Based on interview, record review and review of the facility's Policy, it was determined the facility failed to ensure its abuse policies were implemented for one (1) of eighteen (18) sampled residents (Residents #54). State Registered Nurse Aide (SRNA) #2 alleged she witnessed SRNA #1 putting her hand against Resident #54's mouth and nose pushing down, while stating, Do not fucking spit on me again, on 01/12/2020 at approximately 1:15 PM. However, SRNA #2 failed to immediately notify the Charge Nurse or administrative staff of what she had witnessed as per facility Policy. SRNA #2 did inform SRNA #3 of what she had witnessed, and SRNA #3 informed SRNA #4 of the allegation. SRNA #4 then reported the allegation to Licensed Practical Nurse (LPN) #1 on 01/12/2020 at approximately 2:20 PM. LPN #1 notified the Assistant Director of Nursing (ADON) via telephone on 01/12/2020 at approximately 2:53 PM. However, there was no documented evidence the facility Policy was implemented related to reporting the allegation to State Agencies within the two (2) hour timeframe, conducting a thorough investigation or protecting residents from abuse pending an investigation. The allegation was not reported to the State Agencies until 01/15/2020, when the allegation was further investigated, three (3) days after the alleged abuse was witnessed. Additionally, the alleged perpetrator, SRNA #1, continued to work on 01/12/2020 and 01/13/2020, providing direct care, allowing for the potential for further abuse. (Refer to F-609 and F-610) The facility's failure to implement its policies and procedures regarding reporting, and investigating allegations of abuse, and protecting residents after an allegation of abuse, has caused or is likely to cause serious injury, serious harm, serious impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 03/04/2020, and was determined to exist on 01/12/2020. The facility provided an acceptable credible Allegation of Compliance (AoC)/IJ Removal Plan on 03/06/2020, alleging removal of the Immediate Jeopardy on 01/18/2020. The State Survey Agency (SSA) determined the Immediate Jeopardy had been removed 01/18/2020, as alleged. In addition, the SSA validated the facility had implemented corrective action with a compliance date of 02/20/2020, prior to the SSA entering the building on 03/02/2020. Therefore, the SSA determined the facility had past-noncompliance. The findings include: Review of the facility's Abuse Prohibition Policy, dated 07/01/19, revealed anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. All reports of suspected abuse must also be reported to the patient's family and attending physician. Upon receiving the information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED or designee will enter the allegation into the Risk Management System (RMS) and report allegations involving abuse (physical, verbal, sexual, mental) not later than two (2) hours after the allegation is made. Further, an investigation will be initiated within twenty-four (24) hours of an allegation of abuse that focuses on whether abuse or neglect occurred and to what extent; clinical examination for signs of injuries, if indicated; causative factors; and interventions to prevent further injury. The investigation will be thoroughly documented within RMS and the facility will ensure documentation of witnessed interviews. The Center will protect patients from further harm during an investigation. Review of Resident #54's medical record revealed the facility admitted the resident on 10/30/14 with diagnoses to include Dementia, and Hypertension. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/24/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (05) out of fifteen (15) indicating severe cognitive impairment. Review of the facility's Investigation Report, dated 01/15/2020, signed by the CED, revealed an incident of physical/verbal abuse allegedly occurred on 01/12/2020 at approximately 1:15 PM involving Resident #54 . According to the Investigation, LPN #1 called the ADON on 01/12/2020 at 2:53 PM, and asked him to speak with SRNA #1 and SRNA #2 about the care provided to Resident #54. Per the Investigation, on 01/12/2020, after the call from LPN #1, the ADON phoned SRNA #2, who alleged SRNA #1 put her hand to Resident #54's mouth and said, Don't spit on me. On 01/12/2020, the ADON also phoned SRNA #1, and SRNA #3 and obtained verbal Statements. After obtaining the Verbal Statements, the ADON and CED felt the allegation was a lack of professionalism, and did not identify this as an allegation of abuse. The facility failed to further investigate and failed to report the allegation to State Agencies. In addition, SRNA #1, the alleged perpetrator, continued to work as scheduled. Further review of the facility's Investigation, revealed on 01/14/2020, SRNA #2 notified the CED of a different version of the situation related to Resident #54, which included profane language and possible physical abuse. SRNA #2 was instructed to come to the facility for further interview and to give a written Statement. Per the Investigation, SRNA #2's Written Statement obtained on 01/15/2020, was inconsistent with the Verbal Statement obtained on 01/12/2020. Further the Investigation revealed on 01/15/2020, SRNA #2 alleged that on 01/12/2020, SRNA #1 said to Resident #54, Do not fucking spit on me again. SRNA #2 further alleged SRNA #1 put her hands on the resident's mouth and nose and it looked like she pushed onto the resident's face. Continued review of the Investigation, revealed on 01/15/2020, when the ADON and the CED determined this was an allegation of abuse, the alleged perpetrator, SRNA #1, was suspended, which was three (3) days after the alleged incident was witnessed. SRNA #2 was also suspended on 01/15/2020 for not immediately reporting the allegation of abuse to her direct supervisor on 01/12/2020. The facility reported the allegation to Adult Protective Services (APS) and the Ombudsman on 01/15/2020 at 3:00 PM; the Office of Inspector General (OIG/ the SSA) on 01/15/2020, at 3:49 PM; and Resident #54's Physician and Son on 01/15/2020 at 4:00 PM. The State Agencies were notified of the allegation, three (3) days after the alleged incident was witnessed. Interview on 03/04/2020 at 3:17 PM, with the Interim Director of Nursing (DON), revealed he was the ADON at the time of the alleged violation on 01/12/2020, involving Resident #54. Per interview, the facility Abuse Prohibition Policy was not implemented related to reporting, and investigating allegations of abuse, nor was the Policy implemented related to protecting residents after the allegation of abuse related to Resident #54. Per interview, during the facility's investigation it was identified SRNA #2 failed to immediately notify the Charge Nurse or administrative staff of the allegation on 01/12/2020, as per Policy. Continued interview with the Interim DON, revealed the facility's Policy was not implemented related to initiating a thorough investigation as Verbal Statements obtained on 01/12/2020 from staff involved (SRNA #1, SRNA #2, and SRNA #3) were not validated by these staff members in order to ensure accuracy, and neither he or the CED identified the allegation as an abuse allegation from the Verbal Statements. Per interview, therefore the allegation was not reported to State Agencies within two (2) hours as per Policy. He stated, after further investigation on 01/15/2020, Written Statements were obtained which were inconsistent with the Verbal Statements obtained on 01/12/2020, and the facility did identify the incident as an allegation of abuse. Additional interview revealed as a result of the facility failing to implement the written facility policy related to abuse, SRNA #1, the alleged perpetrator continued to work the rest of her shift on 01/12/2020 and also worked her scheduled shift on 01/13/2020, allowing for the potential for further abuse. Interview with the CED, on 03/06/2020 at 9:06 AM, revealed he acknowledged the facility's written Policy was not implemented related to reporting abuse, investigating abuse, and protecting residents from further potential abuse related to the allegation of abuse for Resident #54. Per interview, the alleged abuse witnessed on 01/12/2020 related to Resident #54 should have been immediately reported to the Charge Nurse, and CED, as per Policy. Further, the allegation should have been reported to State Agencies within two (2) hours, as per Policy. Additional interview revealed there should have been a thorough investigation immediately initiated and SRNA #1, the alleged perpetrator, should have been immediately removed from direct resident care and suspended on 01/12/2020 pending an investigation. The facility provided and acceptable credible Allegation of Compliance (AoC)/IJ Removal Plan on 03/06/2020 that alleged removal of the Immediate Jeopardy (IJ) on 01/18/2020. Review of the AoC/IJ Removal Plan revealed the facility implemented the following: 1. On 01/12/2020, the Assistant Director of Nursing (ADON) interviewed SRNAs involved (SRNA #1 and SRNA #2) regarding the incident related to Resident #54. 2. On 01/12/2020, Licensed Practical Nurse (LPN) #2 completed a head to toe assessment of Resident #54 for any signs of abuse with no corrective action required. Resident #54 was calm and resting quietly at the time of the skin assessment, and the resident did not make any statements. 3. On 01/15/2020, the Center Executive Director (CED) notified the Physician and Resident #54's family member of the allegation and the pending investigation. 4. On 01/15/2020, Resident #54 was interviewed by the Social Service Director (SSD) and the resident stated he/she was well taken care of and had no fear of anyone at the facility. 5. On 01/15/2020, Written Witness Statements were obtained from LPN #1, SRNA #1, SRNA #2, SRNA #3 and SRNA #4. 6. On 01/15/2020, the ADON entered the allegation related to Resident #54 that allegedly occurred on 01/12/2020, into the Risk Management System (RMS). 7. On 01/15/2020, the CED reported the allegation involving Resident #54 to Adult Protective Services (APS), Ombudsman, and the Office of Inspector General (OIG). 8. On 01/15/2020, an AdHOC Quality Assurance/Performance Improvement (QAPI) meeting was held related to the allegation of abuse towards Resident #54. Members in attendance included the CED, ADON, Medical Director, and Social Services. Discussion included development of an action plan including assessment and re-education as well as audits and compliance monitors. The Abuse Policy was discussed, with emphasis on a thorough investigation, timely reporting, and following policy. 9. On 01/16/2020, Resident #54 was re-assessed by LPN #7 with no concerns or corrective action. 10. On 01/17/2020, the Clinical Reimbursement Coordinator (CRC) updated Resident #54's Comprehensive Care Plan and Kardex (Nurse Aide Care Plan) to include interventions to safely care for the resident when behaviors such as spitting occurs. 11. On 01/15/2020, the ADON, SSD, Activity Director and Licensed Nurses interviewed all interviewable residents with a Brief Interview for Mental Status (BIMS) of eight (8) and above to determine if they had experienced or witnessed any abuse in the center including physical abuse. No further concerns were noted. 12. On 01/16/2020, the ADON and Licensed Nurses completed skin assessments for all non-interviewable residents with a Brief Interview for Mental Status (BIMS) of seven (7) or below to determine injury associated with possible abuse. There were no abnormal findings from these skin assessments. 