Every finding on record at Compass Post Acute Rehabilitation

Based on observation, interview, and policy review, the facility failed to ensure three of three observed employes (Cook1, Cook2, and Cook3) performed handwashing after they removed gloves prior to putting on a new pair. Cooks 1 and 3 touched foods with their gloved hands after touching other surfaces which put the food at risk of being contaminated. Findings include: Review of the facility's 2020 Guideline and Procedure policy indicated, All employees will use proper hand washing procedures and glove usage in accordance with State and Federal sanitation guidelines. Employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual resident. Gloves are to be used whenever direct [NAME] contact is required. Hands are washed before donning gloves after removing gloves. Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break, or to go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform, or other non-food contact surface, such as door handles and equipment. Staff should be reminded that gloves become contaminated just as hands do and should be changed often. When in doubt, remove gloves and wash hands again. When gloves must be changed, they are removed, hand washing procedure is followed, and a new pair of gloves is applied. Gloves are never placed on dirty hands; the procedure is always wash, glove, remove, rewash, and re-glove. Review of a 03/13/24 Dietary Uniform Policy in-service included Disposable gloves must be worn when handling food, you must change your gloves in between tasks, when leaving the back line, you must remove your gloves wash your hand and put new gloves on. The in-service had been attended by Cook1, Cook2, and Cook3. Observation of tray service with Cook1 and Cook2 on 04/10/25 at 11:35 AM revealed [NAME] 1 had gloves on, used a suction device to place a heated base onto an insulated bottom and place a heated plate on the insulated bottom. She would change her gloves, place those soiled gloves either in her uniform pocket, a cart next to the steam table, or on the counter next to the heated plate machine. She did not wash her hands before she put new gloves on, at times she touched the fried chicken and potato slices to ensure the portion stayed on the plate. [NAME] 2 was taking the resident trays and placed the plated food on them, retrieved covers to cover the food, and put the trays in the tray cart. She wore the same pair of gloves the entire time. She also put dishes of coleslaw and desserts on the trays. Observation on 04/10/25 at 12:15 PM of Cook3 revealed [NAME] 1 placed a stuffed cabbage roll on a plate. [NAME] 3 took that plated cabbage roll from the tray line to the front counter. He changed his gloves and did not wash his hands before putting on a new pair of gloves. He placed a cutting board on the counter and retrieved a knife from a knife holder. He then used his gloved hands and picked up the cabbage roll and placed it on the cutting board, while he held the cabbage roll, he sliced it into pieces. He then used his gloved hands and held the cut-up cabbage roll and slid the knife under it and placed it in back on the plate. He changed his gloves without washing his hands in between the soiled gloves and the new pair of gloves and carried the plated cabbage roll back to the tray line. Observation on 04/10/25 at 12:3 PM of Cook3 revealed he used his gloved hands to take a hamburger bun out of the bag and then placed the hamburger on the bun. He used his gloved hands to hold the hamburger while he held it, he then put it on a plate. He removed his gloves and lifted the cover of a garbage can and put a new pair of gloves on without washing his hands. [NAME] 3 then picked up the plated hamburger and carried it back to the tray line where [NAME] 2 placed on a resident tray. Observation on 04/10/25 from 11:35 AM through 12:30 PM revealed no staff had washed their hands. The handwashing sink was behind the tray carts. No staff moved the trays carts to use the handwashing sink. Interview on 04/10/25 at 12:45 PM with the Dietary Manager confirmed the dietary staff including Cooks1, 2, and 3 had not washed their hands between glove changes She agreed if they had changed gloves they should have washed their hands. She also said the lids on the large garbage cans in the kitchen stayed on at all times. She agreed that if staff lifted the lids of the garbage cans after they washed their hands, they contaminated their hands. Interview on 04/10/25 at 6:15 PM with the Administrator revealed the staff in the kitchen had been educated several times on the importance of handwashing between glove changes.

51678 Based on record reviews, and interviews, the facility failed to ensure five of 22 sample residents (Resident (R)9, R52, R3, R16, and R34) were provided with the opportunity to attend their care conferences to express their concerns and needs. This failure has resulted in care conference's being completed without residents and/or representative's input and attendance. Findings include: 1. Review of R9's Admission Record, found in the resident's electronic medical record (EMR) under the Census tab revealed the facility admitted the resident on 01/22/24. Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/10/25, located in the resident's EMR under the MDS tab, revealed the facility assessed R9 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of R9's scanned records included a quarterly Care Conference (Care Plan Review) form, dated 04/23/24, under the EMR Miscellaneous tab. The note documented the participants, Social Services Director (SSD), Minimum Data Set Coordinator (MDSC)1, Dietary Manager (DM), and the Activities Director (AD), included the following: invitations to R9, resident representative, offer of the care plan, face sheet information verification, and advance directives verification. The form indicated the resident declined to attend the care conference. Review of R9's scanned records included a quarterly Care Conference (Care Plan Review form, dated 07/23/24, under the EMR Miscellaneous tab. The note documented the participants, SSD, MDSC1, DM, and the AD, included the following: invitations to R9, resident representative, both R9 and his representative attended. Review of R9's scanned records included a quarterly Care Conference (Care Plan Review form, dated 10/24/24, under the EMR Miscellaneous tab. The note documented the participants, SSD, MDSC1, DM, and the AD, included the following: an invitation was placed in R9's room on 10/08/24, an invitation was mailed to his resident representative on 10/01/24, and offer of the care plan was declined. Resident update included Alert and oriented, prefers in room activities, likes family visits, needs help with all ADLs [activities of daily living]. Review of R9's scanned records included an annual Care Conference (Care Plan Review form, dated 12/24/24, under the EMR Miscellaneous tab. The note documented the participants, SSD, MDSC1, DM, AD, and therapy, included the following: an invitation was placed in R9's room on 11/25/24, an invitation was mailed to his resident representative on 11/25/24, and the offer of the care plan was declined. Review of R9's scanned records included a quarterly Care Conference (Care Plan Review form, dated 03/18/25, under the EMR Miscellaneous tab. The note documented the participants, SSD, MDSC1, DM, AD, and therapy, included the following: an invitation was placed in R9's room on 02/28/25, an invitation was mailed to his resident representative on 02/28/25, and an offer of the care plan was declined. During an interview on 04/08/25 at 3:15 PM with R9 he stated was not sure what a care plan conference was. He doubted he had attended any meeting with a group of people. Telephone interview on 04/10/25 at 4:56 PM with Family Member (FM)2 revealed she had only received one invitation for a care conference meeting. SFM2had attended that meeting. She had not received any notifications mailed to her about coming to another care conference. She indicated if she had been invited, she would respond and come to the conference or would like to participate in the conference during a phone call. 2. Review of R52's Admission Record, found in the resident's EMR under the Census tab revealed the facility admitted the resident on 09/23/23. Review of R52's quarterly MDS with an ARD of 01/09/25, found in the resident's EMR under the MDS tab, revealed the facility assessed R52 to have a BIMS score of 03 out of 15 which indicated the resident was severely cognitively impaired. R52's scanned records included a quarterly Care Conference (Care Plan Review form, dated 10/01/24, under the EMR Miscellaneous tab. The note documented the participants, SSD, MDSC1, DM, AD, and therapy, included the following: an invitation was placed in R52's room on 09/06/24, an invitation was mailed to his resident representative on 09/06/24, and an offer of the care plan was declined. Resident update included Continues on [name] hospice. Enjoys spending time with wife and family visits. Attends most activities. It had been indicated that neither R52 nor his representative attended. It had been documented they declined to attend. R52's scanned records included a quarterly Care Conference (Care Plan Review form, dated 01/21/25, under the EMR Miscellaneous tab. The note documented the participants, SSD, MDSC1, DM, AD, and therapy, included the following: an invitation was placed in R52's room on 12/27/24, an invitation was mailed to his resident representative on 12/27/24, and an offer of the care plan was declined. Resident update included Alert with confusion, needs help with some activities. Needs help with some activities of daily living. It had been indicated that neither R52 nor his representative attended. It had been documented they declined to attend. R52's scanned records included an annual Care Conference (Care Plan Review form, dated 04/01/25, under the EMR Miscellaneous tab. The note documented the participants, SSD, MDSC1, DM, AD, and therapy, included the following: an invitation was placed in R52's room on 02/28/25, an invitation was mailed to his resident representative on 02/28/25, and an offer of the care plan was declined. Resident update included Alert with confusion, needs help with some activities. Needs help with some activities of daily living. It had been indicated that neither R52 nor his representative attended. It had been documented they declined to attend. 3. Review of R3's update Face Sheet, located in R3's EMR under the Profile tab, revealed R3 was admitted to the facility on [DATE] with a diagnosis that included cerebral palsy, unspecified, and malignant neoplasm of unspecified site of left female breast. Review of the quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) on 01/29/25, located under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R3 was cognitively intact. Review of the Care Plan Conference Review Meeting Sign in Sheet located in R3's EMR under the Miscellaneous tab revealed R3 had a quarterly Care Plan Conference Review on 03/12/24, the invite request was placed in R3's room on 02/29/24. On attendance, it indicated the resident declined. Care Plan Conference Review on 08/27/24 (quarterly), the invite requested was placed in R3's room on 08/21/24. On attendance, it indicated that R3 declined. Care Plan Conference Review (quarterly) on 02/04/25, the invite was placed in R3's room on 12/27/24. On attendance, it indicated that R3 declined. 4. Review of R16's update Face Sheet, located in R16's EMR under the Profile tab, revealed R16 was admitted to the facility on [DATE] with a diagnosis that included epilepsy, unspecified, not intractable, without status epilepticus, cognitive communication deficit, and, bipolar disorder, unspecified. Review of the annual (MDS with an ARD on 02/21/25, located under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated R16 was cognitively intact. Review of the Care Plan Conference Review Meeting Sign in Sheet located in R16's EMR under the Miscellaneous tab revealed R16 had a quarterly Care Plan Conference Review on 07/22/24, the invite request was placed in R16's room on 06/11/24. On attendance, it indicated the resident declined. Care Plan Conference Review (quarterly) on 09/24/24, the invite was placed in the room on 09/06/24. On attendance, it indicated the resident declined. Care Plan Conference Review (quarterly) on 12/10/24, the invite was placed in the room on 11/25/24. On attendance, it indicated the resident declined. Care Plan Conference Review (quarterly) on 02/25/25, the invite was placed in the room on 01/27/25. On attendance, it indicated the resident declined. 5. Review of R34's update Face Sheet, located in R34's EMR under the Profile tab, revealed R34 was admitted to the facility on [DATE] with a diagnosis that included Parkinson's disease without dyskinesia, without mention of fluctuations, alcohol abuse, uncomplicated, and unspecified visual loss. Review of the quarterly MDS with the ARD) on 03/05/25, located under the MDS tab, revealed a BIMS score of 11 out of 15, which indicated R34 was moderately cognitively intact. Review of the Care Plan Conference Review Meeting Sign in Sheet located in R34 EMR under the Miscellaneous tab revealed R34 had a quarterly Care Plan Conference Review on 07/23/24, the invite request was placed in R34 room on 07/04/23. On attendance, it indicated the resident declined. Care Plan Conference Review (quarterly) on 10/01/24, the invite was placed in the room on 09/06/24. On attendance, it indicated the resident declined. Care Plan Conference Review (annual) on 12/24/24, the invite was placed in the room on 11/25/24. On attendance, it indicated the resident declined. Care Plan Conference Review (quarterly) on 03/11/25, the invite was placed in the room on 02/28/25. On attendance, it indicated the resident declined. During an interview on 04/09/25 at 5:06 PM with the Social Service Director (SSD) revealed that providing the resident with an invitation to the care plan meeting. On the invite, it indicates to contact the SSD to set up a time. When people do not make contact with her, the Interdisciplinary Team (IDT) goes ahead and has the meeting. There are only a couple of people who attend the Care Plan meetings. When asked about follow-up with residents after providing the invite, the SSD indicated not having any follow-up with residents, family members, or resident representatives. When asked about the decline, the SSD revealed that how it is indicated the resident did not attend. During an interview on 04/10/25 at 12:08 PM with the Administrator and Director of Nursing (DON), the DON indicated not being aware that this was the process that was being used and documented for the care conference. The Administrator also indicated being unaware of the process and the care conference attendance sheet showing declined.

Based on observations, interviews, and review of facility policy, the facility failed to ensure foods that were stored in the freezer, refrigerators and dry food storage were appropriately sealed, labeled, dated with a use by date, and/or discarded after the manufacturer's expiration date. This had the potential to affect all residents who received meal trays from the kitchen. Findings include: Review of the facility's undated policy titled, Food Storage (Dry, Refrigerated, and Frozen) revealed, General storage guidelines to be followed: a. all food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded, 2. Aprons, guideline: Aprons shall be worn when preparing or serving food, Procedure: 1. Cloth aprons shall be worn during food production, 2. Disposable aprons shall be worn when washing dishes, 3. Cloth aprons should be removed when leaving the kitchen. Guideline: Food storage Label & Dating, procedure: 1. Products in the freezer that are opened must be labeled with an open date and expiration date. If you do not use of the product, and place part of the product back in the box it must be wrapped appropriately, and dated with an open date and same expiration date. During an observation on 03/24/24 at 10:45 AM, of the walk-in freezer revealed the following: 1 - package of chicken breasts containing 6 chicken breasts was opened and not dated or labeled. 1 - bag of shrimp which was opened with clear plastic wrap over the bag, not dated or labeled. 1 - 1 lbs bag of chicken breast fritters which was opened and not dated or labeled. During an observation on 03/25/24 at 10:32 AM, of the walk-in refrigerator revealed the following: 1 - 8 ounce (oz) package of bagels that were opened and not dated or labeled. 1 - 32 oz carton traditional scrambled egg mix liquid egg product which was opened, not dated or labeled. 1 - box of tomatoes (cherry tomatoes) with a label indicating 03/18/24, however the good through date was smeared and not legible. During a follow-up observation on 03/26/24 at 7:51 AM, of the walk-in freezer revealed the following: 1 - box of 48 4 fluid (fl) oz of Blue Bunny chocolate marble ice cream on the floor. 1 - box of 48 4 fl oz of Blue Bunny vanilla ice cream on the floor. 3 - 4 fl oz of vanilla ice cream out of boxes on the floor. 1 - box of okra with label on box indicating 01/09/24 good through date 02/10/24. 1 - box chicken cordon bleu with label on box indicating 01/05/24 good through 02/13/24. 1 - 40 portions box of pork steak fritters with label on box indicating 12/08/23 good through 12/31/23. During an observation on 03/26/24 at 12:30 PM, the emergency water supply revealed 250, 1-gallon jugs of Crystal [NAME] Alpine Spring Water dated 01/10/23 with a manufacturer's best by date of 3/22/23. During an interview on 03/24/24 at 10:50 AM, the Dietary Manager (DM) revealed that it is her practice to place open bags and containers in dated and labeled boxes and not date label actual packages. During an interview on 03/25/24 at 8:00 AM, the DM stated the good through labels on the stickers on the outside of the box are the expiration dates for what the box contains. During an interview on 03/27/24 at 10:12 AM, the Administrator revealed that the dietary manager manages the kitchen, but he oversees the kitchen along with everything else, and he goes through the kitchen at least once a day to make sure things are labeled, clean and there is no build up on the equipment. The Administrator further states that the dietary manager has a good system, and he trusts her labeling system, but something thing can happen. The Administrator revealed his expectation for open packages is that they be labeled for the date it was opened.

Based on observation, interview, and review of the facility policy titled, Catheter Care, Indwelling, the facility failed to ensure proper catheter care for Resident # 11, for 1 of 3 residents reviewed with an indwelling catheter. The findings included: An observation on 1/7/2021 at approximately 10:30 AM of indwelling foley catheter care for Resident #11 revealed Registered Nurse (RN) #1 performing catheter care as follows: RN #1 washed his/her hands and applied clean gloves. He/she then proceeded to close the door of the resident's room, pull the privacy curtain, and using the bed remote control he/she raised the bed. Then using the same gloved hands put the feeding pump on hold, and took the remote control for the bed again and lowered the head of the bed. The RN then used the same gloved hands and removed Resident #11's brief. He/she then, with the same gloved hands, wiped down each side of the groin area and discarded the wipe each time. RN #11 did not clean inside at the insertion site. The RN then took another wipe and wiped from outer skin down the tubing, twice using the same wipe. An interview on 1/7/2021 at approximately 10:45 AM confirmed that RN #1 had used the same gloved hands to do catheter care that he/she used to close Resident #11's room door, pull the privacy curtain, used the bed control twice, and put the feeding pump on hold. Review on 1/7/2021 at approximately 12:30 PM of the facility policy titled, Catheter Care, Indwelling, stated under the purpose, To promote hygiene, comfort, and decrease the risk of infection for residents with an indwelling catheter.

Based on observation, interview and review of the facility policy titled, Catheter Care, Indwelling, the facility failed to follow a procedure to decrease the risk of infection for Resident #11 during foley catheter care, 1 of 3 reviewed for indwelling catheters. The findings included: An observation on 1/7/2021 at approximately 10:30 AM of indwelling foley catheter care for Resident #11 revealed Registered Nurse (RN) #1 performing catheter care as follows: RN #1 washed his/her hands and applied clean gloves. He/she then proceeded to close the door of the resident's room, pull the privacy curtain, and using the bed remote control he/she raised the bed. Then using the same gloved hands put the feeding pump on hold, and took the remote control for the bed again and lowered the head of the bed. The RN then used the same gloved hands and removed Resident #11's brief. He/she then, with the same gloved hands, wiped down each side of the groin area and discarded the wipe each time. RN #11 did not clean inside at the insertion site. The RN then took another wipe and wiped from outer skin down the tubing, twice using the same wipe. An interview on 1/7/2021 at approximately 10:45 AM confirmed that RN #1 had used the same gloved hands to do catheter care that he/she used to close Resident #11's room door, pull the privacy curtain, used the bed control twice, and put the feeding pump on hold. Review on 1/7/2021 at approximately 12:30 PM of the facility policy titled, Catheter Care, Indwelling, stated under the purpose, To promote hygiene, comfort, and decrease the risk of infection for residents with an indwelling catheter.

Based on observation, interview, and review of facility temperature log and policies titled Dietary, Sanitation In and Manual Pot and Pan Washing, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed with the potential to affect residents receiving a physician ordered diet as evidenced by the following: debris was observed in the microwave, a dark substance was observed in the top of the ice maker, and pans were observed stacked wet. In addition, the freezer part of a unit refrigerator was not working properly in 1 of 2 unit nutrition rooms. The findings included: During initial tour of the kitchen with the Certified Dietary Manager(CDM) on 7/15/19 at 11:33 AM, the following was observed: a black substance was observed inside the kitchen icemaker; food debris observed in the microwave; and cooking pans were stacked/stored wet. At the time of the observation, the CDM confirmed food debris in the microwave, a black substance in the icemaker, and pans stored wet. Observation of the 200 Unit nutrition kitchen on 7/17/19 at 10:50 AM revealed the freezer was four degrees Fahrenheit (F). Ice cream in the freezer upon inspection was soft to touch. On 7/17/19 at 3:40 PM, observation of the 200 Unit nutrition kitchen along with the CDM revealed ice cream continued to be soft to touch and the thermometer was reading 4 degrees F. The CDM at the time of the observation stated ice cream had not been delivered to the unit that day and confirmed the ice cream was not frozen. The log for the freezer temperatures for (MONTH) 2019 was reviewed with temperatures documented in the range of minus 6 degrees F to minus 10 degrees F. Review of the facility policy titled, Dietary, Sanitation in revealed under the procedure section the following: 1. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 7. Microwaves will be cleaned and sanitized after each meal and as needed if debris is noted. Review of the facility policy titled Manual Pot and Pan Washing revealed under the Procedure section the following: 6. After the items are removed from the sanitizer they should be allowed to drain and air dry completely before being returned to storage.

Based on record review, interview, and review of the facility policy titled, Fluid Restriction, the facility failed to ensure a physician ordered fluid restriction for Resident #25 was monitored and documented for 1 of 1 residents reviewed for [MEDICAL TREATMENT]. The findings included: The facility admitted Resident #25 with [DIAGNOSES REDACTED]. Review on 7/17/2019 at approximately 1:35 PM of the medical record for Resident #25 revealed monthly physician orders for (MONTH) 2019 and (MONTH) 2019. The physician order sheets did not contain documentation to ensure Resident #25 was receiving the ordered amount of fluid The Medication Administration Record [REDACTED]. During an interview on 7/18/2019 at approximately 3:32 PM, the Director of Nursing (DON) confirmed that the fluid intake was not being monitored/documented with the amount of fluid consumed by Resident #25 on the MAR indicated [REDACTED]. Review on 7/18/2019 at approximately 4:05 PM of the nursing notes for Resident #25 dated 4/1/2019 through 7/18/2019 revealed they did not indicate that Resident #25 was noncompliant with the 1200 milliliter fluid restriction daily that was ordered by the physician. Review on 7/19/2019 at approximately 5:00 PM of the facility policy titled, Fluid Restriction, states under Policy: It is the policy of this facility to provide fluids as specified by the physician order. The Purpose reads, To ensure fluids needs are met while not exceeding limits established by the physician. Under Procedures, number 2 states, Distribution of fluids will be determined by licensed staff, dietary services supervisor, activities and social services, and the resident. Fluid intake will be encouraged to meet minimum requirements as stated in the physician order.

Based on observation, interview, and record review, the facility failed to clean the Oxygen concentrator filter for 1 of 1 residents reviewed for respiratory care (Resident #13). The findings included: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During initial tour of the facility on 7/15/19 at approximately 11:00 AM, it was noted by a surveyor that Resident #13's oxygen concentrator filter had a large buildup of gray matter. An additional observation of the unclean filter was done on 7/16/19. On 7/17/19 at approximately 3:29 PM, Licensed Practical Nurse (LPN) #1 was asked who provided the Oxygen concentrators and who was responsible for cleaning them. LPN #1 stated Hospice provided the concentrators, but the facility's staff was responsible for cleaning them. When asked whether or not the filter was clean, LPN #1 confirmed it was not and that there was a thick buildup of lint/dust on the filter. Review of the facility's policy titled, Oxygen Equipment on 7/18/19 at 4:20 PM revealed, Oxygen tanks, connectors, and concentrators must be cleaned after use.

