Every finding on record at C M Tucker Jr Nursing Care Center Roddey Pavilio

Based on observation, interview, record review, and review of the facility policy, the facility failed to establish and maintain an effective Infection Prevention and Control Program (IPCP). Specifically, the facility failed to ensure staff followed appropriate hand hygiene during the administration of a gastrojejunostomy (G J) feeding tube flush for one sampled resident (Resident (R)25), and during medication administration for two of three residents reviewed for medication administration (R68 and R70).Findings Include: 1.Review of the policy titled, Infection Control Policy and Procedure, with a revision date of March 2026 revealed, Purpose: The purpose of this operational procedure is to establish infection control functions and responsibilities for Nursing Services at CM [NAME], Jr. Nursing Care Center, reduce and control the danger of infection. Policy: It is the policy of Nursing Services to adhere to the standards of infection control practices while providing services. This will serve as a precautionary measure to prevent the spread of infection or disease. Procedure: 3. Hand Hygiene and Personal Protective Equipment: c. Indications for hand hygiene are: After removal of personal protective equipment, i.e., gloves, gown, mask, respirator, etc. 4. Precautions to Prevent Exposure to Communicable Disease: b. Gloves are to be worn whenever contact with blood or body fluid is likely. Review of the facility policy titled, Medication Administration: Eye Instillation, with revision date of October 2023 revealed, Purpose: To instill medication into the eye. Procedure: 5. Put on gloves and wipe away discharge with tissue or gauze. Discard wipe and gloves and perform hand hygiene. Put on clean gloves. 9. Remove gloves, discard trash, and perform hand hygiene Review of the facility policy titled, Medication Administration, with a revision date of October 2025 revealed, Procedure: 15. If a medication falls on the floor, discard, repeat preparation, and reorder dose from pharmacy. Review of R68's electronic medical record (EMR) showed R68 has an admission date of 06/12/19 and diagnoses including, but not limited to, vascular dementia and unspecified pterygium of the left eye. Review of R68's active orders revealed: Zaditor 0.025% (0.035%) eye drops 1 drop both eyes two times daily. Review of R68's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/05/26 revealed the resident's Brief Interview for Mental Status (BIMS) score was 07 indicating severe cognitive impairment. Review of R70's EMR showed R70 has an admission date of 05/25/11 and diagnoses including, but not limited to seizures, and psychotic disorder with delusions. Review of R70's active orders revealed: Clonazepam 1mg [milligrams] one tablet by mouth twice a day and Norco 5 mg-325 mg tablet one tablet by mouth twice a day. Review of R70's MDS with an ARD of 07/07/26 revealed the resident's BIMS score was Not Assessed, and the resident is rarely or never understood. During an observation on 07/21/26 at 9:45 AM, of medication administration, Licensed Practical Nurse (LPN)2 failed to sanitize her hands, LPN2 then donned gloves in the hallway. As entering R68's room LPN2 touched the resident's door and then touched his bedside table. LPN2 then administered an eye drop in both of R68's eyes. LPN2 removed her gloves and failed to perform hand hygiene. During an interview on 07/21/26 at 9:50 AM, LPN2 stated, I had on gloves, I did not realize that I needed to wash my hands before I put on gloves and after I removed my gloves. During an observation and interview on 07/21/26 at 10:06 AM, of medication administration, LPN2 retrieved medications from the narcotic box and placed them in a medication cup. The medication cup overturned and the Norco and the Clonazepam spilled out onto the floor of the hallway. LPN2 picked the pills up from the floor and placed those pills with R70's other scheduled medications in a separate medication cup. LPN2 picked up the medication cup and started to enter R70's room. This surveyor stopped LPN2 and the medications were wasted and new medications were obtained. LPN2 stated, I did not want to waste the medication. I will have to get another nurse to watch me waste it. She is busy. I just did not want to waste it. During an interview on 07/21/26 at approximately 10:27 AM, the Administrator revealed that her expectation is that the nurses follow all policies and procedures related to medication administration. During an interview on 07/21/26 at 1:26 PM the Director of Nursing revealed that the facility's expectation is for staff to follow facility guidelines when performing medication administration, including infection control procedures. 2. Review of the facility's policy titled Feeding Tube – Maintaining Patency last revised 06/25 revealed that staff are required to knock on the door and gain permission before entering the resident's room, gather equipment, perform hand hygiene, explain the procedure, and provide privacy. The policy directs staff to place the resident in semi Fowler's position, perform hand hygiene again, and put on gloves. Staff must position a towel or disposable pad on the resident, stop the suction or feeding pump or uncap the tube, and flush the tube with 30–60 mL or the prescribed amount of warm water, allowing it to flow in by gravity. The policy states to cap or reconnect the tube once patency is confirmed, then remove and discard gloves, position the resident for comfort, and discard or clean the syringe and store equipment. Review of R25's EMR showed R25 has an admission date of 05/15/16 and diagnoses including, but not limited to, dementia, gastrostomy malfunction, dysphagia (oral phase), quadriplegia, and gastrostomy status. Review of R25's active orders revealed: Flush Tube (specify in notes) By Shift Starting 04/30/26, ICD 10: Z93.1 – Gastrostomy Status. Notes: Flush G port of JG tube with 30 mL of water before and after medication administration. Flush J port of JG tube with 30 mL of water after completing the second G port flush (after medication administration). Review of R25's MDS with an ARD of 06/01/26 revealed the resident's BIMS score was Not Assessed, and the resident is rarely or never understood. Furthermore, R25 was coded for a feeding tube. During a phone interview on 07/21/26 at 10:33 AM, R25's Representative (RP) reported that the resident is bedbound and fully dependent on staff for all care. She stated the facility staff are not flushing the feeding tube correctly and believes this is why the resident repeatedly needs to be sent to the hospital. On 07/21/26 at 1:00 PM, an observation of G J feeding tube care performed by LPN2 was conducted in the presence of a department Registered Nurse. LPN2 sanitized her hands, then donned a gown and applied gloves outside of R25's room. After donning gloves, LPN2 opened the resident's door, walked to the sink and turned the water on. LPN2 then touched her pockets while looking for a pen. She then requested a water bottle from another staff member, accepted it, and initialed the bottle. LPN2 placed a chuck pad near the resident's abdominal tube site, then returned to the sink to rinse a syringe with the same gloves still on. LPN2 stated the resident receives 30 cc on each side at least while administering the flush, then pinched the tubing and re capped it. LPN2 confirmed the findings, removed her gown and gloves, and left the room. During an interview on 07/21/26 at 1:26 PM, The DON stated that the LPN's actions observed during G tube/J tube care are not professional standards of practice. She reported that the facility's expectation is for staff to follow facility guidelines when performing clinical tasks, including tube care and infection control procedures. The DON stated that education was provided on proper care of feeding tubes in 04/26, and LPN2 attended that training.

Based on observation, interview, and a review of facility policy, the facility failed to follow proper infection control protocol in 3 of 3 laundry rooms. Specifically, there was a lack of separation between the clean and soiled laundry room. Laundry staff did not adhere to manufacturer guidelines regarding the use of detergents and sanitizers. Additionally, heavily soiled clothing items were being rinsed out in areas such as resident bathroom toilets/sinks or the sinks in shared shower rooms. This failure had the potential to spread bacteria, viruses, and fungal infections. On 04/18/25 at approximately 11:45 AM, the Administrator and the Director of Nursing (DON) were notified that the failure to follow infection control standards regarding laundry services constituted Immediate Jeopardy (IJ) at F880. On 04/18/25 at approximately 11:45 AM, the survey team presented the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility that IJ existed as of 02/17/25. The IJ was related to 42 CFR 483.80 - Infection Control. On 04/18/25, the facility provided an acceptable IJ Removal Plan. On 04/18/25 at 3:00 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at a lower scope and severity of F. Findings include: Review of the facility policy titled, Infection Control for Laundry-Personal/Unit Based, with a review date of February 2025, documented, It is the policy of Laundry Service to adhere to standards of infection control practice while providing services to prevent the spread of infection and disease . Soiled laundry shall neither be sorted nor rinsed prior to placing in the washer. Further review of the policy revealed, 1. Unit Washer: . b. Laundry detergent is released in pre-measured amounts from an automatic dispensing system . Unit Laundry Room: . d. Clean and soiled clothing will remain separated at all times to avoid contamination. Review of the facility's QAPI Action Plan, with a Date of Implementation 02/17/25 and a Completion Date of 12/31/25, revealed an Action Plan which documented, There is a need for re-education on the proper use of chemicals, adhering to cleaning schedules to ensure facility cleanliness, and laundering process. Further review of the QAPI Action Plan revealed inservice sign in sheets dated: 02/17/25, 03/18/25, and 04/09/25. Additionally, documentation titled Audit to Ensure ALL EVS Policies and Processes are Followed, revealed audits were being conducted for the months of 02/25, 03/25, and 04/25. Results of documentation reviewed for this QAPI, did not confirm or solidify these processes were in place at the time of the survey, evidenced by multiple surveyor observations throughout the survey. During an observation and interview on 04/16/25 at approximately 8:38 AM, the laundry rooms on Unit 140, Unit 130, and Unit 138, were observed with no designation or separation indicating which side was clean and and which side was dirty/soiled linens. Further observation revealed a bag of dirty linens were observed in a thin, clear plastic bag on the floor. Clean linens were sitting strewn and unfolded on top of the dryer and throughout the laundry room. Folded and clean hospital gowns were observed in the left corner of the room. An interview with Laundry Service Worker and the Housekeeping Manager verified that residents' dirty and clean clothes are laundered together in the same space. During an observation and interview on 04/16/25 at approximately 8:38 AM, a container of Oxy Suds Premium Laundry Detergent was observed on a stand next to the washer. The detergent was connected to an automatic dispensing system. The Label instructions read: Instructions Usage: 2 to 4 oz [ounces] for home-type washer, Use 4 to 8 oz per 100lbs [pounds] on commercial machines. Use for HE [High Efficiency] washers; High efficiency - use 2 oz per load. The Laundry Service Worker stated that the automatic dispenser only releases a small amount of detergent. He further explained that he manually adds more detergent to the washer to compensate, without measuring the amount. The Laundry Service Worker further stated he picks up the Oxy Suds container and pours it directly into the washer. During an interview on 04/16/25 at approximately 8:38 AM, the Housekeeping Manager stated that Certified Nursing Assistants (CNA)s manually remove excessive amounts of feces from personal clothing items into residents' toilets, sinks, or shower rooms. During an interview on 04/17/25 at approximately 1:45 PM, the Infection Preventionist (IP) stated that he expects dirty/soiled linens and personal items to be separate in the laundry. During a follow-up interview on 04/17/25 at approximately 2:54 PM, both the Environmental Services (EVS) Supervisor and Housekeeping Manager confirmed that staff rinse fecal matter in the resident sinks before washing personal clothing items. Multiple interviews were conducted on 04/18/25 between approximately 9:12 AM and 9:45 AM, with Registered Nurse (RN)1, CNA1, CNA3, CNA4, CNA5, CNA6, and CNA7, all confirmed the practice of removing feces from the residents' clothing and rinsing the soiled items out into the residents' sinks, toilets, and the shower. At approximately 10:15 AM on 04/18/25, the facility provided an acceptable IJ Removal Plan, which included the following: Facility failed to follow proper infection control standards regarding laundry services in 3 of 3 laundry rooms, to include: 1. Laundry Room not separated into a clean area and dirty/soiled area. 2. Laundry aids were not following manufacturer recommendations regarding detergent/sanitizer use in washing machines. 3. Certified Nursing Assistant were rinsing off heavily soiled clothing items in the resident's personal toilets (CNA) were rinsing off heavily soiled clothing items in the resident's personal toilets (located in their room) before processing them for laundry services. The facility's failure to follow infection control standards in the laundry process has the potential for transmission of pathogens and cross contamination. It places all residents at risk of contracting infections, such as bacterial, viral, fungal, or parasitic infections. Facility previously identified these issues in February 2025 and had placed a QAPI Action Plan in place, with an alleged date of total compliance of 12/31/25. Laundry Staff and CNAs were educated on the Facility's Infection Control for Laundry-Personal Unit Based Policy and process. USA Vendor is currently in facility working to secure laundry detergent for staff not to be able to add additional chemicals. Facility placed signs in the laundry rooms, in order to identify the Clean vs Dirty Side of the laundry room. The EVS Management staff will be utilizing the audit tool created to monitor the deficiencies twice a week until 12/31/202. Results from this audit will be brought forth to the QAPI Committee. Facility has previously put this issue into our QAPI plan. Therefore, will continue to monitor for compliance. The following compliance issues were noted: -Improper use of chemicals, detergent, and sanitizing agents -Failing to adhere to deep cleaning schedules -Failing to keep separate the clean and dirty side of laundry room -Proper disposal of soiled linen. Do not trash without getting approval from resident's RP and/or resident -Failing to measure chemicals when mixing AOC Date 04/18/25

Based on observation, interview, record review, and review of facility policy, the facility failed to provide Resident (R)50 with sufficient daily fluid intake, for 1 of 1 resident reviewed for hydration. Findings include: Review of the facility policy titled Intake and Output last revised October 2023 revealed, To maintain an accurate record of the resident's fluid intake and output. Documentation of intake and output are indicated when there is a change in the resident's intake or output, when intravenous fluid are being administered, or when a resident is on a fluid restriction. Procedure includes identify resident, use both resident's identification bracelet and resident photograph on unit. Record all fluid intake, a cup of ice is equal to approximately mL (milliliter) of fluid, record all intake, every shift. Review of R50's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including but not limited to: schizophrenia, congestive heart failure, and dementia with agitation. Review of R50's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/28/25, revealed that R50 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicates that R50 is cognitively intact. Further review of the Quarterly MDS revealed that R50 requires set up or clean up assistance with the Activities of Daily Living (ADL) task of eating. R50 has no issues with swallowing or nutritional status. During an observation and interview on 04/15/25 at 12:59 PM, R50 was in her in bed with a water jug of 500 liters of water. During interview with R50 she stated that staff do not provide her adequate hydration during day and the only times she receives fluids are during mealtimes and when she gets her medications. Further interview with R50 stated that the last time staff offered to provide her hydration in her water jug was about 2 weeks ago. R50 stated I do not want to drink water that has been sitting for days because it is not fresh. Observation of the 500 liters of water revealed no ice or condensation on the outside of the water jug, it appeared to be room temperature. During an interview on 04/17/25 at 3:55 PM, R50 stated that again today no staff provided her hydration other than with her meals or medications. Review of R50 Intake/Output Monitoring Report for January 2025, revealed the following dates recorded for fluid intake: -01/07/25 at 10:23 AM - 420 mL -01/13/25 at 10:29 AM- 240 mL -01/21/25 at 5:36 PM - 240 mL -01/22/25 at 8:36 AM - 480 mL -01/25/25 at 8:00 PM - 720 mL The record of fluid intake was missing for multiple days in the month of January 2025. There was no other documentation found for the month of January 2025 for R50 Intake/Output monitoring. Record review of R50 Intake/Out Monitoring Report for February 2025, revealed the following dates recorded for fluid intake: -02/01/25 at 7:00 AM - 420 mL -02/01/25 at 7:00 AM - 420 mL -02/03/25 at 6:39 PM - 240 mL -02/10/25 at 10:26 AM - 420 mL -02/10/25 at 10:27 AM - 420 mL -02/11/25 at 8:49 PM - 240 mL The record of fluid intake was missing for multiple days in the month of February 2025. There was no other documentation found for the month of February 2025 for R50 Intake/Output monitoring. Record review of R50 Intake/Output Monitoring Report for Mach 2025, revealed the following dates recorded for fluid intake: -03/07/25 at 8:30 PM - 240 mL -03/12/25 at 10:26 PM - 240 mL -03/25/25 at 1:10 PM - 120 mL -03/25/25 at 1:10 PM - 420 mL -03/29/25 at 2:34 PM - 420 mL -03/29/25 at 2:34 PM - 420 mL The record of fluid intake was missing for multiple days in the month of March 2025. There was no other documentation found for the month of March 2025 for R50 Intake/Output monitoring. Review of R50's Intake/Output Monitoring Report for April 2025, revealed the following dates recorded for fluid intake: -04/09/25 at 1:11 PM - n/a The record of fluid intake was missing for multiple days in the month of April 2025. There was no other documentation found for the month of April 2025 for R50 Intake/Output monitoring. Review of R50's Care Plan last revised on 12/04/24, revealed, [R50] has the potential for complications related to multiple medical problems as evidence by diagnosis of cardiac issues, respiratory issues, history of Urinary Tract Infection, hypertension, gastrointestinal (GI) bleed/anemia . interventions include encourage to drink fluid on meal tray, with medications, and during hydration rounds. During an interview on 04/17/25 at 6:17 PM, the Unit Manager revealed that her expectation is for staff to document resident's input/output for hydration on every shift. During an interview on 04/17/25 at 6:45 PM, the Director of Nursing revealed that their expectation is for staff to document resident's intake/output monitoring in the Electronic Medical Record (EMR) every shift. During an interview on 04/18/25 at 9:55 AM, the Nurse Consultant revealed that the facility was unable to locate any additional documentation for R50 related to her intake/output monitoring for 2025.

Based on interview, record review, document review, and facility policy review, the facility failed to provide supervision to prevent accidents for 1 (Resident #3) of 3 sampled residents reviewed for abuse. Specifically, staff were required to keep Resident #3 within line of sight when the resident was out of their room. On 11/15/2024 at approximately 7:25 PM, staff failed to supervise Resident #3 and found the resident in Resident #4's room. Findings included: A facility policy titled, Special Treatment Modalities and Observation Levels effective 09/2024, revealed, This directive defines the process for administering care to resident populations who because of their behavior/condition, require more intensive monitoring within the facility. It is the policy of [the facility] to provide an appropriate level of supervision for those residents who are at significant risk of harm to self and/or others and/or who may create serious disruption in the environment. The policy revealed, Constant Observation-Line of Sight (COLS): Occurs when an individual staff member may be responsible for up to two (2) residents who remains at all times within the line of sight of the assigned staff. A Face Sheet indicated the facility admitted Resident #3 on 03/21/2023. According to the Face Sheet, the resident had a medical history that included diagnoses of dementia, type 2 diabetes mellitus, encephalopathy, wandering, and schizophrenia. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/10/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. According to the MDS, the resident had physical and verbal behavioral symptoms directed toward others one to three days during the assessment period. The MDS revealed the resident used a manual wheelchair and was independent for sit to stand and chair/bed-to-chair transfer and with walking up to 150 feet. Resident #3's Care Plan Report included an undated problem statement, that indicated the resident had behavioral symptoms that included being resistant to care; noncompliant with care/medications; combative; hard to redirect; easily agitated by others (yelling out, loud disruptions); unpredictable behaviors with episodes of verbal threats of physical aggression towards staff and peers without provoking; spitting towards staff and peers; ineffective understanding of safety; threatening and taunting behavior with attempts to break facility equipment by punching, kicking, and grabbing materials which are thrown at staff. Interventions directed staff to provide special treatment modalities and observation levels per physician orders. The intervention indicated that staff may observe the resident up to ten feet away (initiated 01/01/2023). The facility Five-Day Follow-Up Report, dated 11/22/2024 revealed it was reported that on 11/15/2024 at 7:25 PM, Resident #3 entered Resident #4's room, during shift change and pulled Resident #4's leg. The report revealed that upon investigation, video footage showed Resident #3 coming down the hall from the nurse's station via wheelchair and going to the doorway of Resident #4's room. Video footage showed Resident #3 stood up and entered Resident #4's room. After approximately 30 seconds, the video footage showed two staff members at the doorway of Resident #4's room directing Resident #3 to come out. Per the facility's report, video footage showed Resident #3 left the room and sat in their wheelchair. The report revealed the two staff members stated that they heard Resident #4 saying not to spit or kick them as the staff approached Resident #4's room. Per the report, when they arrived at Resident #4's room, the staff saw Resident #3 pulling Resident #4's leg. The report revealed Resident #3 had a history of aggression towards peers and staff. Per the report, Resident #4 had a history of agitation, yelling, and being verbally aggressive toward staff and others. According to the report, the facility conducted an investigation that included obtaining staff witness and resident statements, conducting record review, and reviewing camera footage. The report revealed the facility determined that Resident #3 entered Resident #4's room where an inappropriate exchange occurred between the residents and neither resident sustained an injury. Per the report, facility staff quickly intervened once Resident #3 entered the room; psychiatry evaluated Resident #4 and Resident #3 and medication adjustments were made, and Resident #3 would remain on continuous line of sight supervision. Per the report, based on the evidence, the facility could not determine Resident #3's intent when they entered Resident #4's room; subsequently, abuse could not be substantiated. Resident #3's 1:1 Observation Flowsheet-Nursing Service for 11/15/2024, revealed staff should observe [the resident] every hour and [NAME] when out of room due to Risk of Injury to Others. Per the flowsheet, at 7:00 PM on 11/15/2024, Certified Nursing Assistant (CNA) #7 documented that Resident #3 was in the hallway and in the resident's room. The flowsheet revealed no further documentation regarding Resident #3's location until 8:00 PM. During an interview on 12/02/2024 at 1:55 PM, Registered Nurse (RN) #19 stated that Resident #3 required continuous observation when the resident was out of their room. During a telephone interview on 12/03/2024 at 2:14 PM, RN #9 stated he was unable to explain how Resident #3 was able to go into Resident #4's room when Resident #3 was supposed to be supervised when out of their room. During an interview on 12/03/2024 at 4:41 PM, CNA #12 stated she started work on the day of the incident at 7:00 PM. CNA #12 stated during the beginning of shift change she noticed an empty wheelchair in front of Resident #4's room. CNA #12 indicated that she saw Resident #3 standing over Resident #4 pulling the resident's leg as if the Resident #3 was trying to put Resident #4's leg back on the bed. Per CNA #12, Resident #4 stated that Resident #3 kicked and spat on them. CNA #12 indicated that she did not witness Resident #3 spitting or kicking Resident #4. CNA #12 indicated that when Resident #3 was out of their room, a TA was supposed to be observing Resident #3. CNA #12 indicated that there was no TA who sat near the nurse's station when she started work at 7:00 PM. During an interview on 12/04/2024 at 2:50 PM, CNA #8 stated Resident #3 was usually a protector of the residents. CNA #8 indicated that she had never seen Resident #3 go in another resident's room. CNA #8 stated she was not aware she was assigned TA duties on the day of the incident until CNA #7, who was leaving, notified her. CNA #8 indicated that when she came in to work, Resident #4 was in bed and requested assistance to sit in their chair. CNA #8 stated she went to get CNA #12 to assist her with getting Resident #4 to a chair. CNA #8 stated they found Resident #3 was in Resident #4's room. Per CNA #8, CNA #12 redirected Resident #3 out of the room and reported the incident to the RN #9. During an interview on 12/04/2024 at 4:49 PM, CNA #7 stated that on the day of the incident, the TA left early due illness, and she took over the observation of residents until 7:00 PM. CNA #7 indicated that during the time she watched residents in the hallway, Resident #3 did not come out of their room. CNA #7 indicated that she was due to get off at 7:00 PM and was at the nurses' station assisting the nurse when the incident occurred. CNA #7 further indicated that CNA #8, was supposed to be assigned TA duties at 7:00 PM, and was supposed to observe residents that were in the hallway. During an interview on 12/04/2024 at 12:25 PM, the Director of Nursing stated that it was her expectation that the staff follow facility and regulatory guidelines related to preventing abuse and keeping residents safe. During an interview on 12/04/2024 at 12:30 PM, the Administrator stated that it was her expectation that the staff follow facility and regulatory guidelines related to preventing abuse and keeping residents safe.

Amended 1/9/25 Based on interview, record review, and facility document and policy review, the facility failed to timely report an allegation of abuse to the state survey agency for 1 (Resident (R)4) of 3 sampled residents reviewed for abuse. Findings included: 1. A facility policy titled, Protection From Harm Program, revised 11/2024, indicated the facility will report all incidents of alleged or substantiated abuse to the proper government agencies as outlined by state, federal and local regulations governing the operation of a long-term nursing care facility. The policy revealed DHEC [Department of Health and Environmental Control] requires the reporting of Resident-to-Resident abuse, altercations involving physical contact between two residents. A Face Sheet indicated the facility admitted R3 on 03/21/2023. According to the Face Sheet, the resident had a medical history that included diagnoses of dementia, type 2 diabetes mellitus, encephalopathy, wandering, and schizophrenia. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/10/2024, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. R3's Care Plan Report included an undated problem statement, that indicated the resident had behavioral symptoms that included being resistant to care; noncompliant with care/medications; combative; hard to redirect; easily agitated by others (yelling out, loud disruptions); unpredictable behaviors with episodes of verbal threats of physical aggression towards staff and peers without provoking; spitting towards staff and peers; ineffective understanding of safety; threatening and taunting behavior with attempts to break facility equipment by punching, kicking, and grabbing materials which are thrown at staff. A Face Sheet indicated the facility admitted R4 on 10/20/2022. According to the Face Sheet, the resident had a medical history that included diagnoses of schizophrenia, schizoaffective disorder, and altered mental status. A quarterly MDS, with an ARD of 09/19/2024, revealed R4 had a BIMS score of 7, which indicated the resident had severe cognitive impairment. An Initial Report, dated 11/16/2024, indicated the facility was informed of an allegation of resident-to-resident abuse on 11/15/2024 at 7:25 PM. A facsimile report dated 11/16/2024, indicated the facility notified the state survey agency of the abuse allegation on 11/16/2024 at 10:51 AM. Per the Initial Report, R3 alleged that R4 pulled their leg and spat on them. During an interview on 12/05/2024 at 12:30 PM, the Director of Nursing stated it was her expectation that facility staff report alleged abuse allegations timely based on facility policy and regulatory guidelines. During an interview on 12/05/2024 at 12:32 PM, the Administrator stated it was her expectation that facility staff report alleged abuse allegations timely based on facility policy and regulatory guidelines.

