**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's investigative report, and review of the facility's abuse policy, it was determined the facility failed to protect one (1) of three (3) sampled residents from abuse/neglect (Resident #9). During an interview with Certified Nursing Assistant (CNA) #33, she stated CNA #35 pushed Resident #9 back into the bed on 10/12/2023 while yelling at the resident and saying, I'm not dealing with your ass tonight. CNA #33 further stated she left the resident's room to report the incident to Licensed Practical Nurse (LPN) #13 who informed her to call the Director of Nursing (DON). She stated CNA #35 was left alone with Resident #9 while she went to inform the nurse. The facility failed to ensure the facility's abuse policy was implemented, and no action was taken to protect the resident from further potential abuse. The facility's failure to ensure residents were protected from abuse/neglect has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/2023 and determined to exist on 10/12/2023 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F607) and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy (IJ) on 10/18/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 10/20/2023 alleging removal of the IJ on 10/20/2023. The SSA validated the removal of the IJ on 10/21/2023, prior to exit on 10/21/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Abuse Prevention Program, dated 10/22/2022, revealed staff members who were suspected of abuse or misconduct would be immediately removed and barred from any further contact with residents of the facility and would be suspended from duty, pending the outcome of the investigation. Further review revealed supervisors would monitor the ability of the staff to meet the needs of the residents, staff understanding of individual resident care needs, and situations such as inappropriate language and insensitive handling. Continued review revealed the policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, mental anguish or deprivation by an individual, including a caretaker, of goods or services that were necessary to attain and maintain physical, mental and psychosocial well-being. Additional review revealed the policy defined verbal abuse as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Physical abuse included hitting, slapping, pinching, kicking, etc. and controlling behavior through corporal punishment. Further review revealed upon receiving reports of physical abuse, the Charge Nurse would immediately examine the resident and the findings of the examination must be recorded in a separate incident report. Continued review of the facility's policy, titled, Abuse Prevention Program, dated 10/22/2022, revealed when an alleged case of abuse or neglect was reported, the Administrator, or person in charge of the facility, would notify the following person or agencies immediately per Kentucky Revised Statute, Chapter 209: Kentucky Cabinet for Health and Family Services, Office of the Inspector General, Division of Long Term Care (LTC), Law Enforcement Officials as per the Policy on Reporting Reasonable Suspicions of a crime in LTC facility, Section 1150B of the Social Security Act. Policy Number 2.11a., the resident representative and the physician. Additionally, review of the policy revealed to prevent resident abuse and if an employee suspected abuse, they were to separate the alleged perpetrator and assure all residents' safety. Additional review of the Abuse Prevention Program policy, dated 10/22/2022, revealed the final investigation would be submitted within five (5) working days of the incident and should contain facts determined during the process of the investigation, the conclusion of the investigation, the police report, and a summary of all interviews conducted with names, addresses, phone numbers, and willingness to testify of all witnesses. Further review revealed the Administrator or DON would request a representative of the Social Services department monitor the resident's feelings concerning the incident as well as the resident's reaction to his/her involvement in the investigation and, unless otherwise requested by the resident, the Social Services representative would provide the Administrator and the DON with a written report of his/her findings in the resident's medical record. Review of Resident #9's admission Record revealed the facility admitted Resident #9, on 02/24/2022, with diagnoses which included Muscle Weakness, Alzheimer's Disease, and Dementia with Mood Disturbance and Anxiety. Review of Resident #9's Quarterly Minimum Data Set (MDS) Assessment, dated 08/06/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15), which indicated severe cognitive impairment. Review of Resident #9's Comprehensive Care Plan, dated 03/02/2022, revealed the facility determined the resident to be at risk for elopement/wandering related to a diagnosis of Alzheimer's Disease with interventions that included: on 03/02/2022 for Wander Guard (an electronic bracelet on the resident's ankle that caused the door alarm to sound if the resident went through the door) per order, to check Wander Guard function/placement as ordered, complete Elopement/Wander Assessment as indicated, redirect wandering as needed, and staff to provide one-to-one (1:1) supervision as needed. Review of the facility's initial report, dated 10/12/2023, revealed CNA #33 heard a scream, went down the hall where she witnessed CNA #35 push Resident #9 in the chest down into the bed while telling the resident to keep his/her ass in the bed. Review of the facility's one-to-one (1:1) sheets revealed CNA #35 was sitting one-to-one (1:1) with Resident #9 from 10/11/2023 at 11:15 PM until 10/12/2023 at 2:15 AM. Review of Certified Nursing Assistant (CNA) #35's time card punch for 10/12/2023 revealed she clocked out at 2:12 AM. Review of the Kentucky Incident Based Reporting System (KYIBRS) Report form, dated 10/12/2023 by Officer #1 of the local police department, CNA #35 was charged with Assault and Wanton Abuse. Review of the facility's five (5) day final report, dated 10/16/2023, revealed Resident #9 no longer resided in the facility, and staff interviews were conducted by Administrator #2 and the Director of Nursing (DON). Further review revealed the nurse immediately did a head to toe skin assessment and no redness or abnormalities were noted. Resident #9 stated I just had to go to the bathroom. All residents on the unit with a Brief Interview for Mental Status (BIMS) score of eight (8) or above were interviewed and no other care concerns were identified by other residents. Skin audits were completed for residents with a BIMS score of seven (7) or below (which indicated cognitive impairment) and no areas of concern were identified. Per the report, the facility concluded, based on a thorough investigation and interview with the accused, physical abuse can not be ruled out; out of an abundance of caution, CNA #35 was terminated from the facility; Resident #9 was noticed to be her usual self the rest of the night without signs or symptoms of any distress or emotional trauma. However, through interviews with staff, the resident exhibited crying episodes, being flustered, and agitation after the incident. The State Survey Agency (SSA) Surveyor attempted to contact CNA #35 by phone three (3) times, but CNA #35 did not return the calls. These attempts occurred on 10/17/2023 at 3:32 PM and 8:55 PM and on 10/18/2023 at 11:02 AM. In an interview with CNA #33 on 10/17/2023 at 5:21 PM, she stated, on 10/12/2023, she was in a resident's room when she heard screaming from Resident #9's room. She further stated she went into Resident #9's room and witnessed the resident standing beside the bed with his/her walker. She stated she then witnessed CNA #35 (who was sitting 1:1 with Resident #9) stand up and use her right hand to push Resident #9 in the chest, causing the resident to fall backward onto the bed with his/her feet flying up into the air. Additionally, she stated CNA #35 said I'm not dealing with your ass tonight. She stated she did not say anything to CNA #35, but left the room and notified Licensed Practical Nurse (LPN) #13, who stated she was unaware of the facility policy. She stated LPN #13 asked her to call the Director of Nursing (DON). She further stated she went to the front lobby area bathroom and called the DON using her cellphone. She stated as she walked toward the front bathroom, she saw CNA #35 come out into the hallway and ask CNA #34 to relieve her so she could take a break. Additionally, she stated the DON told her she was going to call Administrator #2, but did not mention anything else to her about Resident #9 or CNA #35. She stated she walked back to the nurses' station where LPN #13 was standing, and LPN #13 said, I have to send CNA #35 home and I'm nervous. On 10/17/2023 at 5:21 PM, CNA #33 further stated she did not want to be close to CNA #35 when CNA #35 was told to go home because CNA #35 could get ugly quickly. She stated everyone was aware of CNA #35's attitude but denied reporting any concerns to the DON or Administrator #2. Additionally, she stated after CNA #35 left the building, she went back to Resident #9's room where the resident was upset and told another CNA, I'm too little, I can't fight her. She stated the resident had to be taken out of the room into the lobby area to calm down. She further stated she was not aware of the abuse policy and had not been told not to leave the resident alone with CNA #35 after she witnessed her push the resident. She stated she had been told to report the abuse immediately which was why she left the room to get the nurse. In an interview with Certified Nursing Assistant (CNA) #34 on 10/17/2023 at 6:35 PM, she stated she was working on 10/12/2023 when she heard yelling in Resident #9's room and went into the hallway. She further stated CNA #33 went into Resident #9's room, and she went to another resident's room. She stated CNA #33 pulled her aside and told her she had witnessed CNA #35 push Resident #9. She stated she went with CNA #35 to report to Licensed Practical Nurse (LPN) #13. She further stated CNA #35 asked her to relieve her sitting one-on-one (1:1) so she could take a break. She stated when she went into Resident #9's room, Resident #9 was crying and told her she pushed me. She stated CNA #35 told CNA #34 to sit in that chair and don't let him/her get up or touch anything. Additionally, she stated CNA #35 seemed aggravated. She stated LPN #13 came into the room and talked with the resident. She stated CNA #35 came back into the room and CNA #34 left, leaving LPN #13 and CNA #35 in Resident #9's room. She further stated she believed the staff did a good job protecting Resident #9 and reporting timely to administration. In an interview with Licensed Practical Nurse (LPN) #13, on 10/17/2023 at 7:55 PM, she stated on 10/12/2023 around 2:00 AM, she was caring for a resident about two (2) doors down the hall from Resident #9's room. She stated she heard crying coming from Resident #9's room and a high pitched sound, and Resident #9 said, All I wanted to do was go to the bathroom. She further stated she was attending to another resident, and CNA #33 went into Resident #9's room. She stated CNA #33 came to her a few minutes later and told her I need to report abuse. LPN #13 stated CNA #33 told her she had witnessed CNA #35 push Resident #9 back onto the bed, and the resident's limbs went up into the air. She stated CNA #33 told her CNA #35 said to Resident #9 it's time for bed and used vulgar words to address Resident #9. In a continued interview with LPN #13, on 10/17/2023 at 7:55 PM, she stated she told CNA #33 to call the DON. She stated the DON called her and told her to tell CNA #35 to go home pending the investigation of the incident. She stated she went to Resident #9's room where CNA #35 was sitting with Resident #9, and she told CNA #35 she had to go home and watched as she left the building. She further stated she sat with Resident #9 because he/she was so upset and crying. She stated the resident knew she had reported the incident and told her, I'm glad she's gone but you just made it worse; now I'm going to get worse treatment. Additionally, she stated she would definitely consider the resident to be in psychosocial distress. She stated the DON called her back a while later to tell her to call the police, which she did. She further stated the police and family came into the building around 4:00 AM. Additionally, she stated she felt she had signed an abuse policy for the facility but had just been told to sign something and was not sure what the policy was specifically. She stated she felt the staff handled the situation correctly, although CNA #35 should probably have been removed from the facility earlier than she was. In an interview with Officer #1 on 10/17/2023 at 9:08 PM, he stated the local police were called over an hour after the incident occurred, and he responded to the facility on [DATE] at approximately 3:50 AM. He stated he was told by staff that CNA #35 pushed Resident #9 back onto the bed so his/her legs flew up in the air. He further stated Resident #9 was not able to recollect exactly what happened but was visibly upset and flustered. He stated, based on his report, CNA #35 would be arrested and charged with assault and wanton abuse. In an interview with the Director of Nursing (DON) on 10/18/2023 at 9:32 AM, she stated she was called on 10/12/2023 between 2:00 AM and 2:30 AM by CNA #33. She stated CNA #33 told her CNA #35 was sitting one-to-one (1:1) with Resident #9, and she witnessed CNA #35 push Resident #9 in the chest, causing the resident to fall down onto the bed. She further stated she called CNA #35 and told her to leave the building, and she was not sure if CNA #35 was still sitting with Resident #9 at that time or not. She stated she called and notified the Administrator #2. She stated she then called and talked to a nurse, and told her to call the police. Additionally, she stated she left a voice mail for the family. She stated she was not in the building and was unsure how long it took to remove CNA #35 from Resident #9's room. However, she stated from the time the incident occurred until CNA #35 was sent home was approximately ten to fifteen (10-15) minutes. She further stated the Social Services Director (SSD) should have followed up with a psychosocial assessment, but she was not sure if she had time as the resident discharged from the building later that day (10/12/2023). She stated she was aware the police came to the building but was not sure what they did. In an interview with the Medical Director on 10/18/2023 at 7:35 PM, he stated he was not made aware of the situation with Resident #9. In an interview with Administrator #2 on 10/18/2023 at 10:18 AM, he stated he was the Abuse Coordinator and was unaware of any other abuse policy other than the Abuse and Neglect Reporting Policy. He stated he would reach out to the Regional Nurse Consultant to see if another policy was in effect. He further stated he received a call from the DON on 10/12/2023 (unsure of the time, around 2:00 AM) with abuse allegations and proceeded to do an initial report. He stated, once he was notified, he told staff to remove CNA #35 from the facility and do a head-to-toe assessment and skin check on Resident #9. He stated he then told staff to do a skin assessment for all residents with a Brief Interview for Mental Status (BIMS) score below eight (8), which indicated cognitive impairment. He stated he also told staff to interview any residents with a BIMS score of eight (8) or higher and to call the police if needed. Further interview, on 10/18/2023 at 10:18 AM, with the Administrator, he stated the Social Services Director (SSD) did follow up assessments for psychosocial harm. He stated these assessments should have been done throughout the shift during which the alleged abuse occurred and daily until the resident showed no signs of psychosocial harm. He further stated if the SSD was not available, other staff could assist with completing the psychosocial assessments. He stated he interviewed the two (2) witnesses (LPN #13 and CNA #33), the alleged perpetrator, and other staff members. He stated, other than LPN #13 and CNA #33, no one else saw or heard anything. Additionally, he stated he had CNA #33 come into the building and reenact the situation for him and the DON. He stated he did not need to list everyone he interviewed in his report and that the conclusion said based on interviews. He further stated since he could not rule out abuse, CNA #35 had been suspended and would be terminated. The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were asked if they ever witnessed or heard of any abuse or mistreatment of residents. All interviews revealed no issues or concerns with potential abuse or mistreatment. 4. On 10/12/2023, Resident #9 had a second skin assessment completed by the Unit Manager. The skin assessment revealed no redness, bruising, or injury. 5. The DON and Assistant Director of Nursing (ADON) conducted a pain evaluation for Resident #9 on 10/12/2023, and the resident voiced no complaints of pain. The DON and ADON did not observe any behavior of pain by Resident #9. 6. The DON and ADON interviewed residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher on 10/12/2023 regarding any experience or recollection of potential mistreatment or abuse with no concerns found. 7. The DON and ADON performed a skin assessment on residents with a BIMS of seven (7) and below on 10/12/2023 with no signs of redness, bruising, or injury found. 8. The Chief Nursing Officer (CNO) from the consultant team reviewed and updated the Abuse Policy & Procedure on 10/19/2023 to ensure it included all required elements. 9. The CNO held an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 10/19/2023. Those in attendance included the Medical Director (MD), the DON, ADON, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator #1 and #2, Activity Director (AD), and the Regional Travel DON. The attendees reviewed the abuse allegation regarding Resident #9. The attendees considered the incident to be isolated and determined it was addressed appropriately. The CNO shared updates to the Abuse Policy with the attendees. 10. The Regional Director of Operations (RDO), on 10/13/2023, trained the administrative staff on the Abuse Policy, and knowledge was measured by a post-test which required one hundred percent (100%) of correct answers to pass. Administrative staff included the DON, ADON, Minimum Data Set (MDS) Coordinator #1 and #2, SSD, Activity Director (AD), and the Business Office Manager (BOM). 11. The Administrator, DON and ADON educated all facility staff members in all departments on abuse education beginning 10/12/2023 through 10/19/2023. The entire Abuse Policy was reviewed with an emphasis on ensuring resident safety and separating residents from the alleged perpetrator immediately. In addition, education included to immediately report concerns of abuse to the Administrator or an immediate supervisor who would immediately report the allegation to the Administrator. Any staff members who did not complete the education would be reeducated prior to returning to work. Education would be completed by the DON, ADON, Administrator, MDS Coordinator, or SSD. The Administrator would be responsible for overseeing the process. Any staff who failed to comply with the points of the in servicing would be further educated and/or progressively disciplined by their Department Manager or Administrator as indicated up to and including termination. 12. The CNO, on 10/19/2023, retrained the administrative staff on the Abuse Policy and QAPI requirements related to abuse. The retraining included what measures would be put into place and what systemic changes would be made to ensure the deficient practice did not reoccur. 13. All staff members received abuse training upon hire and at least annually. Knowledge and retention would be validated by a posttest and a 100 percent score was required to pass. The Administrator would be responsible for compliance. All contracted staff would receive abuse training prior to resident contact. Knowledge and retention would be validated by a posttest and a 100 percent score would be required to pass. The DON and ADON would complete and monitor this. 14. Department Managers/Administrative Staff conducted daily Guardian Angel Rounds until the Immediate Jeopardy (IJ) was removed. Once IJ was removed, the Guardian Angel Rounds would continue at least three to five (3-5) times per week. Staff would ask each resident if they were being treated appropriately by staff during Guardian Angel Rounds. All identified concerns would be shared at the Morning Meeting and followed up on by the Administrator, DON, ADON, or SSD. Morning meetings would occur seven (7) days a week until the IJ was removed. 15. An Ad-Hoc QAPI meeting would be held within twenty-four (24) hours of any abuse allegation to determine appropriate action and necessary follow-up, seven (7) days a week, and would include the Administrator, DON, and other Department Managers as appropriate. 16. The new facility Administrator began on 10/20/2023. The CNO and Chief Operating Officer (COO) of the consultant team would educate the new Administrator on the Abuse Policy, inform her of her responsibilities as the Abuse Coordinator, and her competency would be validated. The Administrator reports to the Governing Body. 17. The QAPI Committee, consisting of the Administrator, DON, ADON, SSD, and MD would oversee all facility processes related to abuse and neglect and determine whether more systemic actions were necessary. 18. The Administrator, DON, and ADON would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. 19. A member of the consultant team would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. This would be completed daily until the IJ was removed. The State Survey Agency (SSA) validated the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 10/21/2023 as follows: 1. Record review revealed Resident #9 discharged from the facility the morning of the incident. CNA #35 was suspended pending investigation. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she said she was told Certified Nursing Assistant (CNA) #35 exited the building, she assumed to smoke or something. The DON said she was told someone sat with Resident #9. The DON said once she talked to CNA #33 about the allegation of abuse, she called CNA #35 directly and made her leave the facility and made Licensed Practical Nurse (LPN) #13 aware. She stated there was little if any time in which CNA #35 was left alone with Resident #9. The DON further stated LPN #13 did not document Resident #9's skin assessment at the time of the alleged incident. She said the management team started skin assessments the morning of 10/12/2023. 2. Review of the Police Report, completed on 10/12/2023, revealed the police were contacted and arrived at the facility at 3:50 AM, and it was noted the incident took place at approximately 2:40 AM. 3. In an interview with the Activity Director (AD) on 10/21/2023 at 10:36 AM, she stated she was interviewed by the DON about the incident with Resident #9. She stated she had not witnessed any abuse and/or mistreatment of residents in the facility. In an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #6 on 10/21/2023 at 10:58 AM, she stated the DON interviewed her on topics of witnessing any type of abuse. She further stated she had not witnessed abuse. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she could not recall the last dates for abuse training, but she said after the incident with Resident #9, the DON provided reeducation with management. She stated management then did reeducation with the rest of the staff. In an interview with the Human Resources Director (HRD) on 10/21/2023 at 1:44 PM, she stated she was interviewed by the DON. She said she had not witnessed abuse or mistreatment in the facility. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she said she could not remember who talked to her about abuse, but she thought it was discussed in the morning meeting. She also said, in the morning meeting, education was provided about abuse. She further stated staff members were required to take a quiz and pass with a one-hundred (100) percent score. In an interview with the Social Services Director (SSD) on 10/21/2023 at 2:25 PM, she stated the DON interviewed her and asked her if she had witnessed any abuse in the facility. She stated she had not. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she stated, we interviewed all staff in the building about abuse and called everyone who was not in the building. She stated all staff reported they had not witnessed any abuse and had no new concerns to report. 4. Review of Resident #9's skin assessment, dated 10/12/2023, revealed no new injuries were present. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:35 PM, she stated LPN #13 was directed to complete the skin assessment the night of the alleged incident; however, she failed to document it. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated LPN #13 did not do a skin assessment for Resident #9 at the time of the incident. She reported management completed a skin assessment for Resident #9 upon arriving to the facility on [DATE] at approximately 8:30 AM, with no concerns noted. 5. Review of Resident #9's pain assessment form, completed on 10/12/2023 by the DON, revealed the resident was noted to be absent of signs or symptoms of pain related to the abuse allegation. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she had completed a pain assessment on Resident #9 and no complaints were voiced. 6. Review of interview sheets used by the facility on 10/12/2023, for interviews completed on sixteen (16) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher to determine if they felt safe, witnessed any type of abuse, and knew how and who to report concerns to, revealed no concerns. The interview form consisted of the following questions: a) Did they feel safe in the facility? b) Has anyone ever caused you any harm or made you feel afraid, embarrassed since you have been a resident here? c) Have you ever witnessed another resident being treated or spoken to in a manner you felt was unacceptable? and d) Do you know who to report to if you felt threatened, afraid, or spoken to, or treated in an unacceptable manner? Review of completed interview forms on 10/21/2023, revealed all sixteen (16) residents answered the questions appropriately and voiced no concerns. In an interview with Resident #37, on 10/21/2023 at 1:30 PM, he/she stated abuse was discussed with the residents in the Resident Council meetings and they met on the first of every month. The resident stated staff always treated him/her well. In an interview with Resident #39 on 10/21/2023 at 1:35 PM, he/she stated staff treated him/her well and provided good care. In an interview with Resident #38 and Resident #40 (husband and wife) on 10/21/2023 at 1:45 PM, they stated they received good care in the facility and did not have any concerns to report. In an interview with the Social Serviced Director (SSD) on 10/21/2023 at 2:25 PM, she stated the ADON, DON, and she had talked to residents in the facility who had a BIMS score of eight (8) and higher regarding abuse. She stated all interviews were documented on a facility interview sheet. She stated all the residents answered the questions appropriately, and no concerns were found. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated she, the SSD, and the DON went room to room and talked with interviewable residents about abuse. She stated no concerns were identified during the interviews. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated the ADON and the SSD went with her room to room and talked with all residents who had a BIMS score of eight (8) or higher about abuse. She stated all the residents were fine, and nobody had any concerns. 7. Review of sixty-one (61) resident Skin Assessment documents, dated 10/12/2023, revealed Licensed Practical Nurse (LPN) #6 and LPN #7 conducted skin assessments on residents with a BIMS score of seven (7) and lower. Further review of the documents revealed one (1) form was not checked off to show no new areas noted or of any new areas noted. In an interview with LPN/UM #6 on 10/21/2023 10:58 AM, she stated she signed a skin assessment form with the missing check mark. She stated she must have been sidetracked when completing it and recalled the resident did not have any new concerns. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she completed several head-to-toe assessments on residents with a BIMS score of seven (7) and under and found no concerns related to abuse. In an interview with the Assistant Director of Nursing (DON) on 10/21/2023 at 2:53 PM, and the DON on 10/21/2023 at 3:45 PM, they stated they had assisted in conducting the skin assessments of residents with a BIMS score of seven (7) and under. They stated the Unit Managers were also present, and they completed the paperwork. They further stated no new skin concerns were found. 8. Review of the Abuse Policy revealed it was revised to address the Quality Assurance and Performance Improvement (QAPI) changes from Quality Assurance (QA). In an interview with the Chief Nursing Officer (CNO) on 10/21/2023 at 3:11 PM, she stated the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, review of the facility's investigative report, and review of the facility's policy, it was determined the facility failed to ensure its policy was implemented related to completing a thorough investigation, and failed to have an effective Quality Assurance and Performance Improvement (QAPI) program to ensure measures were taken to protect the residents from abuse for one (1) of three (3) sampled residents (Resident #9). Review of the facility's Initial Report, dated 10/12/2023, revealed Certified Nursing Assistant (CNA) #33 was working in a resident's room when she heard a scream and stepped into the hallway. She then witnessed CNA #35 push Resident #9 in the chest down into Resident #9's bed, and CNA #35 told Resident #9 to keep his/her ass in bed. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed Resident #9's abuse incident was not discussed at the meeting. The facility's failure to ensure its policies were implemented related to abuse/neglect has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/2023 and determined to exist on 10/12/2023 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F607) and 42 CFR 483.70 Administration (F835) at the highest scope and severity of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.12, Free from Abuse, Neglect, and Exploitation (F600). The facility was notified of the Immediate Jeopardy (IJ) on 10/18/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 10/20/2023 alleging removal of the IJ on 10/20/2023. The SSA validated the removal of the IJ on 10/21/2023, prior to exit on 10/21/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled Abuse Prevention Program, dated 10/22/2022, revealed it was the facility's policy that staff members, who were suspected of abuse or misconduct would be immediately removed and barred from any further contact with residents of the facility and would be suspended from duty, pending the outcome of the investigation. Additional review revealed the policy defined verbal abuse as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. Further review revealed upon receiving reports of physical abuse, the Charge Nurse would immediately examine the resident, and the findings of the examination must be recorded in a separate incident report. Per the policy, to prevent resident abuse and if an employee suspected abuse, they were to separate the alleged perpetrator and assure all residents' safety. Review of Resident #9's admission Record revealed the facility admitted Resident #9, on 02/24/2022, with diagnoses which included Alzheimer's Disease, history of falling, and dementia with mood disturbance and anxiety. Review of Resident #9's Quarterly Minimum Data Set (MDS) Assessment, dated 08/06/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15), which indicated severe cognitive impairment. Review of the facility's Initial Report, dated 10/12/2023, revealed on 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 heard a scream and went down the hall where she witnessed CNA #35 push Resident #9 in the chest down into the bed while telling the resident to keep his/her ass in the bed. Further review revealed CNA #35 was removed from the facility, and Resident #9's assessment showed no signs of injury. Continued review revealed the resident had a history of dementia with a care plan to follow on dementia. Per the report, statements were written and signed by Licensed Practical Nurse (LPN) #13, CNA #33, and CNA #35. Review of the facility's Five (5) day Final Report, dated 10/16/2023, revealed Resident #9 no longer resided in the facility, and staff interviews were conducted by Administrator #2 and the DON. Further review revealed the nurse immediately did a head to toe skin assessment on Resident #9, and no redness or abnormalities were noted. Resident #9 stated I just had to go to the bathroom. Per the report, all residents on the unit with a Brief Interview for Mental Status (BIMS) score of eight (8) or above were interviewed, and no other care concerns were identified by other residents. Skin audits were completed for residents with a BIMS score of seven (7) or below (which indicated cognitive impairment), and no areas of concern were identified. Continued review revealed the facility concluded, based on a thorough investigation and interview with the accused, physical abuse can not be ruled out; out of an abundance of caution, CNA #35 was terminated from the facility; Resident #9 was noticed to be her usual self the rest of the night without signs or symptoms of any distress or emotional trauma. However, through interviews with staff, the resident exhibited crying episodes, being flustered, and agitation after the incident. Review of the facility's one-to-one (1:1) sheets revealed CNA #35 was sitting one-to-one (1:1) with Resident #9 from 10/11/2023 at 11:15 PM until 10/12/2023 at 2:15 AM. Review of CNA #35's time card punch for 10/12/2023 revealed she clocked out at 2:12 AM. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed a QAPI meeting was held on 10/13/2023 with topics discussed as follows: medication administration; proper progress notes and documentation; use of the chart audit tool; all residents at risk for elopement and the review of all elopement drills; the need for twenty-four/seven (24/7) front door monitoring; resident care plans; and use of the Continuous Quality Improvement (CQI) tool. However, there was no documentation of a discussion about Resident #9's abuse incident. Further review revealed Corporate staff, the Administrator, the DON, the Social Services Director (SSD), and the Minimum Data Set (MDS) attended the meeting. In an interview with CNA #33 on 10/17/2023 at 5:21 PM, she stated, on 10/12/2023, she was in a resident's room when she heard screaming from Resident #9's room. She further stated she went into Resident #9's room and witnessed the resident standing beside the bed with his/her walker. She stated she then witnessed CNA #35 stand up, use her right hand to push Resident #9 in the chest, causing the resident to fall backward onto the bed with his/her feet flying up into the air. Additionally, she stated CNA #35 said to Resident #9, I'm not dealing with your ass tonight. She stated she did not say anything to CNA #35, but left the room and notified LPN #13, who stated she was unaware of the facility's policy on abuse and asked CNA #33 to call the DON, which she did. She stated as she walked toward the front bathroom, she saw CNA #35 come out into the hallway and ask CNA #34 to relieve her so she could take a break. In further interview with CNA #33, on 10/17/2023 at 5:21 PM, she stated the DON told her she was going to call the Administrator #2, but did not mention anything else to her about Resident #9 or CNA #35. She stated she walked back to the nurses' station where LPN #13 was standing, and LPN #13 told her I have to send CNA #35 home and I'm nervous. She stated everyone was aware of CNA #35's attitude but denied reporting any concerns to the DON or Administrator #2. Additionally, she stated after CNA #35 left the building, she went back to Resident #9's room where the resident was upset and told another CNA, I'm too little, I can't fight her. She stated the resident had to be taken out of the room into the lobby area to calm down because she was crying and agitated. She further stated she was not aware of the abuse policy and had not been told not to leave the resident alone with CNA #35 after she witnessed her push the resident. She continued to state she had been told to report the abuse immediately which was why she left the room to get the nurse. In an interview with CNA #34, on 10/17/2023 at 6:35 PM, she stated she was working on 10/12/2023 when she heard yelling in Resident #9's room and went into the hallway. She further stated CNA #33 went into Resident #9's room and she went to another resident's room. She continued to state CNA #33 pulled her aside and told her she had witnessed CNA #35 push Resident #9 and she went with CNA #35 to report to LPN #13. She further stated CNA #35 asked her to relieve her sitting one-on-one (1:1) so she could take a break and, when she went into Resident #9's room, Resident #9 was crying and told her she pushed me. She continued to state CNA #35 told CNA #34 sit in that chair and don't let him/her get up or touch anything. She stated LPN #13 came into the room and talked with the resident, then CNA #35 came back into the room and she left, leaving LPN #13 and CNA #35 in Resident #9's room. CNA #34 further stated no one asked her to write out a statement related to the incident stating, I've been waiting for someone to ask me about the incident, and no one's asked me. In an interview with Licensed Practical Nurse (LPN) #13, on 10/17/2023 at 7:55 PM, she stated on 10/12/2023, she was caring for a resident about two (2) doors down the hall from Resident #9's room around 2:00 AM when she heard crying coming from Resident #9's room, a high pitched sound. She stated Resident #9 said, All I wanted to do was go to the bathroom. She further stated she was attending to another resident, and CNA #33 went into Resident #9's room. She stated CNA #33 came to her a few minutes later and told her, I need to report abuse. She further stated she had witnessed CNA #35 push Resident #9 back onto the bed, and the resident's limbs went up into the air. LPN #13 stated CNA #33 told her CNA #35 said to Resident #9, It's time for bed, and used vulgar words to address Resident #9. Additionally, she stated she told CNA #33 to call the DON, then the DON called her and told her to tell CNA #35 to go home pending the investigation of the incident. She stated she went to Resident #9's room where CNA #35 was sitting with Resident #9 and she told CNA #35 she had to go home and she watched as she left the building. She further stated she sat with Resident #9 because he/she was so upset and crying. She stated the resident knew she had reported the incident and told her, I'm glad she's gone but you just made it worse, now I'm going to get worse treatment. Additionally, she stated she would definitely consider the resident to be in psychosocial distress. She stated the DON called her back a while later to tell her to call the police, which she did. She further stated the police and family came into the building around 4:00 AM. Additionally, she stated she felt she had signed an abuse policy for the facility but had just been told to sign something, and she was not sure what the policy was specifically. She stated she felt the staff handled the situation correctly, although CNA #35 should have probably been removed from the facility earlier than she was. In an interview with Police Officer #1, on 10/17/2023 at 9:08 PM, he stated the local police were called over an hour after the incident occurred, and he responded to the facility on [DATE] at approximately 3:50 AM. He stated staff informed him that CNA #35 pushed Resident #9 back onto the bed so his/her legs flew up in the air. He further stated Resident #9 was not able to recollect exactly what happened but was visibly upset and flustered. He stated, based on his report, CNA #35 would be arrested and charged with assault and wanton abuse. In an interview with the Medical Director on 10/18/2023 at 7:35 PM, he stated he was not made aware of the situation with Resident #9 at any time. He further stated he did not attend the QAPI meeting held on 10/13/2023 either in person or by telephone. In an interview with the DON on 10/18/2023 at 9:32 AM, she stated she was called on 10/12/2023 between 2:00 AM and 2:30 AM by CNA #33 who reported CNA #35 was sitting one-to-one (1:1) with Resident #9, and she witnessed CNA #35 push Resident #9 in the chest, causing the resident to fall down onto the bed. She further stated she called CNA #35 and told her to leave the building, and she was not sure if CNA #35 was still sitting with Resident #9 at that time or not. She states she called and notified Administrator #2, then called and talked to a nurse and told her to call the police. Additionally, she stated she left a voice mail for the family. She stated she was not in the building and was unsure how long it took to remove CNA #35 from Resident #9's room, but from the time the incident occurred until CNA #35, was sent home was approximately ten to fifteen (10-15) minutes. The DON stated she was aware the police came to the building but was not sure what they did. Additionally, she stated the incident was not discussed in the QAPI meeting on 10/13/2023, since it was an allegation and had not been thoroughly investigated at that time. In an interview with Administrator #2 on 10/18/2023 at 10:18 AM, he stated he was the Abuse Coordinator and was unaware of any other abuse policy other than the policy titled Abuse and Neglect Reporting Policy, but would reach out to the Regional Nurse Consultant to see if another policy was in effect. He later presented the State Survey Agency with a policy titled Abuse Prevention Program. He further stated he received a call from the DON on 10/12/2023 (unsure of the time, around 2:00 AM) about an abuse allegation and proceeded to do an initial report. He stated, once he was notified, he told staff to remove CNA #35 from the facility and to complete a head to toe assessment and skin check on Resident #9. He stated he then told staff to do a skin assessment for all residents with a Brief Interview for Mental Status (BIMS) score below eight (8) (which indicated cognitive impairment), and interview any residents with a BIMS score of eight (8) or higher. He further stated the police should be contacted, if needed. During continued interview with the Administrator, on 10/18/2023 at 10:18 AM, he stated he interviewed the two (2) witnesses (LPN #13 and CNA #33), the alleged perpetrator, and other staff members. He stated, other than LPN #13 and CNA #33, no one else saw or heard anything. Additionally, he stated he had CNA #33 come into the building and reenact the situation for him and the DON. The Administrator stated he did not need to list everyone he interviewed in his report and that the conclusion (located on the facility's 5-day investigation report) stated, based on interviews. He further stated since he could not rule out abuse, CNA #35 had been suspended and would be terminated. He stated he discussed the incident in QAPI on 10/13/2023 in passing and that was why it was not listed on the QAPI minutes for 10/13/2023. He further stated he discussed it with the department heads and the Medical Director. However, CNA #34, the staff the resident reported the physical and verbal abuse to, stated in interview, she had not been interviewed related to the incident. Additionally, interview with the Medical Director revealed he was unaware of the incident and did not attend the QAPI meeting held on 10/13/2023. The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were asked if they ever witnessed or heard of any abuse or mistreatment of residents. All interviews revealed no issues or concerns with potential abuse or mistreatment. 4. On 10/12/2023, Resident #9 had a second skin assessment completed by the Unit Manager. The skin assessment revealed no redness, bruising, or injury. 5. The DON and Assistant Director of Nursing (ADON) conducted a pain evaluation for Resident #9 on 10/12/2023, and the resident voiced no complaints of pain. The DON and ADON did not observe any behavior of pain by Resident #9. 6. The DON and ADON interviewed residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher on 10/12/2023 regarding any experience or recollection of potential mistreatment or abuse with no concerns found. 7. The DON and ADON performed a skin assessment on residents with a BIMS of seven (7) and below on 10/12/2023 with no signs of redness, bruising, or injury found. 8. The Chief Nursing Officer (CNO) from the consultant team reviewed and updated the Abuse Policy & Procedure on 10/19/2023 to ensure it included all required elements. 9. The CNO held an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 10/19/2023. Those in attendance included the Medical Director (MD), the DON, ADON, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator #1 and #2, Activity Director (AD), and the Regional Travel DON. The attendees reviewed the abuse allegation regarding Resident #9. The attendees considered the incident to be isolated and determined it was addressed appropriately. The CNO shared updates to the Abuse Policy with the attendees. 10. The Regional Director of Operations (RDO), on 10/13/2023, trained the administrative staff on the Abuse Policy, and knowledge was measured by a post-test which required one hundred percent (100%) of correct answers to pass. Administrative staff included the DON, ADON, Minimum Data Set (MDS) Coordinator #1 and #2, SSD, Activity Director (AD), and the Business Office Manager (BOM). 11. The Administrator, DON and ADON educated all facility staff members in all departments on abuse education beginning 10/12/2023 through 10/19/2023. The entire Abuse Policy was reviewed with an emphasis on ensuring resident safety and separating residents from the alleged perpetrator immediately. In addition, education included to immediately report concerns of abuse to the Administrator or an immediate supervisor who would immediately report the allegation to the Administrator. Any staff members who did not complete the education would be reeducated prior to returning to work. Education would be completed by the DON, ADON, Administrator, MDS Coordinator, or SSD. The Administrator would be responsible for overseeing the process. Any staff who failed to comply with the points of the in servicing would be further educated and/or progressively disciplined by their Department Manager or Administrator as indicated up to and including termination. 12. The CNO, on 10/19/2023, retrained the administrative staff on the Abuse Policy and QAPI requirements related to abuse. The retraining included what measures would be put into place and what systemic changes would be made to ensure the deficient practice did not reoccur. 13. All staff members received abuse training upon hire and at least annually. Knowledge and retention would be validated by a posttest and a 100 percent score was required to pass. The Administrator would be responsible for compliance. All contracted staff would receive abuse training prior to resident contact. Knowledge and retention would be validated by a posttest and a 100 percent score would be required to pass. The DON and ADON would complete and monitor this. 14. Department Managers/Administrative Staff conducted daily Guardian Angel Rounds until the Immediate Jeopardy (IJ) was removed. Once IJ was removed, the Guardian Angel Rounds would continue at least three to five (3-5) times per week. Staff would ask each resident if they were being treated appropriately by staff during Guardian Angel Rounds. All identified concerns would be shared at the Morning Meeting and followed up on by the Administrator, DON, ADON, or SSD. Morning meetings would occur seven (7) days a week until the IJ was removed. 15. An Ad-Hoc QAPI meeting would be held within twenty-four (24) hours of any abuse allegation to determine appropriate action and necessary follow-up, seven (7) days a week, and would include the Administrator, DON, and other Department Managers as appropriate. 16. The new facility Administrator began on 10/20/2023. The CNO and Chief Operating Officer (COO) of the consultant team would educate the new Administrator on the Abuse Policy, inform her of her responsibilities as the Abuse Coordinator, and her competency would be validated. The Administrator reports to the Governing Body. 17. The QAPI Committee, consisting of the Administrator, DON, ADON, SSD, and MD would oversee all facility processes related to abuse and neglect and determine whether more systemic actions were necessary. 18. The Administrator, DON, and ADON would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. 19. A member of the consultant team would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. This would be completed daily until the IJ was removed. The State Survey Agency (SSA) validated the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 10/21/2023 as follows: 1. Record review revealed Resident #9 discharged from the facility the morning of the incident. CNA #35 was suspended pending investigation. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she said she was told Certified Nursing Assistant (CNA) #35 exited the building, she assumed to smoke or something. The DON said she was told someone sat with Resident #9. The DON said once she talked to CNA #33 about the allegation of abuse, she called CNA #35 directly and made her leave the facility and made Licensed Practical Nurse (LPN) #13 aware. She stated there was little if any time in which CNA #35 was left alone with Resident #9. The DON further stated LPN #13 did not document Resident #9's skin assessment at the time of the alleged incident. She said the management team started skin assessments the morning of 10/12/2023. 2. Review of the Police Report, completed on 10/12/2023, revealed the police were contacted and arrived at the facility at 3:50 AM, and it was noted the incident took place at approximately 2:40 AM. 3. In an interview with the Activity Director (AD) on 10/21/2023 at 10:36 AM, she stated she was interviewed by the DON about the incident with Resident #9. She stated she had not witnessed any abuse and/or mistreatment of residents in the facility. In an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #6 on 10/21/2023 at 10:58 AM, she stated the DON interviewed her on topics of witnessing any type of abuse. She further stated she had not witnessed abuse. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she could not recall the last dates for abuse training, but she said after the incident with Resident #9, the DON provided reeducation with management. She stated management then did reeducation with the rest of the staff. In an interview with the Human Resources Director (HRD) on 10/21/2023 at 1:44 PM, she stated she was interviewed by the DON. She said she had not witnessed abuse or mistreatment in the facility. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she said she could not remember who talked to her about abuse, but she thought it was discussed in the morning meeting. She also said, in the morning meeting, education was provided about abuse. She further stated staff members were required to take a quiz and pass with a one-hundred (100) percent score. In an interview with the Social Services Director (SSD) on 10/21/2023 at 2:25 PM, she stated the DON interviewed her and asked her if she had witnessed any abuse in the facility. She stated she had not. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she stated, we interviewed all staff in the building about abuse and called everyone who was not in the building. She stated all staff reported they had not witnessed any abuse and had no new concerns to report. 4. Review of Resident #9's skin assessment, dated 10/12/2023, revealed no new injuries were present. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:35 PM, she stated LPN #13 was directed to complete the skin assessment the night of the alleged incident; however, she failed to document it. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated LPN #13 did not do a skin assessment for Resident #9 at the time of the incident. She reported management completed a skin assessment for Resident #9 upon arriving to the facility on [DATE] at approximately 8:30 AM, with no concerns noted. 5. Review of Resident #9's pain assessment form, completed on 10/12/2023 by the DON, revealed the resident was noted to be absent of signs or symptoms of pain related to the abuse allegation. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she had completed a pain assessment on Resident #9 and no complaints were voiced. 6. Review of interview sheets used by the facility on 10/12/2023, for interviews completed on sixteen (16) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher to determine if they felt safe, witnessed any type of abuse, and knew how and who to report concerns to, revealed no concerns. The interview form consisted of the following questions: a) Did they feel safe in the facility? b) Has anyone ever caused you any harm or made you feel afraid, embarrassed since you have been a resident here? c) Have you ever witnessed another resident being treated or spoken to in a manner you felt was unacceptable? and d) Do you know who to report to if you felt threatened, afraid, or spoken to, or treated in an unacceptable manner? Review of completed interview forms on 10/21/2023, revealed all sixteen (16) residents answered the questions appropriately and voiced no concerns. In an interview with Resident #37, on 10/21/2023 at 1:30 PM, he/she stated abuse was discussed with the residents in the Resident Council meetings and they met on the first of every month. The resident stated staff always treated him/her well. In an interview with Resident #39 on 10/21/2023 at 1:35 PM, he/she stated staff treated him/her well and provided good care. In an interview with Resident #38 and Resident #40 (husband and wife) on 10/21/2023 at 1:45 PM, they stated they received good care in the facility and did not have any concerns to report. In an interview with the Social Serviced Director (SSD) on 10/21/2023 at 2:25 PM, she stated the ADON, DON, and she had talked to residents in the facility who had a BIMS score of eight (8) and higher regarding abuse. She stated all interviews were documented on a facility interview sheet. She stated all the residents answered the questions appropriately, and no concerns were found. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated she, the SSD, and the DON went room to room and talked with interviewable residents about abuse. She stated no concerns were identified during the interviews. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated the ADON and the SSD went with her room to room and talked with all residents who had a BIMS score of eight (8) or higher about abuse. She stated all the residents were fine, and nobody had any concerns. 7. Review of sixty-one (61) resident Skin Assessment documents, dated 10/12/2023, revealed Licensed Practical Nurse (LPN) #6 and LPN #7 conducted skin assessments on residents with a BIMS score of seven (7) and lower. Further review of the documents revealed one (1) form was not checked off to show no new areas noted or of any new areas noted. In an interview with LPN/UM #6 on 10/21/2023 10:58 AM, she stated she signed a skin assessment form with the missing check mark. She stated she must have been sidetracked when completing it and recalled the resident did not have any new concerns. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she completed several head-to-toe assessments on residents with a BIMS score of seven (7) and under and found no concerns related to abuse. In an interview with the Assistant Director of Nursing (DON) on 10/21/2023 at 2:53 PM, and the DON on 10/21/2023 at 3:45 PM, they stated they had assisted in conducting the skin assessments of residents with a BIMS score of seven (7) and under. They stated the Unit Managers were also present, and they completed the paperwork. They further stated no new skin concerns were found. 8. Review of the Abuse Policy revealed it was revised to address the Quality Assurance and Performance Improvement (QAPI) changes from Quality Assurance (QA). In an interview with the Chief Nursing Officer (CNO) on 10/21/2023 at 3:11 PM, she stated the facility's previous Abuse Policy did not have the word Quality Assurance and Performance Improvement (QAPI) and was only identified as Quality Assurance (QA). The CNO stated that was a change in Phase 3 of the Federal Regulation roll out. She stated QAPI was added, and some of the policy was reorganized to make it easier to read. She stated the facility made the eight (8) different components more obvious. The CNO stated it was her expectation the facility would have an Ad-Hoc QAPI meeting within twenty-four (24) hours of any abuse allegation. 9. Review of the sign-in sheets for the Ad-Hoc meeting, dated 10/20/2023, revealed no evidence of a 10/19/2023 meeting, and attendees discussed the updated Abuse Policy and QAPI. Those noted as present were the Interim Administrator, DON, ADON, BOM, Activity Director, Dietary, Maintenance Assistant, LPN #6, LPN #7, HR, Housekeeping Director, Assisted Living Director (she helps at the facility sometimes), MDS Nurse #1 and MDS Nurse #2, Corporate MDS Coordinator, and SSD. Review of a zoom call sign-in sheet of a meeting that was conducted on 10/20/2023 at 1:00 PM revealed those present were the Lead by Chief Nursing Officer (CNO)/Governing Body, Present for call: Regional MDS Coordinator #1, Regional Travel DON, ADON, Maintenance Assistant, DON, BOM, Activity Director, Dietary Director, Interim Administrator, Maintenance Director, Housekeeping Director, Float (not Regional) MDS Nurse #3, and Regional MDS Nurse #2. Review of an email to the DON from the Medical Director, dated 10/20/2023 at 5:02 PM, revealed every policy and tag identified by the State Survey Agency (SSA) was discussed with the Administrator and nursing staff of the facility. The Medical Director noted he had been involved with the policies and procedures to correct processes going f[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's policies, review of the facility's investigative report, and review of the Administrator's and Director's of Nursing job descriptions, it was determined the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility also failed to protect residents from abuse; failed to develop and implement policies that prohibited and prevented abuse; and, failed to establish coordination with the Quality Assurance Performance Improvement (QAPI) program related to abuse allegations. On 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 witnessed CNA #35 push Resident #9 in the chest while yelling at the resident. There was no documented evidence CNA #35 was immediately removed from Resident #9's room or Resident #9 was placed in a safe location away from CNA #35. During an interview with CNA #33, she stated CNA #35 pushed Resident #9 back into the bed on 10/12/2023 while yelling at the resident, I'm not dealing with your ass tonight. CNA #33 stated she left the resident's room to report the incident to Licensed Practical Nurse (LPN) #13 who informed her to call the Director of Nursing (DON). She stated CNA #35 was left alone with Resident #9 while she went to inform the nurse. However, the facility failed to ensure the facility's abuse policy was implemented, and no action was taken to protect the resident from further potential abuse. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed Resident #9's abuse allegation from 10/12/2023 was not discussed. The Administrator's and DON's failure to ensure residents were immediately protected from abuse in a timely manner; failure to thoroughly investigate an abuse incident; and failure to involve the Quality Assurance and Performance Improvement (QAPI) Committee in addressing the abuse incident in a timely manner has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/2023 and determined to exist on 10/12/2023 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F607) and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 10/18/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 10/20/2023 alleging removal of the IJ on 10/20/2023. The SSA validated the removal of the IJ on 10/21/2023, prior to exit on 10/21/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's job description for Administrator, undated, revealed the Administrator led and directed the overall operation of the facility in accordance with resident needs, federal and state government regulations, and company policies/procedures so as to maintain quality care for the residents while achieving the facility's business objectives. Further review revealed the Administrator's Essential Job Functions included: job knowledge and administrative duties, interpersonal skills, safety/infection control, and resident care/dignity. Per the job description, the Administrator's responsibilities also included: communicating and observing the Corporate Compliance Program effectively; working with the facility's management staff and consultants in planning all aspects of the facility's operations, including setting priorities and job assignments; monitoring each department's activities, communicating policies, evaluating performance, providing feedback and assistance, coaching and discipline as needed; ensuring consultants and other support resources were appropriately utilized and a high level of inter-departmental teamwork was maintained; and maintaining a working knowledge and ensuring compliance with all governmental regulations and company Quality Assurance Standards. Continued review revealed the Administrator's responsibilities included: he/she was aware of Resident Abuse Reporting Law, ensured understanding of, and compliance with, all rules regarding residents' rights, possessed strong knowledge regarding state, federal and local regulations as they pertain to long term care, and successfully completed facility conducted orientation, mandatory training, and in-service programs. Review of the facility's job description for the Director of Nursing, undated, revealed the DON, under the supervision of the Administrator, had the authority, responsibility, and accountability for the functions, activities, and training of the nursing services staff, and, in the absence of the Administrator, the DON assumed responsibility for the facility. Further review revealed the DON was responsible for the overall management of resident care twenty-four (24) hours a day, seven (7) days a week and was delegated the responsibility for carrying out the assigned duties in accordance with current existing federal and state regulations and established company policies and procedures. Continued review revealed the DON's Essential Job Functions included: job knowledge/duties, administrative duties, nursing systems, nursing documentation, interpersonal skills, safety, infection control, and resident care/dignity. Per the job description, the DON's responsibilities included: acting appropriately under the direction of the Administrator, acting as an active member of the Interdisciplinary Team (IDT); communicating and observing the Corporate Compliance Program effectively and complying with the Code of Conduct when performing work functions; supervising, evaluating, counseling and disciplining inter-departmental personnel; participating in coordination of resident services through departmental and appropriate staff committee meetings (such as Quarterly Quality Assurance and Assessment and Resident Care policy and procedure meeting); planning staff development programs that would enhance staff knowledge of quality resident care; reviewing all accidents and incidents daily and developing an appropriate plan to prevent future accidents and incidents; conducting periodic reviews of documentation for inconsistencies on each unit; was aware of, and adhered to the Resident's [NAME] of Rights and Confidentiality of Resident Information; was aware of Resident Abuse Reporting Law and ensured all staff understanding/compliance; recognizing, removing, and/or reporting potential hazards; and ensuring nursing personnel complied with residents' personal and property rights. Additionally, the DON must possess strong knowledge of state, federal, and local regulations as they pertained to long term care. Review of the facility's policy titled, Abuse Prevention Program, dated 10/22/2022, revealed it was the policy of the facility for staff members who were suspected of abuse or misconduct would be immediately removed and barred from any further contact with residents of the facility and would be suspended from duty, pending the outcome of the investigation. Further review revealed supervisors would monitor the ability of the staff to meet the needs of the residents, staff understanding of individual resident care needs and situations such as inappropriate language and insensitive handling. Additionally, review of the policy revealed the facility stated to prevent resident abuse and if an employee suspected abuse, they were to separate the alleged perpetrator and assure all residents' safety. Record review revealed the final investigation would be submitted within five (5) working days of the incident and should contain facts determined during the process of the investigation, the conclusion of the investigation, the police report, and a summary of all interviews conducted with names, addresses, phone numbers, and willingness to testify of all witnesses. Further review revealed the Administrator or DON would request a representative of the Social Services Department to monitor the resident's feelings concerning the incident as well as the resident's reaction to his/her involvement in the investigation and, unless otherwise requested by the resident, the Social Services representative would provide the Administrator and the DON with a written report of his/her findings in the resident's medical record. Review of the facility's policy titled Quality Assurance and Performance Improvement, dated 11/2017, revealed it was the policy of the facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focused on indicators of the outcomes of care and quality of life. Further review revealed the QA (Quality Assurance) Committee should be interdisciplinary and consist, at a minimum, of the Director of Nursing Services, the Medical Director or his/her designee, at least three (3) other members of the facility's staff, at least one (1) of which must be the Administrator, Owner, a board member or other individual in a leadership role, and the Infection Control and Prevention Officer. Additionally, adverse events would be monitored in accordance with established procedures for the type of adverse event with the data related to adverse events used to develop activities to prevent them. Per the policy, the governing body and/or executive leadership was responsible and accountable for the QAPI program. Review of the facility's Initial Report, dated 10/12/2023, revealed on 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 heard a scream and went down the hall where she witnessed CNA #35 push Resident #9 in the chest down into the bed while telling the resident to keep his/her ass in the bed. Further review revealed CNA #35 was removed from the facility, and Resident #9's assessment showed no signs of injury. Continued review revealed the resident had a history of dementia with a care plan to follow. Per the report, statements were written and signed by LPN #13, CNA #33, and CNA #35. However, CNA #34, who witnessed some of the incident, was not listed. Review of the facility's Five (5) Day Final Report, dated 10/16/2023, revealed Resident #9 no longer resided in the facility and staff interviews were conducted by Administrator #2 and the DON. Further review revealed the nurse immediately did a head to toe skin assessment and no redness or abnormalities we noted. Resident #9 stated I just had to go to the bathroom. Continued review revealed the facility concluded, based on a thorough investigation and interview with the accused, physical abuse can not be ruled out; out of an abundance of caution, CNA #35 was terminated from the facility; Resident #9 was noticed to be her/his usual self the rest of the night without signs or symptoms of any distress or emotional trauma. However, through interviews with staff, the resident exhibited crying episodes, being flustered, and agitation after the incident. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed a QAPI meeting was held on 10/13/2023 with several topics discussed. However, there was no documentation of a discussion about Resident #9's abuse incident. Further review revealed Corporate staff, the Administrator, the DON. the Social Services Director (SSD), and the Minimum Data Set (MDS) attended the meeting. In an interview with CNA #33 on 10/17/2023 at 5:21 PM, she stated, on 10/12/2023, she was in a resident's room when she heard screaming from Resident #9's room. She further stated she went into Resident #9's room and witnessed the resident standing beside the bed with his/her walker. She stated she then witnessed CNA #35 stand up, use her right hand to push Resident #9 in the chest, which caused the resident to fall backward onto the bed with his/her feet flying up into the air. Additionally, she stated CNA #35 said I'm not dealing with your ass tonight. She stated she did not say anything to CNA #35, but left the room and notified LPN #13, who stated she was unaware of the facility's policy and asked CNA #33 to call the DON, which she did. She stated as she walked toward the front bathroom, she saw CNA #35 come out into the hallway and asked CNA #34 to relieve her so she could take a break. Additionally, she stated the DON told her she was going to call Administrator #2, but did not mention anything else to her about Resident #9 or CNA #35. Additionally, she stated after CNA #35 left the building, she went back to Resident #9's room where the resident was upset and told another CNA, I'm too little, I can't fight her. She stated the resident had to be taken out of the room into the lobby area to calm down because he/she was crying and agitated. She further stated she was not aware of the abuse policy and had not been told not to leave the resident alone with CNA #35 after she witnessed her push the resident. She stated she had been told to report the abuse immediately which was why she left the room to get the nurse. In an interview with CNA #34 on 10/17/2023 at 6:35 PM, she stated she was working on 10/12/2023 when she heard yelling in Resident #9's room and went into the hallway. She further stated CNA #33 went into Resident #9's room and she went to another resident's room. She stated CNA #33 pulled her aside and told her she had witnessed CNA #35 push Resident #9, and she went with CNA #35 to report to LPN #13. She further stated CNA #35 asked her to relieve her sitting one-on-one (1:1) so she could take a break and, when she went into Resident #9's room, Resident #9 was crying and told her she pushed me. She stated CNA #35 told CNA #34 to sit in that chair and don't let him/her get up or touch anything. When asked if she made a statement to anyone from the facility, she stated, No, I've been waiting for someone to ask me about the incident; no one's asked me for a statement. In an interview with LPN #13 on 10/17/2023 at 7:55 PM she stated she felt she had signed an abuse policy for the facility but had just been told to sign something, and was not sure what the policy was specifically. She stated CNA #35 should probably have been removed from the facility earlier than she was. In an interview with Police Officer #1 on 10/17/2023 at 9:08 PM he stated the police were called over an hour after the incident occurred, and he responded to the facility on [DATE] at approximately 3:50 AM. He stated, based on his report, CNA #35 would be arrested and charged with Assault and Wanton Abuse. In an interview with the Social Services Director (SSD) on 10/18/2023 at 10:58 AM, she stated she was aware of the abuse allegation on 10/12/2023 when she arrived to the facility for her regularly scheduled work day (time punch on 10/12/2023 revealed she clocked in at 9:03 AM). She further stated she talked with the resident's son during the morning of 10/12/2023, and he was okay with the situation. However, there was no documented evidence to support her conversation with the son or that she talked with the resident. She stated she did not do a psychosocial assessment on Resident #9. In an interview with the Medical Director on 10/18/2023 at 7:35 PM, he stated he was not made aware of the situation with Resident #9 at any time. In an interview with the DON on 10/18/2023 at 9:32 AM, she stated, after hearing about the abuse allegation concerning Resident #9, she called CNA #35 and told her to leave the building, but she was not sure if CNA #35 was still sitting with Resident #9 at that time or not. She further stated the Social Services Director (SSD) should have followed up with a psychosocial assessment, but she was not sure if she had time as the resident discharged from the building later that day (10/12/2023). Additionally, she stated the incident was not discussed in the QAPI meeting on 10/13/2023 since it was an allegation and had not been thoroughly investigated at that time, and she was instructed by corporate to not discuss it on 10/13/2023. In an interview with Administrator #2 on 10/18/2023 at 10:18 AM, he stated the SSD did follow up assessments for psychosocial harm, and these should have been done throughout the shift on which the alleged abuse occurred and daily until the resident showed no signs of psychosocial harm. He further stated if the SSD was not available, other staff could assist with completing the psychosocial assessments. The Administrator stated he discussed the incident and abuse prevention in QAPI on 10/13/2023 in passing and that was why it was not listed on the QAPI minutes for 10/13/2023. However, he stated CNA #34, a witness to some of the events with Resident #9 on 10/12/2023, was not interviewed. The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were asked if they ever witnessed or heard of any abuse or mistreatment of residents. All interviews revealed no issues or concerns with potential abuse or mistreatment. 4. On 10/12/2023, Resident #9 had a second skin assessment completed by the Unit Manager. The skin assessment revealed no redness, bruising, or injury. 5. The DON and Assistant Director of Nursing (ADON) conducted a pain evaluation for Resident #9 on 10/12/2023, and the resident voiced no complaints of pain. The DON and ADON did not observe any behavior of pain by Resident #9. 6. The DON and ADON interviewed residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher on 10/12/2023 regarding any experience or recollection of potential mistreatment or abuse with no concerns found. 7. The DON and ADON performed a skin assessment on residents with a BIMS of seven (7) and below on 10/12/2023 with no signs of redness, bruising, or injury found. 8. The Chief Nursing Officer (CNO) from the consultant team reviewed and updated the Abuse Policy & Procedure on 10/19/2023 to ensure it included all required elements. 9. The CNO held an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 10/19/2023. Those in attendance included the Medical Director (MD), the DON, ADON, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator #1 and #2, Activity Director (AD), and the Regional Travel DON. The attendees reviewed the abuse allegation regarding Resident #9. The attendees considered the incident to be isolated and determined it was addressed appropriately. The CNO shared updates to the Abuse Policy with the attendees. 10. The Regional Director of Operations (RDO), on 10/13/2023, trained the administrative staff on the Abuse Policy, and knowledge was measured by a post-test which required one hundred percent (100%) of correct answers to pass. Administrative staff included the DON, ADON, Minimum Data Set (MDS) Coordinator #1 and #2, SSD, Activity Director (AD), and the Business Office Manager (BOM). 