Every finding on record at Iva Post-Acute

Based on observation, record review, and interviews, the facility failed to ensure one of one resident (Resident (R)1) reviewed for oxygen administration received oxygen per nasal cannula and the oxygen tubing was changed according to the physician's order. This failure had the potential for the resident to receive increased oxygen causing hyperoxia (cells, tissues and organs are exposed to an excess supply of oxygen.)Findings include:Review of R1's admission Record in the electronic medical record (EMR) under the Profile tab revealed R2 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia.Review of R1's annual Minimum Data Set (MDS) under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 09/17/25 and a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated no cognitive impairment. The resident was coded as receiving oxygen therapy.Review of R1's Care Plan located under the Care Plan tab of the EMR dated 04/03/23 revealed, Pulmonary Hygiene/Respiratory with intervention to administer oxygen per physician orders.Review of R1 Physician Orders located under the Orders tab in the EMR dated 08/28/25 revealed oxygen at 2 Liters per Minute (LPM) via nasal cannula continuously. Further review revealed order dated 08/28/25 to change tubing weekly on Wednesday.Review of R1's Treatment Administration Record (TAR) dated September 2025 located under the Records tab in the EMR revealed on 09/15/25 and 09/16/25, Licensed Practical Nurse (LPN)1 documented that R1 was on oxygen at two LPM continuously.During observations on 09/15/25 at 10:50 AM and on 09/16/25 at 1:45 PM, the resident was lying in bed using a nasal cannula. The oxygen cannister was set at three LPM and the oxygen tubing was dated 09/03/25. During an observation and interview on 09/16/25 at 1:47 PM, LPN1 stated R1 should be on 2 LPM and that the oxygen tubing was changed every 3 days. She observed R1's oxygen and confirmed it was set at 3 LPM and the oxygen tubing was dated 09/03/25.During an interview on 09/16/25 at 5:21 PM, the Director of Nursing (DON) stated she expected oxygen tubing to be changed weekly and that nursing staff should be checking oxygen settings every shift to ensure the setting is per physician orders.

Based on observation, interview, record review, and facility policy review, the facility failed to follow infection control and prevention guidelines regarding Enhanced Barrier Precautions (EBP) while performing indwelling urinary catheter care for two of two residents (Resident (R)1 and R12) reviewed for indwelling urinary catheters of 22 sampled residents. This failure had the potential to spread multidrug resistant organisms (MDROs) to the residents.Findings include:Review of the facility's undated policy titled EBP revealed, Which patients need EBP? Patients with indwelling devices, such as: Urinary Catheters. EBP for all of the following activities: device care or use: urinary catheter. Precautions are to remain in place for duration of resident's stay or until resolution of wound or discontinuation of indwelling medical device.1. Review of R1's admission Record, in the electronic medical record (EMR) under the Profile tab revealed R1 was admitted to the facility on [DATE] with diagnosis of retention of urine.Review of R1's comprehensive Care Plan located in the EMR under the Care Plan tab dated 07/08/25 revealed the focus area: indwelling catheter with interventions to provide catheter care every shift. Further review revealed a focus area dated 07/01/25 for EPB related to indwelling catheter.Review of R1's Physician's Orders dated 08/27/24 located in the EMR under the Orders tab revealed an order Perform Indwelling Catheter Care each shift and as needed.During an interview on 09/15/25 at 5:37 PM, Certified Nurse Aide (CNA)3 and CNA4 stated that staff were not wearing gowns when performing catheter care.During an interview on 09/16/25 at 1:51 PM, CNA4 stated she has received training by the facility several times specifically related to EBP. She was aware that a gown should be worn during catheter care. She stated she did not wear a gown, but should have gone to the Director of Nursing (DON) or central supply to get PPE before providing care.During an interview on 09/16/25 at 2:08 PM, CNA3 stated she only thought residents with wounds required EBP.2.Review of R12's admission Record located in the EMR under the Profile tab revealed the resident was readmitted to the facility on [DATE] with a diagnosis of urinary retention.Review of R12's Order Summary indicated an order for (Foley catheter).During observations on 09/14/25 between 11:00 AM-12:00 PM, revealed R12 had an indwelling urinary catheter.During an observation on 09/15/25 at 4:45 PM of R12's catheter care, CNA1 and CNA2 did not wear a gown, only gloves when providing catheter care.During an interview on 09/16/25 at 1:16 PM, CNA1 confirmed that she did not wear the appropriate PPE while doing R12's catheter care.During an interview on 09/16/25 at 1:40 PM, CNA2 confirmed that when a resident has a catheter, PPE of gown, gloves, and face shield should be worn. CNA2 confirmed that she did not wear a gown or face shield during R12's catheter care.CNA2 stated that a resident that is on EBP, gloves are not enough.During an interview on 09/16/25 at 5:21 PM, the Director of Nursing (DON) stated she expected staff to follow the guidelines according to PPE and EBP protocol. The DON stated that a gown should be worn during high contact care with a resident who has a catheter. She also stated she expected her staff to recognize when a type of care required EBP and inform her or the unit manager if PPE was not provided.

Based on record review, interview, and facility policy review, the facility failed to ensure a resident received their scheduled morning medications before or after a resident returned from dialysis for one of one resident (R)64) reviewed for dialysis out of sample of 22 residents. This had the potential to affect all residents who went out for dialysis treatment.Findings include:Review of the undated facility's policy titled, Care of a Resident with End-Stage Renal Disease revealed, Residents with end-stage renal disease will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff include, specifically timing and administration of medications, particularly those before and after dialysis.Review of R64's Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed R64 was admitted to the facility on [DATE] with diagnosis of end stage renal disease (ESRD).Review of R64's Care Plan located under the Care Plan tab of the EMR dated 08/09/24, revealed the resident needs hemodialysis related to renal failure. The intervention in place was the resident required dialysis three times weekly on Tuesday, Thursday, and Saturday.Review of R64's Physician Orders located under the Orders tab in the EMR dated 09/08/25 revealed an order for amlodipine Cinacalcet (calcium blocker medication) 5 milligram (mg) once daily, Aricept 5 mg once daily, and duloxetine (antidepressant medication) 60 mg once daily. Further review revealed order dated 09/08/25 medication administration times on dialysis days may be adjusted to ensure proper absorption.Review of R64's September 2025 Medication Administration Record (MAR) located under the Orders tab in the EMR dated 09/16/25 amlodipine Cinacalcet 5 mg once daily, Aricept (medication used to treat dementia) 5 mg once daily, and duloxetine 60 mg was not administered on 09/08/25, 09/10/25, 09/12/25, and 09/14/25 During an interview 09/16/25 at 2:22 PM, Licensed Practical Nurse (LPN)1 stated that all R64's medications except her pain medication was held on dialysis days and she did not get them when she returned later in the day. She said she never asked anyone what to do about R64's medication while gone to dialysis.During an interview on 09/16/25 at 5:21 PM, the Director of Nursing (DON) was under the impression that there was an order to hold all R64's medications on dialysis days and she was unaware that the order stated the times may be adjusted.

Based on observation, interview, and review of facility policy, the facility failed to ensure that medications and biologicals that were outdated or without proper labeling were removed from the medication treatment cart for 1 of 1 medication treatment cart. Findings include: Review of the facility policy titled Storage of Medications revised on November 2020, states, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Procedures: 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. During an observation on 07/10/24 at 6:26 AM, of Unit 100/200 Treatment Cart, with Licensed Practical Nurse (LPN)1 revealed the following: 1. Maxorb II AG Alginate Wound Dressing with antibacterial Silver, Lot#83623126340, Ref MSC 9945EP - opened sterile dressing, no longer sterile. 2. Opticell Chitosan-Based Gelling Fiber 4.25 x 4.25 square, Lot#W056844, Ref MSC 7844EP - 1 opened sterile wound dressing, no longer sterile. 3. Opticell AG Chitosan-Based Gelling Fiber 4 x 5 rectangle, Lot# W057510, Ref MSC 9845EP - opened and no longer sterlie. 4. MediHoney Hydrogel, Lot# 053620 - 1 of 4 opened and no longer sterile. Expired on 2023-08. 5. MediHoney Calcium Alginate Dressing with active Leptospermum Honey, Lot#H2345 - opened and no longer sterile. 6. Telfa Non-Adherent Pad Prepack 8x3 Covidien, Lot# 22F067862 - opened and no longer sterile. 7. (Medline) Exuderm Satin Hydrocolloid Wound Dressing 4x4 square10 sterile wound dressings, Lot# C2301191 - 1 of 6 opened and no longer sterile. 8. (Medline) Thera Honey HD Sheet Honey Impregnated sterile wound dressing, Lot# W02307482 - 1 of 9 opened and no longer sterile. 9. (Medline) Maxorb II alginate wound dressing calcium alginate 4x4 square, Lot #83620108396, Ref MSC 7344EP - Expired on 2023 01-01. During an interview on 07/10/24 at 7:20 AM, the findings were verified by LPN1 and discarded. During an interview on 07/10/24 at 9:30 AM, the Director of Nursing (DON) stated, All nurses should check for expired medications.

Based on record review and interviews, the facility failed to ensure the correct form was issued for Resident (R)28 and R35, when Medicare Part A services were ending. Specifically R28 and R35 received the form CMS-R-131 for Part B services and not the correct CMS-10055 for Part A services for 2 of 3 residents reviewed for advanced beneficiary notices. Findings include: Review of a facility document titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) states, Medicare require's SNFs to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: Not medically reasonable and necessary; or Considered custodial. The SNFABN provides information to the beneficiary so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A). Review of R28's Medicare Part A Skilled Services Episode with a start date of 04/30/24, revealed R28's last covered day of Part A Service was 06/07/24. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted and R28 remained in the facility. Review of R35's Medicare Part A Skilled Services Episode with a start date of 04/03/24, revealed R35's last covered day of Part A Services was 04/21/24. The facility/provider initiated the discharge form Medicare Part A Services when the benefit days were not exhausted and R35 remained in the facility. Further review of the documents received by R28 and R35 or their personal representative revealed a Form CMS-10123-NOMNC was given informing them of the last day of Medicare Part A Skilled Services. Further review revealed R28 and R35 received Form CMS-R-131 for Medicare Part B Services. However, R28 and R35 did not receive the required CMS Form-10055. During an interview on 07/11/24 at 9:32 AM, the Business Office Manager and the Assistant Business Office Manager both confirmed that the CMS-R-131 was the form used and not the CMS Form-10055. They stated this is the only form they have and the only form they have been using along with the CMS-10123.