Based on review of the facility policy, interviews, and record review, the facility failed to ensure Resident (R)1 was free from physical abuse by Certified Nursing Assistant (CNA)2. On 03/18/24 at 10:25 AM, the Administrator and the Director of Nursing were notified that the failure to ensure Resident (R)1 was free from physical abuse constituted Immediate Jeopardy (IJ) at F600. On 03/18/24 at 10:25 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 12/30/23. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 03/18/24 at 12:27 PM, the facility presented an acceptable plan of removal of the IJ. On 03/18/24 at 12:57 PM, the survey team validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance, considering the IJ at Past Non-Compliance as of 01/05/24. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility's policy titled, C.M. [NAME], Jr. Nursing Care Center Protection from Harm Program dated November 2023 indicated, Section 2.0 Definitions: a). abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of facility's training titled, Training for: Managing Agitation in the Psychiatric and Long Term Care Setting - MAPS with a revised date of 10/23/20, indicated, General Overview of Physical Skills for Protection (Used when attempts to de-escalate have failed and patient is in crisis/behavioral emergency.) Protection Skills: These skills are used to protect the employee when the patient becomes aggressive and is attempting to strike/hit a staff member. The purpose of these skills is to maintain staff and patient safety, giving the employee adequate time to call for help using the appropriate behavioral emergency code. Section XIII - Physical skills for protection listed protection, release, grip on both writs, two hand on one wrist, bite, grip pressure point, rear choke standing, front choke, rear choke sitting, forearm choke, hair pull, bear hug, basket hold, straight arm hold/and or transport in bed or floor restraint, high blow or punch to head, high blow, pivot and deflect, and kick. Further review of the training did not include arm to back protection skills. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: schizoaffective disorder, depression, and wandering. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 09/07/23 revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating R1 had moderately impaired cognition. Review of R1's Care Plan with a start date of 10/02/23 documented, BEHAVIORAL SYMPTOMS: [R1] has been resistive to care and noncompliant with care/medication, combative, hard to redirect, unspecified type with history of being agitated (Poor insight and judgement), unpredictable behaviors with episodes of verbal threats of physical aggression towards staff and peers without provoking, derogatory language towards staff and peers, sexually inappropriate behaviors, spitting towards staff and peers, and ineffective understanding of safety. Threatening and Taunting behaviors with attempts to break facility equipment by punching, kicking, and grabbing materials which are thrown towards staff. 2/3/24 Making verbal threats softly to himself about causing harm to other individuals. 3/26/23 Resident observed throwing chair at exit door in day area 4/13/2023 RESIDENT SPIT ON STAFF 4/14/23 Alleged Physical Abuse 4/22/23. Resident inappropriate and grabbed staff jacket sleeve. 5/03/2023 Resident punch fire extinguisher down center hallway with left fist 5/31/23 Resident threatened staff with writing pen. 7/9/23: Resident attempted to hit peer with a closed fist 7/12/23: Resident threw chair/table at staff 7/17/23: Resident threw chair and broke the TV 8/18/23 Resident reached over nurses' station and threw the computer monitor three times 9/4/23 Resident spit into staff's face 10/8/23 climbing over nurses station 12/18/23 Resident spit in nurse's face, hair, and arms. 12/19/2023 tried to jump into the Nurses station 12/30/23 Resident reached over glass at nurses' station and threw monitor on floor, spit on staff, not redirectable, resident observed with superficial scratches to face. believing that his clothes were missing. 1/11/24: RESIDENT HIT PEER ON THE KNEE 1/17/24: Resident reached over nurse's station knocking monitors off desk, spit on staff, and urinated on the floor. Goal: Resident will be reminded to of consequences of non-compliance with medications. Review of AIMS dated 11/1/23 and 10/10/23 no noted abnormal involuntary movement. Interventions: Resides on a secure unit-must be supervised when off unit. Observe for and document any exit seeking behavior. Review of R1's Clinical Notes Report dated 12/30/23 documented, Resident became agitated at 11:15 AM to which began climbing on front of nurse desk resulting in resident knocking call bell phone and computer monitors off onto the floor while staff served lunch to the other residents while monitoring resident from a distance. Behavior escalated to resident raising fist to staff in day room during lunch and becoming verbally aggressive and threatening. The resident was escorted from day room to bedroom for a time out to calm down away from other residents. Just after the staff returned to the day room to complete feeding lunch, resident returned without w/c, took a drink of tea, spit on staff member and raised both fists in the air in attempt to come attack and became verbally threatening once again. Resident was assisted by 2 staff members to get out of the day room from other residents for safety to which LPN [Licensed Practical Nurse] was called for assistance and nurse called supervision on duty to unit. Nurse and a staff member assisted resident back to room to get w/c. Resident went to bathroom and while in bathroom, supervisors arrived on unit and took over the de-escalation at that time. All appropriate contacts were made. Review of R1's South Carolina Department of Mental Health Incident Report by Code Management dated 12/30/23 with case #T12723223 indicated, staff member stating she was assaulted by resident and reacted to resident by restraining his right hand behind his back. Review of training in abuse, neglect and exploitation, revealed CNA2 completed this training 06/16/23 and completed MAPS training on 06/28/23. During an interview on 03/07/24 at 1:03 PM, Registered Nurse (RN)1 revealed, she was called down to the unit with another nurse because R1 was being aggressive. RN1 stated R1 was in his bathroom, and he was trying to get out the door of the room saying I'm going to get her. RN1 stated she stayed in the room and talked with R1 a little bit. RN1 was not aggressive towards her. RN1 further stated, normally we attempt to deescalate verbally and get the charge nurse or call the doctor or supervisor. We try different things, like take him to his room. It is normal procedure to take him back to his room. RN1 stated she saw markings on his skin, blood a little from the scratches on his face. R1 had been in the bathroom by himself. During an interview on 03/07/24 at 1:26 PM, CNA1 revealed she witnessed the incident. CNA1 stated the resident was agitated, and they were feeding. During the first incident when we were feeding, I saw him go over towards CNA2. I didn't hear the conversation, but they were going back and forth. CNA1 stated CNA2 pushed R1's wheelchair out of the day room and she escorted them. CNA1 stated she came back first when R1 was calm and CNA2 came back later. CNA1 further stated R1 came back again into the dining room and took a sip of something, his gait was unsteady, came with his fists up, and she heard CNA2 say R1 spit on her. CNA1 stated CNA2 was holding R1 inappropriately, and CNA1 called another nurse to take over. CNA1 and another nurse took R1 back to his room. CNA1 stated she told CNA2 that was not the way to hold R1 and called for the nurse. CNA1 concluded she did not see any scratches on R1's face prior to this incident and she did not see any marks on R1's face after the incident occurred. During an interview on 03/07/24 at 2:04 PM, LPN1 stated, While passing out trays to other residents, [R1] continued to push things off the desk. At this time [R1] was not hurting others or himself. We were trying to get the other residents meals served. Once the desk was cleared R1 stopped. [R1] came into the dining room to eat. [R1] was paying attention to another resident, then he began to be mean to the other resident. He started being mean to another resident. [R1] began to get aggressive, he began to put his fist up to swing at [CNA2] and she deflected at first. LPN1 stated CNA1 reminded CNA2 to not grab him, we don't do that. LPN1 further stated she stayed in the dining room and fed other residents while they escorted [R1] to his room, but I stayed on alert. LPN1 stated CNA2 came back to the dining room and said everything is cool. LPN1 thought R1 was fine, and they had removed him from the situation. LPN1 further stated, CNA1 came back in, and she was kind of stirred and shaken. Then, R1 comes back in without his wheelchair, and they were like where is your chair, and he takes a drink from his cup and spits on CNA2, then proceeds to get physical with her. CNA2 got vocal with him, and CNA2 grabbed him and was again reminded not to do that. That's when LPN1 called the supervisor for extra assistance. LPN1 stated the first time she noticed scratches on R1's face, was after he came out of the bathroom, it was a minor laceration to his lip, and a small scratch on his cheek which was after the second incident when he came into the dining room without his wheelchair. LPN1 concluded the grab CNA2 used with R1 is not a hold we were trained to use. During an interview on 03/07/24 at 2:29 PM, CNA2 stated R1 became agitated, and they took him to his room to calm down. R1 had chased her out of his room and he came back to dining room, and I pushed his hand away, to keep him from getting aggressive with me. CNA2 stated he came towards me aggressively and I pushed him away and he did spit in her face. During an interview on 03/07/24 at 2:48 PM, the Administrator reviewed correspondence forwarded to CNA2 to notify of suspension for alleged abuse and termination for abuse and neglect. The Administrator stated copies of this correspondence could not be provided to surveyor. During an interview on 03/07/24 at 2:57 PM, the Administrator stated the facility no longer has the video of the incident. The Administrator stated when she watched the video you could tell R1 was visibly upset. The Administrator observed staff was trying to deflect R1's strike and deflected in a way that made R1's arm go behind his back. The Administrator stated R 1 was in the day room threatening other residents. R1 was one of the forensic residents, and they had to take him to a safer place, but R1 came back, took a drink of his tea and spits at staff. The nursing staff escorted R1 out and to his room, the Public Safety Officer calmed him down. The Administrator stated when R1 spit, she saw staff intervene to get him out. The staff deflected and while deflecting they hit R1's hand behind his back. The Administrator concluded her expectation of staff is to follow facility policies, follow MAPS, and to use non-pharmacological procedures first. On 03/18/24 at 12:27 PM, the facility presented a plan of removal, which included the following: Upon facility conducting the investigation to include review of staff members' witness statements and review of video footage, it was concluded that staff member used an inappropriate de-escalation maneuver, and inappropriately closed the resident's door. it could not be substantiated that staff member scratched resident in the face, based on previous periods of agitation and aggression prior to this allegation or while resident was in his room/bathroom unattended. 12/30/23 Resident assessed for injury or adverse effect of allegation of Physical Abuse on 12/30/23. Resident was noted with scratches above the right eye, cheek, lateral nose, under the left eye and left inner nose. No adverse effect noted. MD/RP notified on 12/30/23. 12/30/23 Employee was suspended immediately pending investigation. 12/30/23 Residents who have a history of known combative and physical aggression are at risk to have the potential to be affected. Continuous All M300s incidents related to physical aggressive behaviors and combativeness will be reviewed to ensure proper interventions are implemented. Continuous Educate facility staff related to facility's Protection from Harm and MAPs techniques. 01/05/24 M300s incidents related to physical aggressive behaviors and combativeness will be reviewed by the Administrator, DON, and/ or designee to ensure proper interventions are implemented. It will be completed daily for 4 weeks then monthly for 2 additional months to ensure proper interventions are implemented. 04/05/24 AD Hoc QAPI held during daily morning meeting. 01/03/24 Medical Director was notified of the incident and plan for improvement. 12/30/24 This process will be reviewed in QAPI for a minimum of 3 months. 04/05/24

Based on interview and record review, the facility failed to provide supervision to prevent the elopement of 1 of 7 residents reviewed. Resident (R) #7 eloped from the facility on 07/02/2023 at approximately 6:16 PM. This situation placed the resident at increased risk for severe harm and / or death. R7 was outside of a safe area without facility awareness, supervision, or permission, placing her increased risk of heat exposure, dehydration and / or other medical complications, or being struck by a motor vehicle. On 09/18/23 at 1:58 PM, the Administrator and the Director of Nursing (DON) were notified that Resident (R)7's successful elopement from the facility constituted Immediate Jeopardy (IJ) at F689. On 09/18/23 at 1:58 PM, the survey team provided the Administrator and the DON with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 07/02/23. The IJ was related to 42 CFR 483.25 - Quality of Care. On 09/18/23 at 12:41 PM, the facility presented an acceptable plan of removal of the IJ. On 09/19/23 at 12:50 PM, the survey team validated that the IJ was removed as of 07/07/23. Due to the facility's due diligence and implementation of a plan of removal, the IJ is considered at Past Non-Compliance. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility policy tilted Wandering/Elopement Risk Residents with an effective or revised date of April 2023, documented, It will be the policy of [Facility] that all residents of the facility receive care and treatment that promotes freedom of movement in a safe environment. Review of R7's Face Sheet revealed R7 was admitted to the facility on [DATE] with diagnoses including but not limited to, schizoaffective bipolar type, chronic ischemic heart disease, and spinal stenosis. Review of R7's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/23, revealed R7 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating R7 was cognitively intact. Review of R7's Care Plan with an effective date of 04/25/23 revealed the following problems, Potential for injury r/t [related to] falls due to impaired mobility . that could cause orthostatic hypotension, dizziness, drowsiness . Intervention included, On 06/09/23 informed staff to monitor Resident more closely . Review of R7's Clinical Notes dated 07/02/23 at 7:30 PM revealed, Informed via employee from food service that resident was observed in the front parking lot of [NAME] Bldg. at her car standing. Pt. stated that she was waiting for her son, [name of son]. When asked, how did you get out of the bldg, pt. said she knows the code to the door but she was not going to tell . Review of the 07/02/23 video footage of the lobby, revealed R7 exited the facility through the lobby doors at approximately 6:16 PM (5:55 PM according to the timestamp). At 6:36 PM (6:16 PM per timestamp), approximately 20 minutes later, Food Services employee (FSE)1 escorts Certified Nursing Assistant (CNA)1 outside. CNA1 returns to the facility shortly after, assisting R7 inside the facility. Review of timeanddate.com revealed the weather in [NAME], SC on 07/02/23 at 5:53 PM and 6:53 PM was 91 degrees Fahrenheit. Review of FSE1's statement to the facility written on 07/07/23 at 9:05 PM, revealed she saw the resident and believed she was a visitor. In an interview on 09/18/23 at 11:56 AM, FSE1 confirmed her statement to the facility. FSE1 saw the resident in the parking lot and did not immediately realize it was a resident. Review of CNA1's statement to the facility on [DATE] at 7:30 PM, revealed the resident was observed standing in the parking lot behind a car and in front of the building. In an interview on 09/18/23 at approximately 12:24 PM, CNA1 revealed she was in the supervisor's office when FSE1 told them there was a lady outside. CNA1 assisted the resident back inside. This happened in the evening around 7:00 PM. CNA1 further revealed R7 had no history of wandering or exit-seeking. The resident was ambulatory, but she would move about the facility with purpose and clear destinations in mind. In an interview on 09/18/23 at approximately 12:50 PM, the Administrator revealed the facility defined elopement the same way as the Centers for Medicare and Medicaid Services (CMS). The Administrator further revealed CMS defines elopement as a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision. In an interview on 09/19/23 at 11:05 AM, the facility Safety Officer revealed that R7 likely exited by pushing the door until it released, per emergency protocol. If this happened, the door would have alarmed, and the alarm would not have silenced until someone turned it off. In an interview on 09/19/23 at 11:10 AM, the Administrator confirmed the footage has no audio, so it is impossible to know if the alarm sounded when R7 triggered the door's emergency release. Furthermore, during the 22 minutes that the resident was outside the facility, the footage does not show anyone arriving to turn off the alarm. Several people go in and out before FSE1 shows CNA1 the resident outside, but nobody appears to silence the alarm from the lobby. It is possible somebody turned off the alarm from the outside, which the camera would not have been able to capture. However, if this happened, the staff member failed to investigate the cause of the alarm or realize that a resident was standing in the parking lot. The facility's allegation of compliance included: Resident was noted in the parking lot of facility and was brought back into the facility. Resident read signage on door that stated, Push until alarm sounds door can be opened in 15 seconds Therefore, resident completed this task. Resident assessed for injury or adverse effect of elopement on 07/02/23. No injuries or adverse effect noted. MD/RP notified on 07/02/23. Wanderguard placed on 07/02/23. Elopement risk evaluation/assessment completed. Residents at risk of elopement have the potential to be affected. Elopement risk evaluations done on current residents in facility reviewed by nursing manager(s) for accuracy. Residents identified at risk will be reviewed for appropriate interventions. Completed by 07/07/23. Educate facility staff related to facility's wandering/elopement policy/procedures. Completed by 07/06/23. Educate facility staff on CMS's definition of elopement and wandering. Completed by 07/06/23. Elopement risks assessments will be reviewed for accuracy and interventions validated if indicated, during Quarterly Assessments. Monitored Monthly for 3 months. All new residents will have an Elopement risk assessment as part of the Admissions Assessments. Monitored Monthly for 3 months. Quarterly assessments will be reviewed as part of the MOS/Care planning process. Monthly for 3 months. The administrator will make rounds weekly for 4 weeks then monthly for 2 additional months to validate that residents' wanderguards are in place and functioning properly on each unit. Completed by 10/31/23. Ad Hoc QAPI held during daily morning meeting on 07/03/23. QAPI meeting held on 07/27/23. Medical Director was notified of the incident and plan for improvement on 07/02/23. This process will be reviewed in QAPI for a minimum of 3 months. AOC 07/07/23.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident (R)12) of 4 residents reviewed for falls received adequate supervision and assistance devices to prevent accidents. Specifically, R12 did not have a chair alarm in use as required and sustained a fall on 02/21/2023, which resulted in a fractured clavicle. The facility developed an intervention that required staff to provide one on one supervision for the resident. However, on 03/29/2023, staff failed to provide supervision as required and there was no documented evidence the chair alarm was utilized. R12 sustained another fall, which resulted in an abrasion. The facility further failed to ensure quarterly fall risk assessments were consistently completed for 1 (R1) of 4 residents reviewed for falls. Findings include: 1. Review of a facility policy titled, Protection From Harm Program, dated November 2022, specified it was the facility's policy that every resident has the right to the highest level of quality of life in an environment that prevents and/or reduces the number of falls and the resident will receive the most appropriate and effective fall prevention interventions to provide the safest and least restrictive environment. The policy indicated At the time of admission, a Registered Nurse is responsible for completing a Falls Risk Assessment to identify those residents that may be at risk for falls or repeated falls. This assessment is continued periodically throughout the residents stay. The Resident Care Team will review all assessment data and observations to develop a plan of care that prevents or reduces the number of falls or injuries from falls. The plan of care is adjusted or updated any time there is a change in condition that increases the resident's risk of falling. Examples of fall interventions (including but not limited to): were alarms and employee monitoring. A review of a Face Sheet indicated the facility admitted R12 on 06/03/2019 with diagnoses that included schizophrenia, schizoaffective disorder, bipolar type, unspecified dementia with behavioral disturbance, age related osteoporosis (bone disease), restlessness, and agitation. A review of R12's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/01/2023 revealed the resident had a Brief Interview for Mental Status (MDS) score of 0, which indicated the resident was severely cognitively impaired. Further review revealed R12 was independent with bed mobility, transfers, and walking. According to the MDS, the resident had not sustained any falls since the previous MDS assessment. In addition, the MDS revealed R12 utilized a bed alarm and chair alarm daily. Review of R12's Care Plan, dated 02/08/2023, revealed the resident was at risk for falls related to impaired safety awareness, cognitive deficits, use of psychotropic medication, weakness, unsteady gait, and a history of sitting on the floor. Interventions directed staff to provide toileting assistance as needed and with all transfers, provide hipsters (garments fitted with foam pads over both sides of the hip to protect from hip fracture during a fall), keep the bed in the lowest position with the brakes locked, ensure a bed alarm and call light were within reach at all times when the resident was in bed, ensure a self-release belt was in place and check placement when in a wheelchair. A review of the [Facility Name] Incident Report, dated 02/21/2023 at 11:58 PM, indicated R12 had an unwitnessed fall in their room. At 10:50 PM, a nurse walked by the resident's room and saw the resident on the floor at the foot of the resident's bed. The resident sat in an upright position. According to the report, the resident had orders for a chair alarm, but it was not in place at the time of the fall. The form indicated R12 had complaints of right shoulder pain but was assessed and no injury was noted. A review of R12's Hospital Emergency Department record dated 02/23/2023 at 3:00 PM indicated the reason for the visit was a shoulder injury and acute pain. The resident was diagnosed with a closed displaced fracture of the right clavicle. R12 was discharged back to the nursing home on 02/23/2023. A review of the facility's Initial 2/24-Hour Report dated 02/23/2023, that was sent to the state agency revealed the resident had a fall on 02/21/2023 and the cause of the fall was unknown. The resident was transferred to the hospital for x-rays and evaluation/treatment, and it was discovered the resident had sustained a right clavicle fracture. A review of the physical therapy (PT) Clinical Notes Report, dated 02/24/2023 at 8:43 AM, indicated a PT screen was completed due to the unwitnessed fall on 02/21/2023. The note indicated the resident had attempted to ambulate without assistance and sustained a fracture of the right clavicle as a result of the fall. The PT indicated the resident's current safety measures included one-to-one supervision during mealtimes and snack distribution, otherwise close observation every 15 minutes; hipsters; bed/chair alarms; assist with ambulation to the bathroom; bed in the lowest position; and assistance with toileting and ambulation but resident was noncompliant. According to the PT note, at the time of the fall, all safety measures were in place, with exception of chair alarm. According to the note, the PT recommended the use of chair alarm with a pressure pad. Further review of R12's Care Plan Report revealed the facility revised the resident's care plan on 02/24/2023 with an intervention that directed staff to provide one-on-one observation due to fall risk and a fractured clavicle. There was no documented evidence the facility revised the care plan with the PT's recommendation for a pressure pad chair alarm. A review of the [Facility Name] Incident Report, dated 03/29/2023 at 7:30 AM, indicated staff responded to a scream from the hallway, at 12:00 AM on 03/29/2023, and observed R12 on the floor. The resident stated, I fell down, and My knee hurt. A left knee abrasion that measured 1 centimeter (cm) by (x) 1 cm was noted. The protective devices/measures that were in use at the time of the incident included hipsters, half side rails, and a bed in low position. There was no documented evidence that one-on-one observation nor a bed alarm was implemented at the time of the fall. According to the report, the resident would be monitored more closely. A review of Therapeutic Assistant (TA)20's witness statement dated 03/29/2023 at 12:15 AM, indicated she was assigned to supervise R12 on 03/28/2023, beginning at 11:30 PM, The statement revealed TA20 had to leave the room to use the restroom and did not have time to ask another staff to relieve her. She indicated that as she came back from the bathroom, she heard the resident screaming. A review of a facility Record of Employee Counseling form, dated 03/30/2023, revealed that on 03/29/2023, TA20 was assigned to provide one-on-one coverage for R12, who previously experienced a fall that resulted in an injury. The TA's assignment was to observe the resident closely throughout her shift to keep the resident from having another fall. TA20 left the resident without having someone to relieve her to watch the resident until she returned. Observation of R12 on 04/26/2023 at 1:18 PM revealed the resident was in the dayroom and no injuries were observed. Attempts were made to contact TA20 for an interview on 04/26/2023 at 8:50 AM and at 5:50 PM, and on 04/27/2023 at 10:00 AM. There was no answer nor a voicemail option. During an interview on 04/27/2023 at 9:25 AM, Certified Nurse Assistant (CNA)12 stated residents' status could change daily, and staff must know the resident to provide safety measures such as call lights in reach, ensure bed/chair alarms are on, check on the resident every 15 minutes instead of an hourly rotation, and place the bed in low position. CNA12 stated R12 required assistance, but the resident would go to the restroom on their own which resulted in falls. As a result of one of the falls, the resident injured their shoulder. CNA12 did not recall the resident being on one-to-one supervision prior to the last fall. However, since the fall, staff always supervised the resident and kept the resident within arm's reach. CNA12 stated they must get another staff to relieve them to use the restroom. If not, the resident could fall and cause injury. CNA12 was unsure what other interventions should be implemented for R12, other than one-on-one supervision. During an interview on 04/27/2023 at 8:40 AM, Licensed Practical Nurse (LPN)1 revealed she was the charge nurse on the unit when R12 fell approximately one month prior. She stated it was at the beginning of her shift, before 1:00 AM in the morning, when she heard R12 scream. She went directly to the resident's room and observed the resident on the floor, between the bed and the door. The resident was in a sitting position and was alone, but no bed or chair alarm was sounding. When LPN1 entered the room, TA20, who was assigned to monitor the resident one-on-one, came from the hallway, and said she had to leave to go to the bathroom right away. LPN1 stated she was aware TA20 was previously sick and had been off work; however, the LPN stated the TA should not leave a resident that was as impulsive as R12 and had a recent history of falls. LPN1 also stated that the resident had a shoulder injury from a previous fall and must be monitored closely. The LPN recalled the resident had no injuries and no pain, vital signs were obtained, and she notified the supervisor with an incident report. Also, LPN1 stated she assisted R12 back to the chair and had another staff member provide one-on-one supervision. During an interview on 04/26/2023 at 2:00 PM, Medical Doctor (MD)8 revealed R12 continued to have chronic mental illness with active symptoms. Even with medications, the resident's symptoms were ongoing. He stated the resident demonstrated impulsiveness with sudden movements and unpleasant behaviors. He further stated the resident liked to sleep in their chair at night and would get up and grab for whatever the resident wanted. Also, the resident would transfer to the bathroom, even though the resident was now on one-to-one observation. MD #8 indicated the facility must provide staff education with episodic trainings when events and/or incidents occur, as in R12's recent case, to decrease resident risk of falls. During an interview on 04/26/2023 at 2:50 PM, MD7 revealed the on-call night physician notified her of R12's 02/21/2023 unwitnessed fall. The resident had complaints of right shoulder pain, and MD #7 was notified the resident was monitored. She stated the next morning, she assessed R12, and the resident did not demonstrate much pain. However, due to the resident's age and pain, she ordered an x-ray, which revealed a fracture of the clavicle. Therefore, she sent the resident to the hospital for further evaluation and then to the orthopedist, and a sling was placed. MD7 stated the resident was currently on one-on-one monitoring. The physician stated that due to the resident's impulsive behavior, attempts to self-transfer, and fall risk, staff must monitor the resident closely in their room and with transfers. She added the resident had another fall shortly after the first and she was concerned the resident reinjured their clavicle. Also, she was concerned that the staff left the resident alone and the resident had another unwitnessed fall when one-on-one supervision was required. MD7 stated the staff must follow the orders and monitor the residents for their safety. During an interview on 04/28/2023 at 6:23 PM, the Director of Nurses (DON) stated she was aware of R12's falls, as all incidents/accidents must go directly through her and the Administrator. The DON stated when a fall occurred, the nurse should do an incident report and assessments. She stated the incident report included the date and time of the occurrence, any injury, when the resident was last observed, notifications, devices and orders that were in use and not in use at the time, and corrective measures. The DON stated the investigation process involved witness statements and interviews to reveal how, why, and what happened to the resident in an effort to prevent further falls. She stated the interventions they put into place was dependent upon the cause of the fall, which was determined by the DON and the Administrator. She stated if they noted a pattern with falls, then they would collaborate with the physicians and directors. According to the DON, there were standard interventions for nurses and staff to implement. The DON stated the care plan was the resident's lifeline and provided the staff with the information needed to care for the residents and cater to their needs. The DON stated R12 required one-on-one since their last fall and was care planned appropriately. She stated was unsure whether the bed and/or chair alarm sounded when R12 sustained falls; however, she recalled checking the alarms with both incidents and found no issues. Related to the second fall, the DON stated the resident was required to have constant one-on-one supervision and monitoring. She stated the staff member (TA20) should never leave a resident without notifying someone to get relief. Unfortunately, she did not follow the orders nor the facility's expectations with R12, and the resident had another fall. The DON stated this was a perfect example of what could happen if interventions were not implemented. She stated the incident happened, putting the resident at further risk. During an interview on 04/28/2023 at 7:35 PM, the Administrator stated it was her expectation that staff ensure resident safety by reporting and completing the incident report in a timely manner, as well as a complete and thorough investigation to prevent it from reoccurring. The Administrator stated, like care plans, it was the facility's goal to prevent falls from happening and to protect residents from harm. 28196 2. Review of a facility policy titled, Falls Prevention & Management Program, revised in September 2022, indicated, Policy: Upon admission, residents are provided an assessment of their risk for falls; manipulation of the environment to prevent falls; and appropriate management of those who experience a fall. In the section titled, A. Delegation of Authority and Responsibilities, the policy indicated, 3. Registered Nurses are responsible for implementation and oversight of individualized residents fall prevention as follows: a. Assessing fall risk upon admission using the C.M. Tucker Fall Scale (Attachment A). Instructions in Attachment A indicated it was, To be completed by a Registered Nurse upon Admission (Initial), Annually, Quarterly, and Significant Change (SC). A review of R1's Face Sheet revealed the facility admitted the resident on 01/20/1999 with diagnoses that included psychosis, obsessive-compulsive disorder, legal blindness, age-related osteoporosis, and Alzheimer's disease. A review of a significant change Minimum Data Set (MDS), with an Assessment Reference Date of 12/16/2022, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident's vision was severely impaired. The MDS indicated the resident was independent with bed mobility and transfers and required setup assistance only with walking and locomotion on and off the unit. A review of R1's Care Plan Report, revised on 12/18/2022, indicated the resident had the potential for injury due to falls as evidenced by (AEB) congenital blindness and use of antidepressant medication. I A review of R1's Fall Risk Assessments completed from January 2021 through April 2023 revealed there were no quarterly fall risk assessments completed from 06/15/2021 through 12/14/2022. During an interview on 04/28/2023 at 6:30 PM with the Director of Nurses, she stated she expected resident fall risk assessments be completed on admission, quarterly, and after a fall. She indicated that fall risk assessments should be completed at least quarterly to determine if a resident's risk for falls had increased since their last assessment. During an interview on 04/28/2023 at 7:27 PM with the Administrator, she stated she expected staff to follow the policy for fall risk assessments.

