of the facility's residents. If the Kardex was not current, licensed staff would update it and assure the CNA had the updated copy. CNAs were made aware they were to communicate verbally or via the Kardex to the nurses any concerns or need for further assessment or update of the resident's care plan/Kardex. Resident #1's Kardex was reviewed by the Charge Nurse for changes of the Plan of Care for the resident. Observation and interview rounds will be completed by the Administrator, DON, Unit Manager, Team Lead Nurses and/or licensed Clinical Department Heads to ensure each direct care staff person had the Kardex copy on their person and was able to use it. Results of the observations and interviews would be reported to the DON. The DON would report the findings at the 12/22/14 QA meeting. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of Resident #1's skin assessment, dated 11/26/14, revealed no open areas or bruising noted. Review of the Social Services Note, dated 12/19/14 revealed a late entry from the Social Worker to address her interview with the resident on 11/26/14 to discuss the incident/alleged abuse on 11/25/14. Continued review of the Social Service Notes, dated 12/18/14 and 12/19/14, revealed the Social Service Director followed up with the resident to assess Resident #1's psychosocial well-being. Review of Resident #1's Comprehensive Assessment, dated 12/19/14, revealed the resident was assessed by Licensed Practical Nurse (LPN) #7/MDS Nurse with no concerns identified. Review of Resident #1's Kardex revealed a Behavior/Mood care plan was added to the Kardex. Review of Resident #1's Comprehensive Care Plan revealed the resident's care plan was revised on 12/19/14 for staff to analyze key times, places, circumstances, triggers, and what de-escalated his/her behavior and document the information, as the resident was noted to have increased anxiety with showers and when his/her spouse had left for the day. Interview with the DON, on 12/24/14 at 10:23 AM, revealed Resident #1 was assessed "that night" (11/25/14) and Social Services continued to follow up with the resident. She stated Resident #1 resident was assessed again on 12/18/14 and his/her care plan was updated/revised. She reported she reviewed the resident's updated/revised care plan and verified it was complete regarding the changes that needed to be reflected on his/her care plan. She further stated the CNAs' Kardex had been updated with the changes. Continued interview with the DON revealed the SSD also assessed the resident on 12/18/14 and had been following up with the resident by reviewing his/her care plan. Interview with the SSD, on 12/24/14 at 10:05 AM, revealed she talked to Resident #1 on 12/18/14, and had followed up with him/her since. Continued interview revealed Resident #1's care plan was updated related to his/her behavior and bathing. 2. Review of the facility's Resident Rights/Abuse Prevention/Comprehensive Care Plans Audit Worksheets, dated 12/18/14 and 12/19/14, revealed residents with a BIMS score of eight (8) or higher were interviewed by the Director of Social Service, RD, Activity Director and/or Director of Rehabilitation. Two (2) residents, Unsampled Resident A and Unsampled Resident B, who also resided on Resident #1's unit expressed concerns on 12/21/14, regarding staff, these concerns were not abuse related. The residents' concerns were related to staff not being able to work together to provide care, and staff not taking the time to talk to them. Continued review of the audit revealed the Administrator followed up with the two (2) residents on 12/22/14. Interview on 12/24/14, with Unsampled Resident A at 9:30 AM and Unsampled Resident B at 9:40 AM, revealed they were questioned by staff regarding any concerns they had of abuse by staff; however, neither resident expressed concerns regarding abuse. Interview with the Social Services Director, on 12/24/14 at 10:05 AM, revealed she interviewed all of the interviewable residents with a BIMS score of eight (8) or higher on all the facility's units. She reported there were no concerns of abuse given. The Social Services Director stated the Administrator followed up on some residents' concerns which were not related to abuse. Per interview, the interviewable residents would continue to be interviewed regarding any abuse concerns, and observations performed at the time of interview to ensure the residents had no signs or symptoms of abuse. Interview, on 12/23/14 at 3:19 PM, with the Business Office Coordinator revealed the findings of the audits were reported to the QA Committee on 12/22/14. Interview, on 12/24/14 at 10:23 AM, with the Administrator revealed the findings of the interviews and observations were reported to him on 12/19/14, and continued to be reported. 3. Review of the skin assessments, dated 12/19/14, of residents identified as having a BIMS of seven (7) or less and non-interviewable residents revealed they were assessed by nu

