**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 ensure residents were protected from physical abuse for three (3) of eight (8) sampled residents (Residents #1, #6, #7). 1) On [DATE], Licensed Practical Nurse (LPN) #2 struck Resident #1 with his/her fist resulting in Resident #1 having an injury to his/her right eye. Resident #1 had to be taken to the emergency room for further evaluation and was later admitted . 2) On [DATE] Resident #6 slapped Resident #7 on the face while waiting to go outside to smoke, then in return, Resident #7 slapped Resident #6 on the face. The facility's failure to have an effective system in place to ensure residents were free from abuse, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the areas of Substandard Quality of Care at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F609) at the highest scope and severity S/S of a J; and 42 CFR §483.21 Comprehensive Person-Centered Care Plans (F656) at the S/S of a J. Substandard Quality of Care was identified at 42 CFR §483.12, Freedom from Abuse, Neglect, and Exploitation (F600 and F609). The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. The State Survey Agency (SSA) validated the IJ Removal Plan, on [DATE], and determined the facility implemented corrective action, on [DATE], as alleged, before the State Survey Agency's investigation. Therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation and Exploitation, revised on 01/2018, revealed the facility did not condone or tolerate resident abuse (this included verbal abuse, sexual abuse, physical abuse and mental abuse), neglect, misappropriation or exploitation under any circumstances by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving or visiting the resident, family members, legal guardians, sponsors, friends, or other individuals. Per the facility's policy, abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse included hitting, slapping, pinching and kicking. 1) Review of Resident #1's Facility Incident/Accident Report, dated [DATE] at 11:00 PM, signed by Registered Nurse (RN) #2, revealed Resident #1 had a laceration to his/her right cheekbone, under the eye area. The resident's Responsible Party (RP) was notified on [DATE] at 11:50 PM and the resident's physician was notified on [DATE] at 12:15 AM. Continued review revealed the physician had provided wound care orders for the laceration. Further review revealed a handwritten statement by RN #2 which stated, I was called to the shower room by Licensed Practical Nurse (LPN) #2 and when entering the room, Resident #1 was bleeding and verbally upset saying to LPN #2 that it's not over, I'm gonna get you. Ongoing review of the report revealed a small laceration was noted to the resident's cheek bone, under the resident's eye area to the right eye. Continued review revealed, as the shift was ending Certified Nurse Assistant (CNA) #1 called RN#2 and reported LPN #2 told her to say Resident #1 head butted him; however, CNA #1 told RN#2 she had not told the truth about what had occurred. CNA#1 then stated she saw Resident #1 hit at LPN #2, then LPN #2 hit the resident in the face causing a cut under Resident #1's right eye. LPN #2 then told CNA#1 to say Resident #1 had head butted LPN #2 causing the eye injury. Closed Record Review revealed the facility admitted Resident #1 on [DATE] with diagnoses that included: Parkinson's Disease, Non-ST elevation Myocardial Infarction, and Unspecified Dementia with Behaviors. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) Score of ninety-nine (99), which indicated the resident was cognitively impaired. Continued review revealed Resident #1 was not found to exhibit physical or verbal behaviors such as kicking, scratching, threatening, cursing, or screaming at others. Review of Resident #1's care plan, last revised [DATE], revealed the resident had potential for alteration in mood/behaviors due to dementia; had a history of becoming combative with staff at times when attempting to redirect with a goal to include the resident would be free from altercations in mood/behaviors due to diagnosis of dementia with behaviors. Further review of the care plan revealed interventions included: anticipate/ meet needs timely, if resists care, allow to calm down and then reproach for care, talk with resident during care and allow/encourage resident to vent feelings, and staff to back away from resident when he/she becomes combative let him/her calm down before transfers. Review of Resident #1's Psychiatry Progress Notes from [DATE] - [DATE], electronically signed by the Nurse Practitioner (NP), revealed staff reported resident exhibited resistance and combativeness towards staff during care. Further review revealed staff reported the resident received assistance with all Activities of Daily Living (ADL's). Review of a local Police Department Report, dated [DATE] to [DATE], revealed on Friday, [DATE]th, 2022, at approximately 11:00 PM, the perpetrator (LPN #2) struck the victim (Resident #1) in the right eye with his fist causing the victim (Resident #1) minor visible injury. Continued review revealed LPN #2 was interviewed by law enforcement on [DATE] and was served a criminal arrest warrant on [DATE] at 12:32 PM. Review of a Facility's Investigative Summary, dated [DATE], revealed Resident #1 was transferred to the local hospital for further evaluation and treatment. Continued review revealed all staff, except those on Family Medical Leave Act (FMLA) were interviewed about abuse or mistreatment of any resident, and if they had ever witnessed LPN #2 or anyone else abuse or mistreat a resident. Further review revealed LPN #2 was suspended then terminated and was charged with Fourth Degree Assault by local law enforcement. Review of Resident #1's Facility Incident/Accident Report, dated [DATE] at 11:00 PM, signed by Registered Nurse (RN) #2, revealed she was called to the shower room by LPN #2 and when entering the room, Resident #1 was bleeding and verbally upset saying, it's not over, I'm gonna get you. Review of an interview statement with CNA#1, dated [DATE], conducted by Clinical Nurse Consultant (CNC) after the incident occurred, revealed CNA #1 had asked LPN #2 to assist her in the shower room with Resident #1. CNA #1 stated the resident was calm until they attempted to remove Resident #1's shirt. When the shirt was being removed Resident #1 hit at LPN #2, then LPN #2 hit Resident #1 in face/eye area with his fist causing a cut under Resident #1's right eye. CNA #1 stated LPN #2 told her she would have to write a statement saying Resident #1 head butted LPN#2, which caused Resident#1's face/eye injury. CNA #1 stated she asked the LPN why and he did not respond. CNA #1 stated she was scared and intimidated by LPN #2 and that was the reason she did not tell the truth about the incident initially. On [DATE] at 11:09 AM, a telephone interview was attempted with CNA #1 ; however, was unsuccessful as there was no answer and voicemail had not been set up. On [DATE] at 11:11 AM, a Short Message Service (SMS) message was sent to CNA #1 with a response my phone has been shut off, so the State Survey Agency (SSA) Surveyor was unable to conduct for an interview. During a telephone interview with LPN #1 on [DATE] at 3:16 PM, she stated she was on call the night of [DATE] and received a call from LPN #2, reporting the accident with Resident #1 in the shower room. She stated LPN #2 reported Resident #1 had become combative and had head butted nurse. LPN #1 stated she asked if Resident #1 had an injury and was told only small discoloration. During an interview with RN #1 on [DATE] at 4:15 PM, revealed she was working day shift on [DATE], and received report from RN #2, who reported Resident #1 had head butted someone in the shower. RN #1 stated she looked over Resident #1 and saw his/her right eye was black and bruising way down to his/her cheek and his/her eye was almost swollen shut. RN #1 stated Resident #1 needed to go to the ER (Emergency Room) as she feared resident could have a facial fracture. Continued interview revealed about thirty (30) to forty-five (45) minutes into the shift, CNA #1 was at the nurses' station speaking with RN#2, informing her of LPN #2 hitting Resident #1. RN #1 stated she called the DON and then Resident #1's spouse, informing him/her of resident being transferred to the local hospital. During an interview with RN #2, on [DATE] at 1:33 PM, she stated she was working night shift on [DATE] and was called to the shower room where LPN #2, CNA #1, and Resident #1 were located. RN #2 stated Resident #1 had blood under his/her right eye and LPN #2 stated the resident had head-butted him while he was attempting to remove resident's shirt. RN #2 stated she performed first aide to the resident. In a continued interview, she stated at the end of shift, CNA #1 was crying and told RN #2 of LPN #2 using his fist and punched the resident in the eye and had told her to stick to the story of the resident head-butting him. RN #2 stated she contacted the DON immediately and was also getting other staff to check to make sure LPN #2 was off the property. On [DATE] at 2:38 PM and at 5:14 PM, a telephone interview was attempted with LPN #2, however, was unsuccessful as there was no answer. A voicemail was left for LPN #2 to return a telephone call to the SSA Surveyor; however, no return call was received. Interview with the Director of Nursing (DON) on [DATE] at 4:49 PM revealed he received a call early morning of [DATE] from LPN #1, reporting an abuse incident. The DON stated he made calls to the facility's management team and started an investigation. Continued interview revealed CNA #1 was employed by a staffing agency who was contracted with the facility. Further interview revealed CNA #1 had attended abuse training from facility staff prior to working a scheduled shift. Continued interview with the DON revealed CNA #1 stated she was afraid of LPN #2 and that was why she did not tell the truth initially. The DON stated CNA #1 reported immediately the false story of the Resident #1 head butting LPN #2 but did not report LPN #2 hitting Resident #1 and therefore, did not follow the facility's abuse policy. During an interview with the Administrator on [DATE] at 9:47 AM, he stated he was out of town on the date of the event and was made aware of the abuse allegation on [DATE] by the DON. Continued interview with the Administrator he stated the facility failed to protect the resident from harm and staff did not follow the policy to prevent abuse. 