**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review it was determined that the facility failed to ensure an allegation of abuse was reported to the Administrator of the facility and the appropriate state agencies as required for one (1) of thirty-two (32) sampled residents (Resident #305). The findings include: Review of the facility policy and procedure titled Abuse Policy and Procedures, revised 09/25/17, revealed all alleged violations involving abuse or mistreatment of residents would be reported immediately, but no later than two hours after the allegation was made to the Administrator of the facility and to other State officials. Review of Resident #305's medical record revealed the facility admitted the resident on 04/17/18 with diagnoses including Lower Left Extremity Deep Vein Thrombosis, Atrial Fibrillation, Dementia, and Aspiration Pneumonia. Review of Resident #305's Minimum Data Set assessment dated [DATE] revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS). Staff assessment of Mental Status was performed and staff indicated that the resident had both short-term and long-term memory problems. Interview on 05/17/18 at 10:00 AM with Resident #305 revealed the resident was able to answer questions appropriately and stated that a couple of weeks ago a Certified Nursing Assistant (CNA) hurt him/her when providing care. Resident #305 stated the CNA was attempting to turn him/her and when she removed the blanket that the resident's left side was lying on, the resident stated she pulled it so hard that his/her left leg was jerked upward, almost touching my shoulder blade. The resident stated that he/she instructed the CNA to stop, telling her that it had hurt him/her. Resident #305 stated that the CNA replied to the resident that the resident needed to try and help be repositioned. Further interview with Resident #305 revealed he/she did not report the CNA's action to any facility staff until 05/14/18, at which time the resident reported the incident to the Nurse Manager. Interview on 05/17/18 at 10:49 AM with the Nurse Manager revealed that Resident #305's daughter reported the allegation to her on 05/14/18 at about 11:45 AM. The Nurse Manager stated she spoke with Resident #305 who told her that a CNA (name unknown, but gave a description matching CNA #3) had been rough with him/her during care. The resident stated that the CNA had pulled the cover out from under him/her which had hurt his/her leg. The Nurse Manager stated she took CNA #3 into her office and asked her about the allegation, and CNA #3 stated she did not remember the incident happening. The Nurse Manager stated she directed CNA #3 not to go back into Resident #305's room. The Nurse Manager then reported the allegation to the Director of Nursing (DON). However, the Nurse Manager stated she did not document the reported allegation. Interview on 05/17/18 at 11:45 AM with CNA #3 revealed she stated she did not remember being rough with Resident #305, and had provided care to the resident until 05/14/18, when the Unit Manager had questioned her about the incident and instructed her not to go back into Resident #305's room. Interview on 05/17/18 at 12:07 PM with the DON revealed that she was made aware of the incident on 05/14/18 at about 2:30 PM. The DON stated she did not initiate an investigation into the reported allegation when it was reported to her because she was informed that CNA #3 had been instructed by the Unit Manager not to go back into Resident #305's room. However, the DON stated she was aware that CNA #3 was continuing to care for other facility residents. Interview on 05/17/18 at 4:41 PM with the Social Services employee, who is designated as the investigator for abuse allegations, revealed that she was not notified of the allegation made by Resident #305 until 05/17/18, at which time she initiated an investigation. Interview on 05/17/18 at 7:13 PM with the Administrator revealed he had not been informed of the allegation made by Resident #305 until 05/17/18, at which time an investigation was initiated and CNA #3 was suspended pending the outcome of the investigation.