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure facility staff implemented the facility's abuse policy and procedures for one (1) of five (5) sampled residents (Resident #1). In addition, the facility failed to develop a policy consistent with Federal and State Guidelines regarding immediate notification of the Administrator. Resident #1, on 11/25/14, was escorted to the shower room for his/her shower somewhere between 3:30 PM and 4:00 PM. Three (3) staff was present in the shower room with Resident #1, who included Certified Nursing Assistant (CNA) #1, Nurse Aide in Training (NAT) #1 and CNA #2. CNA #2 and NAT #1 witnessed CNA #1 intentionally spray Resident #1 in the face with hot and cold water. However, CNA #2 and NAT #1 did not report the alleged abuse until approximately 6:00 PM which allowed CNA #1 to continue to provide care for Resident #1 and other residents on the unit. At approximately 6:00 PM, NAT #1 informed CNA #4 of the alleged abuse he had witnessed involving Resident #1 in the shower room. CNA #4 reported the alleged abuse to Licensed Practical Nurse (LPN) #1, who reported the incident/alleged abuse to the Director of Nursing (DON). The DON initiated an investigation and removed CNA #1 from resident care after she became aware of the alleged abuse. CNA #1 clocked out from work at 7:05 PM. (Refer to F223 and F225) The facility's failure to ensure an effective system was in place to ensure facility staff implemented the facility's abuse policy and procedures and to develop a policy consistent with Federal and State Guidelines regarding immediate notification of the Administrator was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 12/18/14, and determined to exist on 11/25/14. The facility was notified of the Immediate Jeopardy on 12/18/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 12/23/14, with the facility alleging removal of the Immediate Jeopardy on 12/23/14. The Immediate Jeopardy was verified to be removed on 12/23/14, as alleged, with remaining non-compliance in the area of 42 CFR 483.13, Resident Behavior and Facility Practice, F-226 at a Scope and Severity of a "D" while the facility develops and implements a Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the Abuse Policies for implementation to ensure residents were free from abuse. The findings include: Review of the facility's policy titled, "Abuse/Neglect/Misappropriation of Property", revised October 2014, revealed "abuse" was defined to include the willful infliction of injury, unreasonable confinement, intimidation, or corporal punishment with resulting physical harm, pain, or mental anguish. Continued review of the facility's policy revealed when an incident or occurrence was identified as abuse, neglect or misappropriation an investigation would immediately follow. Review of the Policy, under the "Identification" section for "Staff Reporting Requirements", revealed when staff suspected abuse had occurred against a resident of the facility, they must report the incident to their immediate supervisor and, an investigation would immediately be initiated. However, Policy review revealed no documented evidence of the timeframe in which staff was to report suspected abuse incidents to their immediate supervisor. Additionally, the "Staff Reporting Requirements" of the Policy's "Identification section revealed notification of the DON (Director of Nursing)/Administrator would "occur ASAP (as soon as possible) but no later than two (2) hours if a serious injury" was suspected. However, the "Reporting/Response" section of the Policy revealed "alleged violations were to be reported immediately to the Administrator. Review of the facility's Self-Reported Initial Report Incident form, dated 11/25/14, revealed a staff member reported CNA #1 sprayed Resident #1 in the face with water while giving him/her a shower. Review of the facility's, "5 Day Follow-up/Final Report" form dated 11/28/14 and investigation documentation, revealed two (2) staff witnessed the alleged abuse of Resident #1, and "had the same general statement" that CNA #1 "intentionally sprayed water in the resident's face". Review of the facility's investigation of the incident revealed Resident #1 reported a female aide took the shower head and sprayed him/her