Every finding on record at Lake Marion Nursing Facility

Based on observation, interviews and policy review, the facility failed to ensure kitchen staff labeled and dated foods and discarded expired food for one of one kitchen with the potential to affect 71 residents consuming food out of the kitchen. This failure had the potential to cause expired food to be served to residents. Findings include: Review of the undated facility policy titled, Labeling and Dating Foods (Date Marking) revealed, All foods stored will be properly labeled according to the following guidelines, Unopened cases of dry food items will be dated with the date the case was received into the facility and will be using first in - first out method of rotation. Unopened cases of refrigerated food items will be dated with the date the item was received into the facility and will be stored using the first in – first out method of rotation. Expiration dates on commercially prepared, dry storage food items will be followed. Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. Prepared food or opened food items should be discarded when: The food item does not have a specific manufacturer expiration date and has been refrigerated for 7 days. The food item is leftover for more than 72 hours. The food item is older than the expiration date Observation of the kitchen's freezer on 08/04/26 at 10:45 AM revealed brownies uncovered and not sealed with an expiration date of 07/31/26, a pound cake opened with no date and a bag of corn on the cob with no open or expiration date. Further observation of additional fridge revealed two coleslaw containers with an expiration date of 07/31/26. During an interview with the Dietary Supervisor (DS) on 08/04/26 at 10:55 AM, revealed all food items should be labeled and dated appropriately and that all expired food items should be discarded. During an interview on 08/06/26 at 3:07 PM the Director of Nursing (DON) said she expected all foods to be labeled and dated correctly and that all expired food was discarded timely.

Based on observations, interviews, and facility policy review, the facility failed to ensure medications were properly stored during medication pass and that lock boxes containing Schedule IV (controlled substances) medications were permanently affixed on two of two units (Carolina and Virginia). This deficient practice had the potential to result in unauthorized access, diversion, loss, theft, or misuse of medications or controlled substances. Findings include: Review of the facility's policy titled, Medication Storage in the Facility with a revision date of 02/25/25 revealed, Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures. Temperature. D. Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box should be attached to the inside of the refrigerator. During the medication pass observation on 08/05/26 at 4:48 PM, Licensed Practical Nurse (LPN) 2 was observed to take the blood sugar (BS) of Resident (R) 81. R81's blood glucose measured 289. Based on the blood glucose reading, R81 was to receive 4U (units) of Humalog insulin according to the physician's orders located in the Electronic Medical Record (EMR) under the Orders tab. LPN2 removed the Humalog pen from the cart and placed the insulin pen on top of the cart and left the cart to enter a nearby resident's room to wash her hands leaving the insulin pen unattended. LPN2 returned to the cart and was notified that she left the medication unattended on top of the cart. The LPN voiced reasons for her lack of securing the Humalog pen on top of the cart which were not related to her responsibilities for securing the medication. During an interview with LPN-UM 2 on 08/06/26 at 1:40 PM, after being notified of the observation of the insulin pen being left on top of an unattended medication cart, LPN-UM2 stated she would expect that medications are secured before staff went to wash their hands. During an interview with the Director of Nursing on 08/06/26 at 3:00 PM, the DON stated she expected that medications would be secured and not left unattended.

