Every finding on record at Ellen Sagar Nursing Center

Based on observation, interview, and review of facility policy, the facility failed to ensure medications were properly stored and expired medications were removed from storage, for 4 of 4 medication carts.Findings include:Review of the facility policy titled Safe and Sanitary Handling, Storage, and Wastage and Controlled Substance Management with an effective date of 04/2026, revealed, Policy: To ensure medication are stored properly, handled, transported, and stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and safety, and shall only be accessible to authorized personnel.During an observation on 05/19/26 at 11:35 AM, of the Medication Cart/Back #1 with Licensed Practical Nurse (LPN)4, revealed the following: Acid Gone Antacid that expired in 04/26, Loperamide 2 mg capsules in a blister pack found in a box labeled Sodium Bicarbonate. Six bottles of Buproprion SR 100mg (dated 01/09/26, 02/02/26, 02/26/26, 03/22/26, 04/15/26, and 05/09/26) for Resident (R)15 found in various places in the cart. Omeprazole DR 20 mg tablets in a blister pack found in the left 3rd drawer without box. No expiration date was visible on most of the individual tablet packs. A blister pack card with Clonidine 0.1 mg tablets for R26 that expired 02/28/26. A bottle of Nitrofuran Mono-Macro 100 mg for R26 that expired 03/31/26. Two blister pack cards with Hydroxyzine 25 mg for R53 that expired 04/30/26.During an observation on 05/19/26 at approximately 2:30 PM, of the Medication Cart/Front #1 with LPN3, revealed the following: A bottle of Cipro-Dexameth 4 gtts in right ear for a past resident that was labeled, Until 04/09/26. Fluticasone nasal spray from stock for R55 that did not have a label on the bottle indicating the resident's name, date, and open date. Fluticasone nasal spray from stock for R122 that did not have a label on the bottle indicating the resident's name, dose, and open date. NeoSynephrine nasal spray for R71 that did not have a label on the bottle indicating the resident's name, dose, and open date. Trelegy Ellipta 100-62.5 mg for R78 that did not have a label indicating the open date. Ciclopirox gel 0.77% tube for R87 that was stored without the cap on. During an observation on 05/19/26 at 2:50 PM, of the Medication Cart/Front #2 with LPN1, revealed the following: Fluconazole 100 mg qd x 10 days for R13 that was dated 10/16/25. Ondansetron 4 mg that expired 04/30/26. Spironolactone 25 mg for R18 that expired 02/28/26. Cyclobenzaprine 5 mg for R95 that expired 04/30/26 An unopened vial of Insulin deglu[DATE] mg/ml for R4. Label on the vial stated the insulin needed to be refrigerated until opened. Insulin Lispro pen labeled with an open date of 03/08/26. Label on the pen stated to discard 28 days after opening. (2) Glucagon emergency kits for R3 that expired 04/2026. Simply Thick Easy Mix packets that expired 05/14/26. Stat Strip Glu Con Low test solution that expired 04/17/26. Stat Strip Glu Con High test solution that expired 04/17/26.During an observation on 05/19/26 at 3:45 PM of the Medication Cart/Back #2 with LPN2, revealed the following: Duloxetine 60 mg for R6 that expired 04/30/26. Merilog insulin 100 unit/ml vial for R49 that was opened on 04/12/26 and expired 05/10/26. Lantus insulin 100 units/ml for R97 that was opened 04/17/26 and expired 05/15/26. Nitroglycerin tablets for R17 that expired in 01/2026. An attempted interview on 05/19/26 at 12:03 PM, with the Pharmacy Consultant, by phone, was unsuccessful. A detailed voicemail message requesting a return call was left.During an interview on 05/19/26 at 3:10 PM, Registered Nurse (RN)1 revealed the Pharmacy Consultant comes in once a month to audit the medication carts. She stated the nurses are responsible to check the expiration dates on the medication cards and bottles.During an interview on 05/19/26 at approximately 4:00 PM, with the interim Director of Nursing (DON) and the Administrator, the DON revealed she had planned to audit the carts this week prior to us arriving. She stated she will be putting policies procedures in place to ensure the medication carts are audited regularly. She stated the Unit Managers are responsible for ensuring the carts are audited regularly and completely at the building she usually works in.

Based on review of facility policy, observation, interview, and record review, the facility failed to ensure privacy and dignity was maintained for Resident (R)21. Specifically, the facility left R21's Foley catheter bag uncovered while the resident was in public areas, for 1 of 1 resident reviewed. Findings include:Review of the facility policy titled Resident's Rights and Responsibilities with an effective date of 08/2025, documented, As a resident of this facility, YOU have or your legal guardian has, the right to: . H. Each resident must be treated with respect and dignity and assured privacy during treatment and when receiving personal care, and in a manner or environment that promotes maintenance or enhancement of quality of life.Review of R21's Face Sheet revealed he was admitted to the facility on [DATE]. His diagnoses included, but was not limited to, benign prostatic hyperplasia without lower urinary tract symptoms, hesitancy of micturition, dysuria, and encounter for prophylactic measures.Review of R21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/04/2026, revealed R21 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated R21 had moderate cognitive impairment. Further review of R21's MDS revealed resident is always continent.Review of R21's Care Plan revealed, Focus: Continence/Bowel & Bladder-Risk for alteration in urinary and bowel elimination. Has increased risk for constipation, skin breakdown and UTI's and episodes of incontinence. Goal: Will have no signs/symptoms of bladder infection, will maintain dignity related to elimination care through the next 90 days or next review date. Review of R21's Physician's Orders revealed, EBP (enhanced barrier percautions): Foley catheter (revision date 05/18/2026); Empty foley catheter every hour and record out in PCC (revision date 05/18/2026); Foley catheter care q shift (revision date 05/18/2026); 16 Fr Foley per Urology do not replace catheter (revision date 05/18/2026).Review of R21's Progress Notes revealed, Note Text: Resident has 16Fr Foley s/p Prostate Ablation urinary retention. Catheter care every shift. Empty Foley every 8 hours and record output. Do not replace catheter per urology call for any issues or concerns.During an observation on 05/17/2026 at approximately 11:15 AM, revealed R21 in his wheelchair coming down the hall on Unit One near the nursing station with staff present. R21's Foley catheter bag was observed uncovered.During an observation on 05/18/2026 at approximately 8:50 AM, revealed R21 sitting in a wheelchair on the outside porch area along with other residents and visitors. R21's Foley catheter bag was observed uncovered.During an observation on 05/18/2026 approximately 9:30 AM, revealed R21 sitting in the front lobby with other residents, visitors and staff. R21's Foley catheter bag was observed uncovered. During an interview on 05/18/2026 at 11:55 AM, the Director of Nursing (DON) acknowledged R21's Foley catheter bag was uncovered. The DON stated, she has told the nursing staff to go around and make sure all Foley catheter bags are covered for the dignity of the resident.During an interview on 05/19/2026 at 11:51 AM, the Administrator revealed the expectation is for all Foley catheter bags to be covered for the dignity of the resident. The Administrator stated this is a part of the facility's annual competency training. All Foley catheter bags are currently covered.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure the medication error rate was below 5%. Specifically, the medication error rate was 20%.Findings include:Review of the facility policy, Self-Administration of Medications with a revision date of 06/01/24, revealed, Procedure. 2. Facility, in conjunction with the interdisciplinary team, should assess and determine, with respect to each resident, whether self-administration is either safe or clinically appropriate, based on the resident's functionality and health condition, and 5. Facility should ensure that orders for self-administration list the specific medication(s) the resident can self-administer.Review of the facility policy, Administering of Medications with an effective date of 01/2026, revealed time critical medications, including insulin, should be administered within thirty minutes before or after the scheduled administration time. Insulin should be administered within 30 minutes of mealtimes.During an observation on 05/19/26 at 8:00 AM, Licensed Practical Nurse (LPN)3 placed Atorvastatin 20 mg 2 tablets in the cup of medications for Resident (R)71. Surveyor checked the label on the medication card as LPN3 was preparing the next medication and observed Atorvastatin was ordered to be given at bedtime and only one tablet is to be given. Surveyor brought the error to LPN3's attention. LPN3 removed the Atorvastatin tablets from the medication cup. During the same observation, R71 was to receive saline nasal spray 1 spray into the right nostril. LPN3 handed the saline nasal spray to R71 to self-administer the medication. R71 squeezed the saline nasal spray bottle with weak squeezes continuously. LPN3 stated to R71, It's only supposed to be 2 puffs. That is too many. No order was found for R71 to self-administer saline nasal spray at the time of this medication administration. During the same observation, R71 was to receive Breo Ellipta inhaler 1 puff inhaled. LPN3 handed the Breo Ellipta to R71 to self-administer the medication. R71 inhaled the medication without assistance from LPN3. LPN3 did not ask R71 to rinse his mouth out after inhaling medication. No order was found for R71 to self-administer Breo Ellipta inhaler at the time of this medication administration.During an interview on 05/19/26 at 8:05 AM, LPN3 confirmed she did not ask R71 to rinse his mouth out after using the [NAME] Ellipta inhaler. She stated R71 would not have done it even if she asked him to. She also revealed she gives R71 the saline nasal spray and Breo Ellipta inhaler to self-administer because he wants to do it himself and will get upset if the nurse tries to administer those medications. During an interview on 05/19/26 at 9:10 AM, the interim Director of Nursing (DON) revealed the self-administering of medication requires an assessment to determine if the resident is able to administer the medication safely. If the resident is able to, an order is obtained from the provider to allow the self-administration of medications, and this would be added to the resident's care plan. She stated she will immediately do an assessment for R71 and R61 to determine if they are candidates for self-administering their medications. Regarding LPN3 not asking resident to rinse his mouth out after using the Breo inhaler, the DON revealed, Was there an order for that? I cannot hold them accountable for something that does not have an order.During an observation on 05/19/26 at 8:33 AM, LPN2 handed Flonase nasal spray to R61 for her to self-administer the medication. R61 placed Flonase in each nostril and squeezed to administer 1 puff to each nostril. R61 appeared to inhale through her nose when administering puffs of medication. No order was found for R61 to self-administer Flonase nasal spray at the time of this medication administration. During an observation on 05/19/26 at 10:47 AM, LPN4 administered Insulin Aspart FlexPen 100 units/ml 2 units to R15 after checking his fingerstick blood sugar, which was 238. Review of the Medication Administration Record (MAR) shows the scheduled time for the insulin was 11:30 AM to be given before lunch. During an interview on 05/19/26 at approximately 11:35 AM, LPN4 confirmed the insulin was given before 11:00 AM. She confirmed that lunch had not been served to R15 yet. She stated she thought she had a one-hour window prior to the scheduled time to give the insulin. When Surveyor informed her of the facility's policy regarding insulin administration having only a 30-minute window and should be given within 30 minutes of a meal, she replied, Sometimes, we just have to give it when we see them. We have to catch them when we can.During an interview on 05/19/26 at approximately 4:00 PM, the DON and Administrator were informed of R15's insulin being given early. Both wrote the error down in their notes.

Based on review of the facility policy, observation, record review, and interview, the facility failed to ensure proper hand hygiene after touching soiled linen and removing PPE (personal protective equipment) for 1 of 1 laundry aides observed. The facility also failed to ensure an excessive amount of lint was removed from lint screens for 2 of 2 commercial clothes dryers in the main laundry room. Furthermore, the facility failed to use appropriate infection control practices when storing medical equipment being used by Resident(R)11 for 1 of 1 residents reviewed.Findings include:Review of the facility policy titled, Infection Prevention Policy, states, IP along with the Infection Prevention Committee shall establish goals annually: Goal: Limit Employee, Resident, and Visitor Unprotected Exposure to Pathogens: Goal: Limiting the transmission of infections associated with the use of medical equipment, devices and supplies; Goal: Improving Hand Hygiene facility wide across all disciplines:Review of the facility policy titled, Linen, states, Policy Statement, Clean and soiled linen supplies are handled in a manner that reduces risk for microbial contamination and disease exposure. Procedures: . 2. Soiled and Contaminated Linen 2.2. Hand hygiene must be done after handling soiled linen. 2.3 Appropriate personal protective equipment (PPE) is worn while handling soiled linens. Review of the facility policy titled, Lint Trap Cleaning, states, Procedure- Lint Trap Cleaning: This procedure must be followed a minimum of two times per shift (at the beginning and end of each shift) when an operator is on duty. Put on the required Personal Protective Equipment (PPE), including gloves and goggles. Review of Resident (R)11's Face Sheet revealed the facility admitted resident R11 on 11/25/2025, with diagnoses including but not limited to, Dementia, with agitation, Type 2 Diabetes Mellitus, Chronic Kidney Disease, Stage 3A, schizoaffective disorder, and depressive type generalized anxiety disorder.During an observation on 05/17/26 at 12:55 PM, revealed, R11 was utilizing a Primafit external female non-invasive urine collection device. The Primafit was connected to a suction cannister. The suction cannister was connected to a portable suction machine. The suction cannister and suction machine were located on the floor in the resident's room. There was no barrier on the floor.During an observation on 05/17/2026 at 1:35 PM, revealed, R11 was utilizing a Primafit external female non-invasive urine collection device. The Primafit was connected to a suction cannister. The suction cannister was connected to a portable suction machine. The suction cannister and suction machine were located on the floor in the resident's room. There was no barrier on the floor.During an observation and interview on 05/18/26 at an unspecified time, revealed, R11 was utilizing a Primafit external female non-invasive urine collection device. The Primafit was connected to a suction cannister. The suction cannister was connected to a portable suction machine. The suction cannister and suction machine were located on the floor in the resident's room. There was no barrier on the floor. The Wound Nurse verified the Primafit machine was on the floor and there was no barrier present. The Wound Nurse revealed that the Primafit should not be stored on the floor and there should be a barrier under the machine. During an interview on 05/19/26 at 1:30 PM, the Director of Nursing revealed, I am aware that the Primafit is on the floor and it should not be. I went to the kitchen yesterday and asked for a crate to put the Primafit on, but the kitchen did not have a crate. I am working on getting it off the floor.During an observation on 05/19/26 at approximately 8:20 AM, Laundry Aide observed gowning up, with a plastic gown, gloves and mask to sort soiled linen. After PPE was removed by laundry aide, she did not sanitize her hands. The Laundry Aide reapplied PPE to place soiled linen in the washer. After PPE was removed by laundry aide, she once again did not sanitize her hands. Further observation revealed there was heavy accumulation of lint in one of the dryers. During an interview on 05/19/26 at 8:25 AM, the Laundry Aide revealed, I should have washed my hands when I took off my PPE. I was nervous. the Laundry Aide further revealed, That lint is not mine, I have been off for three days. I clean the lint filter after every dryer use. During an interview on 05/19/26 at 8:57 AM, the Assistant Director of Housekeeping revealed, I expect the laundry aide to clean the lent trap after every dryer use. I also expect the laundry aide to wash their hands after removing their personal protective equipment. During an interview on 05/19/26 at 11:40 AM, the Administrator revealed, They should follow all policies and procedures related to infection control and laundry.

Based on observation and interview, the facility failed to ensure a clean, comfortable, and homelike environment by failing to maintain clean floors and walls in common areas. Findings included: On 03/04/25 at 10:50 AM, an initial tour of the facility was conducted. The walls and baseboards on both sides of the hallway leading to Unit Two were heavily scuffed and soiled. Additionally, there was both loose dirt and buildup observed in the corners. On 03/04/25 at 12:00 PM, an observation of the lunch meal was conducted in the facility's main dining area. The walls, baseboard, and floors near the kitchen entrance from the dining room were heavily soiled. On 03/07/25 at 10:09 AM, an interview was conducted with the Environmental Services (EVS) Supervisor. The EVS Supervisor initially stated, The walls and floors are over [AGE] years old so it is difficult to clean them. The EVS Supervisor was then observed cleaning a small area of one of the affected walls with a cleaning product and a cloth. That area of scuffing and soiling were easily removed. When asked whether the EVS team had a schedule for maintaining cleanliness of the floors and walls, the EVS Supervisor stated, No. An initial observation on 03/04/25 at 11:00 AM and repeated observations over the days of the survey, revealed a wood composite footboard on the resident's bed which had approximately a four inch piece broken off and with the jagged edge exposed. During an interview and observation on 03/07/25 at 9:45 AM, in Resident (R)61's room, the Maintenance Technician (MT)13 reported that the facility had replacements on hand, but no work order had been submitted. During an interview on 03/07/25 at 9:50 AM, the Administrator and Director of Nursing acknowledged that staff were to report any broken or damaged equipment and should have submitted a work order for repair.

Based on review of facility policy, observations, interviews, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. This was evidenced by the ongoing presence of insects affecting 1 of 2 units observed during the survey. Findings include: Review of the facility policy titled Vector and Vermin Control effective on 04/2024, documented in pertinent part Policy: To prevent vermin and vector in the facility, maintain Infection Prevention control practices and report all incidents to EVS [Environmental Services], operations manager and or Administrator/Designee. Review of the Minutes from the Resident Council group meetings dated 02/17/25 at 2:00 PM, revealed that residents raised concern about pest presence at the facility. Specifically, the Minutes documented the residents complained that Bugs are back! Review of the facility's pest control Service Inspection Reports dated 09/13/24, 09/24/24, 9/25/24, 10/16/24, 11/11/24, 11/13/24, 12/06/24, 01/05/25, 02/03/25 and 02/19/25, all documented the facility's pest control vendor visited the facility and treated for targeted pests including but not limited to spiders, cockroaches, ants, bed bugs, etc. The Open Conditions portion of the pest control vendor's service inspection report documented structural deficits such as gaps around pipes going into walls, cracks and crevices around multiple spots throughout the facility contributed to the pest control ineffectiveness at the facility and it was recommended to have the identified areas sealed. There was no evidence that the facility followed up on the pest control vendor's recommendation. During observations conducted across multiple hallways of the facility, as well as the facility's conference room, during the survey dated 03/04/25 through 03/07/25, revealed the presence of multiple black flying insects. During an interview on 03/04/25 2:50 PM, Resident (R)42 stated they experienced continuous presence of bugs in their room. The resident stated the bugs crawled into their room through a crack underneath the radiator and they had made the facility aware of the concern without any solution. The resident stated the presence of bugs in the room disrupted their sleep and made the facility environment feel un-homelike. During an interview on 03/06/25 at 12:05 PM, R48 stated that he has observed bugs, both dead and alive, in several areas of his room and in common areas. R48 further stated that he has killed a bunch of them with tissues. R48 added that he had reported the concern to facility staff members several times, including the Administrator, but that the issue didn't seem to have improved. During an interview on 03/07/25 at 9:46 AM, the Operations Manager verified the facility staff was made aware of the residents' concerns related to the bugs' reappearance at the facility. Specifically, she stated that her department was made aware of the report from the Resident Council group meeting dated 02/17/25, during which the residents raised concern that Bugs are back! She stated that immediately after her attention was brought to the situation, she invited the facility's contracted exterminator company to come out to the facility to provide pest control services. She stated she does not monitor for effectiveness. She added that the Facilities Manager (a title used interchangeably to describe the Maintenance Director) was responsible for following up and addressing the concerns and recommendations made during the exterminators' visits. She however, clarified that if there was a pest control concern after the exterminator's visit, she contacted them again for a revisit. During an interview on 03/07/25 at 10:36 AM, the Facilities Manager stated he was responsible for keeping the facility in good repair. He stated that he periodically went around the facility to check for cracks in the walls and sealed them as necessary to discourage insects and rodents from accessing the facility. He stated the last time he inspected the facility for cracks and/or gaps in the wall was sometime last year. He stated he does not keep a log or documentation of his inspections and findings. He stated he was not informed of the recommendations from the exterminator, and he does not have access to the exterminator's documentation so that he was able to follow-up on whatever recommendation was made during the exterminator's visits. He stated it was important for him to be informed of the recommendations from the exterminators as it drove an action to address any pest infestation concerns across the facility. He stated the lack of follow-up on the exterminator's recommendation made the pest control measures ineffective.

Based on observation, interview, record review, and a review of facility policy, the facility failed to protect the resident's right to receive services by failing to keep Resident (R)38's call devices within reach. This deficient practice affected 1 resident from a total of 40 residents sampled. Findings include: Review of R38's medical record revealed an initial admitted [DATE]. His/her primary medical diagnosis was Type 2 Diabetes. Secondary diagnoses included fracture of the left tibia and cerebral infarction. Review of R38's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/22/25, revealed a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating R38's cognition was impaired. R38 was dependent on facility staff for most activities of daily living (ADLs). During an initial tour of the facility on 03/04/25 at 10:45 AM, R38 was laying in his/her bed with his/her eyes closed. The room lights were off and the window blinds were closed. R38's call device was observed to be wedged behind a bedside table on the resident's left side and was not within reach of the resident in the event he/she needed to call for assistance. During a second tour of Unit Two on 03/04/25 at 2:33 PM, R38 was heard from the hallway yelling Help me! repeatedly. A housekeeper was cleaning the hallway floor approximately 10 feet away from the resident's room but was not responding to R38's calls for help. Upon entering the room, R38 was positioned diagonally in the bed with both of his/her lower extremities hanging off the bed and his/her head laying on the siderail. R38's call device again was observed to be wedged behind the bedside table on the resident's left side and was not within his/her reach. During an interview on 03/04/25 at approximately 2:33 PM, R38 stated, I need somebody to get me out of this bed. The nearby housekeeper was asked to summon assistance to help R38. During an interview on 03/04/25 at 2:47 PM, Licensed Practical Nurse (LPN)14, confirmed he/she was assigned to care for R38 at that time. When asked whether R38 was able to use the call device, LPN14 stated, I think [he/she] does sometimes. When asked how he/she oversees the direct care of his/her assigned residents, to include ensuring call devices were within the reach of residents, LPN14 explained that he/she checked placement when going in and out of rooms. When asked whether he/she was aware that R38's call device was wedged behind his/her bedside table, LPN14 stated, No.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure each resident who received respiratory care and services by the use of oxygen via tracheostomy collar and nasal cannula, had the care consistent with professional standards of practice. The facility also failed to have Physician's Orders for 2 of 7 residents reviewed who received oxygen services (Resident (R)1, R11 and R44). Findings include: Review of facility policy titled, Oxygen Services with an effective date of 1/2025 revealed in the section titled Infection Control the following instructions: Oxygen tubing is changed every [seven] 7 days. Water bottles used for humidification are changed every [seven] 7 days. Oxygen concentrator filters are cleaned every [seven] 7 days. Care should be taken to keep oxygen masks and cannula free from potential contaminants. 1. Review of the medical record for R1 revealed an admitted [DATE]. Diagnoses included but was not limited to: Cerebrovascular Disease, Acute and Chronic Respiratory Failure with Hypoxia, Cardiomegaly, Quadriplegia, Malignant Neoplasm of the Right Kidney, Malignant Neoplasm of the Rectum, Malignant Neoplasm of the Colon, Hypoxemia, Obsessive Compulsive Disorder, Aphasia, Traumatic Brain Injury, Major Depressive Disorder, Dysphagia, Tracheostomy Status and Gastrostomy Status. Review of R1's Physician's Orders revealed an order to wean with oxygen saturation above 90% dated 03/09/25. Additional orders included: 1. Every Sunday night shift, complete the following: change oxygen tubing and water humidification. Date water bottle and tubing. Clean filter on concentrator and wipe down concentrator dated 03/05/25; 2. Change uncuffed trach every 60 days and as needed. Notify (Staff Member Name) to change, dated 01/27/25; 3. NPO (nothing by mouth) dated 10/28/24; 4. Enhanced barrier precautions related to tracheostomy and G-tube dated 10/25/24; oxygen via tracheostomy at one (1) liter per minute to maintain oxygen saturation above 92%. Check oxygen saturation levels two (2) times a day dated 10/21/24. 5. Suction resident as needed for copious secretions and document in the progress notes dated 10/15/24; 6. Change disposable inner cannula every shift and as needed, continue to clean tracheostomy site perimeter with normal saline and place fresh gauze and tracheostomy collar/tracheostomy ties as needed. During an observation on 03/04/25 at 1:48 PM, revealed R1 was in bed with the head of the bed elevated approximately 45 degrees. R1 was observed to have a tracheostomy tube and was wearing a tracheostomy collar to provide oxygen to him/her. The oxygen flow meter read two (2) liters/minute on the concentrator meter. A bottle of water for humidification was attached to the oxygen concentrator and then to the tracheostomy collar in use by R1. The water humidification bottle had a date of 02/03/25 which indicated when it was last changed. The tubing on the tracheostomy collar did not have a date to indicate when it was last changed. During an observation on 03/05/25 at 9:15 AM, revealed the water humidification bottle was still dated 02/03/25 and the tracheostomy collar and oxygen tubing were still not dated. During an observation and interview on 03/05/25 at 11:45 AM, of tracheostomy care, Licensed Practical Nurse (LPN)1 confirmed the container of water for the humidifier had been dated 02/03/25. LPN1 stated he/she was not sure why it had that date, but that he/she had changed it prior to tracheostomy care when he/she made the observation when the 02/03/25 date had been written on the label of the water humidification bottle. Review of R44's medical record revealed R44 was admitted to the facility on [DATE], with diagnoses including but not limited to: Anxiety Disorder, Delusional Disorder, Pain in Throat, Other Diseases of Pharynx, Tachycardia, Major Depressive Disorder, Pain and Post Traumatic Stress Disorder. Review R44's Medication Administration Record (MAR) for March 2025, with an order dated 08/15/24, for two (2) liters of oxygen per minute via nasal cannula as needed. During an observation on 03/04/25 at 11:00 AM, revealed R44's oxygen concentrator was set to five liters per minute. Further observation revealed there was no humidifier bottle and the tubing was not dated as to when it was last changed. During an interview on 03/04/25 at approximetly 11:05 AM, LPN10 was asked to check the respiratory equipment and reported that the correct setting for the oxygen flow was two (2) liters per minute. LPN10 also verified that the oxygen concentrator did not have a humidifier bottle and the tubing was not dated as to when it was last changed. Review of R11's medical record revealed R11 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's Disease, Congestive Heart Failure, Chronic Pain Syndrome, Dementia and Hypertension. Review of R11's MAR for March 2025, included an order dated 02/24/25 for oxygen at two liters per minute via nasal cannula every day and night. Further review of the MAR revealed another order dated 03/02/25, which stated the respiratory equipment was to be changed every Sunday. During an observation on 03/04/25 at 11:00 AM, revealed the oxygen concentrator for R11 was set to three liters of oxygen per minute and the attached humidifier bottle was dated 02/03/25. 37927

Based on observations, interviews, and record review, the facility failed to provide routine drugs to Resident (R)308 as ordered by the physician. This deficient practice affected 1 of 3 residents reviewed for medication administration from a total of 40 residents sampled. Findings included: Review of R308's medical record revealed an initial admitted [DATE], with a primary medical diagnosis of Alzheimer's Disease. During an observation on 03/05/25 at 9:11 AM, of medication administration for R308 with Licensed Practical Nurse (LPN)10, revealed while preparing R308's medications, LPN10 realized that one of the resident's medications (Osteo Bi-Flex) was not available. LPN10 checked the medication cart and the medication room - neither contained the medication. LPN10 stated she would just have to give that later. Review of R308's Physician's Orders revealed an order dated 02/27/25, for Osteo Bi-Flex 100 mg (milligram) to be administered by mouth twice daily as a supplement. Review of R308's Medication Administration Record for February 2025 and March 2025, revealed the medication had not been administered since admission. During an interview on 03/06/25 at 2:05 PM, with the Administrator and the Director of Nursing (DON). The DON revealed, If the medication is ordered, we need to supply it. For OTCs [over the counter medications], we usually order it from our supplier but if we can't get it there, we'll ask the pharmacy to provide it. The DON was asked for evidence that facility staff had attempted to order the medication, but no evidence was provided.

Based on observations, interviews, and record review, facility staff failed to ensure appropriate hand hygiene and gloving practices during the administration of medications. This deficient practice affected 1 of 3 residents, (Resident (R)4), reviewed for medication administration from a total of 40 residents sampled. Findings included: During an observation and interview on 03/05/25 at 8:40 AM, of medication administration for R4 with Licensed Practical Nurse (LPN)10 revealed, before preparing R4's medications, LPN10 applied a pair of disposable gloves. After applying the gloves, LPN10 unlocked the medication cart and prepared several medications for R4, including a Pregabalin capsule (used to treat pain caused by fibromyalgia, or nerve pain in people with diabetes (diabetic neuropathy), herpes zoster (post-herpetic neuralgia), or spinal cord injury), which LPN10 dispensed from the blister pack directly into his/her hand before placing it into the medication cup. LPN10 then dispensed two Calcium 600 mg (milligram) tablets from a stock bottle into the medication cup. LPN10 then removed one 1 of the tablets from the medication cup with his/her fingers and placed it back into the stock bottle and stated, [R4] only gets one. Wearing the same disposable gloves, LPN10 then brought the resident's medications to him/her at bedside. LPN10 handed the oral medications to the resident first. After R4 swallowed the oral medications, LPN10 administered eye drops into both of R4's eyes using the same disposable gloves. LPN10 then prepared two inhalers for the resident to administer and handed both inhalers to the resident sequentially while wearing the same disposable gloves. During an interview on 03/05/25 at 8:50 AM, LPN10 acknowledged administering all of R4's medications using the same disposable gloves and recognized there were several opportunities for hand hygiene and glove changes to have been implemented. LPN10 also acknowledged the particular risk for infection from administering eye drops with gloves that had been in contact with numerous contaminated sources. During an interview on 03/06/25 at 2:05 PM, with the Administrator and the Director of Nursing (DON). The DON confirmed that his/her expectation would have been for LPN10 to wash his/her hands and apply new gloves before administering R4's eye drops. Additionally, the DON explained that medications should be dispensed from the blister packs directly into medication cups and that medications should not be removed from medication cups using fingers.

Based on observations, interviews, and facility policy review, the facility management failed to provide residents with a safe and clean homelike environment. Findings include: 1. Review of the facility's policy titled, Resident's Rights and Responsibilities, effective 9/2022, revealed, To define the resident's rights and responsibilities. The Skilled Nursing Facility recognizes that the basic rights of human beings for independence of expression, decision-making, and action and concern for personal dignity and human relationships are always a great importance .C- Each resident or the resident's legal guardian has the right to: 8. To a safe, clean, comfortable and homelike environment. [sic] On 8/1/23 at 10:00 a.m., 8/2/23 at 9:15 a.m. and 8/3/23 at 8:28 a.m., a clogged air conditioning unit in room [ROOM NUMBER], was observed to have water on the floor underneath the air conditioning unit. There was also water observed inside the air conditioning unit. The air conditioning unit cover was missing pieces of it in several different areas. On 8/1/23 at 10:13 a.m., during an interview with Resident (R)11, the resident stated there was always water coming out of that thing (referring to the air conditioning unit). Resident #11 was asked if someone from the facility staff had checked it, which R11 stated no. On 8/3/23 at 2:00 p.m., in the presence of the Surveyor, the Facilities Coordinator confirmed the air conditioning unit was clogged and that a maintenance order to address the issue had not been completed until the Surveyor notified Administration earlier on 8/3/23. 2. Review of the facility's policy titled, Shower Cleaning, effective 11/2016 and last reviewed 4/2023, revealed Guidelines: Shower rooms cleaning includes tile, flooring, faucets, shower head, and shower curtain if present. [sic] On 8/1/23 at 10:39 a.m., 8/2/23 at 9:00 a.m., and 8/3/23 at 8:15 a.m., the shower room on Unit 1 (located on the hallway with room [ROOM NUMBER]-#19), was observed with a blackish substance in the grout of the walls located in the shower, tiles were observed to be discolored and chipping away from wall, and a brownish corrosion appearing substance underneath a vent on the wall was observed and looked to be from leaking water. During the survey, several residents were interviewed about the shower room on Unit 1. R11, R48, R55, and R294 stated the shower room sometimes looked like it hadn't been cleaned. The residents all stated that it was an older building, however, sometimes they do not want to use the shower room because of the black stains on the walls. An interview with Environmental Services (EVS) staff #1 on 8/3/23 at 10:31 a.m., revealed the facility was in the process of remodeling. EVS staff #1 confirmed the tiles chipping off the walls and the condition of the floors in the shower room. EVS staff #1 stated the mildew in the shower rooms can be cleaned with the Clorox cleaner Avert. EVS staff #1 revealed the shower rooms were cleaned daily however, because the building was older, sometimes it was hard to keep the areas free of mildew. An interview with Certified Nursing Assistant (CNA)1 on 8/3/23 at 10:12 a.m. revealed the shower rooms were cleaned daily by the EVS staff. CNA1 stated he/she has not heard any residents voicing concerns about the cleanliness of the shower room. CNA1 stated the black substance was on the walls of the shower, however, it can be cleaned. An interview with the Facilities Coordinator on 8/3/23 at 2:00 p.m. revealed the black substance on the walls in the shower room could be mildew. The Facilities Coordinator stated the EVS staff were to clean the shower rooms daily An interview with EVS staff #2 on 8/4/23 at 9:25 a.m., revealed he/she usually worked on Unit 2. EVS staff #2 stated the shower rooms were cleaned based on the cleaning schedule that was provided by the EVS Manager. EVS staff #2 stated the walls were to be cleaned with Avert, which was an approved solution to kill mildew and germs. EVS staff #2 stated he/she was unaware of any concerns voiced by residents regarding Unit 1's shower room. An interview with the EVS Manager and the Director of Support Services on 8/4/23 at 9:36 a.m., revealed the black substance on the shower room walls was mildew. The EVS Manager revealed the shower room was cleaned daily. The Director of Support Services stated that the shower rooms could use a little more attention due to Unit 1 being built several years before Unit 2. The EVS Manager agreed with the Director of Support Services.

Based on observations, interviews, and review of the facility policy, the facility failed to ensure trash dumpsters were kept closed. On the first day of survey, two (2) of two (2) trash dumpsters with sliding doors were observed opened. Interviews and a review of the facility's policy revealed the dumpsters should be closed prevent insect and pest infestations. The findings include: Review of the facility's policy titled, Infection Prevention/Trash Containers, dated 4/2023, stated the purpose was, to provide sanitary conditions the trash dumpsters regarding infection prevention of vermin. [sic] The policy stated, the lid to the trash dumpsters will remain closed after use. In addition, the policy stated, the side doors will remain closed after use. On 8/1/23 at 9:00 a.m., observations of the outside of the facility revealed two (2) trash dumpsters with side doors were unattended and the side doors of the dumpsters were left open. A bag of garbage was observed hanging outside the dumpster from the top of one of the dumpsters. Additional observations of the dumpster area during the initial tour of the kitchen on 8/1/23 at 10:00 a.m. revealed the dumpsters remained opened until 10:30 a.m. On 8/1/23 at 10:30 a.m., an interview was conducted with the Dietary Manager (DM). The DM stated garbage from the kitchen area of the facility was placed in the dumpsters and acknowledged the side doors of the dumpsters should be closed and no garbage should be hanging from the dumpster. On 8/1/23 at 10:55 a.m., an interview was conducted with the facility's Administrator. The Administrator stated the facility recently received new dumpsters and the Administrator was not aware the dumpsters had side doors on them. In addition, the Administrator stated the expectations were that the lids and side doors of the dumpsters should remain closed when not in use. On 8/1/23 at 11:02 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the dumpsters should always be closed when not in use to prevent insect and vermin infestation at the facility.

