Ruleville Community Care Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to resolve a grievance submitted by a resident who reported that a CNA caused pain by jerking his legs during repositioning, which hurt his back. The resident stated he reported the incident to staff, but no one followed up with him regarding the complaint. The DON confirmed that a grievance form was completed on behalf of the resident, but the form was not signed by the resident, and there was no documentation indicating that the grievance had been resolved or discussed with the resident. The grievance log listed the complaint as resolved, but there was no evidence of communication with the resident or proper closure of the grievance. Social Services staff confirmed that grievances should be discussed with and signed by residents before being considered resolved.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all alleged abuse violations were reported to the State Survey Agency as required by its own policy. The policy mandates immediate reporting of alleged abuse, neglect, or theft to the administrator and appropriate authorities, including the State Survey Agency, within specified timeframes. However, for three of five reviewed cases involving alleged abuse, the facility did not report the incidents as required. In one instance, a resident with a history of major depressive disorder, anxiety, pain, and cerebral palsy reported that a CNA told her to "shut up" when she complained of leg pain during repositioning. The resident reported the incident to the former administrator, who initiated an internal investigation but did not report the allegation to the State Survey Agency, believing it did not constitute abuse. In another case, a cognitively intact resident with paraplegia reported that two CNAs hurt him during care, including being jerked and slapped with a wet towel. The resident stated that no one followed up with him about his complaint, although the CNAs were removed from his care. A third resident, also cognitively intact and with diagnoses including anxiety, pain, and hemiplegia, reported to the DON that a CNA hurt him during care and spoke to him inappropriately. The DON acknowledged receiving the complaint but considered it a customer service issue and did not report it to the state. In all three cases, the facility failed to follow its policy for reporting alleged abuse to the State Survey Agency, as confirmed by interviews with staff and review of facility records.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to investigate allegations of abuse for two of five residents reviewed, as required by its own policy. One resident reported to staff that two CNAs had hurt him while turning him, and also reported to the administrator that another CNA had slapped his face with a wet towel during a bed bath. The resident stated that after making these reports, the CNAs involved no longer worked with him, but no one from the facility had followed up or interviewed him about the incidents. Another resident reported that a CNA attempted to turn him alone, causing pain, and sometimes spoke to him in an unkind manner. He reported this to the DON, after which the CNA was removed from his care, but again, no investigation or follow-up interview was conducted. Interviews with the DON confirmed awareness of the complaints and that the CNAs were removed from providing care to the residents involved, but no formal investigation was initiated because the DON considered the issues to be customer service concerns rather than abuse. The DON also admitted that an investigation should have been conducted, especially after one resident was sent to the emergency room for back pain following his complaint. The facility's policy requires immediate investigation of any potential abuse or neglect, but this was not followed in these cases. Both residents involved had significant medical histories, including paraplegia and hemiplegia, and were cognitively intact at the time of the incidents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent a resident from being physically restrained with a sheet tied to a wheelchair, without obtaining physician orders, consent, or conducting an assessment for the need of restraints. The incident involved a resident who was observed with a sheet tied around her waist and knotted behind the wheelchair. Several Certified Nursing Assistants (CNAs) reported seeing the resident restrained in this manner, and one CNA reported the situation to a Licensed Practical Nurse (LPN), who allegedly stated it was for the resident's safety. However, the LPN later denied any knowledge of the restraint or instructing staff to use it. The facility's policy, in accordance with the Omnibus Budget Reconciliation Act (OBRA) requirements, states that all residents have the right to be unrestrained, and restraints should only be used as a last resort with proper evaluation and physician orders. Despite this, the facility did not have any physician's orders, consents, or assessments for the use of a mattress with elevated sides and foam wedges that were also in place for the resident. The Director of Nursing (DON) confirmed that an investigation was conducted, but they were unable to determine who applied the restraint. The DON believed the restraint was used for the resident's safety due to recent combative behavior and sliding in the wheelchair. The resident involved had been admitted to the facility with diagnoses including Dementia and Impulse Disorder. The facility's Daily Care Guide for the resident did not list any interventions for the use of foam wedges, and there were no physician's orders for the mattress with elevated sides or wedges. The Unit Manager emphasized that restraints should never be applied without assessment, physician orders, and family consent, as they pose a risk of injury, such as sliding and choking.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of mistreatment involving a resident who was physically restrained with a sheet tied to a wheelchair. The incident involved a resident with diagnoses of Dementia and Impulse Disorder, who was dependent on a wheelchair for locomotion. On 6/9/24, four CNAs observed the resident restrained with a sheet tied around the wheelchair. One CNA reported seeing the resident restrained twice on the same day, with a co-worker indicating that a nurse had instructed not to remove the sheet for the resident's safety. The Director of Nursing (DON) was informed of the incident on 6/10/24 and conducted an investigation. Despite the findings, the facility did not report the incident to the State Agency, as the DON believed it was done for the resident's safety due to her behaviors and falls. The facility was unable to determine who restrained the resident. The Administrator later agreed that using a sheet to restrain the resident was inappropriate and should have been reported as mistreatment.