Based on observations, record review, interviews, and facility policy review, the facility failed to implement infection prevention and control practices related to Enhanced Barrier Precautions (EBP). This deficient practice affected one of 13 sampled residents (Resident (R) 7) and had the potential for the transmission of infectious pathogens. Findings include: Review of the facility's policy titled, Enhanced Barrier Precautions with an updated date of 03/25/24 revealed, Policy It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes h. Wound care: any skin opening requiring a dressing. 1. Review of the admission Record located under the Profile tab of the electronic medical record (EMR) revealed R7 was admitted to the facility on [DATE] with diagnoses including gastrostomy status. Review of the physician's orders located under the Orders tab of the EMR revealed R7 had an active order for Enhanced Barrier Precautions dated 08/12/25. During a medication pass observation on 08/05/26 at 9:55 AM, Licensed Practical Nurse (LPN) 1 was observed to prepare medications for R7. LPN 1 stated that R7's medications were to be crushed and given via tube. Upon entrance into R7's room, no signage was observed to indicate that R7 was on any infection control precautions. LPN1 entered R7's room, and placed the medications prepared for R7 onto a barrier on R7's overbed table. LPN1 proceeded to wash her hands and apply gloves and turn R7's tube feeding pump off. R7's medications as well as the water flushes were administered by LPN1. At the completion of the medication administration, Certified Nurse Aide (CNA) 2 knocked and entered the room of R7 stating she needed to check R7 to see if she needed to be changed. CNA 2 proceeded to provide incontinence and personal care for R7. At 10:18 AM, LPN1 re-entered R7's room to apply Nystatin (an antifungal powder) to R7's neck. CNA2 was observed completing care for R7 without PPE despite R7's active order for EBP related to the presence of a feeding tube. During this observation, LPN1 was asked if R7 was on EBP due to her having a feeding tube. LPN1 stated she was unaware R7 should be on EBP and has not been wearing PPE when giving R7's medications. LPN1 stated she had been employed at the facility approximately one year and was unaware R7 required EBP. During an interview with the Infection Preventionist (IP) on 08/05/26 12:10 PM, the IP stated that R7 should be on EBP and stated that residents will come around and take the signage down. The IP was informed there was no PPE available outside of R7's room and that LPN1 and CNA2 had provided medication administration, incontinence care and personal care without PPE. When asked whose responsibility it is to be sure that signage is in place, she said the Unit Manager should check for posting. During an interview with Unit Manager (UM) 2 on 08/06/26 at 4:00 PM, UM 2 stated that there are a couple of residents that will take down the signage and she has to be sure it stays posted.

Based on observation, interviews, and facility policy review, the facility failed to ensure personal health-related information was maintained in a secure manner for two of two observations when computer screens displayed resident identifiable information. This deficient practice had the potential for unauthorized access to residents' private health information. Findings include: Review of the facility's undated policy titled, Safeguarding Resident Identifiable Information revealed It is the policy of this facility to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information, and to safeguard against unauthorized release of information and records. Policy Explanation and Compliance Guidelines.7. Computer screens showing clinical record information may not be left unattended and readily observable or accessible by other residents or visitors. During the medication pass observation on 08/05/2026 at 8:58 AM , Licensed Practical Nurse (LPN) 2 walked into a resident's room which was located approximately 25 feet away from her assigned medication cart to speak to the resident. The computer on the medication cart remained unlocked and displayed resident names, photographs, and clinical information that was visible to individuals in the area. Upon returning to the cart approximately three to four minute later, LPN 2 was notified that when she walked away, the computer on the medication cart's screen was left open revealing resident names, pictures and other medical information. LPN2 responded by stating that she thought she locked the screen when she left the cart. 2.During an observation on 08/05/26 at 11:29 AM of the Virginia unit revealed one of the medication carts was beside the nurse's station. The cart was locked but the computer screen was left unlocked and visible revealing medical information for R42. There were two residents and several staff who walked by the cart. During an observation and interview on 08/05/26 at 11:35AM, LPN1 who was on another unit walked back and stated she did not realize she left the computer screen unlocked with resident medical information visible. She stated she knew she was supposed to lock the screen before walking away from the nurse's cart. During an interview with Unit Manager (UM) 2 on 08/06/26 at 1:40 PM, when asked what the expectation was for staff to ensure the privacy and security of resident information when leaving the medication cart, the UM stated that she would make sure that health and private information was protected by locking the screen. During an interview with the Director of Nursing (DON) on 08/06/26 at 3:00 PM, when asked about the expectation for computer screens not to be left open and the protection of personal-health information, the DON stated she would have closed the screen if walking away. During a follow-up interview on 08/06/26 at 3:07 PM the DON said nursing staff were supposed to lock their computer screens when they walked away and to ensure they do not allow resident medical information to be accessed.