Based on review of the facility policy, interviews, and observation, the facility failed to provide supervision to 1 of 5 residents (R)3 to prevent accidents and hazards. R3 eloped from the facility on 03/13/23 between approximately 7:20-7:30 PM. Because no staff were on the hallway to hear the door alarm sounding when the resident exited, it was not known she had eloped - placing her at risk of serious harm. No staff were searching for the resident when she was found by Dietary Assistant (DA)1, who was leaving at the end of the shift. On 03/16/23 at approximately 3 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 03/16/23 at 6:05 PM the Administrator and the Director of Nursing were notified that the elopement of R3 constituted Immediate Jeopardy (IJ) at F689, effective 03/13/23. The facility presented an acceptable plan of removal of the IJ on 03/17/23 at 12:20 PM. The survey team validated that the IJ was removed on 03/17/23 at 2 PM following the facility's implementation of the plan of removal. The facility remained out of compliance at F689 at a lower scope and severity of D (isolated with potential for more than minimal harm) following removal of the IJ. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility's policy titled, Elopement Risk Precautions, with a revision date of 09/22 revealed Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Furthermore, A resident who leaves a safe area may be at risk of heat or cold exposure .or being struck by a motor vehicle. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to, dementia with behavioral disturbance, schizoaffective disorder, and mild cognitive impairment of unknown etiology. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/02/23 revealed a Brief Interview of Mental Status (BIMS) score of 99, indicating she could not complete the interview due to her cognitive status. Review of DA1 ' s Narrative of Incident written on 03/13/23 at 07:29 PM revealed that she exited the building from the Unit 2 Dining Room around 7:29 PM. She noticed R3 on the sidewalk outside and took the resident back inside to alert the nursing staff. Interview with DA1 on 03/16/23 at approximately 11:40 AM confirmed her statement to the facility. At the time of the incident, she was leaving the building after her shift had ended. She did not hear the door alarm sounding prior to exiting the facility. She found R3 outside on the sidewalk adjacent to the staff parking lot, approximately 10 - 15 feet from the exit on hall 7 (R3 ' s assigned hall). She escorted the resident back into the building, using the main entrance on Unit 2. Review of DA2 ' s Narrative of Incident written on 03/13/23 revealed she was in the patient common area near unit 2 when DA1 entered with R3. When she saw the resident, she knocked on the window to the unit 2 nursing station to alert the nurses. Interview with DA2 on 03/16/23 at approximately 11:45 AM confirmed her statement to the facility. When DA1 entered with R3, she knocked on the window to the nurse ' s station to alert nursing staff. She did not hear the Hall 7 door alarm at any point. Review of Registered Nurse (RN)1 ' s Narrative of Incident for the facility investigation, written on 03/13/23 at 7:35 PM, revealed she last saw the resident at 7:15 PM in a recliner. At around 7:30 PM, RN1 witnessed dietary staff bringing the resident to the unit. She then heard the alarm sounding on Hall 7. Interview with RN1 on 03/16/23 at approximately 11:50 AM confirmed her statement. She did not hear when the alarm on hallway 7 was first set off because she was at the nurse's station. When the resident was brought in by dietary staff, her wander bracelet set off the alarm of the door she entered. Review of R3 progress notes revealed that RN1 documented exit seeking behaviors from the resident on 03/11/23 at approximately 4:45 PM. Review of R3 ' s Baseline Care Plan revealed R3 ' s exit-seeking behaviors were not care planned until 03/14/23. On 03/14/23, the facility care planned a Code Alert Bracelet to the left ankle of the resident. Review of R3 ' s Medication Record revealed that R3 ' s Code Alert Bracelet to Left Ankle was not documented as in use prior to 03/14/23. Interview with Administrator and Director of Nursing (DON) on 03/16/23 at approximately 11:55 AM confirmed there was no order for the Care Alert Bracelet prior to the elopement on 03/14/23. A clarification order was filled out after the incident. Interview revealed that R3 had a Care Alert Bracelet at the time of the incident, but they confirmed no documentation in the resident ' s chart can verify this. Review of Certified Nursing Aide (CNA)1 ' s Narrative of Incident written on 03/13/23 revealed she was on Hall 8 at the time of the incident. Interview with CNA1 on 3/16/23 at approximately 3:30 PM confirmed her statement to the facility. She was providing care in a resident ' s room on Hall 8 and did not hear the alarm at the time of the incident. She also confirmed she was the CNA for R3. Review of Licensed Practical Nurse (LPN)1 ' s Narrative of Incident written on 03/13/23 at 7:35 PM, revealed she was in the nurse ' s station with RN1 when dietary staff brought in R3 at 7:30 PM on 03/13/23. They were trying to configure a bed/chair alarm for another resident. Interview with LPN1 on 3/16/23 at approximately 4:22 PM confirmed her statement to the facility. She did not hear the alarm going when it first started going off, and she had not started the door alarm protocol when the DA1 escorted R3 back into the building. When staff hear the door alarm, they are meant to check the door sounding the alarm, ensure no resident is exiting or has exited the door, and verify that all residents on the unit are present and accounted for. Instead, both LPN1 and RN1 were still in the nurse ' s station at the time of the incident. Interview with RN1 on 3/16/23 at approximately 4:24 PM confirmed she did not hear the alarm immediately when the resident exited. She only noticed the alarm sounding when the resident was brought in by DA1. She was still in the nurse ' s station, and had not started the door alarm protocol when DA1 escorted R3 back into the building. Review of localconditions.com revealed the temperature in Union County was approximately 48 degrees Fahrenheit at the time of the incident. The weather was clear and without precipitation at the time. The facility's provided removal plan included: R3 was provided 1:1 supervision by staff. The alarm system was retested . RN Supervisor educated all staff on how to respond to elopement and alarms. This was completed by 03/14/23. A care planning session with R3's family was held in person on 3/15/23. A new bull horn system was ordered by facilities and placed in the nurse's station and is hard wired into the door alarm system. The device is estimated to arrive on 03/24/23. Once installed, checks for functioning and compliance will be added to the shift nursing checks of other alarms. A stop sign was placed over the threshold of the exit door on hallway 7 on 03/17/23. A work order was placed to move the wander guard alarm system closer to the end of hallway 7. It was placed on 03/16/23. QAPI will meet on 03/23/23 to discuss R3's elopement. A 100% audit will be completed in the next 7 days of all residents for an elopement risk. All identified residents will have elopement precautions secured and in place. An elopement drill was scheduled for 03/21/23 at 1 PM. Ongoing education will be continued in annual competencies and with new employee orientation.

Based on review of the facility policy, record review, and interviews, the facility failed to ensure 1 of 3 residents, (R)4, reviewed, was free of significant medication errors. R4 was administered medications that were not prescribed to her, by her physician. R4 was administered 6 doses of medications on 03/03/22 at 8 AM, that was prescribed for another resident. Findings include: Review of the policy titled Administering of Medication, under the section, Medication Administration Process, revealed, the Nine Rights of Medication Administration Practice should be confirmed prior to administration.: R4 was admitted to facility on 03/25/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set indicated R4 has a Brief Interview of Mental Status (BIMS) score of 6, indicating R4 was cognitively impaired. Review of R4's Physician Orders indicated medications ordered to be given: [MEDICATION(S)] 5 mg 1 tablet twice daily, [MEDICATION(S)] 1 mg once daily, ABH Gel 0.25/25/25/0.25 mg to wrist daily at 3:00 PM, [MEDICATION(S)] 20 mg daily, [MEDICATION(S)] 10 mg daily at night, Acetaminophen 325 mg 3 times daily, Potassium ER 20 MEQ daily, [MEDICATION(S)] 10 mg; 1 tablet daily, Slow-Mag 71.5 mg; 1 tablet daily, [MEDICATION(S)] 75 MCQ; 1 tablet at night, [MEDICATION(S)] 3 mg; 2 tablets at night and [MEDICATION(S)] Sulfate 325 mg; 1 Tablet by mouth twice daily. The Physician Orders also indicated R4's allergies to include; [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], Penicillin, Sulfa and [MEDICATION(S)]. On 03/03/22 at 8:00 AM, the nurse administering medications gave R4 medications that were prescribed for another resident. Medications that were administered that were not prescribed to R4 were: [MEDICATION(S)] 5-325 tablet by mouth, [MEDICATION(S)] HCL 25 mg; 1 tablet once daily, [MEDICATION(S)] Gram Mix 17gms, [MEDICATION(S)] 25 mg; once daily, [MEDICATION(S)] 100 mg; 1 tablet daily and [MEDICATION(S)] 2 mg. R4 was also administered medications that were prescribed to her on 03/03/22 at 8:00 AM to include; [MEDICATION(S)] 5 mg, [MEDICATION(S)] 1 mg, ABH Gel 0.25/25/25/0.25 mg to wrist, [MEDICATION(S)] 20 mg, Acetaminophen 325 mg, Potassium ER 20 MEQ, [MEDICATION(S)] 10 mg, Slow- Mag 71.5 mg and [MEDICATION(S)] Sulfate 325 mg. An interview conducted with the Director of Nursing (DON) on 08/09/22 at 3:15 PM revealed R4 was mistakenly administered another resident's medication by a new nurse. The Nurse immediately reported the incident to DON. The DON then stated, Upon investigation, it was determined the nurse failed to check the arm band of R4. The DON also stated, There were no adverse reactions noted to R4 following the incident. R4 was monitored, assessed and the Physician and Responsible Party were notified. Staffing education immediately began on 03/03/22 and 03/04/22. Medication and resident identification audits were then conducted 03/06/22. During an interview with the Administrator on 08/09/22 at 4:10 PM, she stated, R4 did not have any adverse effects and appeared to be much better, although she had slept most of the day. When asked her expectations to prevent reoccurrence, she stated, Education has been completed and ongoing and staff will continue to follow facility policies to ensure errors like this do not reoccur.

Based on observation, record review, and staff interviews, and record review, the facility failed to ensure 1 of 5 sample residents (Resident (R)#6) reviewed for functional mobility for limited range of motion received the care and services to assist the resident and maintain, improve, or prevent an avoidable decline in range of motion (ROM). As a result, R6 sustained a decline in the ROM in his/her left-hand/fingers. The Findings include: Review of the facility Face Sheet revealed R6 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/05/2021, revealed R6 had a Brief Interview for Mental Status score of 12 out of 15, which indicated R6 was moderately cognitively impaired. R6 required extensive assistance with two-person assist with activities of daily living (ADLs). Further review of the MDS assessment revealed R6 did not have any functional limitation in ROM in the upper extremity (shoulder, elbow, wrist, hand) or lower extremity (hip, knee, ankle, foot) and did not display any behaviors, or refuse care during the review period. Review of R6's care plan, last revised on 05/19/2021, revealed the facility did not develop a comprehensive person-centered care plan related to R6's bilateral lower extremity contractures or his/her risk for functional decline in ROM (cross-refer F656). On 06/01/2021 at 4:03 PM, R6 was observed in bed. Three of his/her fingers and thumb on his/her left-hand were bent inward towards his/her palm, and his/her left index finger was in a fixed position pointing outward. R6 was unable to open his/her hand. R6 did not have a splint or brace in place or available in his/her room. On 06/02/2021 at 2:53 PM, R6 was observed sitting in a reclining Geri-chair in the hallway watching television. Three of R6's fingers and thumb on his/her left-hand were bent inward towards his/her palm and his/her left index finger was in a fixed position pointing outward. R6 did not have a splint or brace in place. On 06/02/2021 at 3:57 PM, R6 was observed in bed. Three of R6's fingers and thumb on his/her left-hand were bent inward towards his/her palm and his/her left index finger was in a fixed position pointing outward. R6 did not have a splint or brace in place or available in his/her room. Review of the monthly Nursing Summary, dated 05/12/2021 noted movement of upper extremities as moving both upper extremities well; per usual and movement of lower extremities as limited lower extremity; bilateral-existing condition. Review of the physician's Annual Exam,, dated 06/15/2021, revealed R6 did not have a decline, was angry and irritated, difficult to care for at times, received [MEDICATION(S)] (an anticonvulsant) for behaviors, yells and becomes aggressive to staff. Musculoskeletal: normal range of motion, no [CONDITION(S)]. Review of the Physician Orders, dated 06/03/2021, revealed R6 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's Progress Note/ Follow-Up visit, dated 04/01/2021, revealed no acute concerns, pain well controlled with the Tylenol (an analgesic) and [MEDICATION(S)] (an analgesic) as ordered. Further review revealed Musculoskeletal: full range of motion X (times) 4 (four). On 06/03/2021 at 4:03 PM, the Director of Nursing (DON) was asked if R6 was receiving restorative nursing or ROM. S/he stated R6 did not have any limited ROM in his/her left-hand. The DON stated s/he would have to examine R6 to confirm if s/he had any limited ROM. At 4:12 PM, the DON observed R6's left-hand and bilateral legs. Three of R6's fingers and thumb on his/her left-hand were bent inward towards his/her palm, and his/her left index finger was in a fixed position pointing outward. R6 was unable to open his/her left-hand. R6's bilateral lower extremities were in a straight fixed position. R6 was unable to bend his/her legs at the knees. Review of an Interdisciplinary Rehabilitation Screening Form, dated 06/03/2021 (during the survey), completed by the Certified Occupational Therapy Assistant (COTA), revealed R6 had a new/existing deficit -- change of function in his/her range of motion. Further review revealed the COTA documented R6 appears to have a Trigger Finger type of contracture to left-hand. Patient reports no loss of function as a result of this contracture. Patient has agreed to an evaluation to address this issue. Review of the Occupational Therapy Evaluation, dated 06/04/2021 (during the survey), revealed R6 hads a contracture of the left-hand/fingers. Further review revealed the Occupational Therapist (OT) documented R6's current decline in strength/endurance/ROM (range of motion) is affecting their level of dependence in ADL's and requires OT (occupational therapy) intervention to improve their level of ADL independence, positioning, and prevention of further contractures. On 06/01/2021 at 2:53 PM and 2:57 PM, two attempts to interview R6 were unsuccessful. The resident refused to answer interview questions. On 06/04/2021 at 12:48 PM, an interview with the (OT) revealed R6 has a left-hand contracture. The OT stated s/he was unsure what caused the contracture and stated that the contracture may be a Dupuytren's contracture (a hand deformity that usually develops over years) or caused by the use of medications. The OT stated s/he would provide resident with a soft hand splint and/or towel to prevent the contracture from worsening. On 06/04/2021 at 12:54 PM, an interview with the COTA revealed R6 was last screened for therapy on 12/10/2020. The COTA stated R6 did not have a change in his/her functional range of motion and that s/he did not become aware of R6's left-hand contracture until 06/03/2021 (during the survey) when the DON requested a therapy screening. On 06/04/2021 at 1:08 PM; Licensed Practical Nurse (LPN) 8 was asked when s/he noticed R6 could not open his/her left-hand. LPN 8 stated R6's left-hand had always been that way as long as s/he could remember. On 06/04/2021 at 1:14PM; an interview with Registered Nurse (RN) 9 revealed s/he did not become aware R6's left-hand contracture until 06/03/2021 (during the survey). S/he stated that if a resident had a contracture on admission; the contracture would be documented on the admission assessment. RN 9 stated that the Certified Nursing Aides (CNAs) perform weekly skin/body audits on residents and licensed nurses perform monthly nursing assessments. RN 9 was asked to provide any documentation noting the limited ROM in R6's left-hand. RN 9 stated there were no other assessments documenting R6 had limited ROM in his/her left-hand. On 06/04/2021 at 1:21 PM; an interview with the Physical Therapist revealed s/he has not seen R6 for PT and was not aware that R6 had a change of condition. S/he confirmed R6 had a left-hand contracture, but was unable to state when the contracture developed and was unaware of his/her diagnoses/pre-existing condition. On 6/4/21 at 2:35 PM, an interview with the DON revealed that due to COVID-19 the facility stopped their restorative nursing program. The DON stated that the residents previously on a restorative program were moved over to nursing and the licensed nurses conduct ROM and assessed residents for limited ROM during the monthly nursing assessments. On 6/4/21 at 3:01 PM, an interview with the Administrator and DON revealed that due to COVID-19; the facility did not have a restorative nursing program. The Administrator stated the facility did not have a policy on ROM or a policy on restorative nursing. Resident's previously receiving restorative nursing services were transferred to nursing services and nursing services was responsible for providing ROM to residents. The Administrator stated R6 did not have contractures and did not have any upward flexion, or internal rotation of his/her extremities. S/he stated R6 had stiffness related to his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, record review, and staff interviews, the facility failed to develop a comprehensive care plan addressing functional limitation in range of motion (ROM) for 1 of 5 sample residents (Resident (R) #6) reviewed for ROM. As a result, R6 sustained a decline in ROM in his/her left-hand/fingers. The Findings include: Review of the facility Face Sheet revealed R6 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/05/2021, R6 had a Brief Interview for Mental Status score of 12 out of 15, which indicated R6 was moderately cognitively impaired. R6 required extensive assistance with two-person assist with activities of daily living (ADLs). Further review of the MDS assessment revealed R6 did not have any functional limitation in range of motion in the upper extremity (shoulder, elbow, wrist, hand) or lower extremity (hip, knee, ankle, foot) and did not display any behaviors, or refuse care during the review period. Observations conducted on R6 on 06/01/2021 at 4:03 PM, 06/02/2021 at 2:53 PM, and 06/02/2021 at 3:57 PM, revealed three of R6's fingers and thumb on his/her left-hand were bent inward towards his/her palm, and his/her left index finger was in a fixed position pointing outward. R6 was unable to open his/her left-hand. R6 did not have a splint or brace in place or available in his/her room. On 06/03/2021 at 4:12 PM, in the presence of the Director of Nursing (DON), revealed R6 seated in a reclining Geri-chair. Three of R6's fingers and thumb on his/her left hand were bent inward towards his/her palm, and his/her left index finger was in a fixed position pointing outward. Both of R6's legs were positioned straight out in-front of him/her. R6 was unable to open his/her left-hand or bend both his/her legs at the knees. Review of R6's comprehensive care plans, last revised on 05/19/2021, did not reveal the facility developed a comprehensive person-centered care plan that included any problems, goals or current or previous approaches related to the R6's bilateral lower extremity contractures and risk for functional decline in ROM. Review of the Occupational Therapy Evaluation,dated 06/04/2021 (during the survey), revealed Resident #6 had a contracture of the left hand/fingers. Resident #6's current decline in strength/endurance/ROM (range of motion) is affecting their level of independence in ADL's and required OT (occupational therapy) intervention to improve their level of ADL independence, positioning, and prevention of further contractures. Attempts to interview R6 on 06/01/2021 at 2:53 PM and 2:57 PM were unsuccessful. The resident refused to respond to interview questions. During an interview with the Administrator and DON on 06/04/2021 at 3:01 PM, the Administrator stated R6 did not have contractures and did not have any upward flexion, or internal rotation of his/her extremities. S/he stated R6 had stiffness and the facility would not care plan stiffness because it was related to R6's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, record review, staff interview, the facility failed to identify a change in the skin condition for 1 of 4 residents (Resident (R48). Specifically, the facility failed to identify and investigate a bruise on R48's right hand. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R48 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated R48 was moderately cognitively impaired. R48's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R48 required physical assistance in bathing, supervision from one staff member for dressing, and supervision after set-up assistance with bed mobility, transfers, walking in the corridor, locomotion on the unit, and toileting. The care plan last revised 04/07/2021 revealed R48 was at risk for impaired skin integrity related to dry skin, episodes of [CONDITION(S)], history of [CONDITION(S)], took aspirin daily, and had [CONDITION(S)] (improper functioning of the vein valves in the leg, causing swelling and skin changes). The pertinent interventions directed staff to conduct weekly skin audits, observe the resident's skin condition with daily care, and report changes to the nurse. Observations conducted on 06/01/2021 at 12:44 PM and 06/03/2021 at 12:40 PM revealed R48 sitting in his/her room. R48 had a large, dark blue, circular bruise on the right hand, in between the right thumb and right index finger. R48 was not sure when or how the bruise occurred. Review of the Skin Check Roster: dated 05/01/2021 thru 06/04/ , completed by the certified nurse aides (CNAs), revealed staff documented no new concerns on 05/08/2021, 05/09/2021, 05/20/2021, 05/21/2021, 05/23/2021, 05/26/2021, 05/28/2021, 05/29/2021, and 06/03/2021. Review of R48's Progress Notes dated 05/14/2021 through 06/03/2021 did not reveal staff noted or identified R48 had a bruise to his/her right hand. During an interview with the director of nursing (DON) on 06/03/2021 at 4:30 PM, the DON was asked to provide a copy of the facility's investigation related to the bruise on R48's right hand. S/he stated that s/he needed to look for the incident report. During a second interview with the DON on 06/04/2021 at 10:23 AM, The DON indicated that the facility did not have an investigation or incident report related to the bruise on R48's right hand. S/he stated that s/he started an internal investigation today (06/04/2021). S/he said that s/he interviewed nurses and residents, not yielding any results regarding how and when the bruise appeared on R48's hand. However, R48 was not scheduled for a body audit until 06/06/2021. During an interview with CNA6 on 06/04/2021 at 10:31 AM, CNA6 stated that s/he did not notice the bruise on R48's right hand. S/he said that if staff notices a bruise on a resident, staff usually notified the nurse immediately. S/he stated that the staff does not wait until the weekly skin assessments are completed to address a bruise. Bruises are addressed immediately. During an interview with CNA7 on 06/04/2021 at 10:39 AM, CNA7 stated that on 06/03/2021, R48 wore arm protectors (Geri Sleeves) and that s/he did not notice the bruise on R48's right hand while providing care to the resident. CNA7 stated that if s/he noted a bruise on a resident s/he would document it in the electronic health record and notify the nurse. During an interview with the Licensed Practical Nurse (LPN) 8 on 06/04/2021 at 10:35 AM, LPN8 stated that s/he did not notice the bruise on R48's right hand. S/he said that when staff noticed a bruise on a resident, the staff would normally notify the physician and family. S/he reviewed the clinical record to see if R48 had any recent lab work that contributed to the bruise, but no recent lab work was completed. S/he said the resident probably bumped his/her hand against something and that staff is currently filling out the incident report. During a third interview with the DON on 06/04/2021 at 11:35 AM, the DON stated that associates would complete an incident report if they saw something (i.e., bruise, injury, etc.) and usually place the incident report in his/her box for review the next day. S/he stated that the LPNs complete body audits on Sundays, and that staff did not identify a bruise on R48's right hand on the previous Sunday. S/he stated R48 could have obtained the injury at any time because s/he continues to try to provide care to his/her roommate.

Based on interview, record review, facility policy and procedure, the facility failed to follow their grievance policy and procedure, complete a grievance, and thoroughly search the facility for missing personal items for 1 of 2 residents (Resident (R) 48) reviewed for missing personal property. As a result, the facility did not locate the resident's personal property until 06/03/2021. Review of the facility's policy and procedure titled Resident/Family Complaint and Grievance Policy, dated 02/2021, indicated, Each resident or authorized resident voicing a complaint/grievance shall receive a timely response from the facility that addressed the concern. The Skilled Nursing Facility shall actively seek a resolution and shall keep the resident or resident's representative apprised of progress. If the resident or resident's representative is satisfied with the resolution, the complaint grievance shall be considered closed. Resolution or an update shall be communicated within a timely manner to the resident and or legal representative. When the grievance/complaint cannot be resolved in a timely manner the facility shall inform the resident/representative of the continuing investigation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R48 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. The resident's pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with R48 on 06/02/2021 at 8:55 AM, R48 stated that his/her high school yearbooks and pictures were missing. During a follow-up interview with R48 at 2:56 PM, the resident said staff temporarily moved him/her to another room, and when s/he returned, his/her high school yearbooks and pictures were missing. R48 stated that s/he reported the missing items to staff during a meeting and his/her sister. R48 did not remember if the staff followed up with him/her regarding the missing personal items. Review of the Progress Notes dated 04/01/2021 through 06/02/2021 did not reveal R48 reported or that staff followed up on any missing personal items. Review of the Resident Council Minutes dated 04/19/2021 revealed R48 reported, [AGE] year books [sic] ??? [sic] missing. During an interview with Registered Nurse (RN) 1 on 06/02/2021 at 3:20 PM, RN1 denied any knowledge R48 was missing any personal items. During an interview with the Social Worker (SW) 2 on 06/03/2021 at 9:20 AM, the SW2 stated s/he did not have any grievances on file for R48. During an interview with Housekeeper (HSK) 3 on 06/03/2021 at 9:25 AM, HSK3 stated that the family usually handled R48's laundry and that R48 did not report any missing items recently. During an interview with the Housekeeping Manager (HM) 4 on 06/03/2021 at 9:31 AM, the HM4 stated that s/he had not received any report that R48 was missing any personal items. During an interview with Activity Staff (AS) 5 on 06/03/2021 at 9:32 AM, the AS5 said that R48 reported missing personal items during a Resident Council Meeting about a month ago. The AD said the missing items R48 reported should be documented in the Resident Council meeting minutes. During a second interview with the SW2 on 06/03/2021 at 10:09 AM, SW2 acknowledged that R48 reported s/he was missing some books during the Resident Council Meeting. SW2 stated that s/he looked for R48's books but did not complete a grievance. S/he stated that staff does not file a grievance for every resident concern voiced in the Resident Council Meeting. A request was made for a copy of the investigation and follow-up. SW2 stated that s/he was unable to provide any documentation at that time. On 06/03/2021, at 11:30 AM, SW2 returned with a notebook containing handwritten notes related to multiple residents and multiple tasks. SW2 said s/he noted that s/he was unable to find the resident's yearbooks, talked with the resident and that the resident was OK. A review of the information in the notebook revealed that on 04/19/2021, the SW noted, [resident name] missing annuals? A second entry (at the bottom of the page), dated 04/26/2021 (no time noted), indicated, [resident name] – unable to find yearbooks talked with [resident name] – OK. During a third interview with SW2 on 06/04/2021 at 10:30 AM, SW2 stated that on 06/03/2021 a Certified Nurse Aid (CNA) overheard the conversation regarding the resident's missing personal items. The CNA told the SW that s/he saw a drawer in an area not previously searched by the staff. The staff located the resident's missing yearbooks and pictures and returned them to R48. During an interview with R48 on 06/04/2021 at 10:45 AM, R48 was sitting in his/her room, going through his/her pictures and yearbooks. R48 stated the facility found and returned his/her lost items on 06/03/2021 and that s/he was happy to have the items back. During an interview with the Administrator on 06/04/2021 at 11:56 AM, the Administrator stated that staff did not write up missing items as a grievance. Instead, the SW tracks the missing items, tries to contact the family, and replaces the missing items. The Administrator stated the staff would not be expected to follow up on a missing item they could not replace.

Based on record review, facility policy review, and interviews, the facility failed to ensure two physicians evaluated and signed off on the Decisional Capacity for 1 of 2 residents. (Resident (R) 2) reviewed for advanced directives before changing the resident's code status as required by state law. This failure placed the residents at risk of receiving, failure to receive, or a delay in receiving Cardiopulmonary Resuscitation (CPR). Findings include: Review of the facility policy and procedure titled Advanced Directives, dated ,d+[DATE], indicated, If an adult resident is incapable of making his or her health treatment decisions, the resident's Advance Directive is presumed to be valid. In all cases in which an Advance Directive is to be disregarded, persuasive and credible evidence must exist that the resident lacks decision making [sic] capacity at the time the Directive was made. Review of the facility's Face Sheet, dated [DATE], revealed R2 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed R2 was a Do Not Resuscitate (DNR). Review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed R2 was rarely or never understood. Review of the Progress Note Addressing Decision Capacity, dated [DATE], signed by one physician, indicated R2 DOES NOT meet ALL the criteria for decisional capacity, therefore is not able to make healthcare decisions for self. Furthermore, it is my opinion that due to the patient's medical condition(s), this lack of capacity is not likely to change in the immediate future. R2 was not oriented to time and place, did not have the ability to understand and use information logically to reach a decision and did not have the ability to be realistic in decision making (i.e., to understand the consequences of a decision). Further review revealed, This process requires a note with signatures of TWO Physicians! A progress note should be written regarding both the patient's medical condition and mental capacity. Review of the Physician's Order Form dated [DATE], signed by the physician on [DATE], revealed the physician provided a telephone/verbal order that indicated R2 was a DNR. During an interview with the Director of Nursing (DON) on [DATE] at 3:05 PM and [DATE] at 12:00 PM, the DON acknowledged R2 did not meet the criteria for decisional capacity to make healthcare decisions and that the Progress Note Addressing Decision Capacity required a second physician's signature. The DON acknowledged the facility did not obtain a second physician's signature for decisional capacity for R2 was not received until [DATE] (during the survey). During an interview with Social Services Director (SSD) on [DATE] at 3:20 PM, the SSD acknowledged that the facility did not obtain a second physician's signature for decisional capacity until [DATE] (during the survey). During an interview with Social Worker 2 on [DATE] at 12:10 PM, SW2 acknowledged the facility did not obtain a second physician's signature for decisional capacity for R2 until [DATE].

Based on observation, interview and facility policy review, the facility failed to follow standard and transmission-based precautions in Coronavirus (COVID)-19 positive resident rooms and failed to prevent development and transmission of communicable diseases and infections on three (3) of three (3) COVID positive halls and two (2) of two (2) Quarantine halls. The findings included: The facility policy titled, Transmission Based Policy dated 8/2020, D.1. Staff shall wear gown and gloves to place the food tray on the over bed table, and when retrieving trays. C.1. Gloves and gowns-required for entry into the patient room by personnel that provide direct patient care .and personnel that are in the patient environment for an extended amount of time, regardless of their role. 3. Personal Protective Equipment should be removed and discarded at the point of use. Health care workers visiting a patient on contact precautions during work shift must adhere to these requirements. The facility document titled, COVID-19 Door Sign and Isolation Update, undated, directed, Special COVID-19 Precautions means: Patient room door will have an orange 'Special Precautions' sign. Door will have a stop sign with date and time limited when an N95 is required for entry into the room. If the patient requires airborne at all times (such as vents), then write 'At all times' in the blanks on the sign. THESE DOOR SIGNS ARE CRUCIAL FOR CORRECT PPE USAGE. Centers for Disease Control (CDC) Guidelines for Contact Precautions directed, Contact precautions are intended to prevent transmission of infections that are spread by direct (e.g., person-to-person) or indirect contact with the resident or environment, and require the use of appropriate PPE (Personal Protective Equipment), including a gown and gloves upon entering (i.e., before making contact with the resident or resident's environment) the room or cubicle. Prior to leaving the resident's room or cubicle, the PPE is removed, and hand hygiene is performed. The facility policy titled, Waste Disposal dated 7/2020 directed, 1. All areas of patient care shall have a designated container for storage of infectious wastes. 2. Infectious waste cans in storage areas shall remain covered while awaiting transport. During interview on 11/12/2020 at approximately 10:00 a.m., the Administrator stated the facility designated three (3) halls on the Red Unit for COVID positive residents, and two (2) halls on the Yellow Unit for Quarantined residents. The Administrator stated on both Red and Yellow Units staff were required to wear full PPE (gown, gloves, mask and face shield) when entering a resident room, and a mask and face shield were required in the hallways on the Red and Yellow Units. All staff in the building were always required to wear an N-95 respirator mask and a face shield in the building. The facility followed the Special Precautions guidelines which was a combination of contact, droplet and airborne precautions without the strict airborne precautions, such as a negative pressure room. Observation on 11/12/2020 at 11:40 a.m. on the Red Unit Hall 3 (COVID positive residents on this hall), revealed two (2) flip-top garbage cans with the lids stuck in an open vertical position with discarded PPE visible and not allowing the lids to close. During interview at that time, CNA #4 stated, I change gown and gloves between residents, and wear the mask and face shield all the time, even in the hallway, and add the gown and gloves in resident rooms. We wear the face shields and the masks all day and then leave them in bags before we go home. When we leave the resident rooms, we remove our PPE in the hall in these garbage cans. Signs on the doors of residents' rooms revealed, Stop, COVID-19 Hot Zone .wear PPE at all times. Two (2) additional signs described donning and doffing of PPE to include gown, gloves, mask and eye protection. Observation on 11/12/2020 at 11:45 a.m. on the Red Unit, Hall 1 and Hall 2 revealed 2 (two) open garbage cans on each hall filled with discarded PPE; a total of four (4) large open garbage containers on the U-shaped hall. Signs on the doors of residents' rooms revealed, Stop, COVID-19 Hot Zone .wear PPE at all times. Two (2) additional signs described donning and doffing of PPE to include gown, gloves, mask and eye protection. Observation on 11/12/2020 from 11:57-11:59 a.m. on the Red Unit, Hall 2 (two) revealed Certified Nursing Assistant (CNA) #1 entered and exited a COVID positive resident room with only a mask and face shield on. Interview on 11/12/2020 at 12:01 p.m. with CNA #1 who stated s/he was educated on PPE before s/he was off; s/he had returned to work the day before from being off 13 days because s/he was Covid positive. CNA #1 stated s/he was educated to wear a face mask, face shield, gown and gloves, and stated, I wasn't thinking; I should have worn a gown and gloves. I was educated (on PPE use) but things are more intense now, since I've been back. In an interview on 11/12/20 at 12:05 p.m., Licensed Practical Nurse (LPN) #2 stated s/he did monitor the staff to wear the appropriate PPE. LPN #2 stated CNA #1 should have worn a gown and gloves to enter the resident's room. Observation on 11/12/2020 from 12:12 - 12:25 p.m. of the meal tray pass on the Red Unit, Hall 1 and 2 revealed the following observations of CNA #1 delivering trays: -Donned PPE but did not wash hands first and did not fasten the gown ties. -Delivered tray to resident in room [ROOM NUMBER]B, leaned over the edge of the bed, touched the resident's bedside table, the gown touching the siderail, bedside table and the and the Styrofoam food container. -Did not clean hands, change gloves or change gown. -Delivered tray to resident in 3A, touching the bedside table with the gown. -Did not clean hands, change gloves or change gown. -Delivered tray to resident in 4A, touching the bedside table. CNA #1 set the tray on the bedside table, then leaned over the back of the resident's wheelchair, and hugged the resident, touching the resident's hair, shirt and the back of the wheelchair with hands, gown and face shield. -Did not clean hands or face shield and did not change gloves or change gown. -Delivered tray to resident in 6B, gown had fallen down to CNA #1's elbows, adjusted the bedside table, set the tray down, and adjusted the resident's blankets, touching all items with gown and hands. -Did not clean hands, change gloves or change gown. Tied the neck ties in the back of the gown. -Delivered tray to resident in 7A, set the tray on the bedside table, used the bed control to sit the resident up higher, picked up the fall mat from the floor and folded it and set it aside, opened the food container and cut the meat. Attempted to feed the resident, touching the straw, and moving it among three (3) containers of fluids. Sat on the resident's bed, gown not covering uniform to feed the resident. -12:25 p.m. Removed the gown and gloves and placed them in the open hallway garbage can. Observation on 11/13/2020 from 8:40 - 8:53 a.m. revealed open garbage containers filled with discarded PPE on the Red Unit, Halls 1 and 2; total of four (4) open garbage containers, and on the Red Unit, Hall 3 two flip-tops garbage cans in the hallway with the lids stuck in the open vertical position. Observation on the Yellow Unit (Quarantine Unit) revealed two (2) flip-top garbage cans in the open position with discarded PPE visible. Further observation on 11/13/2020 at 8:53 a.m. revealed Housekeeping (HK) staff #3 coming out of a resident's room with only a mask and face shield. During interview at that time, HK #3 stated s/he had been educated on PPE. S/he stated, I was supposed to have on a gown and gloves to go into the room, I was wrong. We are supposed to take off the PPE before leaving the room and throw away in the room. Any time I walk into a Red or Yellow room even if I don't touch anything, I should wear a mask, shield, gown and gloves. In an interview on 11/13/2020 at 10:35 a.m., the Director of Nursing (DON) stated during meal tray pass CNA #1 should have changed gowns in between resident rooms, changed gloves and cleaned hands. The DON further stated HK #3 should have gowned and gloved and cleaned hands after leaving the resident's room. The DON acknowledged garbage cans should have covers to keep germs from floating around. The DON stated, I never thought about the open trash containers. Usually for (resident with) TBP (Transmission-Based Precautions) [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) or VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]) we would have the trash containers in the resident's room, but in this case, there didn't seem to be enough room. So, the staff goes out into the halls to toss their PPE; it seemed like a good solution. The DON acknowledged that soiled laundry should be covered when in the hallway, and contaminated PPE should also be contained in the hallway. The DON stated the Yellow Unit was for quarantine for 14 days, and staff should wear the same PPE as on the Red Unit. The DON stated CNA #1 had the following education related to PPE: 3/24/2020 PPE Training, 3/3/2020- and 4/1/2020 Mask Training and 6/24/2020 Infection Control. The DON stated CNA #1 was re-educated for wearing PPE when s/he returned to work, but acknowledged it was not documented in CNA #1's education record and had no recent training. The DON acknowledged HK #3 did not have any PPE education documented in his/her education record. The facility had 24 Covid positive residents living in the building.