Based on observation, interview, and review of facility policy, the facility failed to ensure that Resident (R)31 received medications safely through enteral feeding, for 1 of 1 resident reviewed. Findings include: Review of the facility policy titled Administering Medications through an Enteral Tube dated 2001, states, The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. Preparation: 3. Assemble the equipment and supplies as needed. General Guidelines: 7. Towel or Chux pad 12. Stethoscope Steps in the Procedure: 4. d. Fold bed linens to the resident ' s waist and cover the chest with a towel or Chux pad. 6. Verify placement of feeding tube Review of (R)31 ' s Face Sheet revealed R31 was admitted to the facility on [DATE], with a diagnoses including but not limited to: Parkinson ' s Disease with Dyskinesia, without mention of fluctuations. Review of (R)31 ' s Quarterly Minimum Data Set (MDS) with an Assessment Reference Data (ARD) of 07/03/24, revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating (R)31 has severe cognitive impairment. Review of (R)31 ' s Care Plan with a start date of 06/27/24 documented, Enteral Nutrition/Medications: Resident has [x] GT [] JT [] NGT [] Other and is at risk for enteral nutrition complications related to aspiration pneumonia, clogged tubing, excessive residual. Further review of R31's Care Plan revealed the following approach, check for residual as ordered, check for tube placement as ordered, check lung sounds for signs and symptoms of fluid overload as needed, check lung sounds for signs and symptoms of fluid overload as needed, monitor intake and output per protocol, monitor weight per protocol, and notify MD if unable to tolerate. Review of (R)31 ' s Physician Orders with a start date of 06/25/24 documented, Enteral Feed, continuous feed Jevity 1.5 45ml/hr with 100 ml free water flush every 4 hours. During an observation on 07/10/24 at 5:00 PM, Licensed Practical Nurse (LPN)1 administered Vancomycin HCL 750mg (2.5ml). LPN1 pulled the sheet back from R31, stopped Tube Feed (TF), removed plunger from syringe and placed on bedside table. LPN1 than placed the syringe in TF port. Poured medications in syringe. Water flush poured after medication gravitated by gravity. LPN1 than placed the syringe on the bare sheet. The TF was reconnected and TF restarted. LPN1 took the plunger off the bedside table and reinserted it into the syringe. During an interview on 07/10/24 at 5:15 PM, LPN1 stated, Oh, I need to place a towel down on the bed and bedside table, plus check for placement. LPN1 concluded, I totally tossed the syringe in the trash due to contamination. During an interview on 07/10/24 at 5:30 PM, the Director of Nursing (DON) stated, We will give an in-service on Tube Feeding to ensure medications are being given per protocol using proper procedure.

Based on review of facility policy, record review, and interview, the facility failed to ensure Resident (R)15's coordination of care between hospice and the facility, for 1 of 1 resident reviewed for Hospice Care and Services. Findings include: Review of the undated facility policy titled, Hospice Program revealed , Policy Interpretation and Implementation: #9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including the following: a. Determining the appropriate hospice plan of care; b. Changing the level of services provided when it is deemed appropriate; c. Providing medical direction, nursing and clinical management of the terminal illness; #10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure the level of care provided is appropriately based on the individual resident's needs. d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. #12. Our facility has designated someone to coordinate care provided to the resident by out facility and the hospice staff. (Note: this individual is a member of the IDT with clinical and assessment skills who is operating within the state scope of practice act.) He or she is responsible for the following: a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for resident's receiving these services; b. Communication with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family. Review of the Hospice Services Agreement dated July 9, 2024, states on page 5, Section E, Coordination of Care: (i) General - Facility shall participate in any meetings, when requested by Hospice, for the coordination of services provided to Hospice Patients. Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day. Review of R15's Face Sheet revealed R15 was admitted to the facility with diagnoses including but not limited to: cerebrovascular accident, chronic viral hepatitis C, psychoactive substance abuse, anxiety, falls, and convulsions. R15 was admitted for hospice care and services on 02/29/24 with a diagnosis of cerebrovascular accident. Review on 07/10/24 at 3:49 PM, of R15's Medical Record revealed no indication of Hospice visit assessments, to include findings during the assessments for progress, decline or if changes were needed to the care plan for R15. Furthermore, there was no specified nursing staff designated by the facility for the hospice staff to report to ensure continuity of care for R15. During an interview on 07/11/24 at 8:30 AM, the Director of Nursing (DON) provided the hospice notes from the hospice nurses visits from 04/02/24 through 07/09/24. The DON stated that the Hospice entity had sent the daily assessments overnight to the facility. The DON stated that the assessments should have been in the hospice binder to ensure coordination of care between hospice and the facility staff working with R15. .

Based on observations, record review, and interviews, the facility failed to include a Registered Nurse (RN) on the daily staff posting for the month of March, June, and July of 2024. Findings include: A policy for the daily staffing sheet was not provided when requested on 07/11/24 at 2:00 PM. Review of the daily staffing sheets, as worked, posted for each shift from March 2024, June 2024, and July 1-11, 2024, did not include a designated registered nurse for at least eight (8) hours. Review of the Daily Staffing sheets revealed a line which indicated RN, each sheet revealed a blank indicating RN hours were not listed. During an interview on 07/11/24 at 1:20 PM, the Operation Manager stated the RN hours should be included on the daily staff posting. The Operation Manager revealed they were completing the daily staff posting in January and February and they are not sure why the Human Resource (HR) officer for the facility did not include the RN hours when they took over the task. The Operation Manager concluded the HR officer was new.

Based on record review and interview, the facility failed to assure professional standards of communication occurred between the facility and the dialysis center for 1 of 1 resident reviewed, Resident (R)10. Findings include: Review of the facility policy titled End-Stage Renal Disease, Care of a Resident With with a revision date of September 2010, the policy statement revealed, Residents with end-stage renal disease (ERSD) will be cared for according to currently recognized standards of care. Policy Interpretation and Implementation, 4. Agreements between facility and contracted ERSD facility include all aspects of how the resident's care will be managed including: b: how information will be exchanged between the facilities. Review of the facility's SNF (Skilled Nursing Facility) Dialysis Services Agreement dated 12/27/11 revealed, Obligations of Nursing Facility, 2. Interchange of information: The Nursing Facility shall provide for the interchange of information useful or necessary for the care of the ERSD Residents, including a Registered Nurse as a contact person at the Nursing Facility whose responsibilities include oversight of provision of services to the ESRD residents. D. Mutual Obligations, 1. Collaboration of Care: Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and ESRD Dialysis Unit. Documentation shall include, but not be limited to, participation in care conferences, continual quality improvements program, annual review of infection control policies and procedures. Review of R10's Face Sheet revealed R10 was last admitted to the facility on [DATE], with diagnoses including but not limited to: Type 2 diabetes mellitus with diabetic kidney disease and End Stage Renal Disease (ESRD). Review of R10's Care Plan, dated 04/29/24, revealed R10 received hemodialysis for ESRD. Review of R10's Dialysis Communication Record revealed the following Dialysis Communication Records were faxed to the facility on [DATE] at 12:57 PM: 06/01/24, 06/04/24, 06/11/24, 06/15/24, 06/20/24, and 06/22/24. Further review of R10's Dialysis Communication Record revealed records were missing for the following dates: 07/04/24, 07/06/24, and 07/09/24. During an interview on 07/11/24 at 10:05 AM, Licensed Practical Nurse (LPN)2 revealed that R10 goes to dialysis on Tuesday, Thursday and Saturday and R10 is usually picked up around 11:15 AM. LPN2 also revealed that when R10 leaves for dialysis that a face sheet and the communication sheet goes with them to dialysis, the dialysis center completes it, returns it to the facility, and once it is returned we send it to medical records. During an interview on 07/11/24 at 1:41 PM, the Director of Nursing (DON) revealed when R10 is sent out to dialysis they are sent with a communication form and a copy of their face sheet. The dialysis center sends back the communication form and face sheet, and if there are changes it will be listed on the communication form. The nurses are to return the communication form to medical records. The DON further explains that when the resident returns the nursing staff should check their access cite. During an interview on 07/11/24 at 2:08 PM, the Medical Records Coordinator stated, When the resident goes out to dialysis a face sheet, a communication sheet, and an order summary goes with them and it all comes back with them. The Medical Records Coordinator explains, 3rd shift staff usually starts the communication form either hand written or opened up in PCC [Point Click Care] then 1st shift completes it with vital signs and weights before the resident leaves, then the returning nurse looks at the communication sheet to make sure its completed correctly and if not completed correctly, I have to contact the dialysis center to get them to correct it. When they return, I have to go to the floor to retrieve the form from my box on the floor. If the form is not correct, I call them and let them know I am faxing it and they fax it back. The Medical Records Coordinator verified they are responsible for keeping up with the communication form and keeping them in a folder and stated If some are missing, I go looking for them, and if they are not in the facility I contact the dialysis center.

Based on observations, interview, record review, and facility policy review, the facility failed to ensure infection control procedures were followed for two residents (R)29 and R41 of six residents observed during medication administration and for one resident (R48) of seven residents observed for the provision of wound care. Findings include: The facility's policy related to infection control specific to medication administration were requested but no specific policy was able to be located by the facility prior to survey exit on 04/13/22. 1. Review of the undated Admission Record, found in the electronic medical record (EMR) under the Profile tab, revealed R29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R29's Order Summary Report most recently dated 02/16/22 and found in the EMR under the Orders tab revealed orders for blood glucose monitoring, [MEDICATION(S)] insulin per sliding scale, subcutaneously, four times daily, via insulin pen for her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Observation of Registered Nurse (RN)1 on 04/12/22 at 11:29 AM revealed the RN was observed completing R29's blood sugar monitoring and administering insulin. While preparing the resident for testing and insulin administration, RN1 placed the shared unit blood sugar monitor on the resident's bedside table in her room without placing a clean barrier between the monitor and the potentially contaminated surface in the room. After administering R29's medication, RN1 placed the blood sugar monitor on the top of the medication cart. During an interview with RN1 on 04/12/22 at 11:40 AM, she stated she was unaware a clean barrier should be used between equipment or medications being put back in the medication cart and surfaces in common areas or resident rooms. She stated, No one ever told me that, but it makes sense. 2.Review of the undated Admission Record, found in the EMR under the Profile tab, revealed R41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R41's Order Summary Report most recently dated 02/16/22 and found in the EMR under the Orders tab revealed orders for blood glucose monitoring and insulin [MEDICATION(S)] 10 unit subcutaneously, three times daily routinely, via insulin pen for her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Observation of RN 2 on 04/12/22 at 11:43 AM revealed while preparing R41's testing and insulin administration, RN2 placed the shared unit blood sugar monitor on the resident's bedside table and the container of test strips on the resident's windowsill in her room without placing a clean barrier between the monitor and the test strip container and potentially contaminated surfaces in the room. After administering R41's medication RN2 placed the blood sugar monitor and the container of test strips on the top of the medication cart. During an interview with RN2 on 04/12/22 at 11:54 AM, she stated, I knew I was supposed to put a clean barrier down for things going back to cart. I don't know why I didn't do that. I should have done that. During an interview with the Director of Nursing (DON) and the Infection Preventionist, Visiting (IVP) from a sister facility on 04/13/22 at 6:02 PM, the IVP stated all nurses were educated to place a barrier between common surfaces and equipment or medication to be put back in the medication cart, or to use aseptic technique to sanitize those items prior to placing them back in or on the medication cart. The DON stated it was her expectation nursing practice the same. 3. Review of the facility's policy titled Wound Care revised 10/10 revealed. verification of physician orders, gather supplies, ensure table is cleaned prior to arranging supplies .2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to the resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves .7. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers .10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. 11. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water. 12. Remove dry gauze. Apply treatments as indicated. 16. Discard disposable items into the designated container .Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly . Review of R48's Admission Record located in in the EMR under the Profile tab revealed she was originally admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R48's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Clean with wound cleanser. Apply [MEDICATION(S)] once daily and cover with abdominal (ABD) pad. Observation on 04/12/22 at 2:56 PM revealed RN1 with the assistance of Licensed Practical Nurse (LPN)1 administered wound care to R48. Both nurses washed their hands, then assisted R48 from her chair to the bed. RN1 then donned gloves, cleaned the over the bed table with sanitizing wipes, placed wound care supplies on the table for use during procedure. RN1 doffed soiled gloves, did not perform hand sanitizing prior to donning new gloves. RN1 then removed the soiled dressing located on R48's sacrum and placed soiled dressing in a trash bag, She then cleansed the sacral wound with wound cleanser, put a small amount of silver cream on her soiled gloved finger and applied it to open sacral wound. RN1 then covered the wound with abdominal (ABD) pad and secured it with tape. Used supplies were then discarded in the trash bag, RN1 doffed gloves in the trash bag, and then exited the room. LPN1 doffed soiled gloves and placed them in the trash and then washed her hands. Interview on 04/12/22 at 3:15 PM with RN1 confirmed nurses are supposed to perform hand sanitizing before entering the room and after they exit. RN1 stated she was unaware she was supposed to change gloves and sanitize her hands after removing soiled dressing, cleansing the wound, and applying new dressing. Additionally, RN1 was not aware she was not supposed to apply [MEDICATION(S)] cream to her soiled, gloved finger and then directly apply to the wound. Interview on 04/13/22 at 6:04 PM with the DON confirmed nurses are expected to perform hand sanitizing prior to performing wound care, after removing soiled dressing, and when moving from a dirty to clean area. All staff should perform hand sanitizing after completing resident care and exiting the room.