2) Review of the facility's incident Report, dated [DATE] at 1:15 PM, revealed CNA #7 reported while he was taking the residents outside for a smoke break, Resident #6 attempted to go too, and Resident #7 told Resident #6 he/she could not go because he/she did not smoke. Resident #6 slapped Resident #7 on the face, then Resident #7 slapped Resident #6 on the face. Both residents were separated and assessed to have no injuries. Both residents were placed on 1:1 with staff until seen by psychiatric (psych) services. a) Review of Resident #6's admission Record revealed the facility admitted the resident on [DATE] with diagnoses to include Traumatic Brain Injury (TBI), Dementia, Major Depressive Disorder, History of Transient Ischemic Attack (TIA); and Cognitive Communication Deficit. Review of Resident #6's Significant Change MDS, dated [DATE], revealed the facility had assessed the resident to have e BIMS score of three (3) out of fifteen (15) indicating the resident was severely cognitive impaired. Continued review revealed the resident had difficulty focusing attention and had disorganized thinking behavior present that fluctuates, which comes and goes. Further review revealed Resident #6 did not have any behaviors indicated. Continued review revealed, under the section for Preferences for Customary Routine and Activities, the resident preferred doing things with groups of people. A review of Physician Orders effective [DATE] revealed Resident #6 was prescribed Mirtazapine 15 milligram (mg) every hour of sleep; Sertraline 25 mg QD; and Memantine 10 mg by mouth twice. Review of a skin assessment dated [DATE] revealed Resident #6 had no injuries noted. Observation of Resident #6, on [DATE] at 1:05 PM, revealed the resident was sitting in the wheelchair in his/her room. The State Survey Agency (SSA) Surveyor attempted an interview with the resident, but the resident's speech was incoherent and garbled. b) Review of Resident #7's admission Record revealed the facility admitted the resident on [DATE] with diagnoses to include Bipolar Disorder, Major Depressive Disorder, Obsessive-Compulsive Disorder, and Anxiety Disorder. Review of a Quarterly MDS dated [DATE] revealed Resident #7 had a BIMS score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Continued review revealed Resident #7 had no indication of delirium or behaviors indicated. Review of Nurses Note dated [DATE] revealed the resident was assessed by psych service and no new orders were given by the Advanced Practice Registered Nurse (APRN). Review of Nurses Note dated [DATE] at 1:25 PM, revealed the resident had an altercation with another resident (Resident #6) related to Resident #6 attempted to follow Resident#7 out on smoke break. Resident #7 told Resident #6 you cannot go, resulting in Resident #6 slapping Resident #7 on the face. Resident #7 retaliated by slapping Resident#6 on the face. During an interview with Resident #7, on [DATE] at 2:30 PM, the resident stated he/she was allowed to go out and smoke six (6) times a day. Resident #7 stated We were all gathered at the doorway waiting for staff to bring the cigarettes and take us out. She stated Resident #6 was unstable and he/she started to come outside and he/she knew the resident was not allowed outside, so she blocked the doorway with his/her arms and told Resident #6 he/she could not go out and Resident #6 slapped me across the face. Per the interview, she stated she did not think about it but then slapped the resident back. Further, the resident stated she could not recall if staff was around at the time of the incident. During a telephone interview with CNA #5 (Agency) on [DATE] at 1:24 PM, he stated he remembered the event but not vividly. CNA#5 stated he could not remember the exact verbal exchange between the two residents and he was trying to get between the two residents. CNA #5 stated he did not recall Resident #6 slapping Resident #7, but he thought Resident #6 may have pushed the other resident, then Resident #7 slapped Resident #6. CNA #5 further stated he was agency staff and was not familiar with Resident #6 and Resident #7's previous behaviors. He also stated while attempting to intervene in the altercation between Resident #6 and Resident #7, Resident #6 reached around him and was able to hit Resident #7. During an interview with the Director of Nursing (DON ) on [DATE] at 10:41 AM, she stated Resident #6 was in the process of being redirected when the altercation occurred The DON stated it was his expectation that all staff followed the facility's abuse policy. During an interview with the Administrator, on [DATE] at 11:44 AM, he stated he expected staff to follow the facility's policy. Per the interview, he stated the CNA followed the policy because the CNA was in the process of intervening but was not successful. **The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], that alleged removal of the Immediate Jeopardy (IJ) on [DATE] ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was assessed by RN #2 and first aid provided for injuries after the Medical Doctor was notified, resident was sent to the Emergency Room. Notifications were made to the state survey agency, law enforcement and resident representative. Facility leadership was contacted about the allegation and investigation. Resident #1 was admitted to the hospital and did not return to the facility. LPN #2 was suspended then terminated. CNA #1 was an agency employee and did not return to the facility again. 2. All residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and above were interviewed about any type of abuse. No concerns noted. Residents with a BIMS score of seven (7) or below had skin assessments completed by a Licensed Practical Nurse or Registered Nurse. No concerns were identified. All staff were interviewed by the Director of Nursing, Staff Development Coordinator, or Corporate Nurse Consultants to ensure all allegations of abuse, neglect, exploitation, or misappropriation were reported and investigated. There were no concerns noted. The Interdisciplinary Team (Director of Nursing, Staff Development Coordinator, and reviewed resident records and incident reports for documentation of bruising and injuries of unknown origin from [DATE] when LPN #2 started work, until [DATE]. This was completed for all units (including discharged and deceased residents); no concerns noted. 3. In-service began for all staff (licensed and unlicensed, agency and facility) beginning on [DATE], by the Director of Nursing or Staff Development Coordinator regarding the Abuse Policy, with emphasis on reporting all allegations of abuse immediately to the Administrator, DON, or Nurse Manager on call. The in-service also addressed going to the nurse on the other unit to report an allegation involving a co-worker, if needed, going out to car to use your phone to call, etc. A post-test was given regarding the Abuse Policy and Procedure to ensure comprehension and retention of in-service material. Signs were posted at the time clock, staffing roster was checked and staff were not allowed to work without being re-educated. Sign-in sheets and post-tests were maintained by the Staff Development Coordinator to ensure that no staff worked who have not been trained. The facility new hire orientation includes education of the abuse policy. Agency staff orientation includes education of the abuse policy prior to working. 