Based on review of facility files and interview, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. Resident #1 was noted with a fracture of unknown origin. Resident #1 was transferred as a stand and pivot, the CNA (certified nurse aide) did not use the sit to stand lift the resident required. The resident's Nurse Aide Information sheet did not contain accurate information related to the resident requiring a lift for transfers. One of three residents reviewed for accidents. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 10/19/17. The CNA observed the resident's right lower leg to be swollen and warm to the touch. Resident #1 had a history of [REDACTED]. The physician was notified and a venous Doppler was ordered. The Doppler results were negative and the physician was notified. An x-ray was ordered and revealed a tiny cortical fracture in proximal tibia. Resident #1 was a stand assist transfer with stand up lift. Review of Resident #1's (MONTH) (YEAR) physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Radiology Report dated 10/19/17 revealed the resident had a tiny proximal tibial metaphyseal cortical fracture. Review of Resident #1's care plan revealed resident needs assist with ADL's (activities of daily living) due to decreased cognition and decreased mobility was identified as a problem area. Interventions and approaches were listed on the care plan and included transfers with mechanical lift and sling lift pad in wheelchair for positioning. There was no indication what type of lift the resident required. A copy of the Nurse Aide's Information Sheet for Resident #1 was included in the facility's investigation file. Review of the form revealed the resident's status was noted as lift to chair with two assist. Review of Resident #1's Nurse Aide's Information Sheet revealed nothing that indicated the resident required a lift for transfers. There was no additional information related to transfers on the form. Review of Resident #1's Nurse's Progress Note dated 10/18/17 at 9:50 AM revealed the CNA and nurse reported the resident having a swollen, discolored area to the right lower leg (shin area). The physician was called and notified with a new order for ultrasound of the right lower leg related to [MEDICAL CONDITION] and discoloration. On 10/18/17 at 4:47 PM the Doppler results were received and were negative for blood clot. The Nurse's Progress Note dated 10/18/17 at 5:37 PM indicated Resident #1's daughters requested the resident receive an x-ray of the leg. The nurse informed them that the physician would be in the facility and would look at the resident then. The resident's daughters insisted on an x-ray. The nurse called the nurse practitioner and left a message. Review of the Nurse's Progress Note dated 10/18/17 at 6:00 PM revealed received a call back from the nurse practitioner and an x-ray of the right leg was ordered. There were no Nurse's Progress Notes between 9/29/17 and 10/18/17 at 9:50 AM. Review of Resident #1's Physician's Progress Note dated 10/19/17 revealed the resident was seen for right leg pain and swelling. The note indicated the other day the resident began to experience swelling and pain in the right lower extremity. They were unable to determine any specific traumatic event or problem which occurred. Unfortunately due to the resident's dementia, s/he could not provide any reliable history. Review of Resident #1's Quarterly Minimum (MDS) data set [DATE] revealed the resident's Brief Interview for Mental Status score was 7, which indicated the resident was non-interviewable. CNA #1's facility-obtained statement dated 10/19/17 revealed on Tuesday night (10/17/17) on the 7:00 PM- 7:00 AM shift s/he put Resident #1 to bed., pivot to stand. Resident #1 was able to stand and was transferred to bed with no complaints of pain. CNA #1 immediately called LPN (Licensed Practical Nurse) #1 to the room to assure the resident that s/he was on the bed and not on the floor. LPN #1 came in and assured Resident #1 that everything was okay and that s/he was on the bed. LPN #1's facility-obtained statement dated 10/19/17 indicated s/he was called to Resident #1's room by CNA #1 on 10/17/17. The CNA stated Resident #1 was really confused and kept asking the CNA to get him/her out of the floor but the resident was in the bed. LPN #1 walked over to the resident and told him/her that s/he was in the bed and not in the floor. Resident #1 stated No I am not, I am in the floor. The resident was redirected that s/he was in bed and not on the floor. In an interview with the surveyor on 1/23/18 at approximately 11:50 AM, CNA #3 stated s/he had worked at the facility almost 3 years. CNA #3 stated residents' transfer status is on a care plan sheet in the resident's closet and also the PCR (patient care record) book. It's the same information, they have it in two places. CNA #3 reviewed the Nurse Aide information sheet for Resident #1 and stated s/he would not use a lift for the resident because it was not indicated on the form. In an interview with the surveyor on 1/23/18 at approximately 11:55 AM, CNA #4 stated s/he had worked at the facility almost 6 months. CNA #4 stated residents' transfer status is on a care plan sheet in the resident's closet and also the PCR book. CNA #4 reviewed the Nurse Aide information sheet for Resident #1 and stated s/he would not use a lift for the resident because it was not indicated on the form. In an interview with the surveyor on 1/23/18 at approximately 12:05 PM, the DON (Director of Nursing) stated the CNAs look at the Nurse Aide Information sheet which is in the PCR book and the wall locker in the resident's rooms. The DON confirmed Resident #1's Nurse Aide Information sheet indicated two assist, but did not have information that the resident required a lift for transfers. The DON stated Resident #1 had been back and forth between the sit to stand lift and the total lift. Resident #1 required a sit to stand lift at the time the fracture was identified. The DON stated the nurses and the unit coordinator (RN (Registered Nurse) supervisor) are responsible for updating the care plan when there are changes in care. If the care plan says mechanical lift it is a generic term, it could be different types of lifts. They have sit to stand, hoyer, and a steady lifts that will go all the way to the floor to pick residents up. The DON stated it should be on the CNA Information Sheet what type of lift is required. In a telephone interview with the surveyor on 1/23/18 at approximately 12:45 PM, CNA #1 confirmed s/he transferred Resident #1 as a stand and pivot per his/her statement. CNA #1 stated Resident #1 was a one person assist, which means s/he was a stand and pivot transfer. CNA #1 stated that was the information on Resident #1's CNA information sheet. CNA #1 stated the paperwork in Resident #1's room and in the PCR book both said one person assist and not sit to stand lift.

Based on review of facility files and interview, the facility failed to develop and implement a comprehensive person-centered care plan that included the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident #1's care plan and Nurse Aide Information Sheet revealed the resident's transfer status was not identified. One of three residents reviewed for care plans. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 10/19/17. The CNA (Certified Nurse Aide) observed the resident's right lower leg to be swollen and warm to the touch. Resident #1 had a history of [REDACTED]. The physician was notified and a venous Doppler was ordered. The Doppler results were negative and the physician was notified. An x-ray was ordered and revealed a tiny cortical fracture in proximal tibia. Resident #1 was a stand assist transfer with stand up lift. Review of Resident #1's (MONTH) (YEAR) physician's orders [REDACTED]. Review of Resident #1's care plan revealed resident needs assist with ADL's due to decreased cognition and decreased mobility was identified as a problem area. Interventions and approaches were listed on the care plan and included transfers with mechanical lift and sling lift pad in wheelchair for positioning. There was no indication what type of lift the resident required. A copy of the Nurse Aide's Information Sheet for Resident #1 was included in the facility's investigation file. Review of the form revealed the resident's status was noted as lift to chair with two assist. Review of Resident #1's Nurse Aide's Information Sheet revealed nothing that indicated the resident required a lift for transfers. There was no additional information related to transfers on the form. Review of Resident #1's Nurse's Progress Note dated 10/18/17 at 9:50 AM revealed the CNA and nurse reported resident having swollen, discolored area to the right lower leg (shin area). Called the physician and reported with new order for ultrasound of the right lower leg related to [MEDICAL CONDITION] and discoloration. On 10/18/17 at 4:47 PM the Doppler results were received and were negative for blood clot. The Nurse's Progress Note dated 10/18/17 at 5:37 PM indicated Resident #1's daughters requested the resident receive an x-ray of the leg. The nurse informed them that the physician would be in the facility and would look at the resident then. The resident's daughters insisted on x-ray. The nurse called the nurse practitioner and left a message. The Nurse's Progress Note dated 10/18/17 at 6:00 PM indicated received a call back from the nurse practitioner and an x-ray of the right leg was ordered. CNA #1's facility-obtained statement dated 10/19/17 revealed on Tuesday night (10/17/17) on the 7:00 PM- 7:00 AM shift s/he put Resident #1 to bed., pivot to stand. Resident #1 was able to stand and was transferred to bed with no complaints of pain. CNA #1 immediately called LPN #1 to the room to assure the resident that s/he was on the bed and not on the floor. LPN (Licensed Practical Nurse) #1 came in and assured Resident #1 that everything was okay and that s/he was on the bed. LPN #1's facility-obtained statement dated 10/19/17 indicated s/he was called to Resident #1's room by CNA #1 on 10/17/17. The CNA stated Resident #1 was really confused and keeps asking the CNA to get him/her out of the floor but the resident was in the bed. LPN #1 walked over to the resident and told him/her that s/he was in the bed and not in the floor. Resident #1 stated No I am not I am in the floor. The resident was redirected that s/he was in bed and not the floor. In an interview with the surveyor on 1/23/18 at approximately 11:50 AM, CNA #3 stated s/he had worked at the facility almost 3 years. CNA #3 stated residents' transfer status is on a care plan sheet in the resident's closet and also the PCR (patient care record) book. It's the same information, they have it in two places. CNA #3 reviewed the Nurse Aide information sheet for Resident #1 and stated s/he would not use a lift for the resident because it was not indicated on the form. In an interview with the surveyor on 1/23/18 at approximately 11:55 AM, CNA #4 stated s/he had worked at the facility almost 6 months. CNA #4 stated residents' transfer status is on a care plan sheet in the resident's closet and also the PCR book. CNA #4 reviewed the Nurse Aide information sheet for Resident #1 and stated s/he would not use a lift for the resident because it was not indicated on the form. In an interview with the surveyor on 1/23/18 at approximately 12:05 PM, the DON (Director of Nursing) stated the CNAs look at the Nurse Aide Information sheet which is in the PCR book and the wall locker in the resident's rooms. The DON confirmed Resident #1's Nurse Aide Information sheet indicated two assist, but did not have information that the resident required a lift for transfers. The DON stated Resident #1 had been back and forth between the sit to stand lift and the total lift. Resident #1 required a sit to stand lift at the time the fracture was identified. The DON stated the nurses and the unit coordinator (RN (Registered Nurse) supervisor) are responsible for updating the care plan when there are changes in care. If the care plan says mechanical lift it is a generic term, it could be different types of lifts. They have sit to stand, hoyer, and a steady lifts that will go all the way to the floor to pick residents up. The DON stated it should be on the CNA Information Sheet what type of lift is required.

Based on review of facility files and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident #1 was noted to have complaints of pain on 8/1/17 and there was no documentation that the resident was monitored for pain. Resident #1 was found to have a right femur fracture on 8/3/17. One of three residents reviewed for fracture. The findings included: The facility reported an allegation of neglect to the State Agency for Resident #1 by Certified Nursing Assistant (CAN) #1 on 8/3/17. Review of the facility's Five-Day Follow-Up Report dated 8/8/17 indicated after investigation, Resident #1 was found to have right knee fracture from attempted transfer to wheelchair without lift or two-person assist. The Initial 24-hour Report dated 8/3/17 revealed Resident #1 stated that while being pivoted by CNA #1, the CNA assisted him/her to slide to the floor and at that time his/her right knee popped. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 6. The Quarterly MDS dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 5. The Quarterly MDS coded Resident #1 as totally dependent for transfers. Review of the care plan revealed resident needs moderate to max assistance with ADLs was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with assist of mechanical lift. Review of the Nurses' Progress Notes dated 8/2/17 indicated called to room by CNA to look at resident's leg. Right leg is swollen. States had pain in leg while receiving peri-care. RN supervisor notified who also looked at leg. Resident's socks removed and legs elevated. The previous note was dated 7/21/17 and noted weekly summary and body audit completed. The next note was noted as a late entry for 8/1/17 and indicated resident complained in wheelchair that right knee popped while being transferred to bed. Some slight [MEDICAL CONDITION] noted, daughter present. Daughter stated possible the footrest (missing) may have caused pain and [MEDICAL CONDITION]. Replaced footrest. Reported to nurse to get something for pain and monitor. The note was completed by RN #1. The Nurses' Progress Note dated 8/3/17 at 3:00 AM indicated the resident had complaints of pain and swelling to the right knee and warm to touch. Ice pack applied and elevated. As needed Tylenol given related to pain. On 8/3/17 at 5:00 AM the Nurses' Note indicated Tylenol was effective. Resident states My knee still hurts but feels a lot better since that ice. Ice appears to be effective. Swelling slightly reduced in size and less warm to touch. Resident now resting quietly. At 10:10 AM the note indicated the physician was asked to see the resident related to right knee pain. X-ray and CBC ordered stat. The Nurses' Progress Note dated 8/3/17 at 6:40 PM indicated the nurse practitioner was notified of the x-ray results and a new order was received to send the resident to the emergency room for evaluation and treatment related to complaints of pain. There was no additional documentation related to monitoring the resident for complaints of pain or assessing the resident's knee. Review of Resident #1's August Medication Administration Record [REDACTED]. The resident did not receive the as needed medication any other time during the month of August. Resident #1 received scheduled Tylenol 2 tablets (650 mg) three times daily for pain at 8:00 AM, 4:00 PM, and 8:00 PM. Review of the physician progress notes [REDACTED]. Apparently the other day during the transfer his/her knee was some way twisted. The exact mechanism of action was unknown, and from conversation with the facility staff history does not seem to be consistent with another. Resident #1 is a poor historian. The physician ordered an x-ray. The note was signed 8/3/17 at 4:24 PM. Review of the Mobilex Radiology Report dated 8/3/17 revealed the conclusion was noted as possible non-displaced fracture through the medial femoral condyle. Further evaluation with oblique views was recommended. Registered Nurse (RN) #1's facility-obtained statement dated 8/1/17 indicated at approximately 8:40 AM, resident's niece reported that the resident's right leg hurt and that s/he needed his/her foot rest on the wheel chair. RN #1 assessed the resident's right and left legs. Resident stated hurts more with movement, grimaced. Resident also reported it happened while being put to bed. Niece stated she felt like it was because resident had been up in wheelchair without foot rest. RN #1 and CNA #1 found the foot rest. CNA #1 replaced them on the wheelchair. RN #1 reported to the primary nurse and asked if resident could get something for pain and to continue to monitor his/her leg. RN #1's facility-obtained statement dated 8/4/17 indicated when s/he arrived to work on 8/3/17 s/he was made aware that Resident #1 was in the hospital with a fracture. It had been reported to another RN that CNA #1 had dropped the resident while transferring without a lift. When CNA #1 was called to the office to investigate the incident, s/he stated s/he never lifted the resident without a lift. CNA #1 did observe the resident in the wheelchair without a foot rest with the resident's leg stuck behind the front wheel and had to lift the chair up and get the resident's leg free. RN #1 explained to CNA #1 that this was considered an incident and should have been reported to the primary nurse. RN #1's facility-obtained statement dated 8/7/17 indicated upon entering Resident #1's room since return from the hospital s/he asked the resident how s/he hurt his/her leg. Resident #1 replied That (boy/girl) holding me up made me slide into the floor. Asked how s/he had picked the resident up and if s/he had used the lift. Resident #1 replied no, s/he had him/her under his/her arms. Resident #1 stated (s/he) picked me up under my arms and put me in the chair. In an interview with the surveyor on 8/15/17 at approximately 2:20 PM, RN #1 stated s/he is the unit manager for Unit 1. RN #1 stated that the resident's niece said his/her leg was hurting out in the lobby. RN #1 went and assessed the resident's leg and it was painful. Resident #1 didn't have petals on his/her wheelchair and his/her niece felt that may be what was causing the resident's leg to hurt. Normally the resident had petals but staff said they couldn't find them that day. RN #1 walked down the hall and found them on another wheelchair. The CNA said they looked like the resident's and the CNA checked and they fit Resident #1's wheelchair. The petals were on an extra wheelchair that was on the hall. Resident #1's knee had slight [MEDICAL CONDITION]. RN #1 stated s/he had the resident's nurse give the resident his/her pain medication. RN #1 stated s/he was not assigned to the resident, s/he was on as unit manager. The niece thought the resident's leg might be bothering him/her because it was not supported by the petal. RN #1 told the resident's nurse to monitor the resident's leg and let him/her know if there were any additional complaints of pain. RN #1 stated s/he did not hear anything else about the resident's leg until s/he heard the resident went out to the hospital with a fracture. RN #1 works days Monday-Friday. RN #1 stated Resident #1 was a total lift prior to the incident. RN #3's facility-obtained statement dated 8/1/17 indicated on 8/1/17 at 8:45 AM, the resident's niece reported to RN supervisors, RN #3 and RN #1, the resident complained of pain to the right knee. Resident states It happened when I was put back to bed. Assessment findings of slight [MEDICAL CONDITION] noted to right knee and pain with movement. Niece states It might be from sitting up in wheelchair without a foot rest. Foot rest placed by CNA, RN to monitor. In an interview with the surveyor on 8/15/17 at approximately 2:35 PM, RN #3 stated s/he is the wound care nurse. RN #1 stated the resident's niece told them about the resident complaining of pain. RN #1 stated s/he does not remember anything about the incident. In an interview with the surveyor on 8/15/17 at approximately 2:45 PM, Licensed Practical Nurse (LPN) #1 stated the resident's family member stated the resident was complaining his/her leg hurt. LPN #1 stated s/he gave him some Tylenol. The resident doesn't usually complain about anything. Resident #1 said s/he was hurting. LPN #1 didn't look at the resident's leg. LPN #1 worked 7 AM-7 PM. CNA #1's facility-obtained statement dated 8/4/17 indicated on the afternoon of 8/1/17 at approximately 11:30 AM, Resident #1 was transferred from the bed to the chair using the lift. Resident #1's wheel chair only had one left pedal attached to it. When the resident was in the hallway his/her right leg twisted under the chair. Resident #1 called out and said that his/her leg was stuck. CNA #1 then began to undo the resident's leg. RN #1 walked up and said that Resident #1 needed two pedals on his/her wheelchair. They began to look throughout the facility for another pedal to add to the resident's wheelchair. After they found a right pedal that would fit, RN #1 and CNA #1 put the pedal on the right side of the wheelchair. The day in question, the resident did not complain of any pain or discomfort and his/her leg was not swollen. After Resident #1's wheelchair was adjusted his/her sister took over and pushed the resident to the lobby. In an interview with the surveyor on 8/16/17 at approximately 10:15 AM, RN #2 (Director of Education) stated the only registry verification for CNA #1 was the one checked on 7/10/17. CNA #1's date of hire was 7/5/17. RN #2 confirmed the registry verification was done after the employee's date of hire. In an interview with the surveyor on 8/16/17 at approximately 1:50 PM, the Director of Nursing (DON) stated s/he was not at the facility when the incident happened with Resident #1. The DON stated s/he usually goes back to interview staff who worked with the resident prior to the incident. The DON stated s/he would have looked back to try to find out when the pain started. The DON stated Resident #1 did not usually complain of pain. The DON stated the resident could tell you what happened. The DON stated s/he would expect the nurses to monitor a resident for a new complaint of pain. Review of the Disciplinary Action Form dated 8/4/17 revealed the facility placed CNA #1 on administrative leave pending results of investigation for resident care. Review of an email dated 8/14/17 from Spartanburg Regional to staffing agency that CNA #1 was employed by revealed due to the current issue involving (CNA #1), managers are terminating his/her contract effective immediately. There was no documentation in any emails provided that the facility notified the staffing agency about the incident that led to the termination of CNA #1's contract.

Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving abuse or neglect were reported immediately, but not later than 2 hours after the allegation was made. The facility also failed to have evidence that all alleged violations were thoroughly investigated. Resident #1 was noted to have complaints of pain on 8/1/17 and the allegation of neglect was not reported to the State Agency until 8/3/17. Review of the facility's investigation revealed statements from three staff members, the Registered Nurse (RN) Supervisor on the unit (RN #1), the wound care nurse (RN #3) and Certified Nursing Assistant (CNA) #1. It was noted on the Daily Assignment Sheet for 8/1/17 that CNA #1 was not assigned to Resident #1. There were no statements from the staff assigned to care for the resident on the days surrounding the incident. One of two residents reviewed for reportable incidents. The findings included: The facility reported an allegation of neglect to the State Agency for Resident #1 by CNA #1 on 8/3/17. Review of the facility's Five-Day Follow-Up Report dated 8/8/17 indicated after investigation, Resident #1 was found to have right knee fracture from attempted transfer to wheelchair without lift or two-person assist. The Initial 24-hour Report dated 8/3/17 revealed Resident #1 stated that while being pivoted by CNA #1, the CNA assisted him/her to slide to the floor and at that time his/her right knee popped. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 6. The Quarterly MDS dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 5. The Quarterly MDS coded Resident #1 as totally dependent for transfers. Review of the care plan revealed resident needs moderate to max assistance with ADLs was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with assist of mechanical lift. Review of the Nurses' Progress Notes dated 8/2/17 indicated called to room by CNA to look at resident's leg. Right leg is swollen. States had pain in leg while receiving peri-care. RN supervisor notified who also looked at leg. Resident's socks removed and legs elevated. The previous note was dated 7/21/17 and noted weekly summary and body audit completed. The next note was noted as a late entry for 8/1/17 and indicated resident complained in wheelchair that right knee popped while being transferred to bed. Some slight [MEDICAL CONDITION] noted, daughter present. Daughter stated possible the footrest (missing) may have caused pain and [MEDICAL CONDITION]. Replaced footrest. Reported to nurse to get something for pain and monitor. The note was completed by RN #1. The Nurses' Progress Note dated 8/3/17 at 3:00 AM indicated the resident had complaints of pain and swelling to the right knee and warm to touch. Ice pack applied and elevated. As needed Tylenol given related to pain. On 8/3/17 at 5:00 AM the Nurses' Note indicated Tylenol was effective. Resident states My knee still hurts but feels a lot better since that ice. Ice appears to be effective. Swelling slightly reduced in size and less warm to touch. Resident now resting quietly. At 10:10 AM the note indicated the physician was asked to see the resident related to right knee pain. X-ray and CBC ordered stat. The Nurses' Progress Note dated 8/3/17 at 6:40 PM indicated the nurse practitioner was notified of the x-ray results and a new order was received to send the resident to the emergency room for evaluation and treatment related to complaints of pain. There was no additional documentation related to monitoring the resident for complaints of pain or assessing the resident's knee. Review of Resident #1's August Medication Administration Record [REDACTED]. The resident did not receive the as needed medication any other time during the month of August. Resident #1 received scheduled Tylenol 2 tablets (650 mg) three times daily for pain at 8:00 AM, 4:00 PM, and 8:00 PM. Review of the physician progress notes [REDACTED]. Apparently the other day during the transfer his/her knee was some way twisted. The exact mechanism of action was unknown, and from conversation with the facility staff history does not seem to be consistent with another. Resident #1 is a poor historian. The physician ordered an x-ray. The note was signed 8/3/17 at 4:24 PM. Review of the Mobilex Radiology Report dated 8/3/17 revealed the conclusion was noted as possible non-displaced fracture through the medial femoral condyle. Further evaluation with oblique views was recommended. RN #1's facility-obtained statement dated 8/1/17 indicated at approximately 8:40 AM, resident's niece reported that the resident's right leg hurt and that s/he needed his/her foot rest on the wheel chair. RN #1 assessed the resident's right and left legs. Resident stated hurts more with movement, grimaced. Resident also reported it happened while being put to bed. Niece stated she felt like it was because the resident had been up in wheelchair without a foot rest. RN #1 and CNA #1 found the foot rest. CNA #1 replaced them on the wheelchair. RN #1 reported to the primary nurse and asked if resident could get something for pain and to continue to monitor his/her leg. RN #1's facility-obtained statement dated 8/4/17 indicated when s/he arrived to work on 8/3/17 s/he was made aware that Resident #1 was in the hospital with a fracture. It had been reported to another RN that CNA #1 had dropped the resident while transferring without a lift. When CNA #1 was called to the office to investigate the incident, s/he stated s/he never lifted the resident without a lift. CNA #1 did observe the resident in the wheelchair without a foot rest with the resident's leg stuck behind the front wheel and had to lift the chair up and get the resident's leg free. RN #1 explained to CNA #1 that this was considered an incident and should have been reported to the primary nurse. RN #1's facility-obtained statement dated 8/7/17 indicated upon entering Resident #1's room since return from the hospital s/he asked the resident how s/he hurt his/her leg. Resident #1 replied That (boy/girl) holding me up made me slide into the floor. Asked how s/he had picked the resident up and if s/he had used the lift. Resident #1 replied no, s/he had him/her under his/her arms. Resident #1 stated (s/he) picked me up under my arms and put me in the chair. In an interview with the surveyor on 8/15/17 at approximately 2:20 PM, RN #1 stated s/he is the unit manager for Unit 1. RN #1 stated that the resident's niece said his/her leg was hurting out in the lobby. RN #1 went and assessed the resident's leg and it was painful. Resident #1 didn't have petals on his/her wheelchair and his/her niece felt that may be what was causing the resident's leg to hurt. Normally the resident had petals but staff said they couldn't find them that day. RN #1 walked down the hall and found them on another wheelchair. The CNA said they looked like the resident's and the CNA checked and they fit Resident #1's wheelchair. The petals were on an extra wheelchair that was on the hall. Resident #1's knee had slight [MEDICAL CONDITION]. RN #1 stated s/he had the resident's nurse give the resident his/her pain medication. RN #1 stated s/he was not assigned to the resident, s/he was on as unit manager. The niece thought the resident's leg might be bothering him/her because it was not supported by the petal. RN #1 told the resident's nurse to monitor the resident's leg and let him/her know if there were any additional complaints of pain. RN #1 stated s/he did not hear anything else about the resident's leg until s/he heard the resident went out to the hospital with a fracture. RN #1 works days Monday-Friday. RN #1 stated Resident #1 was a total lift prior to the incident. RN #3's facility-obtained statement dated 8/1/17 indicated on 8/1/17 at 8:45 AM, the resident's niece reported to RN supervisors, RN #3 and RN #1, the resident complained of pain to the right knee. Resident states It happened when I was put back to bed. Assessment findings of slight [MEDICAL CONDITION] noted to right knee and pain with movement. Niece states It might be from sitting up in wheelchair without a foot rest. Foot rest placed by CNA, RN to monitor. In an interview with the surveyor on 8/15/17 at approximately 2:35 PM, RN #3 stated s/he is the wound care nurse. RN #1 stated the resident's niece told them about the resident complaining of pain. RN #1 stated s/he does not remember anything about the incident. In an interview with the surveyor on 8/15/17 at approximately 2:45 PM, Licensed Practical Nurse (LPN) #1 stated the resident's family member stated the resident was complaining his/her leg hurt. LPN #1 stated s/he gave him some Tylenol. The resident doesn't usually complain about anything. Resident #1 said s/he was hurting. LPN #1 didn't look at the resident's leg. LPN #1 worked 7 AM-7 PM. CNA #1's facility-obtained statement dated 8/4/17 indicated on the afternoon of 8/1/17 at approximately 11:30 AM, Resident #1 was transferred from the bed to the chair using the lift. Resident #1's wheel chair only had one left pedal attached to it. When the resident was in the hallway his/her right leg twisted under the chair. Resident #1 called out and said that his/her leg was stuck. CNA #1 then began to undo the resident's leg. RN #1 walked up and said that Resident #1 needed two pedals on his/her wheelchair. They began to look throughout the facility for another pedal to add to the resident's wheelchair. After they found a right pedal that would fit, RN #1 and CNA #1 put the pedal on the right side of the wheelchair. The day in question, the resident did not complain of any pain or discomfort and his/her leg was not swollen. After Resident #1's wheelchair was adjusted his/her sister took over and pushed the resident to the lobby. In an interview with the surveyor on 8/16/17 at approximately 10:15 AM, RN #2 (Director of Education) stated the only registry verification for CNA #1 was the one checked on 7/10/17. CNA #1's date of hire was 7/5/17. RN #2 confirmed the registry verification was done after the employee's date of hire. In an interview with the surveyor on 8/16/17 at approximately 1:50 PM, the Director of Nursing (DON) stated s/he was not at the facility when the incident happened with Resident #1. The DON stated s/he usually goes back to interview staff who worked with the resident prior to the incident. The DON stated s/he would have looked back to try to find out when the pain started. The DON stated Resident #1 did not usually complain of pain. The DON stated the resident could tell you what happened. The DON stated s/he would expect the nurses to monitor a resident for a new complaint of pain. Review of the Disciplinary Action Form dated 8/4/17 revealed the facility placed CNA #1 on administrative leave pending results of investigation for resident care. Review of an email dated 8/14/17 from Spartanburg Regional to staffing agency that CNA #1 was employed by revealed due to the current issue involving (CNA #1), managers are terminating his/her contract effective immediately. There was no documentation in any emails provided that the facility notified the staffing agency about the incident that led to the termination of CNA #1's contract.