Based on interview, record review, and facility policy review, the facility failed to ensure staff maintained documented evidence of a thorough investigation of alleged misappropriation for 1 (Resident (R)25) of 5 residents reviewed for unnecessary medications. Findings include: Review of a facility policy titled Discrepancies, Loss And/Or Diversion of Medications revised on 02/25/25 revealed, . A. Immediately upon the discovery or suspicion of a discrepancy, suspected loss or diversion, the director of nursing or supervisor is immediately notified. The nurse(s) noting the discrepancy should remain on duty until relieved by the director of nursing or supervisor. The director of nursing, or in the director's absence the designee, investigates and makes every reasonable effort to reconcile all reported discrepancies. The director of nursing documents and reports irreconcilable differences to the administrator and consultant pharmacist. 1) The information should not be discussed with other individuals outside of administrative staff. 2) During the process, the Consultant Pharmacist may be available to verify suspected loss. The policy further revealed, C. Loss of supply of medication, included, 3) Document the loss and the investigation process. Review of R25's admission Record revealed the facility admitted R25 on 07/22/24. According to the admission Record, the resident had a medical history that included, but was not limited to, diagnoses of colostomy, osteoarthritis, and rheumatoid arthritis. Review of R25's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/17/25, revealed R25 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident had intact cognition. Review of R25's Care Plan Report included a focus area revised on 02/04/25 that indicated the resident was at risk for unrelieved or worsening pain due to the effects of rheumatoid arthritis, osteoarthritis, and ostomy. Interventions directed staff to administer medication as ordered for osteoarthritis (initiated 07/22/24) and administer medication as ordered for rheumatoid arthritis (initiated 07/22/24). Review of R25's Order Recap [Recapitulation] Report contained an order dated 12/27/24 for hydrocodone-acetaminophen 5-325 milligram (mg), with instructions to give one tablet three times a day. Review of Pharmacy Consolidated Delivery Sheets dated 07/17/25 indicated the pharmacy delivered 90 tablets of R25's hydrocodone-acetaminophen 5-325 mg.Review of R25's Accountability Record revealed a handwritten note that stated 60 of (to indicate 60 of 90 tablets to be accounted for on the Accountability Record). The Accountability Record revealed that on 07/17/25 there were 60 tablets remaining. Further review revealed there was no Accountability Record for the additional 30 tablets to account for a total of 90 tablets that were dispensed per the Consolidated Delivery Sheets. Review of R25's Progress Notes dated 08/09/25 at 5:24 PM revealed R25 had enough hydrocodone-acetaminophen (5-325 mg) available until the next morning. The notes revealed the facility on-call pharmacy was notified for additional medication, and the pharmacy revealed that on 07/17/25 a 30-day supply was dispensed, and the medication could not be refilled until 08/16/25. Review of a Five-Day Follow-Up Report, dated 08/18/25, revealed that after an investigation the facility could not find 30 tablets of R25's hydrocodone-acetaminophen 5-325 mg. During an interview on 09/05/25 at 11:10 AM, the Administrator stated that all residents had been audited on narcotics by the consultant pharmacist on Tuesday (08/12/25) after the incident. She stated the consultant pharmacist audited everyone who administered narcotics. During an interview on 09/05/25 at 11:42 AM, the Consultant Pharmacist stated she made copies of all of the tracker sheets for all residents on narcotics but did not have documentation of the residents who were reviewed. She stated she reviewed every scheduled and as-needed medication for the residents with the names of the individuals who dispensed the medication to see if a nurse was giving more medication. During an interview on 09/05/25 at 12:34 PM, the Chief Clinical Officer (CCO) stated the folder supplied to the surveyor was all the information that had been investigated. The folder contained the initial notification to the State Agency, 5-Day follow up investigation, three witness statements, accountability records (narcotic sheet) for R2, R25, and R70, and a copy of a medication pill pack for R70. There was no documentation of the audit performed by the Consultant Pharmacist.