4. The Quality Assurance (QA) Committee members include the Administrator, DON, Medical Director (or designated physician in his absence), infection preventionist/staff development, and social services director. The QA Committee and its members were directly involved with corrective action and follow-up. The Medical Director was on vacation but was informed of the incident on [DATE]. Resident #1's attending physician was contacted twice on [DATE] about the incident and participated in a QA Committee Meeting on [DATE], to discuss corrective action, training, care plans, audits, etc. Another QA meeting was conducted with the Medical Director, on [DATE]. QA discussion included abuse allegation, resident safety, corrective action, reporting to agencies and law enforcement, resident and staff interviews, resident body sweep, compliance with policies, staff education, care planning for resident behavior and resident safety. QA determined that the late reporting was an isolated occurrence. The IDT meets daily on Monday (Saturday and Sunday discussed Monday) through Friday and reviews all allegations of abuse, neglect, etc. each morning; any concerns raised are brought to the QA Committee for follow-up by Administrator or DON. Prior to this event, no concerns of late reporting were noted. Interviews were conducted by the clinical coordinators or DON with 4 residents & 4 employees per unit to ensure timely reporting, if indicated. The interviews were done five times weekly for two weeks, weekly for one month, and monthly for one quarter with results reported to IDT Monday through Friday. The Administrator, DON, and others formally reviewed monitoring with the Medical Director on site on [DATE] and [DATE]; no concerns of abuse or late reporting were noted. QA Committee met monthly in July and August and quarterly thereafter. ** The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows ** 1. Review of Resident #1's Medical Record revealed an assessment had been completed by Registered Nurse (RN #2) and the resident received treatment for injuries, then was transferred to the local hospital Emergency Room. During an Interview with RN #2 on [DATE] at 1:33 PM, she stated she assessed Resident #1 for injury on [DATE], treated the injuries, and made notification to the attending physician and resident representative. Review of the facility's investigation revealed Licensed Practical Nurse (LPN) #2 was suspended pending the outcome of the investigation. Certified Nurse Aide (CNA) #1 's agency contract was terminated with the facility. Review of the local police department report dated [DATE] revealed local law enforcement arrived at the facility on [DATE]. LPN #2 was interviewed by the Sheriff's Department on [DATE] in his county. On [DATE] LPN #2 was arrested by the Kentucky State Police and charged with fourth degree assault. Review of local hospital records dated [DATE] revealed Resident #1 was admitted on [DATE] with diagnosis to include peri-orbital soft tissue hematoma to the right eye, and a right peri-orbital laceration requiring steri-strip closure of the laceration. Resident #1 was discharged from the hospital [DATE] to a Long-Term Care facility in Tennessee to be closer to family. Interview with the Director of Nursing on [DATE] at 4:49 PM, he stated he called LPN #2 on [DATE] and informed him he was suspended pending the outcome of the investigation. The DON further stated LPN#2 was later terminated. Per interview, the facility reported LPN #2 to the Kentucky Board of Nursing and his license had emergency suspension effective [DATE], then indefinite suspension effective [DATE]. 2. Review of the facility's Resident Census dated [DATE] revealed all residents with resident Brief Interview for Mental Status (BIMS) score of eight (8) and above were interviewed about any type of abuse and the response was documented next to name. Further review revealed no concerns were identified. Review of Skin Integrity Assessment forms for all residents with a BIMS score of seven (7) revealed skin assessments had been completed by a Licensed Practical Nurse or Registered Nurse and no new concerns had been identified. Review of staff listings by department and a list of all Agency staff assigned to work at the facility dated [DATE] - [DATE] revealed all staff had been interviewed by the Director of Nursing (DON), Staff Development Coordinator (SDC), or Corporate Nurse Consultants (CNS) and questioned if they had ever worked with LPN #2 and had they ever witnessed any type of abuse and no concerns were verbalized by staff A review of resident records and incident reports for documentation dated [DATE] revealed all residents (current, discharged , deceased ) who had incident reports completed from [DATE] to [DATE] were reviewed by the Interdisciplinary Team (DON, SDC, and Administrative Assistant) for documentation of bruising and injuries of unknown origin, and no concerns noted. During an Interview with SDC on [DATE] at 11:52 AM, and Administrative Assistant on [DATE] at 2:25 PM, and the DON on [DATE] at 2:15 PM, they stated they conducted interviews on abuse with all residents with a BIMS score greater than 8, and completed skin assessments for all residents with a BIMS score less than 8 and no concerns had been identified. 3. Review of in-service education and sign-in sheets dated [DATE] through [DATE] revealed education had been initiated by the DON and SDC with all facility and agency staff and was conducted until all staff were educated on the facility's Abuse Policy, what was considered abuse, and to report abuse to the Administrator or DON immediately. Education was provided face to face and via telephone calls. This was completed on [DATE]. Education was ongoing for all new hires and agency staff. Review of Post-tests dated [DATE] through [DATE] revealed all facility staff from Dietary, Nursing, Housekeeping, Administrative, and therapy received the tests. All reviewed indicated a score of 100% and several different tests were administered. During an Interview with the Staff Development Coordinator (SDC) on [DATE] at 11:52 AM she stated all facility staff, including agency, had received education on the abuse policy, different types of abuse and how to report abuse. The SDC stated post tests were provided and all staff had to make 100% and if not, they were retrained and tested again until they attained a 100% score. The SDC stated agency staff (not utilized currently) had been educated prior to being assigned a shift to work. During an Interview with the DON on [DATE] at 2:15 PM, he stated all staff were educated on abuse, types of abuse, who to report suspected abuse to, and to always protect the resident. The DON stated different abuse post-tests were provided to deter cheating by staff. During an interview with RN #1 on [DATE] at 4:15 PM, she stated she had received abuse training and post tests were conducted. During an Interviews on [DATE] with Dietary Aide #1 at 9:34 AM, Housekeeping Aide #1 at 10:20 AM, LPN #5 at 11:07 AM, Administrative Assistant at 11:25 AM, and CNA #8 at 2:44 PM, revealed they received education form the SDC on abuse, types of abuse, when to report abuse and whom to report abuse to and had completed a posttest with 100% passing score. 4. Review of Quality Assurance (QA) Meeting Minutes dated [DATE] revealed the DON, MDS Nurse, Social Services Director (SSD), SDC, Registered Nurse Supervisor, and the Medical Director (via telephone) attended the meeting. Continued review revealed topic of discussion included abuse allegation, resident safety, training, care plans, and audits. The Administrator was on vacation at the time. During an Interview with the DON on [DATE] at 2:15 PM he stated the first QA meeting was held on [DATE] and the abuse allegation and corrective action was discussed, and the actions taken to keep the residents safe and help prevent a future occurrence. He further stated, additional QA meeting were held on [DATE], [DATE], [DATE], and on [DATE] to discuss new abuse allegations, resident safety, training, care plans, and current facility audits. Review of the QA binder revealed meetings were held quarterly thereafter. Review of facility audit tool titled QA Audit Reporting revealed the QA Committee Members interviewed four (4) employees per unit five (5) times per week for two (2) weeks, weekly for one month, and monthly for one quarter. The form listed the following questions: Any reports of verbal, physical, sexual, mental abuse, neglect, involuntary seclusion, misappropriation, exploitation, etc.; Allegation reported timely to administrative staff, MD, RR, and appropriate state agencies; Allegation thoroughly investigated; Alleged perpetrator removed immediately and resident protected upon report of allegation; Employees able to verbalize understanding of Abuse Policy and Procedures, specifically, and reporting of any alleged abuse/neglect, misappropriation. The audits began on [DATE] and the audits were ongoing. Further review revealed the Administrator presented all audit findings to the QAPI at each meeting. Review of completed QA audit reports revealed they were completed for 4 employees, 5 times a week, for 2 weeks; once a week for one month; and once a month for a quarter. No concerns were identified. During an Interview with the DON on [DATE] at 4:49 PM, SDC on [DATE] at 11:52 AM, the Administrator on [DATE] at 9:47 AM, they stated they had QAPI meeting on [DATE], [DATE], [DATE], [DATE], and [DATE] to discuss new abuse allegations, resident safety, training, care plans, and current facility audits. Additionally, QA Committee Members would conduct four (4) employees on all unit five (5) times per week for two (2) weeks, weekly for one month, and monthly for one quarter. Staff would be asked if they had knowledge of any reports of verbal, physical, sexual, mental abuse, neglect, involuntary seclusion, misappropriation, exploitation; if they had reported allegation timely to administrative staff, MD, Resident Representative (RR), and appropriate state agencies; if allegations of abuse were thoroughly investigated; if the alleged perpetrator had been removed immediately and if other residents had been protected upon report of allegation of abuse; if employees were able to verbalize understanding of Abuse Policy and Procedures, specifically, and reporting of any alleged abuse/neglect, misappropriation.