Based on record review, interviews and review of facility policy, the facility failed to ensure appropriate monitoring for one Resident (R) R6 of three residents reviewed for unnecessary use of [CONDITION(S)] medication. Specifically, behaviors were not monitored related to medications administered for [CONDITION(S)] and sleep for R6. Findings include: The facility's Behavioral Assessment, Intervention and Monitoring Policy most recently revised in 03/2019 read, in pertinent part, Behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment; and When medications are prescribed for behavioral symptoms, documentation will include: e. Specific target behaviors and expected outcomes; and h. monitoring for efficacy and adverse consequences. Review of the Admission Record located in the Electronic Medical Record (EMR) revealed R6 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, unspecified [CONDITION(S)] not due to a substance or physiological condition, and [CONDITION(S)]. Review of R6's [CONDITION(S)] Medication Care Plan, most recently revised on 10/20/21 and found in the EMR under the Care Plan tab, indicated R6 was receiving antipsychotic and antidepressant medications related to his diagnoses of [CONDITION(S)] and [CONDITION(S)]. Approaches included: Administer medications as ordered. Observe for tolerance and effectiveness. Report any possible adverse side effects to MD (Medical Doctor). Review of the Minimum Data Set (MDS) located in the MDS tab in the EMR with an Assessment Reference Date (ARD) of 12/29/21, indicated a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating the resident was moderately cognitively impaired. The assessment indicated the resident exhibited behaviors including threatening, screaming, and cursing at others on one to three of seven days of the assessment period and indicated R6 received antipsychotic and antidepressant medications on seven of seven days during the assessment period. Review of R6's Order Summary Report found in the EMR under the Orders tab and dated 04/12/22, indicated orders for [MEDICATION(S)] (an anti-psychotic medication) 100 milligrams (mg) by mouth in the evening and 75 mg during the day for unspecified [CONDITION(S)] and for Trazadone (an anti-depressant medication) 50 mg once daily at bedtime for [CONDITION(S)]. Review of R6's Medication Administration Records (MARs) and Treatment Administration Records (TARs) located under the Orders tab in the EMR for 03/2022 and 04/2022 revealed nothing to indicate threatening and cursing behaviors related to R6's use of [MEDICATION(S)] or hours of sleep for his use of Trazadone were being monitored. Review of R6's Progress Notes from 03/2022 and 04/2022 revealed nothing to indicate behaviors for the use of [MEDICATION(S)] for R6's cursing and threatening behavior or hours of sleep for his use of Trazadone were being monitored. During an interview with the Regional Director of Clinical Services (RDCS) on 04/12/22 at 7:32 PM, she verified no behavior documentation for R6's use of anti-psychotic medication or antidepressant medication for sleep could be found in the resident's record. She stated all behaviors related to the use of [CONDITION(S)] medications were to be monitored on the MAR/TAR or in the resident's Progress Notes. She stated all [CONDITION(S)] medications were to be monitored by the Director of Nursing (DON) and the rest of the Inter-Disciplinary Team each weekday morning in the facility's daily clinical stand-up meeting. During an interview with the Director of Nursing (DON) on 04/13/22 at 5:59 PM, she confirmed her expectation was specific behaviors were to be documented for the administration of any [CONDITION(S)] medication for a resident. She stated, behaviors related to R6's use of Trazadone for sleep and [MEDICATION(S)] for his threatening and cursing behaviors should have been documented in either the MAR or the progress notes.

Based on interview, observation, and record review, the facility failed to implement care planned interventions for accidents for 1 of 3 residents. Resident #1 was care planned to have a pad alarm in place when in bed and chair, but observation revealed no alarm while Resident was in chair throughout the day. Resident #1 was later discovered on the floor, and it was unclear how long they had been on floor due to lack of alarm in place. The findings included: Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's care plan on 11/10/20 at approximately 10:15 AM revealed the care plan intervention to use a pad alarm for bed and wheelchair. Observation of Resident #1 on 11/10/20 at approximately 4 PM revealed there was no pad alarm in place per care plan. Observation of Resident #1 on 11/10/20 at approximately 4:45 PM revealed there was still no pad alarm in place per care plan. The lack of alarm was confirmed with the Administrator by interview, who was also present. Observation of Resident #1 on 11/10/20 at approximately 4:50 PM revealed the resident was on the floor in front of their chair at the nurse's station. As there was no pad alarm, staff were uncertain how long the resident had been on the floor, though from observation it could not have been longer than five minutes. Interview with Clinical Consultant, who was also present, confirmed there was no alarm in place per the Resident's care plan. While the presence of a pad alarm would not have prevented a fall, it would have minimized the time the fall went undiscovered, possibly sparing the resident from further injury. Interview with Administrator and Clinical Consultant at approximately 5:20 PM revealed that Resident #1 was assessed and only a skin tear was discovered.

Based on interview, observation, and record review the facility failed to provide appropriate supervision for accidents for 1 of 3 residents. Resident 1 was ordered to have a pad alarm in place when in bed and chair, but observation revealed no alarm throughout the day while in chair. Resident 1 was later discovered on the floor, and it was unclear how long they had been on floor due to lack of alarm. The findings included: Resident 1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1 orders on 11/10/20 at approximately 10:15 AM revealed an order for [REDACTED]. Observation of Resident 1 on 11/10/20 at approximately 4 PM revealed there was no pad alarm in place per orders. Observation of Resident 1 on 11/10/20 at approximately 4:45 PM revealed there was still no pad alarm in place per orders. The lack of alarm was confirmed with the Administrator by interview, who was also present. Observation of Resident 1 on 11/10/20 at approximately 4:50 PM revealed the resident was on the floor in front of their chair at the nurse's station. As there was no pad alarm, staff were uncertain how long the resident had been on the floor, though form observation it could not have been longer than five minutes. Interview with Clinical Consultant, who was also present, confirmed there was no alarm in place per the resident's orders. While the presence of a pad alarm would not have prevented a fall, it would have minimized the time the fall went undiscovered, possibly sparing the resident from further injury. Interview with Administrator and Clinical Consultant at approximately 5:20 PM revealed that Resident #1 was assessed and only a skin tear was discovered.

