| 60 |
MERRY WOOD LODGE |
15019 |
P O BOX 130 |
ELMORE |
AL |
36025 |
2019-03-02 |
607 |
K |
1 |
0 |
KDKT11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, medical record review and review of the facility's policy titled OPS300 Abuse ProhibitionAbuse Policy, the facility failed to: 1) intervene and correct situations to prevent further abuse (Prevention); 2) ensure a Licensed Practical Nurse (LPN) and the Director of Nursing Service (DNS) reported an allegation of abuse to the Administrator, who serves as the Abuse Coordinator. Furthermore, this allegation of abuse was not reported timely to the State Survey Agency (Reporting); 3) protect Resident Identifier (RI) #2 and potentially other residents from abuse perpetrated by RI #1 (Protection); and 4) investigate an allegation of physical abuse (Investigation). On 4/19/2018 at approximately 4:45 PM, loud voices were heard in the hallway near room [ROOM NUMBER] on the Memory Care Unit. Staff responded and found RI #5 and RI #1 in a physical altercation; they were striking each other with their fists. On 11/23/2018 around 6:45 PM, RI #1 and RI #4 were found on the floor in RI #4's room. RI #4 said RI #1 entered his/her room, uninvited, used the bathroom and then tried to lay down in the empty bed. RI #4 tried to remove RI #1 and both residents fell to the floor. RI #1 sustained superficial scratches to the neck/chest, a skin tear to the right forearm and a torn t-shirt. On 12/16/2018 at approximately 6:55 PM, RI #1 and RI #3 were discovered on the floor in the residents' room. RI #3 had a cracked tooth and RI #1 had minor scratches on his/her right arm. On 1/25/2019 at 3:05 PM, RI #1 was ambulating in the hallway and bleeding from injuries to the right hand. There were three lacerations across the resident's knuckles. The trail of blood was followed and the staff observed RI #3 in his/her wheelchair bleeding from the lower lip, with a possible broken tooth. On 2/15/2019 at 7:45 PM, RI #1 and RI #2 were ambulating in the hallway towards each other, when RI #1 struck RI #2 with his/her right fist on RI #2's chin. The facility concluded RI #1 struck RI #2 with no warning or provocation and physical abuse did occur. During the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed RI #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. These deficient practices affected RI #2, RI #3, RI #4 and RI #5, four of five sampled residents reviewed for resident to resident altercations; and placed these residents in immediate jeopardy for serious injury, harm or death. These failures also had the potential to affect the remaining residents who resided on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F607. Findings include: Refer to F600 The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . POLICY . The Center will implement an abuse prohibition program through the following: . * Prevention of occurrences; . * Investigation of incidents and allegations; * Protection of patients during investigations; and * Reporting of incidents, investigations, and Center response to the results of their investigations . PURPOSE To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse . PR[NAME]ESS 1. The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse . PREVENTION The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS . 4. Actions to prevent abuse . will include: . 4.2 identifying, correcting, and intervening in situations in which abuse . is more likely to occur . Contained within the facility's investigation file were the following: On 4/19/2018 at approximately 4:45 PM, loud voices were heard in the hallway near room [ROOM NUMBER] on the Memory Care Unit. Staff responded and found RI #5 and RI #1 in a physical altercation; they were striking each other with their fists. Before staff could intervene, RI #5 fell to the floor and struck the back of his/her head against the floor or wall. Both residents sent to the local hospital for evaluation and returned back to the facility. Law enforcement, the residents' families and physician were notified. RI #5 was sent to acute Geri-Psych on 4/20/2018. RI #1 had a medical condition that delayed transfer to Geri-Psych; he/she remained on close monitoring by staff until sent. The facility concluded that physical abuse did occur; however, they could not determine the aggressor or the victim. As a result of the incident, the staff was provided education on proactive identification and response to possible resident aggression; position residents in common areas to respect personal space and freedom of movement. On 11/23/2018 around 6:45 PM, RI #1 and RI #4 were found on the floor in RI #4's room. RI #4 said RI #1 entered his/her room, uninvited, used the bathroom and then tried to lay down in the empty bed. RI #4 tried to remove RI #1 and both residents fell to the floor. RI #1 sustained superficial scratches to the neck/chest, a skin tear to the right forearm and a torn t-shirt. The facility concluded that no physical abuse occurred - the contact was deemed accidental. On 12/16/2018 at approximately 6:55 PM, RI #1 and RI #3 were discovered on the floor in the residents' room. RI #3 had a cracked