**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 immediately initiate an investigation of an allegation of physical abuse for one (1) of thirty-two (32) sampled residents (Resident #305), and failed to protect further potential abuse while the investigation was in progress. The findings include: Review of the facility policy and procedure entitled Abuse Policy and Procedures, revised 09/25/17, revealed all alleged violations involving abuse would be thoroughly investigated immediately, and in order to protect residents from further potential abuse employees of the facility who have been accused of resident abuse will be placed on leave pending the outcome of the investigation. Review of the Medical Record for Resident #305 revealed the facility admitted the resident on 04/17/18 with diagnoses including Left Extremity Deep Vein Thrombosis, Atrial Fibrillation, Dementia, and Aspiration Pneumonia. Review of Resident #305's Minimum Data Set assessment dated [DATE], revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS). Staff assessment of Mental Status was performed and staff indicated that the resident had both short-term and long-term memory problems. Interview on 05/17/18 at 10:00 AM with Resident #305 revealed the resident was able to answer all questions appropriately. The resident stated he/she had reported an allegation of abuse to the Nurse Manager on 05/14/18. Resident #305 stated that a Certified Nursing Assistant (CNA) (identified by the facility as CNA #3) had been rough with him/her while providing care a couple of weeks ago (exact date unknown). Interview on 05/17/18 at 10:49 AM with the Nurse Manager confirmed that Resident #305 had reported to her on 05/14/18, that a CNA matching the description of CNA #3 had been rough with him/her while providing care. The Nurse Manager stated she spoke with CNA #3 on 05/14/18, who denied the allegation. The Nurse Manager stated she instructed CNA #3 to not go back into Resident #305's room, but allowed the CNA to continue to care for other facility residents. The Nurse Manager stated she reported the allegation of abuse to the Director of Nursing (DON) on 05/14/18. Interview on 05/17/18 at 12:07 PM with the DON confirmed that she had been notified by the Nurse Manager on 05/14/18, that Resident #305 had made an allegation of abuse against CNA #3, and that the Nurse Manager had informed her that she had instructed CNA #3 not to provide care to Resident #305. However, the DON failed to initiate an investigation into the allegation, failed to protect residents from further potential abuse by allowing CNA #3 to continue to provide care to other residents, and failed to notify Social Services of the allegation. Interview with the Social Services employee on 05/17/18 at 4:41 PM, revealed she was designated as the facility investigator for allegations involving abuse. However, the Social Services employee stated she had failed to initiate an abuse investigation related to the allegations made by Resident #305 on 05/14/18, because she was not notified of the abuse allegation until 05/17/18. The Social Services employee stated at that time an abuse investigation was initiated. Interview on 05/17/18 at 7:13 PM with the Administrator revealed that he was not notified of the allegation of abuse made by Resident #305 on 05/14/18 until 05/17/18. The Administrator stated at that time an investigation was initiated and CNA #3 was suspended from the facility pending the outcome of the investigation, to protect other residents from potential abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the facility policy it was determined the facility failed to implement the comprehensive plan of care for one (1) of thirty-two (32) sampled residents. Review of Resident #59's comprehensive care plan revealed the resident required a splint to the right hand. However, observations of Resident #59 revealed the resident was not wearing the splint as required. The findings include: Review of the facility policy, Care Plans-Comprehensive, Med-Pass, revised September 2010, revealed the comprehensive care plan would be utilized by staff as a reference for daily resident care, as well as a tool for relaying each resident's personal preferences and routine. Review of the medical record revealed the facility admitted Resident #59 to the facility on [DATE] with diagnoses of Hypertension, Peripheral Vascular Disease, Benign Prostatic Hypertrophy, Dementia, Anxiety Disorder, Depression, and Chronic Obstructive Pulmonary Disease. Review of Resident #59's Minimum Data Set (MDS) significant change assessment, dated 03/29/18, revealed the facility assessed the resident to be severely cognitively impaired. The MDS also revealed Resident #59 was totally dependent on staff for all activities of daily living (ADLs) and required two (2) or more staff persons to complete all ADL care. Review of an Occupational Therapy (OT) Progress and Discharge Summary for Resident #59, dated 03/01/18, revealed OT had performed passive stretch exercises to the resident's right hand since 02/27/18 for preparation to initiate a right hand splint for the resident. Further review of the discharge summary revealed Resident #59 was discharged to nursing staff with a splinting schedule established for nursing staff to follow. Review of Resident #59's comprehensive plan of care, dated 03/29/18, revealed staff would ensure that the resident utilized a right resting hand splint, which was to be applied for two hours and then removed for two hours alternately throughout the daytime hours. Observation of Resident #59 on 05/16/18 at 10:33 AM, found the resident lying on the right side, both hands were clinched/contracted, with no splint applied. Continued observation of Resident #59 on 05/16/18 at 1:21 PM, revealed the resident was observed to have no hand splint in place. Observation of Resident #59 on 05/17/18 at 9:22 AM, revealed the resident lying on the left side with the head of the bed elevated 45 degrees. No splints were observed to be applied. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for May 2018 revealed the records did not reflect that the resident had the hand splint applied as ordered. Interview with State Registered Nurse Aide (SRNA) #1 on 05/17/18 at 9:28 AM, revealed she checked the plan of care for her assigned residents daily, but had not applied the resident's hand splint on 05/17/18 as required. Interview with Licensed Practical Nurse (LPN) #1 on 05/16/18 at 4:18 PM, revealed she did not recall the resident having splints ordered and did not recall ever seeing splints on the resident. LPN #1 checked the MAR and TAR for May 2018 and stated that it was not on those records for them to check to make sure the splints were on/off as ordered. She also stated it was the responsibility of the nurse assigned to the resident to monitor and ensure that care was being provided for residents as dictated by the plan of care. Interview with LPN #2 on 05/16/18 at 4:18 PM, revealed she was also unaware that Resident #59 was required to utilize a hand splint. Interview with the Director of Nursing (DON) on 05/17/18 at 7:24 PM, revealed it was the nurse aide's responsibility to place the splints on and off the residents, but the nurse had to sign off to ensure it had been done. The DON confirmed that for the month of May 2018 there was no documentation on Resident #59's MAR/TAR to alert the nurse to check and ensure the splint was applied as required.