Based on interviews, record reviews, and policy review it was determined the facility failed to implement their Abuse Prevention policy to ensure residents were free of physical, verbal, and psychological abuse by facility staff for four of four residents (Resident #7, Resident #5, Resident #6, and Resident #4) sampled for abuse allegations in a total sample of nine. This deficient practice had the potential to affect all the facility's residents placing the facility's residents at risk for staff abuse. Although staff education on abuse and reporting was initiated on 01/08/2020 resident abuse continued to occur through 04/28/2020. The failure of the facility to monitor staff and residents to ensure the abuse education and policies were implemented related to abuse prevention created an Immediate Jeopardy (IJ) situation that was identified on 05/13/2020 at 7:30 PM during the Complaint Investigations for SC 187; SC 960; SC 998 and SC 782 for four of nine sampled residents (Resident #4, Resident #5, Resident #6, and Resident #7) and had the potential to affect all facility residents. On 05/13/2020 at 7:30 PM the facility Administrator and Director of Nursing was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified related to Complaint SC 187, SC 998, SC 960, and SC 782 and provided a copy of the CMS-IJ Template. The facility presented a plan for removal of the immediate jeopardy for F600, F607 and F609 on 05/14/2020 at 4:30 PM. The State Agency accepted the facility Immediate Jeopardy Removal Plan on 05/14/2020 at 5:15 PM. The survey team validated that the Immediate Jeopardy removal plan for F600, F607 and F609 was in place and was removed on 05/14/2020 at 5:15 PM following the facility's implementation of the plan of removal. The deficient practice will remain at a F widespread and severity lowered to potential for minimum harm following the removal of the immediate jeopardy.Findings include: Review of the facility's Abuse Prevention policy, dated 11/20/2019, indicated Verbal, sexual, physical, and mental abuse .of a resident .are prohibited .Staff receives orientation and ongoing training, at a minimum yearly, on: Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents, .What constitutes a crime; What constitutes abuse, neglect, and misappropriation of resident property; How to recognize signs of burnout, frustration and stress that may lead to abuse; Signs and symptoms of abuse (bruises, injuries of unknown origin, crying, fearful, increased agitation, and withdrawal .All allegations /incidences of abuse, neglect, and exploitation are reviewed at QA (Quality Assurance) meetings for any further resolution related to educational opportunities. Review of the facility's Inservice Training indicated the facility's staff was retrained on abuse/neglect prevention on 01/08/2020, 01/09/2020, 01/10/2020, 02/20/2020, 04/21/2020, and 05/01/2020. The training included the review of the facility's Abuse Prevention policy. The alleged perpetrators involved in the following abuse incidents had attended all the training, and review of the employee's records revealed they had all had previous abuse training pertaining to recognition and reporting of abuse. Cross reference F600-Free from Abuse and Neglect- The facility failed to protect four residents (Resident #4, Resident #5, Resident #6, Resident #7) of four sampled residents from staff to resident physical, verbal, and psychological abuse. This deficient practice had the potential to affect all of the facility residents who receive care at the facility. Cross reference F609- The facility staff failed to report resident abuse for four of four residents (Resident #7, Resident #6, Resident #5 and Resident #4) sampled for abuse. Additionally, the facility staff failed to report an injury of unknown source for one of four residents (Resident #5) sampled for alleged abuse with injuries to administration per policy. This deficient practice had the potential to affect all the facility's residents potentially leaving the residents vulnerable to staff abuse. 1. On 01/03/2020 Resident #7 was held down by three Certified Nurse Aides (CNA) #3, CNA #4, and CNA #5, while CNA #6 was hitting Resident #7 forcefully in the face with a pillow. This physical abuse was witnessed by Registered Nurse (RN) #3. Refer to SC 187. Review of the facility's Five-Day Follow-Up Report dated 01/10/2020, revealed After completion of investigation including staff and resident statements it is determined that the incident of alleged abuse was substantiated. Psychosocial support provided to resident. Employees involved were terminated. All staff were re-educated on abuse/neglect. Staff involved in the physical abuse case involving Resident #7 were unavailable for interview due to being terminated on 01/07/2020. 2. Review of the facility's Accident/Incident Form dated 04/02/2020, the facility had reported an injury of unknown source for Resident #5. Specifically, the details of reportable incident: CNA #8 reported bruising on right hand/arm of resident to nurse. When asked resident what happened resident said two (racial slur) twisted his arm. Refer to SC 782. Review of the quarterly minimum data assessment ( MDS) for Resident #5 dated 03/26/2020 failed to evidence physical behaviors of hitting and documented Resident #5 had poor cognition with a brief mental status score of 4. Review of the facility's Five-Day Follow-up Report dated 04/02/2020, revealed upon completion of the investigation to include both staff and resident interviews, it is determined that the allegation of abuse is unsubstantiated. RN#2 signed a witness statement Resident #5 was hitting his/her hand/arm against siderail of bed, which was then documented by the facility to be the cause of the bruising and finger fracture. Interview with CNA #8 was conducted on 05/13/2020 at 8:00 PM. CNA #8 was asked when she/he saw the bruising, why did she/he report it immediately? CNA #8 stated, I was going to report to nurse but got distracted when I went to answer a call light. CNA #8 made no reference to Resident #5 being combative on 03/28/2020 during care. During an interview conducted with Resident #5 on 05/12/2020 at 9:54 AM stated he/she did not have any issues with any staff members. he/she said they have not experienced staff members being rough with him/her. Resident #5 said he/she was happy with their care at the facility and that he/she has not been here long. The resident stated he/she was not fearful of any staff members. The resident could not recall how he/she injured their finger. The interview of Resident #5 was conducted 45 day after the incident and the resident has a [DIAGNOSES REDACTED]. Review of the record for behaviors with the DON on 05/14/2020 at 11:15 AM in the conference room confirmed there was no documentation at the time of the incident in the resident's progress notes of this resident behavior to verify Resident #5 was hitting his arms against the siderails to confirm the behavior on 03/26/2020. There was no further investigation as to how the finger of Resident #5's finger was fractured. A request was made to the DON to provide any behavior documentation for Resident #5 that would indicate the injury to Resident #5 was related self injury. No evidence was provided prior to exit on 05/14/2020. 3 On 04/28/2020 at approximately 9:30 AM Resident #6 requested to be discharged due to an incident with two CNAs (CNA #7 and CNA #8). Resident #6 reported that CNA #7 threatened to kill him and that CNA #7 and CNA #8 were talking over him. Resident #6 also reported that both CNA #7 and CNA #8 made inappropriate sexual comments while providing care for the residents' roommate, Resident #4. Resident #6 was discharged on [DATE] per the resident' request. Refer to SC 960 Review of Resident #6's discharge MDS dated [DATE] revealed a BIMS score of 15, indicting cognition intact. Review of the facility's Five-Day Follow-Up Report dated 05/01/2020, revealed After completion of investigation to include staff interviews, resident interviews, and medical record review, it was determined that (CNA #7) did make inappropriate comments to resident and will no longer work at the facility .(CNA #8) will receive re-education on abuse/neglect/customer services and reporting inappropriate actions of other staff. 4. A second report on 04/28/2020 at approximately 9:30 a.m., Resident #6 reported to the Administrator that CNA #7 and CNA #8 were making inappropriate comments to Resident #4 while providing resident care. Resident #4 is total dependent on staff to provide care and is non-verbal secondary to a stroke. Review of the facility's Five-Day Follow-Up Report dated 05/01/2020, revealed After completion of investigation to include staff interviews, resident interviews, and medical record review, it was unable to be determined if any inappropriate conversation occurred. CNA #7 will no longer work at facility following progressive discipline non-related to this allegation. CNA #8 will receive re-education on abuse/neglect/customer service. CNA #7 was unavailable for interview due to termination. During an interview with CNA #8 conducted on 05/13/2020 in the conference room. CNA #8 was asked if threatening a resident was considered verbal abuse? CNA #8 stated Yes, it is. CNA #8 was asked if she/he had witnessed CNA #7 threaten any residents? CNA #8 stated, Yes, Resident #6, while they were turning the resident. CNA #8 also stated CNA #7 told Resident #4 who was kicking during care, if you hurt my baby, there will be problems. CNA #8 was asked why didn't he/she report the incident immediately? CNA #8 stated, I just didn't think it was an issue, and didn't think much about it. Interview was conducted with the Director of Nursing (DON) on 05/14/2020 at 11:00 A.M. in the conference room. The DON was asked when did the incident involving the verbal abuse towards Resident #4 and Resident #6 occur? The DON responded, on 04/28/2020, Resident #6 reported the incident and that it occurred on the 3-11 shift. The DON was asked why both CNA's were not terminated as was with the incident in January with Resident #7? The DON stated, the resident (Resident #6) told her it was (CNA #7) and not (CNA #8) that had made the comments. The DON was asked why do you think the CNA didn't report the incident to the charge nurse immediately per the facility's policy and training? The DON stated, I'm not sure why, (CNA #7) was a ring-leader, maybe (CNA #8) was too intimidated by (CNA #7). A review of the facility's Employee Inservice records, provided by the facility, revealed the facility staff had been educated on abuse, neglect and reporting on orientation, October 2019, on 01/08/2020, 01/09/2020, 02/20/2020, 04/21/2020, and 05/01/2020. The Immediate Jeopardy Removal Plan included the following: Summary of Incidents: 01/03/2020 a Registered Nurse (RN) #3 witnessed three Certified Nurse Aides (CNA)#3, CNA #4, and CNA #5 holding a combative resident providing care while CNA #6 was hitting resident (Resident #7) in the face with a pillow. Accident/Incident Reporting Form dated 4/2/2020, indicating report is for injury of unknown source or alleged abuse, revealed CNA reported bruising on right hand/arm of resident to nurse. When asked resident what happened resident said two (racial slur) twisted his arm .characteristics of injury was discoloration and bruising to right forearm noted, and hand swollen, x-ray revealed fracture of 5th proximal phalanx (finger). Resident #6 alleged (CNA #7) threatened (Resident #6) while providing care and that both (CNA #7 and CNA #8) were talking over (Resident #6) while providing his/her care. Resident assessed with [REDACTED].#7 and CNA #8 were suspended. Resident discharged home on[DATE], one day earlier than expected at his request. Resident #6 alleged (CNA #7 and CNA #8) were making inappropriate and sexual remarks while providing care to Resident #4. Immediate action: The staff involved in the abuse allegation for Resident #7, RN #3 and four CNAs, (CNA #3, CNA #4, CNA #5, and CNA #6) were terminated on 01/7/2020 due to the abuse allegation being confirmed. The staff involved in the abuse allegation for Resident #5, both CNA #7 and CNA #8 were suspended pending investigation on 03/29/2020. CNA #7 was terminated, and CNA #8 received disciplinary action. The staff involved in the abuse allegation for Resident #4 and Resident #6, CNA# 7 was terminated following the progressive disciplinary process on 05/02/2020 and one CNA #8 was addressed with a disciplinary action on 05/02/2020. This nurse aide CNA #8 was in the room when the verbal abuse occurred but did not participate in the verbal abuse. The resident who was verbally abused confirmed that this nurse aide did not participate in the verbal abuse. The nurse aide was suspended while the facility investigated the incident. The facility discussed with residents if they had any complaints about this nurse aide and did not receive any complaints. The facility also reviewed the grievance logs, his/her personnel record, talked to other staff that she had worked with and did not receive any complaints. This nurse aide was reeducated on the abuse and neglect policy and notification of the Abuse Coordinator, was given a 90-day probation period which will include direct supervision, written counseling, which is the last step of their disciplinary process and if anything, else occurs, he/she would be terminated. CNA #8 is still currently employed by the facility. All other residents assessed and identified to be at a risk for abuse, the facility has initiated the following steps: On 05/13/2020 the facilities total census was 52 residents, with one resident in the hospital. One resident refused to be interviewed or have a body audit completed. Thirty-one interviewable residents were interviewed by the Social Services Director (SSD) on 05/13/2020 at 8:30 PM with no concerns noted related to abuse. Nineteen non-interviewable residents had a body audit completed on 05/13/2020 beginning at 8:30 PM by Nursing Management with no injuries or concerns of abuse noted. The facility has initiated an education plan for all permanent, agency, and contract staff. Education Plan dated 05/13/2020: Upon notification of the immediate jeopardy- education was initiated immediately. Licensed and non-licensed staff to include agency staff were re-educated by Administrator and Director of Nursing beginning on 05/13/2020 at 8:30 PM related to abuse/neglect and timely reporting. Newly hired staff will receive this education during orientation. Staff not present in the facility was educated by phone. Ninety-eight percent of staff were reached and educated. Any staff member not educated or on leave of absence (LOA) will receive this education prior to returning to work. Monitoring of removal plan outcomes: Audits to include, Social Services will interview ten (10) interviewable residents and/or family of non-interviewable residents weekly for three months to ensure that any type of abuse/neglect is reported and investigated. Nursing Administration will complete skin assessments on ten (10) non-interviewable residents weekly for three months. Results of audits to be reviewed at the facility Quality Assurance (QA) Committee meeting monthly for six months and then quarterly thereafter. The Administrator is responsible for monitoring and follow up. Completion date of Immediate Jeopardy 05/14/2020 at 5:15 PM upon verification the removal plan was implemented.