Penalty

Inspection fine: $79,15923 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from neglect, resulting in a tragic incident where one resident died after another resident, who was severely obese and had a history of delusional behavior, lay on top of him. The facility did not identify roommate incompatibility or provide appropriate person-centered behavioral interventions, which placed the deceased resident and others at risk. The incident occurred after the staff responded to a call light and found the obese resident unclothed and lying on top of the deceased resident, who was unresponsive and later pronounced dead. Prior to the incident, there were multiple occasions where the obese resident was found in bed with other residents, including a deaf and mute resident, but these incidents were not thoroughly investigated or addressed by the facility. Staff interviews revealed that the obese resident had a history of delusional episodes and had been observed inappropriately in bed with roommates on previous occasions. Despite these warning signs, the facility did not implement increased monitoring or update the resident's care plan to prevent further incidents. The facility's neglect to address the behavioral issues and roommate incompatibility of the obese resident led to a situation where other residents were at risk of harm. The staff failed to recognize the potential for abuse and did not take necessary actions to protect vulnerable residents, resulting in the death of one resident and placing others in jeopardy.

Removal Plan

• Resident #1 was placed on one-on-one supervision immediately. Psychiatric placement was initiated but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner. Resident #1 remained on one-on-one supervision until he was discharged to the custody of the local police department.
• The Administrator presented to the facility and initiated an investigation with assigned licensed nurses and certified nursing assistants.
• The Administrator notified the MS State Department of Health, Attorney General Office, and Ombudsman.
• An in-service was initiated for all staff regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors.
• A special resident council meeting was conducted by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility.
• The social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates.
• An in-service was initiated by the President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining one-on-one supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses was instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received.
• The President of Operations in serviced the Administrator and Director of Nurses on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies.
• The President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored.
• An interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns.
• A 100% audit was initiated by the social services department to ensure that all Residents had compatible roommates. No issues identified.
• A 100% audit was conducted by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place.
• The Administrator reported the incident involving Resident #1 and Resident #3 to the Mississippi State Department of Health.
• An emergency quality assurance committee met. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional President. The facility discussed the current survey IJ outcomes. 5 IJ were cited for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident #1 had previous behavioral issues with Resident #3. Resident #1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified to include protecting residents from others who get into their beds by intervening and providing one-on-one supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required.
• The Ombudsman was notified of the incident.
• The Administrator reported the incident involving Resident #1 and Resident #3 to the Attorney General Office online system.

Penalty

Inspection fine: $79,15923 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise a comprehensive care plan for a resident known to exhibit behaviors of getting into bed with other residents. This failure resulted in staff not having access to preventative measures to deter such behavior. On one occasion, the resident was found in bed on top of another resident, who was unresponsive and later pronounced dead. This incident placed all residents at risk and was likely to cause serious injury, harm, impairment, or death. The care plan for the resident in question did not include revisions to address the behavior of getting into other residents' beds, despite previous incidents being documented. Staff interviews revealed that the care plan was not updated to reflect these behaviors, and no increased monitoring or interventions were put in place. The resident had a history of delusional, aggressive, and socially inappropriate behavior, and was severely cognitively impaired, which further necessitated the need for a revised care plan. Interviews with facility staff, including the Social Service worker and the Director of Nurses, confirmed that the care plan should have been updated to include one-on-one observation and increased monitoring. The failure to update the care plan and implement necessary interventions left other residents vulnerable to harm, as the resident was ambulatory and could have entered any resident's bed, posing a risk of accidental harm or abuse.

Removal Plan

• Resident #1 was placed on one-on-one supervision immediately. Psychiatric placement was initiated but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner. Resident #1 remained on one-on-one supervision until he was discharged to the custody of the local police department.
• The Administrator presented to the facility and initiated an investigation with assigned licensed nurses and certified nursing assistants.
• The Administrator notified the MS State Department of Health, Attorney General Office, and Ombudsman.
• An in-service was initiated for all staff regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors.
• A special resident council meeting was conducted by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility.
• The social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates.
• An in-service was initiated by the President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining one-on-one supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses were instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received.
• The President of Operations in serviced the Administrator and Director of Nurses on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies.
• The President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored.
• An interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns.
• A 100% audit was initiated by the social services department to ensure that all Residents had compatible roommates. No issues identified.
• A 100% audit was conducted by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place.
• The Administrator reported the incident involving Resident #1 and Resident #3 to the MS State Department of Health.
• An emergency quality assurance committee met. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional President. The facility discussed the current survey IJ outcomes. 5 IJ cites for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident #1 had previous behavioral issues with Resident #3. Resident #1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified to include protecting residents from others who get into their beds by intervening and providing one-on-one supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required.
• The Ombudsman was notified of the incident.
• The Administrator reported the incident involving Resident #1 and Resident #3 to the Attorney General Office online system.