13. On or before 01/17/2020, the CED, and ADON, were re-educated related to the Abuse Policy and reporting requirements and completed post-test by the Regional [NAME] President of Operations (RVPO) or Clinical Quality Specialist (CQS). 14. On or before 01/17/2020, the CRC and Nurse Practice Educator (NPE) were re-educated related to the Abuse Policy and reporting requirements and completed post-tests. The education was provided by the CED and ADON. 15. Starting on 01/16/2020, re-education was provided by the ADON, NPE and CRC for all administrative staff, nursing, therapy, dietary, housekeeping, laundry, and maintenance staff related to the Abuse policy and reporting requirements, to include what constitutes physical and verbal abuse. All staff completed a post-test to validate understanding of the Abuse policy and reporting requirements. By 01/17/2020, seventy four (74) of one hundred (100) employees had been re-educated. Staff not available during this timeframe will be provided re-education and complete a post-test upon day of return to work before providing care by the CED, CRC, NPE, Social Services, or ADON. New staff will be provided education and complete post-tests by the CED, Social Services, CRC, NPE, ADON or CNE during orientation. The facility does not utilize agency staffing at this time. 16. The Center Nurse Executive (CNE) will be re-educated on day of return from Medical Leave by the CED and CQS. 17. On 01/17/2020, Social Services, CED, ADON, CRC, NPE or Licensed Nurses will interview five (5) employees daily across all shifts x two (2) weeks including weekends and holidays, then three (3) x per week x two (2) weeks, then two (2) x per week x four (4) weeks and then every other week x eight (8) weeks, then monthly x one (1) month, then ongoing thereafter as determined by the QAPI committee to ensure staff understand the abuse policy including reporting allegations to the CED immediately. Any concerns identified will be addressed at that time. 18. Starting on 01/17/2020, the CNE, ADON, CRC, NPE or Licensed Nurses will complete body audits of all residents daily for two (2) weeks then weekly for ten (10) weeks to ensure no evidence of abuse with corrective action upon discovery. 19. Starting on 01/17/2020, the CNE, Social Services, ADON, CRC, NPE, Activity Director, admission Director, or Licensed Nurse will interview five (5) residents daily across all shifts x two (2) weeks including weekends and holidays, then three (3) x per week x two (2) weeks, then weekly x four (4) weeks, then every other week x eight (8) weeks, then monthly x one (1) month, then ongoing thereafter as determined by the QAPI committee to determine any issues with staff treatment or abuse while in the center. Any concerns identified will be addressed at that time. 20. Starting on 01/17/2020 and ongoing, the CED and/or CNE will audit abuse investigations daily x two (2) weeks including weekends and holidays; then three (3) per week x two (2) weeks; then weekly x four (4) weeks; then every other week x eight (8) weeks; then monthly x two (2) months; then ongoing thereafter as determined by the QAPI committee to determine that Abuse allegations are reported timely as per the Abuse Policy. Any concerns identified will be addressed at that time. 21. The Regional Executive Director (RED) will review for implementation of the Abuse Policy including reporting abuse allegations timely monthly for six (6) months and ongoing thereafter as determined by QAPI. 22. The QAPI Committee met on 02/19/2020 and discussed the following to ensure ongoing compliance: initial report and information; the abatement plan for IJ removal; resident interviews and findings; staff interviews; AdHOC QAPI; skin checks; staff education; abuse policy; self-reported incidents, and guidelines regarding timely reporting. Findings related to the audits and interviews will be reported to the QAPI committee monthly x six (6) months for further review and recommendation for any additional follow up and/or in-servicing until the concern is resolved and ongoing thereafter as determined by the QAPI Committee. The QAPI committee consists of the CED, CNE, ADON, Medical Director, Social Service, Director Food Service, Dietician, Health Information Manager, Business Office Manager, Therapy Program Director, Maintenance Director, Activity Director and SRNAs. The State Survey Agency validated the implementation of the facility's AoC/IJ Removal Plan as follows: 1. Review of the Written Statement, signed by the ADON, dated 01/13/2020, revealed the ADON phoned SRNAs #1, #2, and #3 on 01/12/2020 to obtain verbal witness statements related to the incident involving Resident #54. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:30 PM, revealed he called SRNAs #1, #2, and #3 on 01/12/2020 to obtain verbal witness statements related to the incident involving Resident #54. Interview with SRNA #1, on 03/05/2020 at 8:01 AM; SRNA#2, on 03/04/2020 at 9:45 AM; and SRNA #3, on 03/04/2020 at 10:05 AM, revealed they received a phone call from the Interim DON (previous ADON) on the afternoon of 01/12/2020 and gave Statements over the phone regarding the 01/12/2020 incident related to Resident #54 2. Review of the Attestation Statement, signed by LPN #2, dated 01/12/2020, revealed she completed a head to toe assessment on Resident #54 for any signs of abuse. Per the Statement, she explained the procedure to the resident, and the resident was calm and resting quietly at the time of the assessment. Further review revealed Resident #54 did not make any statements at the time of the assessment. Review of the Skin Assessment, dated 01/12/2020 at 4:00 PM, completed by LPN #2, revealed no skin issues were noted, and no injuries were noted. Phone interview was attempted with LPN #2, on 03/06/2020 at 8:00 AM; however, the nurse was unable to be reached. 3. Review of Resident #54's Progress Notes, dated 01/15/2020 at 4:00 PM, revealed the CED called the resident's Physician and family member to inform them of the allegation and pending investigation. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he did call the Physician and Resident #54's family member on 01/15/2020, to report the allegation and pending investigation. 4. Review of the Progress Note, dated 01/15/2020, revealed the SSD interviewed Resident #54 regarding the incident, with no concerns noted. Interview with the SSD, on 03/06/2020 at 2:40 PM, revealed she did interview Resident #54 on 01/15/2020, and had visited him/her several times since the incident. The SSD stated Resident #54 had no concerns, and was pleasant, smiling and had no changes in his/her behavior. 5. Interview with SRNA #2 on 03/04/2020 at 10:46 AM revealed on 01/14/2020 she was asked to come to the facility to write a Written Statement and give an interview related to the incident regarding Resident #54. Interview with SRNA #4 on 03/05/2020 at 8:33 AM; SRNA #1, on 03/05/2020 at 8:06 AM; and SRNA #3 on 03/05/2020 at 9:18 AM, revealed they were asked to provide a written Statement of what they witnessed on 01/12/2020, related to the incident regarding Resident #54. 6. Review of the RMS Event Summary Report, dated 01/15/2020, revealed the Interim DON (previous ADON) entered the alleged allegation of abuse related to Resident #54. The Summary Report also included Resident #54's date of birth , room number, primary nurse's name, event location, and notification to the Physician, family and the Police Department. Interview with the Interim DON (previous ADON), on 03/06/2020 at 2:56 PM, revealed he did in fact enter the event into the Risk Management System on 01/15/2020. 7. Review of the facility's Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, revealed OIG was notified on 01/15/2020 at 3:00 PM, of the 01/12/2020 alleged incident of physical/verbal abuse involving Resident #54. The allegation was also reported to APS and the Ombudsman on 01/15/2020 at 3:00 PM. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he did fax the facility's Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, related to the allegation involving Resident #54 to the appropriate State Agencies on 01/15/2020. 8. Review of the AdHOC QAPI Meeting Minutes and Signature Page dated 01/15/2020, revealed the CED, ADON, Medical Director, and Social Services did meet to discuss and review the 01/12/2020 incident of alleged abuse involving Resident #54. Per the Meeting Minutes, discussion included interventions to resolve potential Immediate Jeopardy (IJ) situation; immediate action plan for IJ removal; review of the investigation; review of the QAPI Audits; review of the Education; and review of the Abuse Policy and reporting guidelines with emphasis on a thorough investigation, timely reporting, and following policy. Interview with the SSD, on 03/06/2020 at 1:40 PM, revealed she did attend the QAPI meeting on 01/15/2020. She stated there was discussion related to the allegation of abuse related to Resident #54 from the 01/12/2020 incident. Per interview, the team discussed a plan to resolve the situation. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed he did attend the QAPI meeting on 01/15/2020 related to the allegation of abuse involving Resident #54. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he conducted the QAPI Meeting on 01/15/2020 to review the initial report of the allegation of abuse, and come up with a plan to abate the immediacy of the potential Jeopardy. He further stated QAPI also reviewed the Abuse policy and reporting guidelines. 9. Review of the Skin Check Assessment, dated 01/16/2020 at 7:23 PM, revealed LPN #7 completed the assessment with no concerns noted. Phone interview was attempted with LPN #7 on 03/06/2020 at 10:00 AM; however, the nurse could not be reached. 10. Review of Resident #54's Comprehensive Centered Care Plan, revealed an update by the CRC on 01/17/2020, to state if the resident exhibits increased behaviors such as spitting or hitting, ensure safety of resident and reproach as resident allows. Further review revealed provide resident with opportunities for choice during care/activities to provide sense of control. Review of Resident #54's Kardex, revealed an update on 01/17/2020 to include behaviors of spitting and interventions if spitting occurs. Interview with the CRC, on 03/06/2020 at 1:47 PM, revealed she updated Resident #54's Comprehensive Centered Care Plan and Kardex on 01/17/2020. She stated she added interventions related to the resident's increase in behaviors related to spitting. 11. Review of Resident Interviews Sheets, revealed all residents that were interviewable were interviewed on 01/15/2020. The following questions were asked to interviewable residents: 1) Do staff meet your needs?; 2) Do staff treat you like you would want to be treated?; 3) Are staff friendly when meeting your needs?; 4) Has any staff member ever spoken harshly to you?; and 5) Are you fearful of any staff member? The Resident Interviews Sheets included: Interviewer name; Resident name; and the date. Interview with the SSD, on 03/06/2020 at 1:40 PM, revealed she assisted with resident interviews on 01/15/2020. She stated none of the residents she interviewed had any concerns with care. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed he assisted with interviewing residents on 01/15/2020, and the residents had no concerns. Interview with LPN #4, on 03/06/2020 at 12:10 PM, revealed she assisted with interviewing residents on 01/15/2020. She further stated no residents voiced concerns related to any abuse at the facility. 