Based on interviews, record review, video footage review, and facility policy review, the facility failed to protect 3 (Residents (R)11, R3, R15) of 11 residents' right to be free from mental/verbal/physical abuse by staff and residents. Specifically, the facility failed to protect R11's right to be from verbal abuse by Certified Nursing Assistant (CNA)17; failed to protect R3's right to be free from physical abuse by R2; and failed to protect R15's right to be free from physical and mental abuse by Therapeutic Assistant (TA)27 and TA28. Findings include: The facility's policy, titled, Protection From Harm Program, dated November 2022, indicated, A significant aspect of resident's rights is the right to be free from abuse/neglect. [The facilities] have a zero tolerance for any type of abuse. The policy indicated, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy revealed, Instances of abuse of all residents, irrespective of any mental or physical condition cause harm, pain or mental anguish. 'Willful' as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Further review of the policy revealed, Physical Abuse means hitting, slapping, pinching, kicking, and includes controlling resident behavior through corporal punishment. The policy indicated, Verbal abuse means any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within the hearing distance, regardless of their age, disability or ability to comprehend. According to the policy, Covered and non-covered [facility] employees and agency staff will be held responsible in the prevention of abuse and neglect of all residents. Further review of the policy revealed, When circumstances suggest that an employee has abused, neglected or exploited a resident, the employee is advised of the allegation, informed of his/her legal rights and is immediately removed from the facility until the incident has been thoroughly investigated. This action allows for the employee to be safe from further accusations/confrontations with the accusing resident, family member, or other [facility] employees and agency staffing and for the resident to feel safe and secure. The resident, if necessary, will be afforded the opportunity to relocate to another area of the facility if he/she no longer feels comfortable in the present setting. Under no circumstances will the facility tolerate any type of repercussions to the resident or employee for making a complaint regarding abuse or suspected abuse. 1. A review of R11's Face Sheet revealed the facility admitted the resident on 02/14/2023 with diagnoses that included type 2 diabetes mellitus, schizoaffective disorder- bipolar type, neurocognitive disorder, unsteadiness on feet, and difficulty in walking. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/14/2023, revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident had delusions but did not have any behavioral symptoms. A review of R11's Care Plan Report, initiated on 02/22/2023, indicated the resident had the potential for impaired psychosocial functioning related to diagnoses of major neurocognitive disorder and schizoaffective disorder, and related to being a recent admission to a new facility. Interventions directed staff to introduce themselves to the resident and explain their role in the resident's care and to maintain a calm, therapeutic environment, and structured routine. The care plan also directed staff to observe for any changes or decline in cognition, mood, or behavior and to report to the medical doctor/psychiatrist. A review of the facility's [Facility Name] Incident Report, dated 02/28/2023, revealed on 02/27/2023, Speech Language Pathologist (SLP) #26 witnessed a verbal interaction between CNA17 and R11. CNA17 made a statement that caused the resident to become upset. R11 responded with profanity and upon returning to their room the resident stated, I want to leave; he may try to do something while I'm sleeping. SLP26 reassured the resident that nothing would happen, and no one would harm the resident. Further review of the report revealed no injury to R11. A review of the facility's Accident/Incident Reporting Form, dated 03/03/2023, indicated that on 02/28/2023, SLP26 reported that on 02/27/2023 she witnessed a verbal interaction between CNA17 and R11. SLP26 overheard CNA17 tell R11 to move out of the way because the resident was moving too slowly. R11 responded to CNA17 by saying his/her legs were too weak, CNA17 then responded back to the resident and said, They will send you back where you came from. The resident stopped walking, turned around, and started using profanity at CNA17. After R11 returned to their room, the resident stated to SLP #26 that the resident wanted to leave because CNA17 may try to do something to them while sleeping. SLP26 explained to the resident that nothing would happen to them, and no one would harm the resident. When the Director of Nursing (DON) and Day Shift Supervisor interviewed CNA17 about the incident, CNA17 stated R11 was walking to their room, and as the resident walked past the CNA, the resident said they had to use the restroom. CNA17 stated he told the resident to hurry up, and he encouraged the resident to move faster. CNA17 stated he did not recall and was unsure whether he told the resident they would be sending the resident back where they came from. CNA17 was suspended and terminated. Further review revealed the facility substantiated that abuse occurred. During an observation and interview on 04/24/2023 at 10:20 AM, R11 was sitting on their bed in their room with no bruises or injuries observed. R11 stated no one had been mean or hurt them, and no one had made negative statements toward the resident. The resident did not recall any staff telling them to move out of the way or they were going to send them back. R11 denied the incident occurred. During an interview on 04/27/2023 at 12:50 PM, SLP #26 stated R11 received therapy from February 2023 to March 2023 related to the resident's history of dysphagia. SLP #26 stated the alleged abuse occurred on 02/27/2023 at 5:11 PM in the hallway. After the dinner meal, when staff were picking up the dinner trays for the residents that had completed their meals, SLP #26 stated she observed CNA17 with a tray in his hand. R11 was coming out of the dayroom into the hallway. CNA17 stated to the resident, Move out of the way, you are moving too slow. During that time, R11 was pushing their wheelchair and said their legs were weak. CNA17 then repeated the statement, You are moving too slow. Also, CNA17 stated to the resident, They will send you back where you came from. At that point, the resident turned around and addressed CNA17's comment with profanity. CNA17 again repeated, They are going to send you back where you came from. SLP26 stated a nurse from night shift was also present and was assisting with collecting trays. SLP26 stated the nurse approached her and said, I did not perceive the situation as abuse. The SLP stated at no point did CNA17 raise his voice or raise his hands to the resident. The CNA spoke in a leveled, non-elevated tone and nonaggressive actions. Further, SLP26 revealed she spoke with RN18 on 02/28/2023 at 8:48 AM, the next day, and informed her of the situation, and a report was filed. SLP26 also stated she had a conversation with the Administrator who told the SLP if she thought the incident was actual abuse on 02/27/2023, she should have reported immediately. During an interview on 04/27/2023 at 8:47 PM, CNA17 revealed he was no longer employed at the facility related to a false abuse allegation. CNA17 stated he recalled the incident with R11 well and briefly stated that he was only trying to motivate the resident to be more mobile and independent. CNA17 said that at no point in his health care career would he ever intentionally harm or verbally abuse a resident; however, if manipulating a resident to be more independent was abuse then, Yes, it was verbal abuse. During an interview on 04/27/2023 at 8:15 AM, Licensed Practical Nurse (LPN)13 revealed R11 came from another facility where staff created a bullying environment. She stated she had just walked up on the situation while gathering trays and heard CNA17 say to the resident, You got to speed it up; I don't want them to send you back. Subsequently, it caused the resident to trigger and instantly become aggressive, using profanity, and the resident replied, I'm not going back there. LPN13 stated she intervened, calmed the resident, removed CNA17 from the situation, and took over the resident's care. During an interview on 04/28/2023 at 6:23 PM, the DON stated verbal abuse did occur, and CNA17 was terminated. The DON stated abuse would not be tolerated at the facility and there was zero tolerance for any type of abuse. During an interview on 04/28/2023 at 7:35 PM, the Administrator also stated abuse of no type would be tolerated. He stated, We are a zero-tolerance facility. 2. A review of R15's Face Sheet revealed the facility admitted the resident on 03/212023, with diagnoses that included psychoactive substance use with persisting dementia, type 2 diabetes mellitus, encephalopathy, schizophrenia, and extrapyramidal and movement disorder. A review of R15's Care Plan Report, dated 03/23/2023, indicated the resident had altered thought processes and impaired decision making related to diagnoses of major neurocognitive disorder secondary to paranoid schizophrenia and depression. The resident had behavioral episodes of being combative and hard to redirect, a history of being agitated (poor insight and judgement), unpredictable behaviors with episodes of verbal threats of physical aggression, and ineffective understanding of safety. Interventions included for staff to provide one-on-one (1:1) observation for safety, observe and assess the resident's mood and behavior, observe for signs of psychological trauma such as increased agitation, and worried facial expression, change in sleeping pattern or appetite. Additional care plan interventions indicated staff should provide a calm therapeutic environment and structured routine, observe for escalating behaviors and be sure needs were met, when escalating behaviors were identified, remove the resident to a more quiet place and observe until behaviors are resolved; and if the resident was experiencing significant agitation that was impacting the resident's safety and the safety of others, contact the unit physician or on call physician. A review of the [Facility Name] Incident Report, revealed TA28 indicated that on 04/13/2023 at 5:12 PM, a resident offered R15 a brush comb. R15 then snatched the hairbrush from the resident and stood up from his/her wheelchair to fight. According to the report, TA #27 held the resident down while seated in the wheelchair while TA28 took the hairbrush from the resident. TA28 documented that the resident spit on his face. According to the report, initially, the facility planned to retrain the staff; however, on 04/14/2023, the facility reviewed video surveillance footage and suspended the staff. A review of the facility's Accident/Incident Reporting Form submitted to the state agency on 04/19/2023 as a five-day report revealed on 04/14/2023, the Administrator and Director of Nursing (DON) reviewed video footage related to a report of R15 spitting in TA #28's face. Upon reviewing the video footage from the dayroom, TA27, and TA28, used what appeared to be excessive force with R15. The investigation indicated after snatching the hairbrush, R15 attempted to stand up, and TA #27 came from behind the resident to calm them down by sitting R15 back in their wheelchair. R15 was viewed trying to punch the two [NAME], and TA27 was observed holding R15's arms at their side. According to the report, alleged physical abuse was not substantiated for TA #27; however, the facility substantiated psychological abuse on TA #28 because the TA was seen on video continuing to insight the [resident's] behavior by pointing his finger in the resident's face, and jumping at the resident which made the resident more agitated. On 02/25/2023 at 2:00 PM and 6:00 PM, and on 02/26/2023 at 5:46 PM, attempts were made to contact TA27; however, there was no answer and no option to leave a voicemail. On 02/25/2023 at 2:00 PM and 6:00 PM, and on 02/26/2023 at 5:46 PM, attempts were made to contact TA28; however, there was no answer and no option to leave a voicemail. During an interview on 04/27/2023 at 3:43 PM with Social Worker (SW) #32, he stated he had met and followed up with R15 after the incident to ensure their safety and recalled no issues. During an interview on 04/26/2023 at 1:30 PM with TA29, she stated she worked all units. The TA's duties were to sit with residents that required one-on-one observation and ensure their safety. She stated [NAME] were trained to supervise residents with behaviors, such as with R15. She said staff must redirect them and stay calm. [NAME] were allowed to prevent accidents, cue residents, and call for help, but should not restrain a resident. During an interview on 04/26/2023 at 10:48 AM with CNA14, she stated she did not witness the incident with R15 and the [NAME]. She stated staff, including [NAME], were required to stay calm and be aware of the resident's assessment and how they communicated. If a resident was agitated, staff must redirect and calm the resident and not take the resident's behavior personally. CNA14 stated staff were not permitted to force the resident or hold them down. CNA14 also stated staff were not permitted to use a raised voice, demine the resident, or point their fingers, or invade the resident's space because such behavior could be viewed as abuse. During an interview on 04/27/2023 at 8:15 AM with Licensed Practical Nurse (LPN)13, she revealed she did not witness the incident with R15; however, stated staff needed to approach R15 calmly and explain the situation. LPN13 added [NAME] were not allowed to touch the residents and were trained on proper intervention techniques. During an interview on 04/27/2023 at 3:50 PM, Therapeutic Director (TD) #31 revealed all [NAME] were trained regarding how to provide one-on-one observation, remaining at least an arms reach of the resident, not touching a resident, and most importantly, not restraining a resident in any way. He stated the [NAME] must also consider the resident's history and status, and redirect/deescalate the resident when they were having behaviors. TD31 stated the facility's expectations were to provide close monitoring and alert nursing staff if the resident's aggression continued. He stated the incident with R15 was shocking. TD31 stated neither TA27 nor TA28 had ever posed a threat to any residents and were not loud or threatening. TD31 stated he felt that in that situation, the staff were trying to get the item (brush) from the resident to prevent serious harm to residents and staff. During an interview on 04/28/2023 at 6:23 PM, the DON stated R15 was abused. The DON added she would have never expected that type of behavior, and she felt they were trying to prevent harm to R15 and the other residents. However, it was abuse and was unacceptable. The DON stated abuse would not be tolerated at the facility, and the facility had zero tolerance for any type of abuse. During an interview on 04/28/2023 at 7:35 PM, the Administrator stated it was her expectation that staff ensure resident safety and protect them from harm. She stated abuse of any type would not be tolerated. They were a zero tolerance facility. 28196 3. A review of R2's Face Sheet revealed the facility admitted the resident on 09/30/2014 with diagnoses that included schizophrenia, schizoaffective disorder, and dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/14/2023, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident did not have physical or verbal behavioral symptoms directed toward others. The MDS indicated the resident transferred and walked independently and was independent in locomotion on the unit. According to the MDS, the resident had no functional limitations in range of motion in the upper or lower extremities. The MDS indicated the resident used a walker for mobility. A review of R2's Care Plan, revised 01/12/2023, indicated the resident had the potential for impaired adjustment and psychosocial functioning in a long-term care facility related to their diagnoses and history of behavior problems. The care plan indicated that on 01/12/2023, the resident hit another resident multiple times. Interventions directed staff to encourage the resident to notify staff when angry or dysregulated (inability of a person to control or regulate their emotional responses to provocative stimuli). The care plan indicated the resident agreed to leave area when upset. A review of R3's Face Sheet revealed the facility admitted the resident on 05/19/2009 with diagnoses that included intracranial injury with loss of consciousness, dementia with behavioral disturbance, personality change, obsessive-compulsive disorder, schizoaffective disorder, and quadriplegia. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/31/2023, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had other behavioral symptoms not directed toward others, such as verbal/vocal symptoms, like screaming and disruptive sounds, daily during the review period. The MDS indicated the resident was totally dependent on staff for bed mobility, transfers, locomotion on the unit, dressing, eating, toilet use, and personal hygiene. The MDS indicated the resident had functional limitations in range of motion in their bilateral upper and lower extremities and used a wheelchair for mobility. Review of R3's Care Plan Report, revised 01/12/2023, revealed a problem related to behaviors and cognition. The care plan indicated the resident had behavior and mood problems related to their diagnoses and became verbally abusive toward the staff and yells out at unseen others when agitated. The care plan indicated that on 01/12/2023 the resident was struck by another resident in the day area with no injuries noted. Interventions directed staff to monitor R3 when the resident was up in the chair, alternate areas when the resident was up in the chair, and attempt one-on-one (1:1) interaction with the resident in a quiet/calm setting during periods when the resident was yelling and screaming out. A review of the [Facility Name] Incident Report, dated 01/12/2023 at 11:00 AM, revealed R3 was sitting in the day room when R2 hit R3 in the mouth. The report also indicated that another resident in the day room observed what happened and informed the nurse on the unit about the incident. R3 was assessed, and a small abrasion was noted on the resident's left upper gums. The two residents were separated, and an investigation was immediately initiated. Review of the 5-day investigation report, dated 01/17/2023, revealed that during the investigation into the incident, Medical Doctor (MD)7 and MD8 viewed video footage with the Director of Nursing (DON). It was noted that on 01/12/2023 at approximately 11:03 AM, R2 was seen yelling across the day room at R3, appearing to tell them to shut up. This was determined by reading R2's lips. The report indicated that in the video footage R2 was seen using their walker to walk over to R3 and then was seen punching R3 on the left side of their face approximately six times. The report indicated that during the investigation, R2 was asked by MD7 and MD8 about the incident, and the resident said R3 was making too much noise and kept banging on their wheelchair. R2 was apologetic and stated that they let their emotions take over their brain and stated they would never do it again. The report indicated R2 was placed on close observation every 30 minutes for seven days for aggression toward their peers. The report indicated R2 did not have a history of hitting other residents; this was an isolated incident. On 04/28/2023 at 5:50 PM, the surveyor viewed video footage of the incident described above with the DON. R2 and R3 were observed in the day room, sitting approximately 12 to 15 feet apart prior to the incident. R2 was sitting in a chair with their rolling walker positioned next to them, and R3 was sitting in a reclined geriatric chair. R2 stood up, ambulated toward R3, and R2 punched R3 six times on the left side of their face with a closed fist. Another resident (the only other person in the room) was observed to leave the day room and return approximately three minutes later with a staff member, who immediately separated R2 and R3. During an interview on 04/27/2023 at 8:58 AM, Certified Nursing Assistant (CNA)5 stated R2 could stand and walk with their walker. She said staff had to encourage R2 to get up and go to the day room and not sleep all day. She said that for the most part, R2 was usually calm and respectful. She said she was only aware of this one time that the resident lashed out and hit R3. CNA5 stated that the two residents were in the day room, and there were not any staff in the day room when the incident occurred. She said the only other person in the day room at that time was another resident, who came out of the day room and reported the incident to the staff at the nurses' station. CNA5 said she ran to the day room to see what had happened, found R2 standing over R3 with a mad face, and R3's lip was bleeding. CNA5 said she asked R2 what had happened, and R2 told her it was just too much noise because R3 liked to yell and would not be quiet, and that was why R2 hit R3. CNA5 stated R3 could not do anything for themself, required total care, and screams all day long. She said that when R3 was yelling, staff checked on the resident frequently, at least every 30 minutes, to see if the resident was okay or if they needed anything. During an interview on 04/27/2023 at 9:55 AM, Registered Nurse (RN)6 stated she recalled an incident earlier this year between R2 and R3. She said she heard a resident calling for help and when she got to the day room, CNA5 told her that R2 had hit R3. She indicated that when she entered the day room, R2 was back in their chair. RN6 stated that R3 had a slight abrasion on their gum line, but nothing that needed first aid. RN6 said R2 told her that R3 was being too loud. She said R2 had never tried to do anything like that in the past that she was aware of. She also indicated that R2 and R3 were no longer allowed to be in the day room by themselves without a staff member. RN6 said they rotated the common areas where the residents were placed because R3 was defenseless. During an interview on 04/28/2023 at 5:58 PM, the DON said she expected residents to be free from abuse and confirmed that R2, who had a BIMS score of 15 which indicated intact cognition, intentionally physically abused R3, who was defenseless. During an interview on 04/28/2023 at 7:25 PM, the Administrator said she expected residents to be free from abuse from other residents, staff, and visitors.

Based on record review, facility policy review, and interviews, the facility failed to ensure allegations of abuse were reported timely for 1 (Resident (R)11) of 11 residents reviewed for abuse. Findings included: The facility's policy, titled, Protection From Harm Program, dated November 2022, indicated, A significant aspect of resident's rights is the right to be free from abuse/neglect. The facility will have a zero tolerance for any type of abuse. The policy indicated, If a covered or non-covered [facility] employee or agency staffing member has reason to believe that a resident has been or is likely to be abused, neglected or exploited or if a covered or non-covered [facility] employee or agency staffing member suspects that a resident has been a victim of any other crime they must insure safety of the resident and report the incident immediately, within 24 hours, but no longer than 24 hours. If serious bodily injury has occurred then the report must be made within two hours. A review of R11's Face Sheet revealed the facility admitted the resident on 02/14/2023 with diagnoses that included type 2 diabetes mellitus, schizoaffective disorder- bipolar type, neurocognitive disorder, unsteadiness on feet, and difficulty walking. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/14/2023, revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident had delusions but did not have any behavioral symptoms. A review of R11's Care Plan Report, initiated on 02/22/2023, indicated the resident had the potential for impaired psychosocial functioning related to diagnoses of major neurocognitive disorder and schizoaffective disorder and recent admission to a new facility. Interventions directed staff to introduce themselves to the resident and explain their role in the resident's care, maintain a calm, therapeutic environment, and a structured routine. The care plan also indicated for staff to observe for any changes or decline in cognition, mood, or behavior and to report to the medical doctor/psychiatrist. A review of the facility's [Facility Name] Incident Report, dated 02/28/2023, revealed that on 02/27/2023, Speech Language Pathologist (SLP) #26 witnessed a verbal interaction between Certified Nursing Assistant (CNA)17 and R11. CNA17 made a statement that caused the resident to become upset. R11 responded with profanity and upon returning to their room, the resident stated, I want to leave; he may try to do something while I'm sleeping. SLP #26 reassured the resident that nothing would happen, and no one would harm the resident. Further review of the report revealed there was no injury to R11; however, the SLP did not report the incident until 02/28/2023, the day after the incident. During an interview on 04/27/2023 at 12:50 PM, Speech Language Pathologist SLP26 stated R11 was on therapy case load for skilled services. After the dinner meal on 02/27/2023 at 5:11 PM, in the hallway, staff were picking up the dinner trays for the residents that had completed their meals. SLP26 stated she observed CNA #17 with a tray in his hand. R11 was coming out of the dayroom into the hallway. CNA17 stated to the resident, Move out of the way, you are moving too slow. During that time, R11 was pushing their wheelchair and said their legs were weak. CNA17 then repeated the statement, You are moving too slow. Also, CNA17 stated to the resident, They will send you back where you came from. At that point, the resident turned around and addressed CNA17's comment with profanity. CNA17 again repeated, They are going to send you back where you came from. SLP26 stated a nurse from night shift duty was also present at the time and was assisting with collecting trays. SLP26 stated the nurse approached her and said, I did not perceive the situation as abuse. SLP26 revealed she spoke with RN #18 on 02/28/2023 at 8:48 AM, the next day, and informed her of the situation, and an abuse report was filed. During an interview on 04/27/2023 at 8:15 AM, Licensed Practical Nurse (LPN)13 indicated she was familiar with R11. The resident was very pleasant and cooperative. LPN13 stated the resident came from a bullying environment from their last facility. She stated that regarding the incident with R11, she had just walked up on the situation while gathering trays and heard CNA17 say to the resident, You got to speed it up; I don't want them to send you back. Therefore, it caused the resident to trigger and instantly become aggressive with profanity, and the resident replied, I'm not going back there. There was no documented evidence LPN13 reported the incident as an allegation of abuse. LPN13 stated she felt it was an educational moment for CNA17. During an interview on 04/28/2023 at 6:23 PM, the Director of Nursing (DON) stated as soon as she was made aware of the abuse allegation, on 02/28/2023, she reported to all the appropriate authorities. The DON stated reporting was a must. She stated even if staff were not sure, it must be reported. During an interview on 04/28/2023 at 7:35 PM, the Administrator stated it was her expectation that staff ensure resident safety by reporting immediately.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure the care plan was implemented for 1 (Resident (R)12) of 4 sampled residents reviewed for accidents. The facility developed a care plan that included an intervention that required staff to provide one on one supervision for R12 due to fall risk and a fractured clavicle. However, on 03/28/2023, the facility failed to supervise R12, and the resident sustained a fall. Findings include: A review of the facility's Resident Care Conference policy, dated February 2023, indicated, Resident Care Conferences (RCC) are herby established for the purpose of providing the most effective utilization of available resources in the planning and re-evaluation of an individualized care and treatment plan which is based on a comprehensive assessment. The RCC of each unit shall meet weekly. Special reviews are scheduled as needed. All staff engaged in any aspect of the care of residents are considered members of the RCC. There was no documented evidence the policy addressed the facility's procedure for ensuring resident care plans are implemented. A review of a Face Sheet indicated the facility admitted R12 on 06/03/2019 with diagnoses that included schizophrenia, schizoaffective disorder, bipolar type, unspecified dementia with behavioral disturbance, age related osteoporosis (bone disease), restlessness, and agitation. A review of R12's annual Minimum Data Set (MDS), with an Assessment Reference Date of 02/01/2023 revealed the resident had a Brief Interview for Mental Status (MDS) score of 0, which indicated the resident was severely cognitively impaired. According to the MDS, R12 was independent with bed mobility, transfers, and walking. According to the MDS, the resident had not sustained any falls since the previous MDS assessment. Review of R12's Care Plan, dated 02/08/2023, revealed the resident was at risk for falls related to impaired safety awareness, cognitive deficits, use of psychotropic medication, weakness, unsteady gait, and a history of sitting on the floor. On 02/24/2023, the facility revised the resident's care plan with an intervention that directed staff to provide one-on-one observation due to fall risk and a fractured clavicle. A review of the [Facility Name] Incident Report, dated 03/29/2023 at 7:30 AM, indicated staff responded to a scream from the hallway, at 12:00 AM on 03/29/2023, and observed R12 on the floor. The resident stated, I fell down, and My knee hurt. A left knee abrasion that measured 1 centimeter (cm) by (x) 1 cm was noted. The protective devices/measures that were in use at the time of the incident included hipsters, half side rails, and a bed in low position. There was no documented evidence that one-on-one observation was implemented at the time of the fall. A review of Therapeutic Assistant (TA)20's witness statement dated 03/29/2023 at 12:15 AM, indicated she was assigned to supervise R12 on 03/28/2023, beginning at 11:30 PM, The statement revealed TA20 had to leave the room to use the restroom and did not have time to ask another staff to relieve her. She indicated that as she came from the bathroom, she heard the resident screaming. Attempts were made to contact TA20 for an interview on 04/26/2023 at 8:50 AM and at 5:50 PM, and on 04/27/2023 at 10:00 AM. There was no answer nor a voicemail option. During an interview on 04/27/2023 at 8:40 AM, Licensed Practical Nurse (LPN)1 revealed she was the charge nurse on the unit when the fall occurred. She stated before 1:00 AM that morning, she heard R12 scream. When LPN1 entered the room, TA20, who was assigned to monitor the resident one-on-one, came from the hallway, and said she had to leave to go to the bathroom right away. LPN1 stated she was aware TA20 was previously sick and had been off work; however, the LPN stated the TA should not leave a resident that was as impulsive as R12 and had a recent history of falls. LPN1 also stated that the resident had a shoulder injury from a previous fall and must be monitored closely. During an interview on 04/26/2023 at 2:50 PM, Medical Doctor (MD)7 revealed due to R12's impulsive behavior, attempts to self-transfer, and fall risk, staff must monitor the resident closely in their room and with transfers. The resident had previously had a clavicle fracture and she was concerned the resident reinjured their clavicle. Also, she was concerned that the staff left the resident alone and the resident had another unwitnessed fall when one-on-one supervision was required. MD7 stated the staff must monitor residents for their safety. During an interview on 04/28/2023 at 6:23 PM, the Director of Nurses (DON) stated R12 was required to have constant one-on-one supervision and monitoring. She stated the staff member (TA20) should never leave a resident without notifying someone to get relief. Unfortunately, TA20 did not follow the orders nor the facility's expectations with R12, and the resident had another fall. The DON stated this was a perfect example of what could happen if interventions were not implemented. She stated the incident put the resident at further risk. During an interview on 04/28/2023 at 7:35 PM, the Administrator stated, like care plans, it was the facility's goal to prevent falls from happening and to protect residents from harm.