Based on observation and interview, the facility failed to dispose of refuse properly for one of one grease receptacles. Grease was not contained in the refuse container leaving the spill visible. The findings included: On 7/15/19 at approximately 2:00 PM, observation of the grease receptacle outside the kitchen revealed spillage. On 7/17/19 at approximately 12:00 PM, observation of the grease receptacle with the Certified Dietary Manager(CDM) revealed spillage of grease. At the time of the observation, the CDM confirmed the spillage. Measurement of the grease spillage revealed an area of 60 inches long and 36 inches at the widest point of the spill.

Based on record review, interview, review of the facility policy titled Administration of an Intermittent Infusion, and review of the South Carolina Board of Nursing Advisory Option #9, the facility failed to provide care and services that met professional standards of practice for one of one sampled resident with a Peripheral Inserted Central Catheter(PICC) Line. Resident #172 was administered PICC Line flushes and antibiotics by Licensed Practical Nurses(LPN) with no documentation of advanced training and there were multiple days when a Registered Nurse (RN) was not on site when the LPN's administered the medications and flushes via the PICC Line. The findings included: The facility admitted Resident #172 with [DIAGNOSES REDACTED]. Record review on 6/14/18 of the current physician orders revealed an order for [REDACTED]. Review of the Medication Administration Records for (MONTH) (YEAR) revealed Licensed Practical Nurses administered medication and flushed the resident's PICC Line everyday from 6/1/18-6/13/18. Review of the facility staffing sheets for the time of 6/1/18-6/12/18 revealed there was no Registered Nurse in the building as required while the medication and flushes were being administered via a PICC Line per documentation on the medication record. The facility on 6/14/18 was asked to provide documentation that the LPN's taking care of the resident's PICC line had been trained to work with a PICC line. The facility could not provide education for two of the three LPN's who had administered medications or flushes through the PICC line. During an interview with the Director of Nursing on 6/14/18, s/he was unaware a RN was required to be on site during the administration of medications/flushes through the PICC line by an LPN. Review of the facility policy titled Administration of an Intermittent Infusion revealed the following under the section To Be Performed By: .The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation is documented in accordance with organizational policy. Per the South Carolina Department of Labor, Licensing and Regulation, (Advisory Opinion # 9B) states: The selected LPN shall document completion of special education and training to include: cardiopulmonary resuscitation and intravenous therapy course relative to the administration of fluids via peripheral and central venous access devices/lines that includes didactic and supervised clinical competency training with return demonstration The LPN may not give medications directly into the vein (intravenous push) or insert medication via an external catheter site (port A cath). The Agency must have specific standing orders to deal with potential complications or emergency situations and provision for supervision by the RN. Section 40-33-20 defines supervision as meaning the process of critically observing, directing, and evaluating another's performance.

Based on record review, observation and interview the facility failed to provide written Notice of Transfer to the Resident/ Resident Representative for Resident #17, 1 of 2 sampled residents reviewed for hospitalization . The findings included: The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Record review on 06/13/18 at approximately 9:50 AM revealed this Nurse's Note dated 05/13/18 - Call placed to NP (Nurse Practitioner), new order send to emergency room for evaluation Sent via Ambulance/stretcher at 4:35 PM. No Notice of Transfer found in medical record. In an interview on 06/14/18 at approximately 1:13 PM the Director of Nursing confirmed that related to providing written Notice of Transfer, they were in process of educating staff on the need to complete documentation and none was available for Resident #17.

Based on record review and interview, the facility failed to develop a care plan for a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. Resident #65 did not have a care plan related to his/her pressure ulcer. The findings included: The facility admitted #65 with [DIAGNOSES REDACTED]. Record review on 6/13/18 revealed Resident #65 developed a Left Buttock Wound. Review of the current physician orders [REDACTED]. Further review of the physician orders [REDACTED]. Review of Resident #65's care plan revealed there was no care plan developed for the pressure area. During an interview with the Assistant Director of Nursing on 6/14/18 at 10:57 AM, s/he after further investigation, confirmed a care plan had not been developed for Resident #65's pressure ulcer.

Based on record review, and interview, and review of the facility policy titled Change in Condition Reporting, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 reviewed for accidents and 1 of 1 for change in condition. Resident #67 did not have complete neurochecks following an accident. Resident #38 with a change of condition in respiratory status with delay with transfer to the hospital. The findings included: The facility admitted Resident #38 with [DIAGNOSES REDACTED]. Record review on 6/13/18 of the nurse's notes revealed on 5/19/18 at 04:26 Resident #38 had experienced increased respiratory distress during the evening. Difficulty maintaining oxygen saturation values was documented as 90% on 2 liters of oxygen at midnight. The nurse's note revealed oxygen was increased to 4 liters and the oxygen saturation dropped to 76% . Oxygen was increased to 6 liters. Resident #38's blood pressure radially was 88/38, pulse 112 and irregular and respirations were 26. At 2:30 AM, on call was notified. Oxygen saturation dropped to 56% at 3:00 AM and the resident was switched to a mask. On call was called again. Oxygen saturation increased to 69%, 911 was called, vitals were rechecked. Resident was transferred to hospital, the responsible party was notified. On 6/13/18 at 2:00 PM, after reviewing the nurse's notes, the Director of Nursing confirmed the resident should have been sent out to the hospital earlier and not kept in the facility as long after the change of condition. Review of the facility policy titled Change of Condition Reporting revealed under the Procedures section listed the following: Life Threatening Change-1. Licensed nurse will initiate appropriate first aid measures until emergency response personnel arrive on the scene. 2. Licensed nurse will inform the primary physician (alternate physician or Medical Director) of resident status as soon as possible before, during or after the change of condition. Based on record review, observation and interview the facility failed to complete Neurological Checks for an Unwitnessed Fall with an injury for Resident #67, 1 of 2 sampled residents reviewed for Accidents. The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 06/14/18 at approximately 5:25 PM revealed an Incident Report dated 06/05/18 detailing a fall by Resident #67 which stated, resident asked for something for pain. The resident stated that he/she was hurting and that his/her right side hurt, pointed to rib area. Resident #67 stated he/she fell coming back from the bathroom and hit the footboard of the bed. He/she had a red area on the outer right upper extremity, red area to the right side of chest and also the right knee Neuro checks started due to unwitnessed fall. Further review of the medical record revealed a form entitled Neurological Observations Form dated 06/15/18 with Resident #67's name. The form had no entries in the columns labeled L[NAME] (Level of Consciousness), Cran (Cranial Check), Pupil, Hand Grip and Notes for the assessment times detailed on the form. In an interview on 06/14/18 at approximately 6:23 PM the Director of Nursing (DON) stated staff would be expected to complete all columns of the form for a complete assessment. The DON also provided a copy of facility policy entitled Neurological Evaluation which stated, Any resident having an injury involving the head or an unobserved fall will have neuro checks and vital signs taken at least every 8 hours for 24 hours or per specific facility, policy or physician's order.

Based on record review, observation and interview, the facility failed to ensure that residents were aware of the location of the State Agency Survey results for 1 of 1 resident council interviewed in the Resident Council group meeting. The findings included: On 6/14/2018 at approximately 11AM, the Resident Council meeting minutes from (MONTH) (YEAR)-May (YEAR) were reviewed and provided no documentation that the council discussed the location of the State Agency Survey results. During a random observation on 6/14/2018 at approximately 1PM, it was revealed that the survey results were located in the lobby, on a brown, mantle-like surface. The surface appeared to be high in nature, which could present issues for residents who may be wheelchair bound. The Resident Council group meeting was held on 6/14/2018 at 245PM and all residents in attendance stated that they did not know the location of the State Agency Survey results.

Based on record review, interview, and review of the facility policy titled 7.0 Medication Shortages/Unavailable Medications, the facility failed to notify the resident's physician related to the unavailability of an ordered medication(1 of 2 residents reviewed for intravenous medication). The physician was not notified of the unavailability of Resident #2's intravenous medication. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 3/20/18 revealed a physician's order dated 1/3/18 for [MEDICATION NAME] [MED] Suspension 1500 milligrams (mgs) intravenously every 8 hours [MEDICAL CONDITION] to Left Great Toe. Review of the Medication Administration Record [REDACTED]. Further record review revealed the physician was not notified of the unavailability of the medication. During an interview with the Director of Nursing on 3/20/18 at 12:30 PM, s/he confirmed the resident had missed doses of the ordered medication and the physician had not been notified. S/he continued by stating if there was no medication in the facility, staff were to call the back up pharmacy and notify the physician for any further orders. Review of the facility policy titled 7.0 Medication Shortages/Unavailable Medications revealed the following: 5. If the medication is unavailable from pharmacy or a third party pharmacy, and cannot be supplied from the manufacturer, the facility should obtain alternate physician/prescriber orders, as necessary.

Based on record review and interview, the facility failed to develop a care plan related to Resident #1's behavior (1 of 2 reviewed for intravenous medications). Resident #1 had an order for [REDACTED]. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 3/19/18 revealed a physician's orders [REDACTED]. Further review of the nurse's notes revealed Resident #1 removed the PICC line on 2/16/18, 2/25/18, and 2/28/18. Review of Resident #1's care plan revealed the resident was not care planned for the behavior of removing the PICC line. During an interview with the Care Plan Coordinator on 3/20/18 at 12:16 PM, s/he stated s/he did not recall if the behavior had been reported to the care plan team, but the behavior should have been care planned.

Based on record review, interview, and review of the facility policy titled 7.0 Medication Shortages/Unavailable Medications, the facility failed to obtain physician ordered intravenous (IV) medication in a timely manner (1 of 2 residents reviewed for intravenous medication). The facility failed to obtain an IV medication ([MEDICATION NAME] [MED] Suspension) timely. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 3/20/18 revealed a physician's order dated 1/3/18 for [MEDICATION NAME] [MED] Suspension 1500 milligrams (mgs) intravenously every 8 hours [MEDICAL CONDITION] to Left Great Toe. Review of the Medication Administration Record [REDACTED]. Further record review revealed the physician was not notified of the unavailability of the medication to see if their were further orders from the physician. During an interview with the Director of Nursing on 3/20/18 at 12:30 PM, s/he confirmed the resident had missed doses of the ordered medication and the physician had not been notified. S/he continued by stating if there was no medication in the facility, staff were to call the back up pharmacy and notify the physician for any further orders. Review of the facility policy titled 7.0 Medication Shortages/Unavailable Medications revealed the following: 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order or reorder for the next scheduled delivery. 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the emergency Medication Supply, the facility should notify pharmacy and arrange for an emergency delivery. 3. If a medication shortage is discovered after normal pharmacy hours: 3.1 A licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. 3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 emergency delivery; or, 3.2.2 Use of an emergency (back-up) third party pharmacy.

Based on record review and interview, the facility failed to ensure Resident #1's Peripherally Inserted Central Catheter (PICC) line was secured to prevent removal (1 of 2 reviewed for intravenous medications). Resident #1 had an order for [REDACTED]. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 3/19/18 revealed a physician's orders [REDACTED]. Further review of the nurse's notes revealed Resident #1 removed the PICC line on 2/16/18, 2/25/18, and 2/28/18. Further review of the nurse's notes revealed no intervention was implemented to prevent Resident #1 from removing his/her PICC line. Review of Resident #1's care plan revealed the resident was not care planned for the behavior of removing the PICC line. During an interview with the Care Plan Coordinator on 3/20/18 at 12:16 PM, s/he stated s/he did not recall if the behavior had been reported to the care plan team, but the behavior should have been care planned. S/he continued by stating s/he did not know of what type intervention could have been implemented.

Based on record review and interview, the facility failed to ensure Resident #1's medical record was accurate (1 of 1 reviewed for accuracy of medical record). Resident #1 signed consent for insertion of Peripheral Inserted Central Catheter (PICC) after deemed by two physician's as incapable of making healthcare decisions. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 3/19/18 revealed an Authorization for Allow Natural Death-Patient without Ability to Consent form dated 2/14/18 by two physicians on Resident #1's chart. Further review of the form revealed the resident was in a non-cognitive state, with no reasonable possibility of regaining cognitive function. Further record review revealed Resident #1 signed a consent form to have a PICC line reinserted on 2/27/18. During an interview with the Director of Nursing on 3/20/18, s/he confirmed the findings.

Based on review of facility files and interview, the facility failed to ensure resident medical records were provided completely, in a timely manner, and cost-based fees were followed per facility policy. Resident #2's power of attorney requested a copy of the resident's medical record on 5/3/17. The facility faxed a bill for the fees for the copies on 6/6/17. Copies of the resident's medical record were emailed on 10/12/17. The request was sent for the resident's entire file and the facility did not submit the entire file. The facility did not provide Nurses' Notes, assessments, or medication/treatment administration orders. The facility fee form did not follow the facility's policy related to the fees for copies of medical records. One of three residents reviewed for record requests. The findings included: The Medical Records staff provided a handwritten list of resident medical record requests. The staff stated that there was no log to indicate when requests were received or when they were fulfilled. The medical records staff stated s/he keeps a copy of all the information that is sent in a file for each resident record request. Reviewed copies of the information requested that were provided in the file for Resident #2. Noted there were no nursing progress, assessments, or administration records notes in the file. There was a letter addressed to the owner of the facility dated 6/23/17 from an attorney's office that indicated the request for the entire chart and medical record for Resident #2 dated 5/3/17 had not been received. Review of the Medical Records Copy Charges form dated 6/6/17 revealed a record processing fee of $25.00, Pages 1-30 @ $.65 for a total of $19.50, Pages 31+ @ $.50 for a total of $26.00 with a total charge of $70.50. In an interview with the surveyor on 10/23/17 at approximately 3:05 PM, medical records staff stated s/he scanned the information in the request folder into his/her computer and then emailed the information to the email provided. That is all the information s/he provided for the medical record request. In an interview with the surveyor on 10/23/17 at approximately 3:30 PM, medical records staff stated s/he doesn't know when s/he received the request letter dated 5/3/17. S/he does not keep a log of when s/he receives request. They do not provide information on CDs per corporate policy. The copy of the letter dated 6/23/17 came in with another letter that was dated 9/6/17 to show where they sent it because the medical records staff never received the letter dated 6/23/17. That letter was addressed to the owner of the corporation. Medical records staff stated s/he does not know what happened to the original letter addressed to the owner of the company. Medical records staff stated s/he received the letter dated 5/3/17 and faxed the fee form on 6/6/17. The next information s/he received was the letter dated 9/6/17, which she received on 9/8/17. A staff member from the attorney's office called on 9/12/17 and said s/he did not receive the fee form. Medical records staff emailed the invoice on 9/12/17. The next email s/he received was 10/11/17 indicating payment was made 9/15/17 and the records had not been received. Medical records staff checked with the business office because s/he had not been informed about payment and was told the payment had been received. S/he emailed the records on 10/12/17. Medical records staff did not send Nurses' Notes, generally s/he doesn't send unless they specifically request the information. S/he also did not send medication administration records. Medical records staff confirmed s/he did not send a copy of the entire medical record. Medical records staff stated if records are emailed, they are still charged per sheet. Medical records staff also stated s/he did not send the resident's assessments. Medical records staff stated s/he figures they will contact him/her if they need additional information. Medical records staff confirmed Nurses' Notes and assessments are part of the resident's medical record and care. At approximately 4:15 PM, medical records staff stated s/he did not know about the 2 days to respond to record requests. S/he also stated the charge per the form s/he had is different than the policy. The Medical Records Copying Charges form was one that s/he was provided when s/he started in medical records. Review of the facility's Accessing Health Information Policy indicated the resident's legal representative may receive a copy of the clinical record within two working days after the request, at a photocopying charge not to exceed the amount specified in this manual. Further review revealed Charges for Releasing Information provided that a facility may collect a charge of $.25 per page for making and providing copies of clinical records. If the facility collects a retrieval charge as outlined in the section below, the facility may not charge for making and providing copies of the first 10 pages of a clinical record. A facility may collect a $15.00 retrieval charge in addition to the per page charge as outlined above. If the person requesting the copies asks that the copies be provided within 2 working days, and the facility provides the copies within 2 working days, the facility may collect a fee of $10.00 in addition to the other charges.

Based on record review, interviews and facility files, the facility failed to protect residents from abuse for one of one resident's (#178) coerced without an investigation or report to state agencies. One of one resident (resident #69) with misappropriation of funds, without a thorough investigation and 2 residents with allegations of abuse that were not reported to state agency. It was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of 3/17/2016. The findings included: During the Recertification and Complaint Survey, on 4/21/16 the Department of Health and Environmental Control (DHEC) Certification State Agency office received an additional eight (8) allegations of abuse/neglect. Review of the allegations revealed the facility had identified a concern related to the allegation that involved resident # 178. The facility admitted resident # 178 with [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status Score of 15. S/he was alert and oriented and able to make decisions regarding his/her ability to make decisions regarding activities of daily living. Review of the additional allegations revealed an allegation of 3/16/16 related to resident #178. Per the allegation, the resident had complained that a nurse had snatched off a neck brace. Review of the facility's grievance files revealed a grievance of the allegation. Through the facility investigation of the allegation, the resident had stated the nurse had startled him/her when removing the neck brace and was not abused. The Administrator, Director of Nursing (DON), Director of Nursing in Training (DON in training), and Social Services (SS) were interviewed by the surveyor on 4/21/16 at approximately 11:30 AM. During the interview the Administrator and DON stated that a note was left under the administrator's door, signed by the resident. The administrator provided the note for review. The note stated, I will (sic) like to speak to the Patient Advocate about my collar being snatched off by male nurse. Please call them for me, thanks for asking about my care. I was informed S/he is Ombudsman ---- (name of person). The administrator went to the resident and was told by the resident that someone had come in his/her room at 3:00 AM, wearing a hoodie and had him/her sign a paper. The resident did not know who the person was or what was on the paper that s/he signed. The resident stated s/he did not write the note and did not want to talk to the patient advocate. The DON stated the same person seen in Resident #178's room was seen on the same night by staff members copying resident charts. The DON stated when s/he came in, the person had already left the facility. During the interview the Administrator and DON and DON in training stated the person that had entered the facility during the night was an employee, a Licensed Practical Nurse (LPN), who worked the 7A-7P shift. The employee was out on medical leave at the time of the survey. The DON in training stated that they had been informed the LPN had been observed sitting outside of other staff member's homes, in a car. The Administrator was asked by the surveyor, what had been done to protect the residents from unknown persons entering the building in the middle of the night, coercing the residents. The Director of Nursing stated the County Sheriff's Department had been asked by the facility to be placed on their security patrol route. The DON did not know how often the police would patrol the facility at night. S/he did not know what medical records had been allegedly copied by the person. The DON and DON-in-training were unable to provide an investigation into the incident with resident #178, regarding the night visitor nor any information regarding the copied medical records. The DON in training repeatedly stated the employee was just doing what s/he thought was right. The facility was aware of the middle of the night entrance into the building by an off duty employee. The resident informed them of an unknown person dressed in a hoodie coercing him/her to sign a note that the resident did not write. The resident did not know who the person was or what was written on the note. They were also aware of the allegation of medical records being copied and removed from the facility. There was no investigation, no preventive measures put into place to protect the residents, or the facility medical records. There was no documentation that the Sheriff's Department was contacted, or how often they would patrol the facility. There was no documentation the alleged perpetrator had been investigated regarding the medical records. On 4/21/16 at approximately 3:00 PM the Administrator provided a facility document of communications with corporate personnel. The document was a time line related to the incident of 3/16/16. 3/16- LPN was called into the office for inappropriate comments and insubordinate attitude toward the Assistant Director of Nursing (ADON) . The LPN was highly defensive, and aggressive toward myself and ADON when I tried to speak with him/her .Within 30 minutes the LPN brought back an allegation of abuse toward the ADON which stemmed from an incident that happened 14 days prior. I immediately investigated the complaint and interviewed the following: (Resident #178) S/he said that s/he was nervous for them to take the neck brace off, and that s/he got scared. S/he said it felt rough when they had to pull the velcro collar to undo it. S/he said it was rough but said s/h didn't think it was abusive in anyway. The ADON, Certified Nursing Assistant (CNA) and X-ray Tech state that the resident was alert and aware of what was going on. That the ADON was not rough with the resident, nor did s/he jerk or snatch the collar off the resident. 3/17/16- The LPN called myself (administrator) at 6:00 AM to tell me s/he was sick and wasn't coming into work for his/her shift at 7:00 AM; ADON worked his/her shift. The LPN called and texted multiple staff, all day to the point where one staff member called---- for being harassed by him/her. That night the LPN was seen and reported in the building after Midnight- s/he told staff that s/he was here to work on his/her charting. The staff said they found it weird but let him/her continue. 1 staff member said s/he saw the LPN copy papers from a chart, not on his/her normal hallway and take the papers with him/her. 2 staff members said that while the LPN was there she made threats of physical violence toward a CNA, who had just left the building a few hours prior .The LPN was also seen going down the 200 hall, and coming back to the 100 Hall later. 3/18/16- A letter was found signed by resident (#178)that said s/he wanted to speak to the Ombudsman about the neck. The writing on the letter, and the resident's signature were two different styles of writing, We spoke to the resident regarding the letter and s/he said that someone (s/he couldn't tell who, they had a hoodie on s/he thinks) woke him/her fro his/her sleep around 2-3 am and made him/her sign a letter. S/he said s/he was told not to talk to anyone about the letter and not to tell anyone that someone came to visit him. We asked if s/he needed the Ombudsman, and s/he said that s/he didn't request him/her, because s/he did not write the letter. The resident stated he did not sign his/her name the way it was on the letter. So s/he knows s/he was out of it If s/he signed a letter with his /her legal name. The facility admitted resident #69 with [DIAGNOSES REDACTED]. Idiopathic Peripheral [MEDICAL CONDITIONS], Infected Sebaceous Cyst, Fatigue, Adult Failure to Thrive and Open Wound of Toe. 4/20/16 8:00 AM Review of the Medical Record revealed a Quarterly Minimum Data Set ((MDS) dated [DATE]: The resident had a Brief Interview for Mental Status (BIMS) score of 13. S/he had no mood or behaviors. Nurses Notes reviewed from 1/21/16 through 4/19/16. Nurses Notes revealed resident was alert and oriented with periods of confusion. S/He had weakness with unsteady gait and balance. During an interview with the resident on 4/18/16, the resident stated CNA #1 had taken his/her bank card. I gave it to her/him to get my girlfriend a Valentine's present. I told her/him s/he could use it but if s/he did, to let me know. S/he used it but did not let me know. S/he did not bring it back to me. I called the bank to check on my account and I was missing money. It was money I did not spend. I reported it. S/he (CNA) does not work here any more. I heard I was not the only one s/he did that to. Review of the facility investigation of the incident revealed the resident complained to a CNA on 2/29/16 that CNA #1 had his/her card and the resident was missing money from his/her account. The resident had called the bank and found out the money was missing. The facility called the police. The police investigated the incident. The CNA also had the resident's vehicle. The resident reported the missing money to CNA #2. The CNA was interviewed by the surveyor on 4/20/16 at approximately 11:00 AM. The CNA stated the resident had reported to him/her that CNA #1 had the resident's bank card and s/he had missing money from his/her account. The resident said s/he had some money missing and s/he did not authorize it. I asked him/her where the bank card was. S/he stated CNA #1 had it. S/he said s/he would just keep the card and if s/he (resident) needed something s/he could call him/her and s/he would get it with the debit card. S/he authorized the CNA to get cleaning supplies and pay anyone that helped her. I went and told the Administrator everything I told you. The resident told me that the CNA had his/her car at their place. Review of the facility investigation revealed a thorough investigation had not been conducted. The facility had not interviewed any residents that could have been affected with missing money or items. No statement was taken from the resident. There were no staff statements obtained. Following the interview with CNA #2, two staff statements were provided to the surveyor. CNA #2 was asked when s/he had written the statement. The CNA stated s/he had written the statement that morning. Review of the Police Department Reports revealed the police had four warrants out for the CNA. The bank confirmed there were $1,500.00 of unauthorized usage of the resident's bank account. Based on full and/or limited record reviews, interviews and review of the facility's policies, it was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the following area as of 3/17/2016: CFR 483.13(c) F-224 Prohibit Mistreatment/neglect/misappropriation was identified at a scope and severity level of (L). The facility failed to protect Resident #69 and Resident #178 from allegations of abuse. The facility Administrator, Director of Nursing, and Director of Nursing in Training were informed of the Immediate Jeopardy on 4/21/16 at approximately 5:20 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/28/16 at 2:05 PM. Observation, record review and interview provided evidence to the survey team prior to exit the AOC had been implemented by the facility and the Immediate Jeopardy at F-224 was removed, but the citation remained at a lower scope and severity of F. The AOC included the following: AOC: It has been alleged in the context of the pending survey process that the Facility's response to events allegedly occurring on or around March 17th-20th, was insufficient. In an effort to demonstrate and achieve substantial compliance with applicable and involved regulations, the Facility proposes and has initiated implementation of the following plan of correction: * Resident Security- 1. In an effort to put immediate corrective action in place, Resident #1 was asked by the Administrator to inform Facility Administration in the event there is a recurrence of uninvited or unwanted visitors entering (his/her) room (employees or otherwise). Further, the Resident was reminded of (his/her) right to speak with the Department of Health or the Ombudsman should (he/she) ever have questions or concerns, or should (he/her) require additional information on any topic affecting (his/her) Facility admission. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has conducted an investigation into the subject events which included interviews of all residents. Specifically, each resident has been asked if they have ever been visited by people they did not recognize, and where applicable, the time, dates are being investigated to determine the nature of the visit. Further, on 4/22/16, the Facility has provided each current resident with a flyer containing the phone numbers of the South Carolina Department of Health and Environmental Control, and the local Ombudsman. Going forward, this same flyer will be distributed to incoming residents on admission. Additionally, the codes have been changed at each pedestrian entrance door. (4/23/16) 3. The following measures have been put in place to ensure the deficient practice will not reoccur: * A sign-in log was placed at the front desk. All visitors (which includes employees who are in the Facility for reasons other than working a scheduled shift) will be required to sign in at the front desk, and indicate their purpose in visiting the Facility. If a visitor is there to see a resident, the name and room number of the Resident must be indicated on the sign-in log. * All employees have been informed via in-service that they should not be present on Facility premises unless they are assigned to work, or have other work-related business at that time Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * The following information has been inserviced: Abuse, Neglect, Misappropriation, and timely reporting of an allegation Resident Rights, and timely reporting of any violations Door code change for security, an sensitivity of code. * All employees have been trained (4/23/16) that in the event any employee is seen entering the Facility at hours not typically worked by that employee, they are obligated to report such unusual activity to Facility management. Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * Signs have been posted at or near each door leading in to the Facility, instructing all visitors to sign in at the front desk (4/25/16). * The code to all exit doors was changed on 4/21/16. All active employees, and resident responsible parties were notified of the code change. * Protection of Private Health Information 1. In an effort to put immediate corrective action in place, Resident #1 was informed by the Administrator that an employee of Compass Post-Acute Care is alleged to have collected private information about (him/her) outside the scope of (his/her) employment. Our guidance to (him/her) reflected the information we have to date and the possibility that (his/her) protected health information may have ben accessed for reasons unrelated to (his/her) treatment, payment or other healthcare purpose. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has invited members of our Compliance Department to come and evaluate our existing practices. All employees have been re-educated (4/27/16) regarding their obligations under HIPAA, and all new employees (and agency if necessary) will receive the more comprehensive training upon hire via a web-based module [MEDICATION NAME] approximately 45 minutes. 3. In addition to the physical security items listed above, the following measures have been put in place to ensure the deficient practice will not reoccur: * Any time a chart is removed temporarily from the nursing station, the employee doing so must note the removal in the log created to capture this information. The employee will need to log the date, time of removal, time of return, and purpose associated with the temporary removal. * Employees who remove medical records from the Facility or who access the chart for reasons inconsistent with Federal and State Privacy Laws will be disciplined up to and including the possibility of termination. * A video surveillance system is to be installed and contractors have been contacted. The system will provide remote visualization of each door leading in to the Facility, and will also show activity in public or shared areas including but not limited to hallways, nursing stations, dining rooms, etc.). * Resident rooms will not be included in the areas capable of being viewed by the cameras. The Department should also be aware that the employee whose conduct is at issue has been suspended pending the results of our investigation. (He/she) has not worked in the Facility or had contact with any Facility resident since. We allege compliance as of this day (4/27/16).