12. Review of skin assessments completed on 01/16/2020, revealed thirty-three (33) resident skin assessments were completed out of a total of seventy-two (72) residents with no concerns noted. The skin assessments were completed for all residents with a BIMS score of seven (7) or below. Interview with LPN #6, on 03/06/2020 at 12:10 PM, revealed she assisted with performing skin assessments on residents on 01/16/2020. She further stated there were no signs of abuse with the skin assessments she completed. Interview with Registered Nurse (RN) #1, on 03/06/2020 at 1:03 PM, revealed she helped perform skin assessments on residents on 01/16/2020. She stated all shifts were helping. Per interview, she saw no signs of abuse for residents with the skin assessments she completed. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed on 01/16/2020, he and the licensed nurses performed skin assessments on all residents with a BIMS score of seven (7) or below to determine injury associated with possible abuse. 13. Review of the education and post-test documents, revealed the CDE and ADON received education related to the Abuse Policy and reporting requirements on 01/17/2020, which was provided by the CQS. Interview with Interim DON (previous ADON) on 03/06/2020 at 1:56 PM, revealed he was educated by the CQS on 01/17/2020. He stated the education included the Abuse Policy, and reporting requirements, Per interview, he also had to complete a pre and post-test. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he received education regarding the Abuse Policy and reporting requirements on 01/17/2020 by the CQS. Further interview revealed he also completed pre and post tests. Interview with the CQS, on 03/06/2020 at 2:15 PM, revealed she did provide education on the Abuse Policy and reporting requirements to the ADON and CDE on 01/17/2020. She stated they also had to also complete pre and post tests. 14. Review of the education and post-test documents, revealed the CRC and NPE were re-educated related to the Abuse Policy and reporting requirements and completed post-tests. The education was provided by the CED and the ADON. Interview with the with the NPE, on 03/06/2020 at 12:13 PM; and the CRC on 03/06/2020 at 1:47 PM, revealed the Interim DON (previous ADON) and CDE re-educated them related to the Abuse Policy and reporting requirements on 01/17/2020. Per interview they also had to complete a pre and post test. 15. Review of Education sign in sheets and Pre-Test and Post-Test for nursing, therapy, dietary, housekeeping, laundry and maintenance staff related to Abuse and reporting requirements, validated seventy-four (74) out of one-hundred (100) staff were educated on 01/16/2020 and 01/17/2020. The education was completed by the CED, CRC, NPE, Social Services, and ADON. Further review revealed staff that were not educated during that timeframe were not able to work until they had been educated. The facility did not have any agency staff. Interview with the CRC, on 03/06/2020 at 2:47 PM, revealed she provided education to staff on all shifts related to the Abuse policy and reporting requirements. Per interview, education started on 01/16/2020 and by 01/17/2020 seventy-four (74) out of one-hundred (100) staff members had received the education. She further stated any staff member who had not been educated by 01/17/2020 had to receive the education prior to working their next shift. She stated she came in at 10:00 PM at night and worked until 1:00 AM to ensure staff on the off shifts were educated on some dates in January 2020. Interview with LPN #6, on 03/06/2020 at 12:10 PM; Housekeeper #1, on 03/06/2020 at 12:25 PM; SRNA #5, on 03/06/2020 at 12:28 PM; and Maintenance, on 03/06/2020 at 1:36 PM, revealed they received education related to the facility Abuse policy and reporting requirements, to include what constitutes physical and verbal abuse. All staff revealed they completed a post-test to validate understanding of the Abuse policy and reporting requirements. Interview with the CED, on 03/06/2020 at 3:30 PM, revealed the facility had no agency staff at this time. Review of the Staff Education for new employee orientation, revealed training related to the facility Abuse policy and reporting requirements was included. Interview with the CRC, on 03/06/2020 at 2:47 PM, revealed new staff will receive training related to the facility Abuse policy and reporting requirements during orientation. 16. Review of Education Sheets signed by the CNE, revealed the CNE did receive re-education on Abuse Policy and reporting requirements along with a pre and post test on 01/27/2020. The CNE was unavailable for interview as she had resigned and no longer worked at the facility. 17. Review of the Abuse/Neglect Employee Interview Sheets, revealed starting on 01/17/2020, Social Services, CED, ADON, CRC, NPE and Licensed Nurses, performed interviews with five (5) employees daily across all shifts x two (2) weeks, then interviewed employees as per the outlined schedule in the AoC. Interview with the Social Worker, on 03/06/2020 at 1:40 PM, revealed she assisted with staff interviews, and if there were any concerns she would report them to her CED immediately. Interview with the CRC, on 03/06/2020 at 1:47 PM, revealed she assisted with staff interviews on all three (3) shifts and any concerns were being brought to the CED to be addressed immediately. Interview with the CED, on 03/06/2020 on 2:03 PM, revealed employee interview audits were brought to the morning meeting to discuss any concerns and address any issues with the employee interviews related to abuse. Interview with Registered Nurse (RN) #2, on 03/06/2020 at 12:13 PM; SRNA #6, on 03/06/2020 at 12:16 PM; Dietary Manager, on 03/06/2020 at 12:30 PM; Dietary Aide #1, on 03/06/2020 at 12:50 PM; and RN #1, on 03/06/2020 at 1:03 PM, revealed they had been interviewed by administration regarding the facility Abuse Policy and reporting requirements. 18. Review of the Resident Body Audit Sheets, starting 01/17/2020, revealed the audits for all residents were completed for two (2) weeks daily. Review of the Weekly Skin Assessments, for the months of February and March 2020, revealed they were completed for all residents ongoing. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed the facility had a schedule of which residents were due for weekly skin assessments. Per interview, the licensed nurse performed the skin assessment and entered it into the electronic health record. Further, several administrative staff members were reviewing the skin assessments to ensure they were completed and addressing any concerns. He stated this was an ongoing compliance audit. Interview with the NPE, on 03/06/2020 at 2:10 PM, revealed she was auditing skin assessments completed by the licensed nurses and was utilizing the audit form provided by administration. She further stated if there were any concerns she ensured the CED or Interim DON (previous ADON) were aware in order for the concern to be addressed immediately. 19. Review of the Abuse/Neglect Resident Interview Sheets, completed by administration or licensed nurses, revealed on 01/17/2020 the facility started interviewing five (5) residents daily across all shifts and this was ongoing per the schedule outlined in the AoC. Per review, residents had no reports of abuse or neglect. Interview with the NPE, on 03/06/2020 at 12:13 PM; Social Services, on 03/06/2020 at 1:40 PM; and the CRC, on 03/06/2020 at 1:47 PM, revealed they had been assisting with the resident abuse interviews as per the schedule outlined in the AoC. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed he was ensuring the interviews for the residents were being completed. Per interview, the resident interviews were discussed in the QAPI meetings. 20. Re[TRUNCATED]

Based on interview, record review, review of the facility's Policy, and review of the Kentucky Revised Statues (KRS), it was determined the facility failed to ensure all alleged violations involving abuse or neglect, were reported immediately, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse to the Administrator of the facility and to State Agencies for one (1) of eighteen (18) sampled Residents (Resident #54). State Registered Nurse Aide (SRNA) #2 alleged she witnessed SRNA #1 put her hand against Resident #54's mouth and nose, push down, and say, Do not fucking spit on me again, on 01/12/2020 at approximately 1:15 PM. However, SRNA #2 failed to report the alleged violation to Licensed Practical Nurse (LPN) #1, (assigned nurse) or to administrative staff. SRNA #2 did inform SRNA #3 of the alleged violation and SRNA #3 reported the alleged violation to SRNA #4. SRNA #4 reported the alleged violation to LPN #1 on 01/12/2020 at approximately 2:20 PM. LPN #1 immediately notified the Assistant Director of Nursing (ADON) of the allegation, and the ADON obtained Verbal Statements from SRNA #1, SRNA #2 and SRNA #3 on 01/12/2020. However, from the Verbal Statements obtained on 01/12/2020, the Center Executive Director (CED) and the ADON did not identify there was an allegation of abuse. On 01/14/2020, SRNA #2 heard SRNA #1 worked at the facility on 01/13/2020, and questioned the CED as to why SRNA #1 had not been suspended. Subsequently, Written Statements were obtained from staff on 01/15/2020, and Administration identified the incident as an allegation of abuse. SRNA #1, the alleged perpetrator, worked the remainder of her shift on 01/12/2020, and worked on 01/13/2020, providing direct resident care, allowing for the potential for further abuse until she was suspended on 01/15/2020. The State Agencies were notified of the alleged abuse on 01/15/2020, three (3) days after SRNA #1 witnessed the alleged abuse. (Refer to F-607, and F-610). The facility's failure to ensure all allegations of abuse were reported immediately to the Administrator and to State Agencies within two (2) hours, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 03/04/2020, and was determined to exist on 01/12/2020. The facility provided an acceptable credible Allegation of Compliance (AoC)/IJ Removal Plan on 03/06/2020, alleging removal of the Immediate Jeopardy on 01/18/2020. The State Survey Agency (SSA) determined the Immediate Jeopardy had been removed 01/18/2020, as alleged. In addition, the SSA validated the facility had implemented corrective action with a compliance date of 02/20/2020, prior to the SSA entering the building on 03/02/2020. Therefore, the SSA determined the facility had past-noncompliance. The findings include: Review of the facility's Abuse Prohibition Policy, dated 07/01/19 revealed anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. All reports of suspected abuse must also be reported to the patient's family and Attending Physician. Upon receiving the information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED or designee will enter the allegation into the Risk Management System (RMS) and report allegations involving abuse (physical, verbal, sexual, mental) not later than two (2) hours after the allegation is made to local law enforcement, and other agencies as required. The Center will protect patients from further harm during an investigation. Review of KRS Chapter 209.020, revealed an oral or written report was to be made immediately to the State Agencies upon knowledge of suspected abuse, neglect, or exploitation of an adult. Review of Resident #54's clinical record revealed the facility admitted the resident on 10/30/14 with diagnoses to include Dementia, and Hypertension. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/24/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (05) out of fifteen (15) which indicated severe cognitive impairment. Review of the facility's Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, faxed to the Office of Inspector General (OIG, the SSA) on 01/15/2020 at 3:00 PM, revealed an alleged incident of physical/verbal abuse occurred on 01/12/2020 involving Resident #54. Review of the facility's Investigation Report, dated 01/15/2020, signed by the CED, revealed an incident of physical/verbal abuse related to Resident #54 allegedly occurred on 01/12/2020 at approximately 1:15 PM. LPN #1 called the ADON on 01/12/2020 at 2:53 PM requesting him to reach out to SRNA #1 and SRNA #2 related to the care provided to Resident #54. Per the Investigation, on 01/12/2020 after talking to LPN #1, the ADON called SRNA #2 who explained she and SRNA #1 assisted Resident #54 to bed and while SRNA #1 was assisting the resident to sit up in the bed, the resident spit on SRNA #1. SRNA #2 alleged SRNA #1 then put her hand to the resident's mouth and stated, Don't spit on me. SRNA #2 did not report what she had witnessed to the nurses. Further, the ADON called SRNA #1 who stated she put her hand up in the air close to the resident's mouth in order to deflect further attempts to spit on her and told the resident, Stop trying to spit on me. Continued review of the Investigation Report, revealed after obtaining Verbal Statements from LPN #1, SRNA #1, SRNA #2 and SRNA #3 on 01/12/2020, the ADON and CED did not identify there was an allegation of abuse, but felt it was a lack of professionalism. However, Written Statements were not obtained in order to ensure correct information was received. Per the Investigation, on 01/14/2020, SRNA #2, notified the CED of a different version of the situation related to Resident #54 involving profane language and possible physical abuse. SRNA #1 was then instructed to come to the facility for further interview and to give a Written Statement. Per the Investigation, SRNA #2's Written Statement dated 01/15/2020, was inconsistent with the Verbal Statement obtained on 01/12/2020. On 01/15/2020, SRNA #2 alleged that on 01/12/2020, SRNA #1 put her hands on Resident #54's mouth and nose and it looked like she pushed onto the resident's face. After receiving this allegation from SRNA #2, the ADON and the CED determined this was an allegation of abuse. Additional review of the Investigation, revealed the alleged perpetrator, SRNA #1, was suspended on 01/15/2030 after the allegation was reported to the CED. SRNA #2 was also suspended on 01/15/2020 for not reporting the allegation of abuse to her direct supervisor on 01/12/2020. Per the Investigation, Resident #1 was interviewed on 01/15/2020 and did not recall anyone being physically or verbally mean to him/her. The facility reported the allegation to Adult Protective Services (APS) and the Ombudsman on 01/15/2020 at 3:00 PM, and reported the allegation to Resident #54's Physician and Son on 01/15/2020 at 4:00 PM. Interview with SRNA #3, on 03/04/2020 at 9:18 AM, revealed on the afternoon of 01/12/2020 at approximately 2:00 PM, SRNA #2 told her SRNA #1 had put her hand over Resident #54's mouth and cursed at the resident. She stated she advised SRNA #2 to report the incident to the charge nurse. SRNA #3 further stated she (SRNA #3) did not report the incident to the nurse, but she did repeat what SRNA #2 told her to SRNA #4 and SRNA #4 immediately told LPN #1. SRNA #3 stated the ADON called her shortly after that and took a Verbal Statement. Further interview revealed she felt this was an allegation of verbal and physical abuse. Interview with LPN #1, on 03/04/2020 at 9:45 AM, revealed, she was approached by SRNA #4, on 01/12/2020 at approximately 2:20 PM, who reported an alleged incident involving Resident #54, SRNA #1 and SRNA #2. She stated SRNA #4 reported that SRNA #1 allegedly put her hand over Resident #54's mouth because the resident was trying to spit. LPN #1 stated SRNA #4 did not witness the incident, but was notified of the incident by SRNA #3. LPN #1 further stated she immediately called the ADON to report the allegation. Continued interview with LPN #1, verified she was assigned to Resident #54 on the afternoon of 01/12/2020; however, she stated SRNA #2 did not report any allegation of abuse to her on the afternoon of 01/12/2020, nor was she aware Resident #54 was having behaviors that afternoon. Per interview, it was not okay to put your hand over a resident's mouth, as this would be considered physical abuse and any allegation of abuse of any kind should be reported immediately to the direct Supervisor, the ADON, Director of Nursing (DON) or CED and the perpetrator should be immediately removed from resident care. Per interview, SRNA #1 had already clocked out for the day when SRNA #4 notified her of the incident on 01/12/2020. Further interview revealed any allegation of abuse was to be reported to the CED and then to State Agencies within two (2) hours. Phone interview with SRNA #2, on 03/04/2020 at 10:50 AM, revealed on 01/12/2020, she (SRNA #2) and SRNA #1 were assigned to Resident #54. Per interview, on that date at approximately 1:15 PM, they were using the Hoyer lift (mechanical lift) to transfer the resident to bed, and once the resident was in the bed, SRNA #1 asked the resident to sit up so she could remove the lift pad. Per interview, when the resident sat up he/she spit on SRNA #1. SRNA #2 stated, SRNA #1 then put her hand over the resident's mouth and nose and pushed down and said, Do not ever fucking spit on me again. SRNA #2 further stated she told SRNA #3 what happened, but she did not report the incident to LPN #1 because she and SRNA #1 were best friends inside and outside of work, and she did not think LPN #1 would do anything. Per interview, she realized now she should have notified another nurse in the building or called the ADON to report the incident. Additional interview with SRNA #2, revealed she did receive a call later that day on 01/12/2020 at approximately 3:30 PM, from the ADON asking for her Verbal Statement via telephone. She stated she told the ADON, that SRNA #1 put her hand over the resident's mouth and nose and pushed down and said, Do not ever fucking spit on me again. SRNA #2 further stated, on 01/14/2020, she found out SRNA #1 had worked the previous day and then called the CED to inquire as to why SRNA #1 had not been suspended. Per interview, the CED then went to find the ADON, and both the CED and ADON spoke to her on the phone. SRNA #2 stated during the three (3) way phone conversation she again re-iterated what she witnessed on 01/12/2020, and was then accused of giving a different Statement as compared to the Verbal Statement she gave the ADON on 01/12/2020. Per interview, she was instructed to come to the facility the following day on 01/15/2020 to provide a Written Statement. Interview with SRNA #1, on 03/05/2020 at 8:11 AM, revealed on 01/12/2020, she was assigned to Resident #54 and SRNA #2 assisted her with transferring the resident to bed with the Hoyer Lift. Per interview, once the resident was in the bed, she asked the resident to sit up so she could remove the lift pad out from under him/her and the resident sat up and spit in her face. She further stated she placed her hand up between her and the resident's mouth to prevent her/him from spitting on her, and told the resident not to spit on her again. Further interview revealed she received a call from the ADON on 01/12/2020, after she had left the facility and he told her it was reported that she put her hands on a resident's mouth. SRNA #1 denied she put her hand over the resident's mouth and nose, and also denied using foul language or abusing Resident #54. Additional interview revealed she was suspended a few days later on 01/15/2020. Review of the time clock data revealed SRNA #1 continued to work on 01/12/2020 until clocking out at 1:59 PM and also worked 01/13/2020 from 05:53 AM until 1:58 PM. Interview on 03/04/2020 at 3:17 PM, with the Interim Director of Nursing (DON), revealed he was the ADON at the time of the alleged violation on 01/12/2020 involving Resident #54. Per interview, on 01/12/2020 at approximately 2:53 PM, he received a call from LPN #1 who reported SRNA #4 informed her that SRNA #2 witnessed SRNA #1 put her hand over Resident #54's mouth and also witnessed SRNA #1 to tell the resident not to spit on her. He stated LPN #1 told him that SRNA #4 heard this from SRNA #3. Continued interview revealed he then phoned SRNA #1, SRNA #2 and SRNA #3 for Verbal Statements. He stated based on his interviews with SRNA #1, SRNA #2 and SRNA #3, on 01/12/2020, he and the CED did not identify this as an abuse allegation, and therefore did not report the allegation to State Agencies or ensure SRNA #1 was suspended. However, he stated on 01/14/2020, there was a three (3) way phone conversation with the Interim DON, SRNA #2 and the CED, and SRNA #2 alleged during the phone conversation that SRNA #1 put her hand over Resident #54's mouth and nose and told the resident to stop fucking spitting on her. Additional interview revealed SRNA #2 should have immediately reported the allegation of abuse on 01/12/2020, and the alleged perpetrator, SRNA #1, should have been immediately removed from resident care and suspended to prevent further potential abuse to Resident #54 or other residents. The Interim DON verified SRNA #1 did continue to work the rest of the shift on 01/12/2020 after the alleged abuse was witnessed and also worked on 01/13/2020 before she was suspended on 01/15/2020. Interview with the CED, on 03/06/2020 at 9:06 AM, revealed the alleged abuse witnessed on 01/12/2020 related to Resident #54 should have been reported to the charge nurse or administrative staff immediately by SRNA #2. Further, SRNA #1, the alleged perpetrator, should have been immediately removed from direct care and suspended pending an investigation. Per interview, the State Agencies should have been notified of the allegation within two (2) hours, as per Policy and as per State Regulation. However, the CED stated when the incident was relayed to him on 01/12/2020, by the Interim DON, who was the ADON at the time, abuse was not mentioned. Additional interview revealed as a result of staff failing to immediately report the allegation of abuse, SRNA #1 continued working on 01/12/2020 and on 01/13/2020 allowing for the potential for further abuse. The facility provided and acceptable credible Allegation of Compliance (AoC)/IJ Removal Plan on 03/06/2020 that alleged removal of the Immediate Jeopardy (IJ) on 01/18/2020. Review of the AoC/IJ Removal Plan revealed the facility implemented the following: 1. On 01/12/2020, the Assistant Director of Nursing (ADON) interviewed SRNAs involved (SRNA #1 and SRNA #2) regarding the incident related to Resident #54. 2. On 01/12/2020, Licensed Practical Nurse (LPN) #2 completed a head to toe assessment of Resident #54 for any signs of abuse with no corrective action required. Resident #54 was calm and resting quietly at the time of the skin assessment, and the resident did not make any statements. 3. On 01/15/2020, the Center Executive Director (CED) notified the Physician and Resident #54's family member of the allegation and the pending investigation. 4. On 01/15/2020, Resident #54 was interviewed by the Social Service Director (SSD) and the resident stated he/she was well taken care of and had no fear of anyone at the facility. 5. On 01/15/2020, Written Witness Statements were obtained from LPN #1, SRNA #1, SRNA #2, SRNA #3 and SRNA #4. 6. On 01/15/2020, the ADON entered the allegation related to Resident #54 that allegedly occurred on 01/12/2020, into the Risk Management System (RMS). 