tooth and RI #1 had minor scratches on his/her right arm. Neither resident could account for how they ended up on the floor or what happened. The staff did not hear or otherwise observe any interactions between the two residents. RI #1 had been walking around the Memory Care (Dementia) Unit and RI #3 was in the bed, with the bed in the lowest position. RI #3 was sent to the local hospital for evaluation. The facility was unable to substantiate that abuse occurred or who the victim or aggressor was. On 1/25/2019 at 3:05 PM, RI #1 was ambulating in the hallway and bleeding from injuries to the right hand. There were three lacerations across the resident's knuckles. The trail of blood was followed and the staff observed RI #3 in his/her wheelchair bleeding from the lower lip, with a possible broken tooth. RI #1 denied any physical altercation. RI #3, who has a [DIAGNOSES REDACTED]. Law enforcement and the residents' families were notified. Both residents were sent to the local hospital for evaluation. RI #1 returned to the facility later that evening and RI #3 was admitted . On 1/28/2019, RI #1 was transferred to Geri-Psych at a local hospital. There were no witnesses to the incident. Both residents reside on the Memory Care Unit of the facility and they were roommates. The facility concluded that physical abuse occurred; however, they were unable to identify the aggressor or instigator. As the result of the incident, RI #3 was moved to another room when he/she returned to the facility. On 2/15/2019 at 7:45 PM, RI #1 and RI #2 were ambulating in the hallway towards each other, when RI #1 struck RI #2 with his/her right fist on RI #2's chin. This allegation was reported to the SA on 2/15/2019 at 8:50 PM. The five-day report concluded RI #1 struck RI #2 with no warning or provocation. While neither resident was injured, physical abuse did occur. Beginning 2/15/2019 until 2/21/2019, RI #1 was provided 1:1 oversight during the resident's waking hours. On 2/21/2019, RI #1 was transferred to an acute Geri-psychiatric facility. During the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed RI #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. According to the Licensed Practical Nurse (LPN), she informed the DNS; however, she was told to not document anything that she, the DNS, would take care of everything in the morning. On 2/21/2019, RI #1 was discharged to a local Geri-Psychiatric setting. During an interview with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), on 2/28/2019 beginning at 9:36 AM, she was asked what intervention(s) was put in place after the 4/19/2018 incident. EI #2 said there were none for that time period. When asked what intervention(s) were put in place after the 11/23/2018 incident, EI #2 said RI #1 was assisted to his/her room and gotten ready for bed. EI #2 was asked about the 12/26/2018 incident. According to EI #2, after the incident, RI #3 was sent to the hospital and when RI #3 returned to the facility the resident was placed in a room by himself/herself for the remainder of the night to avoid any further confrontations. When asked if RI #1 and RI #3 still shared a room when the 1/25/2019 incident occurred, EI #2 said yes because the facility could not determine whether a resident-to-resident altercation occurred on 12/26/2018 because there was no witnesses and the residents were unable to tell what happened. EI #2 explained that after the 1/25/2019, the same general interventions of close monitoring was in place since the facility treated this incident as a fall. According to EI #2, while there were no witnesses, one could tell something had occurred because RI #1 had blood on his/her knuckles and the trail of blood on the floor led to RI #3, who was found, in the shared room of both residents (RI #1 and RI #3), bleeding from the mouth. EI #2 stated after this incident RI #1 was placed on 1:1 until send out to a Geri-Psych setting. Then on 2/1/2019. the physician came in to assess RI #1 and determined that 1:1 was no longer needed. When asked how the facility monitored RI #1's aggressive behaviors after the 1/25/2019 incident, EI #2 said the same general interventions of monitoring. EI #2 was asked what interventions were put in place after the 2/15/2019 incident between RI #1 and RI #2. She explained there were no interventions for RI #2 other than the assessment for injury; however, RI #1 was placed on 1:1 until discharge or other placement could be found or Geri-Psych arrangements could be made. When asked how staff was made aware that RI #1 was to be placed on 1:1, EI #2 said the night the nurse (EI #4) called her and she instructed the nurse to put someone with RI #1 1:1. Then the next morning, EI #2 stated she made assignments sheets and put them on the unit. EI #2 explained that she only verbally informed the Charge Nurses to place RI #1 on 1:1. EI #2 stated she now realizes that she should have provided written education and had the staff to document that the intervention was being implemented. When asked who was ultimately responsible for ensuring 1:1 interventions were being implemented, EI #2 said she was. During a telephone