Based on record review, interviews and facility files, the facility failed to follow their policy to complete a thorough investigation and report immediately to state agencies any allegations of abuse, neglect and misappropriation of funds. The facility failed to conduct a thorough investigation for 1 of 1 allegations of misappropriation of funds (resident #69). The facility failed to conduct a thorough investigation, ensure protection of a resident (Resident #178) and report allegations of abuse for 2 of 2 residents (Resident #178 and #211) with identified concerns. It was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of 3/17/2016. The findings included: Cross refer to F 224 as it relates to preventing, investigating and reporting allegations of abuse, neglect and misappropriation of funds/personal property. Resident #178 reported someone had entered their room in the middle of the night and had him/her sign a paper. The resident did not know who the person was or what was on the paper. The resident was told not to mention the letter and not to tell anyone that the resident had a visitor. The facility also received reports the person that entered the building in the middle of the night made copies of medical records. No investigation had been conducted nor were the allegations reported to the state agencies. A plan had not been put in place to prevent a re-occurrence Resident # 69 reported to the facility that a Certified Nursing Assistant (CNA) had his/her bank card and had used the card without the resident's authorization. The CNA had the resident's car as well. The facility did not have a thorough investigation of the allegations. The facility's investigation did not include an official statement from the resident. There were no interviews/statements of other resident's that may have been affected by the CNA's practice. There were no statements obtained from the staff. During the Recertification/Complaint Survey, the facility Administration was notified by the surveyor of two allegations of abuse the facility was not aware. The facility Administration stated they would do an investigation. No reports were received by the state agency of the allegations. The facility admitted Resident #211 with [DIAGNOSES REDACTED]. During an individual interview on 4/19/16 at 10:49 AM, Resident #211 stated staff were not nice to her. He/she continued by stating after asking for assistance, the nurse slammed his/her hands down on the counter and asked don't I always help you? He/she continued by stating the Administrator had been informed of the event. Record review on 4/20/16 of the nurse's notes and the social services notes did not reflect the incident. Investigation of the incident was requested on 4/19/16. A grievance form had been completed on 4/17/16 which stated the resident did not feel the nurse provided enough assistance in helping the resident go to the bathroom. Per the findings of the investigation, the nurse felt he/she was trying to help the resident maintain her independence and felt he/she was professional and thorough with the resident's activities of daily living. After the investigation, it was determined the resident did not feel comfortable with the nurse. The action taken was the nurse would not be assigned to the resident. After reviewing the grievance, the facility was asked if they were aware of the nurse allegedly slamming her hands down on the desk when the resident was speaking to him/her. The facility did not have knowledge of the incident. On 4/20/16, an initial 24-hour report was completed and sent to the State Survey Agency. The incident was described as verbal abuse as an employee was overheard yelling and cursing at Resident #211. A witness statement was obtained with a date of 4/16/16 which alleged the nurse in question had cursed at the resident. During an interview with the Administrator on 4/23/16 at 10:59 AM, he/she had no explanation as to why the date on the witness statement was 4/16/16 and no explanation why this was not reported at the time of the incident. Review of the facility policy titled Abuse Policy and Procedure revealed under Section III-A Reporting the following: Any person observing(or hearing a complaint of) mistreatment, neglect, abuse or misappropriation of resident property should immediately report it to the Administrator, Social Services Director, Director of Nursing or other department head. CFR 483.13(c) F-226 Develop/Implement Abuse/Neglect, etc Policies was identified at a scope and severity level of (L). The facility failed to follow and implement policies related to investigation, preventing and reporting of allegations of abuse for Residents #69, #178 and #211. The facility Administrator, Director of Nursing, and Director of Nursing in Training were informed of the Immediate Jeopardy on 4/21/16 at approximately 5:20 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/28/16 at 2:05 PM. Observation, record review and interview provided evidence to the survey team prior to exit the AOC had been implemented by the facility and the Immediate Jeopardy at F-226 was removed, but the citation remained at a lower scope and severity of F. The AOC included the following: AOC: It has been alleged in the context of the pending survey process that the Facility's response to events allegedly occurring on or around March 17th-20th, was insufficient. In an effort to demonstrate and achieve substantial compliance with applicable and involved regulations, the Facility proposes and has initiated implementation of the following plan of correction: * Resident Security- 1. In an effort to put immediate corrective action in place, Resident #1 was asked by the Administrator to inform Facility Administration in the event there is a recurrence of uninvited or unwanted visitors entering (his/her) room (employees or otherwise). Further, the Resident was reminded of (his/her) right to speak with the Department of Health or the Ombudsman should (he/she) ever have questions or concerns, or should (he/her) require additional information on any topic affecting (his/her) Facility admission. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has conducted an investigation into the subject events which included interviews of all residents. Specifically, each resident has been asked if they have ever been visited by people they did not recognize, and where applicable, the time, dates are being investigated to determine the nature of the visit. Further, on 4/22/16, the Facility has provided each current resident with a flyer containing the phone numbers of the South Carolina Department of Health and Environmental Control, and the local Ombudsman. Going forward, this same flyer will be distributed to incoming residents on admission. Additionally, the codes have been changed at each pedestrian entrance door. (4/23/16) 3. The following measures have been put in place to ensure the deficient practice will not reoccur: * A sign-in log was placed at the front desk. All visitors (which includes employees who are in the Facility for reasons other than working a scheduled shift) will be required to sign in at the front desk, and indicate their purpose in visiting the Facility. If a visitor is there to see a resident, the name and room number of the Resident must be indicated on the sign-in log. * All employees have been informed via in-service that they should not be present on Facility premises unless they are assigned to work, or have other work-related business at that time Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * The following information has been inserviced: Abuse, Neglect, Misappropriation, and timely reporting of an allegation Resident Rights, and timely reporting of any violations Door code change for security, an sensitivity of code. * All employees have been trained (4/23/16) that in the event any employee is seen entering the Facility at hours not typically worked by that employee, they are obligated to report such unusual activity to Facility management. Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * Signs have been posted at or near each door leading in to the Facility, instructing all visitors to sign in at the front desk (4/25/16). * The code to all exit doors was changed on 4/21/16. All active employees, and resident responsible parties were notified of the code change. * Protection of Private Health Information 1. In an effort to put immediate corrective action in place, Resident #1 was informed by the Administrator that an employee of Compass Post-Acute Care is alleged to have collected private information about (him/her) outside the scope of (his/her) employment. Our guidance to (him/her) reflected the information we have to date and the possibility that (his/her) protected health information may have ben accessed for reasons unrelated to (his/her) treatment, payment or other healthcare purpose. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has invited members of our Compliance Department to come and evaluate our existing practices. All employees have been re-educated (4/27/16) regarding their obligations under HIPAA, and all new employees (and agency if necessary) will receive the more comprehensive training upon hire via a web-based module [MEDICATION NAME] approximately 45 minutes. 3. In addition to the physical security items listed above, the following measures have been put in place to ensure the deficient practice will not reoccur: * Any time a chart is removed temporarily from the nursing station, the employee doing so must note the removal in the log created to capture this information. The employee will need to log the date, time of removal, time of return, and purpose associated with the temporary removal. * Employees who remove medical records from the Facility or who access the chart for reasons inconsistent with Federal and State Privacy Laws will be disciplined up to and including the possibility of termination. * A video surveillance system is to be installed and contractors have been contacted. The system will provide remote visualization of each door leading in to the Facility, and will also show activity in public or shared areas including but not limited to hallways, nursing stations, dining rooms, etc.). * Resident rooms will not be included in the areas capable of being viewed by the cameras. The Department should also be aware that the employee whose conduct is at issue has been suspended pending the results of our investigation. (He/she) has not worked in the Facility or had contact with any Facility resident since. We allege compliance as of this day (4/27/16).

Based on record review and interviews, the facility failed to provide supervision for the safety of the residents. Resident #178 was visited in the middle of the night by someone s/he did not know, and instructed to sign a paper. The resident was told to not tell anyone about the paper and not to tell anyone about the visit. The facility was made aware of the incident early that same AM and failed to address the incident to ensure not just the safety of Resident #178, but all residents in the building. It was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of 3/17/2016. The findings included: Cross refer to F224 and F226 as it relates to prevention, investigation and reporting abuse/neglect and misappropriation of funds and implementing abuse policies as applicable to ensure resident well being. The facility admitted resident # 178 with [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status Score of 15. S/he was alert and oriented and able to make decisions regarding his/her ability to make decisions regarding activities of daily living. Review of the additional allegations revealed an allegation of 3/16/16 related to resident #178. Per the allegation, the resident had complained that a nurse had snatched off a neck brace. Review of the facility's grievance files revealed a grievance of the allegation. Through the facility investigation of the allegation, the resident had stated the nurse had startled him/her when removing the neck brace and was not abused. The Administrator, Director of Nursing (DON), Director of Nursing in Training (DON in training), and Social Services (SS) were interviewed by the surveyor on 4/21/16 at approximately 11:30 AM. During the interview the Administrator and DON stated that a note was left under the administrator's door, signed by the Resident #178. The administrator provided the note for review. The note stated, I will (sic) like to speak to the Patient Advocate about my collar being snatched off by male nurse. Please call them for me, thanks for asking about my care. I was informed S/he is Ombudsman ---- (name of person). The administrator went to the resident and was told by the resident that someone had come in his/her room at 3:00 AM, wearing a hoodie and had him/her sign a paper. The resident did not know who the person was or what was on the paper that s/he signed. The resident stated s/he did not write the note and did not want to talk to the patient advocate. The DON stated the person was seen by staff members copying resident charts. The DON stated when s/he came in, the person had already left the facility. During the interview the Administrator and DON and DON in training stated the person that had entered the facility during the night was an employee, a Licensed Practical Nurse (LPN), who worked the 7A-7P shift. The employee was out on medical leave at the time of the survey. The DON in training stated that they had been informed the LPN had been observed sitting outside of other staff member's homes, in a car. The Administrator was asked by the surveyor, what had been done to protect the residents from unknown persons entering the building in the middle of the night, coercing the residents. The Director of Nursing stated the County Sheriff's Department had been asked for the facility to be placed on their security patrol route. The DON did not know how often the police would patrol the facility at night. S/he did not know what medical records had been allegedly copied by the person. The DON and DON-in-training were unable to provide an investigation into the incident with resident #178, regarding the night visitor nor any information regarding the copied medical records. The DON in training repeatedly stated, the employee was just doing what s/he thought was right. The facility was aware of the middle of the night entrance into the building by an off duty employee. The resident informed them of an unknown person dressed in a hoodie coercing him/her to sign a note that the resident did not write. The resident did not know who the person was or what was written on the note. They were also aware of the allegation of medical records being copied and removed from the facility. There was no investigation, no preventive measures put into place to protect the residents, or the facility medical records. There was no documentation that the Sheriff's Department was contacted, or how often they would patrol the facility. There was no documentation the alleged perpetrator had been investigated regarding the medical records. On 4/21/16 at approximately 3:00 PM the Administrator provided a facility document of communications with corporate personnel. The document was a time line related to the incident of 3/16/16. 3/16- LPN was called into the office for inappropriate comments and insubordinate attitude toward the Assistant Director of Nursing (ADON) . The LPN was highly defensive, and aggressive toward myself and ADON when I tried to speak with him/her .Within 30 minutes the LPN brought back an allegation of abuse toward the ADON which stemmed from an incident that happened 14 days prior. I immediately investigated the complaint and interviewed the following: (Resident #178) S/he said that s/he was nervous for them to take the neck brace off, and that s/he got scared. S/he said it felt rough when they had to pull the velcro collar to undo it. S/he said it was rough but said s/h didn't think it was abusive in anyway. The ADON, Certified Nursing Assistant (CNA) and X-ray Tech state that the resident was alert and aware of what was going on. That the ADON was not rough with the resident, nor did s/he jerk or snatch the collar off the resident. 3/17/16- The LPN called myself (administrator) at 6:00 AM to tell me s/he was sick and wasn't coming into work for his/her shift at 7:00 AM; ADON worked his/her shift. The LPN called and texted multiple staff, all day to the point where one staff member called---- for being harassed by him/her. That night the LPN was seen and reported in the building after Midnight- s/he told staff that s/he was here to work on his/her charting. The staff said they found it weird but let him/her continue. 1 staff member said s/he saw the LPN copy papers from a chart, not on his/her normal hallway and take the papers with him/her. 2 staff members said that while the LPN was there she made threats of physical violence toward a CNA, who had just left the building a few hours prior .The LPN was also seen going down the 200 hall, and coming back to the 100 Hall later. 3/18/16- A letter was found signed by resident (#178) that said s/he wanted to speak to the Ombudsman about the neck. The writing on the letter, and the resident's signature were two different styles of writing, We spoke to the resident regarding the letter and s/he said that someone (s/he couldn't tell who, they had a hoodie on s/he thinks) woke him/her from his/her sleep around 2-3 am and made him/her sign a letter. S/he said s/he was told not to talk to anyone about the letter and not to tell anyone that someone came to visit him. We asked if s/he needed the Ombudsman, and s/he said that s/he didn't request him/her, because s/he did not write the letter. The resident stated he did not sign his/her name the way it was on the letter. So s/he knows s/he was out of it If s/he signed a letter with his /her legal name. CFR 483.25(h) F-323 Free of Accident Hazards/supervision/devices was identified at a scope and severity level of (L). The facility failed to provide supervision for the safety of Resident #178 and all facility residents. The facility Administrator, Director of Nursing, and Director of Nursing in Training were informed of the Immediate Jeopardy on 4/21/16 at approximately 5:20 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/28/16 at 2:05 PM. Observation, record review and interview provided evidence to the survey team prior to exit the AOC had been implemented by the facility and the Immediate Jeopardy at F-323 was removed, but the citation remained at a lower scope and severity of F. The AOC included the following: AOC: It has been alleged in the context of the pending survey process that the Facility's response to events allegedly occurring on or around March 17th-20th, was insufficient. In an effort to demonstrate and achieve substantial compliance with applicable and involved regulations, the Facility proposes and has initiated implementation of the following plan of correction: * Resident Security- 1. In an effort to put immediate corrective action in place, Resident #1 was asked by the Administrator to inform Facility Administration in the event there is a recurrence of uninvited or unwanted visitors entering (his/her) room (employees or otherwise). Further, the Resident was reminded of (his/her) right to speak with the Department of Health or the Ombudsman should (he/she) ever have questions or concerns, or should (he/her) require additional information on any topic affecting (his/her) Facility admission. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has conducted an investigation into the subject events which included interviews of all residents. Specifically, each resident has been asked if they have ever been visited by people they did not recognize, and where applicable, the time, dates are being investigated to determine the nature of the visit. Further, on 4/22/16, the Facility has provided each current resident with a flyer containing the phone numbers of the South Carolina Department of Health and Environmental Control, and the local Ombudsman. Going forward, this same flyer will be distributed to incoming residents on admission. Additionally, the codes have been changed at each pedestrian entrance door. (4/23/16) 3. The following measures have been put in place to ensure the deficient practice will not reoccur: * A sign-in log was placed at the front desk. All visitors (which includes employees who are in the Facility for reasons other than working a scheduled shift) will be required to sign in at the front desk, and indicate their purpose in visiting the Facility. If a visitor is there to see a resident, the name and room number of the Resident must be indicated on the sign-in log. * All employees have been informed via in-service that they should not be present on Facility premises unless they are assigned to work, or have other work-related business at that time Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * The following information has been inserviced: Abuse, Neglect, Misappropriation, and timely reporting of an allegation Resident Rights, and timely reporting of any violations Door code change for security, an sensitivity of code. * All employees have been trained (4/23/16) that in the event any employee is seen entering the Facility at hours not typically worked by that employee, they are obligated to report such unusual activity to Facility management. Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * Signs have been posted at or near each door leading in to the Facility, instructing all visitors to sign in at the front desk (4/25/16). * The code to all exit doors was changed on 4/21/16. All active employees, and resident responsible parties were notified of the code change. * Protection of Private Health Information 1. In an effort to put immediate corrective action in place, Resident #1 was informed by the Administrator that an employee of Compass Post-Acute Care is alleged to have collected private information about (him/her) outside the scope of (his/her) employment. Our guidance to (him/her) reflected the information we have to date and the possibility that (his/her) protected health information may have ben accessed for reasons unrelated to (his/her) treatment, payment or other healthcare purpose. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has invited members of our Compliance Department to come and evaluate our existing practices. All employees have been re-educated (4/27/16) regarding their obligations under HIPAA, and all new employees (and agency if necessary) will receive the more comprehensive training upon hire via a web-based module lasting approximately 45 minutes. 3. In addition to the physical security items listed above, the following measures have been put in place to ensure the deficient practice will not reoccur: * Any time a chart is removed temporarily from the nursing station, the employee doing so must note the removal in the log created to capture this information. The employee will need to log the date, time of removal, time of return, and purpose associated with the temporary removal. * Employees who remove medical records from the Facility or who access the chart for reasons inconsistent with Federal and State Privacy Laws will be disciplined up to and including the possibility of termination. * A video surveillance system is to be installed and contractors have been contacted. The system will provide remote visualization of each door leading in to the Facility, and will also show activity in public or shared areas including but not limited to hallways, nursing stations, dining rooms, etc.). * Resident rooms will not be included in the areas capable of being viewed by the cameras. The Department should also be aware that the employee whose conduct is at issue has been suspended pending the results of our investigation. (He/she) has not worked in the Facility or had contact with any Facility resident since. We allege compliance as of this day (4/27/16).