**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 ensure an allegation of physical abuse was reported to the State Agencies and local law authorities immediately, but no later than two (2) hours after the allegation was made for one (1) out of eight (8) sampled residents (Resident #1). On [DATE], LPN #2 struck Resident #1 with his/her fist resulting in Resident #1 having an injury to his/her right eye. Certified Nursing Assistant (CNA) #1 reported to Registered Nurse (RN) #1 that the resident initially head-butted LPN #2; however, later reported to RN #2 that LPN #2 had physically abused Resident #1 by hitting the resident with his fist. The CNA's failure to report timely allowed LPN #2 continued access to Resident #1, to potentially abuse the resident further, and all of the other facility residents, which was the facility's failure to ensure the residents were protected from abuse. The facility's failure to report allegations of abuse has caused or is likely to cause serious injury, Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the areas of Substandard Quality of Care at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F609) at the highest scope and severity S/S of a J; and 42 CFR §483.21 Comprehensive Person-Centered Care Plans (F656) at the S/S of a J. Substandard Quality of Care was identified at 42 CFR §483.12, Freedom from Abuse, Neglect, and Exploitation (F600 and F609). The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. The State Survey Agency (SSA) validated the IJ Removal Plan, on [DATE], and determined the facility implemented corrective action, on [DATE], as alleged, before the State Survey Agency's investigation. Therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of Abuse, Neglect, Misappropriation and Exploitation Policy, undated, revised 01/2018, revealed all allegations involving suspected abuse, neglect, misappropriation or exploitation including injuries of an unknown source or misappropriation of resident property shall be reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the Director of Nursing and/or the Administrator of the facility. Continued review revealed that if the Administrator or Director of Nursing were not in the facility, the person making the allegation would immediately call the Supervisor on Call as listed at each nurses' station. Review of Resident #1's Facility Incident/Accident Report, dated [DATE] at 11:00 PM, signed by Registered Nurse (RN) #2, revealed Resident #1 had a laceration to his/her right cheekbone, under the eye area. Further review revealed a handwritten statement by RN #2 which stated, I was called to the shower room by Licensed Practical Nurse (LPN) #2 and when entering the room, Resident #1 was bleeding and verbally upset saying to LPN #2 that it's not over, I'm gonna get you. Ongoing review of the report revealed a small laceration was noted to the resident's cheek bone, under the resident's eye area to the right eye. Continued review revealed, as the shift was ending Certified Nurse Assistant (CNA) #1 called RN#2 and reported LPN #2 told her to say Resident #1 head butted him; however, CNA #1 told RN#2 she had not told the truth about what had occurred. CNA#1 then stated she saw Resident #1 hit at LPN #2, then LPN #2 hit the resident in the face causing a cut under Resident #1's right eye. LPN #2 then told CNA#1 to say Resident #1 had head butted LPN #2 causing the eye injury. Review of Resident #1's admission Record revealed the facility admitted the resident on [DATE] with diagnoses which included: Parkinson's Disease, Non-ST elevation Myocardial Infarction, and Unspecified Dementia with Behaviors. Review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) Score of 99, which indicated the resident was unable to complete the interview. Continued review revealed Resident #1 was not found to exhibit physical or verbal behaviors such as kicking, scratching, threatening, cursing, or screaming at others. Review of a facsimile confirmation sent to The Office of Inspector General (OIG), revealed it had been sent on [DATE] at 11:53 AM, by the Director of Nursing (DON). However, the incident occurred on [DATE] at 11:00 PM. On [DATE] at 11:09 AM, a telephone interview was attempted with CNA #1 ; however, was unsuccessful as there was no answer and voicemail had not been set up. On [DATE] at 11:11 AM, a Short Message Service (SMS) message was sent to CNA #1 with a response my phone has been shut off, so the State Survey Agency (SSA) Surveyor was unable to conduct an interview. During an interview with RN #1, on [DATE] at 4:15 PM, she stated Certified Nursing Assistant (CNA) #1 recanted the story she first told RN #1. She stated the CNA originally reported the resident had head butted Licensed Practical Nurse (LPN) #1; however, later reported LPN #2 had hit the resident with his fist. Per the interview, the CNA waited until about forty-five (45) minutes in her shift to repot the allegation of abuse. RN #1 stated she called the Director of Nursing (DON) to inform her of the reported allegation of abuse. During an interview with RN #2, on [DATE] at 1:33 PM, she stated she was working night shift on [DATE] and was called to the shower room where LPN #2, CNA #1, and Resident #1 were located. RN #2 stated Resident #1 had blood under right eye and LPN #2 stated resident had head-butted him while he was attempting to remove resident's shirt. In a continued interview, RN #2 stated that at the end of the CNA's shift CNA #1 was crying and told RN #2 that LPN #2 had physically abused the resident, by punching the resident in the eye with his fist. RN #2 stated she contacted the DON immediately and was also getting other staff to check to make sure LPN #2 was off the property. On [DATE] at 2:38 PM at 5:14 PM, a telephone interview was attempted with LPN #2; however, was unsuccessful as there was no answer. A voicemail was left for LPN #2 to return a telephone call to the SSA Surveyor; however, no return call was received. In an interview with the DON on [DATE] at 4:49 PM, revealed he received a call on the morning of [DATE] from LPN #1, who was on call for the facility during the time of the incident. She stated, LPN #1 told the DON the incident involving Resident #1 had not been reported truthfully by CNA #1. The DON then stated, LPN#1 said Resident #1 had not head butted LPN#2 as originally reported. Per interview, LPN #1 told the DON LPN#2 hit Resident #1 in the face with his fist causing the injury to the right eye. The DON stated the facility's investigation revealed CNA #1 reported she was afraid of LPN #2 and that was why she did not tell the truth initially. The DON stated CNA #1 reported immediately the false story of the Resident #1 head butting LPN #2 but did not report LPN #2 hit Resident #1, and therefore, did not follow the facility's abuse policy. The DON stated CNA #1 could have went to the other side of the facility, to the bathroom, or even to her car to make a telephone call to report the abuse she had witnessed. The DON further stated it was his expectation that staff follow the facility's Abuse Policy. During an interview with the Administrator, on [DATE] at 9:47 AM, he stated he was out of town on the date of the incident and was made aware of the abuse allegation on [DATE] by the DON. The Administrator stated all staff have been educated on abuse and were expected to report immediately . Further, the Administrator stated the facility failed to protect the resident from harm and staff did not follow the policy to prevent abuse. **The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], that alleged removal of the Immediate Jeopardy (IJ) on [DATE] ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was assessed by RN #2 and first aid provided for injuries after the Medical Doctor was notified, resident was sent to the Emergency Room. Notifications were made to the state survey agency, law enforcement and resident representative. Facility leadership was contacted about the allegation and investigation. Resident #1 was admitted to the hospital and did not return to the facility. LPN #2 was suspended then terminated. CNA #1 was an agency employee and did not return to the facility again. 2. All residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and above were interviewed about any type of abuse. No concerns noted. Residents with a BIMS score of seven (7) or below had skin assessments completed by a Licensed Practical Nurse or Registered Nurse. No concerns were identified. All staff were interviewed by the Director of Nursing, Staff Development Coordinator, or Corporate Nurse Consultants to ensure all allegations of abuse, neglect, exploitation, or misappropriation were reported and investigated. There were no concerns noted. The Interdisciplinary Team (Director of Nursing, Staff Development Coordinator, and reviewed resident records and incident reports for documentation of bruising and injuries of unknown origin from [DATE] when LPN #2 started work, until [DATE]. This was completed for all units (including discharged and deceased residents); no concerns noted. 3. In-service began for all staff (licensed and unlicensed, agency and facility) beginning on [DATE], by the Director of Nursing or Staff Development Coordinator regarding the Abuse Policy, with emphasis on reporting all allegations of abuse immediately to the Administrator, DON, or Nurse Manager on call. The in-service also addressed going to the nurse on the other unit to report an allegation involving a co-worker, if needed, going out to car to use your phone to call, etc. A post-test was given regarding the Abuse Policy and Procedure to ensure comprehension and retention of in-service material. Signs were posted at the time clock, staffing roster was checked and staff were not allowed to work without being re-educated. Sign-in sheets and post-tests were maintained by the Staff Development Coordinator to ensure that no staff worked who have not been trained. The facility new hire orientation includes education of the abuse policy. Agency staff orientation includes education of the abuse policy prior to working. 