interview on 2/27/2019 at 9:31 AM, EI #5, a Certified Nursing Assistant (CNA) acknowledged she witnessed RI #1 hit RI #2 on 2/20/2019. EI #5 stated she didn't know RI #1 was 1:1 when the second incident on 2/20/2019 happened. During a telephone interview on 2/27/2019 at 10:36 AM, EI #7, a CNA acknowledged that she worked in the facility's locked (Dementia) unit during the second shift on 2/20/2019. When asked if RI #1 had been on 1:1, EI #7 said yes she had heard that RI #1 was on 1:1 before, but she didn't think RI #1 was on 1:1 when she worked in the facility. EI #7 was asked how the CNAs would know if a resident was placed on 1:1 and she replied, I guess the nurse or supervisor would tell us. In an interview on 2/27/2019 at 3:45 PM, EI #6 acknowledged that she was assigned to care for RI #1 during the 2:00 PM to 10:00 PM shift on 2/20/2019. When asked if RI #1 was on 1:1 during her shift on 2/20/2019, EI #6 said no, the staff had been told that RI #1 was taken off 1:1. EI #6 explained that if RI #1 was 1:1, there would have been a paper with names on to let the staff know what time they were assigned to watch RI #1, but when she came in there was no sheet to let the staff know the resident was on 1:1. When asked when RI #1's 1:1 was discontinued, EI #6 said she didn't know. On 2/26/2019 at 3:49 PM, an interview was conducted with EI #4, the 2:00 PM to 10:00 PM (2nd shift) LPN assigned to work on the Homestead (Dementia) Unit. EI #4 was asked if there was another altercation involving RI #1 on 2/20/2019. EI #4 said yes. EI #4 said she heard someone yelling and saw of the aides running up the hall. Later EI #4 was told that RI #1 was beating RI #2 in the head. EI #4 said she called the DNS. According to EI #4, the DNS asked her what happened to the 1:1. EI #4 stated this was the first time she knew that 1:1 should have continued. EI #4 explained she didn't know the resident was still to be on 1:1. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, he was asked what intervention(s) were put in place after the 4/19/2018 incident. EI #1 said RI #5 was discharged to the hospital for evaluation and subsequently sent to a mental health setting, while RI #1 was placed on close monitoring while out of bed. When asked what was done to deter the 11/23/2018 from reoccurrence, EI #1 said RI #5 was assigned to another room outside of the Memory Care Unit. According to EI #1, the 12/16/2018 incident between RI #1 and RI #3 was treated as a fall. When asked what interventions were put in place after the 2/15/2019 resident-to-resident altercation between RI #1 and RI #2, EI #1 said RI #1 was placed on 1:1 until discharged from the facility on 2/21/2019. When asked should 1:1 have continued until RI #1 was discharged , EI #1 stated I thought it did but I now know that on 2/20/19, (RI #1) was observed in (RI #2's) room and was hitting (RI #2) in the face. According to EI #1, he was not made aware of this incident until 2/27/2019. RI #1's care plan titled Resident/patient exhibits, or has the potential to exhibit physical behaviors such . Physical aggression toward others . initiated 2/6/2018 had the following interventions: redirect and offer rest periods if resident becomes agitated was initiated on 5/4/2018 by EI #2; a medication review by the psychiatrist was initiated on 11/24/2018 by EI #2; a roommate change was initiated on 1/30/2019 by EI #12, a LPN; supervision to and from activity was initiated on 1/30/2019 by EI #12; medication adjustment was created on 2/5/2019 by EI #11, a Registered Nurse (RN); an attempt to keep RI #1 in populated areas and provide redirection as needed was initiated on 1/30/2019 by EI #12 and revised on 2/7/2019 by EI #2; 1:1 supervision with escalation of behaviors as needed was initiated on 2/7/2019 by EI #2; an activity board for 1:1 entertainment was initiated on 2/7/2019 by EI #2; monthly psychiatrist visits were initiated on 2/7/2019 by EI #2; and 1:1 supervision was initiated on 2/18/2019 by EI #11, a RN. REPORTING/RESPONSE The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS . 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. 6. Upon receiving information concerning a report of suspected or alleged abuse . the CED (Center Executive Director) or designee will perform the following: 6.1 Enter allegation into the Risk Management System (RMS). 6.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made . 