directly in the face with water. The resident asked the female aide to stop but the aide laughed at the resident and continued to spray him/her. Review of NAT #1's written statement dated 11/25/14 at 7:15 PM, revealed on 11/25/14 at 4:00 PM, Resident #1 was being given a shower and was sprayed in the face with hot water by CNA #1, and the resident screamed "stop spraying my face, you are burning me". Review of CNA #2's written statement dated 11/25/14 at 6:15 PM, revealed CNA #1 "intentionally" sprayed Resident #1 in the face with water at approximately 4:30 PM. However, further review of the "5 Day Follow-up/Final Report" form and investigation documentation revealed no documented evidence the Administrator was immediately notified of the alleged abuse, per the facility's policy. Interview, on 12/17/14 at 1:09 PM, with NAT #1 revealed he did not tell anyone what he had witnessed in the shower room until around 5:30 PM. Even though the facility's policy stated when staff suspected abuse had occurred against a resident of the facility, they must report the incident to their immediate supervisor. Further interview revealed he observed CNA #1 before being a "bit aggressive" with residents and a little "rough" and he had heard her yell at residents. However, even though he thought these behaviors could be abusive he had never reported this information to his immediate supervisor, as per facility policy. In regards to the incident on 11/25/14, NAT #1 revealed he had not been aware of the Policy requirements regarding reporting to his immediate supervisor, the DON or Administrator, as the facility had not provided adequate training on the Policy. He was an aide in training and did not know if what he had observed was abuse or not. He completed orientation via the computer and document review revealed he acknowledged he had reviewed the abuse policy and was responsible for its content on 11/11/14. Per interview, NAT #1 stated he now was aware he should have reported the alleged abuse to his supervisor immediately so the DON and Administrator could have been notified and thereby, ensured Resident #1 and other residents were safe. Interview, on 12/16/14 at 5:25 PM and on 12/17/14 at approximately 3:30 PM, with CNA #2 revealed she was aware of the facility's abuse policy. She stated if she witnessed abuse she would report it to her "supervisor or someone in charge". However, she indicated she was "non-confrontational", and even though she thought the incident was abusive she had not reported it to RN #1, her immediate supervisor, as per the facility's policy. Continued interview revealed she realized later on she should have reported the incident as possible abuse, but she did not see a need to report it at the time as NAT #1 had already reported it. Interview, on 12/17/14 at 2:35 PM, with CNA #1 revealed she was not aware of a concern with her care of Resident #1 until the DON approached her later on after dinner. CNA #1 stated the DON asked her to write a statement concerning the alleged abuse of Resident #1, and then told her she was suspended. CNA #1 reported she was informed by the Administrator she was terminated, on 11/28/14, due to statements provided to them from NAT #1. Interview, on 12/16/14 at 5:43 PM, with LPN #1 revealed on 11/25/14, CNA #4 reported what NAT #1 had told her regarding the shower room incident involving Resident #1. LPN #1 stated she immediately reported the incident to the DON, and the DON asked her if CNA #1 was removed from resident care. She stated she told the DON this had not occurred. Interview with Registered Nurse (RN) #1, on 12/16/14 at 4:27 PM, revealed she was the nurse supervising the CNAs on Resident #1's hall which included CNA #1 and CNA #2 on 11/25/14. However, she stated neither CNA #2 nor NAT #1 reported the incident/alleged abuse to her on 11/25/14, after it occurred. Continued interview revealed she was not made aware of the alleged abuse of Resident #1 by CNA #1, until the next day, 11/26/14. According to RN #1, her expectation would have been for CNA #2, who was under her supervision, to have reported the abuse to her immediately. RN #1 indicated NAT #1 should have reported the alleged abuse to her or his direct supervisor immediately. Interview with the DON on 12/18/14 at 1:00 PM, revealed LPN #1 told her NAT #1 informed CNA #4 what he had witnessed in the shower room involving Resident #1 and CNA #1. She revealed she removed CNA #1 from resident care, questioned her regarding the shower incident, had her write a statement and then informed CNA #1 to leave the facility. Per interview, after ensuring CNA #1 