4. The Quality Assurance (QA) Committee members include the Administrator, DON, Medical Director (or designated physician in his absence), infection preventionist/staff development, and social services director. The QA Committee and its members were directly involved with corrective action and follow-up. The Medical Director was on vacation but was informed of the incident on [DATE]. Resident #1's attending physician was contacted twice on [DATE] about the incident and participated in a QA Committee Meeting on [DATE], to discuss corrective action, training, care plans, audits, etc. Another QA meeting was conducted with the Medical Director, on [DATE]. QA discussion included abuse allegation, resident safety, corrective action, reporting to agencies and law enforcement, resident and staff interviews, resident body sweep, compliance with policies, staff education, care planning for resident behavior and resident safety. QA determined that the late reporting was an isolated occurrence. The IDT meets daily on Monday (Saturday and Sunday discussed Monday) through Friday and reviews all allegations of abuse, neglect, etc. each morning; any concerns raised are brought to the QA Committee for follow-up by Administrator or DON. Prior to this event, no concerns of late reporting were noted. Interviews were conducted by the clinical coordinators or DON with 4 residents & 4 employees per unit to ensure timely reporting, if indicated. The interviews were done five times weekly for two weeks, weekly for one month, and monthly for one quarter with results reported to IDT Monday through Friday. The Administrator, DON, and others formally reviewed monitoring with the Medical Director on site on [DATE] and [DATE]; no concerns of abuse or late reporting were noted. QA Committee met monthly in July and August and quarterly thereafter. ** The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows ** 1. Review of Resident #1's Medical Record revealed an assessment had been completed by Registered Nurse (RN #2) and the resident received treatment for injuries, then was transferred to the local hospital Emergency Room. During an Interview with RN #2 on [DATE] at 1:33 PM, she stated she assessed Resident #1 for injury on [DATE], treated the injuries, and made notification to the attending physician and resident representative. Review of the facility's investigation revealed Licensed Practical Nurse (LPN) #2 was suspended pending the outcome of the investigation. Certified Nurse Aide (CNA) #1 's agency contract was terminated with the facility. Review of the local police department report dated [DATE] revealed local law enforcement arrived at the facility on [DATE]. LPN #2 was interviewed by the Sheriff's Department on [DATE] in his county. On [DATE] LPN #2 was arrested by the Kentucky State Police and charged with fourth degree assault. Review of local hospital records dated [DATE] revealed Resident #1 was admitted on [DATE] with diagnosis to include peri-orbital soft tissue hematoma to the right eye, and a right peri-orbital laceration requiring steri-strip closure of the laceration. Resident #1 was discharged from the hospital [DATE] to a Long-Term Care facility in Tennessee to be closer to family. Interview with the Director of Nursing on [DATE] at 4:49 PM, he stated he called LPN #2 on [DATE] and informed him he was suspended pending the outcome of the investigation. The DON further stated LPN#2 was later terminated. Per interview, the facility reported LPN #2 to the Kentucky Board of Nursing and his license had emergency suspension effective [DATE], then indefinite suspension effective [DATE]. 2. Review of the facility's Resident Census dated [DATE] revealed all residents with resident Brief Interview for Mental Status (BIMS) score of eight (8) and above were interviewed about any type of abuse and the response was documented next to name. Further review revealed no concerns were identified. Review of Skin Integrity Assessment forms for all residents with a BIMS score of seven (7) revealed skin assessments had been completed by a Licensed Practical Nurse or Registered Nurse and no new concerns had been identified. Review of staff listings by department and a list of all Agency staff assigned to work at the facility dated [DATE] - [DATE] revealed all staff had been interviewed by the Director of Nursing (DON), Staff Development Coordinator (SDC), or Corporate Nurse Consultants (CNS) and questioned if they had ever worked with LPN #2 and had they ever witnessed any type of abuse and no concerns were verbalized by staff A review of resident records and incident reports for documentation dated [DATE] revealed all residents (current, discharged , deceased ) who had incident reports completed from [DATE] to [DATE] were reviewed by the Interdisciplinary Team (DON, SDC, and Administrative Assistant) for documentation of bruising and injuries of unknown origin, and no concerns noted. During an Interview with SDC on [DATE] at 11:52 AM, and Administrative Assistant on [DATE] at 2:25 PM, and the DON on [DATE] at 2:15 PM, they stated they conducted interviews on abuse with all residents with a BIMS score greater than 8, and completed skin assessments for all residents with a BIMS score less than 8 and no concerns had been identified. 3. Review of in-service education and sign-in sheets dated [DATE] through [DATE] revealed education had been initiated by the DON and SDC with all facility and agency staff and was conducted until all staff were educated on the facility's Abuse Policy, what was considered abuse, and to report abuse to the Administrator or DON immediately. Education was provided face to face and via telephone calls. This was completed on [DATE]. Education was ongoing for all new hires and agency staff. Review of Post-tests dated [DATE] through [DATE] revealed all facility staff from Dietary, Nursing, Housekeeping, Administrative, and therapy received the tests. All reviewed indicated a score of 100% and several different tests were administered. During an Interview with the Staff Development Coordinator (SDC) on [DATE] at 11:52 AM she stated all facility staff, including agency, had received education on the abuse policy, different types of abuse and how to report abuse. The SDC stated post tests were provided and all staff had to make 100% and if not, they were retrained and tested again until they attained a 100% score. The SDC stated agency staff (not utilized currently) had been educated prior to being assigned a shift to work. During an Interview with the DON on [DATE] at 2:15 PM, he stated all staff were educated on abuse, types of abuse, who to report suspected abuse to, and to always protect the resident. The DON stated different abuse post-tests were provided to deter cheating by staff. During an interview with RN #1 on [DATE] at 4:15 PM, she stated she had received abuse training and post tests were conducted. During an Interviews on [DATE] with Dietary Aide #1 at 9:34 AM, Housekeeping Aide #1 at 10:20 AM, LPN #5 at 11:07 AM, Administrative Assistant at 11:25 AM, and CNA #8 at 2:44 PM, revealed they received education form the SDC on abuse, types of abuse, when to report abuse and whom to report abuse to and had completed a posttest with 100% passing score. 4. Review of Quality Assurance (QA) Meeting Minutes dated [DATE] revealed the DON, MDS Nurse, Social Services Director (SSD), SDC, Registered Nurse Supervisor, and the Medical Director (via telephone) attended the meeting. Continued review revealed topic of discussion included abuse allegation, resident safety, training, care plans, and audits. The Administrator was on vacation at the time. During an Interview with the DON on [DATE] at 2:15 PM he stated the first QA meeting was held on [DATE] and the abuse allegation and corrective action was discussed, and the actions taken to keep the residents safe and help prevent a future occurrence. He further stated, additional QA meeting were held on [DATE], [DATE], [DATE], and on [DATE] to discuss new abuse allegations, resident safety, training, care plans, and current facility audits. Review of the QA binder revealed meetings were held quarterly thereafter. Review of facility audit tool titled QA Audit Reporting revealed the QA Committee Members interviewed four (4) employees per unit five (5) times per week for two (2) weeks, weekly for one month, and monthly for one quarter. The form listed the following questions: Any reports of verbal, physical, sexual, mental abuse, neglect, involuntary seclusion, misappropriation, exploitation, etc.; Allegation reported timely to administrative staff, MD, RR, and appropriate state agencies; Allegation thoroughly investigated; Alleged perpetrator removed immediately and resident protected upon report of allegation; Employees able to verbalize understanding of Abuse Policy and Procedures, specifically, and reporting of any alleged abuse/neglect, misappropriation. The audits began on [DATE] and the audits were ongoing. Further review revealed the Administrator presented all audit findings to the QAPI at each meeting. Review of completed QA audit reports revealed they were completed for 4 employees, 5 times a week, for 2 weeks; once a week for one month; and once a month for a quarter. No concerns were identified. During an Interview with the DON on [DATE] at 4:49 PM, SDC on [DATE] at 11:52 AM, the Administrator on [DATE] at 9:47 AM, they stated they had QAPI meeting on [DATE], [DATE], [DATE], [DATE], and [DATE] to discuss new abuse allegations, resident safety, training, care plans, and current facility audits. Additionally, QA Committee Members would conduct four (4) employees on all unit five (5) times per week for two (2) weeks, weekly for one month, and monthly for one quarter. Staff would be asked if they had knowledge of any reports of verbal, physical, sexual, mental abuse, neglect, involuntary seclusion, misappropriation, exploitation; if they had reported allegation timely to administrative staff, MD, Resident Representative (RR), and appropriate state agencies; if allegations of abuse were thoroughly investigated; if the alleged perpetrator had been removed immediately and if other residents had been protected upon report of allegation of abuse; if employees were able to verbalize understanding of Abuse Policy and Procedures, specifically, and reporting of any alleged abuse/neglect, misappropriation.