Penalty

Inspection fine: $79,15923 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision and monitoring for residents with behavioral needs, leading to a tragic incident involving two residents. Resident #1, who was severely cognitively impaired and had a history of behavioral issues, was found unclothed and lying on top of Resident #2, resulting in Resident #2's death. Prior to this incident, Resident #1 had been observed in bed with another resident, Resident #3, but no increased monitoring or interventions were implemented despite the potential risk. The facility's records indicate that Resident #1 had been admitted with diagnoses including unspecified mood affective disorder, unspecified psychosis, and anxiety disorder. Despite these conditions and previous incidents of inappropriate behavior, such as getting into bed with other residents, the facility did not update Resident #1's care plan or increase supervision. Staff interviews revealed that the potential for harm was not recognized, and no actions were taken to prevent further incidents. The lack of appropriate interventions and monitoring placed all residents at risk, particularly those who were vulnerable, such as Resident #3, who was deaf and mute. The facility's failure to act on previous incidents and the absence of a proactive approach to managing Resident #1's behaviors directly contributed to the fatal incident involving Resident #2.

Removal Plan

• Resident #1 was placed on one-on-one supervision immediately. Psychiatric placement was initiated but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner. Resident #1 remained on one-on-one supervision until he was discharged to the custody of the local police department.
• The Administrator presented to the facility and initiated an investigation with assigned licensed nurses and certified nursing assistants.
• The Administrator notified the MS State Department of Health, Attorney General Office, and Ombudsman.
• An in-service was initiated for all staff regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors.
• A special resident council meeting was conducted by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility.
• The social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates.
• An in-service was initiated by the President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining one-on-one supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses was instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received.
• The President of Operations in serviced the Administrator and Director of Nurses on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies.
• The President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored.
• An interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns.
• A 100% audit was initiated by the social services department to ensure that all Residents had compatible roommates. No issues identified.
• A 100% audit was conducted by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place.
• The Administrator reported the incident involving Resident #1 and Resident #3 to the MS State Department of Health.
• An emergency quality assurance committee met. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional President. The facility discussed the current survey IJ outcomes. 5 IJ cites for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident #1 had previous behavioral issues with Resident #3. Resident #1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified to include protecting residents from others who get into their beds by intervening and providing one-on-one supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required.
• The Ombudsman was notified of the incident by the Administrator.
• The Administrator reported the incident involving Resident #1 and Resident #3 to the Attorney General Office online system.

Penalty

Inspection fine: $79,15923 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to recognize and appropriately address the behaviors of a resident diagnosed with mental disorders, leading to a tragic incident. The resident, who was admitted with diagnoses including Unspecified Mood Affective Disorder, Unspecified Psychosis, and Anxiety Disorder, exhibited behaviors such as physical aggression, verbal aggression, delusions, and inappropriate social interactions. Despite these documented behaviors, the facility did not implement adequate monitoring or interventions, resulting in the resident being found unclothed and lying on top of another resident, who subsequently died. Prior to the incident, there were multiple occasions where the resident was found inappropriately in bed with other residents, yet the facility did not increase monitoring or update the care plan to address these behaviors. Staff interviews revealed that the resident was not placed on special monitoring before the incident, and there was a lack of documentation and follow-up on the resident's behavior. The facility's failure to act on these warning signs and implement person-centered behavioral interventions contributed to the incident. The State Agency identified Immediate Jeopardy and Substandard Quality of Care due to the facility's inaction, which placed other residents at risk. The facility's policies on behavior management and monitoring were not effectively followed, leading to a failure in providing a safe environment for all residents. The lack of appropriate supervision and intervention for the resident's behaviors ultimately resulted in the death of another resident, highlighting significant deficiencies in the facility's care practices.

Removal Plan

• Resident #1 was placed on one-on-one supervision immediately. Psychiatric placement was initiated but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner. Resident #1 remained on one-on-one supervision until he was discharged to the custody of the local police department.
• The Administrator presented to the facility and initiated an investigation with assigned licensed nurses and certified nursing assistants.
• The Administrator notified the MS State Department of Health, Attorney General Office, and Ombudsman.
• An in-service was initiated for all staff regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors.
• A special resident council meeting was conducted by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility.
• The social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates.
• An in-service was initiated by the President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining 1-on-1 supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses was instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received.
• The President of Operations in serviced the Administrator and Director of Nurses on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies.
• The President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored.
• An interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns.
• A 100% audit was initiated by the social services department to ensure that all Residents had compatible roommates. No issues identified.
• A 100% audit was conducted by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place.
• The Administrator reported the incident involving Resident #1 and Resident #3 to the MS State Department of Health.
• An emergency quality assurance committee met. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional President. The facility discussed the current survey IJ outcomes. 5 IJ cites for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident #1 had previous behavioral issues with Resident #3. Resident #1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified to include protecting residents from others who get into their beds by intervening and providing 1-on-1 supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required.
• The Ombudsman was notified of the incident.
• The Administrator reported the incident involving Resident #1 and Resident #3 to the Attorney General Office online system.