Based on review of facility files and interviews, the facility failed to Administer in a way to maintain safety of residents named in allegations of abuse/neglect misappropriation of funds. It was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of 3/17/2016. The findings included: Cross refer to F224- Prevent, investigate and report allegations of abuse/neglect, misappropriation of funds Cross Refer to F226: Developing Policies and Procedures for Abuse/Neglect and Misappropriation of funds/personal property. Cross refer to F323: Supervision to prevent accidents/incidents. Supervision not provided to prevent unknown person entering facility and resident's rooms when sleeping. During the Recertification and Complaint Survey, on 4/21/16 the Department of Health and Environmental Control (DHEC) Certification State Agency office received an additional eight (8) allegations of abuse/neglect. Review of the allegations revealed the facility had identified a concern related to the allegation that involved resident # 178. The facility admitted resident # 178 with [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status Score of 15. S/he was alert and oriented and able to make decisions regarding his/her ability to make decisions regarding activities of daily living. Review of the additional allegations revealed an allegation of 3/16/16 related to resident #178. Per the allegation, the resident had complained that a nurse had snatched off a neck brace. Review of the facility's grievance files revealed a grievance of the allegation. Through the facility investigation of the allegation, the resident had stated the nurse had startled him/her when removing the neck brace and was not abused. The Administrator, Director of Nursing (DON), Director of Nursing in Training (DON in training), and Social Services (SS) were interviewed by the surveyor on 4/21/16 at approximately 11:30 AM. During the interview the Administrator and DON stated that a note was left under the administrator's door, signed by the resident. The administrator provided the note for review. The note stated, I will (sic) like to speak to the Patient Advocate about my collar being snatched off by male nurse. Please call them for me, thanks for asking about my care. I was informed S/he is Ombudsman ---- (name of person). The administrator went to the resident and was told by the resident that someone had come in his/her room at 3:00 AM, wearing a hoodie and had him/her sign a paper. The resident did not know who the person was or what was on the paper that s/he signed. The resident stated s/he did not write the note and did not want to talk to the patient advocate. The DON stated the same person seen in Resident #178's room was seen on the same night by staff members copying resident charts. The DON stated when s/he came in, the person had already left the facility. During the interview the Administrator and DON and DON in training stated the person that had entered the facility during the night was an employee, a Licensed Practical Nurse (LPN), who worked the 7A-7P shift. The employee was out on medical leave at the time of the survey. The DON in training stated that they had been informed the LPN had been observed sitting outside of other staff member's homes, in a car. The Administrator was asked by the surveyor, what had been done to protect the residents from unknown persons entering the building in the middle of the night, coercing the residents. The Director of Nursing stated the County Sheriff's Department had been asked by the facility to be placed on their security patrol route. The DON did not know how often the police would patrol the facility at night. S/he did not know what medical records had been allegedly copied by the person. The DON and DON-in-training were unable to provide an investigation into the incident with resident #178, regarding the night visitor nor any information regarding the copied medical records. The DON in training repeatedly stated the employee was just doing what s/he thought was right. The facility was aware of the middle of the night entrance into the building by an off duty employee. The resident informed them of an unknown person dressed in a hoodie coercing him/her to sign a note that the resident did not write. The resident did not know who the person was or what was written on the note. They were also aware of the allegation of medical records being copied and removed from the facility. There was no investigation, no preventive measures put into place to protect the residents, or the facility medical records. There was no documentation that the Sheriff's Department was contacted, or how often they would patrol the facility. There was no documentation the alleged perpetrator had been investigated regarding the medical records. CFR 483.75 F-490 Effective Administration resident well-being was identified at a scope and severity level of (L). The facility administration failed to ensure appropriate policies and procedures were implemented to protect residents from Abuse/Neglect and failed to provide supervision for the safety of all residents. The failure of the facility to ensure implementation of these policies placed all residents at risk for serious harm. The facility Administrator, Director of Nursing, and Director of Nursing in Training were informed of the Immediate Jeopardy on 4/21/16 at approximately 5:20 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/28/16 at 2:05 PM. Observation, record review and interview provided evidence to the survey team prior to exit the AOC had been implemented by the facility and the Immediate Jeopardy at F-490 was removed, but the citation remained at a lower scope and severity of F. The AOC included the following: AOC: It has been alleged in the context of the pending survey process that the Facility's response to events allegedly occurring on or around March 17th-20th, was insufficient. In an effort to demonstrate and achieve substantial compliance with applicable and involved regulations, the Facility proposes and has initiated implementation of the following plan of correction: * Resident Security- 1. In an effort to put immediate corrective action in place, Resident #1 was asked by the Administrator to inform Facility Administration in the event there is a recurrence of uninvited or unwanted visitors entering (his/her) room (employees or otherwise). Further, the Resident was reminded of (his/her) right to speak with the Department of Health or the Ombudsman should (he/she) ever have questions or concerns, or should (he/her) require additional information on any topic affecting (his/her) Facility admission. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has conducted an investigation into the subject events which included interviews of all residents. Specifically, each resident has been asked if they have ever been visited by people they did not recognize, and where applicable, the time, dates are being investigated to determine the nature of the visit. Further, on 4/22/16, the Facility has provided each current resident with a flyer containing the phone numbers of the South Carolina Department of Health and Environmental Control, and the local Ombudsman. Going forward, this same flyer will be distributed to incoming residents on admission. Additionally, the codes have been changed at each pedestrian entrance door. (4/23/16) 3. The following measures have been put in place to ensure the deficient practice will not reoccur: * A sign-in log was placed at the front desk. All visitors (which includes employees who are in the Facility for reasons other than working a scheduled shift) will be required to sign in at the front desk, and indicate their purpose in visiting the Facility. If a visitor is there to see a resident, the name and room number of the Resident must be indicated on the sign-in log. * All employees have been informed via in-service that they should not be present on Facility premises unless they are assigned to work, or have other work-related business at that time Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * The following information has been inserviced: Abuse, Neglect, Misappropriation, and timely reporting of an allegation Resident Rights, and timely reporting of any violations Door code change for security, an sensitivity of code. * All employees have been trained (4/23/16) that in the event any employee is seen entering the Facility at hours not typically worked by that employee, they are obligated to report such unusual activity to Facility management. Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * Signs have been posted at or near each door leading in to the Facility, instructing all visitors to sign in at the front desk (4/25/16). * The code to all exit doors was changed on 4/21/16. All active employees, and resident responsible parties were notified of the code change. * Protection of Private Health Information 1. In an effort to put immediate corrective action in place, Resident #1 was informed by the Administrator that an employee of Compass Post-Acute Care is alleged to have collected private information about (him/her) outside the scope of (his/her) employment. Our guidance to (him/her) reflected the information we have to date and the possibility that (his/her) protected health information may have ben accessed for reasons unrelated to (his/her) treatment, payment or other healthcare purpose. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has invited members of our Compliance Department to come and evaluate our existing practices. All employees have been re-educated (4/27/16) regarding their obligations under HIPAA, and all new employees (and agency if necessary) will receive the more comprehensive training upon hire via a web-based module [MEDICATION NAME] approximately 45 minutes. 3. In addition to the physical security items listed above, the following measures have been put in place to ensure the deficient practice will not reoccur: * Any time a chart is removed temporarily from the nursing station, the employee doing so must note the removal in the log created to capture this information. The employee will need to log the date, time of removal, time of return, and purpose associated with the temporary removal. * Employees who remove medical records from the Facility or who access the chart for reasons inconsistent with Federal and State Privacy Laws will be disciplined up to and including the possibility of termination. * A video surveillance system is to be installed and contractors have been contacted. The system will provide remote visualization of each door leading in to the Facility, and will also show activity in public or shared areas including but not limited to hallways, nursing stations, dining rooms, etc.). * Resident rooms will not be included in the areas capable of being viewed by the cameras. The Department should also be aware that the employee whose conduct is at issue has been suspended pending the results of our investigation. (He/she) has not worked in the Facility or had contact with any Facility resident since. We allege compliance as of this day (4/27/16).

Based on record review and interviews, the facility failed to maintain the safety and confidentiality of resident records and failed to safeguard clinical record information against unauthorized use. It was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of 3/17/2016. The findings included: Cross refer to F224- Prevent, investigate and report allegations of abuse/neglect, misappropriation of funds related to Resident #178. Cross refer to F226-Developing Policies and Procedures for Abuse/Neglect and Misappropriation of funds/personal property related to Resident #178. Cross refer to F-323 Supervision to prevent accidents/incidents related to Resident #178. During the Recertification and Complaint Survey, on 4/21/16 the Department of Health and Environmental Control (DHEC) Certification State Agency office received an additional eight (8) allegations of abuse/neglect. Review of the allegations revealed the facility had identified a concern related to the allegation that involved resident # 178. The administrator went to the resident (#178) and was told by the resident that someone had come in his/her room at 3:00 AM, wearing a hoodie and had him/her sign a paper. The resident did not know who the person was or what was on the paper that s/he signed. The resident stated s/he did not write the note and did not want to talk to the patient advocate. The DON stated the same person seen in Resident #178's room was seen on the same night by staff members copying resident charts. The DON stated when s/he came in, the person had already left the facility. During the interview the Administrator and DON and DON in training stated the person that had entered the facility during the night was an employee, a Licensed Practical Nurse (LPN), who worked the 7A-7P shift. The employee was out on medical leave at the time of the survey. The Administrator was asked by the surveyor, what had been done to protect the residents from unknown persons entering the building in the middle of the night, coercing the residents. The Director of Nursing stated the County Sheriff's Department had been asked by the facility to be placed on their security patrol route. The DON did not know how often the police would patrol the facility at night. S/he did not know what medical records had been allegedly copied by the person. The DON and DON-in-training were unable to provide an investigation into the incident with resident #178, regarding the night visitor nor any information regarding the copied medical records. The DON in training repeatedly stated the employee was just doing what s/he thought was right. Additional information from documentation provided in a timeline from the Administrator included the following: 3/17/16- The LPN called myself (administrator) at 6:00 AM to tell me s/he was sick and wasn't coming into work for his/her shift at 7:00 AM; ADON worked his/her shift. The LPN called and texted multiple staff, all day to the point where one staff member called---- for being harassed by him/her. That night the LPN was seen and reported in the building after Midnight- s/he told staff that s/he was here to work on his/her charting. The staff said they found it weird but let him/her continue. 1 staff member said s/he saw the LPN copy papers from a chart, not on his/her normal hallway and take the papers with him/her. 2 staff members said that while the LPN was there she made threats of physical violence toward a CNA, who had just left the building a few hours prior .The LPN was also seen going down the 200 hall, and coming back to the 100 Hall later. CFR 483.75(l)(3), 483.20(f)(5) F-516 Release Resident Information, Safeguard Clinical Records was identified at a scope and severity level of (L). The facility failed to ensure confidentiality and unauthorized use of resident clinical record information for Resident #178. The facility Administrator, Director of Nursing, and Director of Nursing in Training were informed of the Immediate Jeopardy on 4/21/16 at approximately 5:20 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/28/16 at 2:05 PM. Observation, record review and interview provided evidence to the survey team prior to exit the AOC had been implemented by the facility and the Immediate Jeopardy at F-516 was removed, but the citation remained at a lower scope and severity of F. The AOC included the following: AOC: It has been alleged in the context of the pending survey process that the Facility's response to events allegedly occurring on or around March 17th-20th, was insufficient. In an effort to demonstrate and achieve substantial compliance with applicable and involved regulations, the Facility proposes and has initiated implementation of the following plan of correction: * Resident Security- 1. In an effort to put immediate corrective action in place, Resident #1 was asked by the Administrator to inform Facility Administration in the event there is a recurrence of uninvited or unwanted visitors entering (his/her) room (employees or otherwise). Further, the Resident was reminded of (his/her) right to speak with the Department of Health or the Ombudsman should (he/she) ever have questions or concerns, or should (he/her) require additional information on any topic affecting (his/her) Facility admission. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has conducted an investigation into the subject events which included interviews of all residents. Specifically, each resident has been asked if they have ever been visited by people they did not recognize, and where applicable, the time, dates are being investigated to determine the nature of the visit. Further, on 4/22/16, the Facility has provided each current resident with a flyer containing the phone numbers of the South Carolina Department of Health and Environmental Control, and the local Ombudsman. Going forward, this same flyer will be distributed to incoming residents on admission. Additionally, the codes have been changed at each pedestrian entrance door. (4/23/16) 3. The following measures have been put in place to ensure the deficient practice will not reoccur: * A sign-in log was placed at the front desk. All visitors (which includes employees who are in the Facility for reasons other than working a scheduled shift) will be required to sign in at the front desk, and indicate their purpose in visiting the Facility. If a visitor is there to see a resident, the name and room number of the Resident must be indicated on the sign-in log. * All employees have been informed via in-service that they should not be present on Facility premises unless they are assigned to work, or have other work-related business at that time Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * The following information has been inserviced: Abuse, Neglect, Misappropriation, and timely reporting of an allegation Resident Rights, and timely reporting of any violations Door code change for security, an sensitivity of code. * All employees have been trained (4/23/16) that in the event any employee is seen entering the Facility at hours not typically worked by that employee, they are obligated to report such unusual activity to Facility management. Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * Signs have been posted at or near each door leading in to the Facility, instructing all visitors to sign in at the front desk (4/25/16). * The code to all exit doors was changed on 4/21/16. All active employees, and resident responsible parties were notified of the code change. * Protection of Private Health Information 1. In an effort to put immediate corrective action in place, Resident #1 was informed by the Administrator that an employee of Compass Post-Acute Care is alleged to have collected private information about (him/her) outside the scope of (his/her) employment. Our guidance to (him/her) reflected the information we have to date and the possibility that (his/her) protected health information may have ben accessed for reasons unrelated to (his/her) treatment, payment or other healthcare purpose. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has invited members of our Compliance Department to come and evaluate our existing practices. All employees have been re-educated (4/27/16) regarding their obligations under HIPAA, and all new employees (and agency if necessary) will receive the more comprehensive training upon hire via a web-based module [MEDICATION NAME] approximately 45 minutes. 3. In addition to the physical security items listed above, the following measures have been put in place to ensure the deficient practice will not reoccur: * Any time a chart is removed temporarily from the nursing station, the employee doing so must note the removal in the log created to capture this information. The employee will need to log the date, time of removal, time of return, and purpose associated with the temporary removal. * Employees who remove medical records from the Facility or who access the chart for reasons inconsistent with Federal and State Privacy Laws will be disciplined up to and including the possibility of termination. * A video surveillance system is to be installed and contractors have been contacted. The system will provide remote visualization of each door leading in to the Facility, and will also show activity in public or shared areas including but not limited to hallways, nursing stations, dining rooms, etc.). * Resident rooms will not be included in the areas capable of being viewed by the cameras. The Department should also be aware that the employee whose conduct is at issue has been suspended pending the results of our investigation. (He/she) has not worked in the Facility or had contact with any Facility resident since. We allege compliance as of this day (4/27/16).

Based on full and/or limited record reviews, interviews, and review of facility policies, it was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed for CFR483.75 F-520 which was identified at a scope and severity level of (L). The facility failed to identify quality deficiencies related to prevention of abuse/neglect, proper implementation of abuse/neglect policies, provision of supervision to ensure resident safety, and provision of medical record security. Failure of the Quality Assurance (QA) Committee to identify and implement action plans related to these quality deficiencies resulted in Immediate Jeopardy for Resident #69 and Resident #178. The findings included: Based on record reviews and interviews, the facility failed to identify concerns related to prevention of abuse/neglect, provision of supervision to ensure resident safety, and provision of medical record security. During an interview on 4/28/16, the Administrator and Director of Nursing stated and confirmed that the QA Committee had not identified and had not implemented action plans related to the concerns identified for Resident #69 and Resident #178. Based on full and/or limited record reviews, interviews, and review of facility policies, it was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of 3/17/2016. The facility Administrator, Director of Nursing, and Director of Nursing in Training were informed of the Immediate Jeopardy on 4/21/16 at approximately 5:20 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/28/16 at 2:05 PM, and the Immediate Jeopardy at F-224, F-226, F-323, F490, F516 and F-520 was removed but the citations remained at a lower scope and severity. The AOC included the following: AOC: It has been alleged in the context of the pending survey process that the Facility's response to events allegedly occurring on or around March 17th-20th, was insufficient. In an effort to demonstrate and achieve substantial compliance with applicable and involved regulations, the Facility proposes and has initiated implementation of the following plan of correction: * Resident Security- 1. In an effort to put immediate corrective action in place, Resident #1 was asked by the Administrator to inform Facility Administration in the event there is a recurrence of uninvited or unwanted visitors entering (his/her) room (employees or otherwise). Further, the Resident was reminded of (his/her) right to speak with the Department of Health or the Ombudsman should (he/she) ever have questions or concerns, or should (he/her) require additional information on any topic affecting (his/her) Facility admission. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has conducted an investigation into the subject events which included interviews of all residents. Specifically, each resident has been asked if they have ever been visited by people they did not recognize, and where applicable, the time, dates are being investigated to determine the nature of the visit. Further, on 4/22/16, the Facility has provided each current resident with a flyer containing the phone numbers of the South Carolina Department of Health and Environmental Control, and the local Ombudsman. Going forward, this same flyer will be distributed to incoming residents on admission. Additionally, the codes have been changed at each pedestrian entrance door. (4/23/16) 3. The following measures have been put in place to ensure the deficient practice will not reoccur: * A sign-in log was placed at the front desk. All visitors (which includes employees who are in the Facility for reasons other than working a scheduled shift) will be required to sign in at the front desk, and indicate their purpose in visiting the Facility. If a visitor is there to see a resident, the name and room number of the Resident must be indicated on the sign-in log. * All employees have been informed via in-service that they should not be present on Facility premises unless they are assigned to work, or have other work-related business at that time Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * The following information has been inserviced: Abuse, Neglect, Misappropriation, and timely reporting of an allegation Resident Rights, and timely reporting of any violations Door code change for security, an sensitivity of code. * All employees have been trained (4/23/16) that in the event any employee is seen entering the Facility at hours not typically worked by that employee, they are obligated to report such unusual activity to Facility management. Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * Signs have been posted at or near each door leading in to the Facility, instructing all visitors to sign in at the front desk (4/25/16). * The code to all exit doors was changed on 4/21/16. All active employees, and resident responsible parties were notified of the code change. * Protection of Private Health Information 1. In an effort to put immediate corrective action in place, Resident #1 was informed by the Administrator that an employee of Compass Post-Acute Care is alleged to have collected private information about (him/her) outside the scope of (his/her) employment. Our guidance to (him/her) reflected the information we have to date and the possibility that (his/her) protected health information may have ben accessed for reasons unrelated to (his/her) treatment, payment or other healthcare purpose. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has invited members of our Compliance Department to come and evaluate our existing practices. All employees have been re-educated (4/27/16) regarding their obligations under HIPAA, and all new employees (and agency if necessary) will receive the more comprehensive training upon hire via a web-based module [MEDICATION NAME] approximately 45 minutes. 3. In addition to the physical security items listed above, the following measures have been put in place to ensure the deficient practice will not reoccur: * Any time a chart is removed temporarily from the nursing station, the employee doing so must note the removal in the log created to capture this information. The employee will need to log the date, time of removal, time of return, and purpose associated with the temporary removal. * Employees who remove medical records from the Facility or who access the chart for reasons inconsistent with Federal and State Privacy Laws will be disciplined up to and including the possibility of termination. * A video surveillance system is to be installed and contractors have been contacted. The system will provide remote visualization of each door leading in to the Facility, and will also show activity in public or shared areas including but not limited to hallways, nursing stations, dining rooms, etc.). * Resident rooms will not be included in the areas capable of being viewed by the cameras. The Department should also be aware that the employee whose conduct is at issue has been suspended pending the results of our investigation. (He/she) has not worked in the Facility or had contact with any Facility resident since. We appreciate your consideration of this AOC, and welcome any questions or comments you might have. Furthermore, we allege compliance as of this day (4/27/16).