had left, she talked to NAT #1 and CNA #2 and asked them to provide their written statements regarding the alleged abuse. She stated her expectation was for staff to report incidents/alleged abuse within "a couple of hours" if harm had occurred to a resident. However, the DON then stated the facility's policy was for staff to report any incidents of alleged abuse immediately, and this was her expectation of staff. However, review of the current facility policy revealed notification would "occur ASAP (as soon as possible) but no later than two (2) hours if a serious injury" was suspected. According to the DON, CNA #2 stayed with Resident #1 to ensure his/her safety after the shower room incident. However, the DON indicated she did not have an answer as to how the facility had ensured other residents were protected if staff hadn't reported the alleged abuse when it occurred. Interview with the Administrator, on 12/18/14 at 2:06 PM, revealed he was notified by the DON on 11/25/14 "between 6:00 PM and 7:00 PM" of the alleged abuse of Resident #1 by CNA #1. He stated he followed-up with NAT #1 and CNA #2, and they both felt CNA #1 intentionally sprayed Resident #1 in the face with water. He revealed NAT #1's waiting to report the alleged abuse was acceptable, because given the "context of the situation" the NAT was not sure whether CNA #1 had intentionally sprayed Resident #1 in the face. The Administrator stated once NAT #1 thought the incident was abuse, he reported it to someone. He stated however, the facility's expectation was if an incident was viewed by staff as abuse, it should be reported as soon as possible. Continued interview revealed if NAT #1 and CNA #2 thought the incident was alleged abuse at the time it occurred, they should have reported it, as per facility policy. He stated once NAT #1 and CNA #2 felt the incident was potentially abuse they had reported it. According to the Administrator, the facility policy's intent was for staff to report possible abuse immediately. He stated staff should "report as soon as reasonably possible". Further interview with the Administrator revealed spraying a resident intentionally in the face with water could be abuse, "if that's what's perceived" by the individual observing it. Per the Administrator, his staff was educated on abuse, knew "right from wrong", and he felt his staff had followed the facility's policy. Additional review of the facility's abuse policy at the time of interview with the Administrator, revealed when staff suspected abuse of a resident had occurred they must report the incident to their immediate supervisor; however, the Policy did not indicate the timeframe in which staff should report to their immediate supervisor. Continued interview with the Administrator on 12/18/14 at 2:06 PM, and review of the facility's abuse policy with him at that time, revealed alleged abuse allegations "should get to the DON as soon as possible". However, the Administrator also indicated it was the intent of the facility's abuse policy for staff to report immediately, and not wait two (2) hours if a serious injury had occurred. He stated the two (2) hour timeframe was meant for management staff to follow when reporting to the State Survey Agency. Per interview, the Administrator revealed he understood how the Policy could have been misinterpreted. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 12/23/14 which alleged removal of the IJ effective 12/23/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was assessed by the DON on 11/26/14, regarding the occurrence in the shower. An RN performed a full skin assessment of Resident #1 on 11/26/14 with no findings related to the occurrence of 11/25/14. A Social Worker (SW) assessed Resident #1 on 11/26/14 and on 12/18/14 and provided support to the resident who voiced no concerns with the staff/shower incident and had no concerns of any other staff member abuse. A MDS Nurse completed a comprehensive assessment of Resident #1 on 12/19/14 and noted no concerns, nor any difficulties with late effects of the occurrence of 11/25/14. Resident #1's Comprehensive Care Plans and Kardex (CNA Care Plan), were verified on 12/20/14 by the DON to reflect individualized approaches to manage his/her behaviors. 