**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 develop and implement a comprehensive person-centered care plan for three (3) of eight (8) sampled residents (Resident #1, Resident #6, Resident #7) that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs. 1). On [DATE], Resident #1 was combative during care and LPN #2 struck Resident #1 with his fist resulting in Resident #1 having an injury to his/her right eye. Review of the resident's care plan revealed staff should have backed away from resident when he/she becomes combative let him/her calm down. However, the staff member failed to implement the resident's Person-Center Comprehensive Care Plan when the resident became combative during care. 2). On [DATE] Resident #6 slapped Resident #7 on the face while waiting to go outside to smoke, then Resident #7 slapped Resident #6 on the face. a) Review of the Resident #6's care plan revealed staff were to provide the resident an organized, structured environment. However; interviews and record review revealed the resident followed the smokers outside for their smoke break and the facility staff failed to assist the resident, causing a physical altercation. b) Review of Resident #7's care plan revealed staff were to provide one-to-one supervision (1:1) when the resident had increased mood and behavior. However, when the resident blocked Resident #7 from exiting the courtyard door, the facility failed to increase the resident's supervision and monitoring, to include 1:1 supervision, to prevent the physical altercation. The facility's failure to ensure resident care plans were implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the areas of Substandard Quality of Care at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F609) at the highest scope and severity S/S of a J; and 42 CFR §483.21 Comprehensive Person-Centered Care Plans (F656) at the S/S of a J. Substandard Quality of Care was identified at 42 CFR §483.12, Freedom from Abuse, Neglect, and Exploitation (F600 and F609). The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. The State Survey Agency (SSA) validated the IJ Removal Plan, on [DATE], and determined the facility implemented corrective action, on [DATE], as alleged, before the State Survey Agency's investigation. Therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy Care Plan Policy & Protocol, revised 09/2017, revealed the facility would develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Continued review revealed the [NAME] would also be utilized as a guide for the Nurse Aides in providing care on a daily basis. Continued review of the policy revealed it was a working tool and revisions would be made when indicated. As part of the care plan, the Nurse Aide [NAME] (an overview of each residents care needs) would reflect person-centered care preferences 1. Review of Resident #1's admission Record revealed the facility admitted the resident on [DATE] with diagnosis to include Parkinson's Disease, Non-ST elevation Myocardial Infarction, and Unspecified Dementia with Behaviors. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE] revealed a Brief Interview for Mental Status (BIMS) Score of ninety-nine (99), which indicated the resident was cognitively impaired. Continued review revealed Resident #1 was not found to exhibit physical or verbal behaviors such as kicking, scratching, threatening, cursing, or screaming at others. Review of Resident #1's care plan, last revised [DATE], revealed the resident had potential for alteration in mood/behaviors due to dementia; had a history of becoming combative with staff at times when attempting to redirect with a goal to include the resident would be free from altercations in mood/behaviors due to diagnosis of dementia with behaviors. Interventions included: anticipate/ meet needs timely, if resistive to care, allow to calm down and then reapproach for care, talk with resident during care and allow/encourage resident to vent feelings, and staff to back away from resident when he/she becomes combative let him/her calm down before transfers. On [DATE] at 11:09 AM, a telephone interview was attempted with CNA #1 ; however, was unsuccessful as there was no answer and voicemail had not been set up. On [DATE] at 11:11 AM, a Short Message Service (SMS) message was sent to CNA #1 with a response my phone has been shut off, so the State Survey Agency (SSA) Surveyor was unable to conduct an interview. During an interview with RN #1, on [DATE] at 4:15 PM, she stated she was working day shift [DATE], and received report from RN #2, who reported Resident #1 had head butted someone in the shower. RN #1 stated she looked over Resident #1 and saw his/her right eye was black and bruising way down the cheek and eye was almost swollen shut. RN #1 stated Resident #1 needed to go to the ER (Emergency Room) as she feared the resident could have a facial fracture. Continued interview revealed about thirty (30) to forty-five (45) minutes into the shift, CNA #1 was at the nurses' station speaking with RN#2, informing her of LPN #2 hitting Resident #1. Per the interview, RN#1 stated Resident #1 would become agitated at times and staff should have walked away and reapproached the resident at a later time to allow the resident time to calm down. She further stated LPN #2 should have followed the Care Plan. During an interview with RN #2 on [DATE] at 1:33 PM she was working night shift on [DATE] and was called to the shower room where LPN #2, CNA #1, and Resident #1 were located. RN #2 stated Resident #1 had blood under right eye and LPN #2 stated resident had head-butted him while he was attempting to remove resident's shirt. RN #2 performed first aide to resident. Continued interview revealed at end of shift, CNA #1 was crying and told RN #2 of LPN #2 used his fist and punched the resident in the eye. Further, RN#2 stated Resident #1 would become agitated with care and staff should have walked away to allow the resident time to calm down. She further stated LPN #2 should have followed the Care Plan. On [DATE] at 2:38 PM and at 5:14 PM, a telephone interview was attempted with LPN #2, however, was unsuccessful as there was no answer. A voicemail was left for LPN #2 to return a telephone call to the SSA Surveyor; however, no return call was received. Interview with the DON, on [DATE] at 4:49 PM, revealed he received a call on the morning of [DATE] from LPN #1, who was on call for the facility during the time of the incident. She stated, LPN #1 told the DON the incident involving Resident #1 had not been reported truthfully by CNA #1. The DON then stated, LPN#1 said Resident #1 had not head butted LPN#2 as originally reported. Per the interview, .LPN #1 told the DON LPN#2 hit Resident #1 in the face with his fist causing the injury to the right eye. The DON stated the facility's investigation revealed CNA #1 reported she was afraid of LPN #2 and that was why she did not tell the truth initially. The DON stated CNA #1 could have went to the other side of the facility, to the bathroom, or even to her car to make a telephone call to report the abuse she had witnessed. The DON further stated staff should have intervened and redirect when necessary to protect the residents, and it was his expectation that staff follow the facility's policy. During an interview with the Administrator, on [DATE] at 9:47 AM, he stated he was out of town on date of event and was made aware of the abuse allegation on [DATE] by the DON. Continued interview with the Administrator, he stated the facility failed to protect the resident from harm and staff did not follow the policy to prevent abuse. 