Based on record review, interviews and facility files, the facility failed to protect residents from abuse for one of one resident's (#178) coerced without an investigation or report to state agencies. One of one residents (resident #69) with misappropriation of funds, without a thorough investigation and 2 residents with allegations of abuse that were not reported to state agency. The findings included: During the Recertification and Complaint Survey, on 4/21/16 the Department of Health and Environmental Control (DHEC) Certification State Agency office received an additional eight (8) allegations of abuse/neglect. Review of the allegations revealed the facility had identified a concern related to the allegation that involved resident # 178. The facility admitted resident # 178 with [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status Score of 15. S/he was alert and oriented and able to make decisions regarding his/her ability to make decisions regarding activities of daily living. Review of the additional allegations revealed an allegation of 3/16/16 related to resident #178. Per the allegation, the resident had complained that a nurse had snatched off a neck brace. Review of the facility's grievance files revealed a grievance of the allegation. Through the facility investigation of the allegation, the resident had stated the nurse had startled him/her when removing the neck brace and was not abused. The Administrator, Director of Nursing (DON), Director of Nursing in Training (DON in training), and Social Services (SS) were interviewed by the surveyor on 4/21/16 at approximately 11:30 AM. During the interview the Administrator and DON stated that a note was left under the administrator's door, signed by the resident. The administrator provided the note for review. The note stated, I will (sic) like to speak to the Patient Avocate about my collar being snatched off by male nurse. Please call them for me, thanks for asking about my care. I was informed S/he is Ombudsman ---- (name of person). The administrator went to the resident and was told by the resident that someone had come in his/her room at 3:00 AM, wearing a hoodie and had him/her sign a paper. The resident did not know who the person was or what was on the paper that s/he signed. The resident stated s/he did not write the note and did not want to talk to the patient advocate. The DON stated the person was seen by staff members copying resident charts. The DON stated when s/he came in, the person had already left the facility. During the interview the Administrator and DON and DON in training stated the person that had entered the facility during the night was an employee, a Licensed Practical Nurse (LPN), who worked the 7A-7P shift. The employee was out on medical leave at the time of the survey. The DON in training stated that they had been informed the LPN had been observed sitting outside of other staff member's homes, in a car. The Administrator was asked by the surveyor, what had been done to protect the residents from unknown persons entering the building in the middle of the night, coercing the residents. The Director of Nursing stated the County Sheriff's Department had been asked for the facility to be placed on their security patrol route. The DON did not know how often the police would patrol the facility at night. S/he did not know what medical records had been allegedly copied by the person. The DON and DON-in-training were unable to provide an investigation into the incident with resident #178, regarding the night visitor nor any information regarding the copied medical records. The DON in training repeatedly stated the employee was just doing what s/he thought was right. The facility was aware of the middle of the night entrance into the building by an off duty employee. The resident informed them of an unknown person dressed in a hoodie cohering him/her to sign a note that the resident did not write. The resident did not know who the person was or what was written on the note. They were also aware of the allegation of medical records being copied and removed from the facility. There was no investigation, no preventive measures put into place to protect the residents, or the facility medical records. There was no documentation that the Sheriff's Department was contacted, or how often they would patrol the facility. There was no documentation the alleged perpetrator had been investigated regarding he medical records. On 4/21/16 at approximately 3:00 PM the Administrator provided a facility document of communications with corporate personnel. The document was a time line related to the incident of 3/16/16. 3/16- LPN was called into the office for inappropriate comments and insubordinate attitude toward the Assistant Director of Nursing (ADON) . The LPN was highly defensive, and aggressive toward myself and ADON when I tried to speak with him/her .Within 30 minutes the LPN brought back an allegation of abuse toward the ADON which stemmed from an incident that happened 14 days prior. I immediately investigated the complaint and interviewed the following: (Resident #178) S/he said that s/he was nervous for them to take the neck brace off, and that s/he got scared. S/he said it felt rough when they had to pull the velcro collar to undo it. S/he said it was rough but said s/h didn't think it was abusive in anyway. The ADON, Certified Nursing Assistant (CNA) and X-ray Tech state that the resident was alert and aware of what was going on. That the ADON was not rough with the resident, nor did s/he jerk or snatch the collar off the resident. 3/17/16- The LPN called myself (administrator) at 6:00 AM to tell me s/he was sick and wasn't coming into work for his/her shift at 7:00 AM; ADON worked his/her shift. The LPN called and texted multiple staff, all day to the point where one staff member called---- for being harassed by him/her. That night the LPN was seen and reported in the building after Midnight- s/he told staff that s/he was here to work on his/her charting. The staff said they found it weird but let him/her continue. 1 staff member said s/he saw the LPN copy papers from a chart, not on his/her normal hallway and take the papers with him/her. 2 staff members said that while the LPN was there she made threats of physical violence toward a CNA, who had just left the building a few hours prior .The LPN was also seen going down the 200 hall, and coming back to the 100 Hall later. 3/18/16- A letter was found signed by resident (#178)that said s/he wanted to speak to the Ombudsman about the neck. The writing on the letter, and the resident's signature were two different styles of writing, We spoke to the resident regarding the letter and s/he said that someone (s/he couldn't tell who, they had a hoodie on s/he thinks) woke him/her fro his/her sleep around 2-3 am and made him/her sign a letter. S/he said s/he was told not to talk to anyone about the letter and not to tell anyone that someone came to visit him. We asked if s/he needed the Ombudsman, and s/he said that s/he didn't request him/her, because s/he did not write the letter. The resident stated he did not sign his/her name the way it was on the letter. So s/he knows s/he was out of it If s/he signed a letter with his /her legal name. The facility admitted resident #69 with [DIAGNOSES REDACTED]. Idiopathic Peripheral [MEDICAL CONDITIONS], Infected Sebacceous Cyst, Fatigue, Adult Failure to Thrive and Open Wound of Toe. 4/20/16 8:00 AM Review of the Medical Record revealed a Quarterly Minimum Data Set ((MDS) dated [DATE]: The resident had a Brief Interview for Mental Status (BIMS) score of 13. S/he had no mood or behaviors. Nurses Notes reviewed from 1/21/16 through 4/19/16. Nurses Notes revealed resident was alert and oriented with periods of confusion. S/He had weakness with unsteady gait and balance. During an interview with the resident on 4/18/16, the resident stated CNA #1 had taken his/her bank card. I gave it to her/him to get my girlfriend a Valentine's present. I told her/him s/he could use it but if s/he did, to let me know. S/he used it but did not let me know. S/he did not bring it back to me. I called the bank to check on my account and I was missing money. It was money I did not spend. I reported it. S/he (CNA) does not work here any more. I heard I was not the only one s/he did that to. Review of the facility investigation of the incident revealed the resident complained to a CNA on 2/29/16 that CNA #1 had his/her card and the resident was missing money from his/her account. The resident had called the bank and found out the money was missing. The facility called the police. The police investigated the incident. The CNA also had the resident's vehicle. The resident reported the missing money to CNA #2. The CNA was interviewed by the surveyor on 4/20/16 at approximately 11:00 AM. The CNA stated the resident had reported to him/her that CNA #1 had the resident's bank card and s/he had missing money from his/her account. The resident said s/he had some money missing and s/he did not authorize it. I asked him/her where the bank card was. S/he stated CNA #1 had it. S/he said s/he would just keep the card and if s/he (resident) needed something s/he could call him/her and s/he would get it with the debit card. S/he authorized the CNA to get cleaning supplies and pay anyone that helped her. I went and told the Administrator everything I told you. The resident told me that the CNA had his/her car at their place. Review of the facility investigation revealed a thorough investigation had not been conducted. The facility had not interviewed any residents that could have been affected with missing money or items. No statement was taken from the resident. There were no staff statements obtained. Following the interview with CNA #2, two staff statements were provided to the surveyor. CNA #2 was asked when s/he had written the statement. The CNA stated s/he had written the statement that morning. Review of the Police Department Reports revealed the police had four warrants out for the CNA. The bank confirmed there were $1,500.00 of unauthorized usage of the resident's bank account.

Based on record review, interviews and facility files, the facility failed to follow their policy to complete a thorough investigation and report immediately to state agencies any allegations of abuse, neglect and misappropriation of funds. The facility failed to conduct a thorough investigation for 1 of 1 allegations of misappropriation of funds (resident #69). The facility failed to conduct an investigation and report allegations of abuse for 1 of 1 residents the facility identified a concern with (resident # 178). The facility failed to report and provide a thorough investigation of 2 of 2 random allegations of abuse reported to them by the surveyor. The findings included: Cross refer to F 224. Preventing, investigating and reporting allegations of abuse, neglect and misappropriation of funds/personal property. Resident #178 reported someone had entered their room in the middle of the night and had him/her sign a paper. The resident did not know who the person was or what was on the paper. The resident was told not to mention the letter and not to tell anyone that the resident had a visitor. The facility also received reports the person that entered the building in the middle of the night made copies of medical records. No investigation had been conducted nor were the allegations reported to the state agencies. Resident # 69 reported to the facility that a Certified Nursing Assistant (CNA) had his/her bank card and had used the card without the resident's authorization. The CNA had the resident's car as well. The facility did not have a thorough investigation of the allegations. The facility's investigation did not included an official statement from the resident. There were no interviews/statements of other resident's that may have been affected by the CNA's practice. There were no statements obtained from the staff. During the Recertification/Complaint Survey, the facility Administration was notified by the surveyor of two allegations of abuse the facility was not aware. The facility Administration stated they would do an investigation. No reports were received by the state agency of the allegations. The facility admitted Resident #211 with [DIAGNOSES REDACTED]. During an individual interview on 4/19/16 at 10:49 AM, Resident #211 stated staff were not nice to her. He/she continued by stating after asking for assistance, the nurse slammed his/her hands down on the counter and asked don't I always help you? He/she continued by stating the Administrator had been informed of the event. Record review on 4/20/16 of the nurse's notes and the social services notes did not reflect the incident. Investigation of the incident was requested on 4/19/16. A grievance form had been completed on 4/17/16 which stated the resident did not feel the nurse provided enough assistance in helping the resident go to the bathroom. Per the findings of the investigation, the nurse felt he/she was trying to help the resident maintain her independence and felt he/she was professional and thorough with the resident's activities of daily living. After the investigation, it was determined the resident did not feel comfortable with the nurse. The action taken was the nurse would not be assigned to the resident. After reviewing the grievance, the facility was asked if they were aware of the nurse allegedly slamming her hands down on the desk when the resident was speaking to him/her. The facility did not have knowledge of the incident. On 4/20/16, an initial 24-hour report was completed and sent to the State Survey Agency. The incident was described as verbal abuse as an employee was overheard yelling and cursing at Resident #211. A witness statement was obtained with a date of 4/16/16 which alleged the nurse in question had cursed at the resident. During an interview with the Administrator on 4/23/16 at 10:59 AM, he/she had no explanation as to why the date on the witness statement was 4/16/16 and no explanation why this was not reported at the time of the incident. Review of the facility policy titled Abuse Policy and Procedure revealed under Section III-A Reporting the following: Any person observing(or hearing a complaint of) mistreatment, neglect, abuse or misappropriation of resident property should immediately report it to the Administrator, Social Services Director, Director of Nursing or other department head. CFR 483.13(c) F-226 Develop/Implement Abuse/Neglect, etc Policies was identified at a scope and severity level of (L). The facility failed to follow and implement policies related to investigation, preventing and reporting of allegations of abuse for Residents #69, #178 and #211. The facility Administrator, Director of Nursing, and Director of Nursing in Training were informed of the Immediate Jeopardy on 4/21/16 at approximately 5:20 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/28/16 at 2:05 PM. Observation, record review and interview provided evidence to the survey team prior to exit the AOC had been implemented by the facility and the Immediate Jeopardy at F-226 was removed, but the citation remained at a lower scope and severity of F. The AOC included the following: AOC: It has been alleged in the context of the pending survey process that the Facility's response to events allegedly occurring on or around March 17th-20th, was insufficient. In an effort to demonstrate and achieve substantial compliance with applicable and involved regulations, the Facility proposes and has initiated implementation of the following plan of correction: * Resident Security- 1. In an effort to put immediate corrective action in place, Resident #1 was asked by the Administrator to inform Facility Administration in the event there is a recurrence of uninvited or unwanted visitors entering (his/her) room (employees or otherwise). Further, the Resident was reminded of (his/her) right to speak with the Department of Health or the Ombudsman should (he/she) ever have questions or concerns, or should (he/her) require additional information on any topic affecting (his/her) Facility admission. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has conducted an investigation into the subject events which included interviews of all residents. Specifically, each resident has been asked if they have ever been visited by people they did not recognize, and where applicable, the time, dates are being investigated to determine the nature of the visit. Further, on 4/22/16, the Facility has provided each current resident with a flyer containing the phone numbers of the South Carolina Department of Health and Environmental Control, and the local Ombudsman. Going forward, this same flyer will be distributed to incoming residents on admission. Additionally, the codes have been changed at each pedestrian entrance door. (4/23/16) 3. The following measures have been put in place to ensure the deficient practice will not reoccur: * A sign-in log was placed at the front desk. All visitors (which includes employees who are in the Facility for reasons other than working a scheduled shift) will be required to sign in at the front desk, and indicate their purpose in visiting the Facility. If a visitor is there to see a resident, the name and room number of the Resident must be indicated on the sign-in log. * All employees have been informed via in-service that they should not be present on Facility premises unless they are assigned to work, or have other work-related business at that time Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * The following information has been inserviced: Abuse, Neglect, Misappropriation, and timely reporting of an allegation Resident Rights, and timely reporting of any violations Door code change for security, an sensitivity of code. * All employees have been trained (4/23/16) that in the event any employee is seen entering the Facility at hours not typically worked by that employee, they are obligated to report such unusual activity to Facility management. Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * Signs have been posted at or near each door leading in to the Facility, instructing all visitors to sign in at the front desk (4/25/16). * The code to all exit doors was changed on 4/21/16. All active employees, and resident responsible parties were notified of the code change. * Protection of Private Health Information 1. In an effort to put immediate corrective action in place, Resident #1 was informed by the Administrator that an employee of Compass Post-Acute Care is alleged to have collected private information about (him/her) outside the scope of (his/her) employment. Our guidance to (him/her) reflected the information we have to date and the possibility that (his/her) protected health information may have ben accessed for reasons unrelated to (his/her) treatment, payment or other healthcare purpose. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has invited members of our Compliance Department to come and evaluate our existing practices. All employees have been re-educated (4/27/16) regarding their obligations under HIPAA, and all new employees (and agency if necessary) will receive the more comprehensive training upon hire via a web-based module [MEDICATION NAME] approximately 45 minutes. 3. In addition to the physical security items listed above, the following measures have been put in place to ensure the deficient practice will not reoccur: * Any time a chart is removed temporarily from the nursing station, the employee doing so must note the removal in the log created to capture this information. The employee will need to log the date, time of removal, time of return, and purpose associated with the temporary removal. * Employees who remove medical records from the Facility or who access the chart for reasons inconsistent with Federal and State Privacy Laws will be disciplined up to and including the possibility of termination. * A video surveillance system is to be installed and contractors have been contacted. The system will provide remote visualization of each door leading in to the Facility, and will also show activity in public or shared areas including but not limited to hallways, nursing stations, dining rooms, etc.). * Resident rooms will not be included in the areas capable of being viewed by the cameras. The Department should also be aware that the employee whose conduct is at issue has been suspended pending the results of our investigation. (He/she) has not worked in the Facility or had contact with any Facility resident since. We allege compliance as of this day (4/27/16).

Based on record review and interviews, the facility failed to provide supervision for the safety of the residents. Resident #178 was visited in the middle of the night by someone s/he did not know, and instructed to sign a paper. The resident was told to not tell anyone about the paper and not to tell ayone about the visit. The findings included: Cross refer to F224- Prevention, investigation and reporting abuse/neglect and misappropriation of funds. The facility admitted resident # 178 with [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status Score of 15. S/he was alert and oriented and able to make decisions regarding his/her ability to make decisions regarding activities of daily living. Review of the additional allegations revealed an allegation of 3/16/16 related to resident #178. Per the allegation, the resident had complained that a nurse had snatched off a neck brace. Review of the facility's grievance files revealed a grievance of the allegation. Through the facility investigation of the allegation, the resident had stated the nurse had startled him/her when removing the neck brace and was not abused. The Administrator, Director of Nursing (DON), Director of Nursing in Training (DON in training), and Social Services (SS) were interviewed by the surveyor on 4/21/16 at approximately 11:30 AM. During the interview the Administrator and DON stated that a note was left under the administrator's door, signed by the resident. The administrator provided the note for review. The note stated, I will (sic) like to speak to the Patient Avocate about my collar being snatched off by male nurse. Please call them for me, thanks for asking about my care. I was informed S/he is Ombudsman ---- (name of person). The administrator went to the resident and was told by the resident that someone had come in his/her room at 3:00 AM, wearing a hoodie and had him/her sign a paper. The resident did not know who the person was or what was on the paper that s/he signed. The resident stated s/he did not write the note and did not want to talk to the patient advocate. The DON stated the person was seen by staff members copying resident charts. The DON stated when s/he came in, the person had already left the facility. During the interview the Administrator and DON and DON in training stated the person that had entered the facility during the night was an employee, a Licensed Practical Nurse (LPN), who worked the 7A-7P shift. The employee was out on medical leave at the time of the survey. The DON in training stated that they had been informed the LPN had been observed sitting outside of other staff member's homes, in a car. The Administrator was asked by the surveyor, what had been done to protect the residents from unknown persons entering the building in the middle of the night, coercing the residents. The Director of Nursing stated the County Sheriff's Department had been asked for the facility to be placed on their security patrol route. The DON did not know how often the police would patrol the facility at night. S/he did not know what medical records had been allegedly copied by the person. The DON and DON-in-training were unable to provide an investigation into the incident with resident #178, regarding the night visitor nor any information regarding the copied medical records. The DON in training repeatedly stated, the employee was just doing what s/he thought was right. The facility was aware of the middle of the night entrance into the building by an off duty employee. The resident informed them of an unknown person dressed in a hoodie cohering him/her to sign a note that the resident did not write. The resident did not know who the person was or what was written on the note. They were also aware of the allegation of medical records being copied and removed from the facility. There was no investigation, no preventive measures put into place to protect the residents, or the facility medical records. There was no documentation that the Sheriff's Department was contacted, or how often they would patrol the facility. There was no documentation the alleged perpetrator had been investigated regarding the medical records. On 4/21/16 at approximately 3:00 PM the Administrator provided a facility document of communications with corporate personnel. The document was a time line related to the incident of 3/16/16. 3/16- LPN was called into the office for inappropriate comments and insubordinate attitude toward the Assistant Director of Nursing (ADON) . The LPN was highly defensive, and aggressive toward myself and ADON when I tried to speak with him/her .Within 30 minutes the LPN brought back an allegation of abuse toward the ADON which stemmed from an incident that happened 14 days prior. I immediately investigated the complaint and interviewed the following: (Resident #178) S/he said that s/he was nervous for them to take the neck brace off, and that s/he got scared. S/he said it felt rough when they had to pull the velcro collar to undo it. S/he said it was rough but said s/h didn't think it was abusive in anyway. The ADON, Certified Nursing Assistant (CNA) and X-ray Tech state that the resident was alert and aware of what was going on. That the ADON was not rough with the resident, nor did s/he jerk or snatch the collar off the resident. 3/17/16- The LPN called myself (administrator) at 6:00 AM to tell me s/he was sick and wasn't coming into work for his/her shift at 7:00 AM; ADON worked his/her shift. The LPN called and texted multiple staff, all day to the point where one staff member called---- for being harassed by him/her. That night the LPN was seen and reported in the building after Midnight- s/he told staff that s/he was here to work on his/her charting. The staff said they found it weird but let him/her continue. 1 staff member said s/he saw the LPN copy papers from a chart, not on his/her normal hallway and take the papers with him/her. 2 staff members said that while the LPN was there she made threats of physical violence toward a CNA, who had just left the building a few hours prior .The LPN was also seen going down the 200 hall, and coming back to the 100 Hall later. 3/18/16- A letter was found signed by resident (#178) that said s/he wanted to speak to the Ombudsman about the neck. The writing on the letter, and the resident's signature were two different styles of writing, We spoke to the resident regarding the letter and s/he said that someone (s/he couldn't tell who, they had a hoodie on s/he thinks) woke him/her from his/her sleep around 2-3 am and made him/her sign a letter. S/he said s/he was told not to talk to anyone about the letter and not to tell anyone that someone came to visit him. We asked if s/he needed the Ombudsman, and s/he said that s/he didn't request him/her, because s/he did not write the letter. The resident stated he did not sign his/her name the way it was on the letter. So s/he knows s/he was out of it If s/he signed a letter with his /her legal name.

Based on review of facility files and interviews, the facility failed to Administer in a way to maintain safety of residents named in allegations of abuse/neglect misappropriation of funds. The findings included: Cross refer to F224- Prevent, investigate and report allegations of abuse/neglect, misappropriation of funds Cross Refer to F226: Developing Policies and Procedures for Abuse/Neglect and Misappropriation of funds/personal property. Cross refer to F323: Supervision to prevent accidents/incidents. Supervision not provided to prevent unknown person entering facility and resident's rooms when sleeping.