11. The Administrator, DON and ADON educated all facility staff members in all departments on abuse education beginning 10/12/2023 through 10/19/2023. The entire Abuse Policy was reviewed with an emphasis on ensuring resident safety and separating residents from the alleged perpetrator immediately. In addition, education included to immediately report concerns of abuse to the Administrator or an immediate supervisor who would immediately report the allegation to the Administrator. Any staff members who did not complete the education would be reeducated prior to returning to work. Education would be completed by the DON, ADON, Administrator, MDS Coordinator, or SSD. The Administrator would be responsible for overseeing the process. Any staff who failed to comply with the points of the in servicing would be further educated and/or progressively disciplined by their Department Manager or Administrator as indicated up to and including termination. 12. The CNO, on 10/19/2023, retrained the administrative staff on the Abuse Policy and QAPI requirements related to abuse. The retraining included what measures would be put into place and what systemic changes would be made to ensure the deficient practice did not reoccur. 13. All staff members received abuse training upon hire and at least annually. Knowledge and retention would be validated by a posttest and a 100 percent score was required to pass. The Administrator would be responsible for compliance. All contracted staff would receive abuse training prior to resident contact. Knowledge and retention would be validated by a posttest and a 100 percent score would be required to pass. The DON and ADON would complete and monitor this. 14. Department Managers/Administrative Staff conducted daily Guardian Angel Rounds until the Immediate Jeopardy (IJ) was removed. Once IJ was removed, the Guardian Angel Rounds would continue at least three to five (3-5) times per week. Staff would ask each resident if they were being treated appropriately by staff during Guardian Angel Rounds. All identified concerns would be shared at the Morning Meeting and followed up on by the Administrator, DON, ADON, or SSD. Morning meetings would occur seven (7) days a week until the IJ was removed. 15. An Ad-Hoc QAPI meeting would be held within twenty-four (24) hours of any abuse allegation to determine appropriate action and necessary follow-up, seven (7) days a week, and would include the Administrator, DON, and other Department Managers as appropriate. 16. The new facility Administrator began on 10/20/2023. The CNO and Chief Operating Officer (COO) of the consultant team would educate the new Administrator on the Abuse Policy, inform her of her responsibilities as the Abuse Coordinator, and her competency would be validated. The Administrator reports to the Governing Body. 17. The QAPI Committee, consisting of the Administrator, DON, ADON, SSD, and MD would oversee all facility processes related to abuse and neglect and determine whether more systemic actions were necessary. 18. The Administrator, DON, and ADON would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. 19. A member of the consultant team would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. This would be completed daily until the IJ was removed. The State Survey Agency (SSA) validated the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 10/21/2023 as follows: 1. Record review revealed Resident #9 discharged from the facility the morning of the incident. CNA #35 was suspended pending investigation. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she said she was told Certified Nursing Assistant (CNA) #35 exited the building, she assumed to smoke or something. The DON said she was told someone sat with Resident #9. The DON said once she talked to CNA #33 about the allegation of abuse, she called CNA #35 directly and made her leave the facility and made Licensed Practical Nurse (LPN) #13 aware. She stated there was little if any time in which CNA #35 was left alone with Resident #9. The DON further stated LPN #13 did not document Resident #9's skin assessment at the time of the alleged incident. She said the management team started skin assessments the morning of 10/12/2023. 2. Review of the Police Report, completed on 10/12/2023, revealed the police were contacted and arrived at the facility at 3:50 AM, and it was noted the incident took place at approximately 2:40 AM. 3. In an interview with the Activity Director (AD) on 10/21/2023 at 10:36 AM, she stated she was interviewed by the DON about the incident with Resident #9. She stated she had not witnessed any abuse and/or mistreatment of residents in the facility. In an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #6 on 10/21/2023 at 10:58 AM, she stated the DON interviewed her on topics of witnessing any type of abuse. She further stated she had not witnessed abuse. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she could not recall the last dates for abuse training, but she said after the incident with Resident #9, the DON provided reeducation with management. She stated management then did reeducation with the rest of the staff. In an interview with the Human Resources Director (HRD) on 10/21/2023 at 1:44 PM, she stated she was interviewed by the DON. She said she had not witnessed abuse or mistreatment in the facility. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she said she could not remember who talked to her about abuse, but she thought it was discussed in the morning meeting. She also said, in the morning meeting, education was provided about abuse. She further stated staff members were required to take a quiz and pass with a one-hundred (100) percent score. In an interview with the Social Services Director (SSD) on 10/21/2023 at 2:25 PM, she stated the DON interviewed her and asked her if she had witnessed any abuse in the facility. She stated she had not. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she stated, we interviewed all staff in the building about abuse and called everyone who was not in the building. She stated all staff reported they had not witnessed any abuse and had no new concerns to report. 4. Review of Resident #9's skin assessment, dated 10/12/2023, revealed no new injuries were present. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:35 PM, she stated LPN #13 was directed to complete the skin assessment the night of the alleged incident; however, she failed to document it. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated LPN #13 did not do a skin assessment for Resident #9 at the time of the incident. She reported management completed a skin assessment for Resident #9 upon arriving to the facility on [DATE] at approximately 8:30 AM, with no concerns noted. 5. Review of Resident #9's pain assessment form, completed on 10/12/2023 by the DON, revealed the resident was noted to be absent of signs or symptoms of pain related to the abuse allegation. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she had completed a pain assessment on Resident #9 and no complaints were voiced. 6. Review of interview sheets used by the facility on 10/12/2023, for interviews completed on sixteen (16) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher to determine if they felt safe, witnessed any type of abuse, and knew how and who to report concerns to, revealed no concerns. The interview form consisted of the following questions: a) Did they feel safe in the facility? b) Has anyone ever caused you any harm or made you feel afraid, embarrassed since you have been a resident here? c) Have you ever witnessed another resident being treated or spoken to in a manner you felt was unacceptable? and d) Do you know who to report to if you felt threatened, afraid, or spoken to, or treated in an unacceptable manner? Review of completed interview forms on 10/21/2023, revealed all sixteen (16) residents answered the questions appropriately and voiced no concerns. In an interview with Resident #37, on 10/21/2023 at 1:30 PM, he/she stated abuse was discussed with the residents in the Resident Council meetings and they met on the first of every month. The resident stated staff always treated him/her well. In an interview with Resident #39 on 10/21/2023 at 1:35 PM, he/she stated staff treated him/her well and provided good care. In an interview with Resident #38 and Resident #40 (husband and wife) on 10/21/2023 at 1:45 PM, they stated they received good care in the facility and did not have any concerns to report. In an interview with the Social Serviced Director (SSD) on 10/21/2023 at 2:25 PM, she stated the ADON, DON, and she had talked to residents in the facility who had a BIMS score of eight (8) and higher regarding abuse. She stated all interviews were documented on a facility interview sheet. She stated all the residents answered the questions appropriately, and no concerns were found. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated she, the SSD, and the DON went room to room and talked with interviewable residents about abuse. She stated no concerns were identified during the interviews. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated the ADON and the SSD went with her room to room and talked with all residents who had a BIMS score of eight (8) or higher about abuse. She stated all the residents were fine, and nobody had any concerns. 7. Review of sixty-one (61) resident Skin Assessment documents, dated 10/12/2023, revealed Licensed Practical Nurse (LPN) #6 and LPN #7 conducted skin assessments on residents with a BIMS score of seven (7) and lower. Further review of the documents revealed one (1) form was not checked off to show no new areas noted or of any new areas noted. In an interview with LPN/UM #6 on 10/21/2023 10:58 AM, she stated she signed a skin assessment form with the missing check mark. She stated she must have been sidetracked when completing it and recalled the resident did not have any new concerns. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she completed several head-to-toe assessments on residents with a BIMS score of seven (7) and under and found no concerns related to abuse. In an interview with the Assistant Director of Nursing (DON) on 10/21/2023 at 2:53 PM, and the DON on 10/21/2023 at 3:45 PM, they stated they had assisted in conducting the skin assessments of residents with a BIMS score of seven (7) and under. They stated the Unit Managers were also present, and they completed the paperwork. They further stated no new skin concerns were found. 8. Review of the Abuse Policy revealed it was revised to address the Quality Assurance and Performance Improvement (QAPI) changes from Quality Assurance (QA). In an interview with the Chief Nursing Officer (CNO) on 10/21/2023 at 3:11 PM, she stated the facility's previous Abuse Policy did not have the word Quality Assurance and Performance Improvement (QAPI) and was only identified as Quality Assurance (QA). The CNO stated that was a change in Phase 3 of the Federal Regulation roll out. She stated QAPI was added, and some of the policy was reorganized to make it easier to read. She stated the facility made the eight (8) different components more obvious. The CNO stated it was her expectation the facility would have an Ad-Hoc QAPI meeting within twenty-four (24) hours of any abuse allegation. 9. Review of the sign-in sheets for the Ad-Hoc meeting, dated 10/20/2023, revealed no evidence of a 10/19/2023 meeting, and attendees discussed the updated Abuse Policy and QAPI. Those noted as present were the In[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident's Advanced Directives, it was determined the facility failed to ensure the residents' rights to request, refuse, and/or discontinue treatment, and to formulate an advanced directive for one (1) of twenty-five (25) sampled residents (Resident #10). Review of the resident's Advanced Directives revealed the resident had an Advanced Directive for Full Code on [DATE]. However, there was no evidence the Advanced Directive was updated to ensure accuracy. Review of Resident #10's admission Record revealed the facility admitted the resident on [DATE] with an Advanced Directive designated as Full Code. Further review revealed the resident's code status had changed on [DATE] to Do Not Resuscitate (DNR). However, review of the resident's Face Sheet revealed the facility failed to update the resident's code status to DNR on [DATE]. The facility transferred the resident to the hospital on [DATE] with a Full Code status and the resident was intubated and placed on a ventilator. The facility's failure to have an effective system to ensure the residents' rights to requrest, refuse, and/or discontinue treatment, and formulate an advanced directive is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR 483.10 at the highest S/S of a J. The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. IJ is ongoing. (Refer to F657) The findings include: Review of the facility's policy, Advance Directives Policy, dated [DATE], revealed the facility provided to all residents the right to accept or refuse medical and surgical treatment and, at the resident's option, formulate an Advanced Directive. Further review revealed the facility would periodically assess the resident for decision-making capacity and invoke the health care agent or legal representative if the resident was determined not to have decision-making capacity. Continued review revealed the facility would establish mechanisms for documenting and communicating resident choices to the Interdisciplinary Team (IDT). Additionally, if the resident or resident's legal representative executed one or more Advanced Directives, the facility would incorporate the resident's wishes into their plan of care and the resident's desires would be re-evaluated as indicated to ensure the resident's or legal representative's choices were honored timely. Review of the facility's Director of Social Services Job Description, signed by the Social Services Director (SSD) on [DATE], revealed the SSD was responsible for reviewing and explaining the facility's Cardiopulmonary Resuscitation (CPR) policy and DNR regulations, rights, and obligations. Further review revealed the SSD was responsible for obtaining updated information from the Hospital Discharge Planner to prepare various departments of the resident's needs and updating any new assessment information on the resident's chart. Review of Resident #10's admission Record revealed the facility admitted the resident on [DATE] with diagnoses which included Chronic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Anxiety, Dementia, Essential Tremor, and Diabetes. Review of Resident #10's admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), which indicated severe cognitive impairment. Review of Resident #10's Comprehensive Care Plan, dated [DATE], revealed the resident had an Advanced Directive for a Full Code with interventions which included to honor the resident's choices and perform CPR. Review of Resident #10's Electronic Medical Record revealed the resident was admitted to the hospital on [DATE] and readmitted to the facility on [DATE]. Further review revealed an order was initiated on [DATE] for a Full Code status. Review of Resident #10's Advanced Directives revealed a Full Code Advanced Directive, dated [DATE], and signed by the resident's spouse. Further review revealed an Advanced Directive for a Kentucky Emergency Medical Services (EMS) DNR order signed and notarized on [DATE]. Review of Resident #10's hospital records revealed the hospital admitted the resident on [DATE]. Continued review of the emergency room (ER) physican summary revealed the ER staff believed the resident was a Full Code as the resident's Face Sheet listed him/her as a Full Code and an EMS DNR form was not presented at the time of the transfer to the hospital. Continued review revealed the resident was intubated prior to the family's arrival to the hospital. During an interview with Registered Nurse (RN) #2, on [DATE] at 4:40 PM, she stated a discharge summary should be obtained with orders for a resident admitting or readmitting to the facility prior to the resident's arrival. She stated this did not always happen, and, in some cases, the resident arrived with the orders and the discharge summary. RN #2 stated the floor nurses entered the orders from the discharge summary. Additionally, she stated when a resident was sent to the hospital, the nurse should send a copy of their Face Sheet, orders, and the EMS DNR form if applicable. Based on the policy, she stated the resident's Code Status should have been updated appropriately on the Face Sheet and orders, and a EMS DNR form signed. During an interview with the SSD, on [DATE] at 2:45 PM, she stated she discussed Advanced Directives with the resident or their representative upon admission and completed the Advanced Directive as Full Code or DNR at that time. She further stated the nurses were required to have a discharge summary prior to admitting residents to the facility, both at admission and readmission. The SSD stated she communicated frequently with the Discharge Planner/Case Manager at the hospital to determine any needs for any facility residents in the hospital. Additionally, she stated the clinical team discussed during daily clinical meeting any orders, assessments, and Code Status for any admissions or readmissions. The SSD stated she should have been told by the hospital Discharge Planner if the resident changed to a DNR while at the hospital, and should have asked the hospital Discharge Planner to clarify any new orders, including the code status. Additionally, she stated she should have discussed the code status with the resident and his/her family when the resident re-admitted to the hospital. She stated if she had been aware the code status had changed, she would have changed the information in Point Click Care (PCC) (the computer's charting system) that flowed to the Face Sheet so the Face Sheet would have shown Do Not Resuscitate as the code status. During an interview with Minimum Data Set (MDS) Nurse #1, on [DATE] at 3:20 PM, she stated she scanned the resident's EMS DNR form into the Point Click Care (PCC) computer system in [DATE]. She further stated she inherited a stack of papers to scan in from the previous person because the facility did not have a Medical Records Clerk. The MDS Nurse stated she was unaware when the facility received a copy of the EMS DNR. The EMS DNR form was signed and notorized at the hospital on [DATE] prior to the resident returning to the facility that date. During an interview with Family Member #3, on [DATE] at 5:51 PM, he stated he did not remember the facility staff informing him that he was signing a Full Code Advanced Directive on [DATE] because we all knew Resident #10 did not want to be placed on a ventilator. He further stated the hospital had placed Resident #10 on a ventilator in the ER prior to the family arriving to the hospital. Family Member #3 stated the family had to inform the hospital staff that the resident did not want to be intubated. During an interview with the Medical Director (MD), on [DATE] at 7:35 PM, he stated it was his expectation the facility followed the Advanced Directive wishes of the resident and/or the resident's responsible party. He further stated Code Status should be evaluated with any significant change of the resident, upon admission, and upon readmission at a minimum. During an interview with the Director of Nursing (DON), on [DATE] at 3:19 PM, she stated she expected staff to correctly enter Physician's Orders into the computer and for the resident's choice of Advanced Directives be honored. She stated the SSD was responsible for making sure the Advanced Directives were updated as the resident's wishes changed. During an interview with the Administrator, on [DATE] at 3:45 PM, she stated she expected new admission and readmission orders to be discussed during the morning interdisciplinary team (IDT)/clinical meeting. She further stated she expected staff to follow the facility's policies and revise the Medical Record to reflect the resident's wishes to formulate an advanced directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were asked if they ever witnessed or heard of any abuse or mistreatment of residents. All interviews revealed no issues or concerns with potential abuse or mistreatment. 4. On 10/12/2023, Resident #9 had a second skin assessment completed by the Unit Manager. The skin assessment revealed no redness, bruising, or injury. 5. The DON and Assistant Director of Nursing (ADON) conducted a pain evaluation for Resident #9 on 10/12/2023, and the resident voiced no complaints of pain. The DON and ADON did not observe any behavior of pain by Resident #9. 6. The DON and ADON interviewed residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher on 10/12/2023 regarding any experience or recollection of potential mistreatment or abuse with no concerns found. 7. The DON and ADON performed a skin assessment on residents with a BIMS of seven (7) and below on 10/12/2023 with no signs of redness, bruising, or injury found. 8. The Chief Nursing Officer (CNO) from the consultant team reviewed and updated the Abuse Policy & Procedure on 10/19/2023 to ensure it included all required elements. 9. The CNO held an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 10/19/2023. Those in attendance included the Medical Director (MD), the DON, ADON, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator #1 and #2, Activity Director (AD), and the Regional Travel DON. The attendees reviewed the abuse allegation regarding Resident #9. The attendees considered the incident to be isolated and determined it was addressed appropriately. The CNO shared updates to the Abuse Policy with the attendees. 10. The Regional Director of Operations (RDO), on 10/13/2023, trained the administrative staff on the Abuse Policy, and knowledge was measured by a post-test which required one hundred percent (100%) of correct answers to pass. Administrative staff included the DON, ADON, Minimum Data Set (MDS) Coordinator #1 and #2, SSD, Activity Director (AD), and the Business Office Manager (BOM). 11. The Administrator, DON and ADON educated all facility staff members in all departments on abuse education beginning 10/12/2023 through 10/19/2023. The entire Abuse Policy was reviewed with an emphasis on ensuring resident safety and separating residents from the alleged perpetrator immediately. In addition, education included to immediately report concerns of abuse to the Administrator or an immediate supervisor who would immediately report the allegation to the Administrator. Any staff members who did not complete the education would be reeducated prior to returning to work. Education would be completed by the DON, ADON, Administrator, MDS Coordinator, or SSD. The Administrator would be responsible for overseeing the process. Any staff who failed to comply with the points of the in servicing would be further educated and/or progressively disciplined by their Department Manager or Administrator as indicated up to and including termination. 12. The CNO, on 10/19/2023, retrained the administrative staff on the Abuse Policy and QAPI requirements related to abuse. The retraining included what measures would be put into place and what systemic changes would be made to ensure the deficient practice did not reoccur. 13. All staff members received abuse training upon hire and at least annually. Knowledge and retention would be validated by a posttest and a 100 percent score was required to pass. The Administrator would be responsible for compliance. All contracted staff would receive abuse training prior to resident contact. Knowledge and retention would be validated by a posttest and a 100 percent score would be required to pass. The DON and ADON would complete and monitor this. 14. Department Managers/Administrative Staff conducted daily Guardian Angel Rounds until the Immediate Jeopardy (IJ) was removed. Once IJ was removed, the Guardian Angel Rounds would continue at least three to five (3-5) times per week. Staff would ask each resident if they were being treated appropriately by staff during Guardian Angel Rounds. All identified concerns would be shared at the Morning Meeting and followed up on by the Administrator, DON, ADON, or SSD. Morning meetings would occur seven (7) days a week until the IJ was removed. 15. An Ad-Hoc QAPI meeting would be held within twenty-four (24) hours of any abuse allegation to determine appropriate action and necessary follow-up, seven (7) days a week, and would include the Administrator, DON, and other Department Managers as appropriate. 16. The new facility Administrator began on 10/20/2023. The CNO and Chief Operating Officer (COO) of the consultant team would educate the new Administrator on the Abuse Policy, inform her of her responsibilities as the Abuse Coordinator, and her competency would be validated. The Administrator reports to the Governing Body. 17. The QAPI Committee, consisting of the Administrator, DON, ADON, SSD, and MD would oversee all facility processes related to abuse and neglect and determine whether more systemic actions were necessary. 18. The Administrator, DON, and ADON would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. 19. A member of the consultant team would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. This would be completed daily until the IJ was removed. The State Survey Agency (SSA) validated the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 10/21/2023 as follows: 1. Record review revealed Resident #9 discharged from the facility the morning of the incident. CNA #35 was suspended pending investigation. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she said she was told Certified Nursing Assistant (CNA) #35 exited the building, she assumed to smoke or something. The DON said she was told someone sat with Resident #9. The DON said once she talked to CNA #33 about the allegation of abuse, she called CNA #35 directly and made her leave the facility and made Licensed Practical Nurse (LPN) #13 aware. She stated there was little if any time in which CNA #35 was left alone with Resident #9. The DON further stated LPN #13 did not document Resident #9's skin assessment at the time of the alleged incident. She said the management team started skin assessments the morning of 10/12/2023. 2. Review of the Police Report, completed on 10/12/2023, revealed the police were contacted and arrived at the facility at 3:50 AM, and it was noted the incident took place at approximately 2:40 AM. 3. In an interview with the Activity Director (AD) on 10/21/2023 at 10:36 AM, she stated she was interviewed by the DON about the incident with Resident #9. She stated she had not witnessed any abuse and/or mistreatment of residents in the facility. In an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #6 on 10/21/2023 at 10:58 AM, she stated the DON interviewed her on topics of witnessing any type of abuse. She further stated she had not witnessed abuse. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she could not recall the last dates for abuse training, but she said after the incident with Resident #9, the DON provided reeducation with management. She stated management then did reeducation with the rest of the staff. In an interview with the Human Resources Director (HRD) on 10/21/2023 at 1:44 PM, she stated she was interviewed by the DON. She said she had not witnessed abuse or mistreatment in the facility. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she said she could not remember who talked to her about abuse, but she thought it was discussed in the morning meeting. She also said, in the morning meeting, education was provided about abuse. She further stated staff members were required to take a quiz and pass with a one-hundred (100) percent score. In an interview with the Social Services Director (SSD) on 10/21/2023 at 2:25 PM, she stated the DON interviewed her and asked her if she had witnessed any abuse in the facility. She stated she had not. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she stated, we interviewed all staff in the building about abuse and called everyone who was not in the building. She stated all staff reported they had not witnessed any abuse and had no new concerns to report. 4. Review of Resident #9's skin assessment, dated 10/12/2023, revealed no new injuries were present. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:35 PM, she stated LPN #13 was directed to complete the skin assessment the night of the alleged incident; however, she failed to document it. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated LPN #13 did not do a skin assessment for Resident #9 at the time of the incident. She reported management completed a skin assessment for Resident #9 upon arriving to the facility on [DATE] at approximately 8:30 AM, with no concerns noted. 5. Review of Resident #9's pain assessment form, completed on 10/12/2023 by the DON, revealed the resident was noted to be absent of signs or symptoms of pain related to the abuse allegation. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she had completed a pain assessment on Resident #9 and no complaints were voiced. 6. Review of interview sheets used by the facility on 10/12/2023, for interviews completed on sixteen (16) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher to determine if they felt safe, witnessed any type of abuse, and knew how and who to report concerns to, revealed no concerns. The interview form consisted of the following questions: a) Did they feel safe in the facility? b) Has anyone ever caused you any harm or made you feel afraid, embarrassed since you have been a resident here? c) Have you ever witnessed another resident being treated or spoken to in a manner you felt was unacceptable? and d) Do you know who to report to if you felt threatened, afraid, or spoken to, or treated in an unacceptable manner? Review of completed interview forms on 10/21/2023, revealed all sixteen (16) residents answered the questions appropriately and voiced no concerns. In an interview with Resident #37, on 10/21/2023 at 1:30 PM, he/she stated abuse was discussed with the residents in the Resident Council meetings and they met on the first of every month. The resident stated staff always treated him/her well. In an interview with Resident #39 on 10/21/2023 at 1:35 PM, he/she stated staff treated him/her well and provided good care. In an interview with Resident #38 and Resident #40 (husband and wife) on 10/21/2023 at 1:45 PM, they stated they received good care in the facility and did not have any concerns to report. In an interview with the Social Serviced Director (SSD) on 10/21/2023 at 2:25 PM, she stated the ADON, DON, and she had talked to residents in the facility who had a BIMS score of eight (8) and higher regarding abuse. She stated all interviews were documented on a facility interview sheet. She stated all the residents answered the questions appropriately, and no concerns were found. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated she, the SSD, and the DON went room to room and talked with interviewable residents about abuse. She stated no concerns were identified during the interviews. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated the ADON and the SSD went with her room to room and talked with all residents who had a BIMS score of eight (8) or higher about abuse. She stated all the residents were fine, and nobody had any concerns. 7. Review of sixty-one (61) resident Skin Assessment documents, dated 10/12/2023, revealed Licensed Practical Nurse (LPN) #6 and LPN #7 conducted skin assessments on residents with a BIMS score of seven (7) and lower. Further review of the documents revealed one (1) form was not checked off to show no new areas noted or of any new areas noted. In an interview with LPN/UM #6 on 10/21/2023 10:58 AM, she stated she signed a skin assessment form with the missing check mark. She stated she must have been sidetracked when completing it and recalled the resident did not have any new concerns. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she completed several head-to-toe assessments on residents with a BIMS score of seven (7) and under and found no concerns related to abuse. In an interview with the Assistant Director of Nursing (DON) on 10/21/2023 at 2:53 PM, and the DON on 10/21/2023 at 3:45 PM, they stated they had assisted in conducting the skin assessments of residents with a BIMS score of seven (7) and under. They stated the Unit Managers were also present, and they completed the paperwork. They further stated no new skin concerns were found. 8. Review of the Abuse Policy revealed it was revised to address the Quality Assurance and Performance Improvement (QAPI) changes from Quality Assurance (QA). In an interview with the Chief Nursing Officer (CNO) on 10/21/2023 at 3:11 PM, she stated the facility's previous Abuse Policy did not have the word Quality Assurance and Performance Improvement (QAPI) and was only identified as Quality Assurance (QA). The CNO stated that was a change in Phase 3 of the Federal Regulation roll out. She stated QAPI was added, and some of the policy was reorganized to make it easier to read. She stated the facility made the eight (8) different components more obvious. The CNO stated it was her expectation the facility would have an Ad-Hoc QAPI meeting within twenty-four (24) hours of any abuse allegation. 9. Review of the sign-in sheets for the Ad-Hoc meeting, dated 10/20/2023, revealed no evidence of a 10/19/2023 meeting, and attendees discussed the updated Abuse Policy and QAPI. Those noted as present were the Interim Administrator, DON, ADON, BOM, Activity Director, Dietary, Maintenance Assistant, LPN #6, LPN #7, HR, Housekeeping Director, Assisted Living Director (she helps at the facility sometimes), MDS Nurse #1 and MDS Nurse #2, Corporate MDS Coordinator, and SSD. Review of a zoom call sign-in sheet of a meeting that was conducted on 10/20/2023 at 1:00 PM revealed those present were the Lead by Chief Nursing Officer (CNO)/Governing Body, Present for call: Regional MDS Coordinator #1, Regional Travel DON, ADON, Maintenance Assistant, DON, BOM, Activity Director, Dietary Director, Interim Administrator, Maintenance Director, Housekeeping Director, Float (not Regional) MDS Nurse #3, and Regional MDS Nurse #2. Review of an email to the DON from the Medical Director, dated 10/20/2023 at 5:02 PM, revealed every policy and tag identified by the State Survey Agency (SSA) was discussed with the Administrator and nursing staff of the facility. The Medical Director noted he had been involved with the policies and procedures to correct processes going forward. In an interview with the facility's Scheduler on 10/21/2023 at 2:39 PM, she stated she did not attend the meeting in which the abuse allegation which involved Resident #9 was discussed. She stated the meeting was covered with her after the fact as she had a floor assignment. She stated they discussed the change of the abuse policy from QA to QAPI. She said a new question do you feel safe here was added to the list they completed during Guardian Angel rounds. The scheduler stated if there was an allegation of abuse, the resident was to be kept safe and removed from the situation, and then the incident was to be reported to management immediately. She said the most important part was to make sure the resident was safe. In an interview with the Activities Director on 10/21/2023 at 10:36 AM, she stated she recalled a meeting in which management discussed CNA #35 and the allegation she pushed Resident #9 and yelled at the resident. The Activities Director said there were discussions about the aide leaving the resident alone with the alleged perpetrator while she got help and did not get the resident out of danger. The Activities Director stated the aide should have called for someone to come and be with Resident #9 or she should have taken Resident #9 with her to get help. She stated on 10/20/2023 the CNO held a meeting, and they discussed the change from QA to QAPI on the abuse policy. She believed the policy remained the same except for those two (2) areas. In an interview with the Business Office Manager (BOM) on 10/21/2023 at 1:35 PM, she stated she was present at a meeting in which Resident #9 was discussed and what was done wrong, as the aide left the resident with the perpetrator. She stated the aide should have made sure the resident was safe first. She stated they talked about reporting abuse, and staff members needed to make sure it happened timely. The BOM stated they talked about education with the focus on resident safety. In an interview with the Human Resources (HR) Director on 10/21/2023 at 1:44 PM, she stated she was present in a meeting when Resident #9 and how to follow the abuse policy. She further stated the policy was changed to reflect QAPI instead of QA. In an interview with the Housekeeping Director on 10/21/2023 at 11:11 AM, she said the management team discussed what happened with Resident #9 and what could have been done to prevent the entire incident. She stated QA was changed to QAPI which was discussed in their meeting. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she stated she was present in a meeting in which Resident #9 was discussed. She stated the team discussed the allegation of abuse and that the aide left the resident alone with the alleged perpetrator while she went to get help. In an interview with Minimum Data Set (MDS) Coordinator #2 on 10/21/2023 at 2:09 PM, she stated the team discussed the abuse policy and about the change from QA to QAPI to match the federal regulations. She stated all department heads and the administrative team were present. She stated they discussed the abuse allegation related to Resident #9 and the importance of removing the resident to safety before anything else was done. MDS Coordinator #2 stated all abuse concerns had to be reported immediately to the supervisor and to the Abuse Coordinator, who had two (2) hours to report it to the required agencies. In an interview with LPN/UM #6 on 10/21/2023 at 10:58 AM, she stated she was aware the abuse policy had some updates mostly related to the wording of it. She stated management ensured all staff were educated about abuse and understood to make sure the resident was safe before getting help. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated the team met on 10/19/2023, and discussed the abuse policy, reporting procedures, making sure staff knew how to report, who to report to, and when to report any abuse concerns. She stated management reinforced resident safety and not to leave the resident alone with the perpetrator. She also stated the management team was present early on 10/21/2023 before shift change to make sure all staff members were educated before they started their shift on the floor. In an interview with the SSD on 10/21/2023 at 2:25 PM, she stated there was a meeting in which the administrative team and the department heads discussed the new tags related to the abuse allegation. She said they discussed the incident related to Resident #9. The SSD stated they discussed the report of abuse and what action was taken and what they would do from this point. The SSD stated the focus of the meeting was for staff members were to ensure the resident was safe before leaving the room to get help. In an interview with the Medical Director on 10/21/2023 at 5:22 PM, he stated the facility would implement the changes to ensure anytime there was an abuse allegation, a QAPI meeting would be held within one (1) day or that day. He also stated if the allegation was abuse, the person identified as the perpetrator would not be left alone with the resident. The Medical Director stated he would be involved with the Ad-Hoc QAPI meeting, and if he was not available, his Nurse Practitioner would be present. He further stated he was made aware of the changes to the policy to reflect QAPI instead of QA. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:53 PM, she stated she was present in a meeting in which Resident #9 was discussed and the abuse allegation. She said they talked about changes to the abuse policy, such as QA was changed to QAPI, and an immediate meeting would be held for all allegations of abuse. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated they held a meeting and discussed the concerns related to Resident #9. She said they discussed the allegation and the changes in the abuse policy. The DON stated the emphasis of the meeting was educating all the facility staff to ensure a resident was never left alone with an alleged perpetrator. The DON also noted the policy was changed to reflect QAPI instead of QA. In an interview with current Interim Administrator on 10/21/2023 at 11:33 AM, she stated she was called to start at the facility on 10/20/2023 in the morning. The Interim Administrator said the CNO informed her of Resident #9's abuse situation. She stated the facility management staff completed extensive education as well as follow up to ensure all staff understood how to deal with abuse allegations. The Interim Administrator stated the department heads conducted Guardian Rounds at the beginning of each day, and all concerns were addressed as a team. The Interim Administrator stated there were reminder signs posted all throughout the facility, even in the staff restrooms regarding abuse. She stated staff members were given quizzes about reportables and understanding they must report any concerns, even if they were not sure it was abuse. The Interim Administrator stated the department heads would continue to quiz staff. 10. In interviews with the Activities Director on 10/21/2023 at 10:36 AM, the LPN/UM #6 at 10:58 AM, the Business Office Manager (BOM) at 1:35 PM, Human Resource (HR) Director at 1:44 PM, and the MDS Coordinator #2 at 2:09 PM, they stated reeducation over the abuse policy was provided by the DON with the previous Interim Administrator present. They stated all staff took a post-test requiring a 100% passing score. In interviews with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:53 PM, and the DON at 3:45 PM, they stated abuse training was provided by the Regional Director of Operations (RDO) and were given a pretest and post-test. They stated there was a question on the quiz about ensuring the resident was safe and not to leave the resident with an alleged perpetrator when getting help or going to report it. The ADON and DON further stated they discussed signs and symptoms of abuse in residents with dementia and reporting requirements. 11. Review of the education sign-in sheets and quizzes, dated 10/20/2023, revealed all current staff had completed the education and achieved a passing score of 100 percent. In an interview with CNA #15 on 10/21/2023 at 9:58 AM; CNA #37 on 10/21/2023 at 10:05 AM; CNA #32 on 10/21/2023 at 10:08 AM; CNA #14 on 10/21/2023 at 10:15 AM; CNA #38 on 10/21/2023 at 10:20 AM; CNA #39 on 10/21/2023 at 10:41 AM; CNA #21 on 10/21/2023 at 3:12 PM; and CNA #46 on 10/21/2023 at 4:00 PM, all stated they were reeducated by the Regional Travel DON on abuse. Each CNA stated they covered the types of abuse, who to report to, what to do in an abuse situation, and when to report abuse. Each CNA stated they had to take a quiz after the education and score 100 percent to pass. Each aide explained if the quiz was not passed, reeducation was completed on the spot. All CNAs stated the focus of the reeducation was to ensure the resident was never left alone with the alleged perpetrator, and they got help by calling out for help or by hitting the call light. All aides were educated that abuse was to be reported immediately to management, and the Administrator was the Abuse Coordinator. In an interview with Housekeeping Aide (HKA) #4 on 10/21/2023 at 10:27 AM, she stated she had abuse training with the Regional Travel DON. She said the abuse training covered what to do with a resident in an abuse situation, the types of abuse, who to call, and when to call. HKA #4 stated she would contact the Administrator immediately to report an allegations of abuse. The HKA #4 stated if she witnessed any concerns of abuse, she would make sure the resident was safe before she reported it to management. HKA #4 stated she had to take a quiz on abuse and score 100 percent to pass. In an interview with Dietary Aide #1 on 10/21/2023 at 10:49 AM and Dietary Aide #2 on 10/21/2023 at 10:51 AM, they stated they received abuse training by the DON. They reported the abuse training included what to do if they suspected abuse, how long they had to report abuse, who to report to, and to make sure the resident involved in the situation was kept safe and not left alone with the alleged perpetrator. Dietary Aide #1 and #2 also stated they were to report any abuse concerns to the Administrator. In an interview with Dietary [NAME] #1 on 10/21/2023 at 10:46 AM and Dietary [NAME] #2 on 10/21/2023 at 10:53 AM, they stated they were educated by the DON prior to their shift today on the expectations when abuse concerns were identified. Both Dietary [NAME] #1 and #2 stated they had to take a posttest and score 100 percent to pass. They stated they were educated on what to report, when to report, and who to report to. They said they were told if they witnessed abuse the first thing they needed to do was ensure the resident was safe. The next thing they needed to do was report the allegation to management. Both Dietary Cooks identified the Administrator as the Abuse Coordinator. Both stated they were not to ever leave a resident with the alleged perpetrator while they got help. In an interview with LPN #11 on 10/21/2023 at 10:01 AM and LPN #14 on 10/21/2023 at 2:46 PM, they stated they had abuse training last night, and the training was completed by Regional Travel DON. LPN #11 stated training covered the types of abuse, the policy on abuse, what to do in an abuse situation, who to report the allegation to, and when to report the abuse situation. LPN #11 stated she would report allegations of abuse immediately to the Administrator. She also stated she took a posttest which required a passing score of 100 percent. LPN #11 stated when suspected abuse occurred, the first thing she needed to do was ensure the resident was safe and not to leave the resident with the alleged abuser. LPN #11 also stated she would report the allegation immediately to the Manager on Duty. In an interview with Speech Therapist #1 on 10/21/2023 at 2:10 PM, she stated she completed abuse education with many other staff on 10/20/2023. She said the training was completed by the facility DON and also corporate staff. Speech Therapist #1 stated they were educated on what needed to be reported, who it should be reported to, to make sure the resident was safe before going out to get help, and making sure the abuse was immediately reported. She also said they discussed QAPI. She said all staff were required to take and pass a quiz on abuse with a score of 100 percent. She stated those who did not score 100 percent were reeducated on the spot. She stated the Abuse Coordinator was the Administrator. In an interview with the Therapy Program Director (TPD) on 10/21/2023 at 1:48 PM, he stated he attended reeducation on abuse on 10/20/2023, and it was completed by the Regional Travel Nurse and the facility DON. He stated they discussed what abuse was, the types of abuse, when it had to be reported, and who it needed to be reported to. He stated they discussed making sure the resident involved was made safe and not left in the room with the alleged perpetrator when staff reported it to management. The TPD stated staff could use the call light or could call out for help if in that situation. He also stated all staff members were required to take and pass a quiz with a score of 100 percent. He explained the Guardian Angel Rounds, which were when the department heads rounded the entire unit and checked residents' rooms, to make sure there no hazards, were clean, and the residents had everything they needed. The TPD stated any concerns found during the rounds were to be reported immediately if they were serious; if not serious, the form was completed and put in the DON's office. In an interview with the Scheduler on 10/21/2023 at 2:39 PM, she stated agency staff members were given a training packet to complete at the front door prior to their shift. She also stated any staff who were scheduled as needed (PRN) were contacted via telephone, and training was done with them. She stated two (2) staff were required for any verbal training to be conducted. She said she highlighted all agency staff on the schedule and informed the receptionist those staff had a packet to complete prior to their shift. She stated once the training was done, the agency staff would be given their computer log in. In an interview with the ADON on 10/21/2023 at 2:54 PM, she stated all staff were provided a copy of the abuse policy, they were told who abuse allegations were to be reported to, shown where the phone numbers were listed, and informed they were to report all concerns of abuse immediately. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she made sure all staff were reeducated on abuse, through meeting them at the door, calling them at home, or whatever it took to ensure all staff members were trained. She stated any staff who could not be reached would be educated prior to working a shift. The SSA Surveyor attempted an interview with LPN #12 on 10/21/2023 at 3:01 PM; CNA #42 at 3:04 PM; CNA #21 at 3:06 PM; CNA #44 at 3:08 PM; and Kentucky Medication Aide (KMA #4) at 3:11 PM. However, the SSA Surveyor was unable to contact these staff, and voice messages were left on phones where it was possible to leave a message. 12. Review of education on abuse signature sheet, dated 10/20/2023, revealed education was completed by the CNO to all management staff. In an interview with the Activities Director on 10/21/2023 at 10:36 AM, she stated she was provided reeducation on abuse by the Chief Nursing Officer (CNO). She stated the policy was reviewed and they discussed the changes from QA to QAPI. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated the CNO discussed the importance of QAPI and having an Ad-Hoc meeting after an allegation of abuse or when an injury had happened. The ADON also stated the wording in the policy was changed[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, review of the facility's investigative report, and review of the facility's policy, it was determined the facility failed to ensure its policy was implemented related to completing a thorough investigation, and failed to have an effective Quality Assurance and Performance Improvement (QAPI) program to ensure measures were taken to protect the residents from abuse for one (1) of three (3) sampled residents (Resident #9). Review of the facility's Initial Report, dated 10/12/2023, revealed Certified Nursing Assistant (CNA) #33 was working in a resident's room when she heard a scream and stepped into the hallway. She then witnessed CNA #35 push Resident #9 in the chest down into Resident #9's bed, and CNA #35 told Resident #9 to keep his/her ass in bed. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed Resident #9's abuse incident was not discussed at the meeting. The facility's failure to ensure its policies were implemented related to abuse/neglect has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/2023 and determined to exist on 10/12/2023 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F607) and 42 CFR 483.70 Administration (F835) at the highest scope and severity of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.12, Free from Abuse, Neglect, and Exploitation (F600). The facility was notified of the Immediate Jeopardy (IJ) on 10/18/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 10/20/2023 alleging removal of the IJ on 10/20/2023. The SSA validated the removal of the IJ on 10/21/2023, prior to exit on 10/21/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled Abuse Prevention Program, dated 10/22/2022, revealed it was the facility's policy that staff members, who were suspected of abuse or misconduct would be immediately removed and barred from any further contact with residents of the facility and would be suspended from duty, pending the outcome of the investigation. Additional review revealed the policy defined verbal abuse as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. Further review revealed upon receiving reports of physical abuse, the Charge Nurse would immediately examine the resident, and the findings of the examination must be recorded in a separate incident report. Per the policy, to prevent resident abuse and if an employee suspected abuse, they were to separate the alleged perpetrator and assure all residents' safety. Review of Resident #9's admission Record revealed the facility admitted Resident #9, on 02/24/2022, with diagnoses which included Alzheimer's Disease, history of falling, and dementia with mood disturbance and anxiety. Review of Resident #9's Quarterly Minimum Data Set (MDS) Assessment, dated 08/06/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15), which indicated severe cognitive impairment. Review of the facility's Initial Report, dated 10/12/2023, revealed on 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 heard a scream and went down the hall where she witnessed CNA #35 push Resident #9 in the chest down into the bed while telling the resident to keep his/her ass in the bed. Further review revealed CNA #35 was removed from the facility, and Resident #9's assessment showed no signs of injury. Continued review revealed the resident had a history of dementia with a care plan to follow on dementia. Per the report, statements were written and signed by Licensed Practical Nurse (LPN) #13, CNA #33, and CNA #35. Review of the facility's Five (5) day Final Report, dated 10/16/2023, revealed Resident #9 no longer resided in the facility, and staff interviews were conducted by Administrator #2 and the DON. Further review revealed the nurse immediately did a head to toe skin assessment on Resident #9, and no redness or abnormalities were noted. Resident #9 stated I just had to go to the bathroom. Per the report, all residents on the unit with a Brief Interview for Mental Status (BIMS) score of eight (8) or above were interviewed, and no other care concerns were identified by other residents. Skin audits were completed for residents with a BIMS score of seven (7) or below (which indicated cognitive impairment), and no areas of concern were identified. Continued review revealed the facility concluded, based on a thorough investigation and interview with the accused, physical abuse can not be ruled out; out of an abundance of caution, CNA #35 was terminated from the facility; Resident #9 was noticed to be her usual self the rest of the night without signs or symptoms of any distress or emotional trauma. However, through interviews with staff, the resident exhibited crying episodes, being flustered, and agitation after the incident. Review of the facility's one-to-one (1:1) sheets revealed CNA #35 was sitting one-to-one (1:1) with Resident #9 from 10/11/2023 at 11:15 PM until 10/12/2023 at 2:15 AM. Review of CNA #35's time card punch for 10/12/2023 revealed she clocked out at 2:12 AM. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed a QAPI meeting was held on 10/13/2023 with topics discussed as follows: medication administration; proper progress notes and documentation; use of the chart audit tool; all residents at risk for elopement and the review of all elopement drills; the need for twenty-four/seven (24/7) front door monitoring; resident care plans; and use of the Continuous Quality Improvement (CQI) tool. However, there was no documentation of a discussion about Resident #9's abuse incident. Further review revealed Corporate staff, the Administrator, the DON, the Social Services Director (SSD), and the Minimum Data Set (MDS) attended the meeting. In an interview with CNA #33 on 10/17/2023 at 5:21 PM, she stated, on 10/12/2023, she was in a resident's room when she heard screaming from Resident #9's room. She further stated she went into Resident #9's room and witnessed the resident standing beside the bed with his/her walker. She stated she then witnessed CNA #35 stand up, use her right hand to push Resident #9 in the chest, causing the resident to fall backward onto the bed with his/her feet flying up into the air. Additionally, she stated CNA #35 said to Resident #9, I'm not dealing with your ass tonight. She stated she did not say anything to CNA #35, but left the room and notified LPN #13, who stated she was unaware of the facility's policy on abuse and asked CNA #33 to call the DON, which she did. She stated as she walked toward the front bathroom, she saw CNA #35 come out into the hallway and ask CNA #34 to relieve her so she could take a break. In further interview with CNA #33, on 10/17/2023 at 5:21 PM, she stated the DON told her she was going to call the Administrator #2, but did not mention anything else to her about Resident #9 or CNA #35. She stated she walked back to the nurses' station where LPN #13 was standing, and LPN #13 told her I have to send CNA #35 home and I'm nervous. She stated everyone was aware of CNA #35's attitude but denied reporting any concerns to the DON or Administrator #2. Additionally, she stated after CNA #35 left the building, she went back to Resident #9's room where the resident was upset and told another CNA, I'm too little, I can't fight her. She stated the resident had to be taken out of the room into the lobby area to calm down because she was crying and agitated. She further stated she was not aware of the abuse policy and had not been told not to leave the resident alone with CNA #35 after she witnessed her push the resident. She continued to state she had been told to report the abuse immediately which was why she left the room to get the nurse. In an interview with CNA #34, on 10/17/2023 at 6:35 PM, she stated she was working on 10/12/2023 when she heard yelling in Resident #9's room and went into the hallway. She further stated CNA #33 went into Resident #9's room and she went to another resident's room. She continued to state CNA #33 pulled her aside and told her she had witnessed CNA #35 push Resident #9 and she went with CNA #35 to report to LPN #13. She further stated CNA #35 asked her to relieve her sitting one-on-one (1:1) so she could take a break and, when she went into Resident #9's room, Resident #9 was crying and told her she pushed me. She continued to state CNA #35 told CNA #34 sit in that chair and don't let him/her get up or touch anything. She stated LPN #13 came into the room and talked with the resident, then CNA #35 came back into the room and she left, leaving LPN #13 and CNA #35 in Resident #9's room. CNA #34 further stated no one asked her to write out a statement related to the incident stating, I've been waiting for someone to ask me about the incident, and no one's asked me. In an interview with Licensed Practical Nurse (LPN) #13, on 10/17/2023 at 7:55 PM, she stated on 10/12/2023, she was caring for a resident about two (2) doors down the hall from Resident #9's room around 2:00 AM when she heard crying coming from Resident #9's room, a high pitched sound. She stated Resident #9 said, All I wanted to do was go to the bathroom. She further stated she was attending to another resident, and CNA #33 went into Resident #9's room. She stated CNA #33 came to her a few minutes later and told her, I need to report abuse. She further stated she had witnessed CNA #35 push Resident #9 back onto the bed, and the resident's limbs went up into the air. LPN #13 stated CNA #33 told her CNA #35 said to Resident #9, It's time for bed, and used vulgar words to address Resident #9. Additionally, she stated she told CNA #33 to call the DON, then the DON called her and told her to tell CNA #35 to go home pending the investigation of the incident. She stated she went to Resident #9's room where CNA #35 was sitting with Resident #9 and she told CNA #35 she had to go home and she watched as she left the building. She further stated she sat with Resident #9 because he/she was so upset and crying. She stated the resident knew she had reported the incident and told her, I'm glad she's gone but you just made it worse, now I'm going to get worse treatment. Additionally, she stated she would definitely consider the resident to be in psychosocial distress. She stated the DON called her back a while later to tell her to call the police, which she did. She further stated the police and family came into the building around 4:00 AM. Additionally, she stated she felt she had signed an abuse policy for the facility but had just been told to sign something, and she was not sure what the policy was specifically. She stated she felt the staff handled the situation correctly, although CNA #35 should have probably been removed from the facility earlier than she was. In an interview with Police Officer #1, on 10/17/2023 at 9:08 PM, he stated the local police were called over an hour after the incident occurred, and he responded to the facility on [DATE] at approximately 3:50 AM. He stated staff informed him that CNA #35 pushed Resident #9 back onto the bed so his/her legs flew up in the air. He further stated Resident #9 was not able to recollect exactly what happened but was visibly upset and flustered. He stated, based on his report, CNA #35 would be arrested and charged with assault and wanton abuse. In an interview with the Medical Director on 10/18/2023 at 7:35 PM, he stated he was not made aware of the situation with Resident #9 at any time. He further stated he did not attend the QAPI meeting held on 10/13/2023 either in person or by telephone. In an interview with the DON on 10/18/2023 at 9:32 AM, she stated she was called on 10/12/2023 between 2:00 AM and 2:30 AM by CNA #33 who reported CNA #35 was sitting one-to-one (1:1) with Resident #9, and she witnessed CNA #35 push Resident #9 in the chest, causing the resident to fall down onto the bed. She further stated she called CNA #35 and told her to leave the building, and she was not sure if CNA #35 was still sitting with Resident #9 at that time or not. She states she called and notified Administrator #2, then called and talked to a nurse and told her to call the police. Additionally, she stated she left a voice mail for the family. She stated she was not in the building and was unsure how long it took to remove CNA #35 from Resident #9's room, but from the time the incident occurred until CNA #35, was sent home was approximately ten to fifteen (10-15) minutes. The DON stated she was aware the police came to the building but was not sure what they did. Additionally, she stated the incident was not discussed in the QAPI meeting on 10/13/2023, since it was an allegation and had not been thoroughly investigated at that time. In an interview with Administrator #2 on 10/18/2023 at 10:18 AM, he stated he was the Abuse Coordinator and was unaware of any other abuse policy other than the policy titled Abuse and Neglect Reporting Policy, but would reach out to the Regional Nurse Consultant to see if another policy was in effect. He later presented the State Survey Agency with a policy titled Abuse Prevention Program. He further stated he received a call from the DON on 10/12/2023 (unsure of the time, around 2:00 AM) about an abuse allegation and proceeded to do an initial report. He stated, once he was notified, he told staff to remove CNA #35 from the facility and to complete a head to toe assessment and skin check on Resident #9. He stated he then told staff to do a skin assessment for all residents with a Brief Interview for Mental Status (BIMS) score below eight (8) (which indicated cognitive impairment), and interview any residents with a BIMS score of eight (8) or higher. He further stated the police should be contacted, if needed. During continued interview with the Administrator, on 10/18/2023 at 10:18 AM, he stated he interviewed the two (2) witnesses (LPN #13 and CNA #33), the alleged perpetrator, and other staff members. He stated, other than LPN #13 and CNA #33, no one else saw or heard anything. Additionally, he stated he had CNA #33 come into the building and reenact the situation for him and the DON. The Administrator stated he did not need to list everyone he interviewed in his report and that the conclusion (located on the facility's 5-day investigation report) stated, based on interviews. He further stated since he could not rule out abuse, CNA #35 had been suspended and would be terminated. He stated he discussed the incident in QAPI on 10/13/2023 in passing and that was why it was not listed on the QAPI minutes for 10/13/2023. He further stated he discussed it with the department heads and the Medical Director. However, CNA #34, the staff the resident reported the physical and verbal abuse to, stated in interview, she had not been interviewed related to the incident. Additionally, interview with the Medical Director revealed he was unaware of the incident and did not attend the QAPI meeting held on 10/13/2023. The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were asked if they ever witnessed or heard of any abuse or mistreatment of residents. All interviews revealed no issues or concerns with potential abuse or mistreatment. 4. On 10/12/2023, Resident #9 had a second skin assessment completed by the Unit Manager. The skin assessment revealed no redness, bruising, or injury. 5. The DON and Assistant Director of Nursing (ADON) conducted a pain evaluation for Resident #9 on 10/12/2023, and the resident voiced no complaints of pain. The DON and ADON did not observe any behavior of pain by Resident #9. 6. The DON and ADON interviewed residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher on 10/12/2023 regarding any experience or recollection of potential mistreatment or abuse with no concerns found. 7. The DON and ADON performed a skin assessment on residents with a BIMS of seven (7) and below on 10/12/2023 with no signs of redness, bruising, or injury found. 8. The Chief Nursing Officer (CNO) from the consultant team reviewed and updated the Abuse Policy & Procedure on 10/19/2023 to ensure it included all required elements. 9. The CNO held an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 10/19/2023. Those in attendance included the Medical Director (MD), the DON, ADON, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator #1 and #2, Activity Director (AD), and the Regional Travel DON. The attendees reviewed the abuse allegation regarding Resident #9. The attendees considered the incident to be isolated and determined it was addressed appropriately. The CNO shared updates to the Abuse Policy with the attendees. 10. The Regional Director of Operations (RDO), on 10/13/2023, trained the administrative staff on the Abuse Policy, and knowledge was measured by a post-test which required one hundred percent (100%) of correct answers to pass. Administrative staff included the DON, ADON, Minimum Data Set (MDS) Coordinator #1 and #2, SSD, Activity Director (AD), and the Business Office Manager (BOM). 11. The Administrator, DON and ADON educated all facility staff members in all departments on abuse education beginning 10/12/2023 through 10/19/2023. The entire Abuse Policy was reviewed with an emphasis on ensuring resident safety and separating residents from the alleged perpetrator immediately. In addition, education included to immediately report concerns of abuse to the Administrator or an immediate supervisor who would immediately report the allegation to the Administrator. Any staff members who did not complete the education would be reeducated prior to returning to work. Education would be completed by the DON, ADON, Administrator, MDS Coordinator, or SSD. The Administrator would be responsible for overseeing the process. Any staff who failed to comply with the points of the in servicing would be further educated and/or progressively disciplined by their Department Manager or Administrator as indicated up to and including termination. 12. The CNO, on 10/19/2023, retrained the administrative staff on the Abuse Policy and QAPI requirements related to abuse. The retraining included what measures would be put into place and what systemic changes would be made to ensure the deficient practice did not reoccur. 13. All staff members received abuse training upon hire and at least annually. Knowledge and retention would be validated by a posttest and a 100 percent score was required to pass. The Administrator would be responsible for compliance. All contracted staff would receive abuse training prior to resident contact. Knowledge and retention would be validated by a posttest and a 100 percent score would be required to pass. The DON and ADON would complete and monitor this. 14. Department Managers/Administrative Staff conducted daily Guardian Angel Rounds until the Immediate Jeopardy (IJ) was removed. Once IJ was removed, the Guardian Angel Rounds would continue at least three to five (3-5) times per week. Staff would ask each resident if they were being treated appropriately by staff during Guardian Angel Rounds. All identified concerns would be shared at the Morning Meeting and followed up on by the Administrator, DON, ADON, or SSD. Morning meetings would occur seven (7) days a week until the IJ was removed. 15. An Ad-Hoc QAPI meeting would be held within twenty-four (24) hours of any abuse allegation to determine appropriate action and necessary follow-up, seven (7) days a week, and would include the Administrator, DON, and other Department Managers as appropriate. 16. The new facility Administrator began on 10/20/2023. The CNO and Chief Operating Officer (COO) of the consultant team would educate the new Administrator on the Abuse Policy, inform her of her responsibilities as the Abuse Coordinator, and her competency would be validated. The Administrator reports to the Governing Body. 17. The QAPI Committee, consisting of the Administrator, DON, ADON, SSD, and MD would oversee all facility processes related to abuse and neglect and determine whether more systemic actions were necessary. 18. The Administrator, DON, and ADON would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. 19. A member of the consultant team would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. This would be completed daily until the IJ was removed. The State Survey Agency (SSA) validated the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 10/21/2023 as follows: 1. Record review revealed Resident #9 discharged from the facility the morning of the incident. CNA #35 was suspended pending investigation. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she said she was told Certified Nursing Assistant (CNA) #35 exited the building, she assumed to smoke or something. The DON said she was told someone sat with Resident #9. The DON said once she talked to CNA #33 about the allegation of abuse, she called CNA #35 directly and made her leave the facility and made Licensed Practical Nurse (LPN) #13 aware. She stated there was little if any time in which CNA #35 was left alone with Resident #9. The DON further stated LPN #13 did not document Resident #9's skin assessment at the time of the alleged incident. She said the management team started skin assessments the morning of 10/12/2023. 2. Review of the Police Report, completed on 10/12/2023, revealed the police were contacted and arrived at the facility at 3:50 AM, and it was noted the incident took place at approximately 2:40 AM. 3. In an interview with the Activity Director (AD) on 10/21/2023 at 10:36 AM, she stated she was interviewed by the DON about the incident with Resident #9. She stated she had not witnessed any abuse and/or mistreatment of residents in the facility. In an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #6 on 10/21/2023 at 10:58 AM, she stated the DON interviewed her on topics of witnessing any type of abuse. She further stated she had not witnessed abuse. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she could not recall the last dates for abuse training, but she said after the incident with Resident #9, the DON provided reeducation with management. She stated management then did reeducation with the rest of the staff. In an interview with the Human Resources Director (HRD) on 10/21/2023 at 1:44 PM, she stated she was interviewed by the DON. She said she had not witnessed abuse or mistreatment in the facility. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she said she could not remember who talked to her about abuse, but she thought it was discussed in the morning meeting. She also said, in the morning meeting, education was provided about abuse. She further stated staff members were required to take a quiz and pass with a one-hundred (100) percent score. In an interview with the Social Services Director (SSD) on 10/21/2023 at 2:25 PM, she stated the DON interviewed her and asked her if she had witnessed any abuse in the facility. She stated she had not. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she stated, we interviewed all staff in the building about abuse and called everyone who was not in the building. She stated all staff reported they had not witnessed any abuse and had no new concerns to report. 4. Review of Resident #9's skin assessment, dated 10/12/2023, revealed no new injuries were present. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:35 PM, she stated LPN #13 was directed to complete the skin assessment the night of the alleged incident; however, she failed to document it. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated LPN #13 did not do a skin assessment for Resident #9 at the time of the incident. She reported management completed a skin assessment for Resident #9 upon arriving to the facility on [DATE] at approximately 8:30 AM, with no concerns noted. 5. Review of Resident #9's pain assessment form, completed on 10/12/2023 by the DON, revealed the resident was noted to be absent of signs or symptoms of pain related to the abuse allegation. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she had completed a pain assessment on Resident #9 and no complaints were voiced. 6. Review of interview sheets used by the facility on 10/12/2023, for interviews completed on sixteen (16) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher to determine if they felt safe, witnessed any type of abuse, and knew how and who to report concerns to, revealed no concerns. The interview form consisted of the following questions: a) Did they feel safe in the facility? b) Has anyone ever caused you any harm or made you feel afraid, embarrassed since you have been a resident here? c) Have you ever witnessed another resident being treated or spoken to in a manner you felt was unacceptable? and d) Do you know who to report to if you felt threatened, afraid, or spoken to, or treated in an unacceptable manner? Review of completed interview forms on 10/21/2023, revealed all sixteen (16) residents answered the questions appropriately and voiced no concerns. In an interview with Resident #37, on 10/21/2023 at 1:30 PM, he/she stated abuse was discussed with the residents in the Resident Council meetings and they met on the first of every month. The resident stated staff always treated him/her well. In an interview with Resident #39 on 10/21/2023 at 1:35 PM, he/she stated staff treated him/her well and provided good care. In an interview with Resident #38 and Resident #40 (husband and wife) on 10/21/2023 at 1:45 PM, they stated they received good care in the facility and did not have any concerns to report. In an interview with the Social Serviced Director (SSD) on 10/21/2023 at 2:25 PM, she stated the ADON, DON, and she had talked to residents in the facility who had a BIMS score of eight (8) and higher regarding abuse. She stated all interviews were documented on a facility interview sheet. She stated all the residents answered the questions appropriately, and no concerns were found. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated she, the SSD, and the DON went room to room and talked with interviewable residents about abuse. She stated no concerns were identified during the interviews. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated the ADON and the SSD went with her room to room and talked with all residents who had a BIMS score of eight (8) or higher about abuse. She stated all the residents were fine, and nobody had any concerns. 