7. On 01/15/2020, the CED reported the allegation involving Resident #54 to Adult Protective Services (APS), Ombudsman, and the Office of Inspector General (OIG). 8. On 01/15/2020, an AdHOC Quality Assurance/Performance Improvement (QAPI) meeting was held related to the allegation of abuse towards Resident #54. Members in attendance included the CED, ADON, Medical Director, and Social Services. Discussion included development of an action plan including assessment and re-education as well as audits and compliance monitors. The Abuse Policy was discussed, with emphasis on a thorough investigation, timely reporting, and following policy. 9. On 01/16/2020, Resident #54 was re-assessed by LPN #7 with no concerns or corrective action. 10. On 01/17/2020, the Clinical Reimbursement Coordinator (CRC) updated Resident #54's Comprehensive Care Plan and Kardex (Nurse Aide Care Plan) to include interventions to safely care for the resident when behaviors such as spitting occurs. 11. On 01/15/2020, the ADON, SSD, Activity Director and Licensed Nurses interviewed all interviewable residents with a Brief Interview for Mental Status (BIMS) of eight (8) and above to determine if they had experienced or witnessed any abuse in the center including physical abuse. No further concerns were noted. 12. On 01/16/2020, the ADON and Licensed Nurses completed skin assessments for all non-interviewable residents with a Brief Interview for Mental Status (BIMS) of seven (7) or below to determine injury associated with possible abuse. There were no abnormal findings from these skin assessments. 13. On or before 01/17/2020, the CED, and ADON, were re-educated related to the Abuse Policy and reporting requirements and completed post-test by the Regional [NAME] President of Operations (RVPO) or Clinical Quality Specialist (CQS). 14. On or before 01/17/2020, the CRC and Nurse Practice Educator (NPE) were re-educated related to the Abuse Policy and reporting requirements and completed post-tests. The education was provided by the CED and ADON. 15. Starting on 01/16/2020, re-education was provided by the ADON, NPE and CRC for all administrative staff, nursing, therapy, dietary, housekeeping, laundry, and maintenance staff related to the Abuse policy and reporting requirements, to include what constitutes physical and verbal abuse. All staff completed a post-test to validate understanding of the Abuse policy and reporting requirements. By 01/17/2020, seventy four (74) of one hundred (100) employees had been re-educated. Staff not available during this timeframe will be provided re-education and complete a post-test upon day of return to work before providing care by the CED, CRC, NPE, Social Services, or ADON. New staff will be provided education and complete post-tests by the CED, Social Services, CRC, NPE, ADON or CNE during orientation. The facility does not utilize agency staffing at this time. 16. The Center Nurse Executive (CNE) will be re-educated on day of return from Medical Leave by the CED and CQS. 17. On 01/17/2020, Social Services, CED, ADON, CRC, NPE or Licensed Nurses will interview five (5) employees daily across all shifts x two (2) weeks including weekends and holidays, then three (3) x per week x two (2) weeks, then two (2) x per week x four (4) weeks and then every other week x eight (8) weeks, then monthly x one (1) month, then ongoing thereafter as determined by the QAPI committee to ensure staff understand the abuse policy including reporting allegations to the CED immediately. Any concerns identified will be addressed at that time. 18. Starting on 01/17/2020, the CNE, ADON, CRC, NPE or Licensed Nurses will complete body audits of all residents daily for two (2) weeks then weekly for ten (10) weeks to ensure no evidence of abuse with corrective action upon discovery. 19. Starting on 01/17/2020, the CNE, Social Services, ADON, CRC, NPE, Activity Director, admission Director, or Licensed Nurse will interview five (5) residents daily across all shifts x two (2) weeks including weekends and holidays, then three (3) x per week x two (2) weeks, then weekly x four (4) weeks, then every other week x eight (8) weeks, then monthly x one (1) month, then ongoing thereafter as determined by the QAPI committee to determine any issues with staff treatment or abuse while in the center. Any concerns identified will be addressed at that time. 20. Starting on 01/17/2020 and ongoing, the CED and/or CNE will audit abuse investigations daily x two (2) weeks including weekends and holidays; then three (3) per week x two (2) weeks; then weekly x four (4) weeks; then every other week x eight (8) weeks; then monthly x two (2) months; then ongoing thereafter as determined by the QAPI committee to determine that Abuse allegations are reported timely as per the Abuse Policy. Any concerns identified will be addressed at that time. 21. The Regional Executive Director (RED) will review for implementation of the Abuse Policy including reporting abuse allegations timely monthly for six (6) months and ongoing thereafter as determined by QAPI. 22. The QAPI Committee met on 02/19/2020 and discussed the following to ensure ongoing compliance: initial report and information; the abatement plan for IJ removal; resident interviews and findings; staff interviews; AdHOC QAPI; skin checks; staff education; abuse policy; self-reported incidents, and guidelines regarding timely reporting. Findings related to the audits and interviews will be reported to the QAPI committee monthly x six (6) months for further review and recommendation for any additional follow up and/or in-servicing until the concern is resolved and ongoing thereafter as determined by the QAPI Committee. The QAPI committee consists of the CED, CNE, ADON, Medical Director, Social Service, Director Food Service, Dietician, Health Information Manager, Business Office Manager, Therapy Program Director, Maintenance Director, Activity Director and SRNAs. The State Survey Agency validated the implementation of the facility's AoC/IJ Removal Plan as follows: 1. Review of the Written Statement, signed by the ADON, dated 01/13/2020, revealed the ADON phoned SRNAs #1, #2, and #3 on 01/12/2020 to obtain verbal witness statements related to the incident involving Resident #54. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:30 PM, revealed he called SRNAs #1, #2, and #3 on 01/12/2020 to obtain verbal witness statements related to the incident involving Resident #54. Interview with SRNA #1, on 03/05/2020 at 8:01 AM; SRNA#2, on 03/04/2020 at 9:45 AM; and SRNA #3, on 03/04/2020 at 10:05 AM, revealed they received a phone call from the Interim DON (previous ADON) on the afternoon of 01/12/2020 and gave Statements over the phone regarding the 01/12/2020 incident related to Resident #54 2. Review of the Attestation Statement, signed by LPN #2, dated 01/12/2020, revealed she completed a head to toe assessment on Resident #54 for any signs of abuse. Per the Statement, she explained the procedure to the resident, and the resident was calm and resting quietly at the time of the assessment. Further review revealed Resident #54 did not make any statements at the time of the assessment. Review of the Skin Assessment, dated 01/12/2020 at 4:00 PM, completed by LPN #2, revealed no skin issues were noted, and no injuries were noted. Phone interview was attempted with LPN #2, on 03/06/2020 at 8:00 AM; however, the nurse was unable to be reached. 3. Review of Resident #54's Progress Notes, dated 01/15/2020 at 4:00 PM, revealed the CED called the resident's Physician and family member to inform them of the allegation and pending investigation. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he did call the Physician and Resident #54's family member on 01/15/2020, to report the allegation and pending investigation. 4. Review of the Progress Note, dated 01/15/2020, revealed the SSD interviewed Resident #54 regarding the incident, with no concerns noted. Interview with the SSD, on 03/06/2020 at 2:40 PM, revealed she did interview Resident #54 on 01/15/2020, and had visited him/her several times since the incident. The SSD stated Resident #54 had no concerns, and was pleasant, smiling and had no changes in his/her behavior. 5. Interview with SRNA #2 on 03/04/2020 at 10:46 AM revealed on 01/14/2020 she was asked to come to the facility to write a Written Statement and give an interview related to the incident regarding Resident #54. Interview with SRNA #4 on 03/05/2020 at 8:33 AM; SRNA #1, on 03/05/2020 at 8:06 AM; and SRNA #3 on 03/05/2020 at 9:18 AM, revealed they were asked to provide a written Statement of what they witnessed on 01/12/2020, related to the incident regarding Resident #54. 6. Review of the RMS Event Summary Report, dated 01/15/2020, revealed the Interim DON (previous ADON) entered the alleged allegation of abuse related to Resident #54. The Summary Report also included Resident #54's date of birth , room number, primary nurse's name, event location, and notification to the Physician, family and the Police Department. Interview with the Interim DON (previous ADON), on 03/06/2020 at 2:56 PM, revealed he did in fact enter the event into the Risk Management System on 01/15/2020. 7. Review of the facility's Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, revealed OIG was notified on 01/15/2020 at 3:00 PM, of the 01/12/2020 alleged incident of physical/verbal abuse involving Resident #54. The allegation was also reported to APS and the Ombudsman on 01/15/2020 at 3:00 PM. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he did fax the facility's Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, related to the allegation involving Resident #54 to the appropriate State Agencies on 01/15/2020. 8. Review of the AdHOC QAPI Meeting Minutes and Signature Page dated 01/15/2020, revealed the CED, ADON, Medical Director, and Social Services did meet to discuss and review the 01/12/2020 incident of alleged abuse involving Resident #54. Per the Meeting Minutes, discussion included interventions to resolve potential Immediate Jeopardy (IJ) situation; immediate action plan for IJ removal; review of the investigation; review of the QAPI Audits; review of the Education; and review of the Abuse Policy and reporting guidelines with emphasis on a thorough investigation, timely reporting, and following policy. Interview with the SSD, on 03/06/2020 at 1:40 PM, revealed she did attend the QAPI meeting on 01/15/2020. She stated there was discussion related to the allegation of abuse related to Resident #54 from the 01/12/2020 incident. Per interview, the team discussed a plan to resolve the situation. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed he did attend the QAPI meeting on 01/15/2020 related to the allegation of abuse involving Resident #54. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he conducted the QAPI Meeting on 01/15/2020 to review the initial report of the allegation of abuse, and come up with a plan to abate the immediacy of the potential Jeopardy. He further stated QAPI also reviewed the Abuse policy and reporting guidelines. 9. Review of the Skin Check Assessment, dated 01/16/2020 at 7:23 PM, revealed LPN #7 completed the assessment with no concerns noted. Phone interview was attempted with LPN #7 on 03/06/2020 at 10:00 AM; however, the nurse could not be reached. 