2. Review of the facility's incident Report, dated [DATE] at 1:15 PM, revealed CNA #7 reported while he was taking the residents outside for a smoke break, Resident #6 attempted to go too, and Resident #7 told Resident #6 he/she could not go because he/she did not smoke. Resident #6 slapped Resident #7 on the face, then Resident #7 slapped Resident #6 on the face. Both residents were separated and assessed to have no injuries. Both residents were placed on 1:1 with staff until seen by psychiatric (psych) services. a.) Review of Resident #6's admission Record revealed the facility admitted the resident on [DATE] with diagnoses to include Traumatic Brain Injury (TBI), Dementia, Major Depressive Disorder, History of Transient Ischemic Attack (TIA); and Cognitive Communication Deficit. Review of Resident #6's Significant Change MDS dated [DATE], revealed the facility had assessed the resident to have e BIMS score of three (3) out of fifteen (15) indicating the resident was severely cognitive impaired. Continued review revealed resident had difficulty focusing attention and had disorganized thinking behavior present that fluctuates, which comes and goes, changes in severity. Further review revealed Resident #6 did not have any behaviors indicated. Continued review revealed Preferences for Customary Routine and Activities resident prefers doing things with groups of people. Review of Resident #6's Comprehensive Care Plan, initiated on [DATE], revealed the resident was care planned for alternation in cognition related to the resident's displayed modified independent decision making. Continued review revealed on [DATE] handwritten problem for: noted BIMS 02, indicating severely impaired cognitive function, inattention and disorganized thinking, noted with difficulty following tasks/directions, with a goal the resident would be maintained in a safe environment while working against further cognitive decline. Interventions included: be aware the resident may use non-verbal gestures such as nodding, pointing, etc. in effort to communicate a want/need; give clear, simple directions as needed/indicated; observe for improvement or decline in cognition; provide an organized, structured environment with consistency in care. Continued review revealed resident had potential for fear/anxiety and new intervention added on [DATE] of resident placed 1:1 until seen by psych services. The facility; however, failed to ensure the resident's care plan was implemented to provide an organized, structured environment that was consistent with the resident's care, due to his/her cognitive decline. b.) Review of Resident #7's admission Record revealed the facility admitted the resident on [DATE] with diagnoses to include Bipolar Disorder, Major Depressive Disorder, Obsessive-Compulsive Disorder, and Anxiety Disorder. Review of a Quarterly MDS dated [DATE] revealed Resident #7 had a BIMS score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Continued review revealed Resident #7 had no indication of delirium or behaviors indicated. Review of Resident #7's Comprehensive Care Plan, initiated [DATE], revealed the resident was care planned for potential alteration in mood/behavior state related to a history of hypoxic encephalopathy, depression, anxiety, agitation, psychosis, paranoid delusional disorder. Further review revealed the resident becomes anxious at times and has to be redirected, has a history of noncompliance with staff, becoming easily agitated, cursing at staff or other residents with a goal to include the resident would remain free of mood indicators and would have a decrease in behaviors this assessment period. Interventions included: call the residents brother as needed as he was good at redirecting the resident; encourage resident to attend special events, functions and activities to socialize and elevate mood, instruct resident on inappropriate behaviors as needed, provide diversional activities as needs, listening to music, talking/ visiting with male friend, offer 1:1 during mood/behaviors, establish a trusting relationship with resident and encourage him/her to verbalize feelings, psych as needed and resident enjoys going outside to courtyard, assist as needed. Observe whereabouts frequently while in courtyard. The facility; however, failed to ensure staff implemented the resident's care plan to provide increased supervision, such as 1:1, when the resident blocked the doorway with his/her arms preventing Resident #6 from going outside with the other resident. Review of Nurses Note, dated [DATE] at 1:25 PM, revealed the resident had an altercation with another resident (Resident #6) related to Resident #6 attempted to follow Resident#7 out on smoke break. Resident #7 told Resident #6 you cannot go, resulting in Resident #6 slapping Resident #7 in the face. Resident #7 retaliated by slapping Resident#6 in the face. During an interview with Resident #7, on [DATE] at 2:30 PM, the resident stated he/she was allowed to go out and smoke six times a day. Resident #7 stated We were all gathered at the doorway waiting for staff to bring the cigarettes and take us out. The resident stated Resident #6 was unstable and was not allowed outside. The resident stated he/she knew Resident #6 was not allowed outside, so he/she blocked the doorway with his/her arms and told the resident he/she could not go out. Resident #7 stated Resident #6 slapped him/her across the face. Without thinking about it, Resident #7 stated he/she slapped Resident #6 back. The resident further stated he/she could not recall if any staff were around at the time of the incident. During a telephone interview with CNA #5 (Agency), on [DATE] at 1:24 PM, he stated he remembered the event but not vividly. CNA#5 stated he could not remember the exact verbal exchange between the two residents and he was trying to get between the two residents. CNA #5 stated he did not recall Resident #6 slapping Resident #7, but he thought Resident #6 may have pushed the other resident, then Resident #7 slapped Resident #6. CNA #5 further stated he was agency staff and was not familiar with the past behaviors of Resident #6 and Resident #7. He also stated while attempting to intervene in the altercation, Resident #6 reached around him and hit Resident #7. Per the interview, the CNA stated the [NAME] and Resident Care Plan instructed him on how to care for the residents and it should be followed. During an interview with the DON, on [DATE] at 10:41 AM, he stated Resident #6 was in the process of being redirected when the altercation happened. The DON stated staff were attempting to follow the the care plan when the CNA tried to redirect the residents but could not stop the altercation. During an interview with the Administrator, on [DATE] at 11:44 AM, he stated it was his expectation that staff followed the facility's Care Plan Policy to ensure all residents received the care they required. The Administrator stated he felt the CNA had followed the care plan and was attempting to intervene when the altercation occurred. **The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], that alleged removal of the Immediate Jeopardy (IJ) on [DATE] ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was assessed by RN #2 and first aid provided for injuries after the Medical Doctor was notified, resident was sent to the Emergency Room. Notifications were made to the state survey agency, law enforcement and resident representative. Facility leadership was contacted about the allegation and investigation. Resident #1 was admitted to the hospital and did not return to the facility. LPN #2 was suspended then terminated. CNA #1 was an agency employee and did not return to the facility again. 2. All residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and above were interviewed about any type of abuse. No concerns noted. Residents with a BIMS score of seven (7) or below had skin assessments completed by a Licensed Practical Nurse or Registered Nurse. No concerns were identified. All staff were interviewed by the Director of Nursing, Staff Development Coordinator, or Corporate Nurse Consultants to ensure all allegations of abuse, neglect, exploitation, or misappropriation were reported and investigated. There were no concerns noted. The Interdisciplinary Team (Director of Nursing, Staff Development Coordinator, and reviewed resident records and incident reports for documentation of bruising and injuries of unknown origin from [DATE] when LPN #2 started work, until [DATE]. This was completed for all units (including discharged and deceased residents); no concerns noted. 3. In-service began for all staff (licensed and unlicensed, agency and facility) beginning on [DATE], by the Director of Nursing or Staff Development Coordinator regarding the Abuse Policy, with emphasis on reporting all allegations of abuse immediately to the Administrator, DON, or Nurse Manager on call. The in-service also addressed going to the nurse on the other unit to report an allegation involving a co-worker, if needed, going out to car to use your phone to call, etc. A post-test was given regarding the Abuse Policy and Procedure to ensure comprehension and retention of in-service material. Signs were posted at the time clock, staffing roster was checked and staff were not allowed to work without being re-educated. Sign-in sheets and post-tests were maintained by the Staff Development Coordinator to ensure that no staff worked who have not been trained. The facility new hire orientation includes education of the abuse policy. Agency staff orientation includes education of the abuse policy prior to working. 