**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #5, the facility staff failed to implement their abuse policy when an injury of unknown source was identified on 01/12/2021. Resident #5, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses for Resident #5 included but were not limited to atherosclerosis and peripheral vascular disease. Resident #5's most recent Minimum Data Set with an Assessment Reference Date of 01/06/2021 was coded as an annual assessment. The Brief Interview for Mental Status was coded as 99 meaning unable to complete the interview. Cognitive Skills for Daily Decision Making were coded as moderately impaired. Short-term and Long-term memories were coded as memory problem. Functional status for bed mobility and transfers were coded as requiring extensive assistance from staff. On 02/11/2021 at approximately 8:45 A.M., the clinical record was reviewed. A nurse's note dated 01/12/2021 at 6:46 A.M. documented, Note Text: cna reported to writer that she noted discoloration to right hand between 2nd and 3rd fingers, denies pain will continue to monitor the area. The subsequent nurse's notes through 01/18/2021 at 2:26 P.M. were reviewed and the injury of unknown origin to the right hand was not addressed. A nursing skin assessment dated [DATE] at 4:03 P.M. did not document a skin issue on the right hand as indicated in the nurse's note dated 01/12/2021. On 02/12/2021 at approximately 9:20 A.M., a copy of the facility-reported incident and the investigation documentation associated with this injury of unknown origin to the right hand were requested. On 02/12/2021 at approximately 11:15 A.M., an interview with the Director of Nursing was conducted. When asked about a facility-reported incident and the investigation documentation associated with this injury of unknown origin, the Director of Nursing stated that it was not reported investigated or reported to the state agency. The Director of Nursing stated the staff were re-educated and a facility-reported incident will be sent to the state agency. When asked about expectation from staff when an injury of unknown origin is discovered, the Director of Nursing stated the expectation is that the nurse report it as soon as possible so we can send in a FRI [facility-reported incident] and begin the investigation. The Director of Nursing also stated the expectation includes assessing and interviewing residents and staff associated with the injury and notify all the proper people and the doctor. The facility staff provided a copy of their policy entitled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property. In Section E entitled, Investigation under the header Abuse Policy Requirements, it was documented, It is the policy of the Home that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. In Section E, Part 2 and subpart (a), it was documented, Investigation of injuries of Unknown Origin or Suspicious injuries: must be immediately investigated to rule out abuse: (a) Injuries include but are not limited to, bruising of the inner thigh, chest, face, and breast, bruises of an unusual size, multiple unexplained bruises, and/or bruising in an area not typically vulnerable to trauma. In Section G entitled, Reporting and Response under the header, Abuse Policy Requirements, an excerpt documented, It is the policy of this Home that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of Resident property) are reported per Federal and State law. In summary, Resident #5 had an injury of unknown source to her right hand between the 2nd and 3rd fingers (identified on 01/12/2021) and the facility staff failed to implement their abuse policy to report and investigate the matter. On 02/12/2021 at approximately 1:45 P.M., the administrator and Director of Nursing were notified of findings. Based on interview, clinical record review and facility documentation the facility staff failed to implement policies and procedures related to abuse and neglect for 3 Residents (#15, #13, and #5), in a survey sample of 17 Residents. Immediate Jeopardy was called on 2/10/21 at 3:26 P.M. related to Residents #15 and #13. It was abated on 2/12/21 at 5:30 P.M. After Immediate Jeopardy was removed, the deficiency was assigned a Scope and Severity of level 2, isolated. The findings included: 1. For Resident #15, the facility did not implement facility policies and procedures by allowing LPN A to continue to work with Resident #15 after being accused of abusing Resident #15 and written up for Intimidating a Resident [#15] Resident #15 an [AGE] year old woman, was admitted to the facility on [DATE] with diagnoses of but not limited to dementia without behavioral disturbance, anemia, chronic kidney disease, anxiety, major depressive disorder, falls, and atherosclerotic heart disease. Resident #15's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/21/20, an quarterly assessment, coded Resident #15 as having a BIMS (brief interview of mental status) score of 10 out of a possible 15. This score indicates moderate cognitive impairment. The MDS codes the resident as needing extensive assistance with physical assistance of 1 person for toileting, hygiene, dressing and bed mobility. She requires limited assistance with physical assistance of 1 person for walking in room, and transfers. She requires supervision for eating meals. The Resident uses a walker to aid in mobility. On 2/9/21 approximately 1:00 PM Resident #15 was asked about abuse and neglect in the facility, she stated There was one aide that wasn't nice but I told her to leave. She hasn't been around lately. On 2/10/20 during clinical record review it was discovered that the following entry was made in the progress notes: 1/1/21 at 9:18 PM - At 430 PM [Resident #15 name redacted] came out from her room and was ambulating with her rollator. She passed by the nurse's station and stated 'Someone banged my face and head in the bars this morning.' Writer asked if she can recall the name of the