2. On 12/19/14, each cognitively intact resident with a Brief Interview of Mental Status (BIMS) greater than or equal to eight (8) was observed and interviewed by the SW, Registered Dietician (RD), Activity Director and/or Director of Rehabilitation for resident concerns of any potential abuse, neglect or misappropriation. The findings of the interviews and observations were reported to the Administrator on 12/19/14. Any allegation/concern was immediately followed up on by the Administrator, with investigations completed, and notifications made, if indicated, by the Administrator. The findings were to be reported at the 12/22/14 Quality Assurance (QA) Committee meeting by the Business Office Coordinator. The SW was to continue to perform interviewable resident abuse observations and interviews weekly and report the findings to the QA team. 3. On 12/18/14 through 12/19/14, licensed nursing staff conducted head to toe assessments of each cognitively impaired resident, who had a BIMS less than eight (8) or was non-interviewable, for any new or unusual bruises, skin tears etc., or other signs of potential abuse. There were no findings that would trigger an allegation of abuse. The results of the head to toe assessments were reviewed by the DON and Administrator, and the findings reported at the 12/22/14 QA meeting by the DON. The Nursing Management Team which included the DON, ADON, Unit Managers and Team Leads would perform head to toe assessments of each cognitively impaired resident weekly for any new/unusual bruises, skin tears etc., or other signs of potential abuse, with no findings that required action at the time. 4. On 12/18/14 the facility's electronic charting system was modified by the Corporate Nurse to list/show interventions for residents' behaviors on the Kardex (nurse aide care plan). Each residents' Kardex was updated automatically. By 12/19/14 the Registered Nurse (RN)/MDS/Resident Assessment Instrument (RAI) Coordinator reviewed all residents care plans to ensure Behavior Comprehensive Care Plans were in place for each resident assessed to require one. 5. On 12/19/14, the Administrator, Corporate Compliance Officer (CCO) and Corporate Risk Manager (CRM) reviewed each file of resident allegations of abuse or facility self reports of potential abuse in the past thirty (30) days to assure completeness and thoroughness of the investigation. If there were any concerns/gaps identified, they were followed up accordingly by the Administrator. On 12/21/14, the Administrator, CCO and CRM reviewed additional investigation files which were generated by the facility's observations and interviews completed on 12/19/14 through 12/20/14. This included, but was not limited to: immediate removal of any alleged or perpetrating staff from any care area; immediate reporting to the Administrator; interview of resident and staff; assessment of the alleged victim; and review of the investigation action ensuring it met the policy and federal requirements. The Administrator took action, if any required. The alleged perpetrator, CNA #1 was terminated on 11/28/14 after the completion of the facility's investigation. 6. On 12/19/14 all personnel files were audited by the Business Officer Coordinator and Medical Records Director for completion of pre-hire components used by the facility as part of screening and prevention of abuse. The files were found to be one hundred percent (100%) compliant, with evidence of: current License verification; Abuse Registry Check Registration; Criminal Background Check; and Kentucky Caregiver Misconduct Registry check. The findings of the audit were reported to the Administrator on 12/19/14 and were to be reported to the QA Committee on 12/22/14, by the Business Office Coordinator. The Business Office Coordinator and Administrator would review each new hire personnel file to assure verifications and background checks were completed prior to beginning work. 7. The facility's Abuse/Neglect/Misappropriation of Property Policy was reviewed on 12/19/14, which was in place at the time of the survey, addressing concerns identified by surveyors, by comparing it to federal regulations and interpretive guidelines and the contents of the facility's policy. The facility's Abuse/Neglect/Misappropriation of Property Policy was revised on 12/19/14 by the Chief Operating Officer (COO), Vice President (VP) of Risk Management, and CCO. 8. On 12/19/14 the CCO inserviced the Administrator, DON, ADON, Unit Managers and each Department Head on the results of the survey, the facility's root-cause analysis of the deficiencies and the newly revised abuse policy and procedure. Additionally, on 12/19/14 the CCO inserviced each Department Head, in a "Train the Trainer" fashion, on the "Team Member" education which covered Abuse Prevention, Abuse Reporting, Investigations, Comprehensive Care Plans, Kardex (Nurse Aide Care Plans) and the revised policy. On 12/21/14 the CRM and CCO each provided additional education to the Administrator, DON, and Nursing Leadership Team on: review of federal regulations and interpretive guidelines for F223, F225, F226; additional review of the revision of the facility's policy on Abuse/Neglect/Misappropriation of Property; and root cause analysis of the survey findings related to systematic response to allegations. Evidence of the learning was measured via meaningful Question and Answer (Q & A) and discussion of cause examples and a repeat verbalization of understanding of definitions and the facility's system. 