Based on observations, limited record reviews, and interviews, the facility failed to ensure that residents remained free of accident hazards for 5 of 7 sampled residents reviewed for falls, and 1 of 3 sampled residents reviewed for elopement. Residents #2, #5, #7, #8 and #10 had a history of [REDACTED].#10 sustained a fall with fracture. The (2) ordered bed alarms were not noted to be sounding at the time of the fall and were either not functioning properly or not attached as ordered. Residents #2, #5, #7, and #8 were observed with bed alarms either not functioning properly or not plugged in or attached as ordered. Resident #1 had a history of [REDACTED]. The resident exited the facility on 3 occasions with either a delayed staff response to an alarm or failure of the alarm to sound. Facility staff failed to document door alarm checks as per policy. Resident #1's code alert bracelet was scheduled to expire on (,[DATE]) but was working on [DATE] per facility staff. The facility was unable to show documentation that they had been checking the code alert bracelets for expiration as per their policy. The findings included: The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], on [DATE] at 9:05 AM, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 3, indicating severe cognitive impairment. The MDS also revealed that the resident required extensive assistance for bed mobility and transfers. The facility reported a fall with injury for Resident #10 on [DATE]. In the Initial 24-Hour Report the facility documented that Resident #10 had a fall with a left hip fracture on [DATE] at 5:00 AM. The findings of the Five-Day Follow-Up Report submitted by the facility are as follows: Staff reported being in the resident's room approximately 10 minutes before the incident. At that time, the resident was resting in bed with his/her eyes closed per the report. At 5:00 AM on [DATE] Resident #10 was found on the floor in the doorway to his/her room with his/her head against the doorway. Review of an "Incident round/room audit" conducted by the facility after the fall revealed that the tab alert alarm ordered to the bed was not in place. Record Review of the Nurse's Notes revealed notes for [DATE] at 6:45 AM, 8:40 AM and 9:00 AM. The 6:45 AM note indicated the resident was found in the doorway of his/her room at 5:00 AM with a a skin tear to the left upper arm and left forehead. In addition, the resident had a superficial laceration to the top of his/her head. The 8:40 AM note indicated the resident was complaining of pain to his left leg. The physician was notified and orders were received to send the resident to the emergency room for evaluation. The resident was transported to the hospital at 9:00 AM and later diagnosed with [REDACTED]. Record review of the physician's orders [REDACTED]. Review of the Care Plan on [DATE] at 3:05 PM, revealed a problem/need revised on [DATE] that read "Resident is at risk for falls r/t (related to) Orthostatic hypotension, altered mental status and debility. Resident has had multiple falls this review". Pressure pad alarm to the bed and tab alert alarm to the resident while in bed were listed as interventions. Record review of the Incident Reports for Resident #10 on [DATE] at 3:16 PM revealed the resident had falls without injury on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] During an interview with the DON on [DATE] at 9:24 AM, the DON confirmed that the residents pressure pad alarm did not go off when the resident fell . The DON stated s/he did not know why the resident's pressure pad alarm did not alarm when the resident got out of bed. The DON stated the alarm was functioning and went off about 15 minutes before the resident fell . The DON stated the resident was receiving care prior to his/her fall and the pressure pad alarm sounded while receiving care. S/he stated the alarm can be silenced by pressing the reset button, but this does not turn the alarm off. During an interview with the DON at 10:12 AM the DON stated that the tab alert alarm was not connected or on the bed when s/he checked the residents room after the fall. The DON stated the tab alert alarm is supposed to be the back up in case the pressure pad alarm does not function. S/he stated s/he arrived at the facility about 20 minutes after being notified of the fall. During an interview with CNA #1 on [DATE] at 10:25 AM, CNA #1 stated s/he was providing incontinence care to Resident #10 prior to his fall. CNA #1 stated that the resident's pressure pad alarm was functioning properly and did go off when s/he was turning him during care. S/he stated that RN #1 came in the room to check on the resident when the alarm went off. CNA #1 stated s/he hit the reset button to silence the alarm and the lights on the alarm indicated it was on and working. CNA #1 stated s/he finished the resident's care and left the resident's room about 10 minutes before the fall. CNA #1 stated that the tab alert alarm was hooked up to the resident when s/he left the resident's room. CNA #1 stated s/he did not remove the tab alert alarm from the resident's bed and the alarm was clipped to the resident's shirt when s/he left the room. CNA #1 stated that her/his only mistake was not clipping the tab alert alarm to the resident after they were able to get the resident back in bed after the fall. CNA #1 stated s/he accidentally clipped the call light clip to the resident instead of the tab alert clip. During an interview with the DON on [DATE] at 1:10 PM, the DON was informed that CNA #1 stated the tab alert alarm was connected to the resident prior to the fall. The DON stated that CNA #1 did not argue that the tab alert alarm was connected when s/he told CNA #1 that alarm was not connected and resulted in a fall with injury. The DON agreed that the pressure pad alarm may have malfunctioned. During an interview with RN #1 on [DATE] at 1:48 PM, RN #1 stated that s/he heard the pressure pad alarm going off while CNA #1 was providing care to Resident #10 prior to his/her fall. RN #1 stated that s/he went into the resident's room and observed that the tab alert alarm was hooked to the bed, but could not see if it was connected to the resident or not. RN #1 stated s/he left the room and about 10 minutes later CNA #3 told her/him the resident had fallen. RN #1 stated that neither alarm was sounding and did not know why the alarms were not sounding. RN #1 stated that after they got the resident back in bed the pressure pad alarm was functioning properly. RN #1 stated s/he could not see if the tab alert alarm was connected to the resident because the aide was providing care, but the alarm was hooked to the bed. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the Care Plan on [DATE] at 2:05 PM, revealed the resident was at risk for falls. A pressure pad alarm was listed as a safety intervention. The Care Plan also revealed that the resident required an assist of one for transferring and walking. The resident was observed in bed on [DATE] at 6:46 AM. A pressure pad monitor/alert was hooked to the side rail of the resident's bed. The pressure pad connector was not connected to the monitor/alert. At approximately 6:46 AM CNA #3 was observed in the hallway outside the resident's room taking linens to resident rooms. During an interview with Registered Nurse (RN) #1 on [DATE] at 6:51 AM, RN #1 verified that the pressure pad alarm connector was not connected to the monitor/alert. S/he connected the pressure pad alarm. CNA #3 entered the resident's room and stated s/he was coming in to connect the pressure pad alarm. CNA #3 stated she disconnected the alarm for the resident about ,[DATE] minutes ago, so the resident could get up to the bath room. CNA #3 stated the resident does not need help getting back into bed after using the bathroom. RN #1 was present and verified that the resident can get to and from the bathroom with out assistance. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the Care Plan on [DATE] at 1:40 PM revealed that the resident was at risk for falls. A pressure pad alarm was listed as a safety intervention. The resident was observed in bed on [DATE] at 7:01 AM. A pressure pad monitor/alert was hooked to the side rail of the resident's bed. The pressure pad connector was not connected to the monitor/alert. During an interview with Certified Nursing Assistant (CNA) #2 on [DATE] at 7:07 AM, CNA #2 verified that the pressure pad alarm connector was not connected to the monitor/alert. S/he connected the pressure pad alarm and stated s/he was just starting her/his shift and making her/his initial rounds. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Observation on [DATE] at approximately 7:00 AM during Initial Tour of the facility revealed Resident #5 in bed. A tab bed alarm was hooked to the bedrail but the tab cord was not attached to the resident and noted hanging down from the bedrail. This was verified by CNA #8. A review of the resident's care guide on the closet door with CNA #8 revealed no indication that the resident used a bed alarm. The CNA did not attempt to re-attach the tab alarm to the resident's clothing. After exiting the room, the surveyor asked the CNA if s/he was going to re-attach the bed alarm. The CNA responded that s/he wasn't going to do this because the resident would just keep removing it. The CNA then went and spoke with CNA #7 who was coming down the hall. CNA #8 informed CNA #7 that the resident's tab alarm was not attached because the resident had removed it. CNA #7 responded that this was true, that the resident would just remove it if it was re-attached. Record review on [DATE] at 1:18 PM of the resident's care plan revealed Resident #5 was at risk for falls due to decreased mobility and a history of falls. The resident was care planned to have a bed alarm for safety in addition to other preventive measures. A review of the [DATE] cumulative orders revealed orders for a bed alarm. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Observation on [DATE] at 7:11 AM revealed Resident #2 in bed. The bed alarm was not blinking indicating the alarm was not working. (Other alarms in place were observed to flash). Observation on [DATE] at 7:33 AM with CNA #9 revealed the bed alarm was still not blinking. The CNA had the resident stand up and the bed alarm did not sound. The CNA pressed down on the bed alarm and fiddled with the box but was unable to get the bed pad alarm to sound. The CNA stated s/he didn't know what was wrong with the bed alarm. A review on [DATE] of the resident's care plan revealed Resident #2 was at risk for falls related to decreased mobility and Psychosis. The Care Plan entry indicated the resident had a previous fracture due to a fall. Approaches included the use of a bed alarm for safety. A review of [DATE] cumulative orders revealed orders for a bed pressure pad alarm. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. A review of current Social Services notes revealed Resident #1 with a Brief Interview of Mental Status score of 4. Social Services notes documented that Resident #1 frequently makes attempts to exit the facility. A review of the facility self reported incident dated [DATE] (24 hour report) and follow up report dated [DATE], revealed Resident #1 exited through a facility hall door (Unit 2 East Hall) on [DATE] at approximately 3:00 AM. The door alarm had not sounded and the resident was observed coming around the side of the building by a floor tech on the front porch and brought back in through the front door. A body audit revealed no injury. According to the facility report, CNA #4 had been disciplined for not checking the door alarms on her/his shift. A statement included in the facility report by Licensed Practical Nurse (LPN) #1 revealed documentation of alarm checks had not been done (initialed) by CNA #4 in a timely fashion. According to the DON, the policy at the time included that the door alarms were to be checked at the start of the shift and every 2 hours. The DON stated that CNA #4 had signed the alarm check sheet on [DATE] after the resident had been found outside. A review on [DATE] and [DATE] of the door alarm check sheets revealed that staff were to initial every 2 hours, "...To indicate Alarm is Turned On, Initial each square". On the [DATE] door alarm check sheet for unit 2, there were 30 blanks where facility staff failed to initial that the door alarm checks had been completed. There were multiple blanks on the door alarm check sheets for unit 2 for [DATE]. There were multiple blanks on the door alarm check sheet for unit 1 for January, February, and [DATE]. The facility was unable to provide door alarm check sheets for [DATE]. According to documentation in the record and staff interview, Resident #1 attempted to exit the building almost daily, and would repeatedly set off the door alarms. A review of Incident reports revealed that in addition to the elopement attempt on [DATE] in which the resident was "going to fix his/her tire", there were 2 other elopement attempts of concern. An instance of elopement occurred on [DATE] at approximately 8:30 AM in which the Nurse's Notes documented that "The nurse from 3rd shift informed staff that the resident was outside. The nurse brought the resident back in the facility. The resident ha(d) no injuries. Will inform MD/NP on call service and family." A review of the [DATE] Incident Report revealed the same information. According to the [DATE] "Exit Seeking" documentation, the resident went out the unit 2 glass exit door (which required a code in order for the door to open). Facility documentation did not indicate if the door alarm had sounded or not; and did not include information as to why the resident had not been followed outside the building by facility staff who may have heard the alarm. There was no indication of how the resident may have gotten out of the building. The Incident Report also documented ([DATE]) that the resident's Code Alert bracelet had been changed. When asked why the bracelet had been changed, the DON stated the Unit Manager had indicated the code alert had been close to the expiration date. The DON stated s/he would look for anything else that might be documented for this incident to include witness statements, but did not provide any additional information. A phone interview on [DATE] at approximately 4:30 PM with Licensed Practical Nurse (LPN) #1 revealed information that s/he had worked the ,[DATE] shift on [DATE] and had stayed over for an educational inservice that morning. Upon leaving the building sometime around 8:00 AM on [DATE] (out the service hallway close to unit 1 where the timeclock is located), s/he was going to her/his car out in the back parking lot when 1 of 2 staff members seated in the smoking area hollered at her/him and asked if that was Resident #1 outside the building. According to LPN #1, s/he did not see where the resident was, since her/his vision was obscured by bushes. LPN #1 stated that s/he did see the 2 staff members wheel the resident back into the building and identified one as CNA #5. LPN #1 was unaware of any alarms that had sounded or of how the resident was able to exit the facility. An interview on [DATE] at 7:45 AM, CNA #5 stated that s/he and CNA #6 had been on their morning smoke break (at approximately 9:00 AM), seated outside on the picnic table bench near the back parking area on the morning of [DATE]. S/he saw Resident #1 wheeling him/herself down the sidewalk outside of the main entrance for Station 2. CNA #5 stated s/he hollered at LPN #1 to ask if it was Resident #1, because the distance was far and s/he was unsure. CNA #5 could not recall how far the resident got outside of the building and stated that s/he just recalled pushing the resident back in the facility. CNA #5 could not remember if the alarm sounded when s/he pushed the resident back in the Station 2 main door. When asked if anyone had come out to get Resident #1, CNA #5 stated that when s/he pushed the resident back in, somebody (s/he couldn't recall who), was by the door but s/he didn't know what they were doing. During an interview on [DATE] at 8:15 AM, the unit manager, LPN #2, stated that the reason the code alert had been changed was because it was close to expiring. An interview on [DATE] at 10:07 AM with CNA #6 confirmed s/he was outside with CNA #5 when the resident exited the facility unaccompanied. According to CNA #6, s/he and CNA #5 were working a different unit that day (Unit 1). CNA #6 also stated there was someone (unknown) at the unit 2 main door when they brought the resident back in. CNA #6 stated the alarm was going off at the door when they brought the resident back. CNA #6 verified that a code had to be entered in order for the resident to get out the door. A review of Incident reports on [DATE] revealed a delayed response to an elopement attempt on [DATE] in which it was documented that the resident had been out of sight for approximately 5 minutes. The resident was asked why s/he had gone out the door and stated s/he was drunk and going home. A Nurse's Note dated [DATE] at 2:00 AM stated, "Res(ident) OOB (out of bed) in w/c (wheelchair) sitting in lobby at 1:50 AM- visually seen by staff. CNAs down halls making rounds-this writer passing meds. Door alarm on Unit 2 at entrance/exit sounded. This writer cut off alarm + noted resident's empty w/c outside of BR door at entrance/exit. This nurse + CNA ---, assigned to resident, immediately went outside and noted res(ident) in parking lot on the backside of building...". During an interview on [DATE] at 8:30 AM, the DON was asked who was responsible for changing out the code alert bracelets and stated it would have been the unit manager or it may have been delegated to the nurse on duty that day. When asked how the facility was tracking the expiration dates for the code alert bracelets, the DON stated the Risk Manager had kept a log of this information, but s/he had left in December and now it was expected that when the code alert was checked daily that it would be checked for expiration dates. The DON was unable to provide any current or past documentation that the Code Alert bracelets had been checked for expiration or that the facility was keeping a log of this information. The DON provided a current policy on "Wandering Resident Management, Elopement Prevention" on [DATE] at 9:15 AM which defined elopement "...as the ability of a resident to successfully leave the nursing facility unsupervised and unnoticed and enter into harms way...". According to the policy, after a code alert is placed on a resident, "Documentation of the Code Alert Checks will be made on the PCR books (which is the Resident's Care Record) on each shift daily. The date of application of the Code Alert bracelet is documented in the nurses note, and followed through in the Elopement Books as indicated. On __ of each month, the Risk Manager checks all Code Alert bracelets and documents in the log book. Code Alert bracelets are checked daily by the assigned Certified Nursing Assistant and documented in the resident's PCR sheet and in the log book!!!!!!!!!" During an interview on [DATE] at 9:20 AM, the unit manager, LPN #2 was asked about who was responsible for checking the code alert bracelets and what they checked the bracelets for. According to LPN #2, the CNAs document checking the placement and function in the record (MAR) and also in the alarm check book. S/he stated that the nurses go behind the CNAs and also initial the alarm book that these checks were completed. LPN #2 was unsure who checked the code alert bracelets for the expiration date. Observation on [DATE] at 9:30 AM with a unit secretary revealed a Code Alert bracelet on Resident #1's ankle with a handwritten date of [DATE]. The bracelet expired on ,[DATE]. Later, when asked about the handwritten date on the bracelet, the unit secretary stated that s/he had just changed out the resident's code alert bracelet that day because it had expired in April of 2015. The unit secretary stated that though the unit had expired, the bracelet was still functioning when s/he changed it out. Observation of a Code Alert bracelet in a box in the DON's office revealed an expiration date of ,[DATE]. A check with the transmitter tester revealed this bracelet was functioning. According to the DON, this was the only expired Code Alert bracelet that s/he had knowledge of.

Based on record review, interviews and observations, the facility failed to follow the Care Plan for Residents # 2, 5, 7, 8, and 10, 5 of 7 residents reviewed for falls. Pressure pad and tab alert alarms were not connected and/or were not working properly. The findings included: The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the Care Plan on 5/19/2015 at 3:05 PM, revealed a problem/need revised on 4/9/2015 that read "Resident is at risk for falls r/t (related to) Orthostatic [MEDICAL CONDITION], altered mental status and debility. Resident has had multiple falls this review". Pressure pad alarm to the bed and tab alert alarm to the resident while in bed were listed as interventions. Record Review of the Nurse's Notes revealed notes for 4/28/2015 at 6:45 AM, 8:40 AM and 9:00 AM. The 6:45 AM note indicated the resident was found in the doorway of his/her room at 5:00 AM with a a skin tear to the left upper arm and left forehead. In addition, the resident had a superficial laceration to the top of his/her head. The 8:40 AM note indicated the resident was complaining of pain to his left leg. The physician was notified and orders were received to send the resident to the emergency room for evaluation. The resident was transported to the hospital at 9:00 AM and later diagnosed with [REDACTED]. During an interview with the Director of Nursing (DON) on 5/20/2015 at 9:24 AM s/he confirmed that the residents pressure pad alarm did not go off when the resident fell . S/he stated s/he did not know why the resident's pressure pad alarm did not alarm when the resident got out of bed. The DON stated the alarm was functioning and went off about 15 minutes before the resident fell . The DON stated the resident was receiving care prior to his/her fall and the pressure pad alarm sounded while receiving care. S/he stated the alarm can be silenced by pressing the reset button, but this does not turn the alarm off. During an interview with the DON at 10:12 AM the DON stated that the tab alert alarm was not connected or on the bed when s/he checked the residents room after the fall. The DON stated the tab alert alarm is supposed to be the back up in case the pressure pad alarm does not function. S/he stated the facilities investigation concluded that the tab alert alarm was not connected to the resident at the time of the fall. During an interview with CNA #1 on 5/20/2015 at 10:25 AM, CNA #1 stated s/he always starts morning rounds around 5:00 AM or a little before 5:00 AM. CNA #1 stated s/he was providing incontinence care to Resident #10 prior to his/her fall. CNA #1 stated that the resident's pressure pad alarm was functioning properly and did go off when s/he was turning the resident during care. S/he stated that RN #1 came in the room to check on the resident when the alarm went off. CNA #1 stated s/he finished the resident's care and left the resident's room about 10 minutes before the fall. CNA #1 stated that the tab alert alarm was hooked up to the resident's shirt when s/he left the resident's room. CNA #1 stated that her/his only mistake was not clipping the tab alert alarm to the resident after they were able to get the resident back in bed after the fall. CNA #1 stated s/he accidentally clipped the call light clip to the resident instead of the tab alert clip. During an interview with the DON on 5/20/2015 at 1:10 PM, the DON was informed that CNA #1 stated the tab alert alarm was connected to the resident prior to the fall. The DON stated that CNA #1 did not argue that the tab alert alarm was connected when s/he told CNA #1 that the alarm was not connected and resulted in a fall with injury. The DON agreed that the pressure pad alarm may have malfunctioned. During an interview with RN #1 on 5/20/2015 at 1:48 PM, RN #1 stated that s/he heard the pressure pad alarm going off while CNA #1 was providing care to Resident #10 prior to his/her fall. RN #1 stated that s/he went into the resident's room and observed that the tab alert alarm was hooked to the bed, but could not see if it was connected to the resident or not. RN #1 stated s/he left the room and about 10 minutes later CNA #3 told her/him the resident had fallen. RN #1 stated that neither alarm was sounding and did not know why the alarms were not sounding. RN #1 stated that after they got the resident back in bed the pressure pad alarm was functioning properly. RN #1 stated s/he could not see if the tab alert alarm was connected to the resident because the aide was providing care, but the alarm was hooked to the bed The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. A pressure pad alarm was listed as a safety intervention. The Care Plan also revealed that the resident required an assist of one for transferring and walking. The resident was observed in bed on 5/19/2015 at 6:46 AM. A pressure pad monitor/alert was hooked to the side rail of the resident's bed. The pressure pad connector was not connected to the monitor/alert. At approximately 6:46 AM CNA #3 was observed in the hallway outside the resident's room taking linens to resident rooms. During an interview with Registered Nurse (RN) #1 on 5/19/2015 at 6:51 AM, RN #1 verified that the pressure pad alarm connector was not connected to the monitor/alert. S/he connected the pressure pad alarm. CNA #3 entered the resident's room and stated s/he was coming in to connect the pressure pad alarm. CNA #3 stated she disconnected the alarm for the resident about 15-20 minutes ago, so the resident could get up to the bath room. CNA #3 stated the resident does not need help getting back into bed after using the bathroom. RN #1 was present and verified that the resident can get to and from the bathroom with out assistance. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. The resident was observed in bed on 5/19/2015 at 7:01 AM. A pressure pad monitor/alert was hooked to the side rail of the resident's bed. The pressure pad connector was not connected to the monitor/alert. During an interview with Certified Nursing Assistant (CNA) #2 on 5/19/2015 at 7:07 AM, CNA #2 verified that the pressure pad alarm connector was not connected to the monitor/alert. S/he connected the pressure pad alarm and stated s/he was just starting her/his shift and making her/his initial rounds. . The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Observation on 5/19/15 at approximately 7:00 AM revealed Resident #5 in bed with a tab bed alarm hooked to the bedrail but the tab cord was not attached to the resident and noted hanging down from the bedrail. This was verified by Certified Nursing Assistant (CNA) #8. A review of the resident's care guide on the closet door with CNA #8 revealed no indication that the resident used a bed alarm. CNA #8 did not re-attach the tab alarm and exited the room. S/he stated that the resident would just remove the tab alarm again. Record review on 5/20/15 at 1:18 PM of the resident's care plan revealed Resident #5 was at risk for falls due to decreased mobility and a history of falls. The resident was care planned to have a bed alarm for safety in addition to other preventive measures. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Observation on 5/19/15 at 7:11 AM revealed Resident #2 in bed. The bed alarm was not blinking indicating the alarm was not working. (Other alarms in place were observed to flash). Observation on 5/19/15 at 7:33 AM with CNA #9 revealed the bed alarm was still not blinking. The CNA had the resident stand up and the bed alarm did not sound. The CNA pressed down on the bed alarm and fiddled with the box but was unable to get the bed pad alarm to sound. The CNA stated s/he didn't know what was wrong with the bed alarm. A review on 5/20/15 of the resident's care plan revealed Resident #2 was at risk for falls related to decreased mobility and [MEDICAL CONDITION]. The Care Plan entry indicated the resident had a previous fracture due to a fall. Approaches included the use of a bed alarm for safety.

Based on record review, interviews, and a review of the policy provided by the facility entitled "Hydration Program", the facility failed to implement interventions to ensure adequate amounts of fluid intake for 1 of 1 sampled resident reviewed for hydration. Documentation revealed Resident #111 had a decline in condition with a decreased intake of food and fluids. Interviews with nursing staff along with a review of nursing documentation revealed the facility nursing staff did not address this lack of fluid intake aggressively to ensure the resident remained adequately hydrated. The findings included: Cross refers to F-281 as it related to the failure of the facility to assess and monitor Resident #111 with a change in condition. The facility admitted Resident #111 with [DIAGNOSES REDACTED]. The closed record was reviewed. According to the facility Discharge Summary, the resident had been discharged from the facility on 1/8/15 after having been sent out to the hospital for a change in condition. According to the resident's 10/23/14 quarterly Minimum Data Set Assessment, the resident had a Brief Interview of Mental Status score of 00 which indicated severe cognitive impairment at the time of the assessment. A review of lab results in the record revealed a Basic Metabolic Profile dated 6/30/14 that showed normal ranges. The Sodium was 140, Potassium 4.2, BUN (Blood Urea Nitrogen) 18, Creatinine 1.03 A Basic Metabolic Profile dated 10/6/14 showed a normal Sodium level of 143 (Reference Range 135-145), a normal Potassium level of 3.9, Chloride of 112 (Reference Range 101-111), BUN 22 (Reference Range of 6-20), and Creatinine 0.95 (Reference Range of 0.61-1.24 mg/dl). A review on 3/30/15 at 1:45 PM of the resident's comprehensive care plan dated 10/31/14 revealed an entry dated 10/30/14 that documented Resident #111 was at risk for dehydration related to diuretic use and [MEDICAL CONDITION]; and that s/he would have no signs or symptoms of dehydration through the next review on 1/29/15. Approaches included medications as ordered ([MEDICATION NAME] 40 mg daily along with Potassium per the January 2015 cumulative orders), Labs as ordered, Observe and document intake, Encourage fluids as tolerated, Observe effectiveness of meds ([MEDICAL CONDITION]), and Notify MD (Physician) as needed. A care plan entry dated 10/28/14 for nutrition revealed "...Resident feeds self. Assist as needed. Encourage adequate food and fluid intake. Record amounts consumed." A review of the January 2015 Medication Administration Record [REDACTED]. A review of the facility's "Resident Diet Sheet" documentation for Resident #111 revealed that in December 2014, the resident consumed between 720 ml (milliliters) and 2400 ml of fluids daily (except on 12/31/14, at which time only 480 ml of fluid intake for the day had been documented). A review of the January 2015 documentation revealed a decrease in the amount of fluids taken in daily from the previous month. The intake information included the following amounts of fluids for the day: January 1, 2015- 720 ml. (480 given with meals, and 240 given by the nurse) January 2, 2015 540 ml (300 given with meals, and 240 given by the nurse) January 3, 2015 600 ml (600 given with meals) January 4, 2015 240 ml (240 given with meals) January 5, 2015 960 ml (240 with meals, 360 given by the nurse, and 360 given by staff assist or for snack) January 6, 2015 360 ml (120 with meals, and 240 by the nurse) January 7, 2015 270 ml (120 with meals, and 150 by the nurse) January 8, 2015 570 ml (480 with breakfast and 90 by the nurse) The sheet included information that the resident had refused breakfast and lunch on January 5th, and had refused breakfast on January 6th and 7th. There were blanks for the percent consumed/fluid intake for the dinner meal service to include fluids offered on January 6th and 7th for the evening. The total amounts of fluid documented for the 2 evenings had been "0". There was a blank in the boxes for fluids offered the evening of January 4th. The total for amount of fluids for the evening had been documented as "0". The intake sheet did not indicate that nursing staff had been pushing fluids for the resident. A review of Nurse's Notes from 1/1/15 through 1/8/15 revealed nothing to indicate that staff were trying to push fluids or that it had been noted that the resident had a decreased fluid intake. The notes documented several entries that the resident had been drowsy and/or hard to arouse. A note dated 1/4/15 at 11:15 AM documented the resident resting in bed without signs of distress or discomfort with the resident too lethargic to administer medications. A note dated 1/6/15 at 3:00 PM documented, "Resident drowsy/asleep entire shift, arousal to voice. Refused meals, took meds (without) difficulty...". A Nurse's Note dated 1/7/15 at 1:00 PM documented that the Nurse Practitioner had seen the resident for a sick visit due to a noted decline in ADLs (Activities of Daily Living) with new orders having been received. A review of Physician Telephone Orders revealed the following: "1/7/15 1 pm- 1) UA (Urinalysis) (with) C & S (Culture and Sensitivity) (AMS) Altered Mental Status, 2) (Check) CBC (Complete Blood Count), BMP (Basic Metabolic Panel) in AM 1/8/15. A review on 03/30/2015 at 2:09 PM of of the Nurse Practitioner's Progress Note dated 1/7/15 revealed s/he had been asked to see the resident due to a change in condition. "...Resident has had a major change in his condition recently. S/he used to be up & around now s/he is in bed confused, incontinent, unable to even feed himself/herself. S/he did see psyche recently & had a change in medications & that was just a few days ago. S/he is afebrile..., weight 202 pounds...In bed not following commands or answering [MEDICAL CONDITION] has improved...". There was no indication that the nurse practitioner had been made aware that the resident had a decline in his/her fluid intake though labs had been ordered. A review on 3/30/15 of lab results taken by the hospital on [DATE] (Admission) and supplied to the surveyor by the facility revealed the resident's Sodium level had been critically high at 171 (Reference Range 135-145), Chloride was critically high at 134 (Reference 101-111), BUN was high at 112 (Reference Range 6-20), and Creatinine was high at 5.62 (Reference Range 0.61-1.24). The resident's Troponin level was also critically high at 1.04 (Reference Rang 0-0.04). The urine culture was negative. During an interview on 3/31/15 at approximately 8:00 AM, the intake sheets that showed a decline in fluid intake from December to January were reviewed with the DON along with the Nurse's Notes documentation noted above that showed a decline in his/her condition. The information included on the Bowel and Bladder Re-Training Program Toileting Schedule from 1/1/15 through 1/8/15 was also reviewed. According to the DON, the "X" in the box indicated that the resident had been changed and/or had voided. The record indicated the resident had been incontinent and/or had voided multiple times throughout the day. The resident was documented as having no voiding (no urine output from 7:00 AM-2:00 PM on 1/5/15), with an "X" for the 3:00 PM time which indicated the resident had been incontinent shortly after that. The DON was informed of the concern that the documentation in the resident's record did not show that the facility had implemented measures to keep the resident hydrated. The DON stated the facility had a system in place to monitor the fluid intake of residents. S/he would get me the facility's policy on hydration and see if there was any documentation for Resident #111 related to pushing fluids. During an interview on 3/31/15 at approximately 8:50 AM, the DON stated that a nurse would add up all the intake amounts for the day, and if the intake was less than a certain amount, a list would be given to the nurses to push fluids on those residents. A review of this documentation provided by the Unit Secretary revealed that names of residents with daily fluid intakes of less than 1500 ml would be included on the log. If any resident had 3 consecutive days of less than 1500 ml fluid intake, this information would be recorded in the day book. A review of Resident #111's 24 hour fluid intake amounts documented on the January 2015 log revealed the following intake amounts that were less than 1500 ml : January 1, 2015- total of 720 ml. January 2, 2015- total of 540 ml January 3, 2015- total of 600 ml January 4, 2015- total of 240 ml January 5, 2015- total of 960 ml January 6, 2015- total of 360 ml January 7, 2015- total of 120 ml The surveyor requested the information from the Day Book for the resident along with the 24 hour reports for the resident for January. The Day Book information was not provided (the DON had said s/he was unsure if this information was kept). A review of the 24 hour reports for January 2015 for Resident #111 did not show any information related to fluid intake amounts or that fluids were to be pushed. During an interview on 3/31/15 at 9:00 AM, the ward secretary stated s/he was the one who transcribed the 24 hour fluid intakes onto the log. The ward secretary stated that from this log, s/he generated a list of resident names who needed to have fluids pushed. When asked if there was any monitoring done to ensure the fluids were pushed on those residents, the ward secretary stated that s/he was just responsible for giving the list to the nurses. Licensed Practical Nurse (LPN) #2 (who was present at the nurse's station during the interview with the ward secretary on 3/31/15 at 9:06 AM), added information that once s/he received the list of residents that needed fluids pushed, s/he would document how much the resident took in on the intake sheet,or if the resident had refused fluids s/he would document this. When asked how the CNAs (Certified Nursing Assistants) assisted in the process of pushing fluids, LPN #2 stated that the push fluids list was also shown to the CNAs and the dietary aides. During an interview on 3/30/15 at 2:56 PM, LPN #7 (on the schedule to have worked with the resident on the 3-11 shift on 1/6/15 and 1/7/15) stated that s/he could recall nothing unusual about the resident other than that the resident was more lethargic than usual and not getting around as good on 1/7/15. According to LPN #7, the CNAs hadn't said anything about a decline in feeding or drinking. LPN #7 stated that at times the resident would refuse to eat and that this would not be abnormal for the resident. During a phone interview on 3/30/15 at approximately 3:15 PM, LPN #5 (on the schedule to work with the resident on 1/8/15 from 7-3) stated that some days the resident would eat good and sometime s/he wouldn't. LPN #4 stated that at times they would have to prompt the resident to eat, and sometimes the food would just dribble back out of his/her mouth. The nurse said that this was an ongoing thing for the resident. S/he believed the resident had been eating and drinking okay. When asked how s/he knew this. LPN #5 stated that the CNAs would document this in their book, and would get the nurse if the resident wasn't eating or drinking. LPN #5 could not recall any concerns with the resident not eating or drinking and did not believe any of the CNAs had informed her/him of any eating drinking problems. During a phone interview on 3/30/15 at 3:50 PM, LPN #6 (scheduled to work with the resident on 1/5/15, 1/6/15, and 1/7/15 from 7-3) stated s/he could not recall the resident not eating or drinking well, or that the resident had decline and would not feed him/herself. LPN #6 stated that no one had reported a decline to her/him or s/he would have noted it. During an interview on 3/31/15 at 7:32 AM, LPN #4 (on the schedule to have worked with the resident on the 11-7 shift on 1/5/15 and 1/7/15), stated after reviewing the January Nurse's Notes that s/he could not recall any decline or changes in the resident. A review of the policy provided by the facility entitled "Hydration Program", dated 9/2009 and reviewed/revised on 1/5/10 revealed the facility's program would encourage residents to receive adequate amounts of fluid intake to promote adequate nutrition. Under "Procedures" was listed, "A. Patient Care Record is reviewed daily for any resident with intake less than 1200 cc. B. Any Resident with less than 1200 cc should be recorded for the "push fluid". C. Push Fluids is defined by: Any Resident who does not consume 1200 mls in a 24 hour period. D. If the Resident on "push fluids" continues not to consume 1200 ml for 3 days (an average may be used), the MD and family will be contacted. E. The Resident will be observed for s/s dehydration if they continue to consume less than 1200 ml per day. F. Push Fluids G. Documentation will begin in the nurses' notes beginning the 4th day, after 3 consecutive days on "push fluids", following notification of family and interventions received from MD."

Based on record review and interviews, the nursing staff failed to document thorough nursing assessments related to a change in condition for 1 of 1 sampled resident reviewed for hydration. Resident #111 was noted to be more lethargic than usual, being hard to arouse, and with weakness with ambulation. According to staff interviews, this was attributed to tiredness from the resident having been up all night. A thorough nursing assessment for the resident had not been documented by the nursing staff taking care of the resident to identify possible causes for the lethargy. Vital Signs had not been documented for approximately 24 hours preceding the resident's transfer to the hospital. The finding included: The facility admitted Resident #111 with [DIAGNOSES REDACTED]. The closed record was reviewed. A review of Nursing Notes dated 10/10/14 through 1/2/15 revealed Resident #111 was up, ambulatory, and confused with behaviors. Starting on 1/3/15, the Nurse's Notes documented a change in the resident with increased drowsiness noted. The documentation included the following: 1/3/15 at 5:45 AM- "VS 120/79, 81, 18, 98.1, Rested in bed this hs (bedtime). Drowsy this AM Neuro (checks) WNL (Within Normal Limits)...". 1/3/15 at 1:45 PM- "Resident (up) OOB (Out of Bed) resting in wc (wheelchair), presenting (with) drowsiness and weakness (with) ambulation. Continues (with) neuro (checks) and routine VS (checks) all WNL. Will continue to monitor." 1/4/15 at 11:15 AM- "Resident resting in bed, (no) noted s/sx (signs/symptoms) distress/discomfort. Resident too lethargic to admin(ister) med(ications). Continues (with) (increased) agitation when trying to arouse, not enough to awaken. VS wnl. Following shift nurse notified. Will continue to monitor." 1/5/15 at 3:40 AM- "VS 149/78, 90, 20, 98.7 resident (up) in dayroom, unsteady on feet, combative with staff at times, (no) injuries noted from previous fall." 1/5/15 at 3:00 PM- "Remains on neurochecks, (no) deficits noted. Rested in bed majority of shift. VSS WNL." 1/6/15 at 3:00 PM "Resident drowsy/ asleep entire shift, arousal to voice. Refused meals, took meds (without) difficulty. UTO ( Unable to Obtain) VS due to resident constantly moving and attempting to remove BP (Blood Pressure) cuff." (The vital signs were noted to be stable that day at 6:00 pm) 1/7/15 at 6:00 AM- "Rested quietly this hs. Drowsy this hs. No adverse behavior." 1/7/15 at 1:00 PM- "-- NP (Nurse Practitioner) seen resident for sick visit, due to noted decline in ADLS and NP assessed resident + reviewed meds + labs. N/Os received. RP notified." A review on 03/30/2015 at 2:09 PM of of the Nurse Practitioner's Progress Note dated 1/7/15 revealed s/he had been asked to see the resident due to a change in condition. "...Resident has had a major change in his condition recently. S/he used to be up & around now s/he is in bed confused, incontinent, unable to even feed himself/herself. S/he did see psyche recently & had a change in medications & that was just a few days ago. S/he is afebrile..., weight 202 pounds...In bed not following commands or answering [MEDICAL CONDITION] has improved...". Continued review of Nurse's Notes in the record included the following: 1/7/15 at 6:20 PM- "Res(ident) resting quietly in bed. Res(ident) has been lethargic this shift. No distress noted." 1/7/15 at 11:50 PM- "Cath(eter) U/A (Urinalysis) obtained for u/a (with) c + s (culture and sensitivity). No difficulty. Approx(imately) 100 cc yellow clear urine obtained." 1/8/15 at 11:05 AM- "Resident presenting (with) unresponsiveness, pinpoint pupils, constant moaning. Unable to obtain VS, BP 126/92, HR 182 (Per nurse interview this was 102 and not 182. Rcvd (Received) order per GNP to send out to (hospital) ER (emergency room ) , RP notified. Resident admitting to (hospital) ICU (Intensive Care Unit) Dx (Diagnosis) [MEDICAL CONDITION] at 1645 in report from ER charge nurse --." A review of vital sign documentation in the record revealed that prior to sending the resident out on 1/8/15, the last vital signs for Resident #111 had been documented on 1/7/15 at 11:00 AM (on the vital sign flow sheet) and were: 123/78, 97.8, 69, 20. A set of vital signs documented on the 1/7/15 Nurse Practitioner's Progress note were pulse 69, respirations 18, and blood pressure of 137/68. During an interview on 3/31/15 at 7:39 AM, the Director of Nursing (DON) reviewed the nursing documentation and was informed of the surveyor's concern that a thorough nursing assessment had not been completed for the resident by the facility nursing staff. According to the DON, if there is a change in condition, the nursing staff should do acute charting for the resident. This would go on for 3 days and if there was no change, the physician would evaluate the resident. If this was the new norm, the acute charting would stop. The charting would continue if this was still a concern for the resident. When asked how it would be decided that a resident was to be placed on acute charting, the DON said that for falls or for obvious need the nurses would go ahead and start it. If there was a change in condition noted on the 24 hour reports supplied by the units, they would discuss this in the morning meetings and have the resident place on acute charting. After reviewing the nursing documentation to include the Nurse Practitioner's 1/7/15 note, the DON agreed that Resident #111 should have been placed on acute charting and would expect the nurses to document a note and vital signs for the resident every shift. The DON verified there was no nursing documentation for the 1/7/15 night shift (besides the note that the resident had been catheterized); and no thorough nursing assessment for the resident for the days prior to the Nurse Practitioner's visit when the resident had been noted to be lethargic, in bed, having refused a meal, and too lethargic to administer medications to. Some of the nurses who were noted on the schedule to have worked with the resident during the 1st week of January were asked about any noted changes in the resident's condition and included the following: During an interview on 3/30/15 at 2:56 PM, LPN #7 thought the resident had been more lethargic than usual and not getting around as good on 1/7/15; but did not recall anything else different for the resident. S/he could not recall anything unusual for the resident on 1/6/15. During a phone interview on 3/30/15 at 3:15 PM, LPN #5 (who sent the resident out the morning of 1/8/15) stated that s/he believed that the change in the resident had been going on for a couple of days, with the resident constantly falling asleep then getting up and walking around. When asked if any other changes had been noted, s/he stated just a decline for awhile. When asked if s/he was supposed to be monitoring the resident for anything, the nurse was unsure since s/he didn't have the record in front of her/him. During a phone interview on 3/30/15 at approximately 3:30 PM, Certified Nursing Assistant (CNA) #3 stated s/he had noted a decline in the resident on 1/5/15 with the resident being hard to arouse and drowsy, and in bed which was unusual. This continued on 1/6/15 according to the CNA. The CNA stated that the primary nurse for the resident was aware of this. During a phone interview on 3/30/15 at 3:50 PM, LPN #6 stated that the resident had been very confused. When asked if s/he had noticed any changes in the resident prior to the resident having been sent out on 1/8/15, the nurse could not recall any. S/he stated s/he was not aware the resident had been noted to be difficult to arouse. the nurse stated the resident had been sleepy, but that they were able to wake the resident up. According to the nurse, no one had reported a decline to her/him or s/he would have noted it in the record. During an interview on 3/31/15 at 7:32 AM, LPN #4 could not recall a decline or change in condition for the resident during the first week in January.