Based on policy review, record review, observations, and interviews, the facility failed to ensure 1 of 7 resident, (R)1 was free from physical abuse. Specifically, Certified Nursing Assistant (CNA)1 was observed pouring water and CNA2 was observed slapping R1 abruptly until he folded up in a fetal position. The action of the CNAs violated the resident's right to be free from abuse and mistreatment. Findings include: Review of the facility's policy titled, ''C.M. Tucker Jr Nursing Care Center Protection from Harm Program,'' revised 11/2021, revealed C.M Tucker Nursing Care Center has a zero tolerance for any type of abuse. It is expected that all covered and non-covered DMH employees and agency staffing members carry out their duties in such a manner that the safety and rights of all residents are protected to the fullest extent possible. Review of the ''Initial 2/24-Hour Report,'' provided by the facility, dated 04/29/22 indicated CNA3 reported on 04/29/22 that CNA1 dumped hot water and soap on a resident and another CNA (CNA2) slapped the same resident so hard that he curled up in a fetal position. CNA3 was terminated for reporting the abuse 2 days late. CNAs 1 and 2 were terminated for substantiated abuse against the resident. Review of the letter titled, Suspension without pay Pending Investigation provided by the facility, dated 04/29/22 indicated that CNA1 & CNA2 had been suspended pending investigation. Review of the letter titled, Notice of termination provided by the facility, dated 05/06/22 indicated CNA1 & CNA2 had been terminated due to the investigation revealing that there was sufficient evidence to show that they did commit patient abuse. Review of R1's electronic medical record (EMR) Face sheet tab indicated that he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's EMR Care Plan located in the RAI (Resident Assessment Instrument) tab of the EMR revealed episodes of anxiety, verbal abuse, paranoia, accusations and anger related to his diagnoses. Threatens staff frequently and spits on them at times, is not easily re-directed. Will strike out and hit staff and peers when he is angry. He exhibits combative and aggressive behavior. He has a history of smearing feces, stripping, spitting, yelling, cussing, provoking verbal physical accusations with peers and making sexually remarks toward females. The care plan additionally identified R1 has a need for activities due to his [CONDITION(S)] with psychotic features along with sexually inappropriate comments and inappropriate behaviors. 4/29/22: Alleged staff to R1 abuse. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/26/22 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating that R1 had no severe cognitive impairment. During an observation and interview on 07/15/22 at 1:40 PM, R1 revealed he was very happy to be at CM Tucker Jr. His room was homelike and spacious. His bathroom was very neat and well kept. During an additional interview with R1 on 07/15/22 at 2:30 PM, he stated he did not remember an incident of anyone pouring water on him. He stated that the staff here are treating him well and he enjoys living here. He states that he has been at this facility for [AGE] years. He has no complaints. During an interview on 07/15/22 at 2:40 PM with Nurse Manager (NM)1, she stated she was not a full-time staff member when the incident occurred. She stated that CNA2 was a registered aid and only helped the CNAs when they were short. CNA1 was a full-time employee and worked the hours of 7a-3p. She confirmed that the personnel responsible for the water incident had been suspended and terminated. During an interview with the Director of Nursing (DON) on 07/15/22 at 2:50 PM, she stated that the incident had been substantiated and the personnel had been suspended and terminated. The DON stated that CNA1 poured soap and water over R1's head after he allegedly grabbed CNA2's butt. CNA2 then slapped R1 across the head and stated, I bet you won't do that again. The DON informed me that the temperature of the water had been undetermined by SLED upon their investigation. There was no injury to R1. Interviews for CNAs 1 and 2 were attempted via telephone with no success.

Based on record review, interview, and review of the facility's policy titled Protection From Harm Program, the facility failed to timely report allegations of resident-to-resident abuse to the Bureau of Certification, Ombudsman Office, and Local Law Enforcement for one of two allegations of abuse reviewed. Findings include: Facility's policy review: Definitions: K. Resident to Resident Altercation is defined as an altercation involving physical contact between two residents. 11.0 Reporting of Abuse Policy: C.M. Tucker, Jr. Nursing Care Center will report all incidents of alleged or substantiated abuse to proper government agencies as outlined by state, federal, and local regulations governing the operation of long-term nursing care facilities. The information in the reports will include, but will not be limited to: Name of resident Sex and age of resident Where and when the incident happened Description of actions taken Preventive measures to prevent incidents from recurring DHEC is requiring the reporting of Resident-to-Resident abuse, an altercation involving physical contact between two residents. Resident to Resident altercation will be reported to the appropriate agencies and must be recorded on an SCDMH Form M-300. The facility admitted Resident (R) 3 on 1/13/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility admitted R2 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility incident report reviewed on 10/5/21 at approximately 2:00 PM revealed that on 8/21/21, R3 came up the hallway, started hitting resident R2 in the face area and stated s/he wanted R2 out of his/her room. Interviews were attempted with R2 and R3 with no success on 10/5/21. In an interview with the Director of Nursing (DON) on 10/05/2021 at approximately 2:48 PM, s/he stated that s/he was told by the Administrator not to report resident to resident altercations to the Bureau of certification, ombudsman, or local law enforcement.

Based on record review and interview the facility failed to develop written policies and procedures to prohibit and prevent abuse that included immediately reporting all alleged violations of abuse to the Administrator or designee within two (2) hours. When an incident of alleged abuse by the Environmental Service Worker towards Resident #1 was reported on 7/1/2020, staff failed to report the allegation to the Administrator or designee within two (2) hours. Findings include: Review of the facility's Protection from Harm Program dated September 2019 indicated, It is expected that all covered and non-covered Department of Mental Health (DMH) employees and agency staffing members carry out their duties in such a manner that the safety and rights of all residents are protected to the fullest extent possible. A significant aspect of resident's rights is the right to be free from abuse/neglect. The facilities of (name of facility) have a zero tolerance for any type abuse. Verbal abuse means any use of oral, written, or gestured language that willfully incudes disparaging and derogatory terms to resident, or their families, or within the hearing distance, regardless of their age, disability or ability to comprehend .If a covered or non-covered DMH employee or agency staffing member has reason to believe that a resident has been or is likely to be abused, neglected or exploited or if a covered or non-covered DMH employee or agency staffing member suspects that a resident has been a victim of any other crime, they must insure safety of the resident and report the incident immediately but no later than 24 hours. If serious bodily injury has occurred then the report must be made within two (2) hours. This policy had not been updated to reflect the regulatory requirement to report allegations of abuse within two (2) hours. Review of Directive 885-07 dated 1/1/2007 indicated Subject: Abuse, Neglect or Exploitation of Patients and Clients Prohibited under the heading of Reporting, it was indicated All Department of Mental Health employees having reason to believe that a patient or client has been abused .must report the circumstances giving rise to such belief in accordance with this paragraph. If the alleged abuse, neglect .occurred in a Department of Mental Health (DMH) facility or residential program operated or contracted for operation by DMH, the employee must: Personally, report the incident to their supervisor. Review of Resident #1's record indicated the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the resident's Annual Minimum Data Set (MDS) with the Assessment Reference Date of 3/25/2020 indicated the Brief Interview for Mental Status (BIMS) score was three (3) indicating the resident was severely cognitively impaired. This MDS indicated the resident had moderate difficulty in hearing, did not have a hearing aid, sometimes understood others and usually made self understood. This MDS indicated the resident had behavioral symptoms not directed toward others, hallucinations and delusions. Review of the MDS indicated the resident was totally dependent on two (2) person physical assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the MDS indicated walking did not occur and locomotion on and off the unit completed with total dependence of one (1) staff. Review of Resident #1's care plan dated 8/19/2020 indicated, close observation for potential for harm to self or others. A problem of potential for combative behaviors as evidence the resident will strike out at peers and staff. A problem of impaired cognition due to [MEDICAL CONDITION] disorder, neurocognitive disorder with behavioral disorder, anxiety, [MEDICAL CONDITION], normal pressure [DIAGNOSES REDACTED] with shunt, and right sided [MEDICAL CONDITION]. The resident curses, is combative, and resistive to care at times. The resident is impulsive, highly distractible, punches, kicks, throws things during care. The resident has frequent delusions, is very paranoid, psychotic, and makes false accusations. Review of the (Name of facility) Incident Report indicated the incident occurred on 7/1/2020 at 2:00 p.m. This report indicated Certified Nursing Aid (CNA#1) on Unit 134 in hallway in front of resident #1's room. CNA#1 documented While sitting in the nursing station documenting I (CNA#1) overheard custodial worker cursing at one (1) of our residents. He/she stated, Leave me the (explicative) alone and shut the (explicative) up, I'm sick of you. At that moment I (CNA #1) reported it to his/her (custodial worker) supervisor. The Incident Report was faxed to the State Survey Agency on 7/1/2020 at 7:56 p.m. Review of the Public Safety Officer's report dated 7/1/2020 at 2:00 p.m. revealed, On the above date and time Subject #1's (Environmental Service Worker's) employment with the SC (South Carolina) Department of Mental Health was terminated by the Complainant (Environmental Service Director) due to her/his use of profane language towards Victim #1 (Resident #1) while on Unit 134 in Roddey Pavilion. Upon arrival, this Reporting Officer observed Subject #1 on the patio in front of Roddey Pavilion using profane language because he/she was upset about being terminated. Subject #1 stated he/she did not use profane language towards any resident. Subject #1 was escorted off the premises by Public Safety Officer and this Reporting Officer. On call investigator (name of Captain) was notified of this incident by (name of Sargent) and SLED (South Carolina Law Enforcement Department) was notified of the incident by nursing staff. There are no further incidents or injuries to report. Total time: 1.00 hour. Review of Incident Witness Statement dated 7/2/2020 at 7:46 a.m. given by Environmental Services Supervisor regarding the incident on 7/1/2020 at 1:20 p.m. noted, I was informed by (name of Environmental Services Director) that employee and Resident had a few words. Employee (name of Environmental Services Worker) had cursed at the resident. I and (Environmental Services Director) had asked (Environmental Services Worker) what happen on the unit. (Environmental Services Worker) was upset and yelling. After a few minutes of trying to hear his/her side (Environmental Services Worker) was upset, yelling and cursing. (Environmental Services Director) then asked if she would walk to the lobby. As we're walking in the main hall, (Environmental Services Worker) is still making a scene. Review of the Incident Witness Statement given on 7/2/2020 at 1:45 p.m. by Physician #1, regarding the incident of resident #1 on 7/1/2020 at 2:00 p.m. indicated I heard a (man/woman) from environmental services raise the volume of his/her voice in response to something (Resident #1) said to him/her. Words were indistinct to me but appeared he/she took what was said to him/her personally. Event was quickly over. In an interview on 10/22/2020 at 11:45 a.m. the Administrator indicated he/she was out of the building that day on 7/1/2020 when the incident occurred. The Assistant Director of Nursing (ADON#1) was acting as the Administrator's designee on that date. In an interview on 10/22/2020 at 2:00 p.m. ADON #1 indicated he/she was not notified of the incident until 7:56 p.m. on 7/1/2020 when the Public Safety Officer (PSO) called him/her to ask if the incident had been reported. ADON #1 asked, What incident? The PSO said we escorted a lady/gentleman off the grounds who was cussing a resident around 2:00 p.m. ADON #1 stated the Receptionist in the lobby said it was around 2:50 p.m. when the Receptionist called the PSO because the (name of alleged perpetrator) Environmental Services Worker was cussing at the Environmental Services Director. ADON #1 indicated the Environmental Services Director's statement was that CNA#1 came to his/her office to notify him/her of some lady cursing a resident. He/she went to unit with (Environmental Supervisor #2) and escorted the Environmental Services Worker off the unit to the lobby. In a telephone interview on 10/22/2020 at 1:05 p.m. CNA #1 indicated she/he had heard really loud cursing coming from outside Resident #1's room. CNA #1 stated the (Doctor) overheard him/her (Environmental Services Worker). CNA#1 indicated he/she first went to a senior housekeeper who said he/she did not want to deal with it and that CNA#1 should go to the Environmental Services Supervisor. CNA#1 said she got Environmental Services Director and Environmental Services Supervisor #2. When questioned if CNA#1 had told his/her supervisor, CNA#1 said he/she let the nursing supervisor know first. CAN #1 stated, I don't know if (Registered Nurse (RN) Supervisor #1) did anything. In an interview on 10/22/2020 at 1:30 p.m. the Environmental Services Director indicated, It was between 1:00 and 2:00 p.m. when the Environmental Services Worker had cursed at Resident #1. CNA#1 had come to tell me about what he/she heard. I immediately went down there to talk to (Environmental Service Worker) and I took her/him off the unit. She/he went into a tirade. She/he was calling me names. I escorted her/him to the front lobby. It was still between 1:00 and 2:00 p.m. Maybe a little after 2:00 PSO was called. They came immediately. Environmental Services Worker had been on the job two (2) months. He/she was from a temporary staff agency. He/she had no other incidents. He/she(Environmental Services Director) had no other complaints about him/her. I was his/her direct supervisor. I did not keep any files on him/her. He/she had education on verbal abuse. In an interview on 10/22/2020 at 10:47 a.m., the Administrator indicated the Environmental Services Worker who was the alleged perpetrator, had the Hand in Hand/Abuse training when he/she first started. The Administrator shared a document showing the Environmental Services Worker's training which included on 5/12/2020 having completed Hand in Hand/Abuse training as well as Patient Rights. In an interview by phone on 10/22/2020 at 3:44 p.m. Physician #1 indicated, I was just there for the aftermath. He/she (Environmental Services Worker) was sent home. I did not really hear; I just saw the aftermath. I saw upsetness. The CNAs looked upset; people were moving about. He/she (Environmental Services Worker) left abruptly. I can't remember if I heard cussing. I did not see any residents. I was not watching closely. I can't remember if (RN Supervisor#1) was there. In an interview on 10/22/2020 at 1:35 p.m. RN Supervisor #1 said he/she had worked on 7/1/2020 on Unit 134. He/she said she/he did not hear any staff cussing loudly. He/she stated Physician#1 said something about them being loud. He/she said he/she went to look, but didn't see anything. He/she did hear someone being loud. He/she said he/she did not see CNA#1. CNA#1 did not say anything to him/her about anyone being loud. He/she said he/she had been the Clinical Nurse Leader that day on Unit 134. He/she said that there had been an on-unit baby shower in the conference room which he/she attended around 1:15 p.m. for her/his 30-minute break. An attempt was made to talk to Resident #1, but he/she did not respond to the questions. In an interview on 10/22/2020 at 1:47 p.m. ADON#2 indicated he/she was the ADON on 7/1/2020. He/she said he/she had spoken to RN Supervisor #1, but he/she did not think he/she had been a direct witness. He/she did not document that he/she had spoken to RN Supervisor #1. He/she indicated he/she was not focused on reporting but was instead focused on abuse. In an interview on 10/22/2020 at 3:05 p.m. the Environmental Services Director indicated that he/she reported directly to the Administrator. The ADON was notified later. The main thing was to get him/her (Environmental Service Worker) out of the building. He/she indicated he/she was trained to report incidents of abuse to the Administrator within a 24 hour period. In a telephone interview on 10/23/2020 at 2:20 p.m. the Director of Nursing said The policy is what it is, like the Administrator indicated that it will be reported in two (2) hours only if there is physical harm and (Resident #1) was not physically harmed.

Based on record review and interview the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, to the Administrator but not later than two (2) hours after the allegation was made, when the events that caused the allegation involved abuse. When an incident of alleged abuse by the Environmental Service Worker towards Resident #1 was reported on 7/1/2020, the supervisor responding did not report to the Administrator or designee within two (2) hours. Findings include: Review of the facility's Protection from Harm Program dated September 2019 indicated It is expected that all covered and non-covered Department of Mental Health (DMH) employees and agency staffing members carry out their duties in such a manner that the safety and rights of all residents are protected to the fullest extent possible. A significant aspect of resident's rights is the right to be free from abuse/neglect. The facilities of (name of facility) have a zero tolerance for any type abuse. Verbal abuse means any use of oral, written, or gestured language that willfully incudes disparaging and derogatory terms to resident, or their families, or within the hearing distance, regardless of their age, disability or ability to comprehend .If a covered or non-covered DMH employee or agency staffing member has reason to believe that a resident has been or is likely to be abused, neglected or exploited or if a covered or non-covered DMH employee or agency staffing member suspects that a resident has been a victim of any other crime, they must insure safety of the resident and report the incident immediately but no later than 24 hours. If serious bodily injury has occurred then the report must be made within two (2) hours. This policy had not been updated to reflect the updated regulatory requirement to report abuse in two (2) hours. Review of Directive 885-07 dated 1/1/2007 indicated Subject: Abuse, Neglect or Exploitation of Patients and Clients Prohibited under the heading of Reporting, it was indicated All Department of Mental Health employees having reason to believe that a patient or client has been abused .must report the circumstances giving rise to such belief in accordance with this paragraph. If the alleged abuse, neglect .occurred in a Department of Mental Health (DMH) facility or residential program operated or contracted for operation by DMH, the employee must: Personally, report the incident to their supervisor. Review of Resident #1's record indicated the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the resident's Annual Minimum Data Set (MDS) with the Assessment Reference Date of 3/25/2020 indicated the Brief Interview for Mental Status (BIMS) score was three (3) indicating the resident was severely cognitively impaired. This MDS indicated the resident had moderate difficulty in hearing, did not have a hearing aid, sometimes understood others and usually made self-understood. This MDS indicated the resident had behavioral symptoms not directed toward others, hallucinations and delusions. Review of the MDS indicated the resident was totally dependent on two (2) person physical assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the MDS indicated walking did not occur and locomotion on and off the unit completed with total dependence of one (1) staff. Review of Resident #1's care plan dated 8/19/2020 indicated, close observation for potential for harm to self or others. A problem of potential for combative behaviors as evidence the resident will strike out at peers and staff. A problem of impaired cognition due to [MEDICAL CONDITION] disorder, neurocognitive disorder with behavioral disorder, anxiety, [MEDICAL CONDITION], normal pressure [DIAGNOSES REDACTED] with shunt, and right sided [MEDICAL CONDITION]. The resident curses, is combative, and resistive to care at times. The resident is impulsive, highly distractible, punches, kicks, throws things during care. The resident has frequent delusions, is very paranoid, psychotic, and makes false accusations. Review of the (Name of facility) Incident Report indicated the incident occurred on 7/1/2020 at 2:00 p.m. This report indicated Certified Nursing Aid (CNA#1) on Unit 134 in hallway in front of resident #1's room. CNA#1 documented While sitting in the nursing station documenting I (CNA#1) overheard custodial worker cursing at one (1) of our residents. He/she stated, Leave me the (explicative) alone and shut the (explicative) up, I'm sick of you. At that moment I (CNA #1) reported it to his/her (custodial worker) supervisor. The Incident Report was faxed to the State Survey Agency on 7/1/2020 at 7:56 p.m. Review of the Public Safety Officer's report dated 7/1/2020 at 2:00 p.m. revealed, On the above date and time Subject #1's (Environmental Service Worker's) employment with the SC (South Carolina) Department of Mental Health was terminated by the Complainant (Environmental Service Director) due to her/his use of profane language towards Victim #1 (Resident #1) while on Unit 134 in Roddey Pavilion. Upon arrival, this Reporting Officer observed Subject #1 on the patio in front of Roddey Pavilion using profane language because he/she was upset about being terminated. Subject #1 stated he/she did not use profane language towards any resident. Subject #1 was escorted off the premises by Public Safety Officer and this Reporting Officer. On call investigator (name of Captain) was notified of this incident by (name of Sargent) and SLED (South Carolina Law Enforcement Department) was notified of the incident by nursing staff. There are no further incidents or injuries to report. Total time: 1.00 hour. Review of the Incident Witness Statement given on 7/2/2020 at 1:45 p.m. by Physician #1, regarding the incident of resident #1 on 7/1/2020 at 2:00 p.m. indicated I heard a (man/woman) from environmental services raise the volume of his/her voice in response to something (Resident #1) said to him/her. Words were indistinct to me but appeared he/she took what was said to him/her personally. Event was quickly over. In an interview on 10/22/2020 at 11:45 a.m. the Administrator indicated he/she was out of the building that day on 7/1/2020 when the incident occurred. The Assistant Director of Nursing (ADON#1) was acting as the Administrator's designee on that date. In an interview on 10/22/2020 at 2:00 p.m. ADON #1 indicated he/she was not notified of the incident until 7:56 p.m. on 7/1/2020 when the Public Safety Officer (PSO) called him/her to ask if the incident had been reported. ADON #1 asked, What incident? The PSO said we escorted a lady/gentleman off the grounds who was cussing a resident around 2:00 p.m. ADON #1 stated the Receptionist in the lobby said it was around 2:50 p.m. when the Receptionist called the PSO because the (name of alleged perpetrator) Environmental Services Worker was cussing at the Environmental Services Director. ADON #1 indicated the Environmental Services Director's statement was that CNA#1 came to his/her office to notify him/her of some lady cursing a resident. He/she went to unit with (Environmental Supervisor #2) and escorted the Environmental Services Worker off the unit to the lobby. In a telephone interview on 10/22/2020 at 1:05 p.m. CNA #1 indicated she/he had heard really loud cursing coming from outside Resident #1's room. CNA #1 stated the (Doctor) overheard him/her (Environmental Services Worker). CNA#1 indicated he/she first went to a senior housekeeper who said he/she did not want to deal with it and that CNA#1 should go to the Environmental Services Supervisor. CNA#1 said she got Environmental Services Director and Environmental Services Supervisor #2. When questioned if CNA#1 had told his/her supervisor, CNA#1 said he/she let the nursing supervisor know first. CAN #1 stated, I don't know if (Registered Nurse (RN) Supervisor #1) did anything. In an interview on 10/22/2020 at 1:30 p.m. the Environmental Services Director indicated, It was between 1:00 and 2:00 p.m. when the Environmental Services Worker had cursed at Resident #1. CNA#1 had come to tell me about what he/she heard. I immediately went down there to talk to (Environmental Service Worker) and I took her/him off the unit. She/he went into a tirade. She/he was calling me names. I escorted her/him to the front lobby. It was still between 1:00 and 2:00 p.m. Maybe a little after 2:00 PSO was called. They came immediately. Environmental Services Worker had been on the job two (2) months. He/she was from a temporary staff agency. He/she had no other incidents. He/she (Environmental Services Director) had no other complaints about him/her. I was his/her direct supervisor. I did not keep any files on him/her. He/she had education on verbal abuse. In an interview on 10/22/2020 at 10:47 a.m., the Administrator indicated the Environmental Services Worker who was the alleged perpetrator, had the Hand in Hand/Abuse training when he/she first started. The Administrator shared a document showing the Environmental Services Worker's training which included on 5/12/2020 having completed Hand in Hand/Abuse training as well as Patient Rights. In an interview by phone on 10/22/2020 at 3:44 p.m. Physician #1 indicated, I was just there for the aftermath. He/she (Environmental Services Worker) was sent home. I did not really hear, I just saw the aftermath. I saw upsetness. The CNAs looked upset; people were moving about. He/she (Environmental Services Worker) left abruptly. I can't remember if I heard cussing. I did not see any residents. I was not watching closely. I can't remember if (RN Supervisor#1) was there. In an interview on 10/22/2020 at 1:35 p.m. RN Supervisor #1 said he/she had worked on 7/1/2020 on Unit 134. He/she said she/he did not hear any staff cussing loudly. He/she stated Physician#1 said something about them being loud. He/she said he/she went to look but didn't see anything. He/she did hear someone being loud. He/she said he/she did not see CNA#1. CNA#1 did not say anything to him/her about anyone being loud. He/she said he/she had been the Clinical Nurse Leader that day on Unit 134. He/she said that there had been an on-unit baby shower in the conference room which he/she attended around 1:15 p.m. for her/his 30-minute break. An attempt was made to talk to Resident #1, but he/she did not respond to the questions. In an interview on 10/22/2020 at 1:47 p.m. ADON#2 indicated he/she was the ADON on 7/1/2020. He/she said he/she had spoken to RN Supervisor #1, but he/she did not think he/she had been a direct witness. He/she did not document that he/she had spoken to RN Supervisor #1. He/she indicated he/she was not focused on reporting but was instead focused on abuse. In an interview on 10/22/2020 at 3:05 p.m. the Environmental Services Director indicated that he/she reported directly to the Administrator. The ADON was notified later. The main thing was to get him/her (Environmental Service Worker) out of the building. He/she indicated he/she was trained to report incidents of abuse to the Administrator within a 24 hour period. In a telephone interview on 10/23/2020 at 2:20 p.m. the Director of Nursing said, The policy is what it is, like the Administrator indicated that it will be reported in two (2) hours only if there is physical harm and (Resident #1) was not physically harmed.

Based on observation, record review and interview, it was determined the facility failed to treat 3 of 3 sampled residents with dignity during a noon meal service (Residents #50, #[AGE], and #[AGE]). The administrator identified ten additional residents who required assistance with eating on ward 130. One sampled resident (Resident #50) had a food tray placed beside him and was not assisted with eating for 25 minutes. Two Certified Nurse Aides (CNAs) #1 and #2 were observed standing beside two sampled residents (Residents #[AGE] and #[AGE]) while assisting the residents to eat. The findings included: 1. A quarterly Minimum Data Set assessment (MDS), dated [DATE], documented Resident #50 was totally dependent on staff for all activities for daily living (ADLs). He was impaired in range of motion with upper and lower extremities, and he was cognitively impaired in decision making. On 0[DATE] at 11:25 AM, resident #50 was observed sitting in the dining room. A food tray was placed on the table next to the resident. CNAs #1 and #2 were observed to be feeding two (Residents #[AGE] and #[AGE]) sampled residents. At 11:49 AM, CNA #2 started to assist Resident #50 with eating. CNA #2 was asked why the resident had not been fed when his food tray was placed beside him. She stated because they were already feeding other residents. She was asked if it would have been possible to have fed two residents at the same time. She didn't respond. On 01/29/20 at 12:00 PM, the Director of Nurses (DON) was asked what an acceptable amount of time was for a food tray to sit beside a resident before staff assisted the resident to eat. The DON stated 45 minutes was an acceptable amount of time for a resident to sit with his food beside him. She was asked if it was a dignity issue for the resident to wait until everyone had eaten before he was fed. She added that it wouldn't bother her. She stated if there wasn't enough staff someone would have to wait to eat. The DON was asked how many residents a CNA could feed at the same time. She stated two. She was asked if it would have been possible for the three residents, who required assistance, to be positioned together so the CNAs could feed two residents at the same time. She stated maybe. 2. A quarterly MDS assessment, dated 12/03/19, documented Resident #[AGE] was totally dependent on staff for all activities of daily living (ADLs). 3. A quarterly MDS assessment, dated [DATE], documented Resident #[AGE] was totally dependent on staff for all ADLs. On 0[DATE] at 11:25 AM, the noon meal pass was observed. CNAs #1 and #2 were observed to be standing while feeding two (Residents #[AGE] and #[AGE]) sampled residents. CNA #1 was asked what the facility policy was related to standing while feeding a resident. She stated they were supposed to sit beside the resident; but she stood because, It is more convenient for me. CNA #2 was asked what the facility policy was related to standing while feeding a resident. She stated they were supposed to sit beside the resident. On 01/29/20 at 12:00 PM, the DON was asked what the facility policy was related to staff standing while assisting residents to eat. She stated they should sit. She was informed of the observations. She said, They should sit.