10. Review of Resident #54's Comprehensive Centered Care Plan, revealed an update by the CRC on 01/17/2020, to state if the resident exhibits increased behaviors such as spitting or hitting, ensure safety of resident and reproach as resident allows. Further review revealed provide resident with opportunities for choice during care/activities to provide sense of control. Review of Resident #54's Kardex, revealed an update on 01/17/2020 to include behaviors of spitting and interventions if spitting occurs. Interview with the CRC, on 03/06/2020 at 1:47 PM, revealed she updated Resident #54's Comprehensive Centered Care Plan and Kardex on 01/17/2020. She stated she added interventions related to the resident's increase in behaviors related to spitting. 11. Review of Resident Interviews Sheets, revealed all residents that were interviewable were interviewed on 01/15/2020. The following questions were asked to interviewable residents: 1) Do staff meet your needs?; 2) Do staff treat you like you would want to be treated?; 3) Are staff friendly when meeting your needs?; 4) Has any staff member ever spoken harshly to you?; and 5) Are you fearful of any staff member? The Resident Interviews Sheets included: Interviewer name; Resident name; and the date. Interview with the SSD, on 03/06/2020 at 1:40 PM, revealed she assisted with resident interviews on 01/15/2020. She stated none of the residents she interviewed had any concerns with care. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed he assisted with interviewing residents on 01/15/2020, and the residents had no concerns. Interview with LPN #4, on 03/06/2020 at 12:10 PM, revealed she assisted with interviewing residents on 01/15/2020. She further stated no residents voiced concerns related to any abuse at the facility. 12. Review of skin assessments completed on 01/16/2020, revealed thirty-three (33) resident skin assessments were completed out of a total of seventy-two (72) residents with no concerns noted. The skin assessments were completed for all residents with a BIMS score of seven (7) or below. Interview with LPN #6, on 03/06/2020 at 12:10 PM, revealed she assisted with performing skin assessments on residents on 01/16/2020. She further stated there were no signs of abuse with the skin assessments she completed. Interview with Registered Nurse (RN) #1, on 03/06/2020 at 1:03 PM, revealed she helped perform skin assessments on residents on 01/16/2020. She stated all shifts were helping. Per interview, she saw no signs of abuse for residents with the skin assessments she completed. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed on 01/16/2020, he and the licensed nurses performed skin assessments on all residents with a BIMS score of seven (7) or below to determine injury associated with possible abuse. 13. Review of the education and post-test documents, revealed the CDE and ADON received education related to the Abuse Policy and reporting requirements on 01/17/2020, which was provided by the CQS. Interview with Interim DON (previous ADON) on 03/06/2020 at 1:56 PM, revealed he was educated by the CQS on 01/17/2020. He stated the education included the Abuse Policy, and reporting requirements, Per interview, he also had to complete a pre and post-test. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he received education regarding the Abuse Policy and reporting requirements on 01/17/2020 by the CQS. Further interview revealed he also completed pre and post tests. Interview with the CQS, on 03/06/2020 at 2:15 PM, revealed she did provide education on the Abuse Policy and reporting requirements to the ADON and CDE on 01/17/2020. She stated they also had to also complete pre and post tests. 14. Review of the education and post-test documents, revealed the CRC and NPE were re-educated related to the Abuse Policy and reporting requirements and completed post-tests. The education was provided by the CED and the ADON. Interview with the with the NPE, on 03/06/2020 at 12:13 PM; and the CRC on 03/06/2020 at 1:47 PM, revealed the Interim [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the facility's Policy, it was determined the facility failed to initiate a thorough investigation in response to an alleged violation of abuse, allowing for further potential abuse for one (1) of eighteen (18) sampled residents (Residents #54). On 01/12/2020 at approximately 1:15 PM, State Registered Nursing Aide (SRNA) #1 and SRNA #2 entered Resident #54's room to assist the resident to bed after lunch. SRNA #2 alleged Resident #54 spit on SRNA #1, and then SRNA #1 put her hand against the resident's mouth and nose, pushed down, and stated, Do not fucking spit on me again. SRNA #2 failed to report the allegation to Licensed Practical Nurse (LPN) #1 (assigned nurse), or to Administration, but did tell SRNA #3 what she had witnessed. SRNA #3 apprised SRNA #4 of the allegation, and SRNA #4 reported the allegation to LPN #1 on 01/12/2020 at approximately 2:20 PM. Although LPN #1 immediately notified the Assistant Director of Nursing (DON) of the allegation, only Verbal Statements were obtained from staff including SRNA #1, SRNA #2, and SRNA #3, with no validation from these staff members that the Verbal Statements written down by the ADON were accurate. From the Verbal Statements obtained on 01/12/2020, the Center Executive Director (CED) and the Assistant DON felt there was lack of professionalism and did not identify there was an allegation of abuse, and did not further investigate. Facility Policy was not followed related to initiating a thorough investigation within twenty-four (24) hours as to whether abuse or neglect occurred, nor was facility Policy followed related to thoroughly documenting the investigation into the Risk Management System (RMS) to include documentation of witnessed interviews. On 01/14/2020, when SRNA #2 heard SRNA #1 worked at the facility on 01/13/2020, she questioned the CED as to why the SRNA had not been suspended. Subsequently written Statements were obtained from staff on 01/15/2020, and Administration identified the incident as an allegation of abuse and suspended SRNA #1 on that date. Due to the facility's failure to initiate a thorough investigation, SRNA #1, the alleged perpetrator, continued to work the remainder of her shift on 01/12/2020, and on 01/13/2020, providing direct resident care, allowing for the potential for further abuse (Refer to F-607, and F-609). The facility's failure to ensure thorough investigations were initiated for alleged violations of abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 03/04/2020, and was determined to exist on 01/12/2020. The facility provided an acceptable credible Allegation of Compliance (AoC)/IJ Removal Plan on 03/06/2020, alleging removal of the Immediate Jeopardy on 01/18/2020. The State Survey Agency (SSA) determined the Immediate Jeopardy was removed on 01/18/2020, as alleged. In addition, the SSA validated the facility had implemented corrective action with a compliance date of 02/20/2020, prior to the SSA entering the building on 03/02/2020. Therefore, the SSA determined the facility had past-noncompliance. The findings include: Review of the facility's Abuse Prohibition Policy, dated 07/01/19 revealed anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. An investigation will be initiated within twenty-four (24) hours of an allegation of abuse that focuses on whether abuse or neglect occurred and to what extent; clinical examination for signs of injuries, if indicated; causative factors; and interventions to prevent further injury. The investigation will be thoroughly documented within the Risk Management System with documentation of witnessed interviews. Conduct interviews using the Alleged Perpetrator/Victim Interview Record and Witness Interview Record. Further, the Center will protect patients from further harm during an investigation. Review of Resident #54's medical record revealed the facility admitted the resident on 10/30/14 with diagnoses to include Dementia, and Hypertension. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/24/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (05) out of fifteen (15) indicating severe cognitive impairment. Observation of Resident #54, on 03/04/2020 at 8:30 AM, revealed the resident was sitting up in a geriatric chair, watching television, with no behaviors noted. Interview was attempted with the resident; however, the resident was not interviewable. Review of the facility's Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, faxed to the Office of Inspector General (OIG) on 01/15/2020 at 3:00 PM, revealed an alleged incident of physical/verbal abuse occurred on 01/12/2020 involving Resident #54. Review of the facility's Investigation Report, dated 01/15/2020, signed by the CED, revealed an incident of physical/verbal abuse related to Resident #54 allegedly occurred on 01/12/2020 at approximately 1:15 PM. Per the Investigation, LPN #1 called the ADON on 01/12/2020 at 2:53 PM, and asked him to reach out to SRNA #1 and SRNA #2 about the care provided to Resident #54. On 01/12/2020, after the call from LPN #1, the ADON called SRNA #2, who stated that she and SRNA #1 were assisting Resident #54 to bed and the resident spit on SRNA #1 while she was helping the resident to sit up in order for the Hoyer lift pad to be removed. SRNA #2 alleged SRNA #1 put her hand to Resident #54's mouth and stated, Don't spit on me. SRNA #2 finished her shift and did not report any allegations to the nurses. On 01/12/2020, the ADON called SRNA #1 and she informed the ADON, that she (SRNA #1) put her hand up in the air close to the resident's mouth to deflect any further attempts to spit on her and told the resident, Stop trying to spit on me. Further review of the facility's Investigation Report, revealed after speaking with LPN #1, SRNA #1, SRNA #2 and SRNA #3 on 01/12/2020 and obtaining Verbal Statements, the ADON and CED did not identify this as an allegation of abuse, but felt it was a lack of professionalism. However, there was no documented evidence SRNA #1, SRNA #2 and SRNA #3 validated or signed the Statements obtained by the ADON on 01/12/2020. Per the Investigation, on 01/14/2020, SRNA #2 called and notified the CED of a different version of the situation related to Resident #54 which involved profane language and possible physical abuse. SRNA #2 was instructed to come to the facility for further interview and to give a Written Statement. SRNA #2's Written Statement on 01/15/2020 was inconsistent with the Verbal Statement obtained on 01/12/2020. On 01/15/2020, SRNA #2 alleged that on 01/12/2020, SRNA #1 stated to Resident #54, Do not fucking spit on me again. SRNA #2 further alleged that SRNA #1 put her hands on the resident's mouth and nose and it looked like she pushed onto the resident's face. On 01/15/2020, the ADON and the CED determined this was an allegation of abuse. The allegation was reported to Adult Protective Services (APS) and the Ombudsman on 01/15/2020 at 3:00 PM. Resident #54's Physician and Son were notified on 01/15/2020 at 4:00 PM. Continued review of the Investigation, revealed the alleged perpetrator, SRNA #1, was suspended on 01/15/2020, after the allegation was reported to the CED. In addition, SRNA #2 was suspended on 01/15/2020 for not immediately reporting the allegation of abuse to her direct supervisor on 01/12/2020. Per the Investigation, Resident #1 was interviewed on 01/15/2020, and could not recall anyone being physically or verbally mean to him/her. Further review of the Investigation, revealed the facility was unable to determine if abuse occurred as all interviews conducted during the investigation revealed no facts to support the allegation, and Resident #1 had no signs of injury. Review of SRNA #2's Verbal Statement obtained from the ADON over the phone, dated 01/12/2020, untimed, revealed on 01/12/2020, after SRNA #1 and SRNA #2 assisted the resident to lye down, SRNA #1 asked the resident