9. On 12/19/14 through 12/22/14 all staff including licensed Nurses, CNAs, licensed Therapists, Social Services, Activity, Dietary, Housekeeping, Business Office and Maintenance was provided inservice education, "Team Member" Education, by the CCO, Administrator, DON or Trained Department Head which covered Abuse Prevention, Abuse Reporting, Investigations, Comprehensive Care Plans, Kardex (Nurse Aide Care Plans) and reporting concerns immediately. The updated abuse policy was reviewed and referred to in all staff "Team Member" education in-services, performed from 12/19/14 through 12/22/14. Evidence of the staff member's learning was measured via a written post-test, with a 100% accuracy required. Any staff member who had not been at work, or was on leave or vacation would complete all education and training prior to working their next shift. No staff member would work without first being inserviced. All newly hired staff members would be provided inservice education on abuse prevention, identification and reporting during their orientation prior to working in the facility through the Interactive Computer Program with a post-test and review of the abuse policy signed for verification. The Business Office Coordinator would track completion. Annual mandatory inservice of abuse, including but not limited to prevention, would continue to be monitored by the Business Office Coordinator; additionally, as indicated by concerns or observations, impromptu inservices for staff would be held as decided by the Administrator, DON, and/or Ombudsman. Also, besides being directly taught to staff, the revised policy was placed in areas staff/team members typically congregate, take breaks and eat lunch. 10. Beginning on 12/20/14, a random observation and interview of staff members was begun by the Administrator, Corporate support staff and Department Heads. The observations and interviews were designed to detect if staff members were knowledgeable about prevention, reporting, investigation of abuse and how to locate and review the revised abuse policy. The facility was to perform interviews of at least twenty (20) staff members weekly until substantial compliance was obtained to ensure each allegation of abuse would be reported immediately by the staff to the DON or Administrator. If the DON or Administrator was not in the facility, staff would contact the DON or Administrator via phone for thorough/timely investigation and reporting. The Administrator would be notified immediately of any allegations. After substantial compliance was obtained, the QA team would determine the frequency of the staff interviews. The findings of each observation and interview developed for this Allegation of Compliance (AOC) were evidence of the operationalization of the facility's policy on abuse/neglect/misappropriation of property. All findings of observations and interviews would be reviewed by the QA Committee to ensure team members understood, implemented and operationalized the policy. 11. The QA team consists of the Medical Director, DON, Administrator and Department Heads. A QA meeting was held on 12/19/14 with the Medical Director, DON, Administrator and other members of the QA Committee. The findings of the State Survey Agency's findings, as well as, deficiencies, including the Scope and Severity, were discussed in the meeting. Action plans to address each deficiency, as well as, the overall system were developed and approved by the QA Committee. On 12/22/14, a second full QA Committee meeting was held to review the action plans to remove the Immediate Jeopardy. Findings of all observations and interviews, compliance with inservicing and results of monitoring were analyzed and discussed. The findings would be reported by the DON, Administrator or Social Service Director and followed by each with Committee recommendations. QA meetings would take place weekly, until the facility was in substantial compliance, and when that occurred the QA Committee would decide on the frequency of meetings with a minimum of quarterly, in order to keep the facility in substantial compliance. 