Based on interviews, record reviews, and policy review it was determined the facility failed to implement their Abuse Prevention policy for four of four residents sampled for abuse. Specifically, the facility staff failed to report to the Administrator, staff to resident abuse for four of four residents (Resident #7, Resident #6, Resident #5, and Resident #4) sampled for abuse. Additionally, the facility staff failed to report an injury of unknown source for one of four residents' (Resident #5) sampled for abuse to the Administrator or Director of Nursing (DON) per policy. This deficient practice had the potential to affect all the facility's residents potentially leaving the residents vulnerable to staff abuse. On 05/13/2020 at 7:30 PM the facility Administrator and Director of Nursing was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified related to Complaint SC 187, SC 998, SC 960, and SC 782 and provided a copy of the CMS-IJ Template. The facility presented a plan for removal of the immediate jeopardy for F600, F607 and F609 on 05/14/2020 at 4:30 PM. The State Agency accepted the facility Immediate Jeopardy Removal Plan on 05/14/2020 at 5:15 PM. The survey team validated that the Immediate Jeopardy removal plan for F600, F607 and F609 was in place and was removed on 05/14/2020 at 5:15 PM following the facility's implementation of the plan of removal. The deficient practice will remain at a F widespread and severity lowered to potential for minimum harm following the removal of the immediate jeopardy. Findings include: Review of the facilities policy titled Abuse Prevention dated 11/20/2019, revealed all allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or Administrator of the facility along with other officials in accordance with state law through established guidelines .Staff receives orientation and ongoing training , at a minimum yearly, on: .How to report their knowledge related to allegations and reasonable suspicion of a crime; notification of their reporting obligations under the Elder Justice Act (EJA) to report a suspicion of a crime to the state survey agency; .Reporting of abuse and whom to report abuse to within the facility. Cross-referenced to F600-Free from Abuse and Neglect - The facility failed to protect four residents ( Resident #4, Resident #5, Resident #6, Resident #7) of four sampled residents from staff to resident physical, verbal, and psychological abuse. This deficient practice had the potential to affect all of the facility residents who receive care at the facility. Cross-referenced to F607-Develop/Implement Abuse/Neglect Polices-The facility failed to implement their Abuse Prevention policy to ensure residents were free of physical, verbal, and psychological abuse by facility staff for four of four residents ( Resident #4, Resident #5, Resident #6, and Resident #7) sampled for abuse allegations. 1. Review of R#7's undated Face Sheet revealed the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of R #7's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/3/2020, revealed the resident's Brief Interview for Mental Status (BIMS) score was a three out of 15, which indicates severe cognitive impairment. The MDS indicated Resident #7 exhibited physical behavioral symptoms directed towards other (e.g., hitting, kicking , pushing , scratching , abusing others sexually) occurred daily, verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) occurs four to six days, but less than daily, other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sound) occurs four to six days, but less than daily. Review of the facility's Accident/Incident Reporting Form dated 1/7/2020 documented on 1/3/2020 Resident #7 was being held down by three Certified Nurse Aides (CNA) #3, CNA #4, and CNA #5, while CNA #6 was hitting Resident #7 forcefully in the face with a pillow. This physical abuse was witnessed by Registered Nurse (RN) #3. RN #3 reported the incident to RN #4 on 1/7/2020. ( Four days after the incident had happened). 2. Review of Resident #6's undated Face Sheet, located in the EMR, under documents tab, revealed the facility admitted the resident on 04/23/2020 for [DIAGNOSES REDACTED]. Review of Resident #6's discharge, located in the EMR under MDS tab, with an ARD of 04/28/2020 revealed the resident's BIMS score was 15 out of 15, indicating the resident was cognitively intact. The MDS did not indicate the resident exhibited any behaviors. Review of the facility's Accident/Incident Report Form dated 04/28/2020 at 11:41 A.M. , provided by the facility, documented Resident #6 alleged (CNA #7) threatened (Resident #6) while providing care and that both (CNA #7 and CNA #8) were talking over (Resident #6) while providing his/her care. 3. Review of Resident #4's undated Face Sheet, located in the EMR, under the documents tab, indicated the facility admitted the resident on 04/20/2020 with the [DIAGNOSES REDACTED]. Review of Resident #4's admission MDS, located in the EMR under the MDS tab, with an ARD of 04/25/2020 indicated the facility was unable to complete a BIMS score for resident. The resident was noted to be non-verbal and unable to answer questions. The MDS did not indicate the resident exhibited any behaviors Review of the facility's Accident/Incident Reporting Form, dated 04/28/2020, provided by the facility, documented roommate (Resident #6) alleges (CNA #7 and CNA #8) were making inappropriate and sexual remarks while providing care to the resident (Resident #4). The verbal abuse involving Resident #6 and Resident #4 occurred on the 3-11 PM shift on 04/27/2020 and wasn't reported until 04/28/2020 by Resident #6. During an interview conducted with CNA #8 on 05/13/2020 at 8:00 P.M. the CNA was asked why s/he had not reported the verbal abuse of CNA #7 towards Resident #6 and Resident #4? CNA #8 stated, I just didn't think it was an issue, and didn't think much about it. 4. Review of Resident #5's undated Face Sheet, located in the EMR under documents tab, indicated the facility admitted the resident on 06/15/19 with [DIAGNOSES REDACTED]. Review of Resident #5's quarterly MDS, located in the EMR under MDS tab, with an ARD of 03/26/2020 indicated the resident's BIMS of four out of 15, which indicates severe cognitive impairment. The MDS indicated the resident does not exhibit any behaviors. Review of the facility's Accident/Incident Reporting Form dated 4/2/2020, indicating report is for injury of unknown source or alleged abuse, revealed CNA reported bruising on right hand/arm of resident to nurse. When asked resident what happened resident said two (racial slur) twisted his arm .characteristics of injury was discoloration and bruising to right forearm noted, and hand swollen, x-ray revealed fracture of 5th proximal phalanx (finger). Review of Administrator's Summary of incident revealed On March 28,2020 two CNA's (CNA #7 and CNA #8) went into resident's (Resident #5) room to provide care. CNA noticed that the resident had a bruise on his/her right arm. CNA was delayed in reporting to the nurse her/his observation until later that evening. On March 29th, 2020 nursing assessed the resident and noted that resident hand and arm was swollen. Resident stated that two (racial slur) twisted his/her arm . In concluding the investigation it is noted that a staff had witnessed resident hitting his 5th digit on residents' hand and bruising of his/her arm. RN #2 provided a written statement which documented on 03/26/2020 resident was very combative towards staff. Resident was swinging his fist trying to strike the CNA and this nurse as we were changing him. Resident did not punch staff because he missed with his fist .repeatedly swinging at staff . The note referenced in the injury investigation was dated 03/26/2020 was 2 days prior to the resident injury. The injury was described as new identified on 03/28/2020. There was no documentation in the resident progress notes of Resident #5 hitting or resisting care on 03/28/20. Review of the quarterly MDS of Resident 5 dated 03/26/2020 failed to identify resident behavior of hitting or kicking. The injury of unknown origin/potential abuse involving Resident #5 was recognized on 03/28/2020 and was not reported until 03/29/2020 per facility documentation. Interview with CNA #8 was conducted on 05/13/2020 at 8:00 PM. CNA #8 was asked when she/he saw the bruising, why did she/he report it immediately? CNA #8 stated, I was going to report to nurse but got distracted when I went to answer a call light. CNA #8 made no reference to Resident #5 being combative on 03/28/2020 during care. During an interview conducted with Resident #5 on 05/12/2020 at 9:54 AM stated he/she did not have any issues with any staff members. he/she said they have not experienced staff members being rough with him/her. Resident #5 said he/she was happy with their care at the facility and that he/she has not been here long. The resident stated he/she was not fearful of any staff members. The resident could not recall how he/she injured their finger. The interview of Resident #5 was conducted 45 day after the incident and the resident has a [DIAGNOSES REDACTED]. Review of the record with the DON on 05/14/2020 at 11:15 AM in the conference room was completed. A request for any additional documentation to evidence behaviors occurred to indicate Resident #5 was combative with care to include notes on 03/28/2020. The facility failed to provide any evidence Resident #5 was combative with care that would indicate self injury on 03/28/2020 prior to exit on 05/14/2020. The Immediate Jeopardy Removal Plan included the following: Summary of Incidents: 01/03/2020 a Registered Nurse (RN) #3 witnessed three Certified Nurse Aides (CNA)#3, CNA #4, and CNA #5 holding a combative resident providing care while CNA #6 was hitting resident (Resident #7) in the face with a pillow. Accident/Incident Reporting Form dated 4/2/2020, indicating report is for injury of unknown source or alleged abuse, revealed CNA reported bruising on right hand/arm of resident to nurse. When asked resident what happened resident said two (racial slur) twisted his arm .characteristics of injury was discoloration and bruising to right forearm noted, and hand swollen, x-ray revealed fracture of 5th proximal phalanx (finger). Resident #6 alleged (CNA #7) threatened (Resident #6) while providing care and that both (CNA #7 and CNA #8) were talking over (Resident #6) while providing his/her care. Resident assessed with [REDACTED].#7 and CNA #8 were suspended. Resident discharged home on[DATE], one day earlier than expected at his request. Resident #6 alleged (CNA #7 and CNA #8) were making inappropriate and sexual remarks while providing care to Resident #4. Immediate action: The staff involved in the abuse allegation for Resident #7, RN #3 and four CNAs, (CNA #3, CNA #4, CNA #5, and CNA #6) were terminated on 01/7/2020 due to the abuse allegation being confirmed. The staff involved in the abuse allegation for Resident #5, both CNA #7 and CNA #8 were suspended pending investigation on 03/29/2020. CNA #7 was terminated, and CNA #8 received disciplinary action. The staff involved in the abuse allegation for Resident #4 and Resident #6, CNA# 7 was terminated following the progressive disciplinary process on 05/02/2020 and one CNA #8 was addressed with a disciplinary action on 05/02/2020. This nurse aide CNA #8 was in the room when the verbal abuse occurred but did not participate in the verbal abuse. The resident who was verbally abused confirmed that this nurse aide did not participate in the verbal abuse. The nurse aide was suspended while the facility investigated the incident. The facility discussed with residents if they had any complaints about this nurse aide and did not receive any complaints. The facility also reviewed the grievance logs, his/her personnel record, talked to other staff that she had worked with and did not receive any complaints. This nurse aide was reeducated on the abuse and neglect policy and notification of the Abuse Coordinator, was given a 90-day probational period which will include direct supervision, written counseling, which is the last step of their disciplinary process and if anything, else occurs, he/she would be terminated. CNA #8 is still currently employed by the facility. All other residents assessed and identified to be at a risk for abuse, the facility has initiated the following steps: On 05/13/2020 the facilities total census was down to 52 residents, with one resident in the hospital. One resident refused to be interviewed or have a body audit completed. Thirty-one interviewable residents were interviewed by the Social Services Director (SSD) on 05/13/2020 at 8:30 PM with no concerns noted related to abuse. Nineteen non-interviewable residents had a body audit completed on 05/13/2020 beginning at 8:30 PM by Nursing Management with no injuries or concerns of abuse noted. The facility has initiated an education plan for all permanent, agency, and contract staff. Education Plan dated 05/13/2020: Upon notification of the immediate jeopardy- education was initiated immediately. Licensed and non-licensed staff to include agency staff were re-educated by Administrator and Director of Nursing beginning on 05/13/2020 at 8:30 PM related to abuse/neglect and timely reporting. Newly hired staff will receive this education during orientation. Staff not present in the facility was educated by phone. Ninety-eight percent of staff were reached and educated. Any staff member not educated or on leave of absence (LOA) will receive this education prior to returning to work. Monitoring of removal plan outcomes: Audits to include, Social Services will interview ten (10) interviewable residents and/or family of non-interviewable residents weekly for three months to ensure that any type of abuse/neglect is reported and investigated. Nursing Administration will complete skin assessments on ten (10) non-interviewable residents weekly for three months. Results of audits to be reviewed at the facility Quality Assurance (QA) Committee meeting monthly for six months and then quarterly thereafter. The Administrator is responsible for monitoring and follow up. Completion date of Immediate Jeopardy 05/14/2020 at 5:15 PM upon verification the removal plan was implemented.