to sit up, and the resident spit at SRNA #1. SRNA #2 witnessed SRNA #1 put her hand over Resident #54's mouth and tell the resident not to spit on her (SRNA #1), and this was done in a manner which was unprofessional. This Statement was not signed by SRNA #2. Review of SRNA #2's Written Statement, dated 01/15/2020 at 1:47 PM, revealed on 01/12/2020 at 1:15 PM, SRNA #2 witnessed SRNA #1 to put her hand against the resident's mouth and nose, push down, and state, Do not fucking spit on me again. Phone interview with SRNA #2, on 03/04/2020 at 10:50 AM, revealed on the afternoon of 01/12/2020, she (SRNA #2) and SRNA #1 were assigned to Resident #54. Per interview, on that date at approximately 1:15 PM, they were using the Hoyer lift (mechanical lift) to transfer the resident to bed. SRNA #2 stated Resident #54 was asked to sit up in order for the lift pad which was under the resident to be removed, and when the resident sat up he/she spit on SRNA #1. Per interview, SRNA #1 then put her hand over the resident's mouth and nose and pushed down and said, Do not ever fucking spit on me again. SRNA #2 further stated she informed SRNA #3 of what happened, but she did not report what she had witnessed to LPN #1 because LPN #1 and SRNA #1 were best friends. Further interview with SRNA #2, revealed she did receive a call later that day on 01/12/2020 at approximately 3:30 PM, from the ADON asking for her Verbal Statement via telephone. Per interview, she told the ADON, that SRNA #1 put her hand over the resident's mouth and nose and pushed down and said, Do not ever fucking spit on me again. SRNA #2 further stated, on 01/14/2020, she heard that SRNA #1 had worked the previous day and she called the CED to inquire as to why SRNA #1 had not been suspended. She stated the CED then went to find the ADON, and both the CED and ADON spoke to her on the phone. Per interview, during the three (3) way phone conversation she again re-iterated what she witnessed on 01/12/2020, and was accused of giving a different Statement as compared to the Verbal Statement she gave the ADON on 01/12/2020. Per interview, she was asked to come in the following day on 01/15/2020 to provide a Written Statement. Review of SRNA #1's Written Statement, dated 01/15/2020 at 12:45 PM, revealed when she (SRNA #1) and SRNA #2 were assisting Resident #54 to bed, she raised him/her up to remove the lift pad and the resident spit on her. SRNA documented she raised her hand up between her face and the resident to block the resident from spitting and told the resident, Do not spit on me again, and continued with care. Interview with SRNA #1, on 03/05/2020 at 8:11 AM, revealed on 01/12/2020, she was working with SRNA #2 and was assigned to Resident #54. She stated the resident required the use of a Hoyer lift to be transferred to bed. Per interview, once the resident was in the bed, she asked the resident to sit up so she could remove the lift pad out from under him/her. SRNA #1 stated when Resident #54 sat up, he/she spit in her face, so she placed her hand up between herself and the resident's mouth to prevent him/her from spitting on her again, and told the resident not to spit. She stated she received a call from the ADON on 01/12/2020, after she left the facility and he told her it was reported that she put her hands on a resident's mouth. SRNA #1 denied putting her hand over the resident's mouth and nose, and denied using foul language towards the resident. Continued interview revealed she was suspended a few days later on 01/15/2020. Review of the time clock data revealed SRNA #1 continued to work on 01/12/2020 until clocking out at 1:59 PM and also worked 01/13/2020 from 5:53 AM until 1:58 PM. Review of LPN #1's Written Statement, dated 01/15/2020 at 9:06 AM, revealed SRNA #2 reported to SRNA #3, that SRNA #1 had put her hand over Resident #54's mouth, raised her voice and said something to the resident. Further review revealed the allegation was reported to SRNA #4 by SRNA #3, and subsequently SRNA #4 reported the allegation to LPN #1. Interview with LPN #1, on 03/04/2020 at 9:45 AM, revealed, on 01/12/2020 at approximately 2:20 PM, she was approached by SRNA #4, who reported an alleged incident that happened earlier involving Resident #54, SRNA #1 and SRNA #2. LPN #1 stated SRNA #4 reported that SRNA #1 allegedly put her hand over Resident #54's mouth because the resident was trying to spit. Per interview, SRNA #4 had not witnessed the incident, but was notified of the incident by SRNA #3. LPN #1 stated she immediately went back to the nurse's station and called the ADON to report the allegation in order for him to further investigate. She further stated she assessed the resident and saw no injuries or redness. LPN #1 confirmed she was assigned to Resident #54 on the afternoon of 01/12/2020, but SRNA #2 did not report any allegation of abuse to her on the afternoon of 01/12/2020, nor was she aware Resident #54 was having behaviors that afternoon. LPN #1 confirmed she did not obtain written Statements from any staff after being informed of the allegation on 01/12/2020. Further interview revealed SRNA #1 had already left to go home by the time she was notified of the alleged incident. She stated any allegation of abuse was to be reported immediately to the Supervisor, ADON, Director of Nursing (DON) or CED and the perpetrator was to be immediately removed from resident care. Review of SRNA #3's Verbal Statement, undated and untimed, and documented on a paper with no name of the person taking the Statement, revealed, Not seen anything. This Statement was obtained by the ADON on 01/12/2020 per the facility Investigation. This Statement was not signed by SRNA #3. Review of SRNA #3's Written Statement, dated 01/15/2020 at 9:20 AM, revealed SRNA #2 reported to her that SRNA #1 grabbed Resident #54's face and yelled at him/her. Per the Statement, she had no further comments to add, nor did she witness any type of abuse. Interview with SRNA #3, on 03/04/2020 at 9:18 AM, revealed on the afternoon of 01/12/2020 at approximately 2:00 PM, SRNA #2 informed her SRNA #1 had put her hand over Resident #54's mouth and cursed at the resident. Per interview, she advised SRNA #2 to report what she had witnessed to the Charge Nurse. SRNA #3 stated she (SRNA #3) did not report the incident to the nurse, but did tell SRNA #4. SRNA #3 further stated the ADON called her shortly afterwards and took a Verbal Statement. Per interview, it was not okay to put your hands on a resident or curse a resident. She stated she felt this was an allegation of verbal and physical abuse and no one deserved to be abused. Review of SRNA #4's Written Statement, dated 01/15/2020 at 1:00 PM, revealed SRNA #3 reported to her that when SRNA #1 and SRNA #2 were providing care, SRNA #1 grabbed Resident #54's face and yelled at the resident. Per the Statement, SRNA #4 was not there when the incident happened. Phone interview with SRNA #4, on 03/05/2020 at 8:33 AM, revealed on 01/12/2020 at 2:20 PM, SRNA #3 informed her that SRNA #2 had witnessed SRNA #1 grab Resident #54's jaws and scream at the resident. Per interview, she felt it was verbal and physical abuse and immediately reported what she had been told to LPN #1. She stated LPN #1 then called the ADON. She further stated she did not receive a call from anyone on 01/12/2020 asking her for a Statement. Per interview, she was told to submit a Statement on 01/15/2020 via telephone and she signed it the following day on 01/16/2020. Review of the ADON's Written Statement, dated 01/13/2020, untimed, revealed he received a phone call at home on [DATE] at 2:53 PM, regarding an incident that occurred at the facility from LPN #1 on East Station. After the conversation with LPN #1, he placed phone calls to parties involved (SRNA #1, SRNA #2 and SRNA #3) as well as the facility's CED. According to LPN #1, the incident in question was reported to her by SRNA #4, who had heard information from SRNA #3, who was apprised of the situation from SRNA #2. Per the Statement, the event transpired at approximately 1:15 PM to 1:25 PM on 01/12/2020. Further review of the ADON's Statement, revealed a phone interview was conducted on 01/12/2020 at approximately 2:45 PM with SRNA #2, which revealed SRNA #1 asked the resident to sit up, and at that moment the resident spit on SRNA #1. SRNA #2 informed the ADON she saw SRNA #1 put her hand over the resident's mouth and say, Don't you spit on me, in a manner that she felt was unprofessional. Per the Statement, the ADON discussed with SRNA #2 about the delay in reporting any type of incident that she felt was unprofessional. SRNA #2 explained LPN #1 and SRNA #1 were friends, and she felt if it was reported to LPN #1, nothing would transpire as a result. The ADON informed SRNA #2 that there were three (3) other nurses in the facility at the particular time as well as a phone listing of all department heads that were available to be contacted at any time. Additional review of the ADON's Statement, revealed a phone interview was conducted with SRNA #1, on 01/12/2020. SRNA #1 explained Resident #54 spit on her and she put her hand in the air close to the resident's mouth to deflect any further attempts to spit, and at no time did her hand come in contact with the resident's mouth. SRNA #1 informed the ADON, she told the resident, Stop trying to spit on me, and then continued providing care. Per the Statement, the facility CED was notified of the incident via telephone on 01/12/2020 at 3:45 PM. Interview was conducted on 03/04/2020 at 3:17 PM, with the Interim Director of Nursing (DON), who was the ADON at the time of the alleged violation on 01/12/2020, involving Resident #54. The Interim DON stated, on 01/12/2020 at approximately 2:53 PM, he received a call from LPN #1 who reported SRNA #4 informed her that SRNA #2 witnessed SRNA #1 put her hand over Resident #54's mouth and also witnessed SRNA #1 to tell the resident not to spit on her. Per interview, LPN #1 told him that SRNA #4 heard this from SRNA #3. The Interim DON stated he told LPN #1 he would call the staff involved to find out the facts. Continued interview with the Interim DON, revealed he phoned SRNA #2 on 01/12/2020 and was told after Resident #54 spit on SRNA #1, she witnessed SRNA #1 put her hand over the resident's mouth and say, Don't you spit on me, in an unprofessional manner. Per interview, he then phoned SRNA #1 and SRNA #3 for Verbal Statements. Further interview revealed based on his interviews with SRNA #1, SRNA #2 and SRNA #3, on 01/12/2020, he and the CED did not identify this as an abuse allegation, but did identify lack of professionalism. However, he stated on 01/14/2020, there was a three (3) way phone conversation with the Interim DON, SRNA #2 and the CED, and SRNA #2 informed them what the ADON had typed up as her Verbal Statement was incorrect. Per interview, SRNA #2 alleged during the phone conversation that she had already informed the Interim DON, that SRNA #1 put her hand over Resident #54's mouth and nose and told the resident to stop fucking spitting on her. Continued interview with the Interim DON, revealed SRNA #2 should have immediately reported the allegation of abuse on 01/12/2020, and the alleged perpetrator, SRNA #1 should have been immediately removed from resident care and suspended to prevent further potential abuse to Resident #54 or other residents. He further verified SRNA #1 did continue to work the rest of the shift on 01/12/2020 after the alleged abuse was witnessed and also worked on 01/13/2020 before she was suspended on 01/15/2020. Additional interview with the Interim DON, revealed the