person and she stated 'I don't know.' On 2/10/21 at 11:41 an interview was conducted with the DON and the Administrator who was asked about an incident involving Resident #15 and LPN A. The Administrator stated it happened when she was out sick. She stated that The DON called me at home. When asked what day she was notified she stated she wasn't sure. She also stated 2 CNA's that work night shift reported the incident. When asked who they reported it to she stated They called me at home. I told the DON to do the investigation. The Administrator submitted a Corrective Action Plan for LPN A excerpts are as follows: Employee Name: [redacted] Department: Nursing Date: 1/28/21 Date of Occurrence: 1/1/21 Location: Nursing Time: 11 pm -7 am Action Taken: Written Counseling Description of Issue: [box checked] Policy Violation [box checked] other: Mental Intimidation. Explanation: It was reported to Acting DON by Administrator on 1/6/21 of an incident involving resident # [medical record number redacted] on the morning of 1/1/21. The report stated that Resident was refusing care which was reported to the Charge Nurse, [LPN A name redacted]. At that time, Charge Nurse and CNA both went in to care for Resident. Per report, Resident continued to be resistant to care and Charge Nurse began to pull down Residents clothes while Resident was in bed and was speaking to Resident in a loud and uncalm voice. When Charge Nurse was pulling Resident's clothes off, the bed was unlocked on one side and began to move with the headboard hitting the wall. Charge Nurse locked the bed and continued pulling clothes off, kicking the soiled depends and clothing on the floor at which time she was bumping or hitting the walker and rocking chair with her feet which in turn was hitting the wall and the furniture in the Resident's room. Resident yelled at Charge Nurse to stop and Charge Nurse responded that they were there to help her and she was fighting them and telling them that they were hitting her furniture. Charge Nurse then stated This is how we hit furniture and grabbed the walker or the rocking chair and was hitting it against the wall or the china dresser. CNA approached the Resident and took over washing her up and changing her clothes and Charge Nurse exited the room, however she was still talking to the Resident in a loud and Unocal manner. Per CNA, Resident at this time was reported to be shaking and walked outside of her room and sat in recliner on the unit. Another staff member came to see what all the loud voices was about and to see if everything was okay. The Charge Nurse said everything was Okay. On the night of 1/2/21 staff reported that when they knocked on the Resident's door, Resident jumped, seemed scared and was shaking. She reported to the staff that 'the black woman with the round thing on her head' came into her room and kept hitting her head on the wall. At a later time that same night Resident reported the same thing and also said ' I think it was T, (which is what she calls the Charge Nurse), but why would she do that?' At a later time, a staff member stated that Resident approached her and stated the night nurse [name redacted], who wears that knot on her head, hit her in the arm and the head. The staff member asked when that happened and was told it happened a few nights ago and that the nurse was hitting and kicking her bed and throwing her chair around. Staff also reports that Resident has been telling other people who will listen to her, including her family, that she was hit and kicked by the night nurse, [name redacted], and that she did not want to stay at [facility name redacted] anymore because she might be killed. It was noted that the Corrective Action Plan had not been signed by the DON or the LPN. The DON was asked about why the document had not been signed and she stated The LPN has been out of the facility on Administrative Leave. When asked was that due to this incident she stated, Yes I believe so. On 2/10/21 a review of the time clock punches for LPN A revealed that LPN A continued to work on the very same unit with the Resident until 2/1/21. On this date she was written up for Sleeping on the job. On 2/10/21 at approximately 3:00 PM an interview was conducted with the Administrator and she was asked if the LPN A was still an employee there and she stated that she is supposed to come in on Thursday (2/11/21) to sign the corrective action plan. The Administrator was then asked to provide the survey team with the entire investigation including witness statements. The witness statement from CNA C was reviewed and an excerpt is as follows: 1/14/21 - The incident started when I was cleaning and sanitizing the shower room, when I heard people screaming and yelling, so I immediately ran out and saw the nurse [LPN name redacted] standing at the opening of room [ROOM NUMBER], which is [Resident #15 name redacted] room. The nurse was leaning on the resident's door and the resident was standing inside with her walker extended out in front of the nurse and her aide [CNA name redacted] behind her. I asked them was everything okay and the nurse said yes. When I was emptying my soiled linen cart the resident came to me and said the night nurse, [name redacted], who wear that knot on her head, hit her in the arm and head. I asked her when did this happen she said a few nights ago & the nurse was hitting and kicking her bed and throwing her chair around. I reported this to [Administrator name redacted] and she said she will report it to [DON name redacted] to investigate it, as time went by almost 2 weeks, I heard nothing, so I then called Mother and she stated she had heard something about it and she will look into it better. I wasn't sure if anyone was looking into the matter. [Resident #15 name redacted] was telling anyone including her family, who will listen to her, that she was hit and kicked by the night nurse, and that she didn't want to stay at [facility name redacted] anymore