7. Review of sixty-one (61) resident Skin Assessment documents, dated 10/12/2023, revealed Licensed Practical Nurse (LPN) #6 and LPN #7 conducted skin assessments on residents with a BIMS score of seven (7) and lower. Further review of the documents revealed one (1) form was not checked off to show no new areas noted or of any new areas noted. In an interview with LPN/UM #6 on 10/21/2023 10:58 AM, she stated she signed a skin assessment form with the missing check mark. She stated she must have been sidetracked when completing it and recalled the resident did not have any new concerns. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she completed several head-to-toe assessments on residents with a BIMS score of seven (7) and under and found no concerns related to abuse. In an interview with the Assistant Director of Nursing (DON) on 10/21/2023 at 2:53 PM, and the DON on 10/21/2023 at 3:45 PM, they stated they had assisted in conducting the skin assessments of residents with a BIMS score of seven (7) and under. They stated the Unit Managers were also present, and they completed the paperwork. They further stated no new skin concerns were found. 8. Review of the Abuse Policy revealed it was revised to address the Quality Assurance and Performance Improvement (QAPI) changes from Quality Assurance (QA). In an interview with the Chief Nursing Officer (CNO) on 10/21/2023 at 3:11 PM, she stated the facility's previous Abuse Policy did not have the word Quality Assurance and Performance Improvement (QAPI) and was only identified as Quality Assurance (QA). The CNO stated that was a change in Phase 3 of the Federal Regulation roll out. She stated QAPI was added, and some of the policy was reorganized to make it easier to read. She stated the facility made the eight (8) different components more obvious. The CNO stated it was her expectation the facility would have an Ad-Hoc QAPI meeting within twenty-four (24) hours of any abuse allegation. 9. Review of the sign-in sheets for the Ad-Hoc meeting, dated 10/20/2023, revealed no evidence of a 10/19/2023 meeting, and attendees discussed the updated Abuse Policy and QAPI. Those noted as present were the Interim Administrator, DON, ADON, BOM, Activity Director, Dietary, Maintenance Assistant, LPN #6, LPN #7, HR, Housekeeping Director, Assisted Living Director (she helps at the facility sometimes), MDS Nurse #1 and MDS Nurse #2, Corporate MDS Coordinator, and SSD. Review of a zoom call sign-in sheet of a meeting that was conducted on 10/20/2023 at 1:00 PM revealed those present were the Lead by Chief Nursing Officer (CNO)/Governing Body, Present for call: Regional MDS Coordinator #1, Regional Travel DON, ADON, Maintenance Assistant, DON, BOM, Activity Director, Dietary Director, Interim Administrator, Maintenance Director, Housekeeping Director, Float (not Regional) MDS Nurse #3, and Regional MDS Nurse #2. Review of an email to the DON from the Medical Director, dated 10/20/2023 at 5:02 PM, revealed every policy and tag identified by the State Survey Agency (SSA) was discussed with the Administrator and nursing staff of the facility. The Medical Director noted he had been involved with the policies and procedures to correct processes going f[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, it was determined the facility failed to ensure each resident's comprehensive care plan was developed and/or implemented for four (4) of twenty-five (25) sampled residents, (Residents #4, #9, #15, and #13). 1. Record review revealed Resident #4's care plan was not developed and/or implemented to ensure the resident was monitored related to his/her history of stroke and migraine headaches. 2. On 08/31/2023, at approximately 7:00 PM, Resident #9 attempted to exit the facility through the facility's front lobby door and was brought back inside the facility. However, facility staff did not implement Resident #9's care plan intervention for providing one-to-one (1:1) supervision as needed. Therefore, approximately an hour later, Resident #9 was able to exit the facility without staffs' knowledge. 3. Closed record review revealed Resident #15 sustained a femur fracture on 04/16/2022, after he/she rolled out of his/her low air loss mattress while only one (1) staff provided the resident's Activities of Daily Living (ADL) care. However, Resident #15 was care planned to require extensive assistance of two (2) staff for bed mobility, personal hygiene and turning and repositioning. 4. Record review revealed Resident #13's comprehensive care plan was not implemented to reduce the resident's behaviors which resulted in falls and staff using a gait belt as a restraint to prevent him/her from getting out of his/her chair. The facility's failure to have an effective system to ensure each resident's comprehensive care plan was developed and/or implemented has caused or is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on 09/13/2023 and was determined to exist on 08/31/2023; and on 09/26/2023 and was determined to exist on 07/08/2023, in the area of 42 CFR §482.21 Comprehensive Care Plans Develop and Implement (F656) at the highest Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy (IJ) on 09/13/2023 and on 09/26/2023. IJ is ongoing. (Refer to F604, F684, and F689) The findings include: Review of the facility's policy titled, Care Plan Review undated, revealed residents were to be assessed at least quarterly, and include visual and verbal assessment, obtaining information from the health record, as well as interviewing the nursing assistants prior to completing the Minimum Data Set Assessment and comprehensive person-centered care plan. Further review revealed staff were to evaluate the progress or lack thereof for each resident's goal and document the findings in measurable terms. 1.) Review of Resident #4's admission Record/electronic medical record (EMR) revealed the facility admitted the resident on 10/27/2022, with diagnoses to include: history of Transient Ischemic Attack (TIA) and Cerebral Infarction, Heart Disease, Dementia and Panic Disorder. Continued review revealed Resident #4's last admission was 02/27/2023. Per review, the Medical Director noted on 11/01/2022, that Resident #4 had a prior stroke about two (2) years before being admitted to the facility and had experienced a decline which prevented him/her from living alone. Review of Resident #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), signifying severe cognitive impairment. Continued review revealed Resident #4 had been assessed to be absent of any upper and lower extremity impairments. Per MDS review, the facility assessed Resident #4 to require extensive assistance of two (2) staff for bed mobility, transfers, dressing and toileting. Further review of the MDS Assessment revealed Resident #4 had been assessed to require one (1) person physical assistance for eating, personal hygiene, and to ambulate using the walker. In addition, MDS review further revealed Resident #4 did not have any condition which was expected to limit his/her life expectancy in the next six (6) months. Review of Resident #4's Comprehensive Care Plan initiated on 02/28/2023 and reviewed on 06/27/2023, revealed no documented evidence the facility developed a focus area to monitor the resident for signs and symptoms of a stroke related to his/her history of a stroke, nor for migraine headaches. Review of Resident #4's Progress Note dated 07/07/2023, completed by the current Assistant Director of Nursing (ADON) revealed the Medical Director was present in the facility and assessed the resident related to complaints of blurred vision. Further review revealed the Medical Director ordered Resident #4 to be sent out to the Emergency Department (ED) for evaluation related to a possible migraine headache. In an interview with Certified Nursing Assistant (CNA) #14 on 09/18/2023 at 2:39 PM, she stated she rarely looked at residents' care plans. She stated she knew the residents and what care each of them required. CNA #14 stated any information she needed was received in report at the beginning of her shift. She stated the care plan was important because it told exactly what care each resident required, such as if the resident was to be transferred with a mechanical lift, or what type of diet the resident was on, or if the resident was a one (1) or two (2) persons assist. CNA #14 further stated not following the residents' care plan could cause a resident to get hurt or not receive the necessary care they required. In an interview with Licensed Practical Nurse (LPN) #2 on 09/18/2023 at 3:54 PM, she stated she did not believe CNAs had access to the Kardex and they often asked her how a resident was to be transferred. She stated the previous Director of Nursing (DON) told the nurses they could just tell the CNAs what needed to be done for residents, instead of the CNAs having to look at the residents' care plans. LPN #2 stated the facility's care plan policy stated the Registered Nurse (RN) was to initiate residents' care plans and any changes must be updated on their care plans. She stated if a resident sustained a fall, a new intervention for every fifteen (15) minute checks was initiated. She further stated it must be added to the resident's care plan. LPN #2 stated floor nurses should update residents' care plans, but the floor nurses already did everything., and there was not enough time. She stated there was a lot of miscommunications in the facility, and it made it hard to know what she was responsible for completing. The LPN stated she did not report the miscommunication as she did not feel comfortable reporting to management. LPN #2 stated she regularly provided care for Resident #4, and rarely looked at the care plans because she had worked at the facility for a long time and knew the care each resident needed. She stated any new information was to be provided at report during shift change. The LPN stated on 07/08/2023, at shift change, RN #1 informed her Resident #4 was not speaking to staff because the resident was mad and he/she showed out the night before. LPN #2 stated RN #1 called it showing out when Resident #4 asked to go to the Emergency Department (ED) on 07/07/2023, related to his/her blurred vision. She further stated it was important to use the residents' care plans to direct the residents' care and ensure they received the care they needed for quality of life. LPN #2 stated she should probably look at residents' care plans more; however, felt she just did not have the time to do so. In an interview with LPN #3 on 09/25/2023 at 11:45 AM, she stated staff were to look at the care plan every shift to ensure the residents' needs had not changed. LPN #3 stated she did not look at residents' care plans as often as she should; however, she counted on the pass down information from report for any information regarding changes in the residents. She stated the care plan showed staff how to care for the residents, what they ate, how often the resident was to be checked and changed, all the care for each resident. LPN #3 stated if the care plan did not include every area of care for the resident, it could be dangerous for the resident because care could be overlooked. LPN #3 further stated the care plan must be fully developed. She stated all concerns a resident had should be covered in their care plan, and when asked about Resident #4's history of stroke, she reported that should have been on the resident's care plan to ensure staff knew to observe him/her for signs and symptoms of a stroke. In an interview with MDS Coordinator #1 on 09/26/2023 at 9:14 AM, she stated she had been an Assistant MDS Nurse for twenty (20) years. She stated she attended the Interdisciplinary Team (IDT) meetings when the main MDS Coordinator was absent. MDS Coordinator #1 stated she was also responsible for scanning all documents into residents' EMR. She stated MDS #2 was the one who updated residents' care plans, and reviewed the orders, discharge summaries and twenty-four (24) hour notes. The MDS Coordinator stated the previous MDS Coordinator updated the residents' care plans in real time during the IDT meeting. She stated if the facility was aware Resident #4 had a history of strokes and/or migraine headaches those items should have been on the resident's care plan. Further interview with the MDS Coordinator #1, on 09/26/2023 at 9:14 AM, she stated the facility wanted migraine headaches to be addressed under the pain focus of the care plan because it would otherwise be an unspecified diagnosis and the facility did not want unspecified diagnoses on the resident's care plan. She reviewed Resident #4's care plan and stated the area for coronary artery disease (CAD) would cover the resident for monitoring for signs and symptoms of a stroke. However, she stated the symptoms of CAD would include breathing concerns, chest pain, and edema, whereas symptoms of a stroke would be identified as drooping face, slurred speech, and inability to use one (1) side of the body. MDS Coordinator #1 stated residents' care plans were important because it was the tool to provide better care for each resident, and the care plan could change often based on the resident's needs. She further stated staff should look at the residents' care plans prior to every shift. In addition, the MDS Coordinator #1 stated if the care plan was not developed and implemented the resident would not receive the care needed and the resident could be harmed. In an interview with MDS Coordinator #2 on 09/26/2023 at 10:56 AM, she stated she became the main MDS Coordinator in September 2023. She stated she was trained by the previous MDS Coordinator and received some training by the Corporate MDS person. MDS Coordinator #2 stated she attended morning meetings, read through the twenty-four (24) hour reports, and updated residents' care plans in real time during the meetings. She reviewed Resident #4's care plan and stated a history of TIAs was noted as a diagnosis; however, there had not been a focus area developed on the care plan for stroke monitoring or for migraine headaches for the resident. The MDS Coordinator stated the facility did not want any unspecified diagnoses used and that could be why migraine was not listed. She stated migraines would fall under the pain focus, and she was not sure if migraines could be listed under pain as something to watch for. MDS Coordinator #2 stated she would have to investigate that. In a continued interview with MDS Coordinator #2, on 09/26/2023 at 10:56 AM, she stated symptoms of a stroke and symptoms of CAD were different; however, the resident would still be monitored for the CAD and all changes would be reported, per the care plan. MDS Coordinator #2 stated when Resident #4 came to the facility as a new admission and was noted to have a history of stroke, a separate care plan focus should have been developed to monitor the resident for stroke symptoms. She further stated it would be important for staff to know Resident #4 had a history of a stroke, and ensure they watched for any signs of a new stroke. In an interview with the Director of Nursing (DON), on 09/29/2023 at 1:20 PM, she stated she expected residents' care plans to be developed and implemented based on the resident's admission records to include any hospital discharge summary. She stated even though care plans were not her strong suit, it was important to ensure residents' care plans covered every area of care the resident needed to make sure each resident got the best quality of care. The DON further stated she counted on the MDS Coordinators to ensure residents' care plans were developed and all staff were aware of the care plans to ensure the care plans were implemented. In an interview with the Administrator on 09/29/2023 at 1:30 PM, she stated residents' comprehensive care plans should address every care area and ensure each diagnosis had at least an area to monitor for changes especially if the resident still had those problems. The Administrator stated care plans were discussed in the morning meeting, during which they looked at Progress Notes, the 24-Hour Report, and Discharge Summaries. She stated residents' care plans were then updated in real-time. She stated the care plans should be developed with the admission history because that was the best way to ensure each resident got the best care. The Administrator stated if a focus area was not developed on the care plan, staff would not know to watch for changes in that particular area. She further stated it was a team effort to ensure care plans were developed properly. 2.) Review of Resident #9's admission Record/EMR revealed the facility admitted the resident on 02/24/2022, with diagnoses which included Alzheimer's Disease, Dementia with Mood Disturbance, History of Falling, Lack of Coordination, Muscle Weakness, and Anxiety Disorder. Review of Resident #9's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of five (5) out of fifteen (15), which indicated severe cognitive impairment. Review of Resident #9's Elopement Assessments, dated 02/25/2022 and 08/10/2023, revealed the facility assessed him/her to have an Elopement Score of sixteen (16), which indicated the resident was at high risk for elopement. Review of Resident #9's Comprehensive Care Plan dated 03/02/2022, revealed a focus for the resident being at risk for elopement/wandering related to a diagnosis of Alzheimer's Disease, and with a goal that the resident would not leave the facility's grounds unattended. Continued review revealed interventions dated 03/02/2022, which included redirecting him/her as needed if he/she was wandering. Further review revealed an intervention for staff to provide 1:1 supervision as needed. However, review further revealed there was no documented evidence Resident #9's intervention for 1:1 supervision as needed was implemented on 08/31/2023 at 7:00 PM, after the resident exhibited exit seeking behaviors. Review of Resident #9's Progress Note dated 08/31/2023 at 9:11 PM, signed by the DON revealed the resident was noted to have increased wandering, and was directed back to the unit and his/her bedtime Activities of Daily Living (ADL) care was provided. Continued review revealed Resident #9 was placed on 1:1 supervision; however, there was no documented evidence as to why the 1:1 supervision was provided, and no documented evidence of the resident attempting to exit the facility. Per review of the Note, there was no documented evidence Resident #9's Comprehensive Care Plan intervention for 1:1 supervision had been implemented at 7:00 PM when the resident was exhibiting exit-seeking behaviors. Further review revealed the facility was unable to provide documentation of Resident #9 receiving the 1:1 supervision after exiting the building at 8:00 PM on 08/31/2023. In addition, review further revealed LPN #4 reported she placed Resident #9 on 1:1 supervision after returning the resident to the building; however, had not done so when she removed the resident from the foyer area earlier in the shift (as per the resident's care plan). Observation of Resident #9 on 09/11/2023 at 2:55 PM, revealed the resident was up in his/her wheelchair in the front lobby area with other residents. Observation of Resident #9 on 09/12/2023 at 9:20 AM, revealed the resident in his/her room with no direct supervision being provided. Observation of Resident #9 on 09/12/2023 at 6:15 PM, revealed the resident had a 1:1 sitter providing supervision. Observation of Resident #9 on 09/13/2023 at 3:55 PM, revealed the resident continued to have a 1:1 sitter providing supervision. During an interview with Resident #9's Family Member #2 on 09/13/2023 at 2:58 PM, he stated he received a call from a nurse on 08/31/2023 at approximately 8:00 PM, who told him someone went out the front door and Resident #9 went out the door behind that person and made it onto the sidewalk. He further stated he was told Resident #9 would have increased supervision and he was under the impression someone would be sitting with the resident at all times. During an interview with the Social Services Director (SSD) on 09/12/2023 at 1:42 PM, she stated she saw Resident #9 sitting on a bench close to the front lobby door on 08/31/2023, and thought he/she went out the front lobby door into the foyer but had not gone outside. She stated she was unaware Resident #9 had followed her out the facility door. The SSD further stated 1:1 supervision should have been provided for the resident as per his/her care plan. During an interview with Licensed Practical Nurse (LPN) #4 on 09/12/2023 at 5:41 PM, she stated she responded to the front door alarm sounding on 08/31/2023 at approximately 7:00 PM, and witnessed Resident #9 standing in the foyer area between the door from the front lobby and the outside door. She stated the SSD was in the front lobby and she and the SSD brought the resident back into the lobby area where other residents were watching television. LPN #4 stated she left Resident #9 in the front lobby, unsupervised and went back to her hall to pass medications. She stated on 08/31/2023 at approximately 8:00 PM, she heard the front door alarm sounding again and heard Resident #12 yell that Resident #9 had gone out the front door. LPN #4 stated she found Resident #9 standing on the sidewalk outside the facility and took the resident back inside and placed him/her on 1:1 supervision at that time. In further interview with the Licensed Practical Nurse (LPN) #4, on 09/12/2023 at 5:41 PM, she stated she received a phone call from the DON about an hour and a half later telling her to leave Resident #9 on 1:1 supervision unless the resident was in bed sleeping, in which case he/she did not have to be 1:1. LPN #4 stated the paperwork had been done, floor staff had been told by the administration they were not to update care plan interventions as that was performed by the MDS Nurses or the Administrative Clinical team. She stated that she did not revise Resident #9's Comprehensive Care Plan and thought the DON had revised it. The LPN stated she was unaware Resident #9 had been care planned for 1:1 supervision as needed when the resident attempted to exit the building at 7:00 PM. LPN #4 stated she did not look at residents' care plans every shift, and reported she relied on the previous shift nurse to relay any pertinent information to her. She stated Resident #9 was 1:1 supervision while up in the hallway after exiting the building at 8:00 PM; however, was not directly supervised after lying down on his/her bed that night. LPN #4 further stated the facility was unable to provide any evidence of Resident #9 receiving 1:1 supervision services on 08/31/2023. During an interview with MDS Coordinator #1 on 09/20/2023 at 3:20 PM, she stated the floor staff nurses could update residents' Comprehensive Care Plan interventions. She stated the care plans were also updated daily by the MDS Coordinators during morning clinical meetings. MDS Coordinator #1 stated the MDS Coordinators looked at the orders that had been entered and read the twenty-four (24) hour report book to ensure they were entering appropriate interventions to the residents' care plans. She further stated Resident #9 had an intervention in place for 1:1 supervision as needed, which should have been implemented if the resident attempted to exit seek on 08/31/2023 at 7:00 PM. During an interview with the Director of Nursing (DON) on 09/13/2023 at 12:12 PM, she stated she was aware Resident #9 had gone into the foyer past the lobby door on 08/31/2023, at which time the nurse should have implemented the Comprehensive Care Plan intervention for increased supervision. She stated she called LPN #4 and told her to put Resident #9 on 1:1 supervision and the resident stayed on 1:1 supervision for a day or two (2). The DON stated, however, that she was unable to provide any documentation of Resident #9 receiving 1:1 supervision on 08/31/2023 after he/she exited the facility. She stated the supervision for Resident #9 was placed as an order and no other documentation was completed. She stated she charted a progress note regarding Resident #9 having increased wandering in the resident's chart after speaking with LPN #4. The DON stated, however, she had not revised his/her care plan at that time because MDS updated the care plans at clinical morning meetings. She further stated the MDS Nurses updated Comprehensive Care Plans at the daily clinical meeting after reviewing the past twenty-four (24) hour shift reports and orders. During an interview with the Administrator on 09/13/2023 at 12:24 PM, she stated she was not aware Resident #9 had gotten out the lobby door on 08/31/2023, until the next day. She stated she heard the SSD and a nurse or housekeeper discussing that Resident #9 needed to be redirected. The Administrator stated she was unsure why Resident #9 was placed on 1:1 supervision on 08/31/2023; however, stated she was aware the DON had received a call from staff stating Resident #9 had increased agitation on 08/31/2023. Per the Administrator, all administrative staff said the resident did not elope and was placed on 1:1 for exit seeking. She stated that was probably why Resident #9 was placed on 1:1 supervision. The Administrator stated if Resident #9 was exit seeking at 7:00 PM, the resident should have had increased supervision at that time to prevent him/her from exiting the building at 8:00 PM. 3.) Review of Resident #15's admission Record revealed the facility admitted the resident on 03/28/2022, with diagnoses to include Dementia, Hypertension, and Malnutrition. Review of Resident #15's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of three (3) out of fifteen (15), which indicated the resident had severe cognitive impairment. Further review of the MDS revealed the facility assessed Resident #15 to require the physical assistance of two (2) staff for bed mobility, transfers, toileting, dressing, and for personal hygiene. Review of Resident #15's Comprehensive Care Plan revealed the facility care planned Resident #15 to require extensive assistance of two (2) staff for bed mobility, to turn and reposition, for bathing and showers, dressing, personal hygiene, and toileting. Review of a Change in Condition (CIC) completed on 04/22/2022, by LPN #12 revealed a CNA had been giving Resident #15 a shower on 04/22/2022 and the resident began to cry in pain and his/her right hip was red and swollen. Review of an Interdisciplinary Team (IDT) Note dated 04/28/2022, revealed during care on 04/16/2022 Resident #15 got too close to the edge of the bed and fell out. Per the review, it was noted Resident #15 was immediately assessed and placed back in bed. The Medical Director and resident's representative were notified, and no new orders were given. Continued review of the IDT Note revealed Resident #15 was sent to the Emergency Department (ED) on 04/22/2022 and was admitted to the hospital with a fractured right femur. Further review revealed the IDT noted the fracture was related to Resident #15's fall that happened on 04/16/2022. In addition, review of the IDT Note revealed Resident #15 returned to the facility on [DATE]. In interview on 09/28/2023 at 1:51 PM, CNA #22 stated she knew Resident #15 well and thought she was working on 04/16/2022, when the resident was hurt. CNA #22 stated she heard CNA #24 scream out. She stated the nurse went into the resident's room to assess Resident #15. CNA #22 stated the low air loss mattresses were very tricky and could be slippery. She stated when she provided care for a resident with a low air loss mattress she would not change the resident without the assistance of another staff person. CNA #22 stated Resident #15 used to be able to get out of bed every day; however, the resident's legs were badly contracted, and it was very painful for him/her to be out of bed, and that made it very difficult to provide his/her peri care. However, further record review revealed no documented evidence the facility implemented Resident #15's care plan on 04/16/2022, to ensure two (2) staff provided extensive assistance for the resident's bed mobility, turning and repositioning and personal hygiene. In an interview with the Kentucky Medication Assistant (KMA) #1 on 09/29/2023 at 10:25 AM, she stated that while providing care to a resident who had an air mattress, the aide should use two (2) staff because the bed was filled with air which made the bed unstable, the resident could fall out. KMA #1 additionally stated the use of the low-air loss mattress should have been care planned. In an interview with the current Assistant Director of Nursing (ADON), on 09/29/2023 at 11:03 AM, she stated she worked on 04/16/2022 when an aide provided peri care, by herself, on the resident and the resident rolled out of bed. She stated she was not assigned to the resident's floor and could not remember the details. She said any resident who had a low air loss mattress really needed to have two (2) staff assist with any bed mobility, peri care, personal hygiene and transfer back into the bed. She stated that was for the resident's safety. In an interview with the Director of Nursing (DON) on 09/29/2023 at 1:20 PM, she stated she was not familiar with Resident #15; however, it was her expectation that each resident's care plan was individualized to meet the resident's needs and she expected staff to ensure the care plan was implemented to meet those needs. In an interview with the Administrator on 09/29/2023 at 1:25 PM, she stated the use of an air mattress required an order from the Physician and should be care planned. She stated the air mattress should be checked each shift to ensure it was properly inflated. The Administrator stated the bed had an alarm that sounded if the bed was not at the correct setting, which alerted staff to respond and correct the settings. She stated all nursing staff should be able to adjust the beds, as required while providing care. The Administrator further stated she expected staff to follow the facility's policy to ensure each resident's care plan was updated and implemented to meet the resident's needs. Review of the facility's policy titled, Guidelines for Physical Restraints/Seclusion, last revised 05/17/2023, revealed physical restraints were only to be used as a last resort and only after every other alternative to a physical restraint (based on assessment) had been tried and failed that seemed to have the potential for being used successfully. Continued review revealed the policy noted a physical restraint was never to be used for staff convenience or for discipline. Further review revealed the care plan must reflect the use of the physical restraints to include medical condition as well as releasing at least every two (2) hours per shift. Review further revealed skin checks were to be completed during the use of restraints at the time of application and removal and by the nurse as indicated. 4.) Closed Record Review of Resident #13's medical record Face Sheet revealed the facility admitted the resident on 07/15/2023, with diagnoses of Dementia, Intracerebral Hemorrhage Intraventricular, and Altered Mental Status. Review of Resident #13's admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of zero (0) out of fifteen (15) signifying the resident had severe cognitive impairment. Continued review revealed the facility assessed Resident #13 as requiring extensive assistance of two (2) staff for bed mobility, transfers, toileting, bathing, personal hygiene and one (1) person physical assistance for eating and locomotion. Further review revealed the facility also assessed Resident #13 as absent of behaviors, absent of upper and lower extremity impairments and was able to use a walker and/or a wheelchair for mobility. In addition, review further revealed the facility noted direct care staff believed Resident #13 could increase his/her independence and better his/her Activities of Daily Living (ADLs). Review of Resident #13's Comprehensive Care Plan initiated 07/20/2023, revealed the facility care planned the resident for mood and behaviors related to diagnoses of brief Psychotic Disorder, Depression, Anxiety, Altered Mental Status, Insomnia and Intracerebral Hemorrhage (prior to admission). Per review, it was noted Resident #13 received antidepressant medication therapy, and staff were to attempt diversional activities when the resident was agitated or restless. Review revealed staff were to observe and document all inappropriate behaviors and mood changes. In addition, review revealed staff were also to observe for and document any interventions used to discourage Resident #13's inappropriate behaviors. Continued review of Resident #13's Comprehensive Care Plan initiated 07/20/2023, revealed the facility care planned the resident to require extensive assistance of two (2) staff for all ADL care. Per review, the interventions included to: provide frequent periods of rest as indicated (08/09/2023); redirect as needed (08/09/2023); and use a gait belt for all assisted transfers (08/09/2023). Further care plan review revealed the facility assessed and care planned Resident #13 as a high fall risk with interventions which included: use of not skid socks at all times (07/19/2023); use of non skid pads on floor next to the bed (07/23/2023); use Dycem (non-slip, rubber-like plastic material used to stabilize surfaces) in the resident's wheelchair (07/28/2023); staff to assist the resident to bed when restless and as tolerated (07/30/2023); and staff were to anticipate and meet the resident's needs. Review of Resident #13's Progress Note dated 07/19/2023, entered by Licensed Practical Nurse (LPN) #1, revealed the resident had a private sitter at bedside with the family. Review of a Progress Note dated 07/20/2023, created by RN #1 revealed she documented Resident #13 had a private sitter at his/her bedside as well as family. Review further revealed RN #1 documented on 07/24/2023, Resident #13 had been found lying on the floor and had a quarter sized skin tear on the under part of the forearm. Further review of the 07/24/2023 Note, revealed RN #1 noted Resident #13 was assessed and placed back onto his/her bed. Review of a Progress Note, completed by current Assistant Director of Nursing (ADON) on 07/28/2023, revealed Resident #13 slid out of his/her chair and was on the floor on his/her back. Per review, the ADON noted an immediate intervention to move Resident #13 to the nurse's station for more supervision and the resident was placed on every fifteen (15) minute checks. Continued review revealed no documented evidence the interventions of keeping Resident #13 at the nurse's station for increased supervision and every fifteen

**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 review and revise each resident's Comprehensive Person Centered Care Plan for two (2) of twenty-five (25) sampled residents (Resident #10 and Resident #14). 1. On 08/10/2022, the facility failed to revise Resident #10's Care Plan related to a new order to change the resident's code status to Do Not Resuscitate. Record review revealed the facility initiated a Comprehensive Care Plan on 06/29/2022 for a Full Code Advanced Directive. Continued review revealed on 08/10/2022, the resident's medical record included a signed and notarized Emergency Medical Services (EMS) Do Not Resuscitate (DNR) form. However, the facility failed to ensure the resident's Care Plan and Facesheet were revised to update the change in the resident's code status on 08/10/2022. Therefore, the facility transferred Resident #10 to the hospital on [DATE], as a Full Code. The resident was intubated and placed on a ventilator, which was against the resident's Advanced Directive wishes. 2. On 07/03/2023 Resident #14 sustained a fall, and Mobile x-ray results on 07/05/2023, revealed Resident #14 had an age-indeterminate nondisplaced humeral neck fracture. Review of Resident #14's care plan revealed no documented evidence the facility care planned the resident for his/her impulsive behavior which would have required increased supervision to prevent the resident from falling. The facility's failure to have an effective system to ensure each resident's care plan was reviewed and revised to reflect the resident's care and his/her needs has caused or is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on 09/22/2023 and was determined to exist on 08/10/2022, in the areas of 42 CFR §482.21 Comprehensive Resident Centered Care Plan at the highest Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy (IJ) on 09/22/2023 and IJ is ongoing. (Refer to F578 and F689) The findings include: Review of the facility's policy titled, Care Plan Review, undated, revealed the facility was to update a resident's Comprehensive Care Plan at least Quarterly and with any changes in the resident's orders. Review of the facility's policy titled, Advance Directives Policy, dated 04/05/2022, revealed the facility provided all residents the right to accept or refuse medical and surgical treatment, and, at the resident's option, formulate an Advanced Directive. Continued review revealed the facility was to establish mechanisms for documenting and communicating resident choices to the Interdisciplinary Team (IDT). Further review revealed if the resident or resident's legal representative executed one (1) or more Advanced Directives, the facility was to incorporate the resident's wishes into their care plan. In addition, review further revealed the resident's desires were to be re-evaluated as indicated to ensure the resident's or legal representative's choices were honored timely. Review of the facility's policy titled, Standard Staffing Supervision and Monitoring Guide, revised 01/20/2023, revealed the facility recognized supervision and guidance to the resident as an essential part of nursing care in which standard approaches were successful in meeting the resident's physical and psychosocial needs. Continued review revealed the following if the resident could not be guided, supervised, or redirected during regular intervals of rounds, the resident required every thirty (30) minutes, every fifteen (15) minutes or 1:1 supervision. Further review revealed staff assignments were to be based on the residents' needs as far as their acuity and their assessment results and their person-centered care planning. 