6.5 Notify local law enforcement, Licensing Boards and Registries, and other agencies as required . On 2/26/2019 at 3:49 PM, an interview was conducted with EI #4, the 2:00 PM to 10:00 PM (2nd shift) LPN assigned to work on the Homestead (Dementia) Unit. EI #4 was asked if there was another altercation involving RI #1 on 2/20/2019. EI #4 said yes. EI #4 said she heard someone yelling and saw of the aides running up the hall. Later EI #4 was told that RI #1 was beating RI #2 in the head. EI #4 said she called the DNS. According to EI #4, the DNS told her not to document and that she would take care of it the next day. EI #4 stated the next day around 9:30 PM, RI #1 was picked up and taken to a geri-psychiatric setting. During an interview with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), on 2/28/2019 beginning at 9:36 AM, she was asked if resident-to-resident altercations were reportable to the Alabama State Survey Agency. EI #2 said yes. EI #2 was asked what the staff should do when they observe a resident-to-resident altercation. EI #2 explained the staff are required to call the Abuse Coordinator, who is the facility's Administrator, document the altercation in the RMS (Risk Management System), complete a change of condition report, notify the physician and resident's family; and start to give instructions to the staff on duty. EI #2 acknowledged that none of this was done. When asked why the staff first notified her of the 2/15/2019 resident-to-resident altercation between RI #1 and RI #2, EI #2 said because she had the staff call her for everything. EI #2 stated after the staff calls her, she informs the Administrator. When asked if the 2/20/2019 resident-to-resident altercation involving RI #1 and RI #2 should have been reported to the Alabama State Survey Agency, EI #2 said yes. EI #2 stated the general rule was to report the allegations within two hours. When asked why would the staff stated she was notified of the 2/20/2019 altercation shortly after it occurred and was told to not do anything that she (EI #2) would take care of it in the morning, EI #2 replied I don't know. I would never do that. When asked when she became aware of the resident-to-resident altercation that occurred on 2/20/2019, EI #2 stated it wasn't until the State Surveyor informed her last night (2/27/2019) and two people came into her office on yesterday asking what happened with RI #1. When asked who those two people were, EI #2 said she couldn't remember because people constantly come in and out of her office. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, he acknowledged the 2/20/2019 incident that occurred between RI #1 and RI #2 was a reportable incident to the Alabama State Survey Agency. According to EI #1, he was not made aware of the incident until 2/27/2019 by a representative from the Alabama State Survey Agency. When asked what he expected the staff to do when they became aware of the incident, EI #1 said the Charge Nurse should have notified the Abuse Coordinator, the physician, and the Supervisor; the notifications of all parties should have been documented in the residents' medical records; an assessment should have completed and documented for both residents; an incident report should have been completed; and the provision of 1:1 supervision for RI #1 should have been reinforced. EI #1 acknowledged none of this was done. On 2/27/2019 at 6:46 PM, the Alabama State Survey Agency received a facility reported allegation of physical abuse involving RI #1 and RI #2 that occurred on 2/20/2019 at 7:00 PM. INVESTIGATION The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS . 6.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 6.7.1 whether abuse or neglect occurred and to what extent; 6.7.2 clinical examination for signs of injuries, if indicated; 6.7.3 causative factors; and 6.7.4 interventions to prevent further injury. 6.8 The investigation will be thoroughly documented within RMS. Ensure that documentation of witnessed interviews is included. 6.8.1 Conduct interviews using the Alleged Perpetrator/Victim Interview Record and Witness Interview Record. 6.8.2 Enter a summary of the interviews into RMS. 6.8.3 Interview forms will be kept confidential in a file in the administrative office . During an interview with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), on 2/28/2019 beginning at 9:36 AM, was asked what the staff should do when they observe a resident-to-resident altercation. EI #2 explained the staff are required to call the Abuse Coordinator, who is the facility's Administrator, document the altercation in the RMS (Risk Management System), complete a change of condition report, notify the physician and resident's family; and start to give instructions to the staff on duty. EI #2 acknowledged that none of this was done. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, was asked what he expected the staff to do when they became aware of the incident, EI #1 said the Charge Nurse should have notified the Abuse Coordinator, the physician, and the Supervisor; the notifications of all parties should have been documented in the residents' medical records; an assessment should have completed and documented for both residents; an incident report should have been completed; and the provision of 1:1 supervision for RI #1 should have been reinforced. EI #1 acknowledged none of this was done. According to the facility's investigative summary submitted to the Alabama State Survey dated 3/5/2019, documented . Allegation Summary. On (MONTH) 27, 2019, in the course of an Abbreviated Complaint Surrey by the Alabama Department of Public Health, the Center Executive Director (Abuse Prevention Coordinator) was notified that during the 2-10p shift of (MONTH) 20, 2019, an alleged resident-to-resident altercation occurred between (RI #1) and (RI #2) . Center Findings . * There was no notification to sponsors/physicians; documentation in the record; or, investigation of the allegation until (MONTH) 27, 2019 . PROTECTION The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . 5.2 If the suspected abuse is resident-to-resident, the resident who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. 5.2.1 The Center will provide adequate supervision when the risk of resident-to-resident altercation is suspected. 5.2.2 The Center is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. 5.2.3 The family and physician will be notified . PR[NAME]ESS . 7. The Center will protect patients from further harm during an investigation. 7.1 Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe. 7.2 Assign a representative from Social Services or a designee to monitor the patient's feelings concerning the incident, as well as the patient's involvement in the investigation . During an interview with EI #2, the Center Nurse Executive (CNE), also known as the DNS, on 2/28/2019 beginning at 9:36 AM, was asked what interventions were implemented after this altercation, EI #2 said RI #1 was placed on 1:1. EI #2 was asked how long RI #1 was to be on 1:1. EI #2 replied, (RI #1) was supposed to be on 1:1 from 2/15/19 until (he/she) was D/C (discharged ) or other placement found or Geri-Psych arrangements could be made. When asked if RI #1 was 1:1 since 2/15/2019 until discharged , how it was possible that the resident was involved in another resident-to-resident altercation on 2/20/2019, EI #2 replied she didn't know. EI #2 was asked who was responsible to monitoring RI #1's 1:1 to ensure it was being done. EI #2 stated it was the responsibility of the Charge Nurses, but ultimately she was responsible. EI #2 was asked if RI #1 was on 1:1 from 2/15/2019 until 2/21/2019, should there have been another physical resident-to-resident altercation. EI #2 replied, It would still be possible but less likely if (RI #1) was on 1:1. EI #2 explained that she only verbally informed the Charge Nurses to place RI #1 on 1:1. EI #2 stated she now realizes that she should have provided written education and had the staff to document that the intervention was being implemented. When asked who was ultimately responsible for ensuring 1:1 interventions were being implemented, EI #2 said she was. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, he acknowledged that RI #1 was placed on 1:1 after the resident had been observed by staff to strike RI #2 under the chin on 2/15/2019 until other placement could be achieved; RI #1 was discharged from the facility on 2/21/2019. When asked should 1:1 have continued until RI #1 was discharged , EI #1 stated I thought it did but I now know that on 2/20/19, (RI #1) was observed in (RI #2's) room and was hitting (RI #2) in the face. According to the facility's investigative summary submitted to the Alabama State Survey dated 3/5/2019, documented . Allegation Summary. On (MONTH) 27, 2019, in the course of an Abbreviated Complaint Surrey by the Alabama Department of Public Health, the Center Executive Director (Abuse Prevention Coordinator) was notified that during the 2-10p shift of (MONTH) 20, 2019, an alleged resident-to-resident altercation occurred between (RI #1) and (RI #2) . Center Findings . * The 1:1 supervision of (RI #1) by Center staff, put into place on (MONTH) 15, 2019, was not maintained through (RI #1's) discharge date of (MONTH) 21, 2019, enabling (RI #1) to strike (RI #2) on (MONTH) 20, 2019 . ************************* On 3/2/2019 at 7:15 PM, the facility submitted an Allegation of Credible Compliance for F607, which documented: F-607 J-Development and implementation of written Abuse Prohibition policies. Licensed Nurse discharged RI #1 to Baptist Senior Care Unit on (MONTH) 21, 2019. As of (MONTH) 1, 2019, staff were educated that the first contact for suspected abuse, neglect, misappropriation, or mistreatment is to be reported to the Center Executive Director, who is the Abuse Prevention Coordinator. The Nurse Practice Educator or designee educated 95 of 95 active employees from (MONTH) 27, through (MONTH) 2, (YEAR) on the implementation of Abuse Prohibition policy and procedure to include protection of the resident. Employees on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires are educated on the Abuse Prohibition policy during orientation. The Nurse Practice Educator or designee interviewed staff on (MONTH) 2, 2019, concerning knowledge of unreported instances of abuse, neglect, misappropriation, or mistreatment, to include resident-to-resident altercations. No concerns were identified. Director of Clinical Operations educated the Center Executive Director and Center Nurse Executive on the implementation of Abuse Prohibition policy and procedure to include protection of residents on (MONTH) 1, 2019. Quality Assurance Performance Improvement (QAPI) meeting held on (MONTH) 1, 2019 with Interdisciplinary Team members and reviewed with the Medical Director (via phone) on the center's Abuse Prohibition policy. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F607 was lowered to a [NAME] level on 3/2/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 156. |
2020-09-01 |