Based on observation, interviews and record review, the facility failed to develop a care plan for the use of a waist belt for one of 28 residents (Resident #9). The findings included: Resident #9 was admitted with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident's cognition was severely impaired. She required total assistance with bed mobility and transfers. The MDS did not indicate any use of restraints. During an observation on 0[DATE] at 2:43 PM, Resident #9 was observed sitting up in a wheelchair. She had a blue soft Velcro belt around her waist. She was not able to be interviewed. A review of the resident's care plans did not indicate the use of a waist belt. A review of the current physician's order indicated there was no order for the waist belt. Resident #9's medical record did not have a clear indication for the use of the waist belt. During an interview on 0[DATE] at 3:24 PM, Nurse Manager (NM) #1 reviewed the medical record and indicated she thought the resident wore the waist belt for safety. She stated the resident had a history of [REDACTED]. She stated the resident was able to release the belt independently. She verified there was no physician's order or care plan for the use of the waist belt. During a follow up interview on 0[DATE] at 4:21 PM, she stated up until a few weeks ago, the resident was able to release the waist belt independently. She stated her cognition had declined and she was no longer able to release the belt intentionally. NM #1 stated the resident was not able to get up on her own and required two-person assistance. NM #1 indicated it wasn't clear when the waist belt was implemented. During an interview on 01/30/20 at 9:46 AM, Minimum Data Set Nurse (MDS) #1 reviewed the resident's medical record and verified there was no care plan for the use of the waist belt. She stated whenever she collected the data for the MDS, the resident might have been evaluated in the bed and she didn't see the belt. She stated if there had of been a physician's order written for the waist belt, then she would have seen the resident had the waist belt and developed a care plan for it. She stated there should have been a care plan for the use of the waist belt.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Behaviors for one of 28 sampled residents (Resident #[AGE]). The findings included: Resident #[AGE] had [DIAGNOSES REDACTED]. Record review of nurse's notes, dated for 11/28/19, revealed on that day Resident #[AGE] was verbally abusive and using profanity. Record review of nurse's notes dated for 12/04/19, revealed on that day Resident #[AGE] again had increased aggression, was verbally abusive and swearing at staff. Record review of the annual MDS, dated [DATE], revealed Resident #[AGE] was moderately cognitively impaired. The MDS also revealed Resident #[AGE] had no behavioral issues during the 7-day assessment period between 11/28/19 through 12/04/19. During an interview on 01/30/20 at 4:28 PM, the Social Worker (SW) specified she completed Sections D, E, F and Q on the comprehensive MDS. The SW reviewed the nurse's notes and stated, That was my error. The SW indicated Resident #[AGE]'s behavior should have been documented on the annual MDS. During an interview on 01/30/20 at 11:18 AM, the Administrator stated it was his expectation that staff code the resident's status accurately on the assessment.

Based on observations, record reviews and interviews, the facility failed to ensure that residents on [MEDICAL TREATMENT] were distributed/served meals in accordance with food safety standards. Resident #20 and #65 had [MEDICAL TREATMENT] lunches removed from the facility refrigerator and given to residents without being placed in an insulated container with an ice pack. The meals were in a white paper bag, inside a clear plastic bag. Two of 2 [MEDICAL TREATMENT] residents sampled. The findings included: The facility admitted Resident #65 on 9/26/08 with [DIAGNOSES REDACTED]. An individual resident interview on 10/02/18 at approximately 8:35 AM revealed that Resident #65's [MEDICAL TREATMENT] lunch was not packed in an insulated container with ice packs. The resident stated he/she received items like macaroni salad, turkey sandwich, apple juice and fruit cup. The resident further stated that his/her meals were hot when he/she gets to eat and he/she does not like hot macaroni salad. A random observation on 10/02/18 at approximately 8:46 AM revealed a lunch was packed in the unit refrigerator (Ward 130) in a white paper bag inside a clear plastic bag. There were no insulated containers or ice packs observed. The lunch had a note that included macaroni salad, turkey sandwich, fruit cocktail and apple juice cup. The residents are transported to [MEDICAL TREATMENT] by facility staff. The facility admitted Resident #20 on 5/11/16 with [DIAGNOSES REDACTED]. A random observation on 10/02/18 at approximately 9:43 AM revealed facility staff in progress of transported resident for [MEDICAL TREATMENT] appointment. The resident meal was inside a white paper bag inside a clear plastic bag. The resident sandwich's, fruit cup or juice was not in an insulated container with an ice pack. An interview and observation on 10/02/18 at approximately 11:58 AM with Registered Nurse (RN) #2 and Certified Nursing Assistant (CNA) #1 confirmed the observation. CNA #1 stated the resident meals are transported to [MEDICAL TREATMENT] in the white paper bags inside the clear paper bags. CNA #1 further stated there were no insulated containers to transport resident's food. An observation of the unit refrigerator (Ward 132) revealed there were no ice packs to use if insulated containers were available. An interview on 10/02/18 at approximately 12 PM with Registered Dietitian #2 revealed the resident's meals should be provided in an insulated container and not in paper bagged meals. An interview and observation on 10/03/18 at approximately 8:39 AM with Licensed Practical Nurse (LPN) #3 revealed there were no ice packs for insulated containers on Ward 130. LPN #3 stated he/she had never seen any ice packs on the unit when transporting resident meals for [MEDICAL TREATMENT].

Based on interview and record review the facility failed to provide written notification of transfer/discharge for 1 of 2 residents reviewed for hospitalization . Resident # 39 was discharged to the hospital on [DATE] but the facility did not provide written notification to resident representative or send a copy of notification to the ombudsman. The findings included: Resident # 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing notes on 10/2/18 at approximately 3:24 PM revealed the resident went out to the hospital on [DATE] to rule out aspiration pneumonia. No documentation that written notification was provided to the family was found in the resident's chart. Review of notification to ombudsman on 10/2/18 at approximately 4:10 PM revealed the ombudsman did not receive written notification of Resident # 39 transfer until 9/13/18. Interview with administrator on 10/2/18 at approximately 4:18 PM confirmed the ombudsman did not receive written notification until 9/13/18. Review of policy for notification of transfers to ombudsman and responsible party on 10/3/18 at approximately 9:19 AM revealed the following: When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis.

Based on review of facility files and interview, the facility failed to maintain a safe environment, free from abuse for Resident #4. One of six residents reviewed for Abuse. The findings included: Review of Resident #4's medical record revealed [DIAGNOSES REDACTED]. Review of the resident's care plan revealed disruption in usual sleep pattern related to [DIAGNOSES REDACTED]. Interventions were updated on 5/31/18 to include when in deep sleep staff may need to gently shake to arouse. Review of the Physician's Progress Note dated 3/29/18 revealed the resident continued to require 1:1 observation to prevent him/her from placing non-food items in his/her mouth. Review of the resident's care plan revealed choking risk due to picking up and chewing nonedible items (gloves, paper, etc.) was listed as a problem area. Interventions to the problem were listed on the care plan and included to remove all paper towels or small objects from the resident's room and 1:1 observation for PICA behavior. Review of the Incident Report dated 5/31/18 revealed on 5/22/18 at approximately 7:00 AM CNA #2 was cursing in Resident #4's room, the CNA threw a paper airplane at the resident, and shoved the resident to awaken him/her. The Director of Nursing was notified by two therapeutic aides who witnessed the incident. Therapeutic Assistant #1's facility-obtained statement dated 5/31/18 regarding incident of physical/mental abuse on 5/22/18 indicated the incident occurred at 7:05 AM. During morning preparation of Resident #4, CNA #2 repeatedly teased the resident. Before Therapeutic Assistant #1's relief showed up there were two other residents present in the room. CNA #2 cursed at them all and shoved Resident #4 multiple times. CNA #2 made a paper plane and hit Resident #4 in the face intentionally. Therapeutic Assistant #2's facility-obtained statement dated 5/31/18 indicated s/he witnessed CNA #2 talking about the facility and its' employees, as well as the residents of [ENTITY]. CNA #2 was using vulgar and hateful words. CNA #2 was forceful in waking up Resident #4 the first time. The CNA woke the resident a second time by scaring him/her so much that s/he stood and grabbed CNA #2's arms. CNA #2 then made a paper airplane and hit the resident in the face with it, while laughing. CNA #2's facility-obtained statement dated 6/1/18 indicated s/he went to shake Resident #4 because s/he was breathing shallow and s/he wasn't coherent and CNA #2 thought something was wrong. Resident #4 hadn't slept the prior night and was awake for the third time that CNA #2 had him/her on 11-7 shift. When the resident sleeps s/he is sound asleep and nothing will wake him/her up. CNA #2 has had to put a cold wash cloth on his/her face before to wake him/her up. CNA #2 made a small airplane so they would have something to do while they waited for breakfast trays to come and threw the plane towards the resident, not at him/her directly in the face. In a telephone interview with the surveyor on 6/27/18 at approximately 1:44 PM, Therapeutic Assistant #1 stated that s/he had been at the facility 2-3 weeks when the incident occurred. It was at the end of his/her shift around 7:15 AM. CNA #2 came into resident #4's room and was cursing at staff and residents. Therapeutic Assistant #1 had been assigned 1:1 with Resident #4 on 3rd shift. CNA #2 was talking about how s/he had guns and shoots them, s/he was ranting. CNA #2 started shaking Resident #4 and made a paper airplane and threw it at Resident #4. CNA #2 had brought his/her 1:1 resident into Resident #4's room. The resident did not reside in the room and Therapeutic Assistant #1 stated s/he should not have brought the resident into Resident #4's room. In a telephone interview with the surveyor on 6/27/18 at approximately 1:37 PM, Therapeutic Assistant #2 stated s/he walked in to start his/her shift and stopped by Resident #4's room to say hi to a coworker. S/He went to the nurses' station and when S/he came back, CNA #2 was standing in the doorway ranting about nonsense. Resident #4 is not supposed to sleep during the day and CNA #2 said s/he needed to wake him/her up. CNA #2 slapped the resident on the chest. The resident went to get up and CNA #2 said to stay there. Resident #4 went back to sleep. CNA #2 touched the resident's chest near his/her ribs and the resident stood up and grabbed the CNA by the arm. CNA #2 told the resident to sit down and s/he did. CNA #2 started cursing and talking about how staff was racist. Therapeutic Assistant #2 asked CNA #2 about what flowsheet s/he needed to fill out for 1:1. CNA #2 looked through and took an older sheet and made a paper airplane with it. S/He threw the airplane and it hit the wall, CNA #2 made a comment that if s/he hit Resident #4 he would be awake. CNA #4 went and picked up the paper airplane and threw it at the resident and hit him/her.

Based on review of facility files and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. Resident #1 was placed on 1:1 observation for suicidal ideation. The resident obtained a butter knife and was cutting his/her wrists while on 1:1 observtion. Resident #3 was noted to have a fall that caused a subarachnoid hemorrhage. The resident's alarm was not on at the time of the fall. Two of five residents reviewed for incidents/accidents. The findings included: Review of an Incident Report dated 12/15/17 at 9:50 PM revealed Resident #1 got up to go to the bathroom when a utensil fell . Resident #1 stated it was a knife and s/he wanted it back. Staff told the resident no s/he could not have it back. Resident #1 was using the knife to cut his/her right wrist. It was done under the covers. Resident made no noise to indicate s/he was doing anything or make any movements. First aid was administered to include the area was cleansed with normal saline, triple antibiotic ointment applied and open to air. Resident #1 was noted with several reddened areas to the right wrist and one superficial mark with 2 opened areas 1 cm and 1.5 cm from using a butter knife. Resident #1's [DIAGNOSES REDACTED]. Nursing Progress Notes were reviewed from 10/31 /17- 6/11/18 and noted resident continues on 1:1 observation for [MEDICAL CONDITION]. On 12/15/17 at 11:40 PM the nurse documented staff reported resident had scratched his/her right wrist with a butter knife- when observed resident had 3 superficial scratches and 1 cm plus 1.5 cm laceration areas on the right wrist. Review of the resident's care plan revealed altered thought process related to [MEDICAL CONDITION] disorder with behavioral disturbance as evidenced by [MEDICAL CONDITION] and history of multiple attempts to commit suicide was identified as a problem area. Interventions and approaches were included on the care plan and included 1:1 observation related to suicidal ideation. Review of Resident #1's physician's orders [REDACTED]. A psychiatry consult was ordered ASAP. The orders included plastic silverware only and assess resident's environment every shift and as needed for potential risks and potential dangers. Review of the Physician Restraint Orders and Progress Note dated 12/4/17 revealed 1:1 observation was ordered. Resident voiced wanting to kill him/herself, told counselor from psychology s/he would wrap a cord around his/her neck and told the physician s/he would stab him/herself with a pencil. Review of the facility's Policy and Procedure Directive for restraints revealed 1:1 observation requires the resident to be within sight and arms' reach of the staff at all times. Documentation for 1:1 included the assigned CNA documents every hour in the Restraint Flow sheet. The Licensed Nurse documents in the Nurses Progress Notes every shift addressing the resident's condition and behavior during that time period. The facility was unable to locate the resident's Restraint Flow sheet for 12/15/17. Review of the Activity Calendar for December 2017 revealed on 12/15/17 at 5:00 PM there was a resident Christmas Party in the large dining room. In an interview with the surveyor on 6/12/18 at approximately 10:58 AM, HS Coordinator #1 (counselor) stated Resident #1 was moved to the secure unit a short time after admission. HS Coordinator #1 started working with the resident when s/he moved to the secure unit. Resident #1 said s/he heard the train near the facility and s/he would go out and lay on the tracks, that is what prompted the resident's move to the secure unit. Resident #1 will express suicidal thoughts or that s/he wants to hurt him/herself off and on. Sometimes s/he will tell you how s/he plans to kill him/herself. HS Coordinator #1 stated 1:1 means the person sitting with them has to be within arms reach of the resident. If a resident expresses a suicidal plan then they are placed on 1:1. The sitter should keep eyes on the resident at all times. HS Coordinator #1 stated Resident #1 made a suicide attempt with a butter knife. The resident took the butter knife off of his/her meal tray. In an interview with the surveyor on 6/12/18 at approximately 11:50 AM, CNA #1 stated s/he started his/her 1:1 assignment with Resident #1 at 6:00 PM on 12/15/17 from the function in the large dining room. They went to the resident's room when s/he received the resident because Resident #1 wanted to lay down. There was pizza in the dining room for the residents. Resident #1 got up to go the bathroom and CNA #1 heard a ting ting ting, Resident #1 asked if s/he could have his/her knife back so s/he could finish cutting him/herself. The resident was in bed on his/her side with their back facing CNA #1. The resident stays in bed a lot and just lays there. The knife was a metal butter knife. The resident never flinched or said a word while s/he was in bed. The resident never changed clothes after coming back to his/her room. They went to the bathroom and then walked to the supervisor's office. Resident #1 had scratches on his/her wrist. In an interview with the surveyor on 6/12/18 at approximately 12:30 PM, the Director of Psychology stated they will assess the resident if they express [MEDICAL CONDITION] and decide if they need close observation or 1:1. They have the policies provided, but do not have specific interventions. They assess the resident and decide what they need individually. In an interview with the surveyor on 6/12/18 at approximately 1:40 PM, activity therapist #1 stated they have big events for residents in the main dining room across from the nursing supervisor's office. The room is off the main hall and not on a unit. The night of the incident they had strawberry shortcake and pizza. The party was the Christmas party and started at 5:00 PM. They had plastic spoons available for residents. Review of Resident #3's medical record revealed a Nursing Progress Note dated 12/4/17 at 8:15 PM by RN (Registered Nurse) #1 that indicated s/he observed the resident sitting at the dayroom in front of the table in his/her wheelchair. Asked staff to find CNA to put resident into bed. Revisited dayroom observing resident away from the table, laying on the floor on his/her left side with bleeding. Nurse remained with resident and 911 was called immediately. Time of incident documented as 8:03 PM with last observation of resident prior to incident noted as 8:00 PM. Note alarm was off. Staff education completed by RN #1 on 12/4/17 indicated to ensure chair alarm is functioning and ensure no residents are left in the dayroom unsupervised. Review of the Incident report dated 12/4/17 at 8:03 PM revealed fall, resident observed on his/her left side with bleeding and wheelchair behind him/her. The resident was last observed at 8:00 PM sitting up in the wheelchair at the table. The Incident Report indicated the resident's chair alarm was off. Alarm off with Velcro self-release belt. An ice pack was applied to laceration with pressure near the left eye and 911 was called. Resident was noted to have a subarachnoid hemorrhage in addition to the laceration per hospital report. Review of the facility's Five-day follow-up report dated 12/8/17 revealed the resident sustained [REDACTED]. It appears from the video views, s/he loosened his/her self-release belt and began leaning forward shifting his/her weight causing the wheelchair to tip thus generating a fall. In a telephone interview with the surveyor on 6/14/18 at approximately 12:01 PM, RN #1 stated Resident #3 ate dinner in the dayroom the day of the incident on 12/4/17. After dinner, RN #1 saw Resident #3 in the dayroom. S/he went to get a CNA and the CNA was busy. Resident #3 was not moving around in the dayroom. As RN #1 was walking back in the dayroom, s/he saw Resident #3 on the other side of the room on the floor bleeding. The resident was sitting at the table when s/he first saw the resident. The resident's self-release belt was off when s/he fell . RN #1 went and checked the resident's wheelchair after the resident went out to the hospital and the alarm box was on the chair. RN #1 stated s/he did not hear the alarm sound when the resident fell .

Based on review of facility files and interview, the facility failed to follow their Protection from Harm Program for Resident # 4. One of six residents reviewed for abuse. The findings included: Review of Resident #4's medical record revealed [DIAGNOSES REDACTED]. Review of the resident's care plan revealed disruption in usual sleep pattern related to [DIAGNOSES REDACTED]. Interventions were updated on 5/31/18 to include when in deep sleep staff may need to gently shake to arouse. Review of the Physician's Progress Note dated 3/29/18 revealed the resident continued to require 1:1 observation to prevent him/her from placing non-food items in his/her mouth. Review of the resident's care plan revealed choking risk due to picking up and chewing nonedible items (gloves, paper, etc.) was listed as a problem area. Interventions to the problem were listed on the care plan and included to remove all paper towels or small objects from the resident's room and 1:1 observation for PICA behavior. Review of the Incident Report dated 5/31/18 revealed on 5/22/18 at approximately 7:00 AM CNA #2 was cursing in Resident #4's room, the CNA threw a paper airplane at the resident, and shoved the resident to awaken him/her. The Director of Nursing was notified by two therapeutic aides who witnessed the incident. Therapeutic Assistant #1's facility-obtained statement dated 5/31/18 regarding incident of physical/mental abuse on 5/22/18 indicated the incident occurred at 7:05 AM. During morning preparation of Resident #4, CNA #2 repeatedly teased the resident. Before Therapeutic Assistant #1's relief showed up there were two other residents present in the room. CNA #2 cursed at them all and shoved Resident #4 multiple times. CNA #2 made a paper plane and hit Resident #4 in the face intentionally. Therapeutic Assistant #2's facility-obtained statement dated 5/31/18 indicated s/he witnessed CNA #2 talking about the facility and its' employees, as well as the residents of [ENTITY]. CNA #2 was using vulgar and hateful words. CNA #2 was forceful in waking up Resident #4 the first time. The CNA woke the resident a second time by scaring him/her so much that s/he stood and grabbed CNA #2's arms. CNA #2 then made a paper airplane and hit the resident in the face with it, while laughing. CNA #2's facility-obtained statement dated 6/1/18 indicated s/he went to shake Resident #4 because s/he was breathing shallow and s/he wasn't coherent and CNA #2 thought something was wrong. Resident #4 hadn't slept the prior night and was awake for the third time that CNA #2 had him/her on 11-7 shift. When the resident sleeps s/he is sound asleep and nothing will wake him/her up. CNA #2 has had to put a cold wash cloth on his/her face before to wake him/her up. CNA #2 made a small airplane so they would have something to do while they waited for breakfast trays to come and threw the plane towards the resident, not at him/her directly in the face. In a telephone interview with the surveyor on 6/27/18 at approximately 1:44 PM, Therapeutic Assistant #1 stated that s/he had been at the facility 2-3 weeks when the incident occurred. It was at the end of his/her shift around 7:15 AM. CNA #2 came into resident #4's room and was cursing at staff and residents. Therapeutic Assistant #1 had been assigned 1:1 with Resident #4 on 3rd shift. CNA #2 was talking about how s/he had guns and shoots them, s/he was ranting. CNA #2 started shaking Resident #4 and made a paper airplane and threw it at Resident #4. CNA #2 had brought his/her 1:1 resident into Resident #4's room. The resident did not reside in the room and Therapeutic Assistant #1 stated s/he should not have brought the resident into Resident #4's room. In a telephone interview with the surveyor on 6/27/18 at approximately 1:37 PM, Therapeutic Assistant #2 stated s/he walked in to start his/her shift and stopped by Resident #4's room to say hi to a coworker. S/He went to the nurses' station and when S/he came back, CNA #2 was standing in the doorway ranting about nonsense. Resident #4 is not supposed to sleep during the day and CNA #2 said s/he needed to wake him/her up. CNA #2 slapped the resident on the chest. The resident went to get up and CNA #2 said to stay there. Resident #4 went back to sleep. CNA #2 touched the resident's chest near his/her ribs and the resident stood up and grabbed the CNA by the arm. CNA #2 told the resident to sit down and s/he did. CNA #2 started cursing and talking about how staff was racist. Therapeutic Assistant #2 asked CNA #2 about what flowsheet s/he needed to fill out for 1:1. CNA #2 looked through and took an older sheet and made a paper airplane with it. S/He threw the airplane and it hit the wall, CNA #2 made a comment that if s/he hit Resident #4 he would be awake. CNA #4 went and picked up the paper airplane and threw it at the resident and hit him/her. Review of the facility's Protection from Harm Program in the section labeled Introduction A significant aspect of resident's rights is the right to be free from abuse/neglect. The facilities of C.M. Tucker, Jr. Nursing Care Center have a zero tolerance for any type of abuse. This document reflects the facility's commitment to abuse/neglect prevention and is organized as follows: screening of applicants; training; prevention; identification of abuse; investigation of incidents; protection; reporting of abuse; and facility response In the section labeled Definitions part A Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a care taker, of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical condition cause harm, pain or mental anguish. Willfull as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Part E Mental abuse means, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Part I Physical Abuse means hitting, slapping, pinching, kicking, and includes controlling resident behavior through corporal punishment. Part N Verbal Abuse means any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within the hearing distance, regardless of their age, disability, or ability to comprehend.

Based on record review and interview, the facility failed to ensure that care and services were provided to a resident as evidenced by physician ordered treatments that were not completed daily but signed off as provided. Resident #32, 1 of 1 resident reviewed for neglect, did not have daily dressing changes to a diabetic ulcer for 11 days. The findings included: The facility admitted Resident #32 with [DIAGNOSES REDACTED]. Review of the Physicians Orders at 12:24 PM on 08/08/17 revealed an order dated 05/26/17 to Cleanse Right 3rd digit (tip) with Kara Klenz, dry area, apply (thin layer) of TAO (Triple Antibiotic Ointment), cover with 2x2 secure with [MEDICATION NAME] tape daily x 21 days . At 11:58 AM on 08/08/17, review of the Consults revealed a Podiatry Consultation note dated 06/08/17 that stated The patient last had a podiatry visit 2 weeks ago. There were orders left for the patient to have the dressing changed daily with application of triple antibiotic and a dry sterile dressing for 21 days. The report further indicated The dressing to the right foot is dated 05/28/2017, 10:00 a.m. This would imply that the dressing has not been changed for approximately 11 days. The dressing is soaked through with blood and smells of urine. At this time strikethrough noted on the plantar aspect of the dressing with blood and brown unidentifiable substance in the dressing. There is urine odor noted. During an interview on 08/10/17, the Director of Nursing confirmed that 5 nurses had failed to provide treatments to Resident #32 over a period of 11 days. The Director of Nursing also confirmed the podiatrist had signed and dated the dressing he/she applied on 05/27/17 which was how the doctor knew the dressing had not been changed. On 8/10/17 at 3:40 PM, the facility Administrator was notified that Immediate Jeopardy and /or Substandard Quality of Care existed as of 05/28/2017 and was ongoing related to resident neglect when the podiatrist found that daily dressing changes had not been done as ordered for 11 days. On 8/11/17 at 12:13 PM, a Credible Allegation of Compliance (A(NAME)) was received from the facility. Allegation of Compliance included the following: A) Changes were made in the C. M.(NAME)Jr Nursing Care Center/Roddey Pavilion Protection from Harm Program Policy related to include this statement: Covered Non-Covered and Agency Staffing Members/DMH (Department of Mental Health). There will be a Zero Tolerance' as it relates to Abuse, Neglect and Exploitation of residents/patients and clients. Our employee disciplinary standard will apply to All Staff - Roddey Employees and that of Agencies - Covered, Non-Covered and Agency Staffing Members/DMH. B) Actions to be taken to assure that this type of Neglect does not reoccur 1. Nursing Administration will review TAR (Treatment Assessment Record) daily for 90 days for compliance. TARS have been reviewed since 6/10/17. 2. Nursing administration will inspect resident(s) dressing for dates which should correspond with physician order(s) daily for 90 days for compliance. Inspection of dressings have been reviewed since 6/10/17. C) Education of Nursing Personnel - No nurses will be allowed to work until they have received the following education. 1. Mandatory of Covered and Non-Covered Roddey Pavilion/DMH and agency staffing members C. M. tucker Jr Nursing Care Center Protection From Harm Program with Completion Date 8/11/17 2. Mandatory of Covered and Non-Covered DMH employees and agency staffing members with proper dressing change techniques. Completion Date 8/11/17 3. Mandatory of Covered and Non-covered DMH employees and agency staffing members on Wound Care Skills Lab Completion Date 8/11/17 D) Disciplinary Action: Immediate termination of all nursing staff who failed to provide prescribed dressing changes The survey team completed record reviews, observations and interviews to ensure the facility had implemented their A(NAME). The Immediate Jeopardy was removed on 08/11/17, but the citations at F224, F225, F281, F282, F309, F490 and F514 remained at a lowered scope and severity of D.