1. Review of Resident #10's admission Record/Electronic Medical Record (EMR) revealed the facility admitted the resident on 06/28/2022, with diagnoses which included: Chronic Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Anxiety, and Dementia. Review of Resident #10's Advanced Directives revealed the resident's code status, signed by the resident's spouse, dated 06/28/2022, was Full Code. Review of Resident #10's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), which indicated severe cognitive impairment. Review of Resident #10's Comprehensive Care Plan, dated 06/29/2022, revealed the resident had an Advanced Directive for a Full Code with interventions that included to honor the resident's choices and perform CPR. Review of Resident #10's Advanced Directives for an Emergency Medical Service (EMS) form, signed and notarized on 08/10/2022, revealed the resident's code status changed to Do not Resuscitate (DNR); however, there was no documented evidence the facility sought to clarify the resident's code status with his/her family. A continued review; however, of Resident #10's care plan, initiated on 06/29/2022, revealed no documented evidence the facility updated/revised Resident #10's Comprehensive Care Plan on 08/10/2022, to change his/her code status to DNR. Review of Resident #10's hospital records revealed the hospital admitted the resident on 08/15/2022. Continued review of the emergency room (ER) Physician's Summary revealed ER staff thought Resident #10 was a Full Code as the resident's Face Sheet listed him/her as a Full Code, and an EMS DNR form was not presented at the time of the resident's transfer to the hospital. Further review revealed Resident #10 was intubated prior to the family's arrival at the hospital to clarify the resident's code status. During an interview with the Minimum Data Set (MDS) Nurse #1 on 09/20/2023 at 3:20 PM, she stated she scanned the resident's EMS DNR form into the facility's Point Click Care (PCC) computerized system in December 2022. She stated she inherited a stack of papers to scan in from the previous MDS person because the facility did not have a Medical Records Clerk. The MDS Nurse #1 stated she was not aware when the facility received a copy of the EMS DNR for Resident #10. She stated in general, if a copy of a DNR form was received an order for a DNR status should have been entered into PCC, his/her care plan revised, and the code status changed on the Face Sheet. She stated staff nurses could update residents' Comprehensive Care Plan interventions, and the care plans were updated daily by the MDS Nurses during morning clinical meeting. She further stated the MDS Nurses looked at the orders that had been entered and read the twenty-four (24) hour report book to ensure they were entering appropriate interventions into the residents' care plans. During an interview with the Medical Director on 09/20/2023 at 7:35 PM, he stated it was his expectation the facility staff followed each resident's Comprehensive Care Plan. He further stated he expected residents' care plans to be updated as orders changed. The Medical Director stated the facility staff, including himself, should have spoken with the resident or his/her family/responsible party regarding the code status and followed the resident's wishes, including updating the care plan with that information. During an interview with the Director of Nursing (DON) on 09/22/2023 at 3:19 PM, she stated she expected staff to update all residents' Comprehensive Care Plans as orders changed. She further stated the orders were reviewed daily in the morning Clinical meeting and the Care Plan should have been updated at that time. The DON further stated she expected staff to communicate with the resident and the resident's family and follow the doctor's orders, including revising the care plan as needed. During an interview with the Administrator on 09/22/2023 at 3:45 PM, she stated she expected new admission and readmission orders to be discussed during the morning interdisciplinary team (IDT)/clinical meeting. She further stated she expected staff to follow the facility's policies and revise the Care Plan as needed. The Administrator further stated that she was not present when Resident #10 was a resident and therefore, refused to speculate. 2. Review of Resident #14's admission Record revealed the facility admitted the resident on 10/19/2022 with diagnoses of Alzheimer's Disease; Coronary Artery Disease; Wandering; Difficulty Walking; Hypertension; and Dementia. Review of Resident #14's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of six (6) out of fifteen (15), indicating severely impaired cognition. Continued review revealed the facility assessed Resident #14 to require extensive assistance of two (2) persons for transfers. Review of Resident #14's Comprehensive Care Plan initiated 10/25/2022, revealed the facility developed a focus of being high risk for falls for the resident, as evidenced by potential contributing diagnoses of Alzheimer's Disease and Atrial Fibrillation. Continued review of the care plan revealed the high risk for falls focus had a goal to reduce fall risk and injury through the next review. Per review, the high risk for falls focus had interventions which included: ambulate the resident when attempting to get out of his/her wheelchair with staff assistance and gait belt as tolerated; bed in lowest position as tolerated when not providing care; and ensure the resident was positioned in the center of the bed upon rounding. Further review of the high risk for falls focus revealed additional interventions which included: Dycem to the resident's wheelchair; encourage the resident to go to the dining room for breakfast; encourage him/her to lay down after last medication pass in the evening as tolerated; ensure trash can was at bedside when in bed; and make adjustments to anti-roll backs as needed, added 07/03/2023. Review further revealed other interventions for: staff to offer toileting with rounds; and the resident up in wheelchair when restless as tolerated. In addition, review of Resident #14's care plan revealed no documented evidence the facility care planned for the resident's impulsive behavior, which would have required increased supervision to prevent the resident from falling. Observation on 09/11/2023 at 2:15 PM, revealed Resident #14 seated in a wheelchair with an overbed table in front of him/her. Observation on 09/27/2023 at 10:05 AM, revealed Resident #14 lying on his/her bed with eyes closed, with the bed in the lowest position and call light within reach. Observation on 09/29/2023 at 9:48 AM, revealed Resident #14 seated in a wheelchair near a locked medication cart, rolling the wheelchair back and forth. Review of Resident #14's Fall Risk assessments dated 07/01/2023, revealed the facility assessed the resident to be a high risk for falls. Review of Resident #14's Electronic Medical Record (EMR) revealed the resident sustained a fall on 07/03/2023 at 7:35 PM, when staff observed the resident attempting to stand from the wheelchair by using a handrail. Per review, staff attempted to redirect Resident #14; however, the resident slid down to a sitting position on the floor. Further review revealed Resident #14 sustained injuries of abrasion to his/her right forearm and pain in the right shoulder, and a new order was received to obtain bilateral shoulder x-rays. In addition, review revealed a new care plan intervention was put in place for Resident #14 to be ambulated by staff when attempting to get out of the wheelchair. Review of Resident #14's Right Shoulder X-Ray dated 07/05/2023 revealed an age-indeterminate (when a fracture cannot be dated with certainty) nondisplaced humeral neck (bone in the upper arm) fracture. During an interview on 09/25/2023 at 4:30 PM, with Licensed Practical Nurse (LPN) #3 she stated Resident #14 was impulsive and forgot to call for help. LPN #3 stated when Resident #14 was up in his/her wheelchair, staff should keep the resident engaged with magazines, food, and drinks. The LPN further stated they were to follow Resident #14's care plan and currently the resident was not care planned for the increased supervision. During an interview on 09/26/2023 at 5:06 PM, with Kentucky Medication Aide (KMA) #1 she stated she had started the medication pass for evening shift when she heard another resident say Hey he/she was getting up. KMA #1 stated she looked down the hallway and observed Resident #14 rising from the wheelchair while holding to the handrail, and saw the resident immediately fall to the floor in front of the wheelchair. She stated she yelled for KMA #2, who was at the medication cart and had her back to Resident #14, to turn around; however, by the time KMA #2 turned around, the resident was sitting on the floor. KMA #1 stated she could not recall if the wheelchair rolled back, and no other staff members were in the hallway at the time of the event. She stated the staff knew to check on Resident #14 frequently, due to the resident's attempts to get up unassisted. Further, the KMA stated the resident's care plan should have been updated to reflect the frequency and monitoring for Resident #14. During an interview with the Director of Nursing (DON), on 09/26/2023 at 03:11 PM, she stated she needed more details about the event. She stated realistically a nurse would document what was not in place for a resident; however, she expected the process to start with the nurse identifying what was needed. The DON stated residents needed a care plan to match his/her specific situation. She stated Resident #14's care plan did not address his/her impulsive behavior. The DON stated she expected the resident's care plan to be more detailed with person-centered interventions. She further stated she would expect more supervision to be provided related to Resident #14's impulsive behavior. During an interview on 09/26/2023 at 3:27 PM, with the Administrator, she stated Resident #14 should have had a behavior care plan in place with appropriate interventions. She stated the resident's care plan did not address supervision for him/her. She stated she would have expected Resident #14 to have had 1:1 supervision due to his/her behaviors and history of falls. The Administrator further stated the facility failed to follow its policy for supervision of Resident #14 and his/her care plan was incomplete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, it was determined the facility failed to identify and provide needed care and services that were resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that met each resident's physical, mental, and psychosocial needs for two (2) of twenty-five (25) sampled residents (Resident #4 and Resident #10). 1). On [DATE] at approximately 8:30 AM, the facility's Certified Nursing Assistants (CNAs) reported to Licensed Practical Nurse (LPN) #2 and LPN #3 that Resident #4 exhibited signs and symptoms of a stroke. The LPNs; however, failed to assess the resident immediately when staff reported to them the resident had a change in his/her condition. Subsequently, when LPN #2 arrived to Resident #4's room, approximately one-hour and a half (1 1/2) after staff notified the LPN of the resident's condition, the resident was found unresponsive. The resident was transferred to the Emergency Department (ED) with admitting diagnosis to include Middle Cerebral Artery (MCA) stroke. The resident expired on [DATE]. 2). The facility readmitted Resident #10 on [DATE] from the hospital with orders for Invanz and Daptomycin (Intravenous (IV) antibiotics) daily to treat his/her bacterial infections. However, record review revealed the resident missed one (1) scheduled dose of his/her Invanz Antibiotic and two (2) scheduled doses of his/her Daptomycin Antibiotic. This caused the resident to develop more severe bacterial infections, which the resident had developed since his/her discharge from the hospital. On [DATE], the resident was found unresponsive and was sent to the hospital with a diagnosis of Sepsis (an infection in the bloodstream). The resident expired on [DATE]. The facility's failure to have an effective system to identify and provide needed care and services that were resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice has caused or is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]; and on [DATE] and was determined to exist on [DATE], in the area of 42 CFR §483.25 Quality of Care (F684) at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.25 Quality of Care (F684) . The facility was notified of the Immediate Jeopardy (IJ) on [DATE] and on [DATE] and IJ is ongoing (Refer to F657 and F760) The findings include: Review of the facility's policy titled, Change in Condition Notification, dated 12/2014, revealed it was the policy of the facility to monitor residents for changes in their condition, to respond appropriately to those changes, and to notify the physician and responsible party/family member of changes. Further review of the policy revealed that in the event of a life-threatening change, the facility would initiate emergency care by calling 911 and provide appropriate emergency treatment until they arrive. Review of the facility's policy titled, Care Plan Review undated, revealed residents were to be assessed at least quarterly, and include visual and verbal assessment, obtaining information from the health record, as well as interviewing the nursing assistants prior to completing the Minimum Data Set Assessment and comprehensive person-centered care plan. Further review revealed staff were to evaluate the progress or lack thereof for each resident's goal and document the findings in measurable terms. 1). Review of Resident #4's Closed Electronic Medical Record (EMR) revealed the facility admitted the resident on [DATE] with diagnoses that included: Heart Failure, Atrial Fibrillation (AFib), Stroke, and Transient Ischemic Attack (TIA). Review of Resident #4's admission Progress Note, dated [DATE], revealed the resident had a previous stroke two (2) years ago. Review of the Medical Director's (MD) Note, dated [DATE], revealed the resident had a stroke a few years ago and since then had difficulty taking care of himself/herself. Review of Resident #4's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was assessed to have a Brief Interview of Mental Status (BIMS) score of seven (7) out of fifteen (15), indicating the resident had severe cognitive impairment. Resident #4 was assessed to require extensive assistance of two (2) staff for bed mobility, transfers, dressing, and toileting. The resident was assessed to need one (1) person physical assistance for eating, personal hygiene, and walking on/off the unit. Review of Resident #4's Comprehensive Care Plan initiated on [DATE] and reviewed on [DATE], revealed no documented evidence the facility developed a focus area to monitor the resident for signs and symptoms of a stroke related to his/her history of a stroke. Review of Resident #4's Nursing Progress Note, entered by the current Assistant Director of Nursing (ADON), dated [DATE], revealed the resident complained of blurred vision and feeling scared, the Medical Director was present for regular rounds, assessed the resident and sent him/her to the Emergency Department (ED) for an evaluation. Review of Resident #4's Progress Note, dated [DATE] at 4:17 PM, revealed the resident returned to the facility and all vitals were noted to be at the resident's baseline. Review of Resident #4's Hospital Discharge summary dated [DATE], revealed the resident was seen for a migraine headache. Review of Resident #4's Emergency Medical Services (EMS) Run Report dated [DATE], revealed 911 was called at 9:58 AM, the ambulance arrived at the facility at 10:03 AM, left the facility at 10:17 AM, and arrived at the hospital at 10:23 AM. Continued review revealed the resident was unresponsive, lying supine, responsive to painful stimuli, and breath sounds of twelve (12) breaths per minute (bpm). Review of Resident #4's Hospital Emergency Department (ED) Records dated [DATE], revealed the resident was seen in the ED on [DATE] and a Computerized Tomography (CT) Scan was completed, and a stroke was ruled out. On [DATE] another CT scan was conducted and showed a large left Middle Cerebral Artery (MCA) stroke. Further review of the ED records revealed the resident's prognosis was very poor and the family agreed he/she would be placed on palliative care. The resident expired on [DATE]. In an interview with Certified Nursing Assistant (CNA) #10, on [DATE] at 2:00 PM, she stated on [DATE], between the hours of 8:00 AM and 8:20 AM, during breakfast tray pass to the residents, CNA #15 asked her to check on Resident #4 because he/she did not look good. CNA #10 stated she immediately went to check on the resident and then asked LPN #2 to look at Resident #4 because the resident was not looking like himself/herself. CNA #10 stated she reported the resident's condition to LPN #2 who told her she was in the middle of medication pass and would get there. CNA #10 stated she went on with passing the rest of the breakfast trays before she followed up on Resident #4's status. Per the interview, she stated that since it was reported to the nurse, she did not know what else to do. In a continued interview with CNA #10, on [DATE] at 2:00 PM, she stated after she had completed passing out breakfast trays to the residents, she went back to check on Resident #4, with CNA #9, CNA #13, and CNA#15. She stated the resident did not look good. Further, she stated the resident's face was drooping to one side and she lifted the resident's arm which just flopped down. She said she immediately went to LPN #2 and stated, I think Resident #4 has had a stroke! CNA #10 said LPN #2 looked away from her computer, looked directly into her eyes, and then turned back and kept working from her computer while completing the medication pass. CNA #10 stated when she was getting ready to take her lunch, between the hours of 10:00 AM and 10:30 AM, LPN #2 was sending Resident #4 out to the Emergency Department (ED). Further, CNA #10 stated she saw LPN #2 at the nurse's station, freaking out, saying, Nobody reported anything to me. In an interview with Certified Nursing Assistant (CNA) #9, on [DATE] at 10:57 AM, she stated she did not feel things were addressed by nursing staff when concerns were brought to them. She stated the aides reported to Licensed Practical Nurse (LPN) #2 concerns that Resident #4 had a stroke on [DATE] and the nurse did not check on the resident until hours later. CNA #9 stated Resident #4 did not eat that morning, could not lift his/her arms, and felt those were symptoms of a stroke. In an additional interview with CNA #9, on [DATE] at 1:43 PM, she stated on [DATE] she was not assigned to care for Resident #4. She stated she only saw the resident that morning when she delivered breakfast to the resident. The CNA stated Resident #4 was normally a very independent person, would engage when engaged with, and would answer questions, but on [DATE], the resident's behavior was much different. She stated the resident was out of it, adding, his/her eyes were rolled back, and the resident was not talking. She stated CNA #10 told LPN #2 that the resident did not look right, that the resident's face was drooping, and the resident could not lift his/her arms. CNA #9 stated LPN #2 did not check on the resident's condition immediately. During further interview, with Certified Nursing Assistant (CNA) #9, on [DATE] at 1:43 PM, she stated she and CNAs #10, #13, and #15 went back to check on Resident #4, after passing out breakfast trays, and Licensed Practical Nurse (LPN) #2 still had not assessed the resident. CNA #9 stated she then went over to the B-Hall and asked LPN #3 if she would check on the resident's condition. Per the interview, CNA #9 stated she informed LPN #3 that the resident was not acting like himself/herself, and CNA #10 had reported these concerns to LPN #2, but the LPN still had not responded to check on the resident's condition. CNA #9 stated LPN#3 told her she did not want to step on any toes and that if the nurse on A-Hall asked for help she would get involved. In an interview with CNA #15, on [DATE] at 2:10 PM, she stated on [DATE], during breakfast tray pass, she noticed Resident #4 did not look right and asked CNA #10 to look at the resident. CNA #15 stated Resident #4 usually talked with them but this day he/she was not talking. The CNA stated she told LPN #2 that something was not right with Resident #4 and LPN #2 said, the resident was probably faking because he/she does that sometimes. CNA #15 said CNA #10 also reported to LPN #2 that she was concerned Resident #4 had a stroke. Per the interview, LPN #2; however, did not go check on the resident. CNA #15 stated she also reported to LPN #3 about the concern with Resident #4, but LPN #3; however, also failed to check on the resident's change in condition. CNA #15 stated about two (2) hours had passed before LPN #2 checked on Resident #4. Further, she stated she should have called someone else when she identified LPN #2 did not help Resident #4 and should have gone above the two (2) nurses to report her concerns. In an interview with LPN #2, on [DATE] at 2:40 PM, she stated on [DATE], when she got to Resident #4, the resident was not responsive and the resident was curled up in a little ball. LPN #2 stated she could not recall what CNAs worked on [DATE], but she believed LPN #1 was called to the room to assist with Resident #4. LPN #2 stated, that during the morning report at shift change, Registered Nurse (RN) #1 told her Resident #4 was not talking to us and the resident showed out yesterday and demanded to go to the hospital. LPN #2 stated the resident was sent out to the ED on [DATE] and when the resident returned from the hospital, staff were expected to complete seventy-two (72) hour charting of the resident's vitals. Per the interview, LPN #2 stated she had not completed vitals on the resident during her shift until she entered the resident's room for medication pass at approximately 10:00 AM and found the resident unresponsive. In a continued interview on [DATE] at 2:40 PM, Licensed Practical Nurse (LPN) #2 stated she did not see Resident #4 until she got to the resident's room to administer the resident's medications, which she believed was just before 10:00 AM. LPN #2 stated she had twenty-five (25) residents, and she laid eyes on them, but they cannot all be assessed at the same time. She said Resident #4 was usually quiet and did not engage, so that was not a new behavior for the resident. LPN #2 stated she was not informed of a change in the condition of Resident #4, prior to getting to the resident's room to administer the medications. However, interviews with CNA #9, CNA #10, and CNA #15, all stated they reported Resident #4's change in condition to LPN #2. Further, the CNAs stated LPN #2 failed to respond immediately to assess the resident's condition. In an interview with LPN #1, on [DATE] at 8:40 PM, she stated she did not recall the situation with Resident #4 on [DATE]. She, however, stated that if an aide reported concerns to her about a resident not looking right she would have locked up her medication cart and immediately checked on the resident. She stated she would not wait until she reached the resident during her medication pass. Further, the LPN stated a nurse could not determine what was wrong with a resident until the resident was assessed. LPN #1 stated that an unresponsive resident would have needed to be sent to the hospital for an evaluation. In an interview with LPN #3, on [DATE] at 11:29 AM, she stated she normally worked on the B-Hall. She stated if an aide had reported a resident was not acting right she would immediately go and assess the resident, get vital signs (VS) to compare to the resident's baseline VS, look for signs and symptoms of pain, and ask the resident if he/she was in pain. LPN #3 further stated if management was not on-site, she would contact the Medical Director for directions. LPN #3 stated she heard staff talking about Resident #4 and that he/she was attention seeking when he/she was sent out to the ED on [DATE]. In a continued interview with LPN #3, on [DATE] at 11:29 AM, she stated the morning Resident #4 was sent out for stroke-like symptoms, CNA #9 and CNA #10 came and asked her to look at Resident #4. She stated the aides told her they reported to LPN #2 at least twice their concerns related to Resident #4 and LPN #2 had not assessed or checked on the resident. LPN #3 stated she told the aides if the nurse on duty came and asked for assistance, she would have gone and assessed the resident. Further, she stated she had previously been fussed at for overstepping, as she was told by the previous Director of Nursing (DON) that she could not tell another nurse what to do and it was her job to run the B-Hall. LPN #3 stated she should have gone to assess the resident, and she should have gone above LPN #1 and LPN #2's head by calling the manager on-call. In an interview with the current Assistant Director of Nursing (ADON), on [DATE] at 9:35 AM, she stated if a CNA noted a change in a resident's condition, it should immediately be reported to a nurse and a Stop and Watch should be completed. She stated a Stop and Watch was something they used to notify nursing and management of any concerns with a resident. However, the process stopped under the previous Administration. The ADON stated she was involved in sending Resident #4 to the ED on [DATE]. She stated the Medical Director was present and assessed the resident before sending him/her out to the ED. She stated the Medical Director believed the resident to have had a migraine headache. The ADON stated when the resident returned from the ED, he/she should have been monitored for 72 hours with charting and noting the resident's condition, to determine if the resident's condition stayed the same or changed. She further stated symptoms of a stroke were facial drooping, unreactive pupils, and a weak grip. She stated when assessing a resident for a stroke, the timing was important because some reversal medications only worked for a certain amount of time. She said if any staff identified a change in the resident's condition, a nurse should be notified, and the resident should be checked immediately. In an interview with the Medical Director, on [DATE] at 2:33 PM, he stated he could not recall Resident #4 being sent out to the hospital on [DATE] for a migraine headache. He stated if staff found a resident unresponsive, or had any symptoms related to a stroke, it should be addressed within ten (10) minutes, and he would expect that the nurse would take immediate action. He further stated the nurse's involvement when dealing with a possible stroke should be aggressive and a time delay could result in an unchangeable condition or even death. In an interview with the Director of Nursing (DON), on [DATE] at 3:35 PM, she stated if a CNA found a resident outside of their baseline, she expected a nurse to be notified immediately when the change was noticed. The DON stated if the resident was unresponsive, the nurse should notify the Medical Director and send the resident out to the ED immediately. The DON stated all staff were informed they should contact her with any concerns. The DON stated it was her expectation that staff would respond immediately to concerns related to a resident's change in condition, especially in the case of a possible stroke which could result in death. In an interview with the Administrator on [DATE] at 3:48 PM, she stated if a resident was found not to be acting like himself/herself staff should immediately notify the nurse on duty. She stated she expected the nurse to immediately assess the resident and based on that assessment determine if a change in condition was warranted. The Administrator stated the facility should utilize the Stop and Watch sheets again, in which the aides would complete if they had any concerns about a resident. Further, the Administrator stated in a situation when the resident was unresponsive or had a change in mental status, the aide should have completed the Stop and Watch form after the incident. The Administrator stated she did not understand why staff had not reported these concerns to her. She stated if the staff did not feel as though the nurse on duty responded appropriately, they should have called the DON. The Administrator stated all changes in condition should have been reported to her in real-time as they occurred. 2). Closed record review of Resident #10's admission Record revealed the facility admitted the resident on [DATE] with diagnoses that included: Chronic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Anxiety, Dementia, Essential Tremor, and Diabetes. Review of Resident #10's admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6), which indicated severe cognitive impairment. Review of Resident #10's Comprehensive Care Plan, dated [DATE], revealed the resident had an alteration in elimination and Urinary Tract Infection (UTI) with a history of Extended-spectrum beta-lactamases (ESBL) (an enzyme or chemical which caused some antibiotics not to work for treating bacterial infections and made certain antibiotics required) and incontinence. Interventions included monitoring for and reporting signs and symptoms of UTI, fever, and changes in output/intake, and medications as ordered. Review of Resident #10's Physician's Orders, dated [DATE], revealed Resident #10 had a urinalysis completed which was highly suggestive of a UTI and confirmed with a culture. The resident was placed on treatment and was slow to improve in terms of his/her symptoms. Review of the Physician's Orders, dated [DATE], revealed the resident had been hospitalized a week prior with metabolic encephalopathy that was determined to be secondary to ESBL UTI. Continued review revealed the Physician's Plan was to complete the resident's course of Invanz (an antibiotic used to treat severe infections). Review of Resident #10's Hospital Discharge summary, dated [DATE], revealed the resident had been admitted to the hospital on [DATE] and readmitted to the facility on [DATE] with new orders to administer Invanz daily, for two (2) days, on [DATE] and [DATE] and Daptomycin (an antibiotic used to treat bacterial infections that has entered the bloodstream) daily from [DATE] until [DATE] for the resident's Urinary Tract Infection (UTI). Review of Resident #10's Pharmacy Invoices revealed the Invanz had been delivered on [DATE] at 7:51 PM and the Daptomycin had been delivered on [DATE] at 8:22 AM. Review of the resident's [DATE] Medication Administration Record (MAR) revealed the resident was not administered his/her Invanz on [DATE], missing one (1) scheduled dose of his/her medication to treat his/her severe infection. Continued review of the August MAR revealed the resident was not administered his/her Daptomycin on [DATE] and [DATE], which allowed the resident to miss two (2) scheduled doses of his/her medications to treat his/her bacterial infection that had entered his/her bloodstream. Review of Resident #10's Progress Note,dated [DATE], entered by Registered Nurse (RN) #1, revealed the Daptomycin was unavailable from the pharmacy. Further review revealed Licensed Practical Nurse (LPN) #2 notified the pharmacy and the physician on [DATE] the IV medications were not available. Continued review of the progress note revealed LPN #2 did not administer the Invanz on [DATE] because it was unavailable from the pharmacy. However, a review of the Pharmacy Invoice, dated [DATE], revealed the medication was delivered at 7:51 PM. Review of Resident #10's Progress Note,dated [DATE] at 6:58 AM, by LPN #5, revealed the Daptomycin was unavailable. However, there was no documentation to support the physician was notified of the medication being unavailable on [DATE] at 6:58 AM and no documentation to support the resident's medication was administered after the pharmacy delivered the medication at 8:22 AM. Review of Resident #10's Progress Note, dated [DATE] by LPN #1, revealed the resident was found unresponsive and had to be readmitted to the hospital. Review of Resident #10's Hospital record revealed on [DATE], the hospital admitted the resident. Further review revealed, on [DATE], the resident was diagnosed with Staphylococcus epidermidis and Acinetobacter (bacterial infections) which he/she had developed since being discharged from the hospital on [DATE], and unfortunately, now he/she had new and even more resistant bugs. Continued review of the hospital record revealed the resident had an infection on [DATE] which was sensitive to the Daptomycin. Further review revealed Resident #10 expired on [DATE] with the cause of death being refractory (hypotension and end-organ dysfunction) sepsis (an infection in the bloodstream). During an interview with Registered Nurse (RN) #1, on [DATE] at 9:43 AM, she stated Resident #10 had a history of being hospitalized and she did not recall the resident's IV medication being unavailable on [DATE]. She further stated if the medication was unavailable, she would have notified the pharmacy and the physician and followed any orders given to her by the physician. During an interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 4:00 PM, she stated she did not recall Resident #10 not having IV medications on [DATE] but if a medication was not available, she should have checked the Cubex (the facility's back up and emergency medication storage system), and if unavailable in the Cubex, she would have notified the pharmacy and physician. She further stated she would have followed any orders given by the physician at that time. During an interview with Registered Nurse (RN) #3, on [DATE] at 4:19 PM, she stated if a medication was not available at the time it was scheduled to be administered, she would look in the Cubex, and if it was not in the Cubex, then she would call the pharmacy to have it sent stat (immediately) to the facility, which she stated usually took about four (4) hours. She further stated she would notify the physician of any medication being unavailable at the time it was scheduled to be administered. During an interview with LPN #3, on [DATE] at 4:30 PM, she stated when a medication was unavailable, she would call the pharmacy to see where it was after checking to see if it was in the Cubex, then notify the physician to let him know so he could change the orders if needed. She stated delaying a resident's IV antibiotics related to a UTI could cause complications such as urinary frequency, confusion, painful urination, fever, and sepsis. During an interview with the Medical Director (MD), on [DATE] at 7:35 PM, he stated he could not recall if he was notified on [DATE] and [DATE] of Resident #10's IV medications being unavailable, but it was his expectation to be notified whenever a medication was not available. He further stated the delay of IV medication for one (1) day was not good but the delay of two (2) days was really inexcusable. He continued to state if he was aware of any medications that were not going to be made available for multiple days, he would look at changing the order to another medication that was available. Additionally, he stated the delay in the resident receiving the Invanz and Daptomycin could have contributed to the resident developing sepsis and eventually expiring on [DATE]. During an interview with the Pharmacy Director of Clinical Services, on [DATE] at 5:12 PM, she stated IV medications ordered by 2:00 PM would be delivered to the facility on the following morning. She stated Resident #10's orders came in after 2:00 PM on [DATE], so they should have been delivered on the afternoon of [DATE]. She further stated IV medications were sent out every two (2) days for the length of the prescription. The Pharmacy Director of Clinical Services further stated she was unsure why the facility did not receive both medications on [DATE]. During an interview with the Assistant Director of Nursing (ADON), on [DATE] at 2:42 PM, she stated she signed for the medications for Resident #10 on [DATE] but was not responsible for the care of the resident on that date. She further stated she did not open the bags the medications were in but did accept them at the door from the pharmacy delivery driver and handed them to the nurse working on the floor at that time. She continued to state it was her expectation for the nurses to communicate with each other to ensure medications were given as ordered. During an interview with the Director of Nursing (DON), on [DATE] at 3:19 PM, she stated she had only been at the facility since [DATE] and was not aware of how many deliveries were made to the facility by pharmacy each day. She further stated it was her expectation if a medication was unavailable the nurses would check the Cubex to see if the medication was there, and, if not, call the pharmacy and physician to notify them the medication was unavailable. She continued to state it would have been her expectation that on [DATE], the day shift nurse should have given the resident his/her prescribed medication of Daptomycin, since it arrived after the 6:00 AM scheduled time but was available at 8:22 AM. Additionally, she stated this was a failure to communicate from the night shift to the day shift that the medication had been unavailable and should be given later in the day when the pharmacy delivered it. During an interview with the Administrator, on [DATE] at 3:45 PM, she stated she expected new admission and readmission orders to be discussed during the morning interdisciplinary team (IDT)/clinical meeting. She further stated the nurses should have communicated to the day shift nurse on [DATE] that Resident #10's Daptomycin had not been delivered, and ensured an order was written for a time change for the medication, so the day shift nurse was aware she needed to administer it. She continued to state if the resident did not receive his/her medications for a UTI, he/she could have more discomfort, frequent urination, or increased confusion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure residents received adequate supervision to prevent accidents for three (3) of twenty-five (25) sampled residents (Residents #9, #15, and Resident #14). 