Based on record review and interviews, the facility failed to maintain the safety and confidentiality of resident records and failed to safeguard clinical record information against unauthorized use. It was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of 3/17/2016. The findings included: Cross refer to F224- Prevent, investigate and report allegations of abuse/neglect, misappropriation of funds related to Resident #178. Cross refer to F226-Developing Policies and Procedures for Abuse/Neglect and Misappropriation of funds/personal property related to Resident #178. Cross refer to F-323 Supervision to prevent accidents/incidents related to Resident #178. During the Recertification and Complaint Survey, on 4/21/16 the Department of Health and Environmental Control (DHEC) Certification State Agency office received an additional eight (8) allegations of abuse/neglect. Review of the allegations revealed the facility had identified a concern related to the allegation that involved resident # 178. The administrator went to the resident (#178) and was told by the resident that someone had come in his/her room at 3:00 AM, wearing a hoodie and had him/her sign a paper. The resident did not know who the person was or what was on the paper that s/he signed. The resident stated s/he did not write the note and did not want to talk to the patient advocate. The DON stated the same person seen in Resident #178's room was seen on the same night by staff members copying resident charts. The DON stated when s/he came in, the person had already left the facility. During the interview the Administrator and DON and DON in training stated the person that had entered the facility during the night was an employee, a Licensed Practical Nurse (LPN), who worked the 7A-7P shift. The employee was out on medical leave at the time of the survey. The Administrator was asked by the surveyor, what had been done to protect the residents from unknown persons entering the building in the middle of the night, coercing the residents. The Director of Nursing stated the County Sheriff's Department had been asked by the facility to be placed on their security patrol route. The DON did not know how often the police would patrol the facility at night. S/he did not know what medical records had been allegedly copied by the person. The DON and DON-in-training were unable to provide an investigation into the incident with resident #178, regarding the night visitor nor any information regarding the copied medical records. The DON in training repeatedly stated the employee was just doing what s/he thought was right. Additional information from documentation provided in a timeline from the Administrator included the following: 3/17/16- The LPN called myself (administrator) at 6:00 AM to tell me s/he was sick and wasn't coming into work for his/her shift at 7:00 AM; ADON worked his/her shift. The LPN called and texted multiple staff, all day to the point where one staff member called---- for being harassed by him/her. That night the LPN was seen and reported in the building after Midnight- s/he told staff that s/he was here to work on his/her charting. The staff said they found it weird but let him/her continue. 1 staff member said s/he saw the LPN copy papers from a chart, not on his/her normal hallway and take the papers with him/her. 2 staff members said that while the LPN was there she made threats of physical violence toward a CNA, who had just left the building a few hours prior .The LPN was also seen going down the 200 hall, and coming back to the 100 Hall later. CFR 483.75(l)(3), 483.20(f)(5) F-516 Release Resident Information, Safeguard Clinical Records was identified at a scope and severity level of (L). The facility failed to ensure confidentiality and unauthorized use of resident clinical record information for Resident #178. The facility Administrator, Director of Nursing, and Director of Nursing in Training were informed of the Immediate Jeopardy on 4/21/16 at approximately 5:20 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/28/16 at 2:05 PM. Observation, record review and interview provided evidence to the survey team prior to exit the AOC had been implemented by the facility and the Immediate Jeopardy at F-516 was removed, but the citation remained at a lower scope and severity of F. The AOC included the following: AOC: It has been alleged in the context of the pending survey process that the Facility's response to events allegedly occurring on or around March 17th-20th, was insufficient. In an effort to demonstrate and achieve substantial compliance with applicable and involved regulations, the Facility proposes and has initiated implementation of the following plan of correction: * Resident Security- 1. In an effort to put immediate corrective action in place, Resident #1 was asked by the Administrator to inform Facility Administration in the event there is a recurrence of uninvited or unwanted visitors entering (his/her) room (employees or otherwise). Further, the Resident was reminded of (his/her) right to speak with the Department of Health or the Ombudsman should (he/she) ever have questions or concerns, or should (he/her) require additional information on any topic affecting (his/her) Facility admission. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has conducted an investigation into the subject events which included interviews of all residents. Specifically, each resident has been asked if they have ever been visited by people they did not recognize, and where applicable, the time, dates are being investigated to determine the nature of the visit. Further, on 4/22/16, the Facility has provided each current resident with a flyer containing the phone numbers of the South Carolina Department of Health and Environmental Control, and the local Ombudsman. Going forward, this same flyer will be distributed to incoming residents on admission. Additionally, the codes have been changed at each pedestrian entrance door. (4/23/16) 3. The following measures have been put in place to ensure the deficient practice will not reoccur: * A sign-in log was placed at the front desk. All visitors (which includes employees who are in the Facility for reasons other than working a scheduled shift) will be required to sign in at the front desk, and indicate their purpose in visiting the Facility. If a visitor is there to see a resident, the name and room number of the Resident must be indicated on the sign-in log. * All employees have been informed via in-service that they should not be present on Facility premises unless they are assigned to work, or have other work-related business at that time Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * The following information has been inserviced: Abuse, Neglect, Misappropriation, and timely reporting of an allegation Resident Rights, and timely reporting of any violations Door code change for security, an sensitivity of code. * All employees have been trained (4/23/16) that in the event any employee is seen entering the Facility at hours not typically worked by that employee, they are obligated to report such unusual activity to Facility management. Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * Signs have been posted at or near each door leading in to the Facility, instructing all visitors to sign in at the front desk (4/25/16). * The code to all exit doors was changed on 4/21/16. All active employees, and resident responsible parties were notified of the code change. * Protection of Private Health Information 1. In an effort to put immediate corrective action in place, Resident #1 was informed by the Administrator that an employee of Compass Post-Acute Care is alleged to have collected private information about (him/her) outside the scope of (his/her) employment. Our guidance to (him/her) reflected the information we have to date and the possibility that (his/her) protected health information may have ben accessed for reasons unrelated to (his/her) treatment, payment or other healthcare purpose. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has invited members of our Compliance Department to come and evaluate our existing practices. All employees have been re-educated (4/27/16) regarding their obligations under HIPAA, and all new employees (and agency if necessary) will receive the more comprehensive training upon hire via a web-based module [MEDICATION NAME] approximately 45 minutes. 3. In addition to the physical security items listed above, the following measures have been put in place to ensure the deficient practice will not reoccur: * Any time a chart is removed temporarily from the nursing station, the employee doing so must note the removal in the log created to capture this information. The employee will need to log the date, time of removal, time of return, and purpose associated with the temporary removal. * Employees who remove medical records from the Facility or who access the chart for reasons inconsistent with Federal and State Privacy Laws will be disciplined up to and including the possibility of termination. * A video surveillance system is to be installed and contractors have been contacted. The system will provide remote visualization of each door leading in to the Facility, and will also show activity in public or shared areas including but not limited to hallways, nursing stations, dining rooms, etc.). * Resident rooms will not be included in the areas capable of being viewed by the cameras. The Department should also be aware that the employee whose conduct is at issue has been suspended pending the results of our investigation. (He/she) has not worked in the Facility or had contact with any Facility resident since. We allege compliance as of this day (4/27/16).

Based on full and/or limited record reviews, interviews, and review of facility policies, it was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed for CFR483.75 F-520 which was identified at a scope and severity level of (L). The facility failed to identify quality deficiencies related to prevention of abuse/neglect, proper implementation of abuse/neglect policies, provision of supervision to ensure resident safety, and provision of medical record security. Failure of the Quality Assurance (QA) Committee to identify and implement action plans related to these quality deficiencies resulted in Immediate Jeopardy for Resident #69 and Resident #178. The findings included: Based on record reviews and interviews, the facility failed to identify concerns related to prevention of abuse/neglect, provision of supervision to ensure resident safety, and provision of medical record security. During an interview on 4/28/16, the Administrator and Director of Nursing stated and confirmed that the QA Committee had not identified and had not implemented action plans related to the concerns identified for Resident #69 and Resident #178. Based on full and/or limited record reviews, interviews, and review of facility policies, it was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of 3/17/2016. The facility Administrator, Director of Nursing, and Director of Nursing in Training were informed of the Immediate Jeopardy on 4/21/16 at approximately 5:20 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/28/16 at 2:05 PM, and the Immediate Jeopardy at F-224, F-226, F-323, F490, F516 and F-520 was removed but the citations remained at a lower scope and severity. The AOC included the following: AOC: It has been alleged in the context of the pending survey process that the Facility's response to events allegedly occurring on or around March 17th-20th, was insufficient. In an effort to demonstrate and achieve substantial compliance with applicable and involved regulations, the Facility proposes and has initiated implementation of the following plan of correction: * Resident Security- 1. In an effort to put immediate corrective action in place, Resident #1 was asked by the Administrator to inform Facility Administration in the event there is a recurrence of uninvited or unwanted visitors entering (his/her) room (employees or otherwise). Further, the Resident was reminded of (his/her) right to speak with the Department of Health or the Ombudsman should (he/she) ever have questions or concerns, or should (he/her) require additional information on any topic affecting (his/her) Facility admission. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has conducted an investigation into the subject events which included interviews of all residents. Specifically, each resident has been asked if they have ever been visited by people they did not recognize, and where applicable, the time, dates are being investigated to determine the nature of the visit. Further, on 4/22/16, the Facility has provided each current resident with a flyer containing the phone numbers of the South Carolina Department of Health and Environmental Control, and the local Ombudsman. Going forward, this same flyer will be distributed to incoming residents on admission. Additionally, the codes have been changed at each pedestrian entrance door. (4/23/16) 3. The following measures have been put in place to ensure the deficient practice will not reoccur: * A sign-in log was placed at the front desk. All visitors (which includes employees who are in the Facility for reasons other than working a scheduled shift) will be required to sign in at the front desk, and indicate their purpose in visiting the Facility. If a visitor is there to see a resident, the name and room number of the Resident must be indicated on the sign-in log. * All employees have been informed via in-service that they should not be present on Facility premises unless they are assigned to work, or have other work-related business at that time Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * The following information has been inserviced: Abuse, Neglect, Misappropriation, and timely reporting of an allegation Resident Rights, and timely reporting of any violations Door code change for security, an sensitivity of code. * All employees have been trained (4/23/16) that in the event any employee is seen entering the Facility at hours not typically worked by that employee, they are obligated to report such unusual activity to Facility management. Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * Signs have been posted at or near each door leading in to the Facility, instructing all visitors to sign in at the front desk (4/25/16). * The code to all exit doors was changed on 4/21/16. All active employees, and resident responsible parties were notified of the code change. * Protection of Private Health Information 1. In an effort to put immediate corrective action in place, Resident #1 was informed by the Administrator that an employee of Compass Post-Acute Care is alleged to have collected private information about (him/her) outside the scope of (his/her) employment. Our guidance to (him/her) reflected the information we have to date and the possibility that (his/her) protected health information may have ben accessed for reasons unrelated to (his/her) treatment, payment or other healthcare purpose. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has invited members of our Compliance Department to come and evaluate our existing practices. All employees have been re-educated (4/27/16) regarding their obligations under HIPAA, and all new employees (and agency if necessary) will receive the more comprehensive training upon hire via a web-based module [MEDICATION NAME] approximately 45 minutes. 3. In addition to the physical security items listed above, the following measures have been put in place to ensure the deficient practice will not reoccur: * Any time a chart is removed temporarily from the nursing station, the employee doing so must note the removal in the log created to capture this information. The employee will need to log the date, time of removal, time of return, and purpose associated with the temporary removal. * Employees who remove medical records from the Facility or who access the chart for reasons inconsistent with Federal and State Privacy Laws will be disciplined up to and including the possibility of termination. * A video surveillance system is to be installed and contractors have been contacted. The system will provide remote visualization of each door leading in to the Facility, and will also show activity in public or shared areas including but not limited to hallways, nursing stations, dining rooms, etc.). * Resident rooms will not be included in the areas capable of being viewed by the cameras. The Department should also be aware that the employee whose conduct is at issue has been suspended pending the results of our investigation. (He/she) has not worked in the Facility or had contact with any Facility resident since. We appreciate your consideration of this AOC, and welcome any questions or comments you might have. Furthermore, we allege compliance as of this day (4/27/16).

On days of the complaint inspection, based on record review and interviews, the physician was not notified of a skin tear to Resident #3's left arm or Resident #1's change in condition. The findings included: Cross refers to F-323 as it relates to the failure of the facility to notify the physician of a skin tear to Resident #3's left arm on 09/14/2012. Cross refers to F-329 as it relates to the family of Resident #1 calling Emergency Medical Services (EMS) on 11/03/2012, EMS found 4 [MEDICATION NAME] Patches on the resident. The resident was found with decreased respirations and a blood glucose of 36. [MEDICATION NAME] and [MEDICATION NAME] were administered by EMS and the resident's vital signs improved and s/he became alert and oriented before arrival at the emergency room . Review of the closed medical record revealed [MEDICATION NAME] Patch(s) 25 micrograms was applied to Resident #1's chest upper left and upper right on 10/27/2012 and 10/30/2012 with no documentation that the [MEDICATION NAME] Patches were removed. On 11/02/2012 a [MEDICATION NAME] Patch was applied to Resident #1's chest upper left. The facility admitted Resident #3 from home with hospice care, for short term respite. In an interview with Certified Nurse Aide #1 s/he stated that the resident was injured during incontinent care sometime before midnight on 09/14/2012. Review of the resident's closed medical record showed no assessment or description of the injury and the physician was not notified of the injury from 09/14/2012 until the resident was discharged on [DATE]. Review of the facility investigation included a Resident Incident Report that indicated the incident date was 9-15-12 at 0335. The Narrative of incident and description of injuries stated, "Call to room... observed skin tear to bilateral forearms. No other injury noted tx (treatment) in place. Hospice and family notified..." Record review on 11/18/2012 revealed Nurse's Note from 09/14/2012 - 09/17/2012 the 9/14/2012 note at 0335 stated, "Pt (patient) received skin tear to bilateral hands/forearm hospice nurse notified and husband notified." There was no other documentation regarding the skin tear to Resident #3's arm until 09/16/2012 at 2130 (9:30 PM) "...Bilateral [MEDICATION NAME] intact on both arms..." On 09/17/2012 at 1230 the Nurse's Note stated, "Pt. (patient) D/C'd (discharged ) home per husband/hospice request... All meds given to husband... 1:00 PM Pt's husband notified Administrator that he chose to have the ambulance go ahead and take her/him to the hospital for evaluation of skin tears to arms prior to going home. Husband encouraged to keep us posted on her status." Review of Resident #3's hospital discharge summary dated 09/21/2012 indicated, "...Hospital course: ... 7. [MEDICAL CONDITION] of the arm. The patient was found to have old pieces of paper wrapped around her/his arms on admission. Wound care removed the tape, however, s/he did suffer some skin breakdown during the process. Wound care was consulted and they have dressing the wounds with petroleum gauze... Her/his left arm [MEDICAL CONDITION] is greater than her right. S/he is on [MEDICATION NAME] 100 twice a day..." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the EMS Incident Report dated 11/03/2012 stated, "...Upon arrival found... patient lying in bed... Nurse staff stated that patient eyes rolled back into his head and s/he has not been able to talk today..." Review of the 11/03/2012 Daily Skilled Nurse's Note dated 0900 stated, "Resident eating breakfast in bed. AM medications administered. Alert but confused. SR (side rails) x 2. Bed in lowest position. Wound Vac intact. Foley cath intact draining amber urine. Will continue to monitor." There was no other documentation regarding Resident #1, the arrival of EMS or notification of the physician regarding a change in condition. In an interview with the surveyor on 11/18/2012 the Administrator confirmed there was no documentation related to the incident. S/he stated that the nurse working that day no longer worked at the facility.

On the days of the complaint inspection, based on record review and interview, the facility failed to implement interventions to reduce the risk of skin tears and injury for Resident #3, and failed to document any ongoing assessment of the injured arm or notify the physician post injury for additional medical intervention. Resident #3 was treated for [REDACTED]. Resident #3 was 1 of 2 residents reviewed for injury. The findings included: The facility admitted Resident #3 from home with hospice care, for short term respite. In an interview with Certified Nurse Aide #1 s/he stated that the resident was injured during incontinent care sometime before midnight on 09/14/2012. Review of the resident's closed medical record showed no assessment or description of the injury and the physician was not notified of the injury from 09/14/2012 until the resident was discharged on [DATE]. The only documentation following the injury was a Nurse's Note dated 09/16/2012 at 9:30 PM. The facility admitted Resident #3 with a [DIAGNOSES REDACTED]. Record review on 11/18/2012 revealed Nurse's Note from 09/14/2012 - 09/17/2012 the 9/14/2012 note at 0335 stated, "Pt (patient) received skin tear to bilateral hands/forearm hospice nurse notified and husband notified." There was no other documentation regarding the skin tear to Resident #3 arm until 09/16/2012 at 2130 (9:30 PM) "...Bilateral tegaderm intact on both arms..." On 09/17/2012 at 1230 the Nurse's Note stated, "Pt. (patient) D/C'd (discharged ) home per husband/hospice request... All meds given to husband... 1:00 PM Pt's husband notified Administrator that he chose to have the ambulance go ahead and take her/him to the hospital for evaluation of skin tears to arms prior to going home. Husband encouraged to keep us posted on her status." Review of Resident #3's hospital discharge summary dated 09/21/2012 indicated, "...Hospital course: ... 7. Cellulitis of the arm. The patient was found to have old pieces of paper wrapped around her/his arms on admission. Wound care removed the tape, however, s/he did suffer some skin breakdown during the process. Wound care was consulted and they have dressing the wounds with petroleum gauze... Her/his left arm cellulitis is greater than her right. S/he is on doxycycline 100 twice a day..." Review of the facility investigation included a Resident Incident Report that indicated the incident date was 9-15-12 at 0335. The Narrative of incident and description of injuries stated, "Call to room... observed skin tear to bilateral forearms. No other injury noted tx (treatment) in place. Hospice and family notified. In an undated facility obtained witness statement Certified Nurse Aide (CNA) #1 stated, "Resident was approached like any other resident to dry and reposition. Aides informed resident that they were going to change her brief. In the process of turning, the aide that was turning from front was leaning toward the resident to maintain a sturdy grip. I (sic) the process of changing her the resident became anxious and reached for the lanyard (sic) that was around the aide (sic) neck that held her name tag. The resident jerked laynared (sic) was downward. Which caused the name tag to scrap her skin and cause the skin tear like a deep paper cut." In an interview with the surveyor on 11/27/2012 at 12:25 PM CNA #1 stated the incident happened sometime before midnight on 9/14/2012; that s/he had seen the resident at around 7:00 PM when s/he first came to work. At 7:00 PM s/he was given report by the CNA that was leaving, that the resident was dry and the previous CNA told her/him that Resident #3 was a total assist. "That was all she said." CNA #1 stated that the next time s/he went back to check on the resident was when s/he and CNA #2 changed her, "sometime before midnight." CNA #1 stated that when they rolled the resident toward her/him the resident was panicky, reached up and grabbed the name tag holder cutting her/his arm on the name tag. We had to hold her/his arm while we changed her. Review of Resident #3's Interim Plan of Care dated 09/14/2012 identified a risk for alteration in skin integrity due to incontinence. Interventions included "meds as ordered, assist to turn and reposition as needed, incontinence care as needed, monitor skin integrity weekly and prn, and treatments as ordered." The care plan indicated, "Actual skin alteration Site: Bil (bilateral) L/E (lower extremity) skin tears dated 9-14-12". In an interview with the surveyor on 11/27/2012 at 9:15 AM Resident #3's Responsible Party (RP) stated that s/he e-mailed detailed information regarding the resident's care prior to her/his admission. S/he stated that the e-mail went to the Admission Coordinator on 9/11/2012 and that the e-mail included information about the extreme sensitivity of the resident's skin. Review of the e-mail dated 09/11/2012 stated, "...NOTE: When assisting to stand or walk, grasp only hands, as skin on arms is extremely sensitive, bruises very easily and is subject to skin tears. Use caution during first 25 to 30 minutes after rising from bed, particularly if standing or walking, as uncontrolled muscle contractions sometimes occur and may result in a fall..." In a telephone interview with the surveyor on 11/28/2012 at 9:50 AM the Admissions Coordinator confirmed that s/he received the e-mail from Resident #3's RP prior to her/his admission and the information was given to the Director of Nurses and/or the Admissions Nurse before Resident #3 was admitted or on the day of admission.