On the days of the complaint and extended survey based on observations, record review and interview, the facility Administration failed to administer the facility in a manner that effectively and efficiently used its resources to maintain the physical, mental and psychosocial well-being of each resident. The Administration failed to ensure the facility policies and procedures were followed related to wandering, exit seeking and elopement; the facility policy on Abuse and Neglect was not thoroughly implemented. The findings included: Cross Refer to F-323 related to the facility failure to safeguard residents from accidents and hazards. Resident #1 was found trapped behind a closed door on the Switzer Hall in the Machine Shop with multiple chemicals and other hazards present. The Switzer double door, beauty shop door and Switzer exit door were not on the facility code alert system, the staff was relied on to physically arm or disarm the system using a key. The exit door at the time of the survey, on 1/14/2013 was not armed and could not to be latched without extensive effort and force. During an interview on 1/14/2013, the Administrator confirmed Resident #1 was found on the Switzer Hall in the Machine Shop trapped behind a closed door with multiple chemicals present. The Administrator also confirmed the doors were not part of the Code Alert System and that the Switzer double doors, beauty shop door and Switzer exit door relied on the staff to disarm and then re-arm with use. The Administrator and Director of Nurses confirmed that staff members were in and out of the area multiple times throughout the day. The Administrator also confirmed that the Switzer Exit door was difficult to close and required extensive effort to secure. The Administrator confirmed that an estimate for a new exit door for Switzer was obtained on 10/24/2012. On 1/14/2013 at 4:45 PM the Administration was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-280, F-323 and F-490 at a scope and severity of "K". The Substandard Quality of Care and/or Immediate Jeopardy existed on 1/05/2013 related to the failure of the facility to safeguard residents related to accidents and hazards. The Switzer double doors, Beauty Shop door and the Switzer exit door were not on the Code Alert system and Resident #1 was found trapped behind a closed door of the Switzer machine shop with multiple chemicals and hazards on 1/5/13. On 1/14/2013 the Switzer Exit door was not alarmed and was unable to be secured. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 1/15/2013 had been implemented by the facility and were in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the policy regarding resident elopement. The Administrator was informed of this on 1/15/2013 at 5:30 PM. The Immediate Jeopardy at F-490 was removed but the citations remained at a lower scope and severity of "E".

On the days of the complaint and extended surveys based on observations, record review, interview, review of the Material Data Safety Sheets (MSDS), and review of the facility policy on Wandering and Elopement the facility failed to provide adequate supervision to prevent accidents and hazards for two of four sampled residents (Residents #1 and #3). Resident #1 was found trapped behind a closed door with multiple hazardous chemicals, in a non resident area (on the Switzer Storage Hall) on 1/5/2013. The "Code Alert" system the facility used was not installed on the Switzer double doors, the beauty shop door or the Switzer exit door. Resident #3 exited the facility on 1/4/2013 and was not reassessed. The findings included: During Initial Tour on 1/14/2013 at 1:30 PM with the Director of Nurses (DON), the Switzer double doors were noted to have a key dangling from the instant alarm. In order to arm or disarm the alarm, staff was required to insert the key and turn a quarter turn. The alarm could not be re-armed once a staff member entered the area, leaving the area accessible to the residents. In the Switzer Storage Hall, two desks where the Restorative Staff worked were noted in the open area. Per the DON, the staff members worked first shift and were in and out of the area for those eight hours. After 3 PM, no staff was assigned to work in that area. Also, to the right of the work area was an additional door to the beauty shop. To the left of the work area was a long hallway with four rooms on the right side and three rooms on the left side. On the right, the first room was for brief storage containing multiple boxes on palates. The second and third rooms were for equipment storage containing beds, mattresses, wheelchairs, etc. The last room was the Environmental Services office that remained locked. On the left side, the first room was a linen storage room with multiple carts containing blankets, towels and sheets. The second room was the Maintenance Director's office that remained locked. The last room was the machine shop, where Resident #1 was found on 1/5/2013. The following items were observed in the machine shop: the door was propped open with a 5 gallon bucket of Floor Finish. Some of the chemical had spilled and was noted on the top of the bucket as well as the spout. Also, there were 18 - 1 gallon jugs of cleaning products including Multi-purpose cleaner, Bowl cleaner, Floor wax, SaniMaster 4, Light Duty Cleaner and Glass Cleaner. There were 8 - 3 gallon buckets of floor stripper, and 5 - 5 gallon buckets of another floor cleaner. Three floor cleaning machines were also observed. A flammables cabinet containing sanitzer, gum remover and Solvoil was observed unlocked. A funnel with a chemical substance on the outside was noted on the counter top. Several places on the floor was wet with an unknown liquid. A towel was covering one of the spills. A door was noted lying on its side, propped up along the side of the counter. The Director of Nurses confirmed the presence of all chemicals. The Switzer exit door was observed to have the same keyed instant alarm that relied on staff re-arming with every use. However, the alarm was not set and the door was not latched. The DON was not able to latch the door and confirmed the door was not secured or alarmed. The DON also confirmed the beauty shop door, the Switzer double doors and the Switzer exit door were not on the facility Code Alert system. The DON confirmed the resident was found in the Machine Shop room on the Switzer hallway. S/he also stated that the alarms did not sound. During follow up observations and interview on 1/14/2013 at 2:10 PM, the Maintenance Director and the Administrator confirmed the machine shop room contained multiple chemicals and equipment and that Resident #1 was found on the Switzer Hall in the Machine Shop trapped behind a closed door with multiple chemicals. The Administrator also confirmed the doors were not part of the Code Alert System; that the Switzer double doors, beauty shop door and Switzer exit door relied on staff to disarm and then re-arm every time they used the doors. The Administrator and Director of Nurses confirmed that staff members were in and out of the area multiple times throughout the day. The Maintenance Director used both hands on the bar of the door and forcefully closed the Switzer door exit door. S/he stated that the facility had a quote to replace the Switzer exit door because the door was warped and difficult to close; the quote was dated 10/23/2012 and state, "...We will replace the exterior door to the back hall (Switzer Exit Door). We will supply and install a new hollow metal door complete with new continuous hinge, closer, kick plate, alarm, exit device, sweep, 24 x 32 window kit, threshold and weather stripping". Per the Administrator the replacement of the door had not been approved or scheduled. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum (MDS) data set [DATE] revealed the resident had short term and long term memory problems with severely impaired daily decision making abilities. The resident was also coded as having physical, verbal and other behaviors daily; wandering daily. The resident was independent in locomotion on and off the unit. Review of the Nurse's Notes from 8/30/2012 through 1/14/2013 revealed the following documentation related to exit seeking: 12/30/2012 at 1:30 PM "Resident exit Unit 2 lobby door - noted on sidewalk - Resident states s/he was going home - Code alert bracelet applied to resident at 2 PM..." 01/07/2013 at 10 A "Reported to DON and physician that resident was found in hsk (housekeeping) machine area when CNA (Certified Nursing Assistant) was taking another resident to smoke. Resident cond(ition) satisfy(actory). Stated room cool, unhinged door on floor beside prev(enting) exit. Resident moves throughout facility ad lib. Returned to desk per staff report..." During an interview on 1/14/2013 at 3:05 PM, CNA #1 stated that s/he was taking a resident out to smoke at 4 PM (1/5/2013), s/he stated that s/he turned off the alarms to both the Switzer double doors and the Switzer Exit door. CNA#1 stated that s/he was coming back inside and heard Resident #1 calling out. S/hee stated that s/he paused and listened for a moment and determined that the resident was behind the machine shop door. CNA #1 stated that when s/he pushed the door open, Resident #1 was in her/his wheelchair blocked by a fallen door and was "mad about it". CNA #1 stated that Resident #1 had to have moved several items in the machine shop to get where s/he was. CNA #1 also stated that Resident #1 was "very strong" and could have stood up and gotten the key for herself to disarm the door. S/he also stated that the resident was "into everything and everywhere". CNA #1 stated that the resident was in the machine shop room prior to him/her taking the other resident out to smoke. S/he stated that s/he would have seen the resident coming down the Switzer hall if s/he had followed behind them. CNA #1 also stated that the resident was in the room for "a while" because her/his skin was cool to the touch. S/he stated that s/he escorted the resident out of the area back to the lobby and informed the assigned CNA (CNA#2) and a nurse (Licensed Practical Nurse #1). CNA#1 stated that s/he did not inform anyone else. During an interview on 1/14/2013 at 2:25 PM, CNA#2 stated that s/he was assigned to Resident #1 on 1/5/2013 from 3-11 PM. S/he stated that s/he changed the resident's brief between 3-3:30 PM. After providing care, CNA #2 stated that s/he pushed the resident back into the lobby because the resident was a risk for falls and could not be left alone in her/his room. S/he stated that when s/he finished giving a shower to another resident, CNA#1 informed her/him that Resident #1 was found in the Machine Shop. CNA#2 stated that s/he did not inform the nurse and did not do anything for the resident except provide care as usual. During an interview on 1/14/2013 at 2:20 PM, LPN #1 stated that CNA #1 informed him/her that Resident #1 was found in the Switzer hall Machine Shop. S/he stated that s/he informed CNA #1 to inform the assigned nurse. LPN #1 stated that the assigned nurse would have been LPN #2. S/he stated that s/he followed up with LPN #2 and stated that LPN #2 confirmed CNA#1 had let her/him know. During an interview on 1/14/2013 at 2:35 PM, Licensed Practical Nurse (LPN) #2 stated that s/he did not get to the facility until 5 PM on 1/5/2013 and was not aware of any incident with Resident #1 until 1/7/2013. S/he stated that LPN #3 was working the cart until s/he arrived at 5 PM. LPN #2 stated that Resident #1 was "all over" and would push on the exit door and set the alarms off. S/he stated that this was not a new behavior. During an interview on 1/14/2013 at 3:35 PM, LPN #3 stated that s/he was assigned to the resident until 5 PM. S/he stated that a CNA informed her/him that Resident #1 was found on the Switzer hall machine shop. S/he stated that the alarm never sounded. LPN #3 stated that s/he talked to the resident and didn't see any bruises or skin tears. S/he confirmed that s/he did not notify the physician or the facility administration of the incident. LPN #3 also confirmed there was no nurse's note related to the incident or the subsequent assessment. During an interview on 1/14/2013 at 3:15 PM, the Medical Director stated that Resident #1 was all over the place. S/he stated that the resident was "very strong and very determined." Review of the "Door Alarm Checks" revealed the doors were checked every two hours by the Certified Nursing Assistants. However, there was no indication which doors were checked or how the doors were checked. On 1/5/2013 the log was initialed at 2 PM and 4 PM. During an interview on 1/14/2013 at 2 PM, CNA#3 stated that s/he checked the double doors to the Switzer hall on 1/5/2013 at 2 PM s/he stated that the doors were armed at the time of the check. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored a 3/15 on the Brief Interview of Mental Status and was independent in locomotion on and off the unit. No behaviors were coded during the assessment period. Review of the Nurse's Notes dated 1/4/2013 at 1 PM revealed, "new order for code alert bracelet and U/A (urinalysis) C&S (culture and sensitivity) for AMS (altered mental status). 1:15 PM "Code alert placed on back of wheelchair related to resident trying to exit facility to go home." Review of the Elopement Risk assessment dated [DATE] indicated the resident was not at risk for elopement and there was no Elopement Risk Assessment after the 1/4/2013 incident. Review of the facility policy on "Exit seeking, Wandering and Elopement" dated 10/2012 indicated, "Wandering Risk Assessment: As a part of admission assessment, all newly admitted resident clinical status will be assessed by a licensed nurse to determine their risk assessment for wandering using the Wandering Risk Scale form and reassessed as follows: 72 of admission, every month for residents identified as high risk to wander, whenever there is a change in resident's clinical status." The action required based on Wandering Risk Scale scores were "if the resident is identified as a high risk to wander, the following actions must be taken. i. initiate interdisciplinary care plan. ii. Place a copy of the resident's photograph in the medical record. iii. Assess the residnet's need for Code Alert bracelet." (Resident #1 was not assessed utilizing this policy and assessment until 1/7/2013, Resident #3 was not assessed utilizing this policy and assessment.) Review of the MSDS for Solvoil revealed the Health Hazard Data: "Skin-causes defatting, dryness and irritation. If swallowed: Harmful or fatal if swallowed. Pulmonary aspiration hazard of swallowed and vomiting occurs. If inhaled-concentrated vapors may cause respiratory tract irritation." The Protective measures are: "Eyes: wear chemical splash goggles. Skin: wear any impervious gloves, other protective as necessary to prevent skin contact. Respiratory: Avoid breathing mists or vapors of this product." Review of the MSDS for Gum Remover revealed the health hazards were: "Causes Chemical Burns, if inhaled may be harmful. Asphyxiation hazard due to potential for displacing oxygen. The protective measures were: "Eyes: wear chemical splash goggles. Skin: wear impervious glove." Review of the MSDS for the Floor Wax revealed the health hazards were: "avoid contact with eyes, skin and clothing. Wash thoroughly after handling." Review of the MSDS for the floor cleaner revealed the health hazards were "avoid contact with eyes, skin and clothing. Wash thoroughly after handling." Review of the MSDS for the Cleaner revealed the health hazards were irritation to the eyes, skin and respiratory tract. "Can burn mouth, throat and stomach." Review of the MSDS for the Floor Stripper revealed the health hazards were "Causes eye and skin burns, causes severe respiratory tract infection, may be harmful if swallowed. Eyes: corrosive, skin: corrosive." Review of the MSDS for SaniMaster 4 revealed the health hazards were "causes eye and skin burns. May be harmful if swallowed. May be harmful if absorbed through the skin. May be fatal if swallowed. Do not ingest, do not get in eyes on skin or clothing. Avoid breathing vapor. Keep container closed. Use only with adequate ventilation. Wash thoroughly after handling." On 1/14/2013 at 4:45 PM the Administration was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-280, F-323 and F-490 at a scope and severity of "K". The Substandard Quality of Care and/or Immediate Jeopardy existed on 1/05/2013 related to the failure of the facility to safeguard residents related to accidents and hazards. The Switzer double doors, Beauty Shop door and the Switzer exit door were not on the Code Alert system and Resident #1 was found trapped behind a closed door of the Switzer machine shop with multiple chemicals and hazards on 1/5/13. On 1/14/2013 the Switzer Exit door was not alarmed and was unable to be secured. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 1/15/2013 had been implemented by the facility and were in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the policy regarding resident elopement. The Administrator was informed of this on 1/15/2013 at 5:30 PM. The Substandard Quality of Care and/or Immediate Jeopardy F-323 was removed but the citations remained at a lower scope and severity of "E".

On the days of the complaint and extended survey based on record review and interview, the facility failed to ensure that one of four resident's care plans were periodically reviewed and revised to reflect the care needs of the resident. Resident #1 had a known history of wandering. The facility failed to review/revise the care plan for the resident's wandering behavior and failed to put interventions in place. Resident #1 eloped on 12/30/12 and 1/7/2013. The findings included: Cross Refer to F-323 related to the failure of the facility to safeguard residents from accidents and hazards. Resident #1 was found on 1/5/2013 in the Switzer Hall Machine Shop trapped behind a closed door with multiple chemicals and other hazards. The Switzer double door, beauty shop door and Switzer exit door were not on the facility code alert system and relied on the staff to physically arm or disarm the key. The exit door on 1/14/2013, the day of the survey, was not armed and could not to be latched without extensive effort and force. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum (MDS) data set [DATE] revealed the resident had both short term and long term memory problems with severely impaired decision-making abilities. The resident was coded as having physical, verbal and other behaviors daily. S/he wandered daily and was independent in locomotion on and off the unit. Review of the Nurse's Notes from 8/30/2012 through 1/14/2013 revealed the following documentation related to exit seeking: 12/30/2012 at 1:30 PM "Resident exit Unit 2 lobby door - noted on sidewalk - Resident states s/he was going home - Code alert bracelet applied to resident at 2 PM..." 01/07/2013 at 10 A "Reported to DON and physician that resident was found in hsk (housekeeping) machine area when CNA (Certified Nursing Assistant) was taking another resident to smoke. Resident cond(ition) satisfy(actory). Stated room cool, unhinged door on floor beside prev(enting) exit. Resident moves throughout facility ad lib. Returned to desk per staff report..." Review of the Incident Report dated 12/30/2012 at 1:30 PM indicated, "Resident states going home, going out door, exit seeking." Further review of the Exit Seeking Worksheet revealed the resident went completely out of the door and was out of sight. No injuries were noted. The investigation was not completed and the worksheet was not completed. However, per the physician's orders [REDACTED]. On 1/5/2013, Resident #1 was found on the Switzer Hall Machine Shop trapped behind a closed door in a room with multiple chemicals and other hazards. Review of the Care Plan dated 11/22/2012 identified as a problem/need "#8, 9 c/p: Mood, Behavior..." Approaches included "...Code alert, check every shift..." On 12/30/2012 the care plan was updated with "code alert for elopement attempt". The approaches included "observe for safety, check code alert q (every) shift, observe and document elopement attempts." Further review revealed no problem area and no interventions related to wandering or exit seeking; the 1/5/2013 incident was not care planned. Review of the "Elopement Risk Assessment" dated 8/16/2012 revealed the resident was "at risk" for elopement. However, no interventions were in place. Another "Elopement Risk Assessment" dated 10/4/2012 revealed the resident was no longer at risk for elopement. Further record review revealed, Resident #1 had not been re-assessed related to the 12/30/2012 Elopement, even though the resident was known to wander and exit seek prior to 12/30/2012. On 1/14/2013 at 4:45 PM the Administration was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-280, F-323 and F-490 at a scope and severity of "K". The Substandard Quality of Care and/or Immediate Jeopardy existed on 1/05/2013 related to the failure of the facility to safeguard residents related to accidents and hazards. The Switzer double doors, Beauty Shop door and the Switzer exit door were not on the Code Alert system and Resident #1 was found trapped behind a closed door of the Switzer machine shop with multiple chemicals and hazards on 1/5/13. On 1/14/2013 the Switzer Exit door was not alarmed and was unable to be secured. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 1/15/2013 had been implemented by the facility and were in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the policy regarding resident elopement. The Administrator was informed of this on 1/15/2013 at 5:30 PM. The Immediate Jeopardy at F-280 was removed but the citations remained at a lower scope and severity of "E".

On the days of the Complaint and Extended Surveys based on record review and interview, Immediate Jeopardy was identified as existing in the facility as of 02/14/2012. Allegations of sexual abuse were made involving three residents and Certified Nursing Assistant (CNA)#1; the facility's Medical Director failed to implement policies related to identification, reporting and investigating allegations of sexual abuse, and failed to ensure each resident was assessed and protected from further potential abuse. The findings included: Review of the facility obtained statement taken by Registered Nurse (RN) #1 from Resident #1 on 02/14/2012 at 9:25 PM revealed: "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it-has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." Review of the facility obtained statement taken by RN #1 from Resident #2 on 02/14/2012 at 9:45 PM revealed: "About 2 weeks ago, it's been a good while back, he sat down and had his "thang" out and then he put it back. He was out on the porch. I believe we were out on the porch and he pulled his britches down, its been so long ago. I saw his penis, it was red looking. I left, I haven't spoken to him since....it was very embarrassing, I can't even face him." Further review of the Investigative File revealed staff statements were taken on 02/14/2012 and 02/15/2012, the statements referenced the night shift of 02/14/2012 only for Resident #1. A thorough investigation had not been conducted to include Resident #2 or to include staff statements for the alleged time frames. No staff education was completed on Abuse/Neglect, reporting or sexual abuse related to the incident. In addition, the facility failed to contact the local police department with the allegations. (Resident #1's family member called the police on the evening of 02/14/2012, there was no evidence that Resident #2 was mentioned in the report). The facility did not contact the attending physician and the Medical Director until 02/15/2012. Residents #1 and #2 were not assessed, physically, emotionally or psychosocially. Other residents were not identify, interview or assessed that might have been effected by potential abuse. During an interview on 02/21/2012 at 4:30 PM, the Medical Director stated that he was notified of the sexual abuse allegation on 02/15/2012. He stated that he did not assess the residents since there was no reported penetration. He stated that since it was emotional upsetness there was no reason for an assessment. The Medical Director stated that Resident #2 was interviewed several times regarding the allegation, he stated that when pressed for information, the resident would "clam up." The Medical Director stated that CNA #1 had 2 prior accusations before Residents #1 and #2. During another interview on 02/22/2012 at 12:10 PM, the DON (director of nurses) was asked about the 2 prior accusations, she stated that Resident #6 had stated she was having CNA #1's baby. The DON stated that no investigation had been completed related to the incident. The other accusation was reported to the State Agency in September 2011. Review of the Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS of "3" and no behaviors, hallucinations or [MEDICAL CONDITION] were coded as occurring in the assessment period. Record review revealed, Resident #6 was seen by the psychiatrist 12/19/2011 when the psychiatrist noted increased [MEDICAL CONDITION] and hallucinations. The residents medications were increased. Review of the Nurse's Notes revealed on 12/12/2011 the only documentation was "body audit-skin warm and dry, intact. On 12/19/2011 at 12 PM, (Resident #6) upset because "a girl pushed me out here and shouldn't have, waiting on (CNA #1). (CNA #1) will come and get me and take care of me...you don't know, he'll be here to get me... Attempted to reassure the resident." Further review of the Nurse's Notes from November and December 2011 revealed no other documentation of behaviors, hallucinations or [MEDICAL CONDITION]. Cross Refers to the following citations: 483.10(b)(11) Notification, F-157 was identified at a scope and severity of "K". The facility staff failed to notify the Physician and the Responsible Party of changes in condition or accident. The facility failed to timely notify the Attending Physician/Medical Director of an allegation of sexual abuse. The facility also failed to contact 1 of 3 resident's responsible parties regarding an allegation of sexual abuse. The facility also failed to assure 2 of 3 residents reviewed for blood sugar management had their physician notified of low blood sugars (Residents #1 and #7). 483.13(c) Staff treatment of [REDACTED]." The facility failed to identify, report and thoroughly investigate allegations of sexual abuse for 3 of 3 residents reviewed for sexual abuse. Residents #1, #2 and #6 alleged sexual abuse against Certified Nursing Assistant (CNA) #1. 483.13(c) Develop/Implement Abuse/Neglect, Etc. Policies, F-226 was identified at Substandard Quality of Care and Immediate Jeopardy at a scope and severity of "K". Residents #1, #2, and #3 alleged sexual abuse against Certified Nursing Assistant #1 the facility failed to follow it's policy regarding reporting, investigating and identifying potential abuse related to the allegations. 483.15(g)(1) Medically Related Social Services, F-250 was identified at Substandard Quality of Care and Immediate Jeopardy at a scope and severity of "K". The facility failed to provide medically related social services to three of three residents involved in allegations of sexual abuse. Residents #1, #2 and #6 alleged sexual abuse against Certified Nurses Assistant #1. No Social Service interventions were put in place related to the allegations. 483.20(k)(3) Services Provided Meet Professional Standards, F-281 was identified at Immediate Jeopardy at a scope and severity level of "K". The facility staff failed to identify and assess 3 of 3 residents involved in allegations of sexual abuse (Residents #1, #2 and #6). Facility staff also failed to identify and assess other residents that may have been affected by potential abuse. In addition, facility staff failed to recognize, follow up on and contact the physician regarding blood sugars consistently below 60 mg/dl for two of three residents reviewed receiving Insulin (Residents #1 and #7). . 483.75 Effective Administration, F-490 was identified at Immediate Jeopardy at a scope and severity of "K". The facility Administration failed to follow accepted procedures for the investigation of incidents involving alleged sexual abuse and failed to educate all facility staff regarding the allegations and any interventions necessary to protect all residents at risk of becoming victims. On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended.

On the days of the Complaint and Extended Surveys, Immediate Jeopardy was identified related to the facility staffs failure to identify and assess 3 of 3 residents involved in allegations of sexual abuse (Resident #1, #2 and #6). Facility staff also failed to identify and assess other residents for potential abuse. In addition, facility staff failed to recognize, follow up on and contact the physician regarding blood sugars consistently below 60 mg/dl for two of three residents reviewed receiving Insulin (Residents #1 and #7). The findings included: Review of the "Summary of Investigation on allegation of sexual abuse" dated 02/20/2012 revealed: "During the course of this investigation, another residents name (Resident #2) was mentioned as possibly being involved. (Resident #2's) name is mentioned by the original complainant as having experienced a similar with the employee (sic) in question prior to her experience. (Resident #2) is a close friend of (Resident #1) at the nursing home. At first it was thought that the incident in question had taken place on Tuesday night February 14, 2012, however, it turns out that this was not the case and that the incident happened 2-3 weeks ago with (Resident #2) and 2-3 days ago with (Resident #1). Social Service Director (SSD) and Director of Nursing (DON) have interviewed several employees and residents for similar incidents with the CNA in question. DON visited with (Resident #2) on Wednesday (2/15/12) and resident stated that nothing had happened to her. Resident was given the name of the CNA in question and all she said was "he is sweet and kind man, he does not to a lot for me but he is always appropriate, he has never touched me or asked me to do something." DON had a witness in the room at the time. DON also went back to see (Resident #2) in the afternoon to see if her story had changed, it had not. Later on in the week both SSD and DON went back to (Resident #2) and her story stayed the same. Today we asked (Registered Nurse #1), the nurse involved in the original incident to go back to (Resident #2) and ask her the questions again, and take the original statement with her. A copy of the second statement is attached as written by (RN #1) during the interview today. (CNA #1) was suspended immediately and asked to leave the building. The following day he came to the facility in the morning and wrote his statement which is attached herewith. Looking at the 24 hour report sent to DHEC, (Resident #2's) name does not appear on this, we apologize for the oversight and the RN preparing the document has been educated that every resident's name should appear on the allegation. Administration will also look more closely in the future. Returning to the office the following day the DON looked through all of the assignment sheets from January 1st 2012 through February 14, 2012. Copies of these are enclosed, it was discovered that on 2 occasions only in that 6 week period, February 11 and 12, (CNA #1) had (Resident #1 and Resident #2) respectively. (CNA #1) personnel file has been reviewed with no compromising documentation found. There have been no disciplinary actions against him, his background check was good as is the status of his license. Examination of the residents was not done because there were no allegations of anything other that "putting his penis in my hand." The Union County Sheriff's Department as well as (SLED) met at the nursing home on Friday 2/17/12 at 10:45 AM to speak with the Administrator, DON and SSD... On Wednesday 2/22/12 (SLED) is coming back to (facility) with posters on the new Elder Justice Act ratified at the end of 2010. He will do an education piece to all the manager who will in turn in service the staff. The posters will be put up in the Service Hall where all staff will be able to see them." Review of the facility obtained statement taken by Registered Nurse (RN) #1 from Resident #1 on 02/14/2012 at 9:25 PM revealed: "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it-has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." Review of the facility obtained statement taken by RN #1 on 2/14/12 at 9:45 PM from Resident #2 revealed: "About 2 weeks ago, it's been a good while back, he sat down and had his "thang" out and then he put it back. He was out on the porch. I believe we were out on the porch and he pulled his britches down, its been so long ago. I saw his penis, it was red looking. I left, I haven't spoken to him since...it was very embarrassing, I can't even face him." Review of the second statement obtained by RN #1 on 2/20/12 revealed Resident #2 stated that she did not see CNA #1's penis and that he had never been inappropriate with her. Review of the SSD (social service director) statement dated on 02/15/2012 revealed: "SSD met with (Resident #1's Responsible Party (RP) and Resident #1) to discuss what had happened to her last night. (Resident #1) stated that (CNA #1) had come behind the curtain in her room and placed his penis in her hand. SSD asked her if he had done anything else with his hands or penis during this time. She stated no. (RP) informed (Resident #1) that this is a serious allegation and that she could send this man that she is accusing to jail for a long time, (Resident #1) said I know, he did this to me. SSD asked her when this happened, she stated a weeks ago, I don't remember which shift my mind is as short as my pinky finger. SSD asked (Resident #1) why she did not report this as soon as this happened. She stated , I was scared. SSD: what were you scared of? (Resident #1): I was scared he would come back in here and do other things to me. I saw him after this happened to me in the dining room. He spoke to me when he saw me in the dining room, but he was always nice and would say hello or how are you doing. SSD asked (Resident #1) about her feelings about moving from the facility, as she is apparently not safe in this facility. She stated she would go, (RP) said I know she will miss some of her friends..." Further review of the Investigative File revealed the facility failed to assess, physically, emotionally or psychosocially, Residents #1 and #2. The facility also did not identify, interview or assess other residents at the facility that might have been effected by potential abuse. During an interview on 02/21/2012 at 12 PM, the Director of Nurses confirmed no assessments had been completed for Residents #1 and #2 and confirmed no other resident were assessed for potential sexual abuse. During an interview on 02/21/2012 at 4:30 PM, the Medical Director stated that he was notified of the sexual abuse allegation on 02/15/2012. He stated that he did not assess the residents since there was no reported penetration. He stated that since it was emotional upsetness there was no reason for an assessment. The Medical Director stated that Resident #2 was interviewed several times regarding the allegation, he stated that when pressed for information, the resident would "clam up." The Medical Director stated that CNA #1 had 2 prior accusations before Residents #1 and #2. During another interview on 02/22/2012 at 12:10 PM, the DON was asked about the 2 prior accusations, she stated that Resident #6 had stated she was having CNA #1's baby. The DON stated that no investigation had been completed related to the incident. The other accusation was reported to the State Agency. During an interview on 02/22/2012 at 3 PM, the SSD provided documentation to the surveyor related to Resident #6's allegation. Review of the documentation revealed: "SSD went into (Resident #6's) room on 12/12/2011 and she was very upset and crying...she was very upset and then stated she had had his (CNA #1's) baby and put the baby in the dumpster and the cops were looking for her...SSD ensured (sic) that (Resident #6) had an appointment with her psychiatrist that day, SSD included a letter to (the psychiatrist) regarding the behaviors she is having and requesting an evaluation." The statement was signed and dated on 12/14/2012 with a statement of "SSD has seen no signs of further problems as medications were adjusted by (Psychiatrist). A typed letter that had a handwritten date of 12/12/2012 (the year 12 was lined through with a number one) that revealed: "I am writing this letter on behalf of (Resident #6). She had hallucinations last week..." Record review revealed, Resident #6 was not seen by the psychiatrist until 12/19/2011 when the psychiatrist noted increased [MEDICAL CONDITION] and hallucinations. The residents medications were increased. On 02/22/2012 additional information was provided regarding staff statements. Review of the facility obtained statement dated 02/22/2012 from Staff Assistant #1 revealed: "To whom it may concern, (HR) call me at 4:15 PM on 2/22/12 to ask me questions about something I told (Administrator and Staff Development) this morning about (Resident #2) had told (Resident #1) about (CNA #1). (Resident #1) told me she love me and could trust me. Then she told me what (Resident #2) said that (CNA #1) came into her room, was playing with his penis, he pull it out, (Resident #2) said it was real red then he started to play with her breast that's what (Resident #1) told me. Then (Resident #1) said (Resident #2) was scared of him. (Resident #1) also said what if he bothered (roommate), she couldn't tell anybody about it. (Resident #1) said he should try to bother her should would knock the hell out of him. I told her she should tell someone, that's when she said (Resident #2) was scared of him. (Resident #1) told me about the sexual abuse in Jan second week 2012. I was putting ice on the halls on Unit I. Then I went to (Risk Manager) my supervisor. I ask what I should do, she told me to go to Social Services, I did. I talk with (SSD and SSA) and told her what (Resident #1) had told me. She said (CNA #1) had already been sent 3 times before. (????suspension???) She said she could talk with (Resident #2) and (Resident #1) without them knowing I told her about a report of maybe sexual abuse. (SSD) said she would take care of it. I went to Social Services before 11 AM second week in [DATE]." Additional comments were added by the Staff Assistant: "(SSD) also told me that she didn't want to see (CNA #1) to lose his job. I was also told the names of 2 of the residents who had allegations against (CNA #1). (SSD) told me the names!." Review of the facility obtained statement from the Risk Manager dated 02/22/2012 at 6:30 PM revealed, "(Staff Assistant) stopped me in hall and stated (Resident #2 mentioned to her that she had been touched on the breast, should she tell someone or just keep to herself. I told her to tell Social Services. Later (Staff Assistant) told (SSD). That is the last time it was mentioned." Review of the facility obtained statement from the SSD on 02/22/2012 revealed: "I had no knowledge of sexual abuse on (Resident #2) until I read it in (RN #1's) statement on 2/15/12...." During an interview on 02/24/2012 at 1:15 PM, the ADON (assistant director of nurses) confirmed the written statements and stated that the Staff Assistant reported the incident to her supervisor appropriately. The ADON stated that her supervisor was Risk Management and that she attended all the morning stand up meetings and QA (quality assurance) meetings. The ADON stated that she did not report the incident to anyone. The ADON stated that the SSD, SSA and the Risk Manager had all been suspended. The ADON confirmed that the Risk Manager was considered part of the facility's Administration and was responsible for relaying the information to the rest of the Administration. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Resident #1's Physician order [REDACTED]. The original order was written on 10/13/2011. Further review revealed the resident was to have finger stick blood sugars twice daily at 6 AM and 8 PM. Review of the Symptomatic Protocol signed by the Physician on 02/12/2010 revealed: "[DIAGNOSES REDACTED]/Insulin Reaction - Administer sweetened beverage and/or Glucostat. May administer [MEDICATION NAME] 1 amp/1 mg STAT PRN. If resident has symptoms of insulin reaction (diaphoresis, irritability or altered level of consciousness) and/or blood sugar below 55 may repeat [MEDICATION NAME] once PRN." Special Instructions: "a. Determine blood sugar by finger stick. b. Administer treatments as necessary. c. Re-check 30 minutes after treatment. d. Notify MD immediately if condition hasn't resolved after 30 minutes. Notify MD prior to next insulin or other hypoglycemic agent in order to discuss strategy to prevent recurrence. f. Contact provider if glucose level below 55." Review of the Finger Stick Blood Sugar (FSBS) Record from December 1, 2011 through February 17, 2012 revealed the following: 12/14/2011 at 6 AM FSBS= 46 given juice. No re check was documented. No nurses notes were documented and no physician notification was located. 12/19/2011 at 6 AM FSBS= 55, no intervention and no follow up was documented; 12/22/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/23/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/25/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/28/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 01/3/2012 at 6 AM, FSBS=55, "drink and cookies" were given, no follow up was documented; 01/06/2012 at 6 AM, FSBS=55, "juice and cookie" given, no intervention and no follow up was documented; 01/18/2012 at 6 AM, FSBS=56, "cookies and juice" given, no follow up was documented. 01/19/2012 at 6 AM, FSBS=56, "juice and 1 graham cracker" given, no follow up was documented on log; 01/20/2012 at 6 AM, FSBS= 34, juice and cookies were given, no documented recheck and no physician notification; 01/30/2012 at 6 AM, FSBS=57, "juice/cookies" were given, no recheck was documented; 02/01/2012 at 6 AM, FSBS=56, juice and cookies were given, no documented recheck was recorded; 02/03/2012 at 6 AM, FSBS=46, juice was given and a recheck of 7? was recorded, however, no physician notification was located; 02/06/2012 at 6 AM, FSBS=49, juice was given, a recheck of 58 was documented, however, no physician notification was located; 02/14/2012 at 6 AM, FSBS was 55, no interventions, no rechecks and no physician notification was located; 02/16/2012 at 6 AM, FSBS was 46, juice was given and a recheck of 86 was recorded, however no physician notification was located. Review of the Nurse's Notes revealed on 01/19/2012 at 6:30 AM, "FSBS @ 0600 56, (after) 15 grams (Orange Juice) and graham cracker, FSBS (increased) to 81..." On 02/17/2012 at 2 AM, "...resident sitting in w/c (wheelchair) c chin on chest, clammy and wet with perspiration. Checked FSBS @ 12:30 AM was 26, [MEDICATION NAME] 15 given given PO (by mouth) followed by 3- 8 ounce cups of MedPass 2.0. FSBS rechecked @ 12:45 AM-30, another tube of [MEDICATION NAME] given per symptomatic protocol, rechecked @ 1AM -39. MD called, (Nurse Practitioner) responded. Ordered to give another tube of [MEDICATION NAME] and call 9-1-1. EMS arrived @ 1:10 AM INT started, D50 given, rechecked 228. Resident responding but very sluggish, still not acting like herself. Transferred to (local hospital) for further evaluation and treatment. Resident's daughter contacted c message left on voicemail. Transported @ 1:50 AM." Besides the above two entries, no other documentation was located in the Nurse's Notes or Finger stick log regarding physician notification, interventions and re-checks of low blood sugars. Review of the Physician's Progress Notes revealed on 01/09/2012 the provider documented: "The patient's last A1C was 5.7 and it is in excellent control..." The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the Fingerstick Blood Sugar (FSBS) Record from January and February 2012 revealed on 01/01/2012 the 6 AM blood sugar was 55, juice was given. There was no documented recheck and no physician notification. On 01/29/2012 at 6 AM, the FSBS was 59, juice was given, however there was not a documented recheck. On 02/02/2012 at 6 AM, the FSBS was 47, juice and cookies were given, there was no recheck documented and no physician notification was located. On 2/8 at 6 AM, the FSBS was 55, juice and cookies were given, no recheck was documented. On 02/24/2012 at 6 AM, the FSBS was 58, juice and cookies were given, no recheck was documented. Review of the Nurse's Notes revealed on 02/24/2012 at 6 AM, "FSBS 58, Fig newtons and (two) cranberry juices given, no insulin required." Further review of the Nurses Notes from January 2012 and February 2012 revealed no other documentation related to low blood sugars, rechecks or physician notification. During an interview on 02/24/2012 at 3:45 PM, the Attending Physician stated he was not made aware of Resident #1's low blood sugars. He stated that he does review the Fingerstick Records, however not on every visit and there are times when the logs were not available. He stated that he relied on the nursing staff to inform him of problems or concerns. He confirmed the Symptomatic Protocol including the order to contact the physician with blood sugars less than 55. The Attending Physician also confirmed that a recheck of the low blood sugar was part of the protocol and should have been done. The Attending Physician stated that he reviewed the blood sugars for Resident #1 after she was sent to the hospital on [DATE]. He confirmed at that point he was aware the protocol was not being followed, interventions and rechecks were not documented and that the physician had not been notified per the protocol. The Physician stated that the facility informed him Resident #1 was an isolated case and that there were no other residents where the protocol had not been followed. Resident #7's low blood sugars with no rechecks and no physician notification was shared with the physician. During an interview on 02/24/2012 at 5 PM, the Director of Nurses confirmed the low blood sugars for both Resident #1 and #7. She confirmed there were no documented rechecks for some of the low blood sugars and confirmed the physician had not been notified per the protocol. The DON also confirmed that during the monthly medication reviews, the Pharmacist also did not inform the physician of the low blood sugars. The DON agreed that if an intervention was provided to a resident, then a follow up should be completed with the appropriate documentation. On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended.