Based on review of facility policy, record review, and interviews, the facility failed to protect residents from further abuse, after multiple staff witnessed Certified Nursing Assistant (CNA)1 physically abuse multiple residents and did not report the physical abuse. On 09/20/24 at 11:04 AM, the Administrator and the DON were additionally notified that the failure of staff to report an initial incident of physical abuse, which resulted in further physical abuse, constituted IJ at F609. On 09/20/24 at 11:04 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 07/30/24. The IJ was related to 42 CFR 483.12- Freedom from Abuse, Neglect, and Exploitation. On 09/20/24 at 2:40 PM, the facility provided an acceptable IJ Removal Plan. On 09/20/24 at 2:43 PM, the survey team validated the facility's corrective actions and verified the facility had corrected their noncompliance and the IJ was identified at Past Non Compliance (PNC) as of 08/07/24. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F609, constituting substandard Quality of Care. Findings include: Review of the facility policy titled Abuse Policy with a revision date of 11/2017, revealed, 1. All reported allegations of suspected abuse will be investigated immediately. I. REPORTING OF ALLEGED VIOLATIONS 1. All alleged violations (including mistreatment, neglect or abuse, injuries of unknown origin, and misappropriation of resident property) shall be reported immediately to the administrator the state agency, and other agencies as required. Review of R73's Face Sheet revealed R73 was admitted to the facility on [DATE], with diagnoses including, but not limited to: dementia, moderate, with other behavioral disturbance symptoms and signs involving cognitive functions following cerebrovascular disease, major depressive disorder, pseudobulbar affect, and mood disorder. Review of R10's Face Sheet revealed R10 was admitted to the facility on [DATE], with diagnoses including, but not limited to: dementia with behavioral disturbance, diabetes mellitus, chronic pain, anxiety disorder, and major depressive disorder. Review of R479's Face Sheet revealed R479 was admitted to the facility on [DATE], with diagnoses including, but not limited to: chronic pain, schizophrenia, unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence, and insomnia. During a phone interview on 09/18/2024 at 11:01 AM, R73's daughter revealed, she received a phone call from Licensed Practical Nurse (LPN)4 that an allegation of abuse had occurred on the unit back in August 2024. R73's daughter stated it was not forthcoming that R73 was a victim of abuse. R73's daughter stated a few days later, after the fact, the facility administrator called her and stated she had been the victim of an alleged abuse, body checks were done on R73 and showed nothing. During a phone interview on 09/20/24 at 12:59 PM, R10's son revealed, the facility called him to report that there is an allegation of abuse being investigated in the facility, the day of the allegation in question. R10's son stated the facility did not inform him that his mother was one of the victims during this time. R10's son reveals that 4 to 5 days after the initial contact, the facility informed him that his mother was one of the victims of the alleged abuse investigation. R10's son concluded he would have liked to have been informed of his mother's involvement the day the incident allegedly happened. During a phone interview on 09/20/24 at 12:24 PM, R479's husband and daughter revealed, the only notification he received came from his wife, while the daughter expressed that this was the first time she had heard about the allegation. Review of CNA4's Statement dated 08/02/24, revealed, On August 1st, 2024, [CNA1] assisted me with changing [R10], and in the process, he [CNA1] punched [R10] on the head with his fist. I thought it was a mix-up or something, so I didn't report it that night. The following day August 2nd 2024, [CNA3], [CNA1] and I changed [R10] and again, he [CNA1] punched her on the head with his fist. Another incident happened that night while attempting to change [R479], as she is a 3-person assist. [CNA1] hit her with the bed remote and slapped her in the face with his gloves. Attempt to interview CNA4 on 09/19/24 at 12:06 PM, was unsuccessful. Review of CNA3's statement dated 08/02/24, revealed, [R73] has messed [sic] in his pants and did not want to take a shower for [CNA1]. [CNA2] and I were there for assistance. [R73] was refusing to take a shower and [CNA1] grabbed [R73] by the arm to back in the shower when [R73] had fallen to the floor. While on the floor, [CNA1] hit [R73] on the side of his face. [R73] was crying and stated he never wants [CNA1] to touch him again. [CNA2] stayed with [R73]. [CNA1] apologized and said it would not happen again and feeling sorry for him and his circumstances I did not immediately report the incident. However, there was another incident, and I did report it. Review of a second employee statement form written by CNA3 dated 08/02/24, revealed, Tonight while assisting [CNA4] with [R10]. [CNA1] entered the room to help us, while in the room [CNA1] hit [R10] on the side of her head with his fist. Also, tonight while assisting [CNA1] with [R479], [CNA1] hit [R479] with the bed remote and hit her with his gloves in her face. During an interview on 09/19/24 