12. From 12/19/14 through 12/22/14, the DON, ADON, Corporate RN, RN Managers and/or Team Lead Nurses provided additional inservice/education to the Nursing staff and Interdisciplinary Team (IDT) on the Comprehensive Care Plan and communication of interventions to the Kardex/Nurse Aide Care Plan for implementation. Included in this training was the importance of accessing the Kardex, communicating changes needed to maintain an accurate and updated Plan of Care, including the Kardex, for each of the facility's residents. 13. On 12/19/14 through 12/22/14, the RN/MDS/RAI Coordinator, MDS Licensed Nurses, the Corporate RN, and/or Social Service Director reviewed each residents' care plan for Behavior to assure interventions were appropriate and flowed automatically to the Kardex (nurse aide care plan) based on feedback and assessment by the direct care staff which included the CNAs, licensed Nurses, Unit Managers and Social Service Director. The care plans were updated as indicated. The findings were reviewed with the DON and Administrator on 12/22/14 and would be reported to the QA Committee on 12/22/14 by the DON. The Kardex's were to be reviewed and updated daily by the Charge Nurses, Unit Managers, MDS Nurses, Team Lead Nurses and/or Therapists to assure they were current and provided appropriate interventions for each resident. The Kardex was to be printed off each day by the Charge Nurse and a copy of the Kardex given to the CNAs. The Kardex copy and verbal report from the nurse was given to each CNA to ensure the direct care staff was aware of the interventions in place for each of the facility's residents. If the Kardex was not current, licensed staff would update it and assure the CNA had the updated copy. CNAs were made aware they were to communicate verbally or via the Kardex to the nurses any concerns or need for further assessment or update of the resident's care plan/Kardex. Resident #1's Kardex was reviewed by the Charge Nurse for changes of the Plan of Care for the resident. Observation and interview rounds will be completed by the Administrator, DON, Unit Manager, Team Lead Nurses and/or licensed Clinical Department Heads to ensure each direct care staff person had the Kardex copy on their person and was able to use it. Results of the observations and interviews would be reported to the DON. The DON would report the findings at the 12/22/14 QA meeting. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of Resident #1's skin assessment, dated 11/26/14, revealed no open areas or bruising noted. Review of the Social Services Note, dated 12/19/14 revealed a late entry from the Social Worker to address her interview with the resident on 11/26/14 to discuss the incident/alleged abuse on 11/25/14. Continued review of the Social Service Notes, dated 12/18/14 and 12/19/14, revealed the Social Service Director followed up with the resident to assess Resident #1's psychosocial well-being. Review of Resident #1's Comprehensive Assessment, dated 12/19/14, revealed the resident was assessed by Licensed Practical Nurse (LPN) #7/MDS Nurse with no concerns identified. Review of Resident #1's Kardex revealed a Behavior/Mood care plan was added to the Kardex. Review of Resident #1's Comprehensive Care Plan revealed the resident's care plan was revised on 12/19/14 for staff to analyze key times, places, circumstances, triggers, and what de-escalated his/her behavior and document the information, as the resident was noted to have increased anxiety with showers and when his/her spouse had left for the day. Interview with the DON, on 12/24/14 at 10:23 AM, revealed Resident #1 was assessed "that night" (11/25/14) and Social Services continued to follow up with the resident. She stated Resident #1 resident was assessed again on 12/18/14 and his/her care plan was updated/revised. She reported she reviewed the resident's updated/revised care plan and verified it was complete regarding the changes that needed to be reflected on his/her care plan. She further stated the CNAs' Kardex had been updated with the changes. Continued interview with the DON revealed the SSD also assessed the resident on 12/18/14 and had been following up with the resident by reviewing his/her care plan. Interview with the SSD, on 12/24/14 at 10:05 AM, revealed she talked to Resident #1 on 12/18/14, and had followed up with him/her since. Continued interview revealed Resident #1's care plan was updated related to his/her behavior and bathing. 