Based on record review and interview, the facility failed to prevent neglect related to nursing staff not performing treatments as ordered for Resident #32, 1 of 1 resident reviewed for neglect. In addition the facility failed to implement policies related to investigating and preventing neglect. The findings included: The facility admitted Resident #32 with [DIAGNOSES REDACTED]. Since admission, she has also been diagnosed with [REDACTED]. At 11:58 AM on 08/08/17, review of the Consults revealed Resident #32 had a diabetic ulcer of the right 3rd toe and hammertoe of the 3rd and 4th toe with surgical correction (fusion) of the toes done in July, 2017 to prevent pressure from the hammertoe. Further review revealed a Podiatry Consultation note dated 06/08/17 that stated The patient last had a podiatry visit 2 weeks ago. There were orders left for the patient to have the dressing changed daily with application of triple antibiotic and a dry sterile dressing for 21 days. The report further indicated The dressing to the right foot is dated 05/28/2017, 10:00 a.m. This would imply that the dressing has not been changed for approximately 11 days. The dressing is soaked through with blood and smells of urine. At this time strike through noted on the plantar aspect of the dressing with blood and brown unidentifiable substance in the dressing. There is urine odor noted. Review of the Physicians Orders at 12:24 PM revealed an order dated 05/26/17 to Cleanse Right 3rd digit (tip) with Kara Klenz, dry area, apply (thin layer) of TAO, cover with 2x2 secure with [MEDICATION NAME] tape daily x 21 days . Review of the Treatment Administration Record on 08/09/17 at 2:34 PM revealed the treatment to cleanse right 3rd toe digit with Kara Klenz on area, apply (thin Layer) of TAO (Triple Antibiotic Ointment) cover with 2x2 secure with hypaphix tape daily x (times) 21 days was signed off as completed 05/26/17 through 05/31/17 and 06/01/17 through 06/08/17. On 08/09/17 at 3:18 PM, review of the Nurses Progress Notes dated 5/26/17 through 07/12/17 revealed the podiatrist debrided the right 3rd digit on 05/25/17. On 06/08/17 at 2:40 PM, the note indicated the wound was surrounded by large amount of thick maceration and callus tissue. Moderate odor present to site/dressing . At 7:05 PM the nurse documented that the nursing supervisor was notified that several treatments were missed. The notes also indicated the wound was again debrided on 06/17/17. Review of the facility's Five-Day Follow-Up Report dated indicated the incident was reported to the facility on [DATE] at 2:38 PM by the Medical Director who had been notified by the Podiatrist that the dressing changes to a diabetic ulcer had not been done since 5/28/17. Review of the investigation revealed 3 Certified Nursing Assistants were interviewed related to the incident and all stated they were informed of the incident but otherwise provided no information related to the allegation. RN (Registered Nurse) #2's facility-obtained statement dated 06/09/17 indicated s/he was notified by the Medical Director that the resident's dressing had not been changed since 5/28/17. The statement further indicated that upon assessment of the residents right 3rd digit, maceration was noted. There was no documentation of additional investigation at that time. LPN (Licensed Practical Nurse) #3's facility-obtained statement dated 06/12/17 indicated It was an oversight on my part, frequently alone on unit. No other investigation was noted. Review of the punch detail revealed LPN #3 continued to work in the facility on 06/12, 06/14, and 06/15/17. Review of the the Notice of Suspension revealed LPN #3 was suspended July 6, 7, 8, 9, 11,12, and 15, 2017. LPN #4's facility-obtained statement dated 06/12/17 indicated s/he was told the podiatrist had observed that a daily dressing change had not been done in a number of days. The doctor was quite upset about it. There was no statement indicating why s/he had not completed the dressing changes or any other investigation. A review of the Punch Detail History LPN #4 continued to work in the facility on 06/08, 06/09, 06/12, and 06/13/17 after the incident. Review of the personnel file also revealed LPN #4 was suspended July 6, 10, 11, 13, 15, 16, 19, 21, 25, and 26, 2017. Agency LPN #5 had no facility obtained statement. There was no corrective action taken. Agency LPN #6 had no facility obtained statement. A review of the Punch Detail History revealed LPN #6 continued to work in the facility on 06/09, 06/10, 06/11, 06/14, 06/15, and 06/16/17 after the incident. There was no corrective action. Agency RN #3 had no facility obtained statement. A review of the Punch Detail History revealed RN #3 continued to work in the facility on 06/08, 06/13, and 06/15/17. There was no corrective action. During an interview on 08/10/17 at approximately 8:50 AM, the Director of Nursing stated that the nurses were given one-on-one inservice after the incident involving Resident #32 but that the facility did not have any written evidence of that training. The Director of Nursing further stated that the facility employee nurses did not receive a written warning as stated in the 5-Day Follow Up but received a 10 day suspension. During an interview on 08/10/17 at 4:40 PM, the Director of Nursing stated that the state policy is to complete the investigation of any incident and provide that information to the Human Resources. Human Resources then determines if there is sufficient evidence to warrant suspension. Human Resources then notifies the facility and the employee can then be suspended. The Director of Nursing also stated that s/he had the authority to notify the agency not to send a nurse but further stated In my mind, it wasn't grievous enough. I wasn't going to terminate my employees, so I wasn't going to do that to them (the agency nurses). In addition the Director of Nursing confirmed that s/he did not get statements from the agency nurses and stated that's my oversight. The Director of Nursing confirmed there was little information related to the allegation of neglect in the 2 facility employees statements and confirmed that it was not a thorough investigation. On 8/10/17 at 3:40 PM, the facility Administrator was notified that Immediate Jeopardy and /or Substandard Quality of Care existed as of 05/28/2017 and was ongoing related to resident neglect when the podiatrist found that daily dressing changes had not been done as ordered for 11 days. On 8/11/17 at 12:13 PM, a Credible Allegation of Compliance (A(NAME)) was received from the facility. Allegation of Compliance included the following: A) Changes were made in the C. M.(NAME)Jr Nursing Care Center/Roddey Pavilion Protection from Harm Program Policy related to include this statement: Covered Non-Covered and Agency Staffing Members/DMH (Department of Mental Health). There will be a Zero Tolerance' as it relates to Abuse, Neglect and Exploitation of residents/patients and clients. Our employee disciplinary standard will apply to All Staff - Roddey Employees and that of Agencies - Covered, Non-Covered and Agency Staffing Members/DMH. B) Actions to be taken to assure that this type of Neglect does not reoccur 1. Nursing Administration will review TAR (Treatment Assessment Record) daily for 90 days for compliance. TARS have been reviewed since 6/10/17. 2. Nursing administration will inspect resident(s) dressing for dates which should correspond with physician order(s) daily for 90 days for compliance. Inspection of dressings have been reviewed since 6/10/17. C) Education of Nursing Personnel - No nurses will be allowed to work until they have received the following education. 1. Mandatory of Covered and Non-Covered Roddey Pavilion/DMH and agency staffing members C. M. tucker Jr Nursing Care Center Protection From Harm Program with Completion Date 8/11/17 2. Mandatory of Covered and Non-Covered DMH employees and agency staffing members with proper dressing change techniques. Completion Date 8/11/17 3. Mandatory of Covered and Non-covered DMH employees and agency staffing members on Wound Care Skills Lab Completion Date 8/11/17 D) Disciplinary Action: Immediate termination of all nursing staff who failed to provide prescribed dressing changes The survey team completed record reviews, observations and interviews to ensure the facility had implemented their A(NAME). The Immediate Jeopardy was removed on 08/11/17, but the citations at F224, F225, F281, F282, F309, F490 and F514 remained at a lowered scope and severity of D.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of neglect for Resident #32 and serious injuries of unknown origin for Residents #5 and #13, 3 of 3 residents reviewed. In addition, the injuries of unknown origin were not reported within 2 hours. The findings included: The facility admitted Resident #32 with [DIAGNOSES REDACTED]. Since admission, she has also been diagnosed with [REDACTED]. At 11:58 AM on 08/08/17, review of the Consults revealed Resident #32 had a diabetic ulcer of the right 3rd toe and hammertoe of the 3rd and 4th toe with surgical correction (fusion) of the toes done in July, 2017 to prevent pressure from the hammertoe. Further review revealed a Podiatry Consultation note dated 06/08/17 that stated The patient last had a podiatry visit 2 weeks ago. There were orders left for the patient to have the dressing changed daily with application of triple antibiotic and a dry sterile dressing for 21 days. The report further indicated The dressing to the right foot is dated 05/28/2017, 10:00 a.m. This would imply that the dressing has not been changed for approximately 11 days. The dressing is soaked through with blood and smells of urine. At this time strike through noted on the plantar aspect of the dressing with blood and brown unidentifiable substance in the dressing. There is urine odor noted. Review of the Treatment Administration Record on 08/09/17 at 2:34 PM revealed the treatment to cleanse right 3rd toe digit with Kara Klenz on area, apply (thin Layer) of TAO (Triple Antibiotic Ointment) cover with 2x2 secure with hypaphix tape daily x (times) 21 days was signed off as completed 05/26/17 through 05/31/17 and 06/01/17 through 06/08/17. Review of the facility's Five-Day Follow-Up Report dated indicated the incident was reported to the facility on [DATE] at 2:38 PM by the Medical Director who had been notified by the Podiatrist that the dressing changes to a diabetic ulcer had not been done since 5/28/17. Review of the investigation revealed 3 Certified Nursing Assistants were interviewed related to the incident and all stated they were informed of the incident but otherwise provided no information related to the allegation. RN (Registered Nurse) #2's facility-obtained statement dated 06/09/17 indicated s/he was notified by the Medical Director that the resident's dressing had not been changed since 5/28/17. The statement further indicated that upon assessment of the residents right 3rd digit, maceration was noted. There was no documentation of additional investigation at that time. LPN (Licensed Practical Nurse) #3's facility-obtained statement dated 06/12/17 indicated It was an oversight on my part, frequently alone on unit. No other investigation was noted. Review of the punch detail revealed LPN #3 continued to work in the facility on 06/12, 06/14, and 06/15/17. Review of the the Notice of Suspension revealed LPN #3 was suspended July 6, 7, 8, 9, 11,12, and 15, 2017. LPN #4's facility-obtained statement dated 06/12/17 indicated s/he was told the podiatrist had observed that a daily dressing change had not been done in a number of days. The doctor was quite upset about it. There was no statement indicating why s/he had not completed the dressing changes or any other investigation. A review of the Punch Detail History LPN #4 continued to work in the facility on 06/08, 06/09, 06/12, and 06/13/17 after the incident. Review of the personnel file also revealed LPN #4 was suspended July 6, 10, 11, 13, 15, 16, 19, 21, 25, and 26, 2017. Agency LPN #5 had no facility obtained statement. There was no corrective action taken. Agency LPN #6 had no facility obtained statement. A review of the Punch Detail History revealed LPN #6 continued to work in the facility on 06/09, 06/10, 06/11, 06/14, 06/15, and 06/16/17 after the incident. There was no corrective action. Agency RN #3 had no facility obtained statement. A review of the Punch Detail History revealed RN #3 continued to work in the facility on 06/08, 06/13, and 06/15/17. There was no corrective action. During an interview on 08/10/17 at approximately 8:50 AM, the Director of Nursing stated that the nurses were given one-on-one inservice after the incident involving Resident #32 but that the facility did not have any written evidence of that training. The Director of Nursing further stated that the facility employee nurses did not receive a written warning as stated in the 5-Day Follow Up but received a 10 day suspension. During an interview on 08/10/17 at 4:40 PM, the Director of Nursing stated that the state policy is to complete the investigation of any incident and provide that information to the Human Resources. Human Resources then determines if there is sufficient evidence to warrant suspension. Human Resources then notifies the facility and the employee can then be suspended. The Director of Nursing also stated that s/he had the authority to notify the agency not to send a nurse but further stated In my mind, it wasn't grievous enough. I wasn't going to terminate my employees, so I wasn't going to do that to them (the agency nurses). In addition the Director of Nursing confirmed that s/he did not get statements from the agency nurses and stated that's my oversight. The Director of Nursing confirmed there was little information related to the allegation of neglect in the 2 facility employees statements and confirmed that it was not a thorough investigation. The facility admitted Resident #13 to the facility with [DIAGNOSES REDACTED]. On 08/10/2017 at 8:23 AM, review of an Incident of Injury of Unknown Source for Resident #13 revealed the resident was observed with swelling and discoloration of the right hand on 2/12/17 at 3:15 PM. Review of a radiology report dated 2/12/17 revealed the resident had acute third and fourth metacarpal neck fractures. Further review of the investigative file revealed the incident was reported to the State Agency on 2/13/17 according to the date listed on the Initial 24-hour Report of Incidents. There was no fax confirmation in the file. Further review revealed the 5-Day Follow Up letter sent to the State Agency on 2/19/17 incorrectly stated the incident occurred on 2/13/17 at 10:10 AM. Review of a Significant Change in Status Assessment Minimal Data Set ((MDS) dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 10. Further review of the investigation file revealed no interview with the resident to aid in determining the source of the injury. The facility admitted Resident #5 to the facility with [DIAGNOSES REDACTED]. On 08/10/2017 at 8:46 AM, review of an Incident of Injury of Unknown Source for Resident #5 revealed the resident was observed unable to stand. Left hip bigger than the right side. Resident complains of pain to left hip at 5:45 AM on 6/17/17. Review of the Initial 24-Hour Report of Incidents revealed the incident was reported to the facility on [DATE] at 9:40 AM when the facility called the hospital and was informed the resident had a left [MEDICAL CONDITION] at that time. Further review revealed the incident was reported to the State Agency on 6/19/17 at 12:17 PM. Review of the radiology report dated 6/17/17 revealed the resident had an impacted left intertrochanteric fracture. During an interview on 08/11/17 at 11:07 AM, the Nursing Home Administrator (NHA) declined to confirm the dates the [MEDICATION NAME] for Resident #5 and Resident #13 were faxed to the State Agency until he/she had reviewed the files. The NHA further stated that incidents and allegations went to the Director of Nursing first and that he/she would need to speak to the Director of Nursing before answering any questions. On 08/11/17, the Nursing Home Administrator confirmed he/she was unaware of the changes to the Code of Federal Regulations effective 11/28/16. During an interview at 11:17 AM, the Director of Nursing stated s/he was unaware of the change in the regulation that required allegations of abuse or serious injury be reported to the state agency within 2 hours. During an interview on 08/11/17 at 12:23 PM, the Director of Nursing confirmed there was not fax cover sheet or confirmation that the incident for Resident #5 was reported to the State Agency within 2 hours. The DON also confirmed there was no documentation that the incident for Resident #13 was reported within 2 hours. On 8/10/17 at 3:40 PM, the facility Administrator was notified that Immediate Jeopardy and /or Substandard Quality of Care existed as of 05/28/2017 and was ongoing related to resident neglect when the podiatrist found that daily dressing changes had not been done as ordered for 11 days. On 8/11/17 at 12:13 PM, a Credible Allegation of Compliance (A(NAME)) was received from the facility. Allegation of Compliance included the following: A) Changes were made in the C. M.(NAME)Jr Nursing Care Center/Roddey Pavilion Protection from Harm Program Policy related to include this statement: Covered Non-Covered and Agency Staffing Members/DMH (Department of Mental Health). There will be a Zero Tolerance' as it relates to Abuse, Neglect and Exploitation of residents/patients and clients. Our employee disciplinary standard will apply to All Staff - Roddey Employees and that of Agencies - Covered, Non-Covered and Agency Staffing Members/DMH. B) Actions to be taken to assure that this type of Neglect does not reoccur 1. Nursing Administration will review TAR (Treatment Assessment Record) daily for 90 days for compliance. TARS have been reviewed since 6/10/17. 2. Nursing administration will inspect resident(s) dressing for dates which should correspond with physician order(s) daily for 90 days for compliance. Inspection of dressings have been reviewed since 6/10/17. C) Education of Nursing Personnel - No nurses will be allowed to work until they have received the following education. 1. Mandatory of Covered and Non-Covered Roddey Pavilion/DMH and agency staffing members C. M. tucker Jr Nursing Care Center Protection From Harm Program with Completion Date 8/11/17 2. Mandatory of Covered and Non-Covered DMH employees and agency staffing members with proper dressing change techniques. Completion Date 8/11/17 3. Mandatory of Covered and Non-covered DMH employees and agency staffing members on Wound Care Skills Lab Completion Date 8/11/17 D) Disciplinary Action: Immediate termination of all nursing staff who failed to provide prescribed dressing changes The survey team completed record reviews, observations and interviews to ensure the facility had implemented their A(NAME). The Immediate Jeopardy was removed on 08/11/17, but the citations at F224, F225, F281, F282, F309, F490 and F514 remained at a lowered scope and severity of D.

Based on record review and interview, the facility failed to ensure that the services provided met professional standards of quality as evidenced by treatments that were not provided as ordered but signed off as completed for Resident #32, 1 of 1 resident reviewed for neglect. The findings included: The facility admitted Resident #32 with [DIAGNOSES REDACTED]. Review of the Physicians Orders at 12:24 PM on 08/08/17 revealed an order dated 05/26/17 to Cleanse Right 3rd digit (tip) with Kara Klenz, dry area, apply (thin layer) of TAO (Triple Antibiotic Ointment), cover with 2x2 secure with [MEDICATION NAME] tape daily x 21 days . At 11:58 AM on 08/08/17, review of the Consults revealed a Podiatry Consultation note dated 06/08/17 that stated The patient last had a podiatry visit 2 weeks ago. There were orders left for the patient to have the dressing changed daily with application of triple antibiotic and a dry sterile dressing for 21 days. The report further indicated The dressing to the right foot is dated 05/28/2017, 10:00 a.m. This would imply that the dressing has not been changed for approximately 11 days. The dressing is soaked through with blood and smells of urine. At this time strikethrough noted on the plantar aspect of the dressing with blood and brown unidentifiable substance in the dressing. There is urine odor noted. RN (Registered Nurse) #2's facility-obtained statement dated 06/09/17 indicated s/he was notified by the Medical Director that the resident's dressing had not been changed since 5/28/17. The statement further indicated that upon assessment of the residents right 3rd digit, maceration was noted. There was no documentation of additional investigation at that time. LPN (Licensed Practical Nurse) #3's facility-obtained statement dated 06/12/17 indicated It was an oversight on my part, frequently alone on unit. No other investigation was noted. Review of the punch detail revealed LPN #3 continued to work in the facility on 06/12, 06/14, and 06/15/17. Review of the the Notice of Suspension revealed LPN #3 was suspended July 6, 7, 8, 9, 11,12, and 15, 2017. LPN #4's facility-obtained statement dated 06/12/17 indicated s/he was told the podiatrist had observed that a daily dressing change had not been done in a number of days. The doctor was quite upset about it. There was no statement indicating why s/he had not completed the dressing changes or any other investigation. A review of the Punch Detail History LPN #4 continued to work in the facility on 06/08, 06/09, 06/12, and 06/13/17 after the incident. Review of the personnel file also revealed LPN #4 was suspended July 6, 10, 11, 13, 15, 16, 19, 21, 25, and 26, 2017. Agency LPN #5 had no facility obtained statement. There was no corrective action taken. Agency LPN #6 had no facility obtained statement. A review of the Punch Detail History revealed LPN #6 continued to work in the facility on 06/09, 06/10, 06/11, 06/14, 06/15, and 06/16/17 after the incident. There was no corrective action. Agency RN #3 had no facility obtained statement. A review of the Punch Detail History revealed RN #3 continued to work in the facility on 06/08, 06/13, and 06/15/17. There was no corrective action. During an interview on 08/10/17, the Director of Nursing confirmed that 5 nurses had failed to provide treatments to Resident #32 and had falsified the documentation on the Treatment Administration Record over a period of 11 days per the podiatrist notes. The Director of Nursing also confirmed the podiatrist had signed and dated the dressing he/she applied on 05/27/17 which was how the doctor knew the dressing had not been changed. During an interview on 08/10/17 at approximately 8:50 AM, the Director of Nursing stated that the nurses were given one-on-one inservice after the incident involving Resident #32 but that the facility did not have any written evidence of that training. On 8/10/17 at 3:40 PM, the facility Administrator was notified that Immediate Jeopardy and /or Substandard Quality of Care existed as of 05/28/2017 and was ongoing related to resident neglect when the podiatrist found that daily dressing changes had not been done as ordered for 11 days. On 8/11/17 at 12:13 PM, a Credible Allegation of Compliance (A(NAME)) was received from the facility. Allegation of Compliance included the following: A) Changes were made in the C. M.(NAME)Jr Nursing Care Center/Roddey Pavilion Protection from Harm Program Policy related to include this statement: Covered Non-Covered and Agency Staffing Members/DMH (Department of Mental Health). There will be a Zero Tolerance' as it relates to Abuse, Neglect and Exploitation of residents/patients and clients. Our employee disciplinary standard will apply to All Staff - Roddey Employees and that of Agencies - Covered, Non-Covered and Agency Staffing Members/DMH. B) Actions to be taken to assure that this type of Neglect does not reoccur 1. Nursing Administration will review TAR (Treatment Assessment Record) daily for 90 days for compliance. TARS have been reviewed since 6/10/17. 2. Nursing administration will inspect resident(s) dressing for dates which should correspond with physician order(s) daily for 90 days for compliance. Inspection of dressings have been reviewed since 6/10/17. C) Education of Nursing Personnel - No nurses will be allowed to work until they have received the following education. 1. Mandatory of Covered and Non-Covered Roddey Pavilion/DMH and agency staffing members C. M. tucker Jr Nursing Care Center Protection From Harm Program with Completion Date 8/11/17 2. Mandatory of Covered and Non-Covered DMH employees and agency staffing members with proper dressing change techniques. Completion Date 8/11/17 3. Mandatory of Covered and Non-covered DMH employees and agency staffing members on Wound Care Skills Lab Completion Date 8/11/17 D) Disciplinary Action: Immediate termination of all nursing staff who failed to provide prescribed dressing changes The survey team completed record reviews, observations and interviews to ensure the facility had implemented their A(NAME). The Immediate Jeopardy was removed on 08/11/17, but the citations at F224, F225, F281, F282, F309, F490 and F514 remained at a lowered scope and severity of D.

Based on record review and interview, the facility failed to follow the care plan to provide treatments per the physician's orders for Resident #32, 1 of 1 resident reviewed for neglect. The findings included: The facility admitted Resident #32 with [DIAGNOSES REDACTED]. On 08/08/17 at 11:24 AM, review of the care plan initially dated 12/15/16 and reviewed/ revised 8/3/17 revealed potential for alteration in skin integrity was identified as a problem area. The care plan was updated on 5/26/17 for an area to the tip of right 3rd toe. Interventions and approaches included treatment per MD (physician) orders . Review of the Physicians Orders at 12:24 PM revealed an order dated 05/26/17 to Cleanse Right 3rd digit (tip) with Kara Klenz, dry area, apply (thin layer) of TAO (Triple Antibiotic Ointment), cover with 2x2 secure with [MEDICATION NAME] tape daily x 21 days . At 11:58 AM on 08/08/17, review of the Consults revealed a Podiatry Consultation note dated 06/08/17 that stated The patient last had a podiatry visit 2 weeks ago. There were orders left for the patient to have the dressing changed daily with application of triple antibiotic and a dry sterile dressing for 21 days. The report further indicated The dressing to the right foot is dated 05/28/2017, 10:00 a.m. This would imply that the dressing has not been changed for approximately 11 days. The dressing is soaked through with blood and smells of urine. At this time strikethrough noted on the plantar aspect of the dressing with blood and brown unidentifiable substance in the dressing. There is urine odor noted. During an interview at 11:17 AM on 08/11/17, the Director of Nursing confirmed the care plan stated the treatments were to be done per the physician orders and that the care plan was obviously not followed. During an interview on 08/10/17, the Director of Nursing confirmed that 5 nurses had failed to provide treatments to Resident #32 and had falsified the documentation on the Treatment Administration Record over a period of 11 days per the podiatrist notes. The Director of Nursing also confirmed the podiatrist had signed and dated the dressing he/she applied on 05/27/17 which was how the doctor knew the dressing had not been changed. On 8/10/17 at 3:40 PM, the facility Administrator was notified that Immediate Jeopardy and /or Substandard Quality of Care existed as of 05/28/2017 and was ongoing related to resident neglect when the podiatrist found that daily dressing changes had not been done as ordered for 11 days. On 8/11/17 at 12:13 PM, a Credible Allegation of Compliance (A(NAME)) was received from the facility. Allegation of Compliance included the following: A) Changes were made in the C. M.(NAME)Jr Nursing Care Center/Roddey Pavilion Protection from Harm Program Policy related to include this statement: Covered Non-Covered and Agency Staffing Members/DMH (Department of Mental Health). There will be a Zero Tolerance' as it relates to Abuse, Neglect and Exploitation of residents/patients and clients. Our employee disciplinary standard will apply to All Staff - Roddey Employees and that of Agencies - Covered, Non-Covered and Agency Staffing Members/DMH. B) Actions to be taken to assure that this type of Neglect does not reoccur 1. Nursing Administration will review TAR (Treatment Assessment Record) daily for 90 days for compliance. TARS have been reviewed since 6/10/17. 2. Nursing administration will inspect resident(s) dressing for dates which should correspond with physician order(s) daily for 90 days for compliance. Inspection of dressings have been reviewed since 6/10/17. C) Education of Nursing Personnel - No nurses will be allowed to work until they have received the following education. 1. Mandatory of Covered and Non-Covered Roddey Pavilion/DMH and agency staffing members C. M. tucker Jr Nursing Care Center Protection From Harm Program with Completion Date 8/11/17 2. Mandatory of Covered and Non-Covered DMH employees and agency staffing members with proper dressing change techniques. Completion Date 8/11/17 3. Mandatory of Covered and Non-covered DMH employees and agency staffing members on Wound Care Skills Lab Completion Date 8/11/17 D) Disciplinary Action: Immediate termination of all nursing staff who failed to provide prescribed dressing changes The survey team completed record reviews, observations and interviews to ensure the facility had implemented their A(NAME). The Immediate Jeopardy was removed on 08/11/17, but the citations at F224, F225, F281, F282, F309, F490 and F514 remained at a lowered scope and severity of D.