On the days of the Recertification, Extended, and Complaint Surveys, based on record reviews, observations, interviews, and review of facility infection control policies and procedures and tracking documents, the facility failed to implement treatment and contact precautions in a timely manner, and/or failed to ensure contact precautions were maintained, and/or failed to ensure accurate monitoring and tracking of infections for 7 of 9 residents reviewed who had positive test results for Clostridium Difficile (C-Diff), (Residents #1, #4, #5, #6, #8, #10, and #12). The physician was not notified of the onset of gastrointestinal signs and symptoms of Clostridium Difficile (C-Diff) in a timely manner for four of nine sampled residents reviewed with[DIAGNOSES REDACTED] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. The facility failed to ensure contact precautions were maintained appropriately for Residents #1, #4, #5, #6, #8, #10. Infection surveillance data was inaccurate/missing for residents who had positive test results for[DIAGNOSES REDACTED] (Residents #1, #4, #6, #8, #10, and #12). The Infection Preventionist (IP) was not knowledgeable of job duties and responsibilities for the infection control program. The facility failed to ensure that surveillance data was reviewed frequently enough to identify, investigate, and address the causes of any trends. Facility staff failed to identify an outbreak of[DIAGNOSES REDACTED] and notify the local office of the Department of Health and Environmental Control. Procedures were not in place and/or followed to ensure that facility laundry was hygienically cleaned. Procedures were not in place and/or followed to ensure appropriate daily and terminal cleaning of isolation rooms, including those rooms of residents on contact precautions for[DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #1 on 8/26/11 following hospitalization for Altered Mental Status. She was discharged with [DIAGNOSES REDACTED]. The hospital discharge summary noted that she had been treated with [MEDICATION NAME], which had been changed to [MEDICATION NAME] to continue at the nursing facility until 9-2-11. Record review and interviews revealed that the facility twice failed to identify signs and symptoms of[DIAGNOSES REDACTED] and notify the physician in a timely manner so that interventions could be implemented to treat the infection and prevent its' transmission. Review of Physician Telephone Orders with the Assistant Director of Nurses (ADON) on 5-1-12 at 10:20 AM revealed that on 8-27-11, the physician ordered intravenous fluids for dehydration. On 8-29-11, the resident was started on [MEDICATION NAME] IM (intramuscular) for 3 days for signs and symptoms of a UTI. Review of the Daily Skilled Nurse's Notes with the ADON revealed that on 9/8/11, the resident had a watery, foul smelling stool. The physician was notified and ordered a stool specimen to check for[DIAGNOSES REDACTED]. On 9/9/11, the facility was notified of a positive result and the physician ordered treatment with [MEDICATION NAME] for 10 days and "isolation precautions". [MEDICATION NAME] was completed on 9-19-11. Review of the computerized Activities of Daily Living (ADL) Records on 5-1-12 at 11 AM with Certified Nursing Assistant (CNA) #1 and the ADON revealed that the resident began having 1 to 2 loose stools daily (when bowel movements were documented) on 8-28-11, at times having an odor. Multiple entries had no consistency noted. There was no evidence that the physician was notified until 9-8-11 when the nurse in the Daily Skilled Nurse ' s Notes made the first notation. Following completion of the [MEDICATION NAME] on 9-19-11, review of the Daily Skilled Nurse's Notes and the computerized bowel movement (BM) records revealed that the resident had no further symptoms until 9-24-11 when she experienced four diarrhea stools per the CNA documentation and diarrhea "off + on" by the nurse. The Physician/Extender saw the resident on that date, but the Progress Note indicated that the resident was seen for "altered mental status...preceded by weakness" and "dark urine". There was no mention of current diarrhea/loose stools and no immediate interventions. The document erroneously listed [MEDICATION NAME] as an "active" medication "starting 9-19-11". There was no evidence that the physician was notified of the recurrence of diarrhea until two days later when a 9-26-11 Physician's Telephone Order was written to "Recheck stool for[DIAGNOSES REDACTED]". The 9-26-11 Progress Note again listed [MEDICATION NAME] as an "active" medication "starting 9-19-11". On 9-28-11, the[DIAGNOSES REDACTED] toxin was reported as positive and the physician ordered treatment with [MEDICATION NAME] for ten days. Record review and interviews also revealed that contact precautions were not appropriately maintained for Resident #1. Review of the Daily Skilled Nurse's Notes revealed an entry on 9/6/11 describing the resident as pacing in the hallway and rambling, wandering into other resident's rooms. Further review revealed the resident was not confined to her room once she was placed on contact precautions. On 9/10/11, she ambulated in the hallway and entered other resident's rooms. According to nurses' notes, the resident was often brought out to the nurses' station in a recliner chair on the following days: 9/12, 9/13, 9/14, 9/16, and 9/21/11. The nurse's note on 9/21/11 said the resident was ambulated by staff for toileting and needed two people for assistance most of the time. A nurse's note on 9/22/11 stated the resident was in a rocking chair in the lobby. Staff continued to bring the resident out of her room to sit by the nurses' station, as noted on 9/25/11. Documentation in the nurses' notes continued to show that the resident was brought out to the nurses' station (10/5, 10/9, and 10/11) even though she tested positive for[DIAGNOSES REDACTED] again on 9/28/11. Nurses' notes from this period also showed the resident placed her hands in her brief and then spread fecal matter. A nurse's note on 10/9/11 said the resident was in her chair at the nurses' station disrobing, and digging in her brief. On 10/13/11 the resident attempted to put her soiled fingers in her mouth. When the nurse redirected the resident, the resident "attempted to place her hands all over the writer's belly & arm." The nurse's note did not say if a gown and gloves were implemented at the time of this interaction. A nurse's note on 10/15/11 said she frequently placed her hands in her brief and then on her face. Review of the medical record failed to show an assessment by staff to show why the decision was made to allow the resident into the common areas of the facility, and how the other residents would be kept safe from possible contact with the resident or the environments she visited while positive for[DIAGNOSES REDACTED]. During an interview on 5-1-12 beginning at 10:15 AM, the ADON reviewed the medical record and confirmed the above information. She stated that precautions were implemented when the physician gave the order. She further stated that the physician should have been notified and precautions implemented at the onset of symptoms. She was unable to explain why this had not been done. When asked who would assess to determine the extent of contact isolation required, the ADON stated that she did not know. On 5-1-12 at 11:30 AM, the Administrator joined the interview and stated that the Director of Nurses and/or physician would determine if the resident could come out of their room, based on the type of infection and if on antibiotics. When asked how other residents were kept safe from personal contact with Resident #1 when she was out of her room, the ADON stated she did not know. She reviewed the Minimum Data Set for this period and stated that the resident had severe dementia and exhibited inappropriate social behavior. The Administrator stated that the staff routinely kept the resident at the nurses' station from about 10 AM until mid-afternoon daily. He stated there was always someone at the nurse's station, but he "can't think how someone could stop resident contact in the immediate area." During the survey, four current residents were noted as cognitively impaired self-mobile. Record review and interview revealed that the infection surveillance information was missing and/or incorrect, thus rendering the data collection incomplete for determining trends and patterns. Review of the facility's Infection Control Log for September 2011 did not show Resident #1 as having[DIAGNOSES REDACTED]. The October 2011 log did show the resident as having[DIAGNOSES REDACTED], but with an incorrect onset date of 10/4/11. During an interview on 5-1-12 at approximately 10:30 AM, the ADON reviewed the 9-11 Infection Control Log with the surveyor and verified that Resident #1's information had not been entered. It was also noted that the entries on the log were by resident name, not by infection onset date, thus making it difficult to determine patterns/trends in a timely manner. She stated that she was responsible for the Infection Control Program and was made aware of infections by review of copies of physician's orders [REDACTED]. When asked why the entries in the log were not in sequence, the ADON stated, "I got a pile of telephone orders and I enter them when I get a free moment." When asked if she had identified any patterns/trends, she stated she had not but that she had just been promoted to ADON and made responsible for Infection Control a couple of months previously. She stated she had received no formal training except for how to enter the information into the computer. "It was just read the policies and learn as you go." She could not remember signing anything that stated her responsibilities to the infection control program. Review of the ADON's personnel file on 5-1-12 revealed no job description related to her current position or evidence of infection control training. A job description (signed 1-6-12) presented on 5-2-12 noted one of the Areas of Responsibility under Regulatory Compliance included: "7. Assure that the facility, through established systems is in compliance with infection control regulations. Be responsible for reporting to the DON and Administrator all the pertinent information for Quality Assurance in Infection Control." Resident #4 with [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary with the ADON on 5-1-12 at 6 PM revealed that the resident had been treated for [REDACTED]. She was discharged to the facility with a [MEDICATION NAME] treatment to the lower leg. Record review and interviews revealed that the facility failed to identify signs and symptoms of[DIAGNOSES REDACTED] and notify the physician in a timely manner so that interventions could be implemented to treat the infection and prevent its' transmission. Review of the Daily Skilled Nurse's Notes revealed that on 12/19/11, the resident experienced a large amount of diarrhea stool with mucous. The physician was notified on 12-19-11 and an order received for "Stool for[DIAGNOSES REDACTED] ASAP (as soon as possible). Dx (Diagnosis) possible[DIAGNOSES REDACTED]." A laboratory report dated 12/22/11 showed the resident tested positive for[DIAGNOSES REDACTED]. Five days later, on 12/27/11, the physician/extender saw the resident, ordered [MEDICATION NAME] starting on 12-28-11 to treat the[DIAGNOSES REDACTED], and ordered contact isolation. The physician gave an interim Telephone Order on 12-23-11 for "Preparation H...apply TID (three times daily) to rectal region", indicating that the resident was suffering from swollen, irritated hemorrhoids. On 12-25-11, the physician/extender wrote to decrease [MEDICATION NAME] from twice daily to be given an as needed basis. Review of the computerized ADL Records on 5-1-12 at 6:40 PM with Certified Nursing Assistant (CNA) #1 and the ADON revealed that the resident began having loose stools on 12-16-11. Again, multiple entries had no consistency noted. There was no evidence that the physician was notified until 12-19-11 when the nurse in the Daily Skilled Nurse ' s Notes made the first notation. Based on review of the facility's Census List, the resident was given a roommate on 12/20/11, after exhibiting gastrointestinal symptoms for three days. However, the census for 12/21/11 did not show a roommate. A laboratory report dated 12/22/11 showed the resident tested positive for[DIAGNOSES REDACTED]. On 12/26/11, the facility put another roommate in with the resident. The physician ordered contact isolation, and [MEDICATION NAME] to treat the[DIAGNOSES REDACTED] on 12/27/11. A nurse's note on 12/28/11 revealed the resident was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] due to the ordered contact precautions. The resident's new roommate remained in room [ROOM NUMBER], a likely more contaminated environment. Review of the medical record failed to show any reason for the delay in testing the resident's stool sample (12/19 to 12/22/11). There was also no rationale to show why there was a delay in ordering treatment and the contact precautions (12/22 to 12/27/11). There was no information concerning the delay in isolating the resident from other residents (12/16 to 12/28/11), and/or why it was more appropriate to move the resident infected with[DIAGNOSES REDACTED] to a clean room while leaving the roommate without infection in the more compromised environment. During an interview on 5-1-12 beginning at 6 PM, the ADON reviewed the medical record and confirmed the above information. She stated that the physician should have been notified and precautions implemented at the onset of symptoms. She was unable to explain the reasoning behind moving the infected resident instead of the roommate to a clean room. She thought the DON wanted all residents on isolation precautions on the same hall. When asked about admissions into the room with Resident #4, the ADON stated that the facility "would not normally put anyone in there...possibly it was not communicated to (the person responsible for) Admissions." Review of the 12-11 Infection Log with the ADON on 5-1-12 at approximately 6:30 PM revealed that the onset date was noted as 12-28-11 instead of when the resident began having loose stools (12-16-11), when the first notation was made by the nurse in the Daily Skilled Nurse's Notes or when the physician was notified (12-19-11). Review of the mapping of infections to determine trends revealed that only one room was logged for the resident, though she had been in two during this review period. Resident #6 with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurse's Notes revealed the resident developed loose stools and was placed on contact isolation on 2/17/12. A stool specimen was collected and sent to the laboratory that day. On 2/18/12, the lab reported a positive[DIAGNOSES REDACTED] test. Not until 2/21/12 was treatment ordered for the[DIAGNOSES REDACTED]. Review of the Daily Skilled Nurse's Notes and the facility's Census List showed the resident was admitted to room [ROOM NUMBER], then transferred to room [ROOM NUMBER] the same day due to roommate concerns. In room [ROOM NUMBER], she had a roommate for three days (2/17, 2/18, and 2/19/12) despite the physician's orders [REDACTED]. On 2/19/12, the resident was moved from room [ROOM NUMBER] to room [ROOM NUMBER]. Her roommate remained in room [ROOM NUMBER]. During an interview beginning at 5 PM on 5-1-12, the ADON reviewed the medical record and confirmed the above information. Review of the 2-12 Infection Log with the ADON on 5-1-12 at approximately 5:30 PM revealed that the onset date was noted as 2-27-12 instead of when the resident began having loose stools (2-17-12) and was placed on contact precautions. No pathogen was identified on the log, though the resident had tested positive for[DIAGNOSES REDACTED]. Related [DIAGNOSES REDACTED]. Review of the mapping of infections to determine trends revealed that only one room was logged for the resident, though she had been in two during this review period. The ADON was unable to explain the reasoning behind moving the infected resident instead of the roommate to a clean room. She re-stated that the DON wanted all residents on isolation precautions on the same hall. However, review of the infection mapping revealed isolation precautions for gastrointestinal symptoms/C-Diff being maintained on all four halls. Resident #8 with [DIAGNOSES REDACTED]. Review of the hospital Transfer Discharge Summary with the ADON on 5-1-12 at 5:35 PM revealed that the resident was discharged on intravenous [MEDICATION NAME] and Zocyn to be discontinued on 12-9-11 (for treatment of [REDACTED]. The facility admitted the resident on [MEDICATION NAME] (to be stopped on 11-2-11) and contact precautions for[DIAGNOSES REDACTED]. Record review and interviews revealed that the facility failed to identify persistent signs and symptoms of[DIAGNOSES REDACTED] after the initial treatment and notify the physician in a timely manner so that an assessment could be completed to determine if further interventions were needed to treat the infection. Review of the Daily Skilled Nurse's Notes with the ADON revealed that the resident continued to have loose stools/diarrhea after the [MEDICATION NAME] was stopped (11-2-11) without notification of the physician until 11-12-11. A stool specimen was sent to the lab to be rechecked on 12-6-11. There was no evidence that the physician was notified of the negative results until at least 12-14-11 as evidenced by the run date on the report. There were no initials on the document to indicate that the physician/extender had reviewed the report. The resident was kept on isolation until contact precautions were discontinued on 12-14-11. During an interview on 5-1-12 beginning at 5:35 PM, the ADON reviewed the medical record and confirmed the above information. She was unable to explain why the physician had not been notified of continuing symptoms of[DIAGNOSES REDACTED] so the resident could be assessed for appropriate interventions as needed. Review of the Daily Skilled Nurse's Note revealed the resident contaminated his hands with feces and then contaminated his wound. Documentation also showed he contaminated his environment on 11/30/11 when drops of stool were noted on the floor, commode, and shower chair. Review of the physical therapy notes showed some documentation that the resident received therapy in his room. This documentation showed short distances ambulated a number of times. Other documentation, although the location was not specified, indicated the resident was out of his room for therapy: On 10/28/11 he ambulated 300 feet; on 11/11/11 he ambulated 200 feet; on 11/14/11 he ambulated 250 feet; and on 11/15/11 he ambulated 250 feet three times. There was no information to show what precautions were taken to protect other residents and the environment when the resident came out of his room for therapy. During an interview on 5-1-12 at 5:50 PM, the Rehab Manager stated she would contact the appropriate therapists to determine where the ambulation had been done with the resident. On 5-2-12, the Rehab Manager gave a written statement that "the long distance ambulation was most likely performed out of the room." Their policy was to apply personal protective equipment to the resident and therapists "and to keep any episodes contained. Anything the patient came in contact with was deep cleaned with disinfectant spray." During an interview on 5-2-12 at 11 AM, the Housekeeping and Maintenance Supervisor, in the presence of the chemical vendor representative, stated that 103 Neutral Disinfectant Cleaner had been used exclusively as the disinfectant in the building for deep cleaning all rooms and resident areas until approximately mid-April when bleach wipes had been purchased for cleaning isolation rooms. Resident #10 with a [DIAGNOSES REDACTED]. Review of 8-22-11 Physician/Extender Progress Notes on 5-1-12 at 3 PM revealed that the resident was placed on [MEDICATION NAME] for a vaginal yeast infection. Review of the Telephone Orders revealed that [MEDICATION NAME] and [MEDICATION NAME] were added on 8-25-11. Review of the computerized ADL Records on 5-1-12 at approximately 3:45 PM with Certified Nursing Assistant (CNA) #1 and the ADON revealed that the resident began having loose stools on 8-21-11. There was no evidence that the physician was notified until 8-26-11 when the physician ordered a stool test for[DIAGNOSES REDACTED]. Review of Daily Skilled Nurse's Notes revealed no documented diarrhea/loose stools until 8-28-11. The lab results provided on 8-27-11 were positive for[DIAGNOSES REDACTED]. [MEDICATION NAME] and contact precautions were ordered on [DATE] and the resident was moved to another room, leaving the roommate in the more contaminated area. There was no explanation for the five day delay in notification of the physician or another two day delay in ordering treatment and contact precautions found during the record review. During an interview on 5-1-12 beginning at 3 PM, the ADON reviewed the medical record and confirmed the above information. She stated that the physician should have been notified and precautions implemented at the onset of symptoms. She was unable to explain the reasoning behind moving the infected resident instead of the roommate to a clean room. At 3:15 PM, she and the Administrator noted that the DON wanted all residents requiring isolation precautions on the same hall. Review of the 9-11 Infection Log with the ADON revealed that the onset date of the infection was listed as 8-30-11 with no isolation precautions implemented. Review of the mapping of infections to determine trends revealed that only one room was logged for the resident, though she had been in two during this review period. Resident #12 with [DIAGNOSES REDACTED]. Record review and interviews revealed that the facility failed to identify signs and symptoms of[DIAGNOSES REDACTED] and notify the physician in a timely manner so that interventions could be implemented to treat the infection and prevent its' transmission. Review of the Daily Skilled Nurse's Notes with the ADON on 5-1-12 at 3:45 PM revealed that from 10-29-11 at 7 PM to 10-30 11 at 7 AM, the resident "continues to have small, freq(uent) amounts loose stool." 10-28-11 documented "Continent of all episodes", but was not specific. She had four loose stools in twelve hours on 10/30/11. On 10/31/11, the resident had diarrhea stools three times. A stool specimen was collected and sent to the laboratory. There was no evidence that the physician was notified until a physician's orders [REDACTED]. [MEDICATION NAME] was not ordered for treatment until 11/7/11. This physician's orders [REDACTED]." Contact precautions were ordered again on 11/10/11. There was no evidence in the record to indicate which date the precautions were implemented though the nurses' notes showed that the resident was on contact precautions on 11/9/11. Review of the computerized ADL Records on 5-1-12 at 4:15 PM with Certified Nursing Assistant (CNA) #1 and the ADON revealed that the resident began having loose stools on 10-28-11. There was no evidence that the physician was notified until 11-1-11, 4 days later. Review of the medical record showed no reasons for the delay in ordering treatment or for the delay in instituting contact precautions. During an interview on 5-1-12 beginning at 3:45 PM, the ADON reviewed the medical record and confirmed the above information. She stated that the physician should have been notified and precautions implemented at the onset of symptoms. She was unable to explain why this had not been done. The facility initially admitted Resident #5 on 10-21-11 with [DIAGNOSES REDACTED]. He was hospitalized from 11-11-11 through 11-22-11 for rectal bleeding. Upon readmission to the facility, the resident again suffered rectal bleeding and was hospitalized until 11-30-11. He was readmitted on contact precautions and [MEDICATION NAME] for seven days for treatment of [REDACTED]. Review of the Daily Skilled Nurse's Notes on 5-1-12 at approximately 12 PM with the ADON revealed that the resident had no further diarrhea/loose stools after completion of [MEDICATION NAME] on 12-7-11. Review of the computerized ADL Records on 5-1-12 at approximately 3:45 PM with Certified Nursing Assistant (CNA) #1 and the ADON revealed no documented loose stools after the medication was completed. Review of the Telephone Orders revealed that contact precautions were not discontinued until 12-20-11, 13 days later. During an interview on 5-1-12 beginning at approximately 12 PM, the ADON reviewed the medical record and confirmed the above information. She stated that the resident should have been taken off isolation when the medication was completed without further symptoms in evidence. During an interview on 5-1-12 at 10:15 AM, the Medical Director (and attending physician) stated he would expect to be notified immediately of signs and symptoms of[DIAGNOSES REDACTED] and the on-call physician/extender should be notified of the same on the weekend. If[DIAGNOSES REDACTED] was suspected, he would expect the facility to implement transmission-based precautions immediately, not to wait on lab reports. Review of the facility's policy and procedure for treatment of [REDACTED]. difficile were diarrhea - 3 loose stools in a 24 hour period; and abdominal pain or nausea and vomiting. "When signs and symptoms of [DIAGNOSES REDACTED]icile are present then: 1. Isolate the resident from other residents that do not have [DIAGNOSES REDACTED]icile. Infection control practices must be implemented to including contact precautions and hand hygiene. Hand hygiene should include washing using soap and water. [DIAGNOSES REDACTED]icile spores are resistant to killing by alcohol. 2. Obtain order for to (sic) collect stool for lab. ..." Staff was then directed to obtain the stool specimen, notify the physician with the results, and start the medications as ordered. Review of the facility's Contact Precautions policy and procedure revealed contact precautions were used for pathogens transmitted by direct resident contact or by contact with items in the resident's environment. "BARRIERS INDICATED FOR CONTACT PRECAUTIONS" The policy mandated the use of gloves when entering the room and while providing care to the resident. Gowns were to be worn if substantial contact with the resident, and/or environmental surfaces was anticipated. Gowns were to be removed before leaving the room and once the gown was removed "clothing should not contact potentially contaminated environmental surfaces." If a resident left the room, "precautions should be maintained to minimize the risk of transmission of microorganisms to other residents and contamination of environmental surfaces or equipment." Review of the Infection Control Logs and mapping of infections revealed that the logs contained incorrect/missing data. Residents were moved, some more than once, with only one location mapped. Compilation of infection information for 9-2011 showed one resident with[DIAGNOSES REDACTED]. In 10-2011, five residents were noted with[DIAGNOSES REDACTED]. Four of these are noted above. In 11-2011, six residents were noted with[DIAGNOSES REDACTED]. three of these are noted above. In 12-2011, five residents were noted with[DIAGNOSES REDACTED]. One of these is noted above. In 1-2012, one resident was list with[DIAGNOSES REDACTED]. In 2-2012, six residents were listed with gastrointestinal infections, five with[DIAGNOSES REDACTED]. Nine residents were mapped with "gastointestinal" infections. In 3-2012, one resident was list with[DIAGNOSES REDACTED]. The 4-2012 data was unavailable for review. There was no evidence that the local Regional Office of the Department of Health and Environmental Control was notified. During an interview on 5-1-12 at approximately 10:30 AM, the ADON reviewed the 9-11 Infection Control Log with the surveyor and verified that the entries on the log were by resident name, not by infection onset date, thus making it difficult to determine patterns/trends in a timely manner. She stated that she was responsible for the Infection Control Program and was made aware of infections by review of copies of physician's orders [REDACTED]. When asked why the entries in the log were not in sequence, the ADON stated, "I got a pile of telephone orders and I enter them when I get a free moment." When asked if she had identified any patterns/trends, she stated she had not but that she had just been promoted to ADON and made responsible for Infection Control a couple of months previously. She stated she had received no formal training except for how to enter the information into the computer. "It was just read the policies and learn as you go." She could not remember signing anything that stated her responsibilities to the infection control program. Review of the ADON's personnel file on 5-1-12 revealed no job description related to her current position or evidence of infection control training. A job description (signed 1-6-12) presented on 5-2-12 noted one of the Areas of Responsibility under Regulatory Compliance included: "7. Assure that the facility, through established systems is in compliance with infection control regulations. Be responsible for reporting to the DON and Administrator all the pertinent information for Quality Assurance in Infection Control." It was not specific as to duties and responsibilities to the program as was the job description in the Infection Control Policies and Procedures Manual. Review of the facility's infection control policies and procedures revealed that the requirements for reportable infections per the Centers for Disease Control and the South Carolina Department of Health and Environmental Control were not included. The contents of the manual were noted as "reviewed and revised" by the Administrator on 8-23-11, the "acting" Director of Nurses on 4-6-12, and by the Medical Director on 8-24-11. During an interview on 5-2-12 at 12:45 PM, the ADON was unaware of her duties in relation to reporting requirements. She stated, "It would be either the Administrator or the DON." She was not aware of any documents showing what infections to report or to which agencies they should be reported. During an interview on 5-1-12 at 1 PM, the two housekeepers on duty stated that daily and terminal cleaning of isolation rooms, including those rooms of residents on contact precautions for[DIAGNOSES REDACTED], had been done using 103 Neutral Disinfectant Cleaner. Review of the manufacturer's information revealed content of ammonium chloride. Upon clarification, they stated that they had just gotten bleach wipes for use in these rooms and new procedures, which had been implemented 2-3 weeks previously. Two to three months prior to the survey, the Housekeepers stated that there had been "seven or more residents on isolation at a time". They stated they had attended an infection control inservice in April. During an interview and observation of the laundry process on 5-1-12 at 1:15 PM, the Laundry Aide stated that personal laundry was washed on one of two cycles without bleach as per the signs on the washers. All other cycles for facility laundry used LL3000, a Liquid Laundry Destainer containing sodium hypochlorite. The Housekeeping/Maintenance Supervisor stated that the water temperature in the washers ranged from 110 to 140 degrees and that LL 3000 was not used in personal clothes. The chemical vendor was contacted and stated that if the water temperatures were under 160, LL5600 should be used to sanitize the personal laundry. The facility was not using this chemical. Review of the chemical informatio

On the days of the Recertification, Extended, and Complaint Survey, based on observation, record review and interviews, facility administration failed to ensure that policies and procedures were in place/followed to prevent, recognize, and control the onset and spread of infection within the facility. The findings included: On 5-2-12, review of the facility policy entitled Infection Control Committee - Duties and Responsibilities (Revised June, 2010) revealed that "The Administrator will be responsible for oversight of the Infection Control Program." During an interview on 5-1-12 at 11:45 AM, the Administrator stated that the Infection Control Committee was not a separate entity but was part of the QAA Committee. He presented an action plan for November 2011 that noted the opportunity for improvement as "Proper infection control methods that were in place before are currently not in place." He stated that this was based on general observations of resident care. Steps to correct/improve included: Inservices to be provided to nursing staff by 12-7-11; Compliance rounds to be done daily; and random audits to be done to ensure that infection control procedures were followed. Review of information provided by the facility staff on 5-2-12 revealed that 12 nurses and 1 CNA were inserviced on basic infection control on 11-15-11. Twelve CNAs and two nurses attended an inservice on 11-28-11 on infection control: room set-up/isolation equipment/drawers. Compliance rounds were only documented as completed twice (12-14-11 with 6 residents on isolation, 12-20-11 with 4 residents on isolation). Although additional information regarding completion of the plan and ongoing monitoring/audits were requested, none were provided. Additional inservice records were provided but not all departments/staff were in attendance. There was no evidence that the committee reviewed the implementation of the plan, monitored the outcome, or made needed revisions. During an interview on 5-2-12 at 4 PM, the Administrator stated that he was aware that infection tracking/trending reports were not as accurate as they should be. He stated that he was not personally aware of this but had been advised as a result of a compliance visit by corporate representatives. He stated that the Director of Nurses had not advised him of any concerns. . He stated he reviewed them monthly. He stated he had not identified any trends and was unaware of the reporting requirement until the survey. He stated he had no confidence in the recorded data. When asked if infections were discussed in the QAA meeting, he stated no trends had been identified. When questioned related to the implementation of the November 2011 QA plan of action, he stated he was unaware that the inservices had not been completed. When asked for audits and any additional information to verify implementation of the plan, none were provided. The Administrator was unaware that residents had not been placed on transmission based precautions upon onset of signs and symptoms of [MEDICAL CONDITION]. He was also unaware that new residents were admitted to rooms with residents on [MEDICAL CONDITION] precautions (contact). Cross Refer: CFR 483.65 Infection Control F441 The facility failed to notify the physician of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. The facility failed to ensure contact precautions were maintained appropriately for Residents #1, #4, #5, #6, #8, #10. Infection surveillance data was inaccurate/missing for residents who had positive test results for [MEDICAL CONDITION] (Residents #1, #4, #6, #8, #10, and #12). The Infection Preventionist (IP) was unaware of job duties and responsibilities for the infection control program. The facility failed to ensure that surveillance data was reviewed frequently enough to identify, investigate, and address the causes of any trends. Facility staff failed to identify an outbreak of [MEDICAL CONDITION] and notify the local office of the Department of Health and Environmental Control. Procedures were not in place and/or followed to ensure that facility laundry was hygienically cleaned. Procedures were not in place and/or followed to ensure appropriate daily and terminal cleaning of isolation rooms, including those rooms of residents on contact precautions for [MEDICAL CONDITION]. Cross Refer: CFR 483.10(b)(11) Notification of Changes F157 related to facility failure to notify the attending physician in a timely manner of changes in residents' physical conditions which required intervention/changes in treatment. The physician was not notified of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. Cross Refer: CFR 483.75(i) Medical Director F501 related to Medical Director failure to coordinate medical care in the facility to ensure that resident care was consistent with established infection control policies and procedures. Cross Refer: CFR 483.75 Quality Assessment and Assurance F520 related to QAA Committee failure to conduct ongoing reviews of the processes involved in infection control surveillance and monitoring. Staff failed to follow a plan of action established in 11-11 related to ongoing monitoring of compliance with infection control procedures. The immediacy was removed prior to exit from the facility on 5-2-12 after (1) review of the ongoing training content and participation and staff interviews related to that training were conducted, (2) evidence was presented that the medical record audits (with findings) were completed and any notifications/interventions implemented, (3) basic training was provided to the Infection Preventionist related to job duties/responsibilities, (4) the laundry was checked to ensure that it was being hygienically cleaned (5) job desciptions, duties and responsibilities were reviewed with staff members responsible for infection control data collection and analyzation. CFR 483.75 Administration F490 was lowered to a scope and severity of "F".