1. On 08/31/2023 at approximately 7:00 PM, Resident #9 exhibited exit-seeking behaviors and was witnessed attempting to exit the facility by staff. Staff responded to the alarm and assisted Resident #9 back into the facility; however, failed to increase the resident's supervision. Subsequently, Resident #9 followed closely behind the Social Service Director (SSD) and exited the facility without staff's knowledge. 2. On 04/16/2022, Resident #15 sustained a fracture to his/her femur after the resident rolled off of his/her low air loss mattress while only one (1) staff provided his/her care. The resident was care planned to require the extensive assistance of two (2) staff for bed mobility. 3. The facility assessed Resident #14 to be a high risk for falls. Staff interviews revealed Resident #14 was impulsive, independent, and forgets to ask for assistance which would have required the resident to have increased supervision, to include one-on-one (1:1). On 07/05/2023, Resident #14 stood up and fell while out of staff's reach. Subsequently, the Mobile x-ray revealed the resident had an age-indeterminate nondisplaced humeral neck fracture. The facility's failure to have an effective system to ensure residents received adequate supervision and monitoring to prevent accidents has caused or is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on 09/13/2023 and was determined to exist on 08/31/2023, in the area of 42 CFR §483.52 Free of Accident Hazards/Supervision/Devices (F689) at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.52 Free of Accident Hazards/Supervision/Devices The facility was notified of the Immediate Jeopardy (IJ) on 09/13/2023 and IJ is ongoing. (Refer to F656 and F657) The findings include: Review of the facility's policy titled, Policy and Procedure for Personal Safety Devices for Residents at Risk of Elopement, dated 08/12/2011, revealed it was the policy of the facility that all residents were provided adequate supervision to meet each resident's nursing and personal care needs. Continued review revealed all residents would be assessed for behaviors or conditions that put them at risk of elopement and all residents assessed to be at risk of elopement would be provided with a Personal Safety Device. Further review revealed a plan of care would be developed for all residents identified to be at risk of elopement and all personal safety devices and exit door alarms would be tested daily to assure each device and door alarm were functioning properly. Review of the facility's policy titled, Policy and Procedure Regarding Missing Residents and Elopement, undated, revealed residents at risk for elopement were to be provided at least one of the following safety precautions: staff supervision of facility exits either directly or by video camera, door alarms on facility exits, or a personal safety device that notified facility staff when the resident attempted to or had left the facility without supervision. Continued review revealed all personal safety devices, such as Wander Guard bracelets, were to have their location and function documented every shift, door alarms were to be tested and documented daily, video/camera systems were to be tested and addressed should the screen(s) appear to be malfunctioning or not recording and any concerns were to be immediately addressed if found. Further review revealed if a resident was discovered missing, the facility was to report to the State if the incident met reportable criteria. Further review of the facility's policy titled, Policy and Procedure Regarding Missing Residents and Elopement, undated, revealed a Quality Improvement Committee (QAPI) were to review the facility's systems and response to the elopement to determine whether there were any deficits that should have been addressed. Continued review revealed at the Ad-Hoc QAPI meeting, any Action Plan that was rolled out was to be reviewed and discussed. Additional review revealed should a resident attempt an elopement, a review of his/her individualized care plan was to be completed for any identified needed changes. Review of the facility's policy titled, Standard Staffing Supervision and Monitoring Guide, revised 01/20/2023, revealed the guide emphasized a proactive intervention promoting enhanced physical and psychosocial well-being. The facility recognized supervision and guidance to the resident was an essential part of nursing care in which standard approaches were successful in meeting the resident's physical and psychosocial needs. Continued review revealed: 1). when a resident had been assessed either by the staff nurse or Psychosocial staff to have stable physical and psychosocial needs regular rounds would be maintained to ensure that all the resident's needs were met; 2). If the resident could not be guided, supervised, or redirected during regular intervals of rounds, the resident would require every thirty (30) minute, every fifteen (15) minute or 1:1 supervision; 3). staff assignments were to be based on the resident's needs as far as their acuity, their assessment results, and their person-centered care planning. 1.) Review of Resident #9's admission Record revealed the facility admitted Resident #9, on 02/24/2022, with diagnoses which included Lack of Coordination, Anxiety Disorder, and Muscle Weakness. Additional diagnoses were Alzheimer's Disease, History of Falling, and Dementia with Mood Disturbance and Anxiety. Review of Resident #9's Quarterly Minimum Data (MDS) Set, dated 08/06/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), which indicated severe cognitive impairment. Review of Resident #9's Comprehensive Care Plan, dated 03/02/2022 revealed the facility determined the resident to be at risk for elopement/wandering related to a diagnosis of Alzheimer's Disease with interventions that included: on 03/02/2022 for Wander Guard (an electronic bracelet on the resident's ankle that caused the door alarm to sound if the resident went through the door) per order, to check Wander Guard function/placement as ordered, complete Elopement/Wander Assessment as indicated, redirect wandering as needed, and staff to provide one-to-one (1:1) as needed. However, there was no evidence Resident #9 received increased supervision, to include one-to-one (1:1) supervision after exhibiting exit-seeking behaviors on 08/31/2023 at 7:00 PM. Review of Resident #9's Elopement Assessments, dated 08/10/2023, revealed the facility assessed him/her to have an Elopement Score of sixteen (16), which indicated the resident was a high risk for elopement. Review of Resident #9's Progress Note, dated 08/31/2023 at 9:11 PM, signed by the Director of Nursing (DON), revealed the resident had increased wandering noted and was directed back to his/her unit. Further review revealed bedtime Activities of Daily Living (ADL) care was provided and the resident was placed on one-on-one (1:1). Review of a Work Performed description, completed by the company who serviced the facility's door alarms, dated 09/05/2023, revealed the facility's front door was serviced on 09/01/2023. Further review revealed the front door keypad and maglock was not re-engaging until thirty (30) seconds after the door closed, allowing a resident to tailgate outside of the facility. Observation of Resident #9, on 09/11/2023 at 2:55 PM, revealed the resident was up in his/her wheelchair in the front lobby area with other residents. Observation of Resident #9, on 09/12/2023 at 9:20 AM, revealed the resident in his/her room with no direct supervision. Observation of Resident #9, on 09/12/2023 at 6:15 PM, revealed the resident had a one-to-one (1:1) sitter. During an interview with Resident #12 on 09/12/2023 at 6:17 PM, he/she stated he/she was sitting in the front lobby on 08/31/2023 when he/she witnessed Resident #9 go out the lobby door into the foyer. Per the interview, the resident stated Resident #9 did not get out of the second door to exit the facility. He/she further stated that nurse LPN #4 brought Resident #9 back inside the lobby area. He/she stated the Social Service Director (SSD) was in the room near the nurses' station cleaning up boxes from a staff dinner and had taken her things outside while Resident #9 was sitting on a bench next to the lobby door. Resident #12 stated most staff watched to make sure the door locked, but when the SSD went outside with her final load, Resident #9 went out the door and onto the sidewalk before it completely closed. Resident #12 stated he/she yelled to inform staff that Resident #9 was outside. Resident #12 stated five (5) or six (6) staff members went outside to get Resident #9 and brought him/her back inside after about five (5) minutes. Resident #12 further stated LPN #4 brought her phone to him/her so that he/she could tell the Administrator how Resident #9 exited the facility. During an interview with Family Member #2 on 09/13/2023 at 2:58 PM, he stated he received a call from a staff member at the facility (name unknown) on 08/31/2023 at approximately 8:00 PM, stating someone went out the front door and Resident #9 followed behind them and was located on the sidewalk. He stated he was told during the call that Resident #9 would have increased supervision and he was under the impression someone would was providing one-on-one supervision to the resident. During an interview with Licensed Practical Nurse (LPN) #4, on 09/12/2023 at 5:41 PM, she stated she responded to the front door alarm sounding on 08/31/2023 at approximately 7:00 PM and witnessed Resident #9 standing in the foyer area between the door from the front lobby and the outside door. She further stated the SSD was in the front lobby and she and the SSD brought the resident back into the lobby area where other residents were watching television. She continued to state she left Resident #9 in the front lobby and went back to her hall to pass medications. Further, she stated on 08/31/2023 at approximately 8:00 PM, she heard the front door alarm again and heard Resident #12 yell that Resident #9 went out the front door. LPN #4 stated she followed LPN #2 out of the facility's side door near the kitchen and found Resident #9 standing on the sidewalk outside the facility. The LPN stated she called for assistance to bring a wheelchair to assist the resident back inside. In a continued interview with Licensed Practical Nurse (LPN) #4, on 09/12/2023 at 5:41 PM, she stated Resident #12 told her the SSD had just left and Resident #9 went out the door before it had completely shut. She further stated the resident was returned inside the building and she assisted the resident back to his/her hallway and placed the resident one-on-one (1:1) with staff while LPN #2 called the Administrator and explained what had happened. She stated she had Resident #12 talk with the Administrator on her cell phone. She additionally stated she received a phone call from the Director of Nursing (DON) about one to one and a half (1-1 ½) hours later stating to leave the resident on one-on-one (1:1) supervision unless the resident was in bed sleeping, in which case he/she did not have to be one-to-one (1:1). The LPN stated the DON informed her that paperwork had been completed on the incident and advised her the incident was not reportable since staff always had eyes on the resident. Further review of the resident's record; however, revealed no documentation to support the facility investigated the incident. During an interview with LPN #2 on 09/18/2023 at 4:00 PM, she stated Resident #9 exited the facility on 08/31/2023 at approximately 8:00 PM. She further stated Resident #12 screamed out that Resident #9 had exited the facility and she saw the resident outside the front door. The LPN stated the front door locked down and she was unable to go out the front door, so she exited the side door by the kitchen, to retrieve Resident #9. LPN #2 stated the resident was found on the sidewalk outside the kitchen. She stated she notified the Administrator and had her on speaker phone so she could speak with Resident #12, who reported the resident's elopement. During an interview with a representative from the door alarm company on 09/12/2023 at 8:21 AM, he stated the facility's front door had been replaced on 07/25/2023 and his company's representative did not realize the door contact, which identified if the door was closed and immediately locked down, was taped shut and did not realize it was integrated into the keypad. He further stated the keypad never recognized the door as opened thus it would not lock the door for the required thirty (30) to sixty (60) seconds. He stated the keypad not locking the door down for up to a minute would allow someone to tailgate, or follow another person, out the door before the door locked. During an interview with the Social Services Director (SSD) on 09/12/2023 at 1:42 PM, she stated she saw Resident #9 sitting on a bench close to the front lobby door on 08/31/2023 and thought he/she got out the front lobby door into the foyer but did not go outside. She further stated she was unaware that Resident #9 had followed her out the door. During an interview with the Medical Director on 09/20/2023 at 7:35 PM, he stated it was his expectation that staff would have provided the necessary supervision to keep the resident safe. During an interview with the Director of Nursing (DON), on 09/13/2023 at 12:12 PM, she stated she was aware Resident #9 had gone into the foyer past the lobby door on 08/31/2023. She stated LPN #4 had called the Administrator and notified the Administrator the resident had exited the facility. Per the interview, the DON stated the Administrator then called her and told her LPN #4 called her and stated that while the resident had exited the facility, the LPN had her eyes on the resident. The DON stated she called LPN #4 and told her to put Resident #9 1:1 and he/she stayed 1:1 for a day or two (2). The DON, however, was unable to provide documentation to support the resident received 1:1 supervision on 08/31/2023. She continued to state she specifically asked LPN #4 if the resident had gotten outside, and LPN #4 stated no. She additionally stated she charted a progress note regarding the resident had increased wandering in Resident #9's chart after speaking with LPN #4 but did not come into the facility herself at that time. She stated she did not complete an investigation into the elopement as the Administrator notified her the resident had not been outside the building. The DON stated the potential for harm, of a resident who exited the facility without staff supervision, would have been the potential of falling or getting hit by a car while outside the building. During an interview with the Administrator on 09/13/2023 at 12:24 PM, she stated she was not aware Resident #9 had gotten out the lobby door on 08/31/2023. The Administrator stated she heard the SSD and a nurse or housekeeper discussing the resident needed to be redirected. She continued to state she was unsure why Resident #9 was placed on 1:1 on 08/31/2023. The Administrator stated she was aware the DON had received a call from staff stating Resident #9 had increased agitation on 08/31/2023 and stated that was probably the reasoning behind placing the resident on 1:1 supervision. She further stated the potential risk of harm, should a resident exit the building without staff supervision would be a risk of falls or accidents. Interview with Resident #12 on 09/12/2023 at 6:17 PM; LPN #2 on 09/18/2023 at 4:00 PM; LPN #4 on 09/12/2023 at 5:41 PM; and the DON on 09/13/2023 at 12:12 PM, however, revealed they had discussed concerns of Resident #9 exiting the facility with the Administrator. Review of the facility's policy titled, Incidents/Accidents/Falls, last revised 01/30/2022, revealed it was the policy of the facility to ensure any incident, including accidents related to falls was reported to the nurse in charge and after the resident had been assessed, and deemed to be safe, a Risk Management report was to be entered. The facility was to ensure the incident and/or accident was reported and investigated. The facility was to have a system to track and trend and discuss through the Quality Assurance Performance Improvement (QAPI) program. Such information was to be used to implement corrective action to include training to prevent reoccurrences when possible. Further review revealed any unwitnessed fall required neuro (neurological) checks to be started and continued per policy. Further review of the facility's policy titled, Incidents/Accidents/Falls, last revised 01/30/2022, revealed the progress note related to the event was to include a description of the occurrence to include the time and place, physical and mental status of the resident, time of Physician notification and the Physician response, any new orders, and the time of notification to the responsible part to include unsuccessful attempts. Per review, a completed incident/accident report was to be reviewed by the Director of Nursing (DON) and the Interdisciplinary Team (IDT) during the next meeting. Continued review revealed the Administrator was to be advised of the situation. The policy review revealed documentation of the resident's physical and mental status was to be completed each shift (every eight {8} hours minimally) over the next seventy-two (72) hours and the information was to be communicated from shift to shift until the resident's condition improved. Review further revealed the incidents/accidents/falls policy further revealed all falls required a site investigation to include determining the root cause. 2.) Closed record review of Resident #15's face sheet revealed the facility admitted the resident on 02/13/2020 with diagnoses related to history of Falls, Dementia, Alzheimer's, Osteoporosis without current pathological fractures, and Contracture to his/her right knee. Review of Resident #15's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of three (3) out of fifteen (15), which indicated the resident had severe cognitive impairment. Further review of the MDS revealed the resident required the physical assistance of two (2) staff for bed mobility, transfers, toileting, dressing, and for personal hygiene. Review of Resident #15's person-centered Comprehensive Care Plan (CCP), related to Activities of Daily Living (ADLs), initiated on 03/30/2021, revealed the resident was care planned to require two (2) staff for bed mobility, to turn and reposition, for bathing and showers, dressing, personal hygiene, and toileting. Review of a Progress Note, dated 04/16/2022 at 10:58 PM, revealed the resident appeared to be in no pain or discomfort, and the resident rested in bed with his/her eyes closed. Review of a Progress Note completed by Registered Nurse (RN) #5, on 04/17/2022 at 12:50 AM, revealed the resident rested in bed with eyes closed, no signs and/or symptoms of pain or discomfort due to recent fall, no apparent injuries. Review of a progress note completed by LPN #3 on 04/17/2022 at 2:03 PM, the resident was noted to be resting in bed, no complaints of pain or decreased range of motion noted, no new injuries noted to post fall. Review of a Nursing Progress Note, completed by Registered Nurse (RN) #1, on 04/18/2022 at 2:56 AM, she noted the resident was resting quietly in bed, no sign or symptoms of pain or discomfort, range of motion appeared within normal limits, no apparent injuries. Review of a progress note completed by LPN #2 on 04/18/2022 at 5:45 PM, revealed the resident was lying in bed with eyes closed, resting quietly, no signs or symptoms of pain or discomfort noted, bed in lower position and call light within reach. Review of a Change in Condition (CIC) completed on 04/22/2022 by LPN #12 noted while an aide provided a shower for the resident on 04/22/2022 the resident began to cry in pain and it was noted his/her right hip was red and swollen. Review of an Interdisciplinary Team (IDT) Note dated 04/28/2022, revealed, that during care on 04/16/2022 the resident got too close to the edge of the bed and fell out. It was noted the resident was immediately assessed and placed back in bed. The MD and representative were notified, and no new orders were given. Review of the IDT Note on 04/28/2022, it was noted the resident was sent out to the Emergency Department (ED) on 04/22/2022 and was admitted to the hospital with a fractured right femur. The IDT team noted it was related to the fall that happened on 04/16/2022. However, the facility failed to ensure the resident's fall that occurred on 04/16/2022 was thoroughly investigated to include determining the Root Cause of the resident's fall, as per the facility's policy. Further review of the IDT Note revealed the resident returned to the facility on [DATE]. In an interview with Certified Nursing Assistant (CNA) #22, on 09/28/2023 at 1:51 PM, she stated she worked at the facility for over six (6) years. She stated she knew Resident #15 well and believed she was working on 04/16/2022 when the resident was hurt. She stated she heard the aide scream out and the nurse went into the resident's room, but she could not identify the staff member involved. She stated she believed the aide was an agency staff. CNA #22 stated the low air loss mattresses were very tricky and could be slippery. She stated when she was assigned a resident who had a low air loss mattress, she would not change the resident without assistance. She stated accidents could happen. She also stated it was her personal preference because she just felt it was safer for the resident. CNA #22 stated Resident #15 used to get out of bed daily but at some point, that stopped. She said the resident's legs were contracted badly and it was very painful for the resident to be out of bed which made it very difficult to provide peri care. In an interview with Licensed Practical Nurse (LPN) #3, on 09/25/2023 at 11:45 AM, she stated she could not recall the specific incident with Resident #15, however, she did recall Resident #15 was a two (2) person assist for all ADL care. She stated Resident #15 did not have the ability to roll and she said she could not see how the resident rolled out of bed on his/her own. She stated Resident #15 had a low air loss mattress, which required a two (2) person assist, as the mattress was too unstable, and the resident could fall out of bed. LPN #3 stated the resident enjoyed being up from his/her bed and noticed a change in the resident's condition after his/her fall on 04/16/2022. According to LPN #3, she should have followed the resident more closely as the resident was in his/her bed more than normal. In an interview with the current Assistant Director of Nursing (ADON), on 09/29/2023 at 11:03 AM, she stated she worked on 04/16/2022 when an aide provided peri care, by herself, on the resident and the resident rolled out of bed. She stated she was not assigned to that floor and could not remember the details. She said any resident who had a low air loss mattress really needed to have two (2) staff assist for any bed mobility, peri care, personal hygiene and transfer back into the bed. She stated that was for the resident's safety. In an interview with the Director of Nursing (DON), on 09/29/2023 at 1:20 PM, she stated she was unfamiliar with Resident #15. However, stated it would have been her expectation that the resident's care plan would have been followed, to have two (2) people assist with resident while providing care. In an interview with the Administrator, on 09/29/2023 at 1:30 PM, she stated her expectation would have been for the resident's care plan to have been followed. Review of the facility's policy titled, Standard Staffing Supervision and Monitoring Guide, revised 01/20/2023, revealed the guide emphasized a proactive intervention promoting enhanced physical and psychosocial well-being. Per the policy review, the facility recognized supervision and guidance to the resident as an essential part of nursing care in which standard approaches were successful in meeting the resident's physical and psychosocial needs. Continued review revealed, 1). when a resident had been assessed either by the staff nurse or Psychosocial staff to have stable physical and psychosocial needs regular rounds would be maintained to ensure that all the resident's needs were met; 2). If the resident could not be guided, supervised, or redirected during regular intervals of rounds, the resident would require 30-minute, 15-minute or 1:1 supervision; 3). staff assignments would be based on the resident's needs as far as their acuity, assessment results, and person-centered care planning. 3.) Review of Resident #14's admission Record revealed the facility admitted the resident on 10/19/2022 with diagnoses including Alzheimer's Disease; Coronary Artery Disease; Wandering; Difficulty Walking; Hypertension; and Dementia. Review of Resident #14's Quarterly Minimum Data Set (MDS), dated [DATE] revealed the facility assessed the resident to have had a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), indicating the resident was severely impaired cognitively. Continued review revealed Resident #14 required extensive assistance of two (2) persons for transfers. Review of Resident #14's Comprehensive Care Plan revealed the resident had a focus of being high risk for falls as evidenced by potential contributing diagnoses of Alzheimer's and Atrial Fibrillation, initiated 10/25/2022 with a goal to reduce fall risk and injury through the next review. Interventions included: to ambulate when attempting to get out of his/her wheelchair with staff assistance and gait belt as tolerated; bed in lowest position as tolerated when not providing care; ensure resident was positioned in the center of the bed upon rounding; dycem to his/her wheelchair; encourage resident to go to the dining room for breakfast; encourage to lay down after last medication pass in the evening as tolerated; ensure trash can was at bedside when in bed; adjustments to anti-roll backs as needed (added 07/03/2023); staff to offer toileting with rounds; and up in wheelchair when restless as tolerated. Further review of Resident #14's care plan revealed no documented evidence to support the resident had been care planned for his/her impulsive behaviors which required increased supervision to his/her prevent falls. Review of Resident #14's Fall Risk assessments dated 07/01/2023 revealed the facility assessed the resident to be a high risk for falls. Review of the Mobile x-ray Report for Resident #14, dated 07/05/2023, revealed significant findings of his/her right shoulder arthritis and an age-indeterminate nondisplaced humeral neck fracture. Observation on 09/11/2023 at 2:15 PM revealed the resident was seated in his/her wheelchair with an overbed table in front of the resident. Continued observation revealed the resident had a magazine and a cup of water. Observation on 09/13/2023 at 1:22 PM revealed the resident was seated in a wheelchair near the nurse's station and was eating ice cream. During an interview on 09/26/2023 at 5:06 PM with Kentucky Medication Aide (KMA) #1, stated she had started the medication pass for the evening shift when she heard another resident say, Hey, he/she [Resident #14] is getting up. The KMA #1 stated she looked down the hallway and observed Resident #14 rising from the wheelchair while holding to the handrail, and immediately fell in front of the wheelchair. KMA #1 stated she yelled for the KMA #2, who was at the medication cart and had her back to Resident #14. KMA #1 stated KMA#2 turned around, and when she did, Resident #14 was sitting on the floor. KMA #1 stated all the staff knew to watch Resident #14 and if he/she was awake to bring him/her into the hallway for closer supervision because he/she frequently would attempt to stand unassisted. During an interview on 09/25/2023 at 4:30 PM, with Licensed Practical Nurse (LPN) #3, she stated Resident #14 was impulsive and forgets to call for help. Further, LPN #3 stated when the resident was up in his/her wheelchair, the staff kept the resident engaged with magazines, food, and drink. LPN #3 stated Resident #14 needed to be in sight of staff for more supervision when he/she was awake due to being a high fall risk. During an interview on 09/29/2023 at 3:10 PM, the Medical Director stated Resident #14 had numerous falls due to his/her dementia was non-ambulatory, utilized a wheelchair for mobility, and required assistance for transfers. The Medical Director stated he/she transferred without assistance, and was very stubborn and independent-minded, thinking he/she could still walk. The Medical Director stated Resident #14 was hard to control and the staff kept a close watch on the resident. The Medical Director stated he would expect the facility staff to follow the resident's care plan and provide supervision as ordered. During an interview with the Director of Nursing (DON) on 09/26/2023 at 03:11 PM, she stated she would have expected to see a complete and thorough documentation of the event to help with the investigation. Per the interview, the investigation started with the nurse and the residents needed a person-centered care plan that spoke to the resident's needs and risks. The DON stated Resident #14's care plan did not address his/her impulsive behavior or the need for increased supervision. During an interview on 09/26/2023 at 3:27 PM, with the Administrator, she stated Resident #14 should have had a behavior care plan. Further, she stated the resident's care plan did not address supervision for Resident #14 and added it was her expectation that the resident would be placed on 1:1 supervision due to his/her behaviors. The Administrator stated the facility failed to follow its policy related to providing increased supervision for Resident #14 to prevent his/her falls.

**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 free of significant medication errors for one (1) of twenty-five (25) sampled residents (Resident #10). On [DATE], the facility admitted Resident #10 and on [DATE], Registered Nurse (RN) #4 discovered Resident #10's admission orders had been transcribed incorrectly. Therefore, Resident #10 was administered the wrong medications from [DATE] to [DATE]. The facility's failure to have an effective system to ensure residents were free of significant medication errors is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the area of 42 CFR §483.45 (F760) Pharmacy Services at the highest Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.45 (F760) Pharmacy Services. The facility was notified of the Immediate Jeopardy (IJ) on [DATE] and IJ is ongoing. The findings include: Review of the facility's policy titled, Medication Errors dated 11/2017, revealed medications were to be administered according to the Physician's orders and in accordance with accepted standards and principles which applied to professionals who provided services. Review of the facility's policy titled, Medication Transcription Guidelines dated [DATE], revealed all drug orders received via a transfer sheet were to be verified by the attending Physician and transcribed into the facility's electronic charting system, Point Click Care (PCC). Continued review revealed staff were to complete documentation; clarify orders, and transcribe the prescribed medication orders into PCC. Per review, transcription of newly prescribed medication orders, new order changes, and discontinued medications were to be completed in PCC, and the orders transcribed into PCC were to be electronically transmitted to the provider pharmacy to be filled. Review of the facility's contracted Pharmacy provider's policy, Resident Information (Admission/Change of Status), undated, revealed it was the Pharmacy's policy for the facility to provide complete and accurate information to the Pharmacy relative to admission/readmission and change in status prior to the Pharmacy dispensing medications. Review of the facility's policy titled, Quality Care Process dated [DATE], revealed a daily Continuous Quality Improvement (CQI) meeting was to include a medication administration audit to be run for missed and late medications. Per review, the medication administration audit to determine what had not been signed on the Electronic Medication Administration Record (EMAR). Further review revealed any medications not administered in the previous twenty-four (24) hours were to be looked at for codes as to why some had not taken medications and followed up as needed. The facility did not provide any policy for CQI prior to [DATE]. Review of the Pharmacy Services Agreement between the facility and contract Pharmacy provider, undated, revealed the Pharmacy agreed to provide prescriptions and over the counter medications, whether oral, intravenous (IV), topical, or otherwise, and pharmacy supplies to the facility as requested by the facility pursuant to the order of the resident's attending Physician. Further review revealed the contract Pharmacy agreed to provide the services in accordance with professional standards and all laws, rules, and regulations that applied or related to the performance of the services. Review of Resident #10's admission Record/electronic medical record (EMR) revealed the facility admitted the resident on [DATE], with diagnoses which included Chronic Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Anxiety, Dementia, Essential Tremor, and Diabetes. Review of Resident #10's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), which indicated severe cognitive impairment. Review of Resident #10's previous facility's Discharge summary dated [DATE], revealed the resident had been prescribed Budesonide-formoterol (inhaler used to treat asthma), Diltiazem (high blood pressure), Duo Neb (used to treat breathing conditions), Eliquis (a blood thinner), Gabapentin 600 mg twice a day (used to treat neurological pain), Hydralazine (used to treat high blood pressure), Januvia (used to treat diabetes), Losartan (used to treat high blood pressure), Primidone (used to treat seizures), Spiriva (used to treat breathing conditions), and Tramadol (used to treat pain) upon admission. Further review revealed however, the current facility failed to ensure those medications were transcribed onto Resident #10's current Medication Administration Record (MAR) to be administered to the resident. Review of the [DATE] MAR for Resident #10 revealed the following medications listed as having been administered: Seroquel one (1) tablet (no dosage) at bedtime (used to treat mental disorders); Xarelto twenty (20) mg (a blood thinner) at bedtime; Aspart Insulin two (2) units (used to treat diabetes) with meals and Detemir Insulin sixteen (16) units (used to treat diabetes) twice a day; and Gabapentin three hundred (300) mg (used to treat neurological pain) three times a day from [DATE] until [DATE]. (However, none of the medications listed were prescribed for Resident #10, except for the Gabapentin, which should have been 600 mg twice daily as prescribed). Review of the facility's documentation revealed the facility completed a medication error form; however, there was no documented evidence the facility investigated the medication error related to the resident not receiving his/her prescribed medications, to determine whose medication had been administered to Resident #10. Review of Resident #10's Progress Note dated [DATE], entered by RN #4, revealed the resident had uncontrolled pain, was diaphoretic (sweating heavily), short of breath, and had shaking hands. Continued review of the Note revealed Resident #10 should have been prescribed and have received Tramadol fifty (50) mg (a pain medication) daily and Tramadol fifty (50) mg twice daily as needed for pain, which had not been ordered for the resident upon admission. In interview on [DATE] at 2:50 PM, Registered Nurse (RN) #4 stated she spoke with Resident #10's family member who reported Resident #10 expressed to the family that he/she was in pain due to not having received his/her pain medications. Further review of Resident #10's EMR revealed the resident had been admitted to the hospital on [DATE] and readmitted to the facility on [DATE], with new orders to administer Invanz (antibiotic used to treat infection) daily on [DATE] and [DATE], and Daptomycin (antibiotic used to treat infection) daily from [DATE] until [DATE] for a Urinary Tract Infection (UTI). However, review of Resident #10's [DATE] MAR revealed no documented evidence the resident received the Invanz on [DATE], nor the Daptomycin on [DATE] and [DATE], as ordered to treat his/her infection. Review of Resident #10's Physician's Order sheet (completed by the Physician upon seeing the resident and scanned into the system, not entered into PCC) dated [DATE], and signed by the Medical Director (MD) revealed the resident had a urinalysis completed which had been highly suggestive of a UTI and was confirmed with a culture. Continued review revealed Resident #10 had been placed on treatment for the infection and had been slow to improve in terms of his/her symptoms. Continued review of Physician's Order sheet dated [DATE] and signed by the MD, revealed the resident had been hospitalized a week prior with metabolic encephalopathy that had been determined to be secondary to ESBL ([Extended Spectrum Beta-Lactamases] enzymes from bacteria which cause resistance to some antibiotics) UTI. Further review revealed the Physician's Plan had been to complete Resident #10's course of Invanz. Review of the Pharmacy Invoices revealed the Invanz had been delivered on [DATE] at 7:51 PM, and the Daptomycin had been delivered on [DATE] at 8:22 AM. Review of Resident #10's [DATE] MAR revealed the Invanz had been documented as not having been available on [DATE], and was not administered until [DATE]. Continued review revealed and there was no documented evidence the second dose of Invanz had been administered as ordered. Further review revealed Resident #10 did not receive the first dose of Daptomycin until [DATE], and the doses of Daptomycin were documented as having been unavailable on [DATE] and [DATE]. Review of Resident #10's Progress Note dated [DATE], entered by Registered Nurse (RN) #1, revealed the Daptomycin had been unavailable for administration from the Pharmacy. Review of Resident #10's Progress Note dated [DATE], entered by Licensed Practical Nurse (LPN) #2 revealed she had notified the Pharmacy and the Physician on [DATE] that the intravenous (IV) antibiotic medications had not been available to administer. Further review revealed LPN #2 had been unable to administer the Invanz on [DATE] because it had been unavailable from Pharmacy. Review