Based on record review and interview, the facility failed to implement policies and procedures related to neglect,. investigation, and reporting for Residents #32, #5, and #13, 3 of 3 residents reviewed for reportable incidents. In addition the facility failed to identify and revise their policies and procedures related to changes in the Code of Federal Regulations effective 11/28/2016. Cross refer to F224 and F225 as it relates to investigating and reporting of abuse/neglect. The findings included: Neglect of Resident #32 was identified on 06/08/17. The five nurses involved were allowed to continue working in the facility and on the same unit. Three of the nurses were supplied by a staffing agency and received no disciplinary action from the facility. The two nurses that were employees of the facility received suspension ranging from 7 to 10 days in July, 2017. In addition, Residents #5 and #13 sustained serious injuries of unknown source (fractures) that were not reported within 2 hours as required in the Code of Federal Regulations effective 11/28/16. During an interview on 08/10/17 at 4:40 PM, the Director of Nursing stated that the state policy is to complete the investigation of any incident and provide that information to Human Resources. Human Resources then determines if there is sufficient evidence to warrant suspension. Human Resources then notifies the facility and the employee can then be suspended. The Director of Nursing also stated that s/he had the authority to notify the agency not to send a nurse but further stated In my mind, it wasn't grievous enough. I wasn't going to terminate my employees, so I wasn't going to do that to them (the agency nurses). The Director of Nursing also stated that the nursing supervisors were now checking all dressings daily to ensure the dressings had been changed in accordance with the physicians' orders. The Director of Nursing also stated s/he was not aware of the changes to the Code of Federal Regulations requiring allegations and serious injuries be reported within 2 hours. In addition, the Director of Nursing confirmed that s/he did not get statements from the agency nurses and stated that's my oversight. The Director of Nursing confirmed there was little information related to the allegation of neglect in the 2 facility employees statements and confirmed that it was not a thorough investigation. During an interview of 08/11/17, the NHA also confirmed he was not aware of the changes to the regulations effective 11/28/16. On 8/10/17 at 3:40 PM, the facility Administrator was notified that Immediate Jeopardy and /or Substandard Quality of Care existed as of 05/28/2017 and was ongoing related to resident neglect when the podiatrist found that daily dressing changes had not been done as ordered for 11 days. Immediate Jeopardy existed at a scope and severity of J at the following: 483.12 (b) F224 Free from Neglect - As it relates to daily treatments that were not provided by nursing as ordered by the physician. 483.12(c)(1) F225 Investigate and Report allegations of Abuse, Neglect and Injuries of Unknown Source - As it relates to the facility's failure to thoroughly investigate and report timely the allegation of neglect and 2 injuries of unknown origin with major injuries. 483.21(b)(3) F281 Professional Standards - As it relates to the facility's failure to provide treatments as ordered but yet documented as completed. 483.21(b)(3) F282 In Accordance with Plan of Care - As it relates to the facility's failure to follow the care plan to provide treatments as ordered. 483.25 F309 Quality of care - As it relates to not providing treatments as ordered for a diabetic ulcer. 483.70 F490 Administration - As it relates to the facility's failure to keep informed of changes in the Code of Federal Regulations and to ensure care was provided to the resident. 483.70(i) F514 Medical records - As it pertains to the inaccuracy of the medical record that indicated treatments that were ordered but not provided but yet were documented as completed by staff. On 8/11/17 at 12:13 PM, a Credible Allegation of Compliance (A(NAME)) was received from the facility. Allegation of Compliance included the following: A) Changes were made in the C. M.(NAME)Jr Nursing Care Center/Roddey Pavilion Protection from Harm Program Policy related to include this statement: Covered Non-Covered and Agency Staffing Members/DMH (Department of Mental Health). There will be a Zero Tolerance' as it relates to Abuse, Neglect and Exploitation of residents/patients and clients. Our employee disciplinary standard will apply to All Staff - Roddey Employees and that of Agencies - Covered, Non-Covered and Agency Staffing Members/DMH. B) Actions to be taken to assure that this type of Neglect does not reoccur 1. Nursing Administration will review TAR (Treatment Assessment Record) daily for 90 days for compliance. TARS have been reviewed since 6/10/17. 2. Nursing administration will inspect resident(s) dressing for dates which should correspond with physician order(s) daily for 90 days for compliance. Inspection of dressings have been reviewed since 6/10/17. C) Education of Nursing Personnel - No nurses will be allowed to work until they have received the following education. 1. Mandatory of Covered and Non-Covered Roddey Pavilion/DMH and agency staffing members C. M. tucker Jr Nursing Care Center Protection From Harm Program with Completion Date 8/11/17 2. Mandatory of Covered and Non-Covered DMH employees and agency staffing members with proper dressing change techniques. Completion Date 8/11/17 3. Mandatory of Covered and Non-covered DMH employees and agency staffing members on Wound Care Skills Lab Completion Date 8/11/17 D) Disciplinary Action: Immediate termination of all nursing staff who failed to provide prescribed dressing changes The survey team completed record reviews, observations and interviews to ensure the facility had implemented their A(NAME). The Immediate Jeopardy was removed on 08/11/17, but the citations at F224, F225, F281, F282, F309, F490 and F514 remained at a lowered scope and severity of D.

Based on record review and interview, the facility failed to ensure that the medical records were accurately documented as evidenced by daily treatments that were not provided as ordered for 11 days but signed off as completed for Resident #32, 1 of 1 resident reviewed for neglect. The findings included: The facility admitted Resident #32 with [DIAGNOSES REDACTED]. Review of the Physicians Orders at 12:24 PM on 08/08/17 revealed an order dated 05/26/17 to Cleanse Right 3rd digit (tip) with Kara Klenz, dry area, apply (thin layer) of TAO (Triple Antibiotic Ointment), cover with 2x2 secure with [MEDICATION NAME] tape daily x 21 days . At 11:58 AM on 08/08/17, review of the Consults revealed a Podiatry Consultation note dated 06/08/17 that stated The patient last had a podiatry visit 2 weeks ago. There were orders left for the patient to have the dressing changed daily with application of triple antibiotic and a dry sterile dressing for 21 days. The report further indicated The dressing to the right foot is dated 05/28/2017, 10:00 a.m. This would imply that the dressing has not been changed for approximately 11 days. The dressing is soaked through with blood and smells of urine. At this time strikethrough noted on the plantar aspect of the dressing with blood and brown unidentifiable substance in the dressing. There is urine odor noted. During an interview on 08/10/17, the Director of Nursing confirmed that 5 nurses had failed to provide treatments to Resident #32 and had falsified the documentation on the Treatment Administration Record over a period of 11 days per the podiatrist notes. The Director of Nursing also confirmed the podiatrist had signed and dated the dressing he/she applied on 05/27/17 which was how the doctor knew the dressing had not been changed. On 8/10/17 at 3:40 PM, the facility Administrator was notified that Immediate Jeopardy and /or Substandard Quality of Care existed as of 05/28/2017 and was ongoing related to resident neglect when the podiatrist found that daily dressing changes had not been done as ordered for 11 days. On 8/11/17 at 12:13 PM, a Credible Allegation of Compliance (A(NAME)) was received from the facility. Allegation of Compliance included the following: A) Changes were made in the C. M.(NAME)Jr Nursing Care Center/Roddey Pavilion Protection from Harm Program Policy related to include this statement: Covered Non-Covered and Agency Staffing Members/DMH (Department of Mental Health). There will be a Zero Tolerance' as it relates to Abuse, Neglect and Exploitation of residents/patients and clients. Our employee disciplinary standard will apply to All Staff - Roddey Employees and that of Agencies - Covered, Non-Covered and Agency Staffing Members/DMH. B) Actions to be taken to assure that this type of Neglect does not reoccur 1. Nursing Administration will review TAR (Treatment Assessment Record) daily for 90 days for compliance. TARS have been reviewed since 6/10/17. 2. Nursing administration will inspect resident(s) dressing for dates which should correspond with physician order(s) daily for 90 days for compliance. Inspection of dressings have been reviewed since 6/10/17. C) Education of Nursing Personnel - No nurses will be allowed to work until they have received the following education. 1. Mandatory of Covered and Non-Covered Roddey Pavilion/DMH and agency staffing members C. M. tucker Jr Nursing Care Center Protection From Harm Program with Completion Date 8/11/17 2. Mandatory of Covered and Non-Covered DMH employees and agency staffing members with proper dressing change techniques. Completion Date 8/11/17 3. Mandatory of Covered and Non-covered DMH employees and agency staffing members on Wound Care Skills Lab Completion Date 8/11/17 D) Disciplinary Action: Immediate termination of all nursing staff who failed to provide prescribed dressing changes The survey team completed record reviews, observations and interviews to ensure the facility had implemented their A(NAME). The Immediate Jeopardy was removed on 08/11/17, but the citations at F224, F225, F281, F282, F309, F490 and F514 remained at a lowered scope and severity of D.

Based on review of facility files and interview, the facility failed to ensure each resident was free from physical abuse. Resident #1 was observed to be physically abused by CNA #1. CNA #1 slapped Resident #1 in the face. One of one resident reviewed for abuse. The findings included: The facility reported an incident of physical abuse by CNA #1 for Resident #1 on 3/8/16. Review of Resident #1's Accident/Incident Report dated 3/8/16 revealed the RN Supervisor was informed by a 3:00-1:00 PM shift staff that around 10:30 PM s/he overheard the resident state to two staff don't hit me anymore, then one of them hit the resident again while in the bathroom. The resident was noted to have a slight bluish discoloration on the right breast. Review of Resident #1's medical record revealed the Quarterly Minimum (MDS) data set [DATE] coded the resident as requiring extensive assistance for transfers and dressing, and totally dependent for hygiene. The resident was noted to have a Brief Interview for Mental Status score of 3. Review of the resident's care plan revealed agitated and physical aggressive behaviors during care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if being physically aggressive during care leave her alone and return 15-30 minutes later and attempt care again. Review of the resident's Nurses' Notes revealed a CNA entry dated 3/7/16 at 11:08 PM that indicated the resident refused to be put in bed after two attempts but was changed and put in his/her wheelchair. A Nurses' Note dated 3/8/16 at 6:30 indicated a late entry that at approximately 12:20 AM a staff member from 3-11 shift informed the nurse that s/he overheard the resident state to two staff members don't hit me anymore. Then one of them hit the resident again while in the bathroom in room [ROOM NUMBER]. The physician on call was notified of alleged abuse at 12:48 AM. Review of Resident #1's Accident/Incident Report dated 3/8/16 revealed the RN Supervisor was informed by a 3-11 shift staff at approximately 12:20 AM that during 3-11 shift around 10:30 PM s/he overheard the resident state to the two staff, don't hit me anymore, then one of them hit the resident again while in the bathroom in room [ROOM NUMBER]. The resident's injury was described as a slight bluish discoloration on the right breast. Review of the facility's Five-Day Follow-Up Report dated 3/11/16 indicated the allegation of physical abuse of Resident #1 was substantiated for CNA #1. LPN #1's facility-obtained statement dated 3/12/16 indicated Resident #1 requested to go to bed repeatedly while sitting outside the nurses' station. Notified staff who delayed putting him/her to bed. Notified Nursing Supervisor on unit who requested also for staff to put resident in bed. After an hour the resident became agitated. In an interview with the surveyor on 6/16/16 at approximately 11:30 AM, LPN #1 stated that Resident #1 was at the nurses' station and asked to go to bed. The resident was yelling that s/he was tired and wanted to go to bed. LPN #1 asked CNA #1 and CNA #2 to put the resident to bed. S/he asked the CNAs three times to put the resident to bed. The RN Supervisor came on the unit and asked them to put Resident #1 to bed. They said they would next after another resident. The RN Supervisor saw CNA #1 and CNA #2 come out of the residents room and try to go to another resident. S/he went down the hall and stopped the CNAs from starting with another resident. S/he told them to go put Resident #1 to bed. LPN #1 stated at least an hour passed from the time Resident #1 started saying s/he wanted to go to bed and the time the two CNAs came and took him/her to his/her room. The RN Supervisor's facility-obtained statement dated 3/8/16 revealed Resident #1 stated several times s/he was ready to go to bed and s/he was tired. The RN Supervisor then asked CNA #1 and CNA #2 to put the resident to bed. CNA #1 replied we will get him/her in a few minutes. A few minutes went to several minutes. LPN #1 went down the hall and said why don't you put him/her in bed. The RN Supervisor then waited until they came out of another resident's room, went down the hallway and demanded that they put Resident #1 in bed, it was about 10:15-10:30 PM. The resident was agitated cursing as s/he moved about in his/her wheelchair. In an interview with the surveyor on 6/14/16 at approximately 8:55 AM, the RN Supervisor stated s/he worked 3-11 as the RN Supervisor at the time of the incident. Toward the end of the shift Resident #1 was tired and restless, s/he wanted to go to bed. The resident was tired of being up. The RN Supervisor asked CNA #1 to put the resident to bed. The RN Supervisor stayed for a while to make sure the resident got done. Resident #1 started getting agitated. CNA #1 and CNA #2 went to two rooms to care for residents after being told to put Resident #1 to bed. The other nurse, LPN #1 went and asked them to get the resident in bed between the two rooms. After the second room they started for a third room and the RN Supervisor went down the hall and demanded they put Resident #1 in the bed. The RN Supervisor told the CNAs s/he would do the resident in the room they were heading to. CNAs #1 and #2 took the resident to her room and closed the door. The RN Supervisor did not see the CNAs come out of the room. When she was leaving the unit CNA #3 said s/he wanted to tell him/her something, s/he couldn't talk then because it was shift change and s/he was making assignments. CNA #3 called back a short time later and the RN Supervisor talked with him/her then at approximately 12:20 AM. CNA #3 was working 1:1 sitting with the resident in the room next door which has a joining bathroom. CNA #3 stated Resident #1 was upset, cursing and saying don't hit me anymore. CNA #3 said one of the CNAs hit the resident but s/he wasn't sure which one. The RN Supervisor and another RN went to check the resident around 5:00 AM. They did a body audit and found a blue mark on his/her right breast. The RN Supervisor did not go check on the resident prior to that time. The RN Supervisor called the Administrator around 6:00 AM. The RN Supervisor called SLED at approximately 6:30 AM. The RN Supervisor told the MD about the incident when s/he called about another resident at approximately 1:00 AM. The MD said to do a body audit to check for bruising. The RN Supervisor said it was approximately 20 minutes between the time Resident #1 started saying s/he wanted to go to bed and the CNAs went and took him/her to his/her room. When asked why s/he did not put the resident to bed, the RN Supervisor said that didn't dawn him/her at the time. They could have put the resident to bed. In an interview with the surveyor on 6/14/16 at approximately 4:10 PM, CNA #3 stated s/he worked 3-11 on 3/7/16 on 1:1. CNA #3 heard Resident #1 being pushed in his/her room, saying s/he had to go to the bathroom. Resident #1's bathroom is connected to the room of the resident CNA #3 was assigned to for 1:1. Resident #1, CNA #1 and CNA #2 were in the bathroom, CNA #3 heard Resident #1 say stop hitting me, hit me again [***] . CNA #3 could hear what sounded like hitting. The CNAs pushed the resident back out in his/her room and into the hallway. Resident #1 wandered into room the room where CNA #3 was and started messing with some things on the empty bed. CNA #1 and CNA #2 came in behind him/her a few minutes later. CNA #1 starting hitting Resident #1, slapping him/her in the face a couple of times. CNA #1 said you are not going to talk to me like that. CNA #2 said you shouldn't let him/her talk to you like that. CNA #1 hit the resident again. Resident #1 grabbed CNA #1. CNA #1 and CNA #2 were both on the resident. CNA #3 didn't see anybody hit, but they were struggling. Resident #1 was crying and cussing, saying don't hit me again [***] . They left out the room, CNA #3 ran to the door and told the RN Supervisor s/he needed to talk to him/her. The RN Supervisor said s/he was going to his/her office. CNA #3 had no transportation so s/he left when s/he got off. CNA #3 called the RN Supervisor as soon as s/he got home.

Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit abuse of residents. Resident #1 was observed to be physically abused by CNA #1. The incident was not reported timely and staff did not assess the resident at the time the incident was reported. One of one residents reviewed for abuse. The findings included: The facility reported an incident of physical abuse by CNA #1 for Resident #1 on 3/8/16. Review of Resident #1's Accident/Incident Report dated 3/8/16 revealed the RN Supervisor was informed by a 3:00-1:00 PM shift staff that around 10:30 PM s/he overheard the resident state to two staff don't hit me anymore, then one them hit the resident again while in the bathroom. The resident was noted to have a slight bluish discoloration on the right breast. Review of Resident #1's medical record revealed the Quarterly Minimum (MDS) data set [DATE] coded the resident as requiring extensive assistance for transfers and dressing, and totally dependent for hygiene. The resident was noted to have a Brief Interview for Mental Status score of 3. Review of the resident's care plan revealed agitated and physical aggressive behaviors during care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if being physically aggressive during care leave her alone and return 15-30 minutes later and attempt care again. Review of the resident's Nurses' Notes revealed a CNA entry dated 3/7/16 at 11:08 PM that indicated the resident refused to be put in bed after two attempts but was changed and put in his/her wheelchair. A Nurses' Note dated 3/8/16 at 6:30 indicated a late entry that at approximately 12:20 AM a staff member from 3-11 shift informed the nurse that s/he overheard the resident state to two staff members don't hit me anymore. Then one of them hit the resident again while in the bathroom in room [ROOM NUMBER]. The physician on call was notified of alleged abuse at 12:48 AM. Review of Resident #1's Accident/Incident Report dated 3/8/16 revealed the RN Supervisor was informed by a 3-11 shift staff at approximately 12:20 AM that during 3-11 shift around 10:30 PM s/he overheard the resident state to the two staff, don't hit me anymore, then one of them hit the resident again while in the bathroom in room [ROOM NUMBER]. The resident's injury was described as a slight bluish discoloration on the right breast. Review of the facility's Five-Day Follow-Up Report dated 3/11/16 indicated the allegation of physical abuse of Resident #1 was substantiated for CNA #1. LPN #1's facility-obtained statement dated 3/12/16 indicated Resident #1 requested to go to bed repeatedly while sitting outside the nurses' station. Notified staff who delayed putting him/her to bed. Notified Nursing Supervisor on unit who requested also for staff to put resident in bed. After an hour the resident became agitated. In an interview with the surveyor on 6/16/16 at approximately 11:30 AM, LPN #1 stated that Resident #1 was at the nurses' station and asked to go to bed. The resident was yelling that s/he was tired and wanted to go to bed. LPN #1 asked CNA #1 and CNA #2 to put the resident to bed. S/he asked the CNAs three times to put the resident to bed. The RN Supervisor came on the unit and asked them to put Resident #1 to bed. They said they would next after another resident. The RN Supervisor saw CNA #1 and CNA #2 come out of the residents room and try to go to another resident. S/he went down the hall and stopped the CNAs from starting with another resident. S/he told them to go put Resident #1 to bed. LPN #1 stated at least an hour passed from the time Resident #1 started saying s/he wanted to go to bed and the time the two CNAs came and took him/her to his/her room. The RN Supervisor's facility-obtained statement dated 3/8/16 revealed Resident #1 stated several times s/he was ready to go to bed and s/he was tired. The RN Supervisor then asked CNA #1 and CNA #2 to put the resident to bed. CNA #1 replied we will get him/her in a few minutes. A few minutes went to several minutes. LPN #1 went down the hall and said why don't you put him/her in bed. The RN Supervisor then waited until they came out of another resident's room, went down the hallway and demanded that they put Resident #1 in bed, it was about 10:15-10:30 PM. The resident was agitated cursing as s/he moved about in his/her wheelchair. In an interview with the surveyor on 6/14/16 at approximately 8:55 AM, the RN Supervisor stated s/he worked 3-11 as the RN Supervisor at the time of the incident. Toward the end of the shift Resident #1 was tired and restless, s/he wanted to go to bed. The resident was tired of being up. The RN Supervisor asked CNA #1 to put the resident to bed. The RN Supervisor stayed for a while to make sure the resident got done. Resident #1 started getting agitated. CNA #1 and CNA #2 went to two rooms to care for residents after being told to put Resident #1 to bed. The other nurse, LPN #1 went and asked them to get the resident in bed between the two rooms. After the second room they started for a third room and the RN Supervisor went down the hall and demanded they put Resident #1 in the bed. The RN Supervisor told the CNAs s/he would do the resident in the room they were heading to. CNAs #1 and #2 took the resident to her room and closed the door. The RN Supervisor did not see the CNAs come out of the room. When she was leaving the unit CNA #3 said s/he wanted to tell him/her something, s/he couldn't talk then because it was shift change and s/he was making assignments. CNA #3 called back a short time later and the RN Supervisor talked with him/her then at approximately 12:20 AM. CNA #3 was working 1:1 sitting with the resident in the room next door which has a joining bathroom. CNA #3 stated Resident #1 was upset, cursing and saying don't hit me anymore. CNA #3 said one of the CNAs hit the resident but s/he wasn't sure which one. The RN Supervisor and another RN went to check the resident around 5:00 AM. They did a body audit and found a blue mark on his/her right breast. The RN Supervisor did not go check on the resident prior to that time. The RN Supervisor called the Administrator around 6:00 AM. The RN Supervisor called SLED at approximately 6:30 AM. The RN Supervisor told the MD about the incident when s/he called about another resident at approximately 1:00 AM. The MD said to do a body audit to check for bruising. The RN Supervisor said it was approximately 20 minutes between the time Resident #1 started saying s/he wanted to go to bed and the CNAs went and took him/her to his/her room. When asked why s/he did not put the resident to bed, the RN Supervisor said that didn't dawn him/her at the time. They could have put the resident to bed. In an interview with the surveyor on 6/14/16 at approximately 4:10 PM, CNA #3 stated s/he worked 3-11 on 3/7/16 on 1:1. CNA #3 heard Resident #1 being pushed in his/her room, saying s/he had to go to the bathroom. Resident #1's bathroom is connected to the room of the resident CNA #3 was assigned to for 1:1. Resident #1, CNA #1 and CNA #2 were in the bathroom, CNA #3 heard Resident #1 say stop hitting me, hit me again [***] . CNA #3 could hear what sounded like hitting. The CNAs pushed the resident back out in his/her room and into the hallway. Resident #1 wandered into room the room where CNA #3 was and started messing with some things on the empty bed. CNA #1 and CNA #2 came in behind him/her a few minutes later. CNA #1 starting hitting Resident #1, slapping him/her in the face a couple of times. CNA #1 said you are not going to talk to me like that. CNA #2 said you shouldn't let him/her talk to you like that. CNA #1 hit the resident again. Resident #1 grabbed CNA #1. CNA #1 and CNA #2 were both on the resident. CNA #3 didn't see anybody hit, but they were struggling. Resident #1 was crying and cussing, saying don't hit me again [***] . They left out the room, CNA #3 ran to the door and told the RN Supervisor s/he needed to talk to him/her. The RN Supervisor said s/he was going to his/her office. CNA #3 had no transportation so s/he left when s/he got off. CNA #3 called the RN Supervisor as soon as s/he got home. Review of the facility's Protection From Harm Program revealed When a staff member finds, suspects or witnesses any injry or incident, an Accident/Incident Report and Investigation must be completed according to facility procedure. All allegations of abuse must be reported to SLED. A report begins at that time by the nursing supervisor who will assess the injury/incident, secure treatment if needed, gather witness statements and notify proper individuals.