On the days of the Recertification, Extended, and Complaint Surveys, based on record reviews, observation, and interviews, the Medical Director failed to coordinate medical care in the facility to ensure that resident care was consistent with established infection control policies and procedures. The facility failed to involve the Medical Director in the ongoing evaluation of monitoring infections within the facility and implementation of infection control policies and procedures. The findings included: Based on record reviews and interviews, the physician was not notified of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. The facility failed to ensure contact precautions were maintained appropriately for Residents #1, #4, #5, #6, #8, #10. Infection surveillance data was inaccurate/missing for residents who had positive test results for [MEDICAL CONDITION] (Residents #1, #4, #6, #8, #10, and #12). The Infection Preventionist (IP) was not knowledgeable of job duties and responsibilities for the infection control program. The facility failed to ensure that surveillance data was reviewed frequently enough to identify, investigate, and address the causes of any trends. Facility staff failed to identify an outbreak of [MEDICAL CONDITION] and notify the local office of the Department of Health and Environmental Control. Procedures were not in place and/or followed to ensure that facility laundry was hygienically cleaned. Procedures were not in place and/or followed to ensure appropriate daily and terminal cleaning of isolation rooms, including those rooms of residents on contact precautions for [MEDICAL CONDITION]. Review of the Medical Director Agreement supplied by the facility as part of the extended survey on 5-2-12 revealed that his duties included: "f. Serve as member of the Quality Improvement/Quality Assurance Committees (i.e., Infection Control...) and provide oversight of the function of such committees." Review of the Infection Control Policies and Procedures revealed that duties of the committee included: notification of government agencies of reportable infectious diseases, reviewing laundry practices, develop policies and procedures for surveillance and monitoring of infection control practices. During an interview on 5-1-12 at 10:15 AM, the Medical Director (and attending physician) stated he would expect to be notified immediately of signs and symptoms of [MEDICAL CONDITION] and the on-call physician/extender should be notified of the same on the weekend. If [MEDICAL CONDITION] was suspected, he would expect the facility to implement transmission-based precautions immediately, not to wait on lab reports. During the interview, the Medical Director stated he participated in QAA meeting on a quarterly basis, the last one being "one or two months ago". He stated the Director of Nurses reviewed trends for the previous year related to numbers of infections. He stated he was aware of the increase in the number of residents with [MEDICAL CONDITION] "before the first of the year and in February-3 or 4 at a time." He was not aware that there had been nine gastrointestinal/[MEDICAL CONDITION] infections mapped for the month of February. The facility staff had not spoken with him regarding specific interventions other than "isolation and strict handwashing". He thought ongoing training worked but was unaware that the QAA plan for infection control had not been fully implemented. When asked, the Medical Director stated, "I guess I know outbreaks have to be reported. Have they done it?" Cross Refer: CFR 483.65 Infection Control F441 The facility failed to notify the physician of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. The facility failed to ensure contact precautions were maintained appropriately for Residents #1, #4, #5, #6, #8, #10. Infection surveillance data was inaccurate/missing for residents who had positive test results for [MEDICAL CONDITION] (Residents #1, #4, #6, #8, #10, and #12). The Infection Preventionist (IP) was unaware of job duties and responsibilities for the infection control program. The facility failed to ensure that surveillance data was reviewed frequently enough to identify, investigate, and address the causes of any trends. Facility staff failed to identify an outbreak of [MEDICAL CONDITION] and notify the local office of the Department of Health and Environmental Control. Procedures were not in place and/or followed to ensure that facility laundry was hygienically cleaned. Procedures were not in place and/or followed to ensure appropriate daily and terminal cleaning of isolation rooms, including those rooms of residents on contact precautions for [MEDICAL CONDITION]. Cross Refer: CFR 483.10(b)(11) Notification of Changes F157 related to facility failure to notify the attending physician in a timely manner of changes in residents' physical conditions which required intervention/changes in treatment. The physician was not notified of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. Cross Refer: CFR 483.75 Administration F490 related to facility administration failure to ensure that policies and procedures were in place/followed to prevent, recognize, and control the onset and spread of infection within the facility. Cross Refer: CFR 483.75 Quality Assessment and Assurance F520 related to QAA Committee failure to conduct ongoing reviews of the processes involved in infection control surveillance and monitoring. Staff failed to follow a plan of action established in November 2011 related to ongoing monitoring of compliance with infection control procedures. The immediacy was removed prior to exit from the facility on 5-2-12 after (1) review of the ongoing training content and participation and staff interviews related to that training were conducted, (2) evidence was presented that the medical record audits (with findings) were completed and any notifications/interventions implemented, (3) basic training was provided to the Infection Preventionist related to job duties/responsibilities, (4) the laundry was checked to ensure that it was being hygienically cleaned (5) job desciptions, duties and responsibilities were reviewed with staff members responsible for infection control data collection and analyzation. CFR 483.75(i) Medical Director F501was lowered to a scope and severity of "F".

On the days of the Recertification, Extended, and Complaint Surveys, based on review of quality improvement documents, record reviews, and interviews, the facility failed to identify ongoing quality deficiencies related to monitoring and implementing infection control policies and procedures. The QAA Committee failed to conduct ongoing reviews of the processes involved in infection control surveillance and monitoring. Staff failed to follow a plan of action established in November 2011 related to ongoing monitoring of compliance with infection control procedures. The findings included: During an interview on 5-1-12 at 11:45 AM, the Administrator stated that the Infection Control Committee was not a separate entity but was part of the QAA Committee. He presented an action plan for November 2011 that noted the opportunity for improvement as "Proper infection control methods that were in place before are currently not in place." He stated that this was based on general observations of resident care. Steps to correct/improve included: Inservices to be provided to nursing staff by 12-7-11; Compliance rounds to be done daily; and random audits to be done to ensure that infection control procedures were followed. Review of information provided by the facility staff on 5-2-12 revealed that 12 nurses and 1 CNA were inserviced on basic infection control on 11-15-11. Twelve CNAs and two nurses attended an inservice on 11-28-11 on infection control: room set-up/isolation equipment/drawers. Compliance rounds were only documented as completed twice (12-14-11 with 6 residents on isolation, 12-20-11 with 4 residents on isolation). Although additional information regarding completion of the plan and ongoing monitoring/audits were requested, none were provided. Additional disservice records were provided but not all departments/staff were in attendance. There was no evidence that the committee reviewed the implementation of the plan, monitored the outcome, or made needed revisions. On 5-2-12, review of the facility policy entitled Infection Control Committee - Duties and Responsibilities (Revised June, 2010) revealed that "The Infection Control Committee will oversee the use of proper prevention and control measures, and will help identify, investigate and control outbreaks of infectious diseases within the facility." The Committee failed to identify concerns and develop and implement a plan of action related to failure of staff to notify the physician with onset of signs and symptoms of [MEDICAL CONDITION] in high risk residents. The Committee failed to identify concerns and develop and implement a plan of action related to failure to follow established and/or effective procedures for tracking and trending infections. During an interview on 5-2-12 at 11:15 AM, the Medical Director stated he participated in QAA meeting on a quarterly basis, the last one being "one or two months ago". He stated the DON reviewed trends for the previous year related to numbers of infections. He stated he was aware of the increase in the number of residents with [MEDICAL CONDITION] "before the first of the year and in February-3 or 4 at a time." He was not aware that there had been nine gastrointestinal/[MEDICAL CONDITION] infections mapped for the month of February. The facility staff had not spoken with him regarding specific interventions other than "isolation and strict handwashing". He thought ongoing training worked but was unaware that the QAA plan for infection control had not been fully implemented. When asked, the Medical Director stated, "I guess I know outbreaks have to be reported. Have they done it?" Cross Refer: CFR 483.65 Infection Control F441 The facility failed to notify the physician of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. The facility failed to ensure contact precautions were maintained appropriately for Residents #1, #4, #5, #6, #8, #10. Infection surveillance data was inaccurate/missing for residents who had positive test results for [MEDICAL CONDITION] (Residents #1, #4, #6, #8, #10, and #12). The Infection Preventionist (IP) was unaware of job duties and responsibilities for the infection control program. The facility failed to ensure that surveillance data was reviewed frequently enough to identify, investigate, and address the causes of any trends. Facility staff failed to identify an outbreak of [MEDICAL CONDITION] and notify the local office of the Department of Health and Environmental Control. Procedures were not in place and/or followed to ensure that facility laundry was hygienically cleaned. Procedures were not in place and/or followed to ensure appropriate daily and terminal cleaning of isolation rooms, including those rooms of residents on contact precautions for [MEDICAL CONDITION]. Cross Refer: CFR 483.10(b)(11) Notification of Changes F157 related to facility failure to notify the attending physician in a timely manner of changes in residents' physical conditions which required intervention/changes in treatment. The physician was not notified of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. Cross Refer: CFR 483.75 Administration F490 related to facility administration failure to ensure that policies and procedures were in place/followed to prevent, recognize, and control the onset and spread of infection within the facility. Cross Refer: CFR 483.75(i) Medical Director F501 related to Medical Director failure to coordinate medical care in the facility to ensure that resident care was consistent with established infection control policies and procedures. The immediacy was removed prior to exit from the facility on 5-2-12 after (1) review of the ongoing training content and participation and staff interviews related to that training were conducted, (2) evidence was presented that the medical record audits (with findings) were completed and any notifications/interventions implemented, (3) basic training was provided to the Infection Preventionist related to job duties/responsibilities, (4) the laundry was checked to ensure that it was being hygienically cleaned (5) job desciptions, duties and responsibilities were reviewed with staff members responsible for infection control data collection and analyzation. CFR 483.75 Quality Assessment and Assurance (QAA) F520 was lowered to a scope and severity of "F".

On the days of the Recertification, Extended, and Complaint Surveys, based on record review, interviews, and review of the facility's policy entitled "Condition Change", the facility failed to notify the attending physician in a timely manner of changes in residents' physical conditions, which required intervention/changes in treatment. The physician was not notified of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION]. Three of these four developed symptoms after admission to the facility. This failure to notify the physician in a timely manner resulted in significant delays in treatment and potential for transmission of infection. (Resident # 1, 4, 8 and 12) The findings included: The facility admitted Resident #1 on 8/26/11 following hospitalization for Altered Mental Status. She was discharged with [DIAGNOSES REDACTED]. The hospital discharge summary noted that she had been treated with [MEDICATION NAME], which had been changed to [MEDICATION NAME] to continue at the nursing facility until 9-2-11. Review of Physician Telephone Orders with the Assistant Director of Nurses (ADON) on 5-1-12 at 10:20 AM revealed that on 8-27-11, the physician ordered intravenous fluids for dehydration. On 8-29-11, the resident was started on [MEDICATION NAME] IM (intramuscular) for 3 days for signs and symptoms of a UTI. Review of the Daily Skilled Nurse's Notes with the ADON revealed that on 9/8/11, the resident had a watery, foul smelling stool. The physician was notified and ordered a stool specimen to check for [MEDICAL CONDITION]. On 9/9/11, the facility was notified of a positive result and the physician ordered treatment with [MEDICATION NAME] for 10 days and "isolation precautions". [MEDICATION NAME] was completed on 9-19-11. Review of the computerized Activities of Daily Living (ADL) Records on 5-1-12 at 11 AM with Certified Nursing Assistant (CNA) #1 and the ADON revealed that the resident began having 1 to 2 loose stools daily (when bowel movements were documented) on 8-28-11, at times having an odor. Multiple entries had no consistency noted. There was no evidence that the physician was notified until 9-8-11 when the nurse in the Daily Skilled Nurse ' s Notes made the first notation. Following completion of the [MEDICATION NAME] on 9-19-11, review of the Daily Skilled Nurse's Notes and the computerized bowel movement (BM) records revealed that the resident had no further symptoms until 9-24-11 when she experienced four diarrhea stools per the CNA documentation and diarrhea "off + on" by the nurse. The Physician Extender saw the resident on that date, but the Progress Note indicated that the resident was seen for "altered mental status...preceded by weakness" and "dark urine". There was no mention of current diarrhea/loose stools and no immediate interventions. The document erroneously listed [MEDICATION NAME] as an "active" medication "starting 9-19-11". There was no evidence that the physician was notified of the recurrence of diarrhea until two days later when a 9-26-11 Physician's Telephone Order was written to "Recheck stool for [MEDICAL CONDITION]". The 9-26-11 Progress Note again listed [MEDICATION NAME] as an "active" medication "starting 9-19-11". On 9-28-11, the [MEDICAL CONDITION] toxin was reported as positive and the physician ordered treatment with [MEDICATION NAME] for ten days. During an interview on 5-1-12 beginning at 10:15 AM, the ADON reviewed the medical record and confirmed the above information. She stated that precautions were implemented when the physician gave the order. She further stated that the physician should have been notified and precautions implemented at the onset of symptoms. She was unable to explain why this had not been done. Resident #4 with [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary with the ADON on 5-1-12 at 6 PM revealed that the resident had been treated for [REDACTED]. She was discharged to the facility with a [MEDICATION NAME] treatment to the lower leg. Review of the Daily Skilled Nurse's Notes revealed that on 12/19/11, the resident experienced a large amount of diarrhea stool with mucous. The physician was notified on 12-19-11 and an order received for "Stool for [MEDICAL CONDITION] ASAP (to rule out). Dx (Diagnosis) possible [MEDICAL CONDITION]." A laboratory report dated 12/22/11 showed the resident tested positive for [MEDICAL CONDITION]. Five days later, on 12/27/11, the physician/extender saw the resident, ordered [MEDICATION NAME] starting on 12-28-11 to treat the [MEDICAL CONDITION], and ordered contact isolation. The physician gave an interim Telephone Order on 12-23-11 for "Preparation H...apply TID (three times daily) to rectal region", indicating that the resident was suffering from swollen, irritated hemorrhoids. On 12-25-11, the physician/extender wrote to decrease [MEDICATION NAME] from twice daily to be given an as needed basis. Review of the computerized ADL Records on 5-1-12 at 6:40 PM with Certified Nursing Assistant (CNA) #1 and the ADON revealed that the resident began having loose stools on 12-16-11. Multiple entries had no consistency noted. There was no evidence that the physician was notified until 12-19-11 when the nurse in the Daily Skilled Nurse ' s Notes made the first notation. During an interview on 5-1-12 beginning at 6 PM, the ADON reviewed the medical record and confirmed the above information. She stated that the physician should have been notified and precautions implemented at the onset of symptoms. She was unable to explain why this had not been done. Resident #8 with [DIAGNOSES REDACTED]. Review of the hospital Transfer Discharge Summary with the ADON on 5-1-12 at 5:35 PM revealed that the resident was discharged on intravenous [MEDICATION NAME] and Zocyn to be discontinued on 12-9-11 (for treatment of [REDACTED]. The facility admitted the resident on [MEDICATION NAME] (to be stopped on 11-2-11) and contact precautions for [MEDICAL CONDITION]. Review of the Daily Skilled Nurse's Notes with the ADON revealed that the resident continued to have loose stools/diarrhea after the [MEDICATION NAME] was stopped without notification of the physician until 11-12-11. A stool specimen was sent to the lab to be rechecked on 12-6-11. There was no evidence that the physician was notified of the negative results until at least 12-14-11 as evidenced by the run date on the report. There were no initials on the document to indicate that the physician/extender had reviewed the report. During an interview on 5-1-12 beginning at 5:35 PM, the ADON reviewed the medical record and confirmed the above information. She was unable to explain why the physician had not been notified of continuing symptoms of [MEDICAL CONDITION] so appropriate interventions could be implemented. Resident #12 with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurse's Notes with the ADON on 5-1-12 at 3:45 PM revealed that from 10-29-11 at 7 PM to 10-30 11 at 7 AM, the resident "continues to have small, freq(uent) amounts loose stool." 10-28-11 documented "Continent of all episodes", but was not specific. She had four loose stools in twelve hours on 10/30/11. On 10/31/11, the resident had diarrhea stools three times. A stool specimen was collected and sent to the laboratory. There was no evidence that the physician was notified until a physician's order was received for the [MEDICAL CONDITION] test on 11/1/11. [MEDICATION NAME] was not ordered for treatment until 11/7/11. This physician's order noted that the indication for treatment was "contact isolation precautions in place until resolved." Contact precautions were ordered again on 11/10/11. There was no evidence in the record to indicate which date the precautions were implemented though the nurses' notes showed that the resident was on contact precautions on 11/9/11. Review of the computerized ADL Records on 5-1-12 at 4:15 PM with Certified Nursing Assistant (CNA) #1 and the ADON revealed that the resident began having loose stools on 10-28-11. There was no evidence that the physician was notified until 11-1-11, 4 days later. During an interview on 5-1-12 beginning at 3:45 PM, the ADON reviewed the medical record and confirmed the above information. She stated that the physician should have been notified and precautions implemented at the onset of symptoms. She was unable to explain why this had not been done. Review of the facility policy entitled "Condition Change" on 5-2-12 revealed: "A facility must immediately...consult with a resident's physician...when there is: ...A significant change in the resident's physical...status (i.e., a deterioration in health...); A need to alter treatment significantly..." During an interview on 5-1-12 at 10:15 AM, the Medical Director (and attending physician) stated he would expect to be notified immediately of signs and symptoms of [MEDICAL CONDITION] and the on-call physician/extender should be notified of the same on the weekend. If [MEDICAL CONDITION] was suspected, he would expect the facility to implement transmission-based precautions immediately, not to wait on lab reports. Cross Refer: CFR 483.65 Infection Control F441 The facility failed to notify the physician of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. The facility failed to ensure contact precautions were maintained appropriately for Residents #1, #4, #5, #6, #8, #10. Infection surveillance data was inaccurate/missing for residents who had positive test results for [MEDICAL CONDITION] (Residents #1, #4, #6, #8, #10, and #12). The Infection Preventionist (IP) was unaware of job duties and responsibilities for the infection control program. The facility failed to ensure that surveillance data was reviewed frequently enough to identify, investigate, and address the causes of any trends. Facility staff failed to identify an outbreak of [MEDICAL CONDITION] and notify the local office of the Department of Health and Environmental Control. Procedures were not in place and/or followed to ensure that facility laundry was hygienically cleaned. Procedures were not in place and/or followed to ensure appropriate daily and terminal cleaning of isolation rooms, including those rooms of residents on contact precautions for [MEDICAL CONDITION]. Cross Refer: CFR 483.75 Administration F490 related to facility administration failure to ensure that policies and procedures were in place/followed to prevent, recognize, and control the onset and spread of infection within the facility. Cross Refer: CFR 483.75(i) Medical Director F501 related to Medical Director failure to coordinate medical care in the facility to ensure that resident care was consistent with established infection control policies and procedures. Cross Refer: CFR 483.75 Quality Assessment and Assurance F520 related to QAA Committee failure to conduct ongoing reviews of the processes involved in infection control surveillance and monitoring. Staff failed to follow a plan of action established in November 2011 related to ongoing monitoring of compliance with infection control procedures. The immediacy was removed prior to exit from the facility on 5-2-12 after (1) review of the ongoing training content and participation and staff interviews related to that training were conducted, (2) evidence was presented that the medical record audits (with findings) were completed and any notifications/interventions implemented, (3) basic training was provided to the Infection Preventionist related to job duties/responsibilities, (4) the laundry was checked to ensure that it was being hygienically cleaned (5) job desciptions, duties and responsibilities were reviewed with staff members responsible for infection control data collection and analyzation. CFR 483.10(b)(11) Notification of Changes F157 was lowered to a scope and severity of "E".