at 9:55 AM, CNA3 verified and confirmed the allegations of abuse in her statement. During an interview on 09/19/24 at 1:30 PM, the Administrator revealed she asked CNA3 why she didn't report the abuse the first time on 07/30/24 and CNA3 stated she felt sorry for CNA1 because he was homeless and lived in a hotel. The Administrator stated she doesn't believe the abuse occurred. The Administrator further stated her expectation for staff is to immediately report to a supervisor to ensure residents are safe. On 09/20/24 at 2:40 PM, the facility provided an IJ Removal Plan, which included the following: 1. Residents #10, #73, and #479 were assessed by the Assistant Director of Nursing and another License Nurse on 8/2/2024 to verify injury. No signs or symptoms of abuse were present . CNA1, the accused, was removed from the facility on 08/02/2024 and has not been in the facility since then. He was placed on immediate suspension pending the results of the investigation. On 08/05/2024, CNA1, who was on a probationary period, was terminated from employment related to work performance. 2. The facility has determined that all residents have the potential to be affected by alleged abuse. All residents with who had ever been assigned to or near the accused CNA were interviewed on 8/3/2024 by the Administrator to assess any further allegations of abuse. There were no further concerns reported by any residents. On 8/2/2024, body audits were completed by the Assistant Director of Nursing and a Licensed nurse to assess all residents for any signs or symptoms of abuse, with no findings of injury. 3. On 8/3/2024, an in-service education program was conducted by the Director of Nursing Services and the Administrator with all direct care staff regarding abuse prevention, including the types of abuse, and burnout, as well as addressing circumstances that require reporting including appropriate timeframes. On 8/7/2024, after completion of the investigation, CNAs 3 and 4 were provided additional one-to-one education and disciplinary actions regarding failure to report a suspicion or allegation of abuse immediately. Both CNAs expressed an understanding of this requirement. 4. The Director of Nursing Services, or designee, will continue to conduct audits of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any allegations of abuse are identified, properly investigated and reported to the appropriate people. Further feedback and assurance will be solicited via the facility grievance process and Resident Council. Any findings, allegations, or suspicions of abuse will be immediately reported and investigated per Federal and State regulations. Results of audits and resident feedback will be monitored by the facility QAPI team to ensure compliance is maintained. Corrective action completion date: 8/7/2024.

Based on review of facility policy, record review, and interviews, the facility failed to ensure Residents (R)73, R10, and R479 were free from physical abuse by Certified Nursing Assistant (CNA)1 on 07/30/24 and 08/02/24. On 09/20/24 at 11:04 AM, the Administrator and the Director of Nursing (DON) were notified that the failure to protect multiple residents from from physical abuse constituted Immediate Jeopardy (IJ) at F600. On 09/20/24 at 11:04 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 07/30/24. The IJ were related to 42 CFR 483.12- Freedom from Abuse, Neglect, and Exploitation. On 09/20/24 at 2:40 PM, the facility provided an acceptable IJ Removal Plan. On 09/20/24 at 2:43 PM, the survey team validated the facility's corrective actions and verified the facility had corrected their noncompliance and the IJ was identified at Past Non Compliance (PNC) as of 08/07/24. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard Quality of Care. Findings include: A review of the facility policy titled Abuse Policy with a revision date of 11/2017, revealed, This facility recognizes that each resident has the right to be free from all types of abuse including verbal, sexual, physical . The facility also recognizes that the residents must not be subjected to abuse by anyone, including, but not limited to facility staff . 5. PHYSICAL ABUSE includes but is not limited to, hitting, slapping, punching, biting, and kicking. Review of R73's Face Sheet revealed R73 was admitted to the facility on [DATE], with diagnoses including, but not limited to: dementia, moderate, with other behavioral disturbance symptoms and signs involving cognitive functions following cerebrovascular disease, major depressive disorder, pseudobulbar affect, and mood disorder. Review of R73's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/24, revealed R73 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. Review of R10's Face Sheet revealed R10 was admitted to the facility on [DATE], with diagnoses including, but not limited to: dementia with behavioral disturbance, diabetes mellitus, chronic pain, anxiety disorder, and major depressive disorder. Review of R10's Quarterly MDS with an ARD of 08/30/24, revealed a BIMS score of 99, indicating severe cognitive impairment. Review of R479's Face Sheet revealed R479 was admitted to the facility on [DATE], with diagnoses including, but not limited to: chronic pain, schizophrenia, unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence, and insomnia. Review of R479's