2. Review of the facility's Resident Rights/Abuse Prevention/Comprehensive Care Plans Audit Worksheets, dated 12/18/14 and 12/19/14, revealed residents with a BIMS score of eight (8) or higher were interviewed by the Director of Social Service, RD, Activity Director and/or Director of Rehabilitation. Two (2) residents, Unsampled Resident A and Unsampled Resident B, who also resided on Resident #1's unit expressed concerns on 12/21/14, regarding staff, these concerns were not abuse related. The residents' concerns were related to staff not being able to work together to provide care, and staff not taking the time to talk to them. Continued review of the audit revealed the Administrator followed up with the two (2) residents on 12/22/14. Interview on 12/24/14, with Unsampled Resident A at 9:30 AM and Unsampled Resident B at 9:40 AM, revealed they were questioned by staff regarding any concerns they had of abuse by staff; however, neither resident expressed concerns regarding abuse. Interview with the Social Services Director, on 12/24/14 at 10:05 AM, revealed she interviewed all of the interviewable residents with a BIMS score of eight (8) or higher on all the facility's units. She reported there were no concerns of abuse given. The Social Services Director stated the Administrator followed up on some residents' concerns which were not related to abuse. Per interview, the interviewable residents would continue to be interviewed regarding any abuse concerns, and observations performed at the time of interview to ensure the residents had no signs or symptoms of abuse. Interview, on 12/23/14 at 3:19 PM, with the Business Office Coordinator revealed the findings of the audits were reported to the QA Committee on 12/22/14. Interview, on 12/24/14 at 10:23 AM, with the Administrator revealed the findings of the interviews and observations were reported to him on 12/19/14, and continued to be reported. 3. Review of the skin assessments, dated 12/19/14, of residents identified as having a BIMS of seven (7) or less and non-interviewable residents revealed they were assessed by nursing staff who included RN #4, LPN #8, the ADON and LPN #7. Review of the skin assessments revealed no new or unusual bruising, no concerns were noted. Interview with LPN #8, on 12/23/14 at 7:33 PM, revealed she did skin assessments for residents who had a BIMS of seven (7) or less, or who were non-interviewable. She stated she assessed the residents on 12/19/14, and no concerns were observed or noted. Interview with the DON on 12/24/14 at 10:23 AM, revealed weekly skin assessments were completed by Unit Managers, Nursing Team Leaders and Nursing Management. Per interview, each had a group of residents they assessed and any injuries of unknown source were to be looked into. She reported however, there were no injuries of unknown source observed during the skin assessment audits. The DON indicated she and the Administrator reviewed the skin assessment audits, and the audits were taken by her to the QA meeting on 12/22/14. She revealed the skin assessment audits would continue weekly. Review of the QA Meeting sign-in sheet revealed there was a meeting dated 12/22/14 with all Department Heads present. 4. Review of the statement, signed by the Corporate Nurse, dated 12/22/14, revealed on 12/18/14 she activated a Routine Behavior Monitor for Point of Care, the facility's electronic charting system, and an as needed option for every resident at the facility. Review of Resident #1's Kardex/Nurse Aide Care Plan revealed it was revised to reflect the resident's behavior/mood and included revised interventions for CNAs to assist with resident's care regarding behaviors. Review of the Performance Improvement (PI) Worksheet audit, revealed all residents' with behaviors were assessed for the Kardex being current with appropriate interventions for residents, and if the answer was no, the Kardex was updated. Review of the audit of residents with assessed behaviors, dated 12/19/14, revealed all their care plans were reviewed to ensure Behavior Comprehensive Care Plans were in place. Interview with the RN/MDS/RAI Coordinator, on 12/24/14 at 9:31 AM, revealed she had worked with the Corporate Nurse to ensure residents' behavior care plans would flow to the CNAs' Kardex on the facility's electronic charting system. She stated she reviewed all the residents' care plans and updated as needed. 5. Review of the facility's PI Worksheets revealed on 12/19/14 and 12/20/14, files pertaining to abuse and self-reports were reviewed for the past thirty (30) days by the Administrator or Corporate staff. Resident #1's and Unsampled Resident C's investigations were reviewed with the following areas addressed: evidence of allegation; safe/secure resident-immedia