Based on staff interviews, record reviews, and review of the facility's Abuse Prevention policy, the facility failed to ensure that residents were free from abuse. The facility failed to protect four residents ( Resident #4, Resident #5 Resident #6, and Resident #7) of four sampled residents from staff to resident physical, verbal, and psychological abuse. This deficient practice had the potential to affect all of the facility residents who receive care at the facility. The facility identified the incidents of resident abuse beginning on 01/07/2020 for Resident #7 physical abuse by staff; an injury of unknown origin/potential physical abuse on 03/29/2020 for Resident #5, and verbal abuse on 04/28/2020 for Resident #5 and Resident #6. Although staff education on abuse and reporting was initiated on 01/08/2020 resident abuse continued to occur through 04/28/2020. The failure of the facility to monitor staff and residents to ensure the abuse education and policies were implemented related to abuse prevention created an Immediate Jeopardy (IJ) situation that was identified on 05/13/2020 at 7:30 PM during the Complaint Investigations for SC 187; SC 960; SC 998 and SC 782 for four of nine sampled residents (Resident #4, Resident #5, Resident #6, and Resident #7). On 05/13/2020 at 7:30 PM the facility Administrator and Director of Nursing was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified related to Complaint SC 187, SC 998, SC 960, and SC 782 and provided a copy of the CMS-IJ Template. The facility presented a plan for removal of the immediate jeopardy for F600, F607 and F609 on 05/14/2020 at 4:30 PM. The State Agency accepted the facility Immediate Jeopardy Removal Plan on 05/14/2020 at 5:15 PM. The survey team validated that the Immediate Jeopardy removal plan for F600, F607 and F609 was in place and was removed on 05/14/2020 at 5:15 PM following the facility's implementation of the plan of removal. The deficient practice will remain at a F widespread and severity lowered to potential for minimum harm following the removal of the immediate jeopardy. Findings included: Review of the facility's policy titled Abuse Prevention, dated November 2019, Verbal, sexual, physical, and mental abuse, .are prohibited .All allegations of abuse involving abuse(sic) along with injuries of unknown origin are reported immediately to the charge nurse and/or Administrator of the facility along with other officials in accordance with state law through established guidelines .Training/Identification/Prevention .Staff receives orientation and ongoing training, at a minimum yearly, on: .D. What constitutes a crime; E. What constitutes abuse .F. How to recognize signs of burnout, frustration and stress that may lead to abuse; G. Signs and symptoms of abuse (bruises, injuries of unknown origin, crying, fearful, increased agitation, and withdrawal .8. Follow up .C. All allegations/incidences of abuse .are reviewed at QA (Quality Assurance) meetings for any further resolution related to educational opportunities. 1. Review of Resident #7's undated Face Sheet, located in the electronic medical record (EMR) under documents tab, revealed the facility admitted the resident on 11/26/2019 with the [DIAGNOSES REDACTED]. Review of Resident #7's quarterly Minimum Data Set (MDS) located in the EMR under the tab MDS, with an Assessment Reference Date (ARD) of 03/03/2020 revealed the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated severe cognitive impairment. Further review of Resident #7's functional status revealed the resident required extensive physical assistance of two or more persons for bed mobility, dressing, and toilet assistance. Resident #7 was dependent on staff for transfers between surfaces, eating, and personal hygiene and is wheelchair bound. Review of the facility's Accident/Incident Reporting Form provided by the facility and submitted on 01/07/2020 to the Department of Health and Environmental Control (DHEC) documented on 01/03/2020 a Registered Nurse (RN) #3 witnessed three Certified Nurse Aides (CNA)#3, CNA #4, and CNA #5 holding a combative resident providing care while CNA #6 was hitting resident (Resident #7) in the face with a pillow. Employees involved were terminated. All staff were re-educated on abuse/neglect and reporting. After completion of investigation including staff and resident statements it is determined the incident of alleged abuse was substantiated. Review of RN #3's Witness Statement, dated 01/07/2020, located with the facility's investigation, documented at 10:25 PM I was called by a 2nd shift CNA to tell me that Resident #7's roommate's skin tear bandage was leaking. I proceeded to wound cart to get supplies. At wound cart a CNA called and said that Resident #7 was fighting them. I told them to deal with it till I get there. Upon entering the room, the situation seemed to be under control at that moment. There were four CNAs in the room. Proceeded to treat Resident #7's roommate's skin tear wound. Upon finishing came back around the curtain, observed three CNAs holding Resident #7 down and the fourth repeatedly hitting Resident #7 in the face with a pillow- full force. Told them to get out and finished up with him. He was calm and in no apparent distress at that point. Review of RN #4's Witness Statement, dated 01/07/2020, located with the facility's investigation, documented RN #3 came to me on 01/06/2020 approximately 10:00 PM and stated that he/she witnessed a case of abuse sometime last week. He/she said that he/she was in (Resident #7's) room with the curtain closed doing a dressing and he/she heard a commotion on the other side of the curtain. He/she said he/she looked around the curtain and saw four (4) CNA's. He/she remembers that (CNA #3 and #5) were holding (Resident #7's) hands down and (CNA #6) was taking a pillow and hitting the patient in the face over and over as hard as he/she could because the patient was fighting. (RN #3) said he/she told them to stop and he/she placed his/her hand on (Resident #7's) hand and he/she immediately calmed down. (RN #3) stated he/she told the CNAs that they caused his/her (Resident #7's) agitation and to get out of the room. (RN #3) could not remember the fourth CNA at the time he/she made the statement. Interview was conducted with the Administrator on 05/13/2020 at approximately 3:30 PM. The Administrator was asked when was he/she informed of the abuse against Resident #7? The Administrator stated, I was informed on 01/07/2020 by the DON and reported it to the state immediately. The Administrator was asked why was RN #3 terminated? The Administrator stated, because the nurse failed to follow the abuse policy and report the abuse immediately after it happened on 01/03/2020. The Administrator was asked if the facility had reported the CNA's to the Nurse Aide Registry? The Administrator responded, No, the state reports CNAs to the Nurse Aide Registry when the facility submits the report. Interview was conducted with RN #4 on 05/13/2020 at approximately 8:15 PM in the conference room. RN #4 was asked to recant what RN #3 had told RN #4 concerning Resident #7's incident. RN #4 stated, we were standing outside the facility and RN #3 told me that she/he had witnessed three CNA's holding Resident #7 down while another CNA was hitting the resident in the face with a pillow. RN #4 stated, I immediately called the Director of Nursing and reported it. RN #4 was asked if she/he knew why RN #3 would not have reported it when the abuse happened? RN #4 stated, I think she/he was afraid to get anyone in trouble or that it wouldn't make a difference. RN #4 was asked if she/he thought it would have made a difference if she/he had reported the abuse at the time of the event? RN #4 stated, Yes, we are all responsible for reporting any abuse immediately. RN #4, CNA #3, CNA #4, CNA #5, and CNA #6 were unavailable for interviews. All terminated by the facility related to abuse of Resident #7. 2. Review of Resident #5's Face Sheet, located in the Eelectronic Medical Record (EMR) under documents tab, indicated the facility admitted the resident on 06/15/2019 with [DIAGNOSES REDACTED]. Review of Resident #5's quarterly MDS, located in the EMR under MDS tab, with an ARD of 03/26/2020 indicated the resident's BIMS of four out of 15, which indicates severe cognitive impairment. The MDS indicated the resident does not exhibit any behaviors. Review of the facility's Accident/Incident Reporting Form dated 04/02/2020, indicating report is for injury of unknown source or alleged abuse, revealed CNA #8 reported bruising on right hand/arm of resident to nurse. When asked resident what happened resident said two (racist slur) twisted his arm .characteristics of injury was discoloration and bruising to right forearm noted, and hand swollen, x-ray revealed fracture of 5th proximal phalanx (finger). Review of Administrator's Summary of incident revealed On March 28, 2020 two CNA's (CNA #7 and CNA #8) went into resident's (Resident #5) room to provide care. CNA #8 noticed that the resident had a bruise on his/her right arm. CNA #8 was delayed in reporting to the nurse her/his observation until later that evening. March 29th nursing assessed the resident and noted that resident hand and arm was swollen. Resident stated that two (racist slur) twisted his/her arm .In concluding the investigations it is noted that a staff had witnessed resident hitting his 5th digit on residents' hand and bruising of his/her arm. Review of Witness Report dated 04/02/2020, revealed on 03/26/2020 resident was very combative towards staff. Resident was swinging his/her fist trying to strike the CNA (CNA #8) and this nurse (RN #2) as we were changing him/her. Resident did not punch staff .resident was repeatedly swinging at staff throughout the day as we were trying to provide care. During an interview conducted with Resident #5 on 05/12/2020 at 9:54 AM Resident #5 stated she/he did not have any issues with any staff members. She/he said they have not experienced staff members being rough with him/her. Resident #5 said he/she was happy with their care at the facility and that he/she has not been here long. The resident stated he/she was not fearful of any staff members. The resident could not recall how he/she injured their finger. The resident is identified with poor cognition with a brief mental status score of four on the quarterly MDS completed on 03/26/2020 and was documented as having no behaviors. The interview was conducted approximately 45 days after the noted incident of injury. Review of the record with the DON on 05/14/2020 at 11:15 AM was completed. A request for any additional documentation to evidence behaviors occurred to indicate Resident #5 was combative with care to include notes on 03/28/2020 they may indicate the potential for self-injury. The facility failed to provide any evidence Resident #5 was combative with care that would indicate self injury on 03/28/2020 prior to exit. 3. Review of Resident #6's undated Face Sheet, located in the EMR, under documents tab, revealed the facility admitted the resident on 04/23/2020 for [DIAGNOSES REDACTED]. Review of Resident #6's discharge MDS, located in the EMR under MDS tab, with an ARD of 04/28/2020 revealed the resident's BIMS score was 15 out of 15, indicating the resident was cognitively intact. Review of Resident #6's functional status indicated the resident required supervision with all activities of daily living, except partial assistance with bathing activity. Review of the facility's Accident/Incident Report Form dated 04/28/2020 at 11:41 AM, provided by the facility, documented Resident #6 alleged (CNA #7) threatened (Resident #6) while providing care and that both (CNA #7 and CNA #8) were talking over (Resident #6) while providing his/her care. Resident assessed with [REDACTED]. Resident discharged home on[DATE], one day earlier than expected at his request. After completion of investigation .it was determined CNA #7 did make inappropriate comments to resident and will no longer work at facility following progressive discipline. CNA #8 will receive re-education on abuse/neglect/customer service and reporting inappropriate action of other staff. Review of the Administrator's hand-written statement, dated 04/28/2020, This resident (Resident #6) told Administrator how two CNAs(CNA #7 and CNA #8) that care for (Resident #6) were making awful sexual remarks about his/her roommate(Resident #4) who can't even talk, like why is he/she is sticking his/her leg out like he/she wanted to do something. They (CNA #7 and CNA #8) would get upset with (Resident #6) because he/she has diarrhea and that he/she cannot turn quickly due to his/her spine. They (CNA #7 and CNA #8) seemed to get angry with him/her and push him/her over to change him. At times they won't help him/her turn. When he/she tried to turn to his/her right-side he/she tried to keep from falling on the floor and (CNA #7) said if you kill my baby, I'm going to kill you. (Resident #6) reported the other inappropriate sexual remarks made in the hall was that he/she wasn't going to nurse the baby that he/she was going to save that for the daddy. Review of CNA #8 's Witness Statement, dated 04/29/2020, located with the facility's investigation, documented that he/she and (CNA #7) went into Resident #6's room together and he/she (Resident #6) got into an argument with (CNA #7) telling him/her that he/she did not like his/her job. They proceeded to change him/her and as he/she rolled towards (CNA #7), he/she was moving his/her legs around. (CNA #7) told him/her to watch where he/she was kicking because he/she was pregnant and if he/she kicked him/her it was going to be a problem. (Resident #6) said he/she was not kicking and it's not going to be a problem. Interview was conducted on 05/13/2020 at 8:00 PM with CNA #8. CNA #8 was asked what had happened with Resident #4 and Resident #6 on 4/28/2020? CNA #8 stated, (CNA #7) asked me to help her/him to change Resident #6's brief. While turning (Resident #6), the resident started kicking his/her legs. (CNA #7) told (Resident #6) that if he/she kicked her/him there was going to be problems. They then went to Resident #4 and repositioned him/her so he would slip out of the bed. CNA #8 was asked if she was intimidated by (CNA #7)? CNA #8 stated, No, he/she (CNA #7) was a little rough and could be rude at times. CNA #8 was asked why didn't he/she report the incident to the charge nurse? CNA #8 stated, I didn't think much about it. Interview was conducted with the Director of Nursing (DON) on 05/14/2020 at 11:00 AM in the conference room. The DON was asked when did the incident involving the verbal abuse towards Resident #4 and Resident #6? The DON stated, the resident (Resident #6) reported it on 04/28/2020 at approximately 9:00 AM that it happened on the 3-11 shift. The DON was asked why both CNA's were not terminated as was with the incident in January with Resident #7? The DON stated, the resident (Resident #6) told her it was (CNA #7) and not (CNA #8) that had made the comments. That CNA #7 had been on a progressive disciplinary plan due to being rude. CNA #8 was counseled, re-educated and put on a probationary period. The DON was asked why did the CNA not report the incident to the charge nurse immediately per the facility's policy and training? The DON stated, I'm not sure why, (CNA #7) was a ring-leader, maybe (CNA #8) was too intimidated by (CNA #7). 4. Review of Resident #4's undated Face Sheet, located in the EMR, under the documents tab, indicated the facility admitted the resident on 04/20/2020 with the [DIAGNOSES REDACTED]. Review of Resident #4's admission MDS, located in the EMR under the MDS tab, with an ARD of 04/25/2020 indicated the facility was unable to complete a BIMS score for resident. The resident was noted to be non-verbal and unable to answer questions. Further review of Resident #4's functional status indicated the resident was totally dependent for all activities of daily living. Review of the facility's Accident/Incident Reporting Form, dated 04/28/2020, provided by the facility, documented roommate (Resident #6) alleges (CNA #7 and CNA #8) were making inappropriate and sexual remarks while providing care to resident (Resident #4). CNAs suspended pending outcome of investigation. After completion of investigation .it was unable to be determined if any inappropriate conversation occurred. (CNA #7) will no longer work at facility following progressive discipline non-related to this allegation. (CNA #8) will receive re-education on abuse/neglect/customer service. Interview was conducted on 05/13/2020 at 8:00 PM with CNA #8. CNA #8 was asked what had happened with Resident #4 and Resident #6 on 4/28/2020? CNA #8 stated, (CNA #7) asked me to help her/him to change Resident #6's brief. While turning (Resident #6), the resident started kicking his/her legs. (CNA #7) told (Resident #6) that if he/she kicked her/him there was going to be problems. They then went to Resident #4 and repositioned him/her so he would slip out of the bed. CNA #8 was asked if she was intimidated by (CNA #7)? CNA #8 stated, No, he/she (CNA #7) was a little rough and could be rude at times. CNA #8 was asked why didn't he/she report the incident to the charge nurse? CNA #8 stated, I didn't think much about it. A review of the facility's Employee Inservice records, provided by the facility, revealed the facility staff had been educated on abuse, neglect and reporting on orientation, October 2019, on 01/08/2020, 01/09/2020, 02/20/2020, 04/21/2020, and 05/01/2020. The Immediate Jeopardy Removal Plan included the following: Summary of Incidents: 01/03/2020 a Registered Nurse (RN) #3 witnessed three Certified Nurse Aides (CNA)#3, CNA #4, and CNA #5 holding a combative resident providing care while CNA #6 was hitting resident (Resident #7) in the face with a pillow. Accident/Incident Reporting Form dated 4/2/2020, indicating report is for injury of unknown source or alleged abuse, revealed CNA reported bruising on right hand/arm of resident to nurse. When asked resident what happened resident said two (racial slur) twisted his arm .characteristics of injury was discoloration and bruising to right forearm noted, and hand swollen, x-ray revealed fracture of 5th proximal phalanx (finger). Resident #6 alleged (CNA #7) threatened (Resident #6) while providing care and that both (CNA #7 and CNA #8) were talking over (Resident #6) while providing his/her care. Resident assessed with [REDACTED].#7 and CNA #8 were suspended. Resident discharged home on[DATE], one day earlier than expected at his request. Resident #6 alleged (CNA #7 and CNA #8) were making inappropriate and sexual remarks while providing care to Resident #4. Immediate action: The staff involved in the abuse allegation for Resident #7, RN #3 and four CNAs, (CNA #3, CNA #4, CNA #5, and CNA #6) were terminated on 01/7/2020 due to the abuse allegation being confirmed. The staff involved in the abuse allegation for Resident #5, both CNA #7 and CNA #8 were suspended pending investigation on 03/29/2020. CNA #7 was terminated, and CNA #8 received disciplinary action. The staff involved in the abuse allegation for Resident #4 and Resident #6, CNA# 7 was terminated following the progressive disciplinary process on 05/02/2020 and one CNA #8 was addressed with a disciplinary action on 05/02/2020. This nurse aide CNA #8 was in the room when the verbal abuse occurred but did not participate in the verbal abuse. The resident who was verbally abused confirmed that this nurse aide did not participate in the verbal abuse. The nurse aide was suspended while the facility investigated the incident. The facility discussed with residents if they had any complaints about this nurse aide and did not receive anycomplaints. The facility also reviewed the grievance logs, his/her personnel record, talked to other staff that she had worked with and did not receive any complaints. This nurse aide was reeducated on the abuse and neglect policy and notification of the Abuse Coordinator, was given a 90-day probation period which will include direct supervision, written counseling, which is the last step of their disciplinary process and if anything, else occurs, he/she would be terminated. CNA #8 is still currently employed by the facility. All other residents assessed and identified to be at a risk for abuse, the facility has initiated the following steps: On 05/13/20 the facilities total census was 52 residents, with one resident in the hospital. One resident refused to be interviewed or have a body audit completed. Thirty-one interviewable residents were interviewed by the Social Services Director (SSD) on 05/13/20 at 8:30 PM with no concerns noted related to abuse. Nineteen non-interviewable residents had a body audit completed on 05/13/2020 beginning at 8:30 PM by Nursing Management with no injuries or concerns of abuse noted. The facility has initiated an education plan for all permanent, agency, and contract staff. Education Plan dated 05/13/2020: Upon notification of the immediate jeopardy- education was initiated immediately. Licensed and non-licensed staff to include agency staff were re-educated by Administrator and Director of Nursing beginning on 05/13/2020 at 8:30 PM related to abuse/neglect and timely reporting. Newly hired staff will receive this education during orientation. Staff not present in the facility was educated by phone. Ninety-eight percent of staff were reached and educated. Any staff member not educated or on leave of absence (LOA) will receive this education prior to returning to work. Monitoring of removal plan outcomes: Audits to include, Social Services will interview ten (10) interviewable residents and/or family of non-interviewable residents weekly for three months to ensure that any type of abuse/neglect is reported and investigated. Nursing Administration will complete skin assessments on ten (10) non-interviewable residents weekly for three months. Results of audits to be reviewed at the facility Quality Assurance (QA) Committee meeting monthly for six months and then quarterly thereafter. The Administrator is responsible for monitoring and follow up. Completion date of Immediate Jeopardy 05/14/2020 at 5:15 PM upon verification the removal plan was implemented.