On the days of the Complaint and Extended Survey based on record reviews and interviews, Immediate Jeopardy was identified existing in the facility as of 02/14/2012 related to the facility's failure to utilize its resources effectively and efficiently to attain or maintain the highest practicable well being of each resident. The facility's Administration failed to identify, report and thoroughly investigate allegations of sexual abuse. The findings included: A complaint survey was conducted on 02/21/2012 as a result of a facility reported incident. Resident #1 reported during a telephone conversation, an incident of alleged sexual abuse to her daughter, on the evening of 02/14/2012. Her daughter came to the facility and reported the incident to Registered Nurse (RN) #1. In the following statement taken by RN #1 on 02/14/2012 at 9:25 PM Resident #1 stated, "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it - has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." On 02/22/2012 the Administrator contacted the State Agency with additional information related to the investigation regarding Residents #1 and #2. A faxed report indicated, "Staff Assistant reported to nursing that she had reported to her supervisor and Social Services about a month ago that Resident #1 reported to her that CNA #1 had sexually abused Resident #2." During a telephone conversation on 02/22/2012 the Administrator stated this was the first he had heard of this allegations. Review of the facility obtained statement dated 2/22/2012 from Staff Assistant #1 revealed: "To whom it may concern, (HR) call me at 4:15 PM on 2/22/12 to ask me questions about something I told (Administrator and Staff Development) this morning about (Resident #2) had told (Resident #1) about (CNA #1). (Resident #1) told me she love me and could trust me. Then she told me what (Resident #2) said that (CNA #1) came into her room, was playing with his penis, he pull it out, (Resident #2) said it was real red then he started to play with her breast that's what (Resident #1) told me. Then (Resident #1) said (Resident #2) was scared of him. (Resident #1) also said what if he bothered (roommate), she couldn't tell anybody about it. (Resident #1) said he should try to bother her should would knock the hell out of him. I told her she should tell someone, that's when she said (Resident #2) was scared of him. (Resident #1) told me about the sexual abuse in Jan second week 2012. I was putting ice on the halls on Unit I. Then I went to (Risk Manager) my supervisor. I ask what I should do, she told me to go to Social Services, I did. I talk with (SSD and SSA) and told her what (Resident #1) had told me. She said (CNA #1) had already been sent 3 times before. (????suspension???) She said she could talk with (Resident #2) and (Resident #1) without them knowing I told her about a report of maybe sexual abuse. (SSD) said she would take care of it. I went to Social Services before 11 AM second week in [DATE]." Additional comments were added by the Staff Assistant: "(SSD) also told me that she didn't want to see (CNA #1) to lose his job. I was also told the names of 2 of the residents who had allegations against (CNA #1). (SSD) told me the names!." Review of the facility obtained statement from the Risk Manager dated 02/22/2012 at 6:30 PM revealed, "(Staff Assistant) stopped me in hall and stated (Resident #2 mentioned to her that she had been touched on the breast, should she tell someone or just keep to herself. I told her to tell Social Services. Later (Staff Assistant) told (SSD). That is the last time it was mentioned." Review of the facility obtained statement from the SSD on 02/22/2012 revealed: "I had no knowledge of sexual abuse on (Resident #2) until I read it in (RN #1's) statement on 2/15/12...." During an interview on 02/24/2012 at 1:15 PM, the ADON (assistant director of nurses) confirmed the written statements and stated that the Staff Assistant reported the incident to her supervisor appropriately. The ADON stated that her supervisor was Risk Management and that she attended all the morning stand up meetings and QA (quality assurance) meetings. The ADON stated that she did not report the incident to anyone. The ADON stated that the SSD, SSA and the Risk Manager had all been suspended. The ADON confirmed that the Risk Manager was considered part of the facility's Administration and was responsible for relaying the information to the rest of the Administration. Cross Refers to the following citations: 483.10(b)(11) Notification, F-157 was identified at a scope and severity of "K". The facility staff failed to notify the Physician and the Responsible Party of changes in condition or accident. The facility failed to timely notify the Attending Physician/Medical Director of an allegation of sexual abuse. The facility also failed to contact 1 of 3 resident's responsible parties regarding an allegation of sexual abuse. The facility also failed to assure 2 of 3 residents reviewed for blood sugar management had their physician notified of low blood sugars (Residents #1 and #7). 483.13(c) Staff treatment of [REDACTED]." The facility failed to identify, report and thoroughly investigate allegations of sexual abuse for 3 of 3 residents reviewed for sexual abuse. Residents #1, #2 and #6 alleged sexual abuse against Certified Nursing Assistant (CNA) #1. 483.13(c) Develop/Implement Abuse/Neglect, Etc. Policies, F-226 was identified at Substandard Quality of Care and Immediate Jeopardy at a scope and severity of "K". Residents #1, #2, and #3 alleged sexual abuse against Certified Nursing Assistant #1 the facility failed to follow it's policy regarding reporting, investigating and identifying potential abuse related to the allegations. 483.15(g)(1) Medically Related Social Services, F-250 was identified at Substandard Quality of Care and Immediate Jeopardy at a scope and severity of "K". The facility failed to provide medically related social services to three of three residents involved in allegations of sexual abuse. Resident #1, #2 and #6 alleged sexual abuse by Certified Nurses Assistant #1. No Social Service interventions were put in place related to the allegations. 483.20(k)(3) Services Provided Meet Professional Standards, F-281 was identified at Immediate Jeopardy at a scope and severity level of "K". The facility staff failed to identify and assess 3 of 3 residents involved in allegations of sexual abuse (Residents #1, #2 and #6). Facility staff also failed to identify and assess other residents that may have been affected by potential abuse. In addition, facility staff failed to recognize, follow up on and contact the physician regarding blood sugars consistently below 60 mg/dl for two of three residents reviewed receiving Insulin (Residents #1 and #7). . 483.75(i) Medical Director, F-501 was identified at Immediate Jeopardy at a scope and severity of "K". The Medical Director failed to ensure that the facility policies and procedures were implemented for residents with allegations of sexual abuse. On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended. First Follow-Up Visit During an unannounced, onsite visit on 03/30/2012 at 2:15 PM, it was determined based on interviews, observations, limited record review, and review of facility policies that the Allegation of Compliance had been implemented by the facility and was in practice as of 03/01/2012. The Allegation of Compliance with a completion date of 03/01/2012 was submitted by the facility. The actions listed in the Allegation of Compliance included the following: *Resident #1 is no longer at the facility. discharge date [DATE] *Resident #2's responsible party was notified of the allegation of sexual abuse on 02/22/2012. Attempts began on 02/15/2012 but were unsuccessful. Current phone numbers have been obtained for future reference. *Physician notified 02/21/2012 of possible sexual abuse. *Education has been completed on 02/24/2012 for all licensed staff related to the revised Abuse and Neglect policy. Education included requirements of notifications to MD and Responsible Parties. Education provided by the DON (director of nurses). *Resident's #2 and #6 had Physical Assessments conducted 02/21/2012 *Resident #2 had Psychosocial Assessment completed by the DON on 02/21/2012. Psychosocial Assessments will continue weekly for 30 days. *Resident #6 had Psychosocial Assessment conducted by the MDS Nurse on 02/25/2012. Psychosocial Assessments will continue weekly for 30 days. Other immediate corrective actions included: *Physical Assessments were performed for all residents on 02/21/2012 by Licensed Nursing *Psychosocial Assessments were completed for all residents by 02/25/2012. Assessments completed by Nursing Administration, Licensed Nurses, Admissions Coordinator, Activities Director, Dietary Managers and Business Manager. *Local Police have investigated the allegations of abuse. Union County Sheriff's Office notified 02/21/2012. *SLED (South Carolina Law Enforcement) has investigated all allegations of abuse and failure to report. SLED contacted 02/15/2012. *All families were contacted by the Administrative staff on 02/16/2012 and 02/22/2012 to inquire of any knowledge of abuse. *Revisions to Abuse and Neglect policy included: *Specific procedures related to sexual abuse *Specific procedures related to reporting allegations of abuse *Information on the Elder Justice Act *Education completed for all staff on 02/24/2012 related to the revised Abuse and Neglect policy. Education provided by DON. Education will continue monthly for 90 days, annually and upon hire for Abuse and Neglect. *Employees suspended pending the investigation include: -Certified Nurse Aide (CNA) #1 (suspended 02/14/2012 - terminated 03/07/2012) -Social Services Director - 02/22/2012 - pending -Social Services Assistant - 02/22/2012 - pending -Risk Manager - 02/22/2012 - pending *Abuse and Neglect education provided to Administration Staff on 02/24/2012 The citation at F-490 remained at a lowered scope and severity of "E". The facility will be in compliance at F-490 when an acceptable Plan of Correction is submitted and a follow-up visit is conducted to determine that the facility has implemented their Plan of Correction as stated.

On the days of the Complaint and Extended Survey based on record review and interview, Immediate Jeopardy was identified existing in the facility as of 02/14/2012 related to the facility failure to notify the Physician and the Responsible Party (RP) of changes in condition. The facility failed to timely notify the Attending Physician/Medical Director of an allegation of sexual abuse. The facility also failed to contact 1 of 3 resident's responsible parties regarding an allegation of sexual abuse. The facility also failed to ensure 2 of 3 residents reviewed for blood sugar management had their physician notified of low blood sugars (Resident #1 and #7). The findings included: The facility admitted Resident #2 on with [DIAGNOSES REDACTED]. Review of the Social Services notes dated 02/15/2012 revealed: "DON (Director of Nurses) and SSD (Social Services Director) reviewed statements regarding sexual abuse allegations against another resident in facility, nurses statements included (Resident #2) involvement with separate incident involving same male CNA (certified nursing assistant) (CNA #1). Attempted family contact with daughter/RP (Responsible Party) at 9:50 AM and 3 PM. Home phone had no answer/no voicemail, cell had no answer no VM (voice mail) box set up, no response." Review of the facility obtained statement taken by Registered Nurse (RN) #1 on 02/14/2012 at 9:45 PM from Resident #2 revealed: "About 2 weeks ago, it's been a good while back, he sat down and had his "thang" out and then he put it back. He was out on the porch... I believe we were out on the porch and he pulled his britches down. - its been so long ago. I saw his penis, it was red looking. I left. I haven't spoken to him since. ...it was very embarrassing - I can't even face him." Further review of the Investigative File revealed the facility also did not contact the attending physician and the Medical Director until 02/15/2012. During an interview on 02/21/2012 at 12 PM, the Director of Nurses confirmed that the Physician was not contacted until 02/15/2012. During an interview on 02/21/2012 at 3:15 PM, the SSD and DON confirmed that the facility attempted to contact the Responsible Party (RP) for each resident in the facility. The Administrative staff was asked to notify the RP of each resident in the facility and ensure them the residents were safe. The DON confirmed that there was no documentation that the RP was contacted, who contacted them and when they were contacted. The SSD and DON both confirmed that as of 02/21/2012, Resident #2's responsible party had not been contacted regarding the sexual abuse allegation. Both stated that the facility was unable to reach the RP via telephone. When asked if other methods of communication had been attempted, both stated no other method had been attempted to contact the resident's RP. During an interview on 02/21/2012 at 4:30 PM, the Medical Director stated that he was notified of the sexual abuse allegation on 02/15/2012. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Symptomatic Protocol signed by the Physician on 02/12/2010 revealed: "[DIAGNOSES REDACTED]/Insulin Reaction- Administer sweetened beverage and/or Glucostat. May administer [MEDICATION NAME] 1 amp/1 mg STAT PRN. If resident has symptoms of insulin reaction (diaphoresis, irritability or altered level of consciousness) and/or blood sugar below 55 may repeat [MEDICATION NAME] once PRN." Special Instructions: "a. Determine blood sugar by finger stick. b. Administer treatments as necessary. c. Re-check 30 minutes after treatment. d. Notify MD immediately if condition hasn't resolved after 30 minutes. Notify MD prior to next insulin or other hypoglycemic agent in order to discuss strategy to prevent recurrence. f. Contact provider if glucose level below 55." Review of the Finger Stick Blood Sugar (FSBS) Record from December 1, 2011 through February 17, 2012 revealed the following: 12/14/2011 at 6 AM FSBS= 46 given juice. No re check was documented. No nurses notes were documented and no physician notification was located; 12/19/2011 at 6 AM FSBS= 55, no intervention and no follow up was documented; 12/22/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/23/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/25/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/28/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 01/3/2012 at 6 AM, FSBS=55, "drink and cookies" were given, no follow up was documented; 01/6/2012 at 6 AM, FSBS=55, "juice and cookie" given, no intervention and no follow up was documented; 01/18/2012 at 6 AM, FSBS=56, "cookies and juice" given, no follow up was documented; 01/19/2012 at 6 AM, FSBS=56, "juice and 1 graham cracker" given, no follow up was documented on log; 01/20/2012 at 6 AM, FSBS= 34, juice and cookies were given, there was no documented recheck and no physician notification; 01/30/2012 at 6 AM, FSBS=57, "juice/cookies" were given, no recheck was documented; 02/1/2012 at 6 AM, FSBS=56, juice and cookies were given, no documented recheck was recorded; 02/3/2012 at 6 AM, FSBS=46, juice was given and a recheck of 7? was recorded, however, no physician notification was located; 02/6/2012 at 6 AM, FSBS=49, juice was given, a recheck of 58 was documented, however, no physician notification was located; 02/14/2012 at 6 AM, FSBS was 55, no interventions, no rechecks and no physician notification was located; 02/16/2012 at 6 AM, FSBS was 46, juice was given and a recheck of 86 was recorded, however no physician notification was located. Review of the Nurse's Notes revealed on 01/19/2012 at 6:30 AM, "FSBS @ 0600 56, (after) 15 grams (Orange Juice) and graham cracker, FSBS (increased) to 81..." On 2/17/12 at 2 AM, "...resident sitting in w/c (wheelchair) c chin on chest, clammy and wet with perspiration. Checked FSBS @ 12:30 AM was 26, [MEDICATION NAME] 15 given given PO (by mouth) followed by 3- 8 ounce cups of MedPass 2.0. FSBS rechecked @ 12:45 AM-30, another tube of [MEDICATION NAME] given per symptomatic protocol, rechecked @ 1 AM -39. MD called, (Nurse Practitioner) responded. Ordered to give another tube of [MEDICATION NAME] and call 9-1-1. EMS arrived @ 1:10 AM INT started, D50 given, rechecked 228. Resident responding but very sluggish, still not acting like herself. Transferred to (local hospital) for further evaluation and treatment. Resident's daughter contacted c message left on voicemail. Transported @ 1:50 AM." Besides the above two entries, no other documentation was located in the Nurses Notes or Finger stick log regarding physician notification, interventions and re-checks of low blood sugars. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the Fingerstick Blood Sugar Record from January and February 2012 revealed on 01/01/2012 the 6 AM blood sugar was 55, juice was given. There was no documented recheck and no physician notification. On 01/29/2012 at 6 AM, the FSBS was 59, juice was given, however there was not a documented recheck. On 02/2/2012 at 6 AM, the FSBS was 47, juice and cookies were given, there was no recheck documented and no physician notification was located. On 02/08/2012 at 6 AM, the FSBS was 55, juice and cookies were given, no recheck was documented. On 02/24/2012 at 6 AM, the FSBS was 58, juice and cookies were given, no recheck was documented. Review of the Nurse's Notes revealed on 02/24/2012 at 6 AM, "FSBS 58, Fig newtons and (two) cranberry juices given, no insulin required." Further review of the Nurses Notes from January 2012 and February 2012 revealed no other documentation related to low blood sugars, rechecks or physician notification. During an interview on 02/24/2012 at 3:45 PM, the Attending Physician stated he was not made aware of Resident #1's low blood sugars. He stated that he does review the Fingerstick Records, however not on every visit and there are times when the logs were not available. He stated that he relied on the nursing staff to inform him of problems or concerns. He confirmed the Symptomatic Protocol including the order to contact the physician with blood sugars less than 55. The Attending Physician also confirmed that a recheck of the low blood sugar was part of the protocol and should have been done. The Attending Physician stated that he reviewed the blood sugars for Resident #1 after she was sent to the hospital on [DATE]. He confirmed at that point he was aware the protocol was not being followed, interventions and rechecks were not documented and that the physician had not been notified per the protocol. The Physician stated that the facility informed him Resident #1 was an isolated case and that there were no other residents where the protocol had not been followed. Resident #7's low blood sugars with no rechecks and no physician notification was shared with the physician. During an interview on 02/24/2012 at 5 PM, the Director of Nurses confirmed the physician had not been notified per the protocol. The DON also confirmed that during the monthly medication reviews, the Pharmacist also did not inform the physician of the low blood sugars. On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended.

On the days of the Complaint and Extended Survey based on record review and interview, Immediate Jeopardy was identified existing in the facility as of 02/14/2012 related to the facility failure to notify the Physician and the Responsible Party (RP) of changes in condition. The facility failed to timely notify the Attending Physician/Medical Director of an allegation of sexual abuse. The facility also failed to contact 1 of 3 resident's responsible parties regarding an allegation of sexual abuse (Resident #2). The facility also failed to ensure 2 of 3 residents reviewed for blood sugar management had their physician notified of low blood sugars (Resident #1 and #7). The findings included: The facility admitted Resident #2 on with [DIAGNOSES REDACTED]. Review of the Social Services notes dated 02/15/2012 revealed: "DON (Director of Nurses) and SSD (Social Services Director) reviewed statements regarding sexual abuse allegations against another resident in facility, nurses statements included (Resident #2) involvement with separate incident involving same male CNA (certified nursing assistant) (CNA #1). Attempted family contact with daughter/RP (Responsible Party) at 9:50 AM and 3 PM. Home phone had no answer/no voicemail, cell had no answer no VM (voice mail) box set up, no response." Review of the facility obtained statement taken by Registered Nurse (RN) #1 on 02/14/2012 at 9:45 PM from Resident #2 revealed: "About 2 weeks ago, it's been a good while back, he sat down and had his "thang" out and then he put it back. He was out on the porch... I believe we were out on the porch and he pulled his britches down. - its been so long ago. I saw his penis, it was red looking. I left. I haven't spoken to him since. ...it was very embarrassing - I can't even face him." Further review of the Investigative File revealed the facility also did not contact the attending physician and the Medical Director until 02/15/2012. During an interview on 02/21/2012 at 12 PM, the Director of Nurses confirmed that the Physician was not contacted until 02/15/2012. During an interview on 02/21/2012 at 3:15 PM, the SSD and DON confirmed that the facility attempted to contact the Responsible Party (RP) for each resident in the facility. The Administrative staff was asked to notify the RP of each resident in the facility and ensure them the residents were safe. The DON confirmed that there was no documentation that the RP was contacted, who contacted them and when they were contacted. The SSD and DON both confirmed that as of 02/21/2012, Resident #2's responsible party had not been contacted regarding the sexual abuse allegation. Both stated that the facility was unable to reach the RP via telephone. When asked if other methods of communication had been attempted, both stated no other method had been attempted to contact the resident's RP. During an interview on 02/21/2012 at 4:30 PM, the Medical Director stated that he was notified of the sexual abuse allegation on 02/15/2012. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Symptomatic Protocol signed by the Physician on 02/12/2010 revealed: "[DIAGNOSES REDACTED]/Insulin Reaction- Administer sweetened beverage and/or Glucostat. May administer [MEDICATION NAME] 1 amp/1 mg STAT PRN. If resident has symptoms of insulin reaction (diaphoresis, irritability or altered level of consciousness) and/or blood sugar below 55 may repeat [MEDICATION NAME] once PRN." Special Instructions: "a. Determine blood sugar by finger stick. b. Administer treatments as necessary. c. Re-check 30 minutes after treatment. d. Notify MD immediately if condition hasn't resolved after 30 minutes. Notify MD prior to next insulin or other hypoglycemic agent in order to discuss strategy to prevent recurrence. f. Contact provider if glucose level below 55." Review of the Finger Stick Blood Sugar (FSBS) Record from December 1, 2011 through February 17, 2012 revealed the following: 12/14/2011 at 6 AM FSBS= 46 given juice. No re check was documented. No nurses notes were documented and no physician notification was located; 12/19/2011 at 6 AM FSBS= 55, no intervention and no follow up was documented; 12/22/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/23/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/25/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/28/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 01/3/2012 at 6 AM, FSBS=55, "drink and cookies" were given, no follow up was documented; 01/6/2012 at 6 AM, FSBS=55, "juice and cookie" given, no intervention and no follow up was documented; 01/18/2012 at 6 AM, FSBS=56, "cookies and juice" given, no follow up was documented; 01/19/2012 at 6 AM, FSBS=56, "juice and 1 graham cracker" given, no follow up was documented on log; 01/20/2012 at 6 AM, FSBS= 34, juice and cookies were given, there was no documented recheck and no physician notification; 01/30/2012 at 6 AM, FSBS=57, "juice/cookies" were given, no recheck was documented; 02/1/2012 at 6 AM, FSBS=56, juice and cookies were given, no documented recheck was recorded; 02/3/2012 at 6 AM, FSBS=46, juice was given and a recheck of 7? was recorded, however, no physician notification was located; 02/6/2012 at 6 AM, FSBS=49, juice was given, a recheck of 58 was documented, however, no physician notification was located; 02/14/2012 at 6 AM, FSBS was 55, no interventions, no rechecks and no physician notification was located; 02/16/2012 at 6 AM, FSBS was 46, juice was given and a recheck of 86 was recorded, however no physician notification was located. Review of the Nurse's Notes revealed on 01/19/2012 at 6:30 AM, "FSBS @ 0600 56, (after) 15 grams (Orange Juice) and graham cracker, FSBS (increased) to 81..." On 2/17/12 at 2 AM, "...resident sitting in w/c (wheelchair) c chin on chest, clammy and wet with perspiration. Checked FSBS @ 12:30 AM was 26, [MEDICATION NAME] 15 given given PO (by mouth) followed by 3- 8 ounce cups of MedPass 2.0. FSBS rechecked @ 12:45 AM-30, another tube of [MEDICATION NAME] given per symptomatic protocol, rechecked @ 1 AM -39. MD called, (Nurse Practitioner) responded. Ordered to give another tube of [MEDICATION NAME] and call 9-1-1. EMS arrived @ 1:10 AM INT started, D50 given, rechecked 228. Resident responding but very sluggish, still not acting like herself. Transferred to (local hospital) for further evaluation and treatment. Resident's daughter contacted c message left on voicemail. Transported @ 1:50 AM." Besides the above two entries, no other documentation was located in the Nurses Notes or Finger stick log regarding physician notification, interventions and re-checks of low blood sugars. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the Fingerstick Blood Sugar Record from January and February 2012 revealed on 01/01/2012 the 6 AM blood sugar was 55, juice was given. There was no documented recheck and no physician notification. On 01/29/2012 at 6 AM, the FSBS was 59, juice was given, however there was not a documented recheck. On 02/2/2012 at 6 AM, the FSBS was 47, juice and cookies were given, there was no recheck documented and no physician notification was located. On 02/08/2012 at 6 AM, the FSBS was 55, juice and cookies were given, no recheck was documented. On 02/24/2012 at 6 AM, the FSBS was 58, juice and cookies were given, no recheck was documented. Review of the Nurse's Notes revealed on 02/24/2012 at 6 AM, "FSBS 58, Fig newtons and (two) cranberry juices given, no insulin required." Further review of the Nurses Notes from January 2012 and February 2012 revealed no other documentation related to low blood sugars, rechecks or physician notification. During an interview on 02/24/2012 at 3:45 PM, the Attending Physician stated he was not made aware of Resident #1's low blood sugars. He stated that he does review the Fingerstick Records, however not on every visit and there are times when the logs were not available. He stated that he relied on the nursing staff to inform him of problems or concerns. He confirmed the Symptomatic Protocol including the order to contact the physician with blood sugars less than 55. The Attending Physician also confirmed that a recheck of the low blood sugar was part of the protocol and should have been done. The Attending Physician stated that he reviewed the blood sugars for Resident #1 after she was sent to the hospital on [DATE]. He confirmed at that point he was aware the protocol was not being followed, interventions and rechecks were not documented and that the physician had not been notified per the protocol. The Physician stated that the facility informed him Resident #1 was an isolated case and that there were no other residents where the protocol had not been followed. Resident #7's low blood sugars with no rechecks and no physician notification was shared with the physician. During an interview on 02/24/2012 at 5 PM, the Director of Nurses confirmed the physician had not been notified per the protocol. The DON also confirmed that during the monthly medication reviews, the Pharmacist also did not inform the physician of the low blood sugars. On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended. First Follow-Up Visit During an unannounced, onsite visit on 03/30/2012 at 2:15 PM, it was determined based on interviews, observations, limited record review, and review of facility policies that the Allegation of Compliance had been implemented by the facility and was in practice as of 03/01/2012. The Allegation of Compliance with a completion date of 03/01/2012 was submitted by the facility. The actions listed in the Allegation of Compliance included the following: *Resident #1 is no longer at the facility. discharge date [DATE] *Resident #2's responsible party was notified of the allegation of sexual abuse on 02/22/2012. Attempts began on 02/15/2012 but were unsuccessful. Current phone numbers have been obtained for future reference *Physician notified 02/21/2012 of possible sexual abuse *Education has been completed on 02/24/2012 for all licensed staff related to the revised Abuse and Neglect policy. Education included requirements of notifications to MD and Responsible Parties. Education provided by the DON (director of nurses). *Resident's #2 and #6 had Physical Assessments conducted 02/21/2012 *Resident #2 had Psychosocial Assessment completed by the DON on 02/21/2012. Psychosocial Assessments will continue weekly for 30 days. *Resident #6 had Psychosocial Assessment conducted by the MDS Nurse on 02/25/2012. Psychosocial Assessments will continue weekly for 30 days. Other immediate corrective actions included: *Physical Assessments were performed for all residents on 02/21/2012 by Licensed Nursing *Psychosocial Assessments were completed for all residents by 02/25/2012. Assessments completed by Nursing Administration, Licensed Nurses, Admissions Coordinator, Activities Director, Dietary Managers and Business Manager. *Local Police have investigated the allegations of abuse. Union County Sheriff's Office notified 02/21/2012. *SLED (South Carolina Law Enforcement) has investigated all allegations of abuse and failure to report. SLED contacted 02/15/2012. *All families were contacted by the Administrative staff on 02/16/2012 and 02/22/2012 to inquire of any knowledge of abuse. *Revisions to Abuse and Neglect policy included: *Specific procedures related to sexual abuse *Specific procedures related to reporting allegations of abuse *Information on the Elder Justice Act *Education completed for all staff on 02/24/2012 related to the revised Abuse and Neglect policy. Education provided by DON. Education will continue monthly for 90 days, annually and upon hire for Abuse and Neglect. *Employees suspended pending the investigation include: -Certified Nurse Aide (CNA) #1 (suspended 02/14/2012 - terminated 03/07/2012) -Social Services Director - 02/22/2012 - pending -Social Services Assistant - 02/22/2012 - pending -Risk Manager - 02/22/2012 - pending *Abuse and Neglect education provided to Administration Staff on 02/24/2012 The citation at F-157 remained at a lowered scope and severity of "E". The facility will be in compliance at F-157 when an acceptable Plan of Correction is submitted and a follow-up visit is conducted to determine that the facility has implemented their Plan of Correction as stated.