because she might be killed. A review of the Abuse and Neglect Policy read: Page 9 Paragraph F Protection Abuse Policy Requirements: It is the policy of this HOME that the resident(s) will be protected from the alleged offender(s). Procedure: Immediately upon receiving a report of alleged abuse, the Administrator, and / or designee will coordinate delivery of appropriate medical and or psychological care and attention. Ensuring safety and wellbeing for the vulnerable individual are of utmost priority. Safety, security and support of the Resident, their roommate, if applicable and other Residents with the potential to be affected will be provided. This should include as appropriate: 1. Procedures must be in place to provide the Resident with a safe, protected environment during the investigation. a. The alleged perpetrator will immediately be removed and the Resident protected. Employees accused of alleged abuse will be immediately removed from the Home and will remain removed pending the results of a thorough investigation. (Decision of the extent of immediate disciplinary action will be made by the Administrator and/or designee). 2. For Resident #13 LPN B failed to implement facility policies and procedures by not immediately reporting an allegation of abuse. Resident # 13 a [AGE] year old woman, was admitted to the facility on [DATE], with diagnoses of but not limited to hypertension, malignant neoplasm of pancreas, diabetes, UTI, prosthetic heart valve, and age related macular degeneration. Resident #13's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/4/20, an annual assessment, coded Resident #13 as having a BIMS (brief interview of mental status) score of 14 out of a possible 15. This score indicates no cognitive impairment. The MDS codes the resident as needing extensive assistance with all aspects of ADL care with the exception of eating. Resident #13 is able to feed herself with only supervision. The Resident uses a walker for aid in short distance mobility and a wheelchair for longer distances. On 2/10/21 at approximately 10:00 AM Surveyor C reported the following observation. At 9:20 AM Resident #13 was in wheel chair next to the medication cart. Resident #13 stated Somebody kicked me. LPN C asked Who kicked you? Resident replied I don't know. LPN C assisted the Resident to lift her right pant leg to reveal a dressing on right shin. LPN C then stated to the resident No one kicked you and went on to tell Resident that she had a dressing on her shin from a skin tear. Another staff member then approached Resident and rolled her down the hall in wheel chair. At 10:40 AM, Surveyor B interviewed Resident #13 after she returned from physical therapy. The Resident was asked about the injury to her right shin and she stated Somebody kicked me, I don't remember who. When asked about abuse or neglect she stated I cannot stand that nurse from last night we had a fight. When asked what happened she stated I can't stand her she is rude and she just would not leave me alone, so we got into a fight. She is not a good nurse and she drops stuff and then picks it up off the floor and gives it to you. That's not sanitary or wise these days. She has no patience. I was kicking at her to get her to leave me alone. They know I don't like her and don't want her in my room. On 2/10/21 a review of the clinical record revealed the following progress note: 2/10/21 at 12:59 AM - Resident call bell was on, and staff went to answer the call bell, resident stated she want to go to BR, staff got resident up in the w/c and assisted resident to the bathroom and while assisting resident back to bed she refused to allow staff to apply pillow under her legs and was insisting on keeping her legs outside the bed sa [sic] staff was assisting to put the legs back to bed resident became physically aggressive and started kicking and swinging at staff was verbally aabusive [sic] and told staff she hate her, redirected and assured resident that staff is here to help and to assure her safety. On 2/10/21 at approximately 10:58 AM an interview was conducted with the Administrator who was asked if she was aware of an allegation of abuse by Resident #13. She stated that she had not heard of this but would start an investigation. Immediate Jeopardy was called on 2/10/21 at 3:26 PM, and the Administrator was notified. Immediate Jeopardy Abatement Plan is as follows: All staff on evening shift, 3pm-11pm, for 2/10/21 will be in -serviced on Resident Rights and Abuse and Neglect on 2/10/21. Staff for night shift, 11pm -7 am, will be in serviced before their shift on 2/10/21. Dayshift staff will be in-serviced before their shift on 2/11/21. There will be a mandatory all staff meeting on 2/11/21 at 12 noon for training on Resident's Rights and Abuse and Neglect. All afore-mentioned staff will be provided a copy of the homes policy regarding Resident Rights and Abuse and Neglect at the time of the meeting. All other staff will be trained over the phone or in person before working with residents. LPN B has been removed from schedule and statement requested from this person regarding incident with Resident #13 on 2/10/21. Per policy, LPN B will remain removed pending the results of a thorough investigation and disciplinary action will be made by the Administrator. LPN C has been called for a statement about her conversation with Resident #13 this morning 2/10/21. She has provided documentation of the incident with Resident #13 on 2/10/21. Interviewing every Nursing Resident (24 total) to determine if any abuse, neglect, or resident rights violations have occurred. This has been completed by 2/10/21 by 445 pm. Body checks will be completed by 10 AM on 2/11/21 for cognitively impaired residents. The Abatement Plan will be completed by 4PM on 2/11/21 The survey team verified education in service sheet checks, interviews, and completed skin assessments were reviewed. The Immediate Jeopardy was removed on 2/12/21 at 5:30 PM.