Based on observation, interview, and record review the facility failed to ensure that 1. Residents readmitted to the facility were isolated for 14 days after a hospitalization due to an unknown status for COVID-19 for two (Resident #3 and Resident #9) of five residents reviewed for infection control practices and 2. failed to label/date respiratory care equipment and protect a nebulized mist treatment (NMT) set-up from environmental elements for one (Resident #3) of one residents reviewed for respiratory care resulting in the potential for COVID-19 to go undetected in the facility and outdated respiratory supplies to be used and possible cross contamination of NMT set-ups. Findings include: 1. Review of Resident #3's face sheet, undated, found in the electronic medical record (EMR), under the Admission Record section, revealed the resident was admitted to the facility on [DATE] with a subsequent readmission on 05/11/2020. Resident #3 had [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/30/2020 specified the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of Resident #3's Progress Notes, located in the EMR revealed Resident #3 was hosptalized on [DATE] due to changes in her respiratory status and re-admitted to the facility on [DATE]. Resident #3 was not tested at the hospital for COVID 19 and has not been considered for COVID 19 testing since readmission to the facility. Review of the hospital discharge summary, dated 05/11/2020, no documentation was noted regarding any discussion of testing the resident for COVID 19. The resident was discharged back to the facility with [DIAGNOSES REDACTED]. Resident #3 was placed back in her original room upon readmission and was not placed on any isolation precautions. During an interview on 05/13/2020 at 1:45 PM Resident #3 stated she is able to self-ambulate in her wheelchair, able to use the bathroom on her own, however she occupies the window bed and to use the bathroom must pass by her roommate to get to the bathroom or exit the room. She also stated while in the hospital she was in the intensive care unit (ICU) and then moved to a regular floor before returning to the facility. She further stated she was working with physical therapy and was observed on 05/13/2020 at 4:00 PM walking in the hallway with therapy, not wearing a mask. Observation on 05/13/2020 at 1:50 PM of Resident #3 sitting in her room, revealed her nebulized mist treatment (NMT) set-up was sitting on her nightstand, still put together, with the medication cup attached and condensate observed in the medication cup, not covered or dated. The oxygen tubing that Resident #3 was wearing was also not dated. Observation on 05/14/2020 at 11:00 AM of Resident #3 sitting in her room, revealed her nebulized mist treatment (NMT) set-up was sitting on her nightstand, still put together, with the medication cup attached and condensate observed in the medication cup, placed inside a plastic bag. The oxygen tubing that Resident #3 was wearing was also not dated. Observation on 05/14/2020 at 3:00 PM revealed Resident #3 walking in the hallway with therapy, not wearing a mask. During an interview on 05/14/2020 at 1:45 PM with the DON, she stated the NMT set up should have been taken apart, cleaned, and placed in the plastic bag when the resident finished. She also stated both the NMT and oxygen tubing should be dated. Review of the facility policy titled Respiratory Equipment, dated October 2019, stated under Oxygen #5 .change oxygen tubing every 7 days and date . and under Medication Nebulizers/Continuous Aerosol #7 .store circuit in plastic bag, marked with date and resident's name, between uses . and #9 .discard administration set-up every 7 days and date new tubing . 2. Review of Resident #9's face sheet, undated, found in the EMR revealed, under the Admission Record section, the resident was admitted to the facility on [DATE]. Resident #9 was readmitted to the facility from an inpatient psychiatric stay from 04/28/2020 through 05/06/2020. Resident #9 had [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/30/20 specified the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. Review of Resident #9's Progress Notes, from 04/24/2020 at 5:20 PM to 05/13/2020 at 2:40 PM located in the EMR, revealed Resident #9 was hospitalized for [REDACTED]. Resident #9 was not tested at the hospital for COVID 19 and has not been considered for COVID 19 testing since readmission. Review of the Hospital Post-Acute Care Facility Transfer -COVID 19 Assessment form, completed by the hospital prior to return to the facility on [DATE], the resident was not tested due to COVID testing was not indicated per CDC testing criteria. Resident #9 was placed back in her original room upon readmission and was not placed on any isolation precautions. The resident does not have a roommate, however the resident was ambulatory and alert to person and place, not interviewable, and was observed on 05/13/2020 and 05/14/2020 ambulating throughout the facility, observed going into other resident rooms, and was not wearing a mask while out of her room. During an interview with certified nursing assistants (CNA) #8 and #9, they both stated that Resident #9 was alert and oriented to person and place but was not always easily redirected or someone to hold a conversation with. During an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 05/20/2020 at 3:00 PM, they stated the plan was to utilize 4 rooms at the end of the 100 hall for COVID positive residents, residents currently in the facility who exhibit signs/symptoms of respiratory illness or those who have been tested and they are waiting for results. The DON and ADON also stated the most current policy titled Coronavirus (COVID-19) Precaution Plan, dated 03/30/2020, was the most current policy. The DON and ADON confirmed the policy failed to address the process for readmissions for the 14 day quarantine, only new admissions, to the facility. Neither the DON nor ADON were able to verbalize what the process would be for readmissions. The DON further stated that corporate made the policy on 03/30/2020. During the same interview on 05/13/2020 at 3:00 PM, the ADON, who also serves as the facility Infection Preventionist (IP), stated she was not aware that the Centers for Disease Control (CDC) had updated their recommendations for residents to wear a mask if out of their room. During an interview with the Administrator and DON on 05/13/2020 at 3:50 PM, the Administrator stated the facility currently had no COVID-19 positive residents. The Administrator also stated residents who would fall under isolation precautions would be those residents showing signs or symptoms for COVID-19 or new admissions. The Administrator verified that Resident #3 and Resident #9 were not considered for COVID-19 testing after readmission but stated we could speak with the Nurse Practitioner in the morning (05/14/2020) and ask for an order to test. During the same interview on 05/13/2020 at 3:50 PM with the DON, she stated that corporate develops all policies and procedures and sends them out to the facilities. She stated can make suggestions or recommendations but cannot change the content without corporate approval. She also stated the facility plan for isolation rooms, if the need arises, was to utilize the last four rooms at the end of the 100 hall. She also stated those rooms are currently occupied with residents and room changes would need to be made. Observation of the four rooms at the end of the 100 hall on 05/13/2020 at 4:10 PM revealed they are currently occupied with 2 residents each, who are not currently in isolation for COVID 19 precautions. Review of the facility policy titled Coronavirus (COVID-19) Precaution Plan, dated 03/30/2020, stated under Procedure .As of Today (sic) (no specific date indicated) CDC does not recommend that those who are well wear a facemask to protect themselves from respiratory diseases including COVID-19 . and under New Admissions it stated .All new admissions will be placed in quarantine for 14 days to observe for signs/symptoms of COVID-19. New admissions can be co-horted if admitted within 48 hours of each other. These new admissions do not need to be in isolation unless they develop respiratory symptoms . Under Testing it stated .Residents 65 or older - or - with underlying medical condition for any of the three options below: New onset lower respiratory infection/disease OR pneumonia, fever 100.4 or greater plus cough, or fever 100.4 or greater plus other respiratory symptoms including shortness of breath .