On the days of the Complaint and Extended Survey, Substandard Quality of Care and Immediate Jeopardy was identified as it related to the facility failure to identify, report and thoroughly investigate allegations of sexual abuse for 3 of 3 residents reviewed for sexual abuse. Residents #1, #2 and #6 alleged allegations of sexual abuse against Certified Nursing Assistant (CNA) #1. The findings included: A complaint survey was conducted on 02/21/2012 as a result of a facility reported incident. Resident #1 reported during a telephone conversation to her daughter on the evening of 02/14/2012, an incident of alleged sexual abuse. Her daughter came to the facility and reported the incident to Registered Nurse #1(RN). In the following statement taken by RN #1 on 02/14/2012 at 9:25 PM Resident #1 stated, "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it - has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 received a BIMS score of "13" and was independent with transfers and toilet use. No behaviors were coded as occurring during the assessment period. Review of Resident #1's Care Plan reviewed on 02/02/2012 revealed a problem area of "agitated behavior"; approaches included to observe the resident and to notify the physician as needed. Another problem area was related to anxiety and depression, again the approaches were to observe the resident and notify the physician. No care plan was developed related to behaviors or related to the resident's interactions with staff and other residents. Review of the Physician's Progress Notes dated 01/9/2012 and 01/12/2012 revealed no documentation or assessment related to the resident for behaviors. The most current progress note was dated 01/12/2012. Review of the Nurse's Notes from December 2011 to February 17, 2012 revealed no documentation related to behaviors or sexual abuse. Review of the Social Service notes dated 12/12/2011 and 01/31/2012 revealed the resident was depressed and did not want to come out of her room. On 02/17/2012, "Resident was admitted to (local hospital) today, family notified of bed hold policy and sent (with) transfer." Another note dated 02/17/2012 revealed: "Allegations were made by resident to her daughter by phone that CNA had been sexually inappropriate. SSD (social service director) was notified on 02/15/2012. Internal investigation is underway along with investigations from SLED (South Carolina Law Enforcement Division) and local sheriff's dept (department). Employee has been placed on leave until investigations are complete. 24 Hour report sent on 2/14 when nurse was notified. 5 day report will be sent on 2/21." The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored a BIMS of "3" and was independent with transfers, ambulation and toilet use. No behaviors were recorded as occurring. The resident was coded as having hallucinations and [MEDICAL CONDITION] during the assessment period. Review of the Nurse's Notes revealed no indication of sexual abuse. Review of the Social Service notes dated 02/15/2012 revealed: "DON (director of nurses) and SSD reviewed statements regarding sexual abuse allegations against another resident in facility, nurses statements included (Resident #2) involvement with separate incident involving same male CNA (CNA #1). Attempted family contact with daughter/RP (responsible party) at 9:50 AM and 3 PM. Home phone had no answer/no voicemail, cell had no answer no VM box set up, no response." Another note on 02/15/2012 revealed: "DON and SSD went to interview resident regarding an alleged incident that occurred with her and CNA. Time frame uncertain. Resident stated that she knew the CNA and stated that he was always very kind to her. SSD asked her if CNA in question had ever been sexually inappropriate with her. She responded no, he's always been very nice to me. Upon further questioning, resident had no recall of any sexual/inappropriate behavior by this male CNA." Review of the facility "Summary of Investigation on allegation of sexual abuse" dated 02/20/12 revealed: "During the course of this investigation, another residents name (Resident #2) was mentioned as possibly being involved. (Resident #2's) name is mentioned by the original complainant as having experienced a similar with the employee (sic) in question prior to her experience. (Resident #2) is a close friend of (Resident #1) at the nursing home. At first it was thought that the incident in question had taken place on Tuesday night February 14, 2012, however, it turns out that this was not the case and that the incident happened 2-3 weeks ago with (Resident #2) and 2-3 days ago with (Resident #1). Social Service Director (SSD) and Director of Nursing (DON) have interviewed several employees and residents for similar incidents with the CNA in question. DON visited with (Resident #2) on Wednesday (2/15/12) and resident stated that nothing had happened to her. Resident was given the name of the CNA in question and all she said was 'he is sweet and kind man, he does not to a lot for me but he is always appropriate, he has never touched me or asked me to do something.' DON had a witness in the room at the time. DON also went back to see (Resident #2) in the afternoon to see if her story had changed, it had not. Later on in the week both SSD and DON went back to (Resident #2) and her story stayed the same. Today we asked (Registered Nurse #1), the nurse involved in the original incident to go back to (Resident #2) and ask her the questions again, and take the original statement with her. A copy of the second statement is attached as written by (RN #1) during the interview today. (CNA #1) was suspended immediately and asked to leave the building ... Looking at the 24 hour report sent to DHEC (Department of Health and Environmental Control), (Resident #2's) name does not appear on this, we apologize for the oversight and the RN preparing the document has been educated that every resident's name should appear on the allegation. Administration will also look more closely in the future. Returning to the office the following day the DON looked through all of the assignment sheets from January 1st 2012 through February 14, 2012. ... it was discovered that on 2 occasions only in that 6 week period, February 11 and 12, (CNA #1) had (Resident #1 and Resident #2) respectively. (CNA #1) personnel file has been reviewed with no compromising documentation found. There have been no disciplinary actions against him, his background check was good as is the status of his license. Examination of the residents was not done because there were no allegations of anything other that 'putting his penis in my hand.' The Union County Sheriff's Department as well as (SLED) met at the nursing home on Friday 2/17/12 at 10:45 AM to speak with the Administrator, DON and SSD... " Review of a facility obtained statement taken by RN #1 from Resident #1 on 02/14/2012 at 9:25 PM revealed, "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it-has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." Review of the facility obtained statement taken by Registered Nurse (RN) #1 on 02/14/2012 at 9:45 PM from Resident #2 revealed: "About 2 weeks ago, it's been a good while back, he sat down and had his "thang" out and then he put it back. He was out on the porch... I believe we were out on the porch and he pulled his britches down. - its been so long ago. I saw his penis, it was red looking. I left. I haven't spoken to him since. ...it was very embarrassing - I can't even face him." Review of the SSD statement dated on 02/15/2012 revealed: "SSD met with (Resident #1's Responsible Party (RP) and Resident #1) to discuss what had happened to her last night. (Resident #1) stated that (CNA #1) had come behind the curtain in her room and placed his penis in her hand. SSD asked her if he had done anything else with his hands or penis during this time. She stated no. (RP) informed (Resident #1) that this is a serious allegation and that she could send this man that she is accusing to jail for a long time, (Resident #1) said I know, he did this to me. SSD asked her when this happened, she stated a weeks ago, I don't remember which shift my mind is as short as my pinky finger. SSD asked (Resident #1) why she did not report this as soon as this happened. She stated, I was scared. SSD: what were you scared of? (Resident #1): I was scared he would come back in here and do other things to me. I saw him after this happened to me in the dining room. He spoke to me when he saw me in the dining room, but he was always nice and would say hello or how are you doing. SSD asked (Resident #1) about her feelings about moving from the facility, as she is apparently not safe in this facility. She stated she would go, (RP) said I know she will miss some of her friends..." Review of a facility obtained statement from CNA #1 dated 02/15/2012 at 8:15 AM revealed, "On [DATE] I was working second shift on Unit 2 when (Nurse) asked to speak to me privately. She informed me that (Resident #1) had told her that I had asked her to touch me. (Nurse) also informed me that I had to be sent home until investigation is complete. I immediately left as asked and said that they can call me if any questions are needed from me. I have never asked any resident to touch me in any way. I have always enjoyed working for (facility) and I sincerely hope to continue to stay employed her for years to come. I am willing to speak to whoever at anytime to answer questions to make the investigation complete as possible." Review of the Assignment Sheets revealed CNA #1 was assigned to Unit 1 on February 3, 2012 from 7 P-7 A. He was assigned to Resident #1 on 02/11/2012 from 7 P-7 A and to Resident #2 on 02/12/2012 from 3 P-11 P. Further review of the Investigative File revealed staff statements taken on 02/14/2012 and 02/15/2012 from the night shift assigned to Resident #1 on 02/14/2012. A thorough investigation was not conducted to include Resident #2 and staff statements for the alleged time frames were not obtained. Prior to the 02/22/2012 inservice conducted by SLED, no staff education had been completed on Abuse/Neglect, reporting or sexual abuse related to the incident. In addition, the facility failed to contact the local police department with the allegations. (Resident #1's family member called the police on the evening of 02/14/2012 there was no evidence that Resident #2 was reported to the police). The attending physician and the Medical Director were contacted by the facility 02/15/2012. Residents #1 and #2 were not immediately assessed, physically, emotionally or psychosocially. Interviews and assessments of other residents at the facility that might have been potentially abused were not conducted. Review of CNA #1's employee file revealed no disciplinary action was located in his file. CNA #1 was alleged as a perpetrator in a prior sexual abuse allegation in August 2011. The allegation was unsubstantiated. However, no evidence of the allegation was located in the employee's personnel file. During an interview on 02/21/2012 at 12 PM, the Director of Nurses confirmed CNA #1 was involved in a prior sexual abuse allegation. She stated, that since the allegation was unsubstantiated, she shredded all evidence that would have been normally kept in the employee's file. She stated that this was routine practice for any employee at the facility that had an unsubstantiated allegation. She confirmed again that she shredded the documents and did not keep any evidence in the employee file. During a follow up interview at 2 PM, the DON also confirmed that the local police department was contacted by Resident #1's RP and not the facility. She stated that as of 02/21/2012, the facility had not made a report to local law enforcement regarding the sexual abuse allegation for Residents #1 and #2. The DON confirmed that Residents #1 and #2 had not been assessed. She also confirmed that there had not been an inservice on Abuse and Neglect related to this incident and that SLED was providing education on 02/22/2012. The DON confirmed that CNA #1 was assigned to Resident #1 on 02/11/2012 and that this was approximately "2-3 days" prior to the resident reporting the incident. The DON confirmed that the Physician was not contacted until 02/15/2012. During an interview on 02/21/2012 at 3:15 PM, the SSD and DON confirmed that the facility attempted to contact the Responsible Party (RP) for each resident in the facility. The Administrative staff was asked to notify the RP of each resident in the facility and ensure them the residents were safe. The DON confirmed that there was no documentation that the RP was contacted, who contacted them and when they were contacted. The SSD and DON both confirmed that as of 02/21/2012, Resident #2's responsible party had not been contacted regarding the sexual abuse allegation. Both stated that the facility was unable to reach the RP via telephone. When asked if other methods of communication had been attempted, both stated no other method had been attempted to contact the resident's RP. During an interview on 02/21/2012 at 4:30 PM, the Medical Director stated that he was notified of the sexual abuse allegation on 02/15/2012. He stated that he did not assess the residents since there was no reported penetration. He stated that since it was emotional upsetness there was no reason for an assessment. The Medical Director stated that Resident #2 was interviewed several times regarding the allegation, he stated that when pressed for information, the resident would "clam up." The Medical Director stated that CNA #1 had 2 prior accusations before Residents #1 and #2. During another interview on 02/22/2012 at 12:10 PM, the DON was asked about the 2 prior accusations, she stated that Resident #6 had stated she was having CNA #1's baby. The DON stated that no investigation had been completed related to the incident. The other accusation was reported to the State Agency. During an interview on 02/22/2012 at 3 PM, the SSD provided documentation to the surveyor related to Resident #6's allegation. Review of the Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS of "3" and no behaviors, hallucinations or [MEDICAL CONDITION] were coded as occurring in the assessment period. Review of the documentation revealed: "SSD went into (Resident #6's) room on 12/12/2011 and she was very upset and crying... she was very upset and then stated she had had his (CNA #1's) baby and put the baby in the dumpster and the cops were looking for her... SSD ensured (sic) that (Resident #6) had an appointment with her psychiatrist that day, SSD included a letter to (the psychiatrist) regarding the behaviors she is having and requesting an evaluation." The statement was signed and dated on 12/14/2012 with a statement of "SSD has seen no signs of further problems as medications were adjusted by (Psychiatrist). A typed letter that had a handwritten date of 12/12/12 (the year 12 was lined through with a number one) that revealed: "I am writing this letter on behalf of (Resident #6). She had hallucinations last week..." Record review revealed, Resident #6 was seen by the psychiatrist until 12/19/2011 when the psychiatrist noted increased [MEDICAL CONDITION] and hallucinations. The residents medications were increased. Review of the Nurse's Notes revealed on 12/12/2011 the only documentation was "body audit-skin warm and dry, intact. On 12/19/2011 at 12 PM, (Resident #6) upset because "a girl pushed me out here and shouldn't have, waiting on (CNA #1). (CNA #1) will come and get me and take care of me. ...you don't know, he'll be here to get me... Attempted to reassure the resident." Further review of the Nurse's Notes from November and December 2011 revealed no other documentation of behaviors, hallucinations or [MEDICAL CONDITION]. Review of the Social Service Notes dated 12/19/2011 revealed Resident #6 hallucinating last week when the television is on the news. ...she stated she had CNA #1's baby. On 12/30/2011, "she did go to her psychiatrist after her last [MEDICAL CONDITION] and changes were made to her [MEDICATION NAME] and [MEDICATION NAME] sprinkles..." On 02/22/2012 additional information was provided regarding staff statements. Review of the facility obtained statement dated 2/22/2012 from Staff Assistant #1 revealed: "To whom it may concern, (HR) call me at 4:15 PM on 2/22/12 to ask me questions about something I told (Administrator and Staff Development) this morning about (Resident #2) had told (Resident #1) about (CNA #1). (Resident #1) told me she love me and could trust me. Then she told me what (Resident #2) said that (CNA #1) came into her room, was playing with his penis, he pull it out, (Resident #2) said it was real red then he started to play with her breast that's what (Resident #1) told me. Then (Resident #1) said (Resident #2) was scared of him. (Resident #1) also said what if he bothered (roommate), she couldn't tell anybody about it. (Resident #1) said he should try to bother her should would knock the hell out of him. I told her she should tell someone, that's when she said (Resident #2) was scared of him. (Resident #1) told me about the sexual abuse in Jan second week 2012. I was putting ice on the halls on Unit I. Then I went to (Risk Manager) my supervisor. I ask what I should do, she told me to go to Social Services, I did. I talk with (SSD and SSA) and told her what (Resident #1) had told me. She said (CNA #1) had already been sent 3 times before. (????suspension???) She said she could talk with (Resident #2) and (Resident #1) without them knowing I told her about a report of maybe sexual abuse. (SSD) said she would take care of it. I went to Social Services before 11 AM second week in [DATE]." Additional comments were added by the Staff Assistant: "(SSD) also told me that she didn't want to see (CNA #1) to lose his job. I was also told the names of 2 of the residents who had allegations against (CNA #1). (SSD) told me the names!." Review of the facility obtained statement from the Risk Manager dated 02/22/2012 at 6:30 PM revealed, "(Staff Assistant) stopped me in hall and stated (Resident #2 mentioned to her that she had been touched on the breast, should she tell someone or just keep to herself. I told her to tell Social Services. Later (Staff Assistant) told (SSD). That is the last time it was mentioned." Review of the facility obtained statement from the SSD on 02/22/2012 revealed: "I had no knowledge of sexual abuse on (Resident #2) until I read it in (RN #1's) statement on 2/15/12...." During an interview on 02/24/2012 at 1:15 PM, the ADON (assistant director of nurses) confirmed the written statements and stated that the Staff Assistant reported the incident to her supervisor appropriately. The ADON stated that her supervisor was Risk Management and that she attended all the morning stand up meetings and QA meetings. The ADON stated that she did not report the incident to anyone. The ADON stated that the SSD, SSA and the Risk Manager had all been suspended. The ADON confirmed that the Risk Manager was considered part of the facility's Administration and was responsible for relaying the information to the rest of the Administration. On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended.

On the days of the Complaint and Extended Survey, Substandard Quality of Care and Immediate Jeopardy was identified as it related to the facility failure to identify, report and thoroughly investigate allegations of sexual abuse for 3 of 3 residents reviewed for sexual abuse. Residents #1, #2 and #6 alleged allegations of sexual abuse against Certified Nursing Assistant (CNA) #1. The findings included: A complaint survey was conducted on 02/21/2012 as a result of a facility reported incident. Resident #1 reported during a telephone conversation to her daughter on the evening of 02/14/2012, an incident of alleged sexual abuse. Her daughter came to the facility and reported the incident to Registered Nurse #1(RN). In the following statement taken by RN #1 on 02/14/2012 at 9:25 PM Resident #1 stated, "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it - has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 received a BIMS score of "13" and was independent with transfers and toilet use. No behaviors were coded as occurring during the assessment period. Review of Resident #1's Care Plan reviewed on 02/02/2012 revealed a problem area of "agitated behavior"; approaches included to observe the resident and to notify the physician as needed. Another problem area was related to anxiety and depression, again the approaches were to observe the resident and notify the physician. No care plan was developed related to behaviors or related to the resident's interactions with staff and other residents. Review of the Physician's Progress Notes dated 01/9/2012 and 01/12/2012 revealed no documentation or assessment related to the resident for behaviors. The most current progress note was dated 01/12/2012. Review of the Nurse's Notes from December 2011 to February 17, 2012 revealed no documentation related to behaviors or sexual abuse. Review of the Social Service notes dated 12/12/2011 and 01/31/2012 revealed the resident was depressed and did not want to come out of her room. On 02/17/2012, "Resident was admitted to (local hospital) today, family notified of bed hold policy and sent (with) transfer." Another note dated 02/17/2012 revealed: "Allegations were made by resident to her daughter by phone that CNA had been sexually inappropriate. SSD (social service director) was notified on 02/15/2012. Internal investigation is underway along with investigations from SLED (South Carolina Law Enforcement Division) and local sheriff's dept (department). Employee has been placed on leave until investigations are complete. 24 Hour report sent on 2/14 when nurse was notified. 5 day report will be sent on 2/21." The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored a BIMS of "3" and was independent with transfers, ambulation and toilet use. No behaviors were recorded as occurring. The resident was coded as having hallucinations and delusions during the assessment period. Review of the Nurse's Notes revealed no indication of sexual abuse. Review of the Social Service notes dated 02/15/2012 revealed: "DON (director of nurses) and SSD reviewed statements regarding sexual abuse allegations against another resident in facility, nurses statements included (Resident #2) involvement with separate incident involving same male CNA (CNA #1). Attempted family contact with daughter/RP (responsible party) at 9:50 AM and 3 PM. Home phone had no answer/no voicemail, cell had no answer no VM box set up, no response." Another note on 02/15/2012 revealed: "DON and SSD went to interview resident regarding an alleged incident that occurred with her and CNA. Time frame uncertain. Resident stated that she knew the CNA and stated that he was always very kind to her. SSD asked her if CNA in question had ever been sexually inappropriate with her. She responded no, he's always been very nice to me. Upon further questioning, resident had no recall of any sexual/inappropriate behavior by this male CNA." Review of the facility "Summary of Investigation on allegation of sexual abuse" dated 02/20/12 revealed: "During the course of this investigation, another residents name (Resident #2) was mentioned as possibly being involved. (Resident #2's) name is mentioned by the original complainant as having experienced a similar with the employee (sic) in question prior to her experience. (Resident #2) is a close friend of (Resident #1) at the nursing home. At first it was thought that the incident in question had taken place on Tuesday night February 14, 2012, however, it turns out that this was not the case and that the incident happened 2-3 weeks ago with (Resident #2) and 2-3 days ago with (Resident #1). Social Service Director (SSD) and Director of Nursing (DON) have interviewed several employees and residents for similar incidents with the CNA in question. DON visited with (Resident #2) on Wednesday (2/15/12) and resident stated that nothing had happened to her. Resident was given the name of the CNA in question and all she said was 'he is sweet and kind man, he does not to a lot for me but he is always appropriate, he has never touched me or asked me to do something.' DON had a witness in the room at the time. DON also went back to see (Resident #2) in the afternoon to see if her story had changed, it had not. Later on in the week both SSD and DON went back to (Resident #2) and her story stayed the same. Today we asked (Registered Nurse #1), the nurse involved in the original incident to go back to (Resident #2) and ask her the questions again, and take the original statement with her. A copy of the second statement is attached as written by (RN #1) during the interview today. (CNA #1) was suspended immediately and asked to leave the building ... Looking at the 24 hour report sent to DHEC (Department of Health and Environmental Control), (Resident #2's) name does not appear on this, we apologize for the oversight and the RN preparing the document has been educated that every resident's name should appear on the allegation. Administration will also look more closely in the future. Returning to the office the following day the DON looked through all of the assignment sheets from January 1st 2012 through February 14, 2012. ... it was discovered that on 2 occasions only in that 6 week period, February 11 and 12, (CNA #1) had (Resident #1 and Resident #2) respectively. (CNA #1) personnel file has been reviewed with no compromising documentation found. There have been no disciplinary actions against him, his background check was good as is the status of his license. Examination of the residents was not done because there were no allegations of anything other that 'putting his penis in my hand.' The Union County Sheriff's Department as well as (SLED) met at the nursing home on Friday 2/17/12 at 10:45 AM to speak with the Administrator, DON and SSD... " Review of a facility obtained statement taken by RN #1 from Resident #1 on 02/14/2012 at 9:25 PM revealed, "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it-has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." Review of the facility obtained statement taken by Registered Nurse (RN) #1 on 02/14/2012 at 9:45 PM from Resident #2 revealed: "About 2 weeks ago, it's been a good while back, he sat down and had his "thang" out and then he put it back. He was out on the porch... I believe we were out on the porch and he pulled his britches down. - its been so long ago. I saw his penis, it was red looking. I left. I haven't spoken to him since. ...it was very embarrassing - I can't even face him." Review of the SSD statement dated on 02/15/2012 revealed: "SSD met with (Resident #1's Responsible Party (RP) and Resident #1) to discuss what had happened to her last night. (Resident #1) stated that (CNA #1) had come behind the curtain in her room and placed his penis in her hand. SSD asked her if he had done anything else with his hands or penis during this time. She stated no. (RP) informed (Resident #1) that this is a serious allegation and that she could send this man that she is accusing to jail for a long time, (Resident #1) said I know, he did this to me. SSD asked her when this happened, she stated a weeks ago, I don't remember which shift my mind is as short as my pinky finger. SSD asked (Resident #1) why she did not report this as soon as this happened. She stated, I was scared. SSD: what were you scared of? (Resident #1): I was scared he would come back in here and do other things to me. I saw him after this happened to me in the dining room. He spoke to me when he saw me in the dining room, but he was always nice and would say hello or how are you doing. SSD asked (Resident #1) about her feelings about moving from the facility, as she is apparently not safe in this facility. She stated she would go, (RP) said I know she will miss some of her friends..." Review of a facility obtained statement from CNA #1 dated 02/15/2012 at 8:15 AM revealed, "On [DATE] I was working second shift on Unit 2 when (Nurse) asked to speak to me privately. She informed me that (Resident #1) had told her that I had asked her to touch me. (Nurse) also informed me that I had to be sent home until investigation is complete. I immediately left as asked and said that they can call me if any questions are needed from me. I have never asked any resident to touch me in any way. I have always enjoyed working for (facility) and I sincerely hope to continue to stay employed her for years to come. I am willing to speak to whoever at anytime to answer questions to make the investigation complete as possible." Review of the Assignment Sheets revealed CNA #1 was assigned to Unit 1 on February 3, 2012 from 7 P-7 A. He was assigned to Resident #1 on 02/11/2012 from 7 P-7 A and to Resident #2 on 02/12/2012 from 3 P-11 P. Further review of the Investigative File revealed staff statements taken on 02/14/2012 and 02/15/2012 from the night shift assigned to Resident #1 on 02/14/2012. A thorough investigation was not conducted to include Resident #2 and staff statements for the alleged time frames were not obtained. Prior to the 02/22/2012 inservice conducted by SLED, no staff education had been completed on Abuse/Neglect, reporting or sexual abuse related to the incident. In addition, the facility failed to contact the local police department with the allegations. (Resident #1's family member called the police on the evening of 02/14/2012 there was no evidence that Resident #2 was reported to the police). The attending physician and the Medical Director were contacted by the facility 02/15/2012. Residents #1 and #2 were not immediately assessed, physically, emotionally or psychosocially. Interviews and assessments of other residents at the facility that might have been potentially abused were not conducted. Review of CNA #1's employee file revealed no disciplinary action was located in his file. CNA #1 was alleged as a perpetrator in a prior sexual abuse allegation in August 2011. The allegation was unsubstantiated. However, no evidence of the allegation was located in the employee's personnel file. During an interview on 02/21/2012 at 12 PM, the Director of Nurses confirmed CNA #1 was involved in a prior sexual abuse allegation. She stated, that since the allegation was unsubstantiated, she shredded all evidence that would have been normally kept in the employee's file. She stated that this was routine practice for any employee at the facility that had an unsubstantiated allegation. She confirmed again that she shredded the documents and did not keep any evidence in the employee file. During a follow up interview at 2 PM, the DON also confirmed that the local police department was contacted by Resident #1's RP and not the facility. She stated that as of 02/21/2012, the facility had not made a report to local law enforcement regarding the sexual abuse allegation for Residents #1 and #2. The DON confirmed that Residents #1 and #2 had not been assessed. She also confirmed that there had not been an inservice on Abuse and Neglect related to this incident and that SLED was providing education on 02/22/2012. The DON confirmed that CNA #1 was assigned to Resident #1 on 02/11/2012 and that this was approximately "2-3 days" prior to the resident reporting the incident. The DON confirmed that the Physician was not contacted until 02/15/2012. During an interview on 02/21/2012 at 3:15 PM, the SSD and DON confirmed that the facility attempted to contact the Responsible Party (RP) for each resident in the facility. The Administrative staff was asked to notify the RP of each resident in the facility and ensure them the residents were safe. The DON confirmed that there was no documentation that the RP was contacted, who contacted them and when they were contacted. The SSD and DON both confirmed that as of 02/21/2012, Resident #2's responsible party had not been contacted regarding the sexual abuse allegation. Both stated that the facility was unable to reach the RP via telephone. When asked if other methods of communication had been attempted, both stated no other method had been attempted to contact the resident's RP. During an interview on 02/21/2012 at 4:30 PM, the Medical Director stated that he was notified of the sexual abuse allegation on 02/15/2012. He stated that he did not assess the residents since there was no reported penetration. He stated that since it was emotional upsetness there was no reason for an assessment. The Medical Director stated that Resident #2 was interviewed several times regarding the allegation, he stated that when pressed for information, the resident would "clam up." The Medical Director stated that CNA #1 had 2 prior accusations before Residents #1 and #2. During another interview on 02/22/2012 at 12:10 PM, the DON was asked about the 2 prior accusations, she stated that Resident #6 had stated she was having CNA #1's baby. The DON stated that no investigation had been completed related to the incident. The other accusation was reported to the State Agency. During an interview on 02/22/2012 at 3 PM, the SSD provided documentation to the surveyor related to Resident #6's allegation. Review of the Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS of "3" and no behaviors, hallucinations or delusions were coded as occurring in the assessment period. Review of the documentation revealed: "SSD went into (Resident #6's) room on 12/12/2011 and she was very upset and crying... she was very upset and then stated she had had his (CNA #1's) baby and put the baby in the dumpster and the cops were looking for her... SSD ensured (sic) that (Resident #6) had an appointment with her psychiatrist that day, SSD included a letter to (the psychiatrist) regarding the behaviors she is having and requesting an evaluation." The statement was signed and dated on 12/14/2012 with a statement of "SSD has seen no signs of further problems as medications were adjusted by (Psychiatrist). A typed letter that had a handwritten date of 12/12/12 (the year 12 was lined through with a number one) that revealed: "I am writing this letter on behalf of (Resident #6). She had hallucinations last week..." Record review revealed, Resident #6 was seen by the psychiatrist until 12/19/2011 when the psychiatrist noted increased delusions and hallucinations. The residents medications were increased. Review of the Nurse's Notes revealed on 12/12/2011 the only documentation was "body audit-skin warm and dry, intact. On 12/19/2011 at 12 PM, (Resident #6) upset because "a girl pushed me out here and shouldn't have, waiting on (CNA #1). (CNA #1) will come and get me and take care of me. ...you don't know, he'll be here to get me... Attempted to reassure the resident." Further review of the Nurse's Notes from November and December 2011 revealed no other documentation of behaviors, hallucinations or delusions. Review of the Social Service Notes dated 12/19/2011 revealed Resident #6 hallucinating last week when the television is on the news. ...she stated she had CNA #1's baby. On 12/30/2011, "she did go to her psychiatrist after her last delusions and changes were made to her [MEDICATION NAME] and [MEDICATION NAME] sprinkles..." On 02/22/2012 additional information was provided regarding staff statements. Review of the facility obtained statement dated 2/22/2012 from Staff Assistant #1 revealed: "To whom it may concern, (HR) call me at 4:15 PM on 2/22/12 to ask me questions about something I told (Administrator and Staff Development) this morning about (Resident #2) had told (Resident #1) about (CNA #1). (Resident #1) told me she love me and could trust me. Then she told me what (Resident #2) said that (CNA #1) came into her room, was playing with his penis, he pull it out, (Resident #2) said it was real red then he started to play with her breast that's what (Resident #1) told me. Then (Resident #1) said (Resident #2) was scared of him. (Resident #1) also said what if he bothered (roommate), she couldn't tell anybody about it. (Resident #1) said he should try to bother her should would knock the hell out of him. I told her she should tell someone, that's when she said (Resident #2) was scared of him. (Resident #1) told me about the sexual abuse in Jan second week 2012. I was putting ice on the halls on Unit I. Then I went to (Risk Manager) my supervisor. I ask what I should do, she told me to go to Social Services, I did. I talk with (SSD and SSA) and told her what (Resident #1) had told me. She said (CNA #1) had already been sent 3 times before. (????suspension???) She said she could talk with (Resident #2) and (Resident #1) without them knowing I told her about a report of maybe sexual abuse. (SSD) said she would take care of it. I went to Social Services before 11 AM second week in [DATE]." Additional comments were added by the Staff Assistant: "(SSD) also told me that she didn't want to see (CNA #1) to lose his job. I was also told the names of 2 of the residents who had allegations against (CNA #1). (SSD) told me the names!." Review of the facility obtained statement from the Risk Manager dated 02/22/2012 at 6:30 PM revealed, "(Staff Assistant) stopped me in hall and stated (Resident #2 mentioned to her that she had been touched on the breast, should she tell someone or just keep to herself. I told her to tell Social Services. Later (Staff Assistant) told (SSD). That is the last time it was mentioned." Review of the facility obtained statement from the SSD on 02/22/2012 revealed: "I had no knowledge of sexual abuse on (Resident #2) until I read it in (RN #1's) statement on 2/15/12...." During an interview on 02/24/2012 at 1:15 PM, the ADON (assistant director of nurses) confirmed the written statements and stated that the Staff Assistant reported the incident to her supervisor appropriately. The ADON stated that her supervisor was Risk Management and that she attended all the morning stand up meetings and QA meetings. The ADON stated that she did not report the incident to anyone. The ADON stated that the SSD, SSA and the Risk Manager had all been suspended. The ADON confirmed that the Risk Manager was considered part of the facility's Administration and was responsible for relaying the information to the rest of the Administration. On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended. First Follow-Up Visit During an unannounced, onsite visit on 03/30/2012 at 2:15 PM, it was determined based on interviews, observations, limited record review, and review of facility policies that the Allegation of Compliance had been implemented by the facility and was in practice as of 03/01/2012. The Allegation of Compliance with a completion date of 03/01/2012 was submitted by the facility. The actions listed in the Allegation of Compliance included the following: *Resident #1 is no longer at the facility. discharge date [DATE] *Resident #2's responsible party was notified of the allegation of sexual abuse on 02/22/2012. Attempts began on 02/15/2012 but were unsuccessful. Current phone numbers have been obtained for future reference. *Physician notified 02/21/2012 of possible sexual abuse. *Education has been completed on 02/24/2012 for all licensed staff related to the revised Abuse and Neglect policy. Education included requirements of notifications to MD and Responsible Parties. Education provided by the DON (director of nurses). *Resident's #2 and #6 had Physical Assessments conducted 02/21/2012 *Resident #2 had Psychosocial Assessment completed by the DON on 02/21/2012. Psychosocial Assessments will continue weekly for 30 days. *Resident #6 had Psychosocial Assessment conducted by the MDS Nurse on 02/25/2012. Psychosocial Assessments will continue weekly for 30 days. Other immediate corrective actions included: *Physical Assessments were performed for all residents on 02/21/2012 by Licensed Nursing *Psychosocial Assessments were completed for all residents by 02/25/2012. Assessments completed by Nursing Administration, Licensed Nurses, Admissions Coordinator, Activities Director, Dietary Managers and Business Manager. *Local Police have investigated the allegations of abuse. Union County Sheriff's Office notified 02/21/2012. *SLED (South Carolina Law Enforcement) has investigated all allegations of abuse and failure to report. SLED contacted 02/15/2012. *All families were contacted by the Administrative staff on 02/16/2012 and 02/22/2012 to inquire of any knowledge of abuse. *Revisions to Abuse and Neglect policy included: *Specific procedures related to sexual abuse *Specific procedures related to reporting allegations of abuse *Information on the Elder Justice Act *Education completed for all staff on 02/24/2012 related to the revised Abuse and Neglect policy. Education provided by DON. Education will continue monthly for 90 days, annually and upon hire for Abuse and Neglect. *Employees suspended pending the investigation include: -Certified Nurse Aide (CNA) #1 (suspended 02/14/2012 - terminated 03/07/2012) -Social Services Director - 02/22/2012 - pending -Social Services Assistant - 02/22/2012 - pending -Risk Manager - 02/22/2012 - pending *Abuse and Neglect education provided to Administration Staff on 02/24/2012 The citation at F-223 remained at a lowered scope and severity of "E". The facility will be in compliance at F-223 when an acceptable Plan of Correction is submitted and a follow-up visit is conducted to determine that the facility has implemented their Plan of Correction as stated.

On the days of the Complaint and Extended Survey based on record review and interview, Substandard Quality of Care and Immediate Jeopardy was identified existing in the facility as of 02/14/2012 related to the facility's failure to identify, investigate and report allegations of sexual abuse. The facility failed to follow it's policy regarding reporting, investigating and identifying potential abuse. The findings included: Cross Refer to F-223 as it relates to the facility failure to identify, investigate and report allegations of sexual abuse. Review of the facility policy on Alleged Violations of Mistreatment, Neglect and Abuse revealed the following: "Residents will be free from verbal, sexual and physical or mental abuse... Residents will not be subjected to abuse by anyone including but not limited to ...staff ..." "The facility will investigate all grievances/complaints, accidents/incidents, allegations of abuse..." "Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault." "D. Prevention. The Administrator will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is likely to occur... The Director of Nursing or designee reviews all aspects of accidents/incidents, medical interventions and documentation. Data is trended, analyzed and incorporated into the facility's quality assurance program." "E. Identification. The facility Administrator or designee will identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse; and to determine the direction of the investigation. Methods may include but are not limited to tracking, trending and analysis of facility reports and grievances for occurrences, patterns and trends." "F. Investigation. The individual assigned to conduct the investigation will conduct a thorough investigation of the allegation. Areas/items that may be included as appropriate in the investigation include: ...b. Review the resident's medical record to determine events leading up to the incident...e. Interviews with the resident's attending physician as needed to determine the residents current level of cognitive function and medical condition. f. Interviews with staff members. h. Interview other residents to whom the accused employee provides care and services. i. Review events leading up to the alleged incident." "G. Protection. ...The Nurse in Charge on each shift is responsible for monitoring residents involved in an accident/incident until that resident is considered medically stable. This includes appropriateness of care, family/responsible party notification, physician notification and documentation. Unit staff will assure the safety of the involved resident and/or other residents during an investigation." "H. Reporting. d. Local police departments and professional boards will be notified as deemed appropriate by Administration..." On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended.

On the days of the Complaint and Extended Survey, Substandard Quality of Care and Immediate Jeopardy was identified as it related to the facility failure to provide medically related social services to three of three residents involved in allegations of sexual abuse. Residents #1, #2 and #6 alleged sexual abuse against Certified Nursing Assistant (CNA) #1. No Social Service interventions were put in place related to the allegations. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 received a BIMS score of "13" and was independent with transfers and toilet use. No behaviors were coded as occurring during the assessment period. Review of the Social Services notes dated 12/12/2011 and 01/31/2012 revealed the resident was depressed and did not want to come out of her room. On 02/17/2012, "Resident was admitted to (local hospital) today, family notified of bed hold policy and sent (with) transfer." Another noted date 02/17/2012 revealed: "Allegations were made by resident to her daughter by phone that CNA had been sexually inappropriate. SSD (social service director) was notified on 02/15/2012. Internal investigation is underway along with investigations from SLED (South Carolina Law Enforcement Division) and local sheriff's dept (department). Employee has been placed on leave until investigations are complete. 24 Hour report sent on 2/14 when nurse was notified. 5 day report will be sent on 2/21." The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored a BIMS of "3" and was independent with transfers, ambulation and toilet use. No behaviors were recorded a occurring. The resident was coded as having hallucinations and delusions during the assessment period. Review of the Social Services notes dated 02/15/2012 revealed: "DON (director of nurses) and SSD reviewed statements regarding sexual abuse allegations against another resident in facility, nurses statements included (Resident #2) involvement with separate incident involving same male CNA (CNA #1). Attempted family contact with daughter/RP at 9:50 AM and 3 PM. Home phone had no answer/no voicemail, cell had no answer no VM box set up, no response." Another note on 02/15/2012 revealed: "DON and SSD went to interview resident regarding an alleged incident that occurred with her and CNA. Time frame uncertain. Resident stated that she knew the CNA and stated that he was always very kind to her. SSD asked her if CNA in question had ever been sexually inappropriate with her. She responded no, he's always been very nice to me. Upon further questioning, resident had no recall of any sexual/inappropriate behavior by this male CNA." Review of the facility obtained statement taken by Registered Nurse (RN) #1 from Resident #1 on 02/14/2012 at 9:25 PM revealed: "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it-has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." Review of the facility obtained statement taken by RN #1 on 02/14/2012 at 9:45 PM from Resident #2 revealed: "About 2 weeks ago, it's been a good while back, he sat down and had his "thang" out and then he put it back. He was out on the porch. I believe we were out on the porch and he pulled his britches down, its been so long ago. I saw his penis, it was red looking. I left, I haven't spoken to him since. ...it was very embarrassing, I can't even face him." Review of the SSD statement dated on 02/15/2012 revealed: "SSD met with (Resident #1's Responsible Party and Resident #1) to discuss what had happened to her last night. (Resident #1) stated that (CNA #1) had come behind the curtain in her room and placed his penis in her hand. SSD asked her if he had done anything else with his hands or penis during this time. She stated no. (RP) informed (Resident #1) that this is a serious allegation and that she could send this man that she is accusing to jail for a long time, (Resident #1) said I know, he did this to me. SSD asked her when this happened, she stated a weeks ago, I don't remember which shift my mind is as short as my pinky finger. SSD asked (Resident #1) why she did not report this as soon as this happened. She stated , I was scared. SSD: what were you scared of? (Resident #1): I was scared he would come back in here and do other things to me. I saw him after this happened to me in the dining room. He spoke to me when he saw me in the dining room, but he was always nice and would say hello or how are you doing. SSD asked (Resident #1) about her feelings about moving from the facility, as she is apparently not safe in this facility. She stated she would go, (RP) said I know she will miss some of her friends..." Further review of the Investigative File revealed the facility failed to assess, physically, emotionally or psychosocially, Residents #1 and #2. The facility also did not identify, interview or assess other residents at the facility at risk for potential abuse. During an interview on 02/21/12 at 2 PM, the Director of Nurses confirmed that the residents had not been assessed. During an interview on 2/21/2012 at 4:30 PM, the Medical Director stated that he was notified of the sexual abuse allegation on 02/15/2012. He stated that he did not assess the residents since there was no reported penetration. He stated that since it was emotional upsetness there was no reason for an assessment. The Medical Director stated that Resident #2 was interviewed several times regarding the allegation, he stated that when pressed for information, the resident would "clam up." The Medical Director stated that CNA #1 had 2 prior accusations before Residents #1 and #2. During another interview on 02/22/2012 at 12:10 PM, the DON was asked about other accusations related to CNA #1, she stated that Resident #6 had stated she was having CNA #1's baby. The DON stated that no investigation had been completed related to the incident. The other accusation was reported to the State Agency. During an interview on 02/22/2012 at 3 PM, the SSD provided documentation to the surveyor related to Resident #6's allegation. Review of the Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS of "3" and no behaviors, hallucinations or delusions were coded as occurring in the assessment period. Review of the documentation revealed: "SSD went into (Resident #6's) room on 12/12/11 and she was very upset and crying...she was very upset and then stated she had had his (CNA #1's) baby and put the baby in the dumpster and the cops were looking for her...SSD ensured (sic) that (Resident #6) had an appointment with her psychiatrist that day, SSD included a letter to (the psychiatrist) regarding the behaviors she is having and requesting an evaluation." The statement was signed and dated on 12/14/2012 with a statement of "SSD has seen no signs of further problems as medications were adjusted by (Psychiatrist). A typed letter that had a handwritten date of 12/12/2012 (the year 12 was lined through with a number one) that revealed: "I am writing this letter on behalf of (Resident #6). She had hallucinations last week..." Record review revealed, Resident #6 was not seen by the psychiatrist until 12/19/2011 when the psychiatrist noted increased delusions and hallucinations. The residents medications were increased. Review of the Nurse's Notes revealed on 12/12/2011 the only documentation was "body audit-skin warm and dry, intact. On 12/19/2011 at 12 PM, (Resident #6) upset because "a girl pushed me out here and shouldn't have, waiting on (CNA #1). (CNA #1) will come and get me and take care of me. ...you don't know, he'll be here to get me... Attempted to reassure the resident." Further review of the Nurse's Notes from November and December 2011 revealed no other documentation of behaviors, hallucinations or delusions. Review of the Social Service Notes dated 12/19/2011 revealed Resident #6 hallucinating last week when the television is on the news. ...she stated she had CNA #1's baby. On 12/30, "she did go to her psychiatrist after her last delusions and changes were made to her Abilify and Depakote sprinkles..." On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended.