4. The Quality Assurance (QA) Committee members include the Administrator, DON, Medical Director (or designated physician in his absence), infection preventionist/staff development, and social services director. The QA Committee and its members were directly involved with corrective action and follow-up. The Medical Director was on vacation but was informed of the incident on [DATE]. Resident #1's attending physician was contacted twice on [DATE] about the incident and participated in a QA Committee Meeting on [DATE], to discuss corrective action, training, care plans, audits, etc. Another QA meeting was conducted with the Medical Director, on [DATE]. QA discussion included abuse allegation, resident safety, corrective action, reporting to agencies and law enforcement, resident and staff interviews, resident body sweep, compliance with policies, staff education, care planning for resident behavior and resident safety. QA determined that the late reporting was an isolated occurrence. The IDT meets daily on Monday (Saturday and Sunday discussed Monday) through Friday and reviews all allegations of abuse, neglect, etc. each morning; any concerns raised are brought to the QA Committee for follow-up by Administrator or DON. Prior to this event, no concerns of late reporting were noted. Interviews were conducted by the clinical coordinators or DON with 4 residents & 4 employees per unit to ensure timely reporting, if indicated. The interviews were done five times weekly for two weeks, weekly for one month, and monthly for one quarter with results reported to IDT Monday through Friday. The Administrator, DON, and others formally reviewed monitoring with the Medical Director on site on [DATE] and [DATE]; no concerns of abuse or late reporting were noted. QA Committee met monthly in July and August and quarterly thereafter. ** The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows ** 1. Review of Resident #1's Medical Record revealed an assessment had been completed by Registered Nurse (RN #2) and the resident received treatment for injuries, then was transferred to the local hospital Emergency Room. During an Interview with RN #2 on [DATE] at 1:33 PM, she stated she assessed Resident #1 for injury on [DATE], treated the injuries, and made notification to the attending physician and resident representative. Review of the facility's investigation revealed Licensed Practical Nurse (LPN) #2 was suspended pending the outcome of the investigation. Certified Nurse Aide (CNA) #1 's agency contract was terminated with the facility. Review of the local police department report dated [DATE] revealed local law enforcement arrived at the facility on [DATE]. LPN #2 was interviewed by the Sheriff's Department on [DATE] in his county. On [DATE] LPN #2 was arrested by the Kentucky State Police and charged with fourth degree assault. Review of local hospital records dated [DATE] revealed Resident #1 was admitted on [DATE] with diagnosis to include peri-orbital soft tissue hematoma to the right eye, and a right peri-orbital laceration requiring steri-strip closure of the laceration. Resident #1 was discharged from the hospital [DATE] to a Long-Term Care facility in Tennessee to be closer to family. Interview with the Director of Nursing on [DATE] at 4:49 PM, he stated he called LPN #2 on [DATE] and informed him he was suspended pending the outcome of the investigation. The DON further stated LPN#2 was later terminated. Per interview, the facility reported LPN #2 to the Kentucky Board of Nursing and his license had emergency suspension effective [DATE], then indefinite suspension effective [DATE]. 2. Review of the facility's Resident Census dated [DATE] revealed all residents with resident Brief Interview for Mental Status (BIMS) score of eight (8) and above were interviewed about any type of abuse and the response was documented next to name. Further review revealed no concerns were identified. Review of Skin Integrity Assessment forms for all residents with a BIMS score of seven (7) revealed skin assessments had been completed by a Licensed Practical Nurse or Registered Nurse and no new concerns had been identified. Review of staff listings by department and a list of all Agency staff assigned to work at the facility dated [DATE] - [DATE] revealed all staff had been interviewed by the Director of Nursing (DON), Staff Development Coordinator (SDC), or Corporate Nurse Consultants (CNS) and questioned if they had ever worked with LPN #2 and had they ever witnessed any type of abuse and no concerns were verbalized by staff A review of resident records and incident reports for documentation dated [DATE] revealed all residents (current, discharged , deceased ) who had incident reports completed from [DATE] to [DATE] were reviewed by the Interdisciplinary Team (DON, SDC, and Administrative Assistant) for documentation of bruising and injuries of unknown origin, and no concerns noted. During an Interview with SDC on [DATE] at 11:52 AM, and Administrative Assistant on [DATE] at 2:25 PM, and the DON on [DATE] at 2:15 PM, they stated they conducted interviews on abuse with all residents with a BIMS score greater than 8, and completed skin assessments for all residents with a BIMS score less than 8 and no concerns had been identified. 3. Review of in-service education and sign-in sheets dated [DATE] through [DATE] revealed education had been initiated by the DON and SDC with all facility and agency staff and was conducted until all staff were educated on the facility's Abuse Policy, what was considered abuse, and to report abuse to the Administrator or DON immediately. Education was provided face to face and via telephone calls. This was completed on [DATE]. Education was ongoing for all new hires and agency staff. Review of Post-tests dated [DATE] through [DATE] revealed all facility staff from Dietary, Nursing, Housekeeping, Administrative, and therapy received the tests. All reviewed indicated a score of 100% and several different tests were administered. During an Interview with the Staff Development Coordinator (SDC) on [DATE] at 11:52 AM she stated all facility staff, including agency, had received education on the abuse policy, different types of abuse and how to report abuse. The SDC stated post tests were provided and all staff had to make 100% and if not, they were retrained and tested again until they attained a 100% score. The SDC stated agency staff (not utilized currently) had been educated prior to being assigned a shift to work. During an Interview with the DON on [DATE] at 2:15 PM, he stated all staff were educated on abuse, types of abuse, who to report suspected abuse to, and to always protect the resident. The DON stated different abuse post-tests were provided to deter cheating by staff. During an interview with RN #1 on [DATE] at 4:15 PM, she stated she had received abuse training and post tests were conducted. During an Interviews on [DATE] with Dietary Aide #1 at 9:34 AM, Housekeeping Aide #1 at 10:20 AM, LPN #5 at 11:07 AM, Administrative Assistant at 11:25 AM, and CNA #8 at 2:44 PM, revealed they received education form the SDC on abuse, types of abuse, when to report abuse and whom to report abuse to and had completed a posttest with 100% passing score. 4. Review of Quality Assurance (QA) Meeting Minutes dated [DATE] revealed the DON, MDS Nurse, Social Services Director (SSD), SDC, Registered Nurse Supervisor, and the Medical Director (via telephone) attended the meeting. Continued review revealed topic of discussion included abuse allegation, resident safety, training, care plans, and audits. The Administrator was on vacation at the time. During an Interview with the DON on [DATE] at 2:15 PM he stated the first QA meeting was held on [DATE] and the abuse allegation and corrective action was discussed, and the actions taken to keep the residents safe and help prevent a future occurrence. He further stated, additional QA meeting were held on [DATE], [DATE], [DATE], and on [DATE] to discuss new abuse allegations, resident safety, training, care plans, and current facility audits. Review of the QA binder revealed meetings were held quarterly thereafter. Review of facility audit tool titled QA Audit Reporting revealed the QA Committee Members interviewed four (4) employees per unit five (5) times per week for two (2) weeks, weekly for one month, and monthly for one quarter. The form listed the following questions: Any reports of verbal, physical, sexual, mental abuse, neglect, involuntary seclusion, misappropriation, exploitation, etc.; Allegation reported timely to administrative staff, MD, RR, and appropriate state agencies; Allegation thoroughly investigated; Alleged perpetrator removed immediately and resident protected upon report of allegation; Employees able to verbalize understanding of Abuse Policy and Procedures, specifically, and reporting of any alleged abuse/neglect, misappropriation. The audits began on [DATE] and the audits were ongoing. Further review revealed the Administrator presented all audit findings to the QAPI at each meeting. Review of completed QA audit reports revealed they were completed for 4 employees, 5 times a week, for 2 weeks; once a week for one month; and once a month for a quarter. No concerns were identified. During an Interview with the DON on [DATE] at 4:49 PM, SDC on [DATE] at 11:52 AM, the Administrator on [DATE] at 9:47 AM, they stated they had QAPI meeting on [DATE], [DATE], [DATE], [DATE], and [DATE] to discuss new abuse allegations, resident safety, training, care plans, and current facility audits. Additionally, QA Committee Members would conduct four (4) employees on all unit five (5) times per week for two (2) weeks, weekly for one month, and monthly for one quarter. Staff would be asked if they had knowledge of any reports of verbal, physical, sexual, mental abuse, neglect, involuntary seclusion, misappropriation, exploitation; if they had reported allegation timely to administrative staff, MD, Resident Representative (RR), and appropriate state agencies; if allegations of abuse were thoroughly investigated; if the alleged perpetrator had been removed immediately and if other residents had been protected upon report of allegation of abuse; if employees were able to verbalize understanding of Abuse Policy and Procedures, specifically, and reporting of any alleged abuse/neglect, misappropriation.