Based on observation and interviews the facility failed to post staffing hours for the facility in a public place for viewing on the day of the survey. The findings included: An observation on 7/02/17 at approximately 2 PM revealed staff posting dated 6/30/17 was located on bulletin board in hallway near the administrator's office. An interview on 7/02/17 at approximately 2:10 PM with Minimum Data Set (MDS) Coordinator confirmed the findings that the staff posting noted on the hallway was dated 6/30/17. The MDS Coordinator further stated as far as he/she knows that's the only place where the posting would be noted. An interview on 7/02/17 at approximately 2:15 PM with Licensed Practical Nurse #1 confirmed the only place staff posting would be located was in the hallway near the administrative offices. An interview on 7/02/17 at approximately 3:52 PM with the Director of Nursing confirmed the staff posting had not been updated and noted on the bulletin board since 6/30/17.

Based on observation, interview, and review of the facility's policies, the facility failed to utilize sanitizing solution at the appropriate concentration per manufacturer's specifications or periodically test the sanitizing solution to assure that it maintained the correct concentration in 1 of 1 pot (3 compartment) sink and 1 of 1 red sanitizing bucket tested . The Findings included: At approximately 9:35 AM on 02/27/2017, observation revealed the sanitizer concentration of the sanitizing compartment of the 3 compartment sink was 0 ppm (parts per million). This was confirmed by the FSD (Food Service Director). The FSD stated the tubing kinks sometimes when the bucket starts to run low. Observation also revealed the sanitizer bucket concentration was 0 ppm. Review of the Sanitizer Bucket Log and Pot Sink Sanitation Records indicate the sink was at 200 ppm at 6:00 and 8:00 AM and the sanitizer bucket was at 200 ppm at 6:30 AM. The 10:00 AM and 12:00 PM spaces on the Pot Sink Sanitation Record were also filled out in the same ink and indicated 200 ppm but had been crossed through. Justin Fisher, Cook #1 stated the bucket was the 8:00 AM bucket and the CDM confirmed the sanitization concentration was at 0 ppm. Review of the facility's policy, Sanitation and Infection Control, 5-L, revealed that the chemical being used by the facility for sanitation does not dissipate, but, its effectiveness is impaired by organic soil in the solution. In addition, the policy stated (the) Quat Sanitizer at 200 ppm is the sanitizing agent used for hard surface sanitation. Further review of the policy, page 5-Q, Pot Sink, revealed Test the chemical sanitizer concentration using an appropriate test strip.

Based on record review and interviews, the facility failed to maintain complete and or accurate medical records. Resident # 13, #67, #75 and Resident #104 medical records had incomplete or inaccurate information related to medicare recertification, progress notes, weights, orders and pressure sores. The findings included: The facility admitted resident #13 with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. The Nurse's Notes stated the body was released to the funeral home on [DATE] at 3:50 PM. Further review of the medical record revealed a Physician's Certification and Recertification (Medicare) form. The resident was certified for Medicare on [DATE]. A Recertification was signed by the physician to continue medicare coverage. The recertification was dated as signed by the physician on [DATE]. Five days after the resident had deceased . A Physician's History and Physical was dated [DATE]. The report included an examination of the resident. The examination included the resident was alert and able to open eyes. S/he was unable to open eyes. The Physician's H&P was dated for ,[DATE]. Nine days after the resident had deceased . On [DATE] the resident's record was reviewed with the Assistant Director of Nursing (ADON). The ADON confirmed exam was not done on [DATE]. A handwritten progress note was dated for [DATE], stated the physician was in to assess the resident for history and physical. The facility admitted Resident #104 with [DIAGNOSES REDACTED]. On [DATE] at 10:08 PM, review of the Weekly Pressure Ulcer Record revealed the wound was assessed on [DATE], [DATE], and [DATE]. There were no further measurements or assessments of the wound in the medical record. At 10:18 AM, review of the Nurses' Notes revealed a note dated [DATE] at 3:00 that the Resident left via family. There was no documentation that the resident or family had received any education, physician appointment, or a referral to home health for continued wound care. At 10:59 AM, review of the Social Service Progress Notes revealed a note dated [DATE] that stated discharge from the facility was planned for [DATE]. There was no documentation of the discharge plan being discussed with the resident or family or referral to home health for wound care. During an interview on [DATE] 2:59:15 PM, the Assistant Director of Nursing (ADON) provided a wound care report dated [DATE] that included Resident #104 with measurements but also confirmed the information was not in the resident's clinical record and that the clinical record was not complete. During an interview at 3:45 PM, the Social Services Director (SSD) stated that the resident elected to return home in Georgia and declined having a follow-up physician appointment made as the resident did not have a physician in Georgia. When asked where that was documented, the SSD reviewed the notes and confirmed the documentation was not in the Social Services Progress Notes. The SSD stated it should have been on the IDT (Interdisciplinary Team) Discharge Form. The SSD confirmed the IDT Discharge was not in the closed record and at approximately 4:45 PM confirmed the discharge summary could not be located. The facility admitted Resident #75 on [DATE] with [DIAGNOSES REDACTED]. The facility failed to reconcil cummulative orders with the previous months telephone orders. On [DATE] , review of the Telephone Orders revealed an order on [DATE] to 1) discontinue the soft seat belt, 2) self releasing seat belt with alarm. Further review revealed an order [DATE] to discontinue [MEDICATION NAME]. On [DATE] review of the Cummulative Orders revealed that the cummulative orders for January and February were not updated with the previous months Telephone Orders. Interview on [DATE] at 2:00 PM with the Assistant Director of Nursing confirmed that the telephone orders had not been taken off the cummulative orders . Review of Resident # 67's Registered Dietician (RD) notes dated [DATE] revealed that Resident #67 was admitted on [DATE] with a weight of 188 lbs. The weight documented on [DATE] in the initial evaluation by RD Resident #67's current weight was documented as 171.4 pounds, which indicated a 16.6 pound weight loss since admission. RD recommended 15 mg of [MEDICATION NAME] at bed time to increase appetite. Review of facility weight and vital summary revealed that Resident # 67's weight was 178.4 on [DATE] one day after his/her admitted . Interview with Regional Minimum Data Set (MDS) Coordinator at 12:45 PM on [DATE] revealed the admission weight for Resident # 67 was inaccurate in the RD's records. The weight was retrieved by the RD from the admission nursing evaluation which was documented from the hospital discharge paperwork which stated Resident # 67 weighed 188 pounds on [DATE].