On the days of the Complaint and Extended Survey, Substandard Quality of Care and Immediate Jeopardy was identified as it related to the facility failure to provide medically related social services to three of three residents involved in allegations of sexual abuse. Residents #1, #2 and #6 alleged sexual abuse against Certified Nursing Assistant (CNA) #1. No Social Service interventions were put in place related to the allegations. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 received a BIMS score of "13" and was independent with transfers and toilet use. No behaviors were coded as occurring during the assessment period. Review of the Social Services notes dated 12/12/2011 and 01/31/2012 revealed the resident was depressed and did not want to come out of her room. On 02/17/2012, "Resident was admitted to (local hospital) today, family notified of bed hold policy and sent (with) transfer." Another noted date 02/17/2012 revealed: "Allegations were made by resident to her daughter by phone that CNA had been sexually inappropriate. SSD (social service director) was notified on 02/15/2012. Internal investigation is underway along with investigations from SLED (South Carolina Law Enforcement Division) and local sheriff's dept (department). Employee has been placed on leave until investigations are complete. 24 Hour report sent on 2/14 when nurse was notified. 5 day report will be sent on 2/21." The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored a BIMS of "3" and was independent with transfers, ambulation and toilet use. No behaviors were recorded a occurring. The resident was coded as having hallucinations and delusions during the assessment period. Review of the Social Services notes dated 02/15/2012 revealed: "DON (director of nurses) and SSD reviewed statements regarding sexual abuse allegations against another resident in facility, nurses statements included (Resident #2) involvement with separate incident involving same male CNA (CNA #1). Attempted family contact with daughter/RP at 9:50 AM and 3 PM. Home phone had no answer/no voicemail, cell had no answer no VM box set up, no response." Another note on 02/15/2012 revealed: "DON and SSD went to interview resident regarding an alleged incident that occurred with her and CNA. Time frame uncertain. Resident stated that she knew the CNA and stated that he was always very kind to her. SSD asked her if CNA in question had ever been sexually inappropriate with her. She responded no, he's always been very nice to me. Upon further questioning, resident had no recall of any sexual/inappropriate behavior by this male CNA." Review of the facility obtained statement taken by Registered Nurse (RN) #1 from Resident #1 on 02/14/2012 at 9:25 PM revealed: "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it-has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." Review of the facility obtained statement taken by RN #1 on 02/14/2012 at 9:45 PM from Resident #2 revealed: "About 2 weeks ago, it's been a good while back, he sat down and had his "thang" out and then he put it back. He was out on the porch. I believe we were out on the porch and he pulled his britches down, its been so long ago. I saw his penis, it was red looking. I left, I haven't spoken to him since. ...it was very embarrassing, I can't even face him." Review of the SSD statement dated on 02/15/2012 revealed: "SSD met with (Resident #1's Responsible Party and Resident #1) to discuss what had happened to her last night. (Resident #1) stated that (CNA #1) had come behind the curtain in her room and placed his penis in her hand. SSD asked her if he had done anything else with his hands or penis during this time. She stated no. (RP) informed (Resident #1) that this is a serious allegation and that she could send this man that she is accusing to jail for a long time, (Resident #1) said I know, he did this to me. SSD asked her when this happened, she stated a weeks ago, I don't remember which shift my mind is as short as my pinky finger. SSD asked (Resident #1) why she did not report this as soon as this happened. She stated , I was scared. SSD: what were you scared of? (Resident #1): I was scared he would come back in here and do other things to me. I saw him after this happened to me in the dining room. He spoke to me when he saw me in the dining room, but he was always nice and would say hello or how are you doing. SSD asked (Resident #1) about her feelings about moving from the facility, as she is apparently not safe in this facility. She stated she would go, (RP) said I know she will miss some of her friends..." Further review of the Investigative File revealed the facility failed to assess, physically, emotionally or psychosocially, Residents #1 and #2. The facility also did not identify, interview or assess other residents at the facility at risk for potential abuse. During an interview on 02/21/12 at 2 PM, the Director of Nurses confirmed that the residents had not been assessed. During an interview on 2/21/2012 at 4:30 PM, the Medical Director stated that he was notified of the sexual abuse allegation on 02/15/2012. He stated that he did not assess the residents since there was no reported penetration. He stated that since it was emotional upsetness there was no reason for an assessment. The Medical Director stated that Resident #2 was interviewed several times regarding the allegation, he stated that when pressed for information, the resident would "clam up." The Medical Director stated that CNA #1 had 2 prior accusations before Residents #1 and #2. During another interview on 02/22/2012 at 12:10 PM, the DON was asked about other accusations related to CNA #1, she stated that Resident #6 had stated she was having CNA #1's baby. The DON stated that no investigation had been completed related to the incident. The other accusation was reported to the State Agency. During an interview on 02/22/2012 at 3 PM, the SSD provided documentation to the surveyor related to Resident #6's allegation. Review of the Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS of "3" and no behaviors, hallucinations or delusions were coded as occurring in the assessment period. Review of the documentation revealed: "SSD went into (Resident #6's) room on 12/12/11 and she was very upset and crying...she was very upset and then stated she had had his (CNA #1's) baby and put the baby in the dumpster and the cops were looking for her...SSD ensured (sic) that (Resident #6) had an appointment with her psychiatrist that day, SSD included a letter to (the psychiatrist) regarding the behaviors she is having and requesting an evaluation." The statement was signed and dated on 12/14/2012 with a statement of "SSD has seen no signs of further problems as medications were adjusted by (Psychiatrist). A typed letter that had a handwritten date of 12/12/2012 (the year 12 was lined through with a number one) that revealed: "I am writing this letter on behalf of (Resident #6). She had hallucinations last week..." Record review revealed, Resident #6 was not seen by the psychiatrist until 12/19/2011 when the psychiatrist noted increased delusions and hallucinations. The residents medications were increased. Review of the Nurse's Notes revealed on 12/12/2011 the only documentation was "body audit-skin warm and dry, intact. On 12/19/2011 at 12 PM, (Resident #6) upset because "a girl pushed me out here and shouldn't have, waiting on (CNA #1). (CNA #1) will come and get me and take care of me. ...you don't know, he'll be here to get me... Attempted to reassure the resident." Further review of the Nurse's Notes from November and December 2011 revealed no other documentation of behaviors, hallucinations or delusions. Review of the Social Service Notes dated 12/19/2011 revealed Resident #6 hallucinating last week when the television is on the news. ...she stated she had CNA #1's baby. On 12/30, "she did go to her psychiatrist after her last delusions and changes were made to her Abilify and Depakote sprinkles..." On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended. First Follow-Up Visit During an unannounced, onsite visit on 03/30/2012 at 2:15 PM, it was determined based on interviews, observations, limited record review, and review of facility policies that the Allegation of Compliance had been implemented by the facility and was in practice as of 03/01/2012. The Allegation of Compliance with a completion date of 03/01/2012 was submitted by the facility. The actions listed in the Allegation of Compliance included the following: *Resident #1 is no longer at the facility. discharge date [DATE] *Resident #2's responsible party was notified of the allegation of sexual abuse on 02/22/2012. Attempts began on 02/15/2012 but were unsuccessful. Current phone numbers have been obtained for future reference. *Physician notified 02/21/2012 of possible sexual abuse. *Education has been completed on 02/24/2012 for all licensed staff related to the revised Abuse and Neglect policy. Education included requirements of notifications to MD and Responsible Parties. Education provided by the DON (director of nurses). *Resident's #2 and #6 had Physical Assessments conducted 02/21/2012 *Resident #2 had Psychosocial Assessment completed by the DON on 02/21/2012. Psychosocial Assessments will continue weekly for 30 days. *Resident #6 had Psychosocial Assessment conducted by the MDS Nurse on 02/25/2012. Psychosocial Assessments will continue weekly for 30 days. Other immediate corrective actions included: *Physical Assessments were performed for all residents on 02/21/2012 by Licensed Nursing *Psychosocial Assessments were completed for all residents by 02/25/2012. Assessments completed by Nursing Administration, Licensed Nurses, Admissions Coordinator, Activities Director, Dietary Managers and Business Manager. *Local Police have investigated the allegations of abuse. Union County Sheriff's Office notified 02/21/2012. *SLED (South Carolina Law Enforcement) has investigated all allegations of abuse and failure to report. SLED contacted 02/15/2012. *All families were contacted by the Administrative staff on 02/16/2012 and 02/22/2012 to inquire of any knowledge of abuse. *Revisions to Abuse and Neglect policy included: *Specific procedures related to sexual abuse *Specific procedures related to reporting allegations of abuse *Information on the Elder Justice Act *Education completed for all staff on 02/24/2012 related to the revised Abuse and Neglect policy. Education provided by DON. Education will continue monthly for 90 days, annually and upon hire for Abuse and Neglect. *Employees suspended pending the investigation include: -Certified Nurse Aide (CNA) #1 (suspended 02/14/2012 - terminated 03/07/2012) -Social Services Director - 02/22/2012 - pending -Social Services Assistant - 02/22/2012 - pending -Risk Manager - 02/22/2012 - pending *Abuse and Neglect education provided to Administration Staff on 02/24/2012 The citation at F-250 remained at a lowered scope and severity of "E". The facility will be in compliance at F-250 when an acceptable Plan of Correction is submitted and a follow-up visit is conducted to determine that the facility has implemented their Plan of Correction as stated.

On the days of the Complaint and Extended Survey based on record reviews and interviews, Immediate Jeopardy was identified existing in the facility as of 02/14/2012 related to the facility's failure to utilize its resources effectively and efficiently to attain or maintain the highest practicable well being of each resident. The facility's Administration failed to identify, report and thoroughly investigate allegations of sexual abuse. The findings included: A complaint survey was conducted on 02/21/2012 as a result of a facility reported incident. Resident #1 reported during a telephone conversation, an incident of alleged sexual abuse to her daughter, on the evening of 02/14/2012. Her daughter came to the facility and reported the incident to Registered Nurse (RN) #1. In the following statement taken by RN #1 on 02/14/2012 at 9:25 PM Resident #1 stated, "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it - has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." On 02/22/2012 the Administrator contacted the State Agency with additional information related to the investigation regarding Residents #1 and #2. A faxed report indicated, "Staff Assistant reported to nursing that she had reported to her supervisor and Social Services about a month ago that Resident #1 reported to her that CNA #1 had sexually abused Resident #2." During a telephone conversation on 02/22/2012 the Administrator stated this was the first he had heard of this allegations. Review of the facility obtained statement dated 2/22/2012 from Staff Assistant #1 revealed: "To whom it may concern, (HR) call me at 4:15 PM on 2/22/12 to ask me questions about something I told (Administrator and Staff Development) this morning about (Resident #2) had told (Resident #1) about (CNA #1). (Resident #1) told me she love me and could trust me. Then she told me what (Resident #2) said that (CNA #1) came into her room, was playing with his penis, he pull it out, (Resident #2) said it was real red then he started to play with her breast that's what (Resident #1) told me. Then (Resident #1) said (Resident #2) was scared of him. (Resident #1) also said what if he bothered (roommate), she couldn't tell anybody about it. (Resident #1) said he should try to bother her should would knock the hell out of him. I told her she should tell someone, that's when she said (Resident #2) was scared of him. (Resident #1) told me about the sexual abuse in Jan second week 2012. I was putting ice on the halls on Unit I. Then I went to (Risk Manager) my supervisor. I ask what I should do, she told me to go to Social Services, I did. I talk with (SSD and SSA) and told her what (Resident #1) had told me. She said (CNA #1) had already been sent 3 times before. (????suspension???) She said she could talk with (Resident #2) and (Resident #1) without them knowing I told her about a report of maybe sexual abuse. (SSD) said she would take care of it. I went to Social Services before 11 AM second week in [DATE]." Additional comments were added by the Staff Assistant: "(SSD) also told me that she didn't want to see (CNA #1) to lose his job. I was also told the names of 2 of the residents who had allegations against (CNA #1). (SSD) told me the names!." Review of the facility obtained statement from the Risk Manager dated 02/22/2012 at 6:30 PM revealed, "(Staff Assistant) stopped me in hall and stated (Resident #2 mentioned to her that she had been touched on the breast, should she tell someone or just keep to herself. I told her to tell Social Services. Later (Staff Assistant) told (SSD). That is the last time it was mentioned." Review of the facility obtained statement from the SSD on 02/22/2012 revealed: "I had no knowledge of sexual abuse on (Resident #2) until I read it in (RN #1's) statement on 2/15/12...." During an interview on 02/24/2012 at 1:15 PM, the ADON (assistant director of nurses) confirmed the written statements and stated that the Staff Assistant reported the incident to her supervisor appropriately. The ADON stated that her supervisor was Risk Management and that she attended all the morning stand up meetings and QA (quality assurance) meetings. The ADON stated that she did not report the incident to anyone. The ADON stated that the SSD, SSA and the Risk Manager had all been suspended. The ADON confirmed that the Risk Manager was considered part of the facility's Administration and was responsible for relaying the information to the rest of the Administration. Cross Refers to the following citations: 483.10(b)(11) Notification, F-157 was identified at a scope and severity of "K". The facility staff failed to notify the Physician and the Responsible Party of changes in condition or accident. The facility failed to timely notify the Attending Physician/Medical Director of an allegation of sexual abuse. The facility also failed to contact 1 of 3 resident's responsible parties regarding an allegation of sexual abuse. The facility also failed to assure 2 of 3 residents reviewed for blood sugar management had their physician notified of low blood sugars (Residents #1 and #7). 483.13(c) Staff treatment of [REDACTED]." The facility failed to identify, report and thoroughly investigate allegations of sexual abuse for 3 of 3 residents reviewed for sexual abuse. Residents #1, #2 and #6 alleged sexual abuse against Certified Nursing Assistant (CNA) #1. 483.13(c) Develop/Implement Abuse/Neglect, Etc. Policies, F-226 was identified at Substandard Quality of Care and Immediate Jeopardy at a scope and severity of "K". Residents #1, #2, and #3 alleged sexual abuse against Certified Nursing Assistant #1 the facility failed to follow it's policy regarding reporting, investigating and identifying potential abuse related to the allegations. 483.15(g)(1) Medically Related Social Services, F-250 was identified at Substandard Quality of Care and Immediate Jeopardy at a scope and severity of "K". The facility failed to provide medically related social services to three of three residents involved in allegations of sexual abuse. Resident #1, #2 and #6 alleged sexual abuse by Certified Nurses Assistant #1. No Social Service interventions were put in place related to the allegations. 483.20(k)(3) Services Provided Meet Professional Standards, F-281 was identified at Immediate Jeopardy at a scope and severity level of "K". The facility staff failed to identify and assess 3 of 3 residents involved in allegations of sexual abuse (Residents #1, #2 and #6). Facility staff also failed to identify and assess other residents that may have been affected by potential abuse. In addition, facility staff failed to recognize, follow up on and contact the physician regarding blood sugars consistently below 60 mg/dl for two of three residents reviewed receiving Insulin (Residents #1 and #7). . 483.75(i) Medical Director, F-501 was identified at Immediate Jeopardy at a scope and severity of "K". The Medical Director failed to ensure that the facility policies and procedures were implemented for residents with allegations of sexual abuse. On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended.

On the days of the survey, based on observations, full and/or limited record reviews, interviews, review of the policies provided by the facility entitled "Procedure For Diabetic Monitoring" , "Hyper/[DIAGNOSES REDACTED],SSI,Glucometer Skills Check List" and "Hand Washing" the facility failed to ensure a sanitary environment to prevent the development and transmission of disease and infection by failing to ensure wipes used to disinfect 3 of 4 glucometers between each resident use were approved germicidal wipes. Concerns were identified with 39 residents who received Finger Stick Blood Sugar (FSBS) monitoring in [DATE]. The connector tip of Resident #8's Feeding tube was placed uncovered, on a soiled towel during treatment observation for 1 of 2 residents reviewed for feeding tube flushes. The findings included: On [DATE] at 3:37 PM, Registered Nurse (RN) #4, was asked to demonstrate the procedure for cleaning glucometers. The RN removed a glucometer from her Medication (Med) Cart, removed alcohol wipes from a caddy sitting on her cart and cleaned the meter with the alcohol wipes. At 4:42 PM on 12//,[DATE], Licensed Practical Nurse (LPN) # 3 was asked how she cleaned her glucometer. LPN #3 stated she did not know anything about cleaning the glucometer. In an interview with RN #4, she stated that she had not been inserviced on cleaning glucometers and that she vaguely remembered something about wipes but always cleaned with alcohol wipes. LPN #1 was asked how he cleaned his glucometer, he stated that he cleaned with alcohol wipes. He stated he had worked at the facility for 2 months and always cleaned with alcohol wipes. During an interview on [DATE] at 3:50 PM, Licensed Practical Nurse (LPN) #1 was asked to demonstrate how to clean a glucometer. He stated that once the blood sugar reading was done, he would throw the test strip and lancet into the sharps container. He then demonstrated cleaning the glucometer by using gloved hands and an alcohol pad to wipe the glucometer all over. When asked, he stated he had been using an alcohol pad to clean the glucometer ever since he had started working at the facility a couple of months ago. During an interview on [DATE] at 5:28 PM, LPN #1 was asked if he had ever received training from the facility on using a disinfectant wipe instead of alcohol to clean the glucometer. He stated "If they told me to use disinfectant wipes I don't remember. He stated he had recently put Gluco-Chlor wipes onto the cart and showed the surveyor the wipes which were in date. He stated there had been a few of the wipes in the drawer, but he had never seen them so he didn't know to use them. During an interview on [DATE] at 4:22 PM, Registered Nurse (RN) #1 was asked if she had received any training on using the disinfectant wipes to clean the glucometer. She stated during her orientation to the facility a couple years ago she was told to use Clorox wipes to clean the glucometer. She stated that approximately ,[DATE] weeks ago she was told to use the Gluco-Chlor wipes. She stated she read the package to find out how to use the Gluco-Chlor wipes. On [DATE] at 4:42 PM, during observation of Med pass, LPN #3 gathered supplies for a Finger Stick Blood Sugar (FSBS) to be drawn. The LPN did not clean the meter in the presence of the surveyor prior to entering the room. After checking the resident's FSBS, the nurse returned to her med. cart, drew up the ordered dose of insulin correctly and returned to administer the medication. LPN #3 then returned to the med. cart, again entered the room to do a FSBS on the resident's roommate in the same room. She did not clean the glucometer prior to re-entering the room. After washing her hands and donning gloves, she cleaned the second resident's finger with a alcohol wipe, stuck the resident and placed a strip in the glucometer. At that point the surveyor stopped the LPN and asked her to return to the cart. The surveyor then informed the nurse that she could not let her complete the FSBS due to the nurse not cleaning the glucometer after using it on the previous resident. LPN #3 stated that she had been working at the facility since August and had not been told to clean the glucometer. The nurse then took a Gluco Chlor wipe from her caddy and cleaned the glucometer and stated, "it takes a long time for this to dry." In an interview with the Registered Pharmacist on [DATE] at 4:30 PM, she stated that the pharmacy did not in-service on specific wipes to clean the glucometers but that during medication pass check off they did informed the nurses to clean the glucometers. Review of a (purchase) Order Acknowledgement revealed that on [DATE], 5 boxes of Gluco Chlor (containing 100 wipes per box per box) had been ordered by the facility. The purchase had been approved by the Administrator on [DATE]. No information as to when the product arrived at the facility was provided prior to the survey team exiting the facility. Review of the facility's "Hyper/[DIAGNOSES REDACTED],SSI,Glucometer Skills Check List" (not dated) on [DATE] provided by the Director of Nursing stated "...20. Cleanse meter after each resident use..." An updated "Hyper/[DIAGNOSES REDACTED],SSI,Glucometer Skills Check List" also provided by the DON on [DATE] stated "...Cleanse meter with Gluco chlor swabs after each resident use..." On [DATE] at 1:55 PM, both the Director of Nursing (DON) and the Nursing Home Administrator stated that they were not aware that the nurses were not cleaning the glucometers correctly or not cleaning them between residents until they were informed by the surveyor. When asked who monitored the nurses to ensure that the glucometers were cleansed properly with the appropriate cleanser, the DON stated that Nursing Administration should have been monitoring. The DON was asked if any of the residents in the facility had any known blood borne diseases such as Hepatitis or HIV (Human Immunodeficiency Virus). She provided a note stating that "No residents in the facility as of ,[DATE] have known HIV or Hepatitis or any other blood borne pathogen". During an interview on [DATE] at 2:35 PM, The Medical Director stated that he agreed that the nurses should be using an approved germicidal wipe for cleaning glucometers. Review on [DATE] of [DATE] Medication Administration Records revealed 39 residents had received FSBS monitoring in the month of December. These 39 residents had FSBS done from 1 time daily in the month to up to 4 times daily. Review of the facility Infection Control Logs from [DATE] to the present along with the Monthly Nosocomial Infection Report for 2011 revealed no incidents of residents with blood borne infections. Immediate Jeopardy was determined to exist on [DATE] at 5:45 PM after staff were identified as not using an approved germicidal wipe and/or not cleansing the glucometer between resident FSBS. This systemic practice placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. CFR 483.65 F-441 was identified at a scope and severity of "K". The findings related to the Immediate Jeopardy were identified related to the facility failure to assure that glucometers used for multiple residents were appropriately cleansed and disinfected with an appropriate cleansing agent between use to prevent the transmission of blood borne pathogens. There were 39 residents residing in the facility who received blood glucose testing with the use of the glucometer in [DATE]. The systemic failure of the facility to effectively clean the glucometers placed the residents at risk for serious harm. An Allegation of Compliance was submitted by the facility on [DATE]. During interviews on [DATE] at approximately 2:30 PM, 4 nurses on Unit 1 verbalized and/or demonstrated the proper way to clean a glucometer using appropriate disinfectant wipes and checking the expiration date prior to use. Interviews of 12 licensed nurses on [DATE] at approximately 4:30 PM revealed nursing staff were knowledgeable on using the germicidal wipes and checking for expiration before using them to clean glucometers. Review of staff education on the policy of FSBS and checking expiration dates revealed nursing staff had either been called and informed of the new policy on FSBS and checking the wipes for expiration prior to use or attended the inservice on the units on [DATE]. According to the DON, all of the licensed nurses except for three had been contacted; and a message had been left for the nurses that she would not be allowed to work until she had received information relative to the new policy on FSBS and checking supplies for expiration dates prior to use. Observations, interviews, and review of policy education and signature sheets on [DATE] revealed the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of the new policy requiring staff to use and check germicidal wipes prior to disinfecting glucometers to ensure they had not expired. The Administrator was informed of this on [DATE] at 3:45 PM. The citations at F-281, F-441, and F-490 remained at a lower scope and severity of "E". The facility will be in compliance with F-281, F-441, and F-490 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction. . On [DATE] form 8:05 AM to 8:40 AM, RN #3 was observed administering medications to 2 resident's. The RN failed to wash/sanitize her hands at any time during the observation. A hand sanitizer dispenser was noted to be on the wall in the hallway where the nurse had placed her medication cart while giving the resident's their medications. On 12//,[DATE] at 11:00 AM, in an interview with RN #3, she verified that she did not wash her hands the prior day when administering medications while the surveyor observed. The facility admitted Resident #8 on [DATE] with [DIAGNOSES REDACTED]. Observation of a tube flush on [DATE] at 3:20 PM revealed RN #1 unhooked the tube feeding from the Gastrostomy tube to perform the flush. After she unhooked the feeding tube, she placed the tubing onto the resident's abdomen with the tip of the feeding connector touching the towel draped around the gastrostomy tube. The tubing remained there until she was finished with the procedure. When finished, the nurse did not remove the towel from around the gastrostomy tube. During an interview on [DATE] at 5:02 PM, she verified she had placed the tip of the feeding connector onto the towel. She stated she usually kept the tip between her fingers. After reviewing the record, it was noted that the resident was to be seen on consult because her gastrostomy tube was leaking. Later on when asked, RN #1 verified the towel that was around the gastrostomy tube was there because the tube had been leaking.

On the days of the survey, based on observations, full and/or limited record reviews, interviews, review of the policies provided by the facility entitled "Procedure For Diabetic Monitoring" , "Hyper/[DIAGNOSES REDACTED],SSI,Glucometer Skills Check List" and "Hand Washing" the facility failed to be administered in a manner that ensured staff were trained in the prevention of bloodborne pathogens related to cleaning and disinfecting multiple-resident use glucometers. The findings included: During the days of the survey, it was identified based on observation and interview that facility licensed staff were failing to clean multi use resident glucometers. Interviews revealed that either staff was either not aware of the need to clean the glucometers and or not aware of the proper procedure. There were 39 residents residing in the facility who received Finger Stick Blood Sugar (FSBS) monitoring in [DATE] who had the potential to be affected. Review of a (purchase) Order Acknowledgement revealed that on [DATE], 5 boxes of Gluco Chlor (containing 100 wipes per box per box) had been ordered by the facility. The purchase had been approved by the Administrator on [DATE]. No information as to when the product arrived at the facility was provided prior to the survey team exiting the facility. Review of the facility's "Hyper/[DIAGNOSES REDACTED],SSI,Glucometer Skills Check List" (not dated) on [DATE] provided by the Director of Nursing stated "...20. Cleanse meter after each resident use..." An updated "Hyper/[DIAGNOSES REDACTED],SSI,Glucometer Skills Check List" also provided by the DON on [DATE] stated "...Cleanse meter with Gluco chlor swabs after each resident use..." On [DATE] at 1:55 PM, both the Director of Nursing (DON) and the Nursing Home Administrator stated that they were not aware that the nurses were not cleaning the glucometers correctly or not cleaning them between residents until they were informed by the surveyor. When asked who monitored the nurses to ensure that the glucometers were cleansed properly with the appropriate cleanser, the DON stated that Nursing Administration should have been monitoring. During an interview on [DATE] at 2:35 PM, The Medical Director stated that he agreed that the nurses should be using an approved germicidal wipe for cleaning glucometers. Immediate Jeopardy was determined to exist on [DATE] at 5:45 PM after staff were identified as not using an approved germicidal wipe and/or not cleansing the glucometer between resident FSBS. This systemic practice placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. An Allegation of Compliance was submitted by the facility on [DATE]. During interviews on [DATE] at approximately 2:30 PM, 4 nurses on Unit 1 verbalized and/or demonstrated the proper way to clean a glucometer using appropriate disinfectant wipes and checking the expiration date prior to use. Interviews of 12 licensed nurses on [DATE] at approximately 4:30 PM revealed nursing staff were knowledgeable on using the germicidal wipes and checking for expiration before using them to clean glucometers. Review of staff education on the policy of FSBS and checking expiration dates revealed nursing staff had either been called and informed of the new policy on FSBS and checking the wipes for expiration prior to use or attended the inservice on the units on [DATE]. According to the DON, all of the licensed nurses except for three had been contacted; and a message had been left for the nurses that she would not be allowed to work until she had received information relative to the new policy on FSBS and checking supplies for expiration dates prior to use. Observations, interviews, and review of policy education and signature sheets on [DATE] revealed the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of the new policy requiring staff to use and check germicidal wipes prior to disinfecting glucometers to ensure they had not expired. The Administrator was informed of this on [DATE] at 3:45 PM. The citations at F-281, F-441, and F-490 remained at a lower scope and severity of "E". The facility will be in compliance with F-281, F-441, and F-490 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction. .

On the days of the survey, based on observations, full and/or limited record reviews, interviews, review of facility provided policies related to Hyper/[DIAGNOSES REDACTED], SSI (sliding scale insulin), Procedure For Diabetic Monitoring and the Glucometer Skills Check List , facility nursing staff failed to ensure that approved germicidal wipes were used for the disinfecting/cleaning of 3 of 4 multiple-resident use glucometer's prior to use and or failed to clean glucometer's between residents. Thirty- nine residents in the facility received Finger Stick Blood Sugar (FSBS) monitoring in [DATE]. Resident #11, 1 of 3 residents reviewed for Sliding Scale Insulin did not receive Insulin as ordered for 5 doses. The findings included: Cross refer to F441 as it relates to facility nursing staff failure to ensure that appropriate and effective disinfecting wipes were used to clean multiple-resident use glucometers prior to use. On [DATE] at 3:37 PM, Registered Nurse (RN) #4 was asked by the surveyor to demonstrate how she cleans a glucometer. RN #4 removed a glucometer from her medication (MED) cart and alcohol wipes from a caddy on her cart. She then cleaned the meter using the alcohol wipes and stated that she cleans the glucometer between each resident using alcohol wipes. At 3:42 PM Licensed Practical Nurse (LPN) #3 was asked how she cleans the glucometer. She stated that she did not know anything about cleaning a glucometer and that she does not clean it. She acknowledged she has residents who have Finger Stick Blood Sugars (FSBS) done on her shift. When interviewed, LPN #4 stated that he cleans the glucometer using alcohol wipes. On [DATE] at 1:55 PM, both the Director of Nursing and the Nursing Home Administrator stated that they were not aware that the nurses were not cleaning the glucometers correctly until they were informed by the surveyor. During a telephone interview on [DATE] at 2:35 PM with the Medical Director, he stated that he would expect the facility nurses to clean the glucometers with a sodium Hypochlorite solution and was not aware that they did not. He also stated that he approved the new policy which included cleaning with a approved germicidal product and checking for expiration dates on those products. Review of the facility policy entitled Procedure For Diabetic Monitoring revealed "...15) glucometers that are used for more than one resident must be cleaned and disinfected between residents. 16) Check the expiration date of the approved germicidal wipe before using. 3. To clean the meter: Disinfect the meter after it is turned off. Gently wipe the surface with approved germicidal wipe. Do not put meter under water or spray any cleaning or disinfectant directly onto the meter. Set meter aside on a clean piece of paper and allow the germicidal to dry." Review of the facility's Hyper/[DIAGNOSES REDACTED],SSI,Glucometer Skills Check List all stated to "..Cleanse meter after each resident use..." Immediate Jeopardy was determined to exist on [DATE] at 5:45 PM after staff were identified as not using an approved germicidal wipe and/or not cleansing the glucometer between resident use. CFR 483.20 F-281 was identified at a scope and severity of "K". Facility Licensed staff failed to follow standard precautions related to blood borne pathogens and failed to appropriately clean glucometers used for multiple residents with an appropriate cleansing agent. An Allegation of Compliance was submitted by the facility on [DATE]. During interviews on [DATE] at approximately 2:30 PM, 4 nurses on Unit 1 verbalized and/or demonstrated the proper way to clean a glucometer using appropriate disinfectant wipes and checking the expiration date prior to use. Interviews of 12 licensed nurses on [DATE] at approximately 4:30 PM revealed nursing staff were knowledgeable on using the germicidal wipes and checking for expiration before using them to clean glucometers. Review of staff education on the policy of FSBS and checking expiration dates revealed nursing staff had either been called and informed of the new policy on FSBS and checking the wipes for expiration prior to use or attended the inservice on the units on [DATE]. According to the DON, all of the licensed nurses except for three had been contacted; and a message had been left for the nurses that she would not be allowed to work until she had received information relative to the new policy on FSBS and checking supplies for expiration dates prior to use. Observations, interviews, and review of policy education and signature sheets on [DATE] revealed the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of the new policy requiring staff to use and check germicidal wipes prior to disinfecting glucometers to ensure they had not expired. The Administrator was informed of this on [DATE] at 3:45 PM. The citations at F-281, F-441, and F-490 remained at a lower scope and severity of "E". The facility will be in compliance with F-281, F-441, and F-490 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction. The facility admitted Resident #11 on [DATE] with [DIAGNOSES REDACTED]. Record review on [DATE] at 2:15 PM revealed a [DATE] Documentation Record for Resident #11. One entry stated "Regular Insulin SS (Sliding Scale) Before Meals, Less Than 150=0 Unit, ,[DATE]=0 Unit, ,[DATE]=2 Units, ,[DATE]=4 Units, ,[DATE]=6 Units, ,[DATE]=8 Units...". Further review revealed documentation that 4 units of Insulin had been given for a blood sugar of 241 on [DATE] at 11:30 AM . According to the order, 2 units of Insulin should have been given instead of 4 units. Review of Resident #11's "Fingerstick Blood Sugar Record" for [DATE]- 11:30 AM also documented 4 units of Insulin had been given for the blood sugar of 241. An entry dated [DATE] at 4:30 PM documented 6 units of Insulin had been given for a blood sugar of 352. According to the order, 8 units of Insulin should have been given. The resident's "Fingerstick Blood Sugar Record" also documented 6 units of Insulin had been given for the blood sugar of 352 on [DATE] at 4:00 PM. The above findings were verified by Registered Nurse (RN) #2 after reviewing the record. Continued record review on [DATE] at 9:50 AM revealed Documentation Records and Fingerstick Blood Sugar Records for Resident #11 for October and [DATE]. The October and [DATE] Documentation Records contained entries for "Regular Insulin SS (Sliding Scale) Before Meals, Less Than 150=0 Unit, ,[DATE]=0 Unit, ,[DATE]=2 Units, ,[DATE]=4 Units, ,[DATE]=6 Units, ,[DATE]=8 Units...". The following entries were reviewed which indicated Resident #11 received the incorrect dosages of Insulin: On [DATE] at 11:30 AM, 4 units of Insulin had been documented as having been given for a blood sugar of 245. According to the order, 2 units of Insulin should have been given. On [DATE] at 4:00 PM, 2 units of Insulin had been documented as having been given for a blood sugar of 266 on the Fingerstick Blood Sugar Record. According to the order, 4 units of Insulin should have been given. Review of the Documentation Record for the same date and time ([DATE] at 4:30 PM) revealed documentation that no Insulin had been given for the blood sugar of 266. On [DATE] at 4:30 PM, 2 units of Insulin had been documented as having been given for a blood sugar of 272. According to the order, 4 units of Insulin should have been given. These findings were verified with RN #2 after reviewing the record.