Based on record review, interview and review of facility files, the facility failed to ensure each resident received adequate supervision. Resident #2 was found unresponsive in his/her room on [DATE] at approximately 11:35 AM with food in his/her mouth. Resident #2 had an order for [REDACTED]. The coroner listed Resident #2's cause of death as asphyxiation due to choking on food. One of one residents reviewed for choking. The findings included: Review of an Accident/Incident Report dated [DATE] indicated Resident #2 experienced an unexpected death. House keeper #2 summoned RN (Registered Nurse) #1 to the resident's room and the nurse noted a large amount of undigested food in Resident #2's mouth. Resident #2 was pronounced dead at 11:40 AM. Resident #2 was last seen on [DATE] at 10:00 AM ambulating in the hall. Review of the facility's Final Summary for Resident #2 noted the cause of death as cardiopulmonary death possibly secondary to aspiration. Review of the Report of Postmortem Examination from the Office of the Coroner for Resident #2 dated [DATE] indicated final anatomical [DIAGNOSES REDACTED]. The decedent was prescribed a pureed diet. The cause of death was noted as asphyxiation due to choking on food. The case summary included Resident #2 was found on his/her bed unresponsive with a brown mushy, sticky substance in his/her mouth. It was reported that there had been French toast at breakfast that morning for the regular diet residents. The evidence of injury indicated there was a 7.5 centimeter (cm) x 5 cm x 3 cm aggregate of soft, tan material resembling French toast (darker brown material resembling bread crust present) that was congealed and occluding the upper airway at the level of the epiglottis. Review of Resident #2's closed medical record indicated his/her [DIAGNOSES REDACTED]. His/her Quarterly MDS coded him/her as having short and long term memory problems. Review of Resident #2's medical record revealed a Nurse's Progress Note dated [DATE] at 11:35 AM that indicated the housekeeper summoned staff to the resident's room. When staff entered the room they noted Resident #2 was nonresponsive with a large amount of food in his/her mouth. The food was removed from the resident's mouth and sternal rub was attempted. The resident remained nonresponsive. Resident #2 was noted to have a do not resuscitate order. At 1:45 PM the coroner arrived at the facility and took pictures of the resident's body and gathered information from the resident's chart. Review of Resident #2's Choking Risk Indicators form revealed the assessment completed [DATE] indicated there were no choking risk factors for the resident. Although Resident #2 was on a pureed diet the box for difficulty chewing was marked NA (not applicable). Review of the resident's Quarterly Minimum (MDS) data set [DATE] revealed the resident was independent with ambulation and required no mobility devices. Review of the Psychology Progress Notes dated [DATE] indicated Resident #2 required a locked unit due to wandering and poor safety awareness. Review of the resident's Annual History and Physical dated [DATE] revealed Resident #2 was able to feed him/herself and ambulate independently around the unit. Review of Resident #2's Progress Notes dated [DATE] and [DATE] revealed documentation that the resident was known to wander. Review of Resident #2's care plan revealed resident is seemingly oblivious to needs or safety was identified as a problem area. Interventions and approaches were listed on the care plan and included to observe closely during meals (to prevent taking things from other's trays). Review of the physician's orders [REDACTED]. Review of the resident's Interdisciplinary Care Team - Special Review note dated [DATE] revealed Resident #2 had 14 teeth extracted on [DATE] and his/her diet was changed to pureed. House keeper #2's facility-obtained statement dated [DATE] indicated s/he opened the door to the resident's room and saw Resident #2 lying on the bed on his/her side with something hanging out of his/her mouth. House keeper #2 called the resident's name twice and got no response. House keeper #2 left and went up the hall and saw RN #1 and asked him/her to come and check on Resident #2 because s/he was not responding. RN #1's facility-obtained statement dated [DATE] indicated s/he was called by the housekeeper to Resident #2's room. Resident #2 was lying on the bed with food hanging out of his/her mouth. At 11:25 AM the resident had no pulse, his/her finger tips were cold and cyanotic. In an interview with the surveyor on [DATE] at approximately 11:30 AM, RN #1 stated that s/he was not assigned to Resident #2 on [DATE]. RN #1 was in the hall when the housekeeper came and said s/he needed him/her at approximately 11:25 AM. RN #1 ran to Resident #2's room and s/he was on the bed on his/her left side with foam/food coming out of his/her mouth. Resident #2's fingertips were cold. RN #1 called a code blue but then Resident #2's chart was reviewed and it was noted the resident had a do no resuscitate order. RN #1 stated that House keeper #2 stated there was a meal tray in an open area near the nurse's station. House keeper #2 stated that she had taken the tray to the kitchen earlier. RN #1 stated that the area where the meal tray was located was an area where Resident #2 would pace. RN #1 stated that Resident #2 would pace in the hallways but would not go into other resident's rooms. In an interview with the surveyor on [DATE] at approximately 1:50 PM, the facility Administrator stated that Resident #2 was found by a housekeeper with a large amount of food in his/her mouth. The resident was on a puree diet and ate his/her meals in the unit dayroom. Resident #2 had food in his/her hand and the coroner took a picture of it at the facility. The facility Administrator stated that Resident #2 had a history of [REDACTED].#2 was found at approximately 11:30 AM and that breakfast is served between 7:15 - 8:00 AM. The facility Administrator stated that s/he is not sure where the food came from. In an interview with the surveyor on [DATE] at approximately 1:50 PM, the acting Unit Manager stated that Resident #2 was seen ambulating at approximately 10:30 AM. The Unit Manager stated that s/he looked around the resident's room and surroundings but did not see any other food. The Unit Manager stated s/he was not sure how Resident #2 got the French toast. The Unit Manager stated that s/he removed the food from the resident's mouth and left it for the coroner. The Unit Manager stated that meal trays are usually off the unit by 8:30 AM. The Unit Manager stated that s/he had not witnessed Resident #2 try to take food but that staff had reported the resident had tried to steal food. The Unit Manager stated that there is a staff member in the dayroom to monitor residents and make sure they don't take food. The Unit Manager stated that there were two residents on the unit who eat in their rooms. The other residents eat in the dayroom on the unit or the dining room off the unit. In an interview with the surveyor on [DATE] at approximately 1:50 PM, the facility's Medical Director stated that s/he heard the code blue and responded along with Resident #2's primary physician. The resident's primary physician assessed the resident and stated Resident #2 was already deceased . The Medical Director stated that s/he had not received any reports of Resident #2 stealing food. The Medical Director stated that s/he rounds the facility and is on the unit about once a week and did not see Resident #2 exhibit the behavior of stealing food. It was determined on [DATE] at 3:55 PM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of [DATE] in the following areas: 42 CFR 483.25(h), F-323, Accident Hazards/supervision/devices was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity of "J". The facility failed to ensure each resident received adequate supervision. Resident #2 was found in his/her room unresponsive at approximately 11:35 AM. Resident #2, who had an order for [REDACTED]. On [DATE] at 4:00 PM the facility Administrator was notified that Immediate Jeopardy and Substandard Quality of Care was identified at F-323 at a scope and severity of "J". The Immediate Jeopardy and Substandard Quality of Care existed in the facility as of [DATE] related to Resident #2 choking on a piece of French toast. The facility submitted an Allegation of Compliance (AOC), which was reviewed and approved on [DATE]. The AOC included the following: 1) Resident #2 choked on what appears to have been French toast or at least some type of bread on [DATE] at approximately 11:35 am. Resident #2 is no longer a resident of the facility. 2) Review of residents who have an altered diet and are known to steal food: The resident care team on each unit will review each resident previously identified as having an altered diet and wandering behavior, taking food. The diet, reason for altered diet, behaviors involved in taking food, possible reason for taking food will be reviewed at these care conferences. The Nutritionist shall review the identified residents for possible need for increased caloric intake as well. The resident care teams began and concluded a review of these residents on [DATE]. The resident care team is composed of the following staff members (this is not an all inclusive list nor is attendance required by all team members): Registered Nurse Assessment Coordinator, Unit Manager/Licensed Unit Staff, Unit Social Worker, Unit Activity Therapist, Nutritionist, Pharmacist, Physician, Chaplaincy and Rehab Services Staff. 3) Designation of meal carts: Each unit in the facility shall have designated as the Meal Cart Room, room 101 (the first door on the left as you enter the unit). The room 101 shall be labeled Meal Cart Room. The door to room 101 shall have a slam lock. The slam lock shall lock the door and prevent any entrance from the hallway. The lock is keyed to the facility key which is issued to facility employees of the facility upon hire. The Meal Cart Room locks were added and the rooms ready for use on Sunday [DATE]; however the Meal Cart Rooms were in use starting on [DATE]. The floor of the Meal Cart Room shall be marked to designate a clean side of the room and a dirty side of the room. Signage will be posted on the wall on the respective sides to indicate the clean side and the dirty side. Taped areas on the floor of the Meal Cart Room will further indicated the location of the heated ladder rack cart (clean cart) as well as the location of the flat bed cart on which the dirty trays will be placed. During meal times, positioned in the hallway in an area indicated by a yellow "X" will be a staff member who will monitor the Meal Cart Room and intervene with residents whenever needed to insure that no resident has access to the food on the trays in the Meal Cart Room. The unit assignment sheet shall include staff assigned as the hall monitor. Nutritional services aide shall deliver the heated ladder rack carts and as soon as the carts are delivered, the nutritional services aide will deliver the flat bed cart to the unit. The meal carts will be placed in the location designated by the area so marked on the floor. Once all the meal trays are returned to the flat bed cart, nutritional services will be contacted and will take the flat bed cart back to kitchen area. Staff will remove meal trays from the ladder rack cart and deliver to each resident taking care not to cross the double line into the dirty rack area. In the event that staff cross the double line, hands must be washed before proceeding to deliver trays. If a resident is not on the unit when meal trays are passed, the tray may remain in the ladder rack cart for no more than 30 minutes. The tray will then be returned to the dirty side of the room. One of the extra trays located in the kitchen area will be delivered to the resident in the event that they return to the facility. The kitchen area is located off the unit just off each of the dining rooms where there are heating units to keep the food at the proper temperature. Upon completion of the delivery of each meal to the residents, the door to the Meal Cart Room will remain closed until the next meal time. Whenever the door to the Meal Cart Room is closed, the room is locked by virtue of the fact that the locking mechanism locks whenever the door is pulled closed. Supervision of Residents Dining in Rooms: All residents will be encouraged to dine in the dining room or in the dayroom; however, those the hallways on the unit will be supervised at meal times by staff. The hall monitor will have a direct visualization of the center hallway on the unit. If at any time the hall monitor notes a resident previously identified as having an altered diet and behavior to include wandering and stealing food, the hall monitor will close the door to the Meal Cart Room and assist the resident to the day room. The charge nurse or Unit Manager will monitor the remaining rooms on the unit by being present in the hallway thus giving direct visualization of all rooms on the "short" hallway. If at any time a resident with previously identified altered diet and behaviors is noted, the staff will assist him to the dayroom or to an area near the nurse's station where he/she can be observed. The facility will implement a Safety Huddle of the Day which stall include a 5 minute huddle on a previously identified safety focus. The Safety Huddle shall include a list of all residents with altered diets with wandering behaviors and stealing food. Each resident on the above mentioned list shall be named in order for all staff to know who they are each day, each shift. The Safety Huddle shall include primarily nursing staff but any staff on the unit may participate. The Safety Huddle of the Day will be implemented on [DATE] and will be an ongoing process. Food Brought in From the Outside: The facility will send a letter to the responsible party for all residents regarding food being brought in from the outside. Signage will also be posted on each unit stating that any item brought in by anyone must be checked in with staff prior to giving the item to the resident. The letter will encourage families that food brought in should be consumed during their visit. They will also be encouraged to utilize one of the dining rooms or one of the private conference rooms to dine with their family member in a more homelike atmosphere. The letter to responsible parties will be mailed out on [DATE]. Inservice: All nursing staff were inserviced by the Nursing Home Administrator, Director of Nursing for DIS, and the Unit Managers regarding the Meal Cart Rooms on [DATE] as the rooms were being set up. Additional inservices were conducted on [DATE] by the facility Director of Nursing and the facility Assistant Director of Nursing. The inservice included the layout of the room the clean and dirty sides, significance of the manner the floor was marked, the new process, the reason for this change in process which is that a resident with a known history of stealing/hoarding food choked on food not on his diet, cart delivery form, where staff are to stand and monitor. Staff not working on the days of the inservice will be inserviced by the Unit Manager or Nursing Supervisor as they return to work. Inservices will continue on each unit until all staff have been inservices. The Nursing staffing board composed of all nursing staff will be used to insure that all unit staff have been inserviced on the new process. New hires will receive inservice during unit orientation. Monitoring: The MDI Coordinator Supervisor will monitor the addition and deletion of new residents with altered diet and having behaviors of stealing. All diet changes will be placed on the 24 hours report for 3 days per current policy. The Unit Manager/ Charge Nurse will monitor the Meal Tray process for compliance of staff and for any possible needed revisions. This monitoring will continue until 100% compliance for 30 days is achieved. The monitor will then continue on a monthly basis. The information will be conveyed to the DON who will administer appropriate disciplinary action. The Unit Manager/Charge Nurse will be responsible for checking the Meal Tray Room each week to insure that the floor is still marked to reflect placement of the carts. She will relay this to the DON who will insure that the floor remains properly marked. The social worker on each will monitor the visitor log on each unit weekly and ongoing for any potential problem areas with food items brought in by visitors or family members. The social worker will report to the Social Work Director any identified issues. The Social Work Director will then follow up with the NHA and family if needed. Date of Corrective Action: [DATE] Observations, interviews and review of facility files revealed the plan of correction developed by the facility had been implemented and was in practice removing the deficient practice. Facility nursing staff had been educated and were knowledgeable of the interventions put in place due to the incident with Resident #2. The Administrator was informed of this on [DATE]. The Immediate Jeopardy and Substandard Quality of Care at F-323 was removed but the citation remained at a lowered scope and secerity of "D" at exit.

On the day of the complaint investigation, based on record review and interview, the facility failed to develop a comprehensive care plan for each resident to meet the nursing needs identified in the comprehensive assessment. Resident #1's care plan did not include the amount of assistance needed for ADL care. The findings include: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. resident related to fall, staff states resident fell out of bed noted 3.5 cm (centimeter) laceration above left eye moderate am(oun)t of bleeding noted also .5 cm on the bridge of nose". Review of the Interdisciplinary Care Team - Special Review Note dated 10/29/12 revealed "resident was being provided care @ time of fall. Fall care plan #7 updated to reflect new approach to have 2 staff providing care at all times, have supplies @ prior to providing care and be sure s/he is in the center of the bed removing mats from bedside to provide care." Review of Resident #1's Significant Change Minimum Data Set ((MDS) dated [DATE] and Quarterly MDS dated [DATE] revealed the resident was coded as totally dependent for dressing, hygiene and bathing. Resident #1 was also coded as needing two + person physical assist with dressing, hygiene and bathing. Review of Resident #1's Care Plan revealed it was updated on 10/28/12 with problem area "resident fell out of bed while receiving ADL care. Laceration to L(ef)t forehead 3.5 cm above L(ef)t eye and .5 cm on bridge of nose." Care Plan was updated on 10/29/12 with "2 staff assistant with ADL care at all times." During interview on 11/14/12 at approximately 3:55 PM the Director of Nursing confirmed that Resident #1's care plan was updated to have two people assist with care after the resident fell out of the bed on 10/27/12.

On the day of the complaint investigation, based on record review and interview, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Resident #1 did not receive adequate assistance with care to prevent a fall. The findings include: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Interdisciplinary Care Team - Special Review Note dated 10/29/12 revealed "...resident was being provided care @ time of fall. Fall care plan #7 updated to reflect new approach to have 2 staff providing care at all times, have supplies @ prior to providing care and be sure s/he is in the center of the bed removing mats from bedside to provide care." Review of the Physician's Progress Notes dated 10/1/12 and 10/30/12 revealed a Neurological Examination that included "usual [DIAGNOSES REDACTED] with choreic movements although s/he is currently sleeping without extra movement." Review of the hospital History and Physical dated 10/27/12 revealed Resident #1 had a big bruise on his/her forehead and a laceration which was sutured in the emergency department. Review of Resident #1's Significant Change Minimum Data Set ((MDS) dated [DATE] and Quarterly MDS dated [DATE] revealed the resident was coded as totally dependent for dressing, hygiene and bathing. Resident #1 was also coded as needing two + person physical assist with dressing, hygiene and bathing. Review of Resident #1's CAA Review Report dated 5/11/12 for ADL (Activities of Daily Living)/Rehabilitation Potential revealed summary notes "Resident is total dependence in all ADL's, except bed mobility and transferring. Requires extensive assist of 2 staff." Review of Resident #1's Care Plan revealed it was updated on 10/28/12 with problem area "resident fell out of bed while receiving ADL care. Laceration to L(ef)t forehead 3.5 cm above L(ef)t eye and .5 cm on bridge of nose." Care Plan approaches were updated on 10/29/12 with "2 staff assistant with ADL care at all times." Review of Resident #1's Nursing Guide To Care revealed an update on 10/29/12 "require 2 assist with ADL care". During interview on 11/14/12 at approximately 3:30 PM Certified Nurse Aide(CNA) #1 stated that s/he was providing care to Resident #1 on 10/27/12 and did not have any other staff in the room for assistance. CNA #1 removed a fall mat from beside the bed and turned around to place the mat against the wall. When CNA #1 turned back around s/he saw Resident #1 rolling out of the bed. CNA #1 stated that s/he usually requested assistance from other staff while providing care to Resident #1. CNA #1 stated that s/he usually would request assistance to provide care because of how the resident moved because of his/her condition. During interview on 11/14/12 at approximately 5:15 PM CNA #2 stated that s/he had assisted other CNA's with Resident #1's care. CNA #2 stated that Resident #2 needed assistance with care because of how s/he moves around a lot. During interview on 11/14/12 at approximately 3:55 PM the Director of Nursing confirmed that Resident #1's care plan was updated to have two people assist with care after the resident fell out of the bed. Prior to Resident #1's fall, s/he was not required to have two people assist with care.

On the days of the survey through observation, record review and interview the facility failed to appropriately place two (2) residents (#2 and #4) on a unit conducive to the residents level of functioning. Resident # 2 and 4 remained placed on a locked (restricted freedom) unit when they no longer met the criteria for requiring secured placement. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations made on 02-12-2012 during the initial tour of the secured unit revealed that the unit consisted of 27 residents. The doors were locked and required a staff person to physically unlock the unit to enter or exit the secured unit. Random observations during all three days of the survey revealed Resident #4 in various locations of the locked unit (unit 132). Review of the facilities 'Policy and Procedure Directive' dated November 2011 states that "A resident will be assigned to a locked unit only when such assignment can be fully justified as necessary to assure the safety and welfare of the resident and others. A resident will be assigned to an open unit when he/she no longer meets the criteria for being placed on a locked unit." Per this policy the 'CRITERIA FOR ASSIGNMENT TO A LOCKED UNIT' is: 1. "The resident is able to independently walk or propel a wheelchair and has demonstrated verbally or by behavior or actions that he/she may wander/leave from the nursing unit or building, and is too confused and/or disoriented to avoid danger or harm and cannot independently return to the nursing unit without assistance." 2. The resident exhibits behavior that could be harmful to themselves or others." 'CRITERIA FOR MOVING RESIDENTS FROM A LOCKED UNIT ' is: "It shall be the responsibility of the resident care conference teams to identify those residents on locked units who have improved to the point of no longer requiring a locked unit. As a resident is identified, it will be the responsibility of unit staff to ensure that resident is capable of being in an open environment by developing a plan of care that establishes 'off unit' guidelines for that resident to be able to qualify for transfer". Review of the resident # 4's medical record revealed a "Certification of Inability to Consent - Professional Services" form completed by the 'attending physician' indicating that the resident was reviewed for her inability to consent and she was found to have no limitations. The most current quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eleven - indicative of a moderate impairment. A Social Services Progress Note dated 3-15-11 stated that the resident "choked on a sandwich she sneaked out of the refrigerator on 3-3-11." A [MEDICATION NAME] maneuver was performed. She was placed on 1:1 observations. The resident's care plan stated the resident is on a locked unit for her safety due to eating foods from unit supply and vending machine. Her current diet is pureed with honey thickened liquids. Review of Social Services Progress notes dated 3-30-11 revealed the resident was admitted to the locked unit "because she was non-compliant with her diet and is a risk for choking." A social worker note dated 4-6-2011 stated that the RCC was held today for resident. "A transfer request will be submitted since she does not meet the criteria for a locked unit." The son was notified on 7-6-11 because the resident was placed on an antidepressant. Per the social work note the son stated that "he felt like she had declined since moving to the locked unit." A Social Worker's note dated 7-13-2011 added an addendum to the transfer request submitted in April stating "resident wants to move and her son has noticed a decline since she had been on the locked unit." The note goes on to say that "he was in agreement and said he wanted her to be happy." A Request for Transfer form to an open unit was completed on 4-6-11 "because she does not meet the criteria for a locked unit." The Admissions Committee met on 7-21-2011 and it was decided that the request was "Deferred" by admissions. "Admissions requests that physician speak with son regarding reasons for being on unit 132 so he is aware of danger in allowing her access to vending machines & thus food items which pose a choking hazard to her. There should be documentation in the chart to reflect this conversation". Review of the residents chart revealed no closure to this initial request. A physician progress notes [REDACTED]." During an interview with the Social Worker (SW) on 2-13-12 at 3:50 PM revealed that she was waiting on the Medical Director to talk with the son about the transfer. She also confirmed that the resident continues to be inappropriately placed. Interview with the facility administrator and medical director on 2-14-12 at 3:20 PM confirmed that the facility failed to make a final decision on this transfer request. The Administrator also stated that there will be changes to the admissions/discharge process. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) on 2/12/12 with the Assessment Reference Date of 1/25/12 revealed Resident #2 to have a BIMS (Brief Interview for Mental Status) score of 12, which indicated that the resident was "moderately impaired". Section E 900 "Wandering" of the MDS coded Resident #2 to have not exhibited any wandering behavior. Section G 110 "ADL (Activity of Daily Living) Self Performance and ADL Self Support" revealed Resident #2 as total care with the assist of one person with Bed Mobility and Transfer. Section K 100 "Swallowing Disorder" of the MDS coded Resident #2 to have a swallowing problem which indicated "choking". Review of the Certification of Inability to Consent revealed that Resident #2 had the ability to consent to Level of Care, Chemical and Physical Restraints. Review of "Decisional Capacity Evaluation" completed by the physician 10/31/11 revealed: "Based on this interview pt. (patient) appears to be able to make good decisions and retains the capacity to decide for himself what he should eat. However if actual behavior is different than stated decision then may need to reassess." Following the evaluation there was no evidence that Resident #2's decisional capacity had been reassessed. Record Review on 2/13/12 at approximately 9 AM, revealed a 11/2/11 Physicians Order for "Transfer to locked ward ASAP" (As Soon As Possible). The doors to the unit had wandering device sensors and locks which required a key to enter or to exit. Review of the Social Services Progress Notes dated 11/1/11 stated "Resident #2 has remained non-compliant to his dietary restrictions until placed on 1:1. During that period of time he was assessed for his ability to make sound decisions/judgements. The resident's dietary non-compliance and swallowing problem place him at risk for choking. He goes to the canteen and or asks people to purchase items then begins to cough and sometimes gets strangled." "Resident #2's non-compliance and dietary restrictions have caused him to lose a sense of freedom that separates his ability to intellectualize with passerby's, staff and managing his pleasure spending. This resident did not even want to purchase denture adhesive or clothing but received pleasure from buying food". The Social Worker stated, "He will need reminders initially and attention since his sitter was discontinued (special attention), has to use a thickener in his drinks and cannot buy honey buns any more." Review of the Social Services Progress Notes dated 12/5/11 revealed, "The resident is having a problem with being on a locked unit, but staff members are taking him to activities and to the canteen." Review of the Occupational Therapy Self-Feeding Evaluation on 2/13/12 at approximately 10:30 AM revealed, Resident #2 diet was changed on 12/15/11 from puree to honey-thickened liquids and mechanical soft diet. While being evaluated for a swallowing study "client coughed minimally during the time he was being evaluated." A lunch observation was made by the surveyor on 12/13/12 at approximately 12:10 PM, during which Resident #2 ate fish, tater tots, slaw, dinner roll, peas and drank Nectar Thick water and tea. Throughout the observation there were no signs of aspiration or choking. Review of the Nurses Notes from 11/10/11-2/10/12 revealed no documented episodes of choking or of wandering/exit seeking behaviors. Review of the Resident Care Plan for Resident #2 on 2/13/12 at 1 PM, did not reveal an identified problem for the resident's need to be on a secured unit. On 2/14/12 at approximately 12:50 PM while conducting the Resident Interview, Resident #2 stated, "They moved me to prevent me from going to the canteen. They say I have to be monitored with my eating." Resident #2 also stated during the interview that he had spoke with Social Service Director in regards to the situation and in response they told him "by the time he eats solid food they will send me back to unit 130". During an interview with the Nurse Manager on unit 140 on 2/14/12 at approximately 1:30 PM, she stated, "The resident is in the secured unit due to non compliance of following his diet."

On the days of the survey through observation, record review and interview the facility failed to provide medically-related social services interventions for Resident # 2 and Resident # 4. Resident # 2 and 4 remained placed on a locked (restricted freedom) unit when they no longer met the criteria for needing secured placement. The resident/responsible party had expressed desire to move from the locked unit. Social services failed to provide services which met the residents needs. The findings included: Cross refer to F 223 as it relates to the improper placement of Resident # 2 and # 4 on a locked (restricted freedom) unit when they no longer met the criteria for needing secured placement. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was currently places on a secured unit that consisted of 27 residents. The doors were locked and required a staff person to physically unlock the unit to enter or exit the secured unit. Review of the facilities 'Policy and Procedure Directive' dated November 2011 states that "A resident will be assigned to a locked unit only when such assignment can be fully justified as necessary to assure the safety and welfare of the resident and others. A resident will be assigned to an open unit when he/she no longer meets the criteria for being placed on a locked unit." Per this policy the 'CRITERIA FOR ASSIGNMENT TO A LOCKED UNIT' is: 1. "The resident is able to independently walk or propel a wheelchair and has demonstrated verbally or by behavior or actions that he/she may wander/leave from the nursing unit or building, and is too confused and/or disoriented to avoid danger or harm and cannot independently return to the nursing unit without assistance." 2. The resident exhibits behavior that could be harmful to themselves or others." 'CRITERIA FOR MOVING RESIDENTS FROM A LOCKED UNIT ' is: "It shall be the responsibility of the resident care conference teams to identify those residents on locked units who have improved to the point of no longer requiring a locked unit. As a resident is identified, it will be the responsibility of unit staff to ensure that resident is capable of being in an open environment by developing a plan of care that establishes 'off unit' guidelines for that resident to be able to qualify for transfer". Review of the resident # 4's medical record revealed a "Certification of Inability to Consent - Professional Services" form completed by the 'attending physician' indicating that the resident was reviewed for her inability to consent and she was found to have no limitations. The most current quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eleven - indicative of a moderate impairment. A Social Services Progress Note dated 3-15-11 stated that the resident "choked on a sandwich she sneaked out of the refrigerator on 3-3-11." The Heimlich maneuver was performed. She was placed on 1:1 observations. The resident's care plan stated the resident is on a locked unit for her safety due to eating foods from unit supply and vending machine. Her current diet is pureed with honey thickened liquids. A social service progress note dated 3/22/11 documented alternative solutions to placement on the locked unit which included: "...close the canteen after a certain hour as an option to consider or an attendant/monitor. Certainly no one wants to infringe on the rights of others. A discussion about changing the lock to push-in bar entry/exit with a keyed lock to canteen also mentioned. Ultimately, the transfer option prevailed." A social worker note dated 4-6-2011 stated that the RCC was held today for resident. "A transfer request will be submitted since she does not meet the criteria for a locked unit." A Request for Transfer form to an open unit was completed on 4-6-11 "because she does not meet the criteria for a locked unit." The Admissions Committee met on 7-21-2011 (three months after the resident no longer met the criteria for placement) and it was decided that the request was "Deferred" by admissions. "Admissions requests that physician speak with son regarding reasons for being on unit 132 so he is aware of danger in allowing her access to vending machines & thus food items which pose a choking hazard to her. There should be documentation in the chart to reflect this conversation". A physician progress notes [REDACTED]." The note further documents the resident has had a decreased level of activity and increase in depression. "Spoke to ...is regard to quality of life issues. Asked if he was willing to accept risk of aspiration, choking if transferred to an unlocked unit as well as consideration towards a PEG (gastric tube) and change in code status. "States he will get back." The son was notified on 7-6-11 because the resident was placed on an antidepressant. Per the social work note, the son stated that "he felt like she had declined since moving to the locked unit." A Social Worker's note dated 7-13-2011 added an addendum to the transfer request submitted in April stating "resident wants to move and her son has noticed a decline since she had been on the locked unit." The note goes on to say that "he was in agreement and said he wanted her to be happy." The note does not clarify of what the son was in agreement. A physicians progress note dated 7/13/11 stated "left msg. (message) with ....to discuss transfer issues." A physician progress notes [REDACTED]. to unlocked unit. Explained she would have access to foods not on her diet which would leave her a (increased) risk of choking..said he would call back today." Review of the residents chart revealed no closure to this initial request. No action on behalf of the resident by social services was taken to assure a prompt resolution for the resident. During an interview with the Social Worker (SW) on 2-13-12 at 3:50 PM revealed that she was waiting on the Medical Director to talk with the son about the transfer. She also confirmed that the resident continues to be inappropriately placed 10 months after the resident had been determined to no longer need the locked unit placement and 7 months after the resident's son had told the social worker that he felt his mothers condition was declining since her placement on the locked unit. Interview with the facility administrator and medical director on 2-14-12 at 3:20 PM confirmed the facility failed to make a final decision on the transfer request. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) on 2/12/12 with the Assessment Reference Date of 1/25/12 revealed Resident #2 to have a BIMS (Brief Interview for Mental Status) score of 12, which indicated that the resident was "moderately impaired". Section E 900 "Wandering" of the MDS coded Resident #2 to have not exhibited any wandering behavior. Section G 110 "ADL (Activity of Daily Living) Self Performance and ADL Self Support" revealed Resident #2 as total care with the assist of one person with Bed Mobility and Transfer. Section K 100 "Swallowing Disorder" of the MDS coded Resident #2 to have a swallowing problem which indicated "choking". Review of the Certification of Inability to Consent revealed that Resident #2 had the ability to consent to Level of Care, Chemical and Physical Restraints. Review of "Decisional Capacity Evaluation" completed by the physician 10/31/11 revealed: "Based on this interview pt. (patient) appears to be able to make good decisions and retains the capacity to decide for himself what he should eat. However if actual behavior is different than stated decision then may need to reassess." Following the evaluation, there was no evidence that Resident #2's decisional capacity had been reassessed. Record Review on 2/13/12 at approximately 9 AM, revealed a 11/2/11 Physicians Order for "Transfer to locked ward ASAP" (As Soon As Possible). Review of the Social Services Progress Notes dated 11/1/11 stated "Resident #2 has remained non-compliant to his dietary restrictions until placed on 1:1. During that period of time he was assessed for his ability to make sound decisions/judgements. The resident's dietary non-compliance and swallowing problem place him at risk for choking. He goes to the canteen and or asks people to purchase items then begins to cough and sometimes gets strangled." "Resident #2's non-compliance and dietary restrictions have caused him to lose a sense of freedom that separates his ability to intellectualize with passerby's, staff and managing his pleasure spending. This resident did not even want to purchase denture adhesive or clothing but received pleasure from buying food". The Social Worker stated, "He will need reminders initially and attention since his sitter was discontinued (special attention), has to use a thickener in his drinks and cannot buy honey buns any more." Review of the Social Services Progress Notes dated 12/5/11 revealed, "The resident is having a problem with being on a locked unit, but staff members are taking him to activities and to the canteen." Review of the Occupational Therapy Self-Feeding Evaluation on 2/13/12 at approximately 10:30 AM revealed, Resident #2 diet was changed on 12/15/11 from puree to honey-thickened liquids and mechanical soft diet. While being evaluated for a swallowing study "client coughed minimally during the time he was being evaluated." A lunch observation was made by the surveyor on 12/13/12 at approximately 12:10 PM, during which Resident #2 ate fish, tater tots, slaw, dinner roll, peas and drank Nectar Thick water and tea. Throughout the observation there were no signs of aspiration or choking. Review of the Nurses Notes from 11/10/11-2/10/12 revealed no documented episodes of choking or of wandering/exit seeking behaviors. Review of the Resident Care Plan for Resident #2 on 2/13/12 at 1 PM, did not reveal an identified problem for the resident's need to be on a secured unit. On 2/14/12 at approximately 12:50 PM while conducting the Resident Interview, Resident #2 stated, "They moved me to prevent me from going to the canteen. They say I have to be monitored with my eating." Resident #2 also stated during the interview that he had spoke with Social Service Director in regards to the situation and in response they told him "by the time he eats solid food they will send me back to unit 130". During an interview with the Nurse Manager on unit 140 on 2/14/12 at approximately 1:30 PM, she stated, "The resident is in the secured unit due to non compliance of following his diet."