investigation involving Resident #54 was his first abuse investigation and he should have investigated further as to whether abuse or neglect may have occurred as per facility Policy. He stated the Witness Statements he obtained over the phone on 01/12/2020 should have been reviewed and signed by the staff in order to ensure the correct information was documented after the incident. Further, facility Policy was not followed related to thoroughly documenting the investigation into the Risk Management System (RMS) to include documentation of witnessed interviews. Per interview, after the incident, he received re-education related to conducting abuse investigations and also received tools for completing an abuse investigation. Interview with the CED, on 03/06/2020 at 9:06 AM, revealed he acknowledged the facility's written Policy was not implemented related to investigating abuse. Per interview, the alleged abuse witnessed on 01/12/2020 related to Resident #54 was conveyed as lack of professionalism, and abuse was not identified until 01/15/2020 as a result of the facility's failure to ensure a thorough investigation was initiated in a timely manner with Written Statements obtained from staff involved. Additional interview revealed as a result of staff failing to identify the allegation as abuse and failing to promptly initiate a timely and thorough investigation on 01/12/2020, SRNA #1, the alleged perpetrator, continued working on 01/12/2020 and on 01/13/2020, allowing for the potential for further abuse. Per interview, there should be no deviation from the facility's Abuse Prohibition Policy. The facility provided and acceptable credible Allegation of Compliance (AoC)/IJ Removal Plan on 03/06/2020 that alleged removal of the Immediate Jeopardy (IJ) on 01/18/2020. Review of the AoC/IJ Removal Plan revealed the facility implemented the following: 1. On 01/12/2020, the Assistant Director of Nursing (ADON) interviewed SRNAs involved (SRNA #1 and SRNA #2) regarding the incident related to Resident #54. 2. On 01/12/2020, Licensed Practical Nurse (LPN) #2 completed a head to toe assessment of Resident #54 for any signs of abuse with no corrective action required. Resident #54 was calm and resting quietly at the time of the skin assessment, and the resident did not make any statements. 3. On 01/15/2020, the Center Executive Director (CED) notified the Physician and Resident #54's family member of the allegation and the pending investigation. 4. On 01/15/2020, Resident #54 was interviewed by the Social Service Director (SSD) and the resident stated he/she was well taken care of and had no fear of anyone at the facility. 5. On 01/15/2020, Written Witness Statements were obtained from LPN #1, SRNA #1, SRNA #2, SRNA #3 and SRNA #4. 6. On 01/15/2020, the ADON entered the allegation related to Resident #54 that allegedly occurred on 01/12/2020, into the Risk Management System (RMS). 7. On 01/15/2020, the CED reported the allegation involving Resident #54 to Adult Protective Services (APS), Ombudsman, and the Office of Inspector General (OIG). 8. On 01/15/2020, an AdHOC Quality Assurance/Performance Improvement (QAPI) meeting was held related to the allegation of abuse towards Resident #54. Members in attendance included the CED, ADON, Medical Director, and Social Services. Discussion included development of an action plan including assessment and re-education as well as audits and compliance monitors. The Abuse Policy was discussed, with emphasis on a thorough investigation, timely reporting, and following policy. 9. On 01/16/2020, Resident #54 was re-assessed by LPN #7 with no concerns or corrective action. 10. On 01/17/2020, the Clinical Reimbursement Coordinator (CRC) updated Resident #54's Comprehensive Care Plan and Kardex (Nurse Aide Care Plan) to include interventions to safely care for the resident when behaviors such as spitting occurs. 11. On 01/15/2020, the ADON, SSD, Activity Director and Licensed Nurses interviewed all interviewable residents with a Brief Interview for Mental Status (BIMS) of eight (8) and above to determine if they had experienced or witnessed any abuse in the center including physical abuse. No further concerns were noted. 12. On 01/16/2020, the ADON and Licensed Nurses completed skin assessments for all non-interviewable residents with a Brief Interview for Mental Status (BIMS) of seven (7) or below to determine injury associated with possible abuse. There were no abnormal findings from these skin assessments. 13. On or before 01/17/2020, the CED, and ADON, were re-educated related to the Abuse Policy and reporting requirements and completed post-test by the Regional [NAME] President of Operations (RVPO) or Clinical Quality Specialist (CQS). 14. On or before 01/17/2020, the CRC and Nurse Practice Educator (NPE) were re-educated related to the Abuse Policy and reporting requirements and completed post-tests. The education was provided by the CED and ADON. 15. Starting on 01/16/2020, re-education was provided by the ADON, NPE and CRC for all administrative staff, nursing, therapy, dietary, housekeeping, laundry, and maintenance staff related to the Abuse policy and reporting requirements, to include what constitutes physical and verbal abuse. All staff completed a post-test to validate understanding of the Abuse policy and reporting requirements. By 01/17/2020, seventy four (74) of one hundred (100) employees had been re-educated. Staff not available during this timeframe will be provided re-education and complete a post-test upon day of return to work before providing care by the CED, CRC, NPE, Social Services, or ADON. New staff will be provided education and complete post-tests by the CED, Social Services, CRC, NPE, ADON or CNE during orientation. The facility does not utilize agency staffing at this time. 16. The Center Nurse Executive (CNE) will be re-educated on day of return from Medical Leave by the CED and CQS. 17. On 01/17/2020, Social Services, CED, ADON, CRC, NPE or Licensed Nurses will interview five (5) employees daily across all shifts x two (2) weeks including weekends and holidays, then three (3) x per week x two (2) weeks, then two (2) x per week x four (4) weeks and then every other week x eight (8) weeks, then monthly x one (1) month, then ongoing thereafter as determined by the QAPI committee to ensure staff understand the abuse policy including reporting allegations to the CED immediately. Any concerns identified will be addressed at that time. 18. Starting on 01/17/2020, the CNE, ADON, CRC, NPE or Licensed Nurses will complete body audits of all residents daily for two (2) weeks then weekly for ten (10) weeks to ensure no evidence of abuse with corrective action upon discovery. 19. Starting on 01/17/2020, the CNE, Social Services, ADON, CRC, NPE, Activity Director, admission Director, or Licensed Nurse will interview five (5) residents daily across all shifts x two (2) weeks including weekends and holidays, then three (3) x per week x two (2) weeks, then weekly x four (4) weeks, then every other week x eight (8) weeks, then monthly x one (1) month, then ongoing thereafter as determined by the QAPI committee to determine any issues with staff treatment or abuse while in the center. Any concerns identified will be addressed at that time. 20. Starting on 01/17/2020 and ongoing, the CED and/or CNE will audit abuse investigations daily x two (2) weeks including weekends and holidays; then three (3) per week x two (2) weeks; then weekly x four (4) weeks; then every other week x eight (8) weeks; then monthly x two (2) months; then ongoing thereafter as determined by the QAPI committee to determine that Abuse allegations are reported timely as per the Abuse Policy. Any concerns identified will be addressed at that time. 21. The Regional Executive Director (RED) will review for implementation of the Abuse Policy including reporting abuse allegations timely monthly for six (6) months and ongoing thereafter as determined by QAPI. 22. The QAPI Committee met on 02/19/2020 and discussed the following to ensure ongoing compliance: initial report and information; the abatement plan for IJ removal; resident interviews and findings; staff interviews; AdHOC QAPI; skin checks; staff education; abuse policy; self-reported incidents, and guidelines regarding timely reporting. Findings related to the audits and interviews will be reported to the QAPI committee monthly x six (6) months for further review and recommendation for any additional follow up and/or in-servicing until the concern is resolved and ongoing thereafter as determined by the QAPI Committee. The QAPI committee consists of the CED, CNE, ADON, Medical Director, Social Service, Director Food Service, Dietician, Health Information Manager, Business Office Manager, Therapy Program Director, Maintenance Director, Activity Director and SRNAs. The State Survey Agency validated the implementation of the facility's AoC/IJ Removal Plan as follows: 1. Review of the Written Statement, signed by the ADON, dated 01/13/2020, revealed the ADON phoned SRNAs #1, #2, and #3 on 01/12/2020 to obtain verbal witness statements related to the incident involving Resident #54. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:30 PM, revealed he called SRNAs #1, #2, and #3 on 01/12/2020 to obtain verbal witness statements related to the incident involving Resident #54. Interview with SRNA #1, on 03/05/2020 at 8:01 AM; SRNA#2, on 03/04/2020 at 9:45 AM; and SRNA #3, on 03/04/2020 at 10:05 AM, revealed they received a phone call from the Interim DON (previous ADON) on the afternoon of 01/12/2020 and gave Statements over the phone regarding the 01/12/2020 incident related to Resident #54 2. Review of the Attestation Statement, signed by LPN #2, dated 01/12/2020, revealed she completed a head to toe assessment on Resident #54 for any signs of abuse. Per the Statement, she explained the procedure to the resident, and the resident was calm and resting quietly at the time of the assessment. Further review revealed Resident #54 did not make any statements at the time of the assessment. Review of the Skin Assessment, dated 01/12/2020 at 4:00 PM, completed by LPN #2, revealed no skin issues were noted, and no injuries were noted. Phone interview was attempted with LPN #2, on 03/06/2020 at 8:00 AM; however, the nurse was unable to be reached. 3. Review of Resident #54's Progress Notes, dated 01/15/2020 at 4:00 PM, revealed the CED called the resident's Physician and family member to inform them of the allegation and pending investigation. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he did call the Physician and Resident #54's family member on 01/15/2020, to report the allegation and pending investigation. 4. Review of the Progress Note, dated 01/15/2020, revealed the SSD interviewed Resident #54 regarding the incident, with no concerns noted. Interview with the SSD, on 03/06/2020 at 2:40 PM, revealed she did interview Resident #54 on 01/15/2020, and had visited him/her several times since the incident. The SSD stated Resident #54 had no concerns, and was pleasant, smiling and had no changes in his/her behavior. 5. Interview with SRNA #2 on 03/04/2020 at 10:46 AM revealed on 01/14/2020 she was asked to come to the facility to write a Written Statement and give an interview related to the incident regarding Resident #54. Interview with SRNA #4 on 03/05/2020 at 8:33 AM; SRNA #1, on 03/05/2020 at 8:06 AM; and SRNA #3 on 03/05/2020 at 9:18 AM, revealed they were asked to provide a written Statement of what they witnessed on 01/12/2020, related to the incident regarding Resident #54. 6. Review of the RMS E[TRUNCATED]