of the Progress Note dated [DATE] entered by LPN #5 revealed the Daptomycin had not been available to administer. Continued review revealed however, no documented evidence on [DATE], the Physician was notified the Daptomycin remained unavailable for administration. Review of Resident #10's Progress Note dated [DATE], entered by LPN #1 revealed the resident had been found unresponsive and had been readmitted to the hospital. Review of Resident #10's hospital records revealed the resident had been admitted on [DATE]. Continued review revealed on [DATE], the resident had been diagnosed with staphylococcus epidermidis (a bacterial infection) and Acinetobacter (a bacterial infection) which he/she had developed since being discharged from the hospital on [DATE]. Further review revealed unfortunately, now Resident #10 had new and even more resistant bugs. In addition, review further revealed Resident #10 had an infection on [DATE] which had been sensitive to Daptomycin. Review of Resident #10's Palliative Care Hospital Note dated [DATE], revealed the resident had multiple multi-drug resistant organisms. Continued review revealed Resident #10 expired on [DATE] with the cause of death documented as refractory (hypotension and end-organ dysfunction) sepsis infection. The State Survey Agency (SSA) Surveyor attempted telephone interview on [DATE] at 8:00 AM and 3:18 PM, and on [DATE] at 12:15 PM; however, all attempts were unsuccessful. Messages were left for RN #6, who entered Resident #10's [DATE] orders, to return the SSA Surveyor's call, but no return call was received, and the nurse no longer worked at the facility. During an interview with Registered Nurse (RN) #4 on [DATE] at 2:50 PM, she stated she found Resident #10's medications had been entered incorrectly on [DATE], when the resident had his/her daughter called the facility to inquire about the resident's Tramadol for pain. She stated the orders did not sit right and since this had been a new resident for her, she looked at Resident #10's discharge medications and realized they did not match what the resident had been ordered in the facility's system. RN #4 stated she talked with Resident #10 and his/her family regarding the medications and was told the medications ordered on [DATE] were incorrect. In addition, she stated the facility had a triple check process in place to verify the Physician's orders. The RN stated the orders were to be verified by another nurse (either a nurse on a different hallway or the nurse coming on for the next shift); the clinical team/Unit Manager looked at the orders at the next day's Clinical Meeting; and the night shift nurse was supposed to have completed a twenty-four (24) hour chart check nightly. During an interview with RN #1 on [DATE] at 9:43 AM, she stated Resident #10 had a history of being hospitalized and she did not recall the resident's IV medication having been unavailable on [DATE]. She further stated if the medication had been unavailable, she should have notified the Pharmacy and the Physician and followed any further orders given to her by the Physician. During an interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 4:00 PM, she stated she did not recall Resident #10 not having IV medications on [DATE]; however, if a medication had not been available, she should have checked the Cubex (the facility's automated medication dispensing system medications). LPN #2 stated if the medication had been unavailable in the Cubex, she should have notified the Pharmacy and the Physician. She further stated she would then have followed any orders given to her by the Physician at that time. During an interview with RN #3 on [DATE] at 4:19 PM, she stated if a medication had been unavailable at the time it was scheduled to be administered, she would have looked in the Cubex. RN #3 stated if it had not been available in the Cubex, she would have called the Pharmacy to have it sent immediately to the facility, which usually took about four (4) hours. She further stated she would have notified the Physician of any medication having been unavailable at the time it was scheduled to be administered. During an interview with LPN #3 on [DATE] at 4:30 PM, she stated when a medication was unavailable, she checked the Cubex, and if not in the Cubex, she called the Pharmacy to see where the medication was. She stated she would notify the Physician to let him know so he could change the orders if needed. LPN #3 further stated delaying a resident's IV antibiotics related to a UTI could cause complications such as urinary frequency, confusion, painful urination, fever, and sepsis. During an interview with the Medical Director on [DATE] at 7:35 PM, he stated erroneous administration of Insulin and Xarelto had been pretty bad errors and a resident who received incorrect medications for two (2) days seemed like a lot and was unacceptable. He stated the resident erroneously receiving insulin could have became hypoglycemic, or receiving Xarelto in error could have been at an increased risk for bleeding. The Medical Director stated if a resident did not receive his/her medication as prescribed it could cause increased pain. He stated he could not recall if he had been notified on [DATE] and [DATE] of Resident #10's IV medications not having been available. The Medical Director stated however, it would have been his expectation to be notified whenever a medication was not available. He stated the delay of IV medication for one (1) day was not good, but the delay of two (2) days of the IV medications would have been really inexcusable. The Medical Director stated if he had been made aware of any medications which was not going to be available for multiple days, he would have looked at changing the order to another medication that would have been available. He further stated the delay in Resident #10 receiving his/her Invanz and Daptomycin could have contributed to the resident developing sepsis and eventually expiring on [DATE]. During an interview with the contract Pharmacy's Director of Clinical Services on [DATE] at 5:12 PM, she stated Resident #10's orders came into the Pharmacy after 2:00 PM on [DATE], so the medication should have been delivered on the afternoon of [DATE]. She stated the Pharmacy did not have any system in place to double check the orders placed in Point Click Care and, unless the medication had some abnormal dosage, the Pharmacy would have filled the medication as ordered by facility staff. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 2:42 PM, she stated she signed for the medications for Resident #10 on [DATE]; however, had not been responsible for the care of Resident #10 on that date. She stated she had not opened the bags the medications were in, but had accepted them at the facility door from the Pharmacy delivery driver and handed them to the nurse working on the floor at that time. The ADON stated it was her expectation for the nurses to communicate with each other to ensure medications were given as ordered. She stated any medication errors should have been caught in the morning clinical meeting and investigated, with the resident monitored for any abnormal side effects. The ADON stated all orders were reviewed in the morning clinical meeting and she was unsure why the incorrect medications for Resident #10 entered on [DATE], had not been caught prior to [DATE]. During an interview with the Director of Nursing (DON) on [DATE] at 3:19 PM, she stated it was her expectation if a medication was unavailable for the nurses to check the Cubex to see if it was there, and, if not, to call the Pharmacy and Physician to notify them of the medication being unavailable. She stated it was her expectation for the [DATE] Daptomycin to have been given by day shift once it arrived at the facility. The DON stated had it had been a failure in communication from night shift to day shift that the medication was unavailable and should have been given later in the day when Pharmacy delivered it. She further stated she was not working in the facility in 2022, and could not speak to the triple check process, as the facility did not have a triple check process in place currently. During an interview with the Administrator on [DATE] at 3:45 PM, she stated currently orders were reviewed in the morning clinical meetings for accuracy. The Administrator stated she expected new admission and readmission orders to be discussed during the morning interdisciplinary team (IDT)/clinical meeting. She stated the night shift nurse should have communicated to the day shift nurse on [DATE] that Resident #10's Daptomycin had not been delivered, and ensured an order had been written for a time change of administering the medication, so the day shift nurse would have been aware she needed to administer it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's policies, review of the facility's investigative report, and review of the Administrator's and Director's of Nursing job descriptions, it was determined the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility also failed to protect residents from abuse; failed to develop and implement policies that prohibited and prevented abuse; and, failed to establish coordination with the Quality Assurance Performance Improvement (QAPI) program related to abuse allegations. On 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 witnessed CNA #35 push Resident #9 in the chest while yelling at the resident. There was no documented evidence CNA #35 was immediately removed from Resident #9's room or Resident #9 was placed in a safe location away from CNA #35. During an interview with CNA #33, she stated CNA #35 pushed Resident #9 back into the bed on 10/12/2023 while yelling at the resident, I'm not dealing with your ass tonight. CNA #33 stated she left the resident's room to report the incident to Licensed Practical Nurse (LPN) #13 who informed her to call the Director of Nursing (DON). She stated CNA #35 was left alone with Resident #9 while she went to inform the nurse. However, the facility failed to ensure the facility's abuse policy was implemented, and no action was taken to protect the resident from further potential abuse. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed Resident #9's abuse allegation from 10/12/2023 was not discussed. The Administrator's and DON's failure to ensure residents were immediately protected from abuse in a timely manner; failure to thoroughly investigate an abuse incident; and failure to involve the Quality Assurance and Performance Improvement (QAPI) Committee in addressing the abuse incident in a timely manner has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/2023 and determined to exist on 10/12/2023 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F607) and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 10/18/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 10/20/2023 alleging removal of the IJ on 10/20/2023. The SSA validated the removal of the IJ on 10/21/2023, prior to exit on 10/21/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's job description for Administrator, undated, revealed the Administrator led and directed the overall operation of the facility in accordance with resident needs, federal and state government regulations, and company policies/procedures so as to maintain quality care for the residents while achieving the facility's business objectives. Further review revealed the Administrator's Essential Job Functions included: job knowledge and administrative duties, interpersonal skills, safety/infection control, and resident care/dignity. Per the job description, the Administrator's responsibilities also included: communicating and observing the Corporate Compliance Program effectively; working with the facility's management staff and consultants in planning all aspects of the facility's operations, including setting priorities and job assignments; monitoring each department's activities, communicating policies, evaluating performance, providing feedback and assistance, coaching and discipline as needed; ensuring consultants and other support resources were appropriately utilized and a high level of inter-departmental teamwork was maintained; and maintaining a working knowledge and ensuring compliance with all governmental regulations and company Quality Assurance Standards. Continued review revealed the Administrator's responsibilities included: he/she was aware of Resident Abuse Reporting Law, ensured understanding of, and compliance with, all rules regarding residents' rights, possessed strong knowledge regarding state, federal and local regulations as they pertain to long term care, and successfully completed facility conducted orientation, mandatory training, and in-service programs. Review of the facility's job description for the Director of Nursing, undated, revealed the DON, under the supervision of the Administrator, had the authority, responsibility, and accountability for the functions, activities, and training of the nursing services staff, and, in the absence of the Administrator, the DON assumed responsibility for the facility. Further review revealed the DON was responsible for the overall management of resident care twenty-four (24) hours a day, seven (7) days a week and was delegated the responsibility for carrying out the assigned duties in accordance with current existing federal and state regulations and established company policies and procedures. Continued review revealed the DON's Essential Job Functions included: job knowledge/duties, administrative duties, nursing systems, nursing documentation, interpersonal skills, safety, infection control, and resident care/dignity. Per the job description, the DON's responsibilities included: acting appropriately under the direction of the Administrator, acting as an active member of the Interdisciplinary Team (IDT); communicating and observing the Corporate Compliance Program effectively and complying with the Code of Conduct when performing work functions; supervising, evaluating, counseling and disciplining inter-departmental personnel; participating in coordination of resident services through departmental and appropriate staff committee meetings (such as Quarterly Quality Assurance and Assessment and Resident Care policy and procedure meeting); planning staff development programs that would enhance staff knowledge of quality resident care; reviewing all accidents and incidents daily and developing an appropriate plan to prevent future accidents and incidents; conducting periodic reviews of documentation for inconsistencies on each unit; was aware of, and adhered to the Resident's [NAME] of Rights and Confidentiality of Resident Information; was aware of Resident Abuse Reporting Law and ensured all staff understanding/compliance; recognizing, removing, and/or reporting potential hazards; and ensuring nursing personnel complied with residents' personal and property rights. Additionally, the DON must possess strong knowledge of state, federal, and local regulations as they pertained to long term care. Review of the facility's policy titled, Abuse Prevention Program, dated 10/22/2022, revealed it was the policy of the facility for staff members who were suspected of abuse or misconduct would be immediately removed and barred from any further contact with residents of the facility and would be suspended from duty, pending the outcome of the investigation. Further review revealed supervisors would monitor the ability of the staff to meet the needs of the residents, staff understanding of individual resident care needs and situations such as inappropriate language and insensitive handling. Additionally, review of the policy revealed the facility stated to prevent resident abuse and if an employee suspected abuse, they were to separate the alleged perpetrator and assure all residents' safety. Record review revealed the final investigation would be submitted within five (5) working days of the incident and should contain facts determined during the process of the investigation, the conclusion of the investigation, the police report, and a summary of all interviews conducted with names, addresses, phone numbers, and willingness to testify of all witnesses. Further review revealed the Administrator or DON would request a representative of the Social Services Department to monitor the resident's feelings concerning the incident as well as the resident's reaction to his/her involvement in the investigation and, unless otherwise requested by the resident, the Social Services representative would provide the Administrator and the DON with a written report of his/her findings in the resident's medical record. Review of the facility's policy titled Quality Assurance and Performance Improvement, dated 11/2017, revealed it was the policy of the facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focused on indicators of the outcomes of care and quality of life. Further review revealed the QA (Quality Assurance) Committee should be interdisciplinary and consist, at a minimum, of the Director of Nursing Services, the Medical Director or his/her designee, at least three (3) other members of the facility's staff, at least one (1) of which must be the Administrator, Owner, a board member or other individual in a leadership role, and the Infection Control and Prevention Officer. Additionally, adverse events would be monitored in accordance with established procedures for the type of adverse event with the data related to adverse events used to develop activities to prevent them. Per the policy, the governing body and/or executive leadership was responsible and accountable for the QAPI program. Review of the facility's Initial Report, dated 10/12/2023, revealed on 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 heard a scream and went down the hall where she witnessed CNA #35 push Resident #9 in the chest down into the bed while telling the resident to keep his/her ass in the bed. Further review revealed CNA #35 was removed from the facility, and Resident #9's assessment showed no signs of injury. Continued review revealed the resident had a history of dementia with a care plan to follow. Per the report, statements were written and signed by LPN #13, CNA #33, and CNA #35. However, CNA #34, who witnessed some of the incident, was not listed. Review of the facility's Five (5) Day Final Report, dated 10/16/2023, revealed Resident #9 no longer resided in the facility and staff interviews were conducted by Administrator #2 and the DON. Further review revealed the nurse immediately did a head to toe skin assessment and no redness or abnormalities we noted. Resident #9 stated I just had to go to the bathroom. Continued review revealed the facility concluded, based on a thorough investigation and interview with the accused, physical abuse can not be ruled out; out of an abundance of caution, CNA #35 was terminated from the facility; Resident #9 was noticed to be her/his usual self the rest of the night without signs or symptoms of any distress or emotional trauma. However, through interviews with staff, the resident exhibited crying episodes, being flustered, and agitation after the incident. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed a QAPI meeting was held on 10/13/2023 with several topics discussed. However, there was no documentation of a discussion about Resident #9's abuse incident. Further review revealed Corporate staff, the Administrator, the DON. the Social Services Director (SSD), and the Minimum Data Set (MDS) attended the meeting. In an interview with CNA #33 on 10/17/2023 at 5:21 PM, she stated, on 10/12/2023, she was in a resident's room when she heard screaming from Resident #9's room. She further stated she went into Resident #9's room and witnessed the resident standing beside the bed with his/her walker. She stated she then witnessed CNA #35 stand up, use her right hand to push Resident #9 in the chest, which caused the resident to fall backward onto the bed with his/her feet flying up into the air. Additionally, she stated CNA #35 said I'm not dealing with your ass tonight. She stated she did not say anything to CNA #35, but left the room and notified LPN #13, who stated she was unaware of the facility's policy and asked CNA #33 to call the DON, which she did. She stated as she walked toward the front bathroom, she saw CNA #35 come out into the hallway and asked CNA #34 to relieve her so she could take a break. Additionally, she stated the DON told her she was going to call Administrator #2, but did not mention anything else to her about Resident #9 or CNA #35. Additionally, she stated after CNA #35 left the building, she went back to Resident #9's room where the resident was upset and told another CNA, I'm too little, I can't fight her. She stated the resident had to be taken out of the room into the lobby area to calm down because he/she was crying and agitated. She further stated she was not aware of the abuse policy and had not been told not to leave the resident alone with CNA #35 after she witnessed her push the resident. She stated she had been told to report the abuse immediately which was why she left the room to get the nurse. In an interview with CNA #34 on 10/17/2023 at 6:35 PM, she stated she was working on 10/12/2023 when she heard yelling in Resident #9's room and went into the hallway. She further stated CNA #33 went into Resident #9's room and she went to another resident's room. She stated CNA #33 pulled her aside and told her she had witnessed CNA #35 push Resident #9, and she went with CNA #35 to report to LPN #13. She further stated CNA #35 asked her to relieve her sitting one-on-one (1:1) so she could take a break and, when she went into Resident #9's room, Resident #9 was crying and told her she pushed me. She stated CNA #35 told CNA #34 to sit in that chair and don't let him/her get up or touch anything. When asked if she made a statement to anyone from the facility, she stated, No, I've been waiting for someone to ask me about the incident; no one's asked me for a statement. In an interview with LPN #13 on 10/17/2023 at 7:55 PM she stated she felt she had signed an abuse policy for the facility but had just been told to sign something, and was not sure what the policy was specifically. She stated CNA #35 should probably have been removed from the facility earlier than she was. In an interview with Police Officer #1 on 10/17/2023 at 9:08 PM he stated the police were called over an hour after the incident occurred, and he responded to the facility on [DATE] at approximately 3:50 AM. He stated, based on his report, CNA #35 would be arrested and charged with Assault and Wanton Abuse. In an interview with the Social Services Director (SSD) on 10/18/2023 at 10:58 AM, she stated she was aware of the abuse allegation on 10/12/2023 when she arrived to the facility for her regularly scheduled work day (time punch on 10/12/2023 revealed she clocked in at 9:03 AM). She further stated she talked with the resident's son during the morning of 10/12/2023, and he was okay with the situation. However, there was no documented evidence to support her conversation with the son or that she talked with the resident. She stated she did not do a psychosocial assessment on Resident #9. In an interview with the Medical Director on 10/18/2023 at 7:35 PM, he stated he was not made aware of the situation with Resident #9 at any time. In an interview with the DON on 10/18/2023 at 9:32 AM, she stated, after hearing about the abuse allegation concerning Resident #9, she called CNA #35 and told her to leave the building, but she was not sure if CNA #35 was still sitting with Resident #9 at that time or not. She further stated the Social Services Director (SSD) should have followed up with a psychosocial assessment, but she was not sure if she had time as the resident discharged from the building later that day (10/12/2023). Additionally, she stated the incident was not discussed in the QAPI meeting on 10/13/2023 since it was an allegation and had not been thoroughly investigated at that time, and she was instructed by corporate to not discuss it on 10/13/2023. In an interview with Administrator #2 on 10/18/2023 at 10:18 AM, he stated the SSD did follow up assessments for psychosocial harm, and these should have been done throughout the shift on which the alleged abuse occurred and daily until the resident showed no signs of psychosocial harm. He further stated if the SSD was not available, other staff could assist with completing the psychosocial assessments. The Administrator stated he discussed the incident and abuse prevention in QAPI on 10/13/2023 in passing and that was why it was not listed on the QAPI minutes for 10/13/2023. However, he stated CNA #34, a witness to some of the events with Resident #9 on 10/12/2023, was not interviewed. The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were asked if they ever witnessed or heard of any abuse or mistreatment of residents. All interviews revealed no issues or concerns with potential abuse or mistreatment. 4. On 10/12/2023, Resident #9 had a second skin assessment completed by the Unit Manager. The skin assessment revealed no redness, bruising, or injury. 5. The DON and Assistant Director of Nursing (ADON) conducted a pain evaluation for Resident #9 on 10/12/2023, and the resident voiced no complaints of pain. The DON and ADON did not observe any behavior of pain by Resident #9. 6. The DON and ADON interviewed residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher on 10/12/2023 regarding any experience or recollection of potential mistreatment or abuse with no concerns found. 7. The DON and ADON performed a skin assessment on residents with a BIMS of seven (7) and below on 10/12/2023 with no signs of redness, bruising, or injury found. 8. The Chief Nursing Officer (CNO) from the consultant team reviewed and updated the Abuse Policy & Procedure on 10/19/2023 to ensure it included all required elements. 9. The CNO held an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 10/19/2023. Those in attendance included the Medical Director (MD), the DON, ADON, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator #1 and #2, Activity Director (AD), and the Regional Travel DON. The attendees reviewed the abuse allegation regarding Resident #9. The attendees considered the incident to be isolated and determined it was addressed appropriately. The CNO shared updates to the Abuse Policy with the attendees. 10. The Regional Director of Operations (RDO), on 10/13/2023, trained the administrative staff on the Abuse Policy, and knowledge was measured by a post-test which required one hundred percent (100%) of correct answers to pass. Administrative staff included the DON, ADON, Minimum Data Set (MDS) Coordinator #1 and #2, SSD, Activity Director (AD), and the Business Office Manager (BOM). 11. The Administrator, DON and ADON educated all facility staff members in all departments on abuse education beginning 10/12/2023 through 10/19/2023. The entire Abuse Policy was reviewed with an emphasis on ensuring resident safety and separating residents from the alleged perpetrator immediately. In addition, education included to immediately report concerns of abuse to the Administrator or an immediate supervisor who would immediately report the allegation to the Administrator. Any staff members who did not complete the education would be reeducated prior to returning to work. Education would be completed by the DON, ADON, Administrator, MDS Coordinator, or SSD. The Administrator would be responsible for overseeing the process. Any staff who failed to comply with the points of the in servicing would be further educated and/or progressively disciplined by their Department Manager or Administrator as indicated up to and including termination. 12. The CNO, on 10/19/2023, retrained the administrative staff on the Abuse Policy and QAPI requirements related to abuse. The retraining included what measures would be put into place and what systemic changes would be made to ensure the deficient practice did not reoccur. 13. All staff members received abuse training upon hire and at least annually. Knowledge and retention would be validated by a posttest and a 100 percent score was required to pass. The Administrator would be responsible for compliance. All contracted staff would receive abuse training prior to resident contact. Knowledge and retention would be validated by a posttest and a 100 percent score would be required to pass. The DON and ADON would complete and monitor this. 14. Department Managers/Administrative Staff conducted daily Guardian Angel Rounds until the Immediate Jeopardy (IJ) was removed. Once IJ was removed, the Guardian Angel Rounds would continue at least three to five (3-5) times per week. Staff would ask each resident if they were being treated appropriately by staff during Guardian Angel Rounds. All identified concerns would be shared at the Morning Meeting and followed up on by the Administrator, DON, ADON, or SSD. Morning meetings would occur seven (7) days a week until the IJ was removed. 15. An Ad-Hoc QAPI meeting would be held within twenty-four (24) hours of any abuse allegation to determine appropriate action and necessary follow-up, seven (7) days a week, and would include the Administrator, DON, and other Department Managers as appropriate. 16. The new facility Administrator began on 10/20/2023. The CNO and Chief Operating Officer (COO) of the consultant team would educate the new Administrator on the Abuse Policy, inform her of her responsibilities as the Abuse Coordinator, and her competency would be validated. The Administrator reports to the Governing Body. 17. The QAPI Committee, consisting of the Administrator, DON, ADON, SSD, and MD would oversee all facility processes related to abuse and neglect and determine whether more systemic actions were necessary. 18. The Administrator, DON, and ADON would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. 19. A member of the consultant team would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. This would be completed daily until the IJ was removed. The State Survey Agency (SSA) validated the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 10/21/2023 as follows: 1. Record review revealed Resident #9 discharged from the facility the morning of the incident. CNA #35 was suspended pending investigation. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she said she was told Certified Nursing Assistant (CNA) #35 exited the building, she assumed to smoke or something. The DON said she was told someone sat with Resident #9. The DON said once she talked to CNA #33 about the allegation of abuse, she called CNA #35 directly and made her leave the facility and made Licensed Practical Nurse (LPN) #13 aware. She stated there was little if any time in which CNA #35 was left alone with Resident #9. The DON further stated LPN #13 did not document Resident #9's skin assessment at the time of the alleged incident. She said the management team started skin assessments the morning of 10/12/2023. 2. Review of the Police Report, completed on 10/12/2023, revealed the police were contacted and arrived at the facility at 3:50 AM, and it was noted the incident took place at approximately 2:40 AM. 3. In an interview with the Activity Director (AD) on 10/21/2023 at 10:36 AM, she stated she was interviewed by the DON about the incident with Resident #9. She stated she had not witnessed any abuse and/or mistreatment of residents in the facility. In an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #6 on 10/21/2023 at 10:58 AM, she stated the DON interviewed her on topics of witnessing any type of abuse. She further stated she had not witnessed abuse. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she could not recall the last dates for abuse training, but she said after the incident with Resident #9, the DON provided reeducation with management. She stated management then did reeducation with the rest of the staff. In an interview with the Human Resources Director (HRD) on 10/21/2023 at 1:44 PM, she stated she was interviewed by the DON. She said she had not witnessed abuse or mistreatment in the facility. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she said she could not remember who talked to her about abuse, but she thought it was discussed in the morning meeting. She also said, in the morning meeting, education was provided about abuse. She further stated staff members were required to take a quiz and pass with a one-hundred (100) percent score. In an interview with the Social Services Director (SSD) on 10/21/2023 at 2:25 PM, she stated the DON interviewed her and asked her if she had witnessed any abuse in the facility. She stated she had not. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she stated, we interviewed all staff in the building about abuse and called everyone who was not in the building. She stated all staff reported they had not witnessed any abuse and had no new concerns to report. 4. Review of Resident #9's skin assessment, dated 10/12/2023, revealed no new injuries were present. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:35 PM, she stated LPN #13 was directed to complete the skin assessment the night of the alleged incident; however, she failed to document it. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated LPN #13 did not do a skin assessment for Resident #9 at the time of the incident. She reported management completed a skin assessment for Resident #9 upon arriving to the facility on [DATE] at approximately 8:30 AM, with no concerns noted. 5. Review of Resident #9's pain assessment form, completed on 10/12/2023 by the DON, revealed the resident was noted to be absent of signs or symptoms of pain related to the abuse allegation. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she had completed a pain assessment on Resident #9 and no complaints were voiced. 6. Review of interview sheets used by the facility on 10/12/2023, for interviews completed on sixteen (16) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher to determine if they felt safe, witnessed any type of abuse, and knew how and who to report concerns to, revealed no concerns. The interview form consisted of the following questions: a) Did they feel safe in the facility? b) Has anyone ever caused you any harm or made you feel afraid, embarrassed since you have been a resident here? c) Have you ever witnessed another resident being treated or spoken to in a manner you felt was unacceptable? and d) Do you know who to report to if you felt threatened, afraid, or spoken to, or treated in an unacceptable manner? Review of completed interview forms on 10/21/2023, revealed all sixteen (16) residents answered the questions appropriately and voiced no concerns. In an interview with Resident #37, on 10/21/2023 at 1:30 PM, he/she stated abuse was discussed with the residents in the Resident Council meetings and they met on the first of every month. The resident stated staff always treated him/her well. In an interview with Resident #39 on 10/21/2023 at 1:35 PM, he/she stated staff treated him/her well and provided good care. In an interview with Resident #38 and Resident #40 (husband and wife) on 10/21/2023 at 1:45 PM, they stated they received good care in the facility and did not have any concerns to report. In an interview with the Social Serviced Director (SSD) on 10/21/2023 at 2:25 PM, she stated the ADON, DON, and she had talked to residents in the facility who had a BIMS score of eight (8) and higher regarding abuse. She stated all interviews were documented on a facility interview sheet. She stated all the residents answered the questions appropriately, and no concerns were found. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated she, the SSD, and the DON went room to room and talked with interviewable residents about abuse. She stated no concerns were identified during the interviews. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated the ADON and the SSD went with her room to room and talked with all residents who had a BIMS score of eight (8) or higher about abuse. She stated all the residents were fine, and nobody had any concerns. 7. Review of sixty-one (61) resident Skin Assessment documents, dated 10/12/2023, revealed Licensed Practical Nurse (LPN) #6 and LPN #7 conducted skin assessments on residents with a BIMS score of seven (7) and lower. Further review of the documents revealed one (1) form was not checked off to show no new areas noted or of any new areas noted. In an interview with LPN/UM #6 on 10/21/2023 10:58 AM, she stated she signed a skin assessment form with the missing check mark. She stated she must have been sidetracked when completing it and recalled the resident did not have any new concerns. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she completed several head-to-toe assessments on residents with a BIMS score of seven (7) and under and found no concerns related to abuse. In an interview with the Assistant Director of Nursing (DON) on 10/21/2023 at 2:53 PM, and the DON on 10/21/2023 at 3:45 PM, they stated they had assisted in conducting the skin assessments of residents with a BIMS score of seven (7) and under. They stated the Unit Managers were also present, and they completed the paperwork. They further stated no new skin concerns were found. 8. Review of the Abuse Policy revealed it was revised to address the Quality Assurance and Performance Improvement (QAPI) changes from Quality Assurance (QA). In an interview with the Chief Nursing Officer (CNO) on 10/21/2023 at 3:11 PM, she stated the facility's previous Abuse Policy did not have the word Quality Assurance and Performance Improvement (QAPI) and was only identified as Quality Assurance (QA). The CNO stated that was a change in Phase 3 of the Federal Regulation roll out. She stated QAPI was added, and some of the policy was reorganized to make it easier to read. She stated the facility made the eight (8) different components more obvious. The CNO stated it was her expectation the facility would have an Ad-Hoc QAPI meeting within twenty-four (24) hours of any abuse allegation. 9. Review of the sign-in sheets for the Ad-Hoc meeting, dated 10/20/2023, revealed no evidence of a 10/19/2023 meeting, and attendees discussed the updated Abuse Policy and QAPI. Those noted as present were the In[TRUNCATED]