Admission MDS with an ARD of 07/18/24, revealed a BIMS score of 10 out of 15 indicating moderately impaired cognition. Review of the Local Sheriff's Office Incident Report dated 08/02/24 revealed, Offense - Simple Assault. On 08/03/2024, a Deputy with the Local Sheriff's Office was dispatched to 1527 Urbana Rd (Lake [NAME] Nursing Care Facility) in the [NAME] area of Clarendon County SC in reference to an Assault. Upon arrival, the Deputy contacted [Licensed Practical Nurse (LPN)4] the head nurse of the facility at the time. [LPN4] stated that 3 of her co-workers came to her to report an assault on a resident by another co-worker. The co-worker who assaulted the resident was identified as [CNA1]. Deputy identified the 3 co-workers as [CNA2], [CNA3], and [CNA4] that were witnesses to the assault . The case is active for offenses of Simple assault. A review of witness statements revealed the following: On 08/02/24, CNA2 revealed, [R73] didn't want to get in the shower after he pooped on himself. [CNA1 and CNA3] and I was trying to talk to him to get in the shower, but he was very stubborn. Me and [CNA3] started to talk to him calmly. [CNA1] grabbed his hand to assist him in the shower. As I was getting more gloves, I saw [R73] on the floor. He started to cry. Me and [CNA3] got him off the floor and [R73] stated, I don't want him [CNA1] around me. After we calmed him down, I had no choice but to clean him up. [R73] finally calmed down and had a great night. Registered Nurse (RN)1's statement revealed, On the above date (7.29.2024 7A-7P), a little after supper [CNA2 and CNA4] pulled me into an empty room. They proceeded to tell me that they witnessed (orderly) [CNA1] being abusive towards residents. They stated that the orderly hit the resident in 107A in the face with a closed fist and also saw him hit the resident in 111 in the face with his gloves. I immediately took them both to the unit manager's office so that they could make her aware of what they witnessed, I have not personally witnessed or heard any physical or verbal abuse towards residents during my shift. CNA4's statement dated 08/02/24, revealed, On August 1st, 2024, [CNA1] assisted me with changing [R10], and in the process, he [CNA1] punched [R10] on the head with his fist. I thought it was a mix-up or something, so I didn't report it that night. The following day August 2nd 2024, [CNA3], [CNA1] and I changed [R10] and again, he [CNA1] punched her on the head with his fist. Another incident happened that night while attempting to change [R479], as she is a 3-person assist. [CNA1] hit her with the bed remote and slapped her in the face with his gloves. CNA3's statement dated 08/02/24, revealed, [R73] has messed [sic] in his pants and did not want to take a shower for [CNA1]. [CNA2] and I were there for assistance. [R73] was refusing to take a shower and [CNA1] grabbed [R73] by the arm to back in the shower when [R73] had fallen to the floor. While on the floor, [CNA1] hit [R73] on the side of his face. [R73] was crying and stated he never wants [CNA1] to touch him again. [CNA2] stayed with [R73]. [CNA1] apologized and said it would not happen again and feeling sorry for him and his circumstances I did not immediately report the incident. However, there was another incident, and I did report it. Review of a second employee statement form written by CNA3 dated 08/02/24, revealed, Tonight while assisting [CNA4] with [R10]. [CNA1] entered the room to help us, while in the room [CNA1] hit [R10] on the side of her head with his fist. Also, tonight while assisting [CNA1] with [R479], [CNA1] hit [R479] with the bed remote and hit her with his gloves in her face. Review of CNA1's statement dated 08/05/24, revealed an interview with CNA1 conducted face to-face with the Director of Nursing (DON) and Administrator. CNA1 was placed on administrative leave Friday 08/02/24, after allegations of abuse were reported. He verbalized assisting with the care of R73 in the shower, he reports catching the resident's arm in an attempt to keep him from falling but denies striking him in any way. Regarding R10, he reports assisting with changing her clothes and getting her ready for bed and denies hitting her in the head. In the care of R479, he reports assisting with getting her in the bed via Hoyer, denies hitting her in the head with the bed remote, and slapping her in the face with his gloves. An attempted interview on 09/19/24 at 9:29 AM, with R479 was unsuccessful as the resident is non-interviewable. An attempted interview on 09/19/24 at 9:39 AM, with R10 was unsuccessful as the resident is non-interviewable. During an interview on 09/19/24 at 9:55 AM, CNA3 verified and confirmed the allegations of abuse in her statement. Attempt to interview via phone with CNA2 on 09/19/2024 at 11:08 AM, was unsuccessful. Attempt to interview via phone with RN1 on 09/19/2024 at 11:10 AM, was unsuccessful. Attempt to interview via phone with CNA4 on 09/19/2024 at 12:06 PM, was unsuccessful. Attempt to interview with CNA1 via phone on 09/19/2024 at 12:24 PM, was unsuccessful. During a phone interview on 09/18/24 at 11:01 AM, R73's daughter revealed, There is one staff member there that I've always had questions about. One Sunday, not too long ago, my brother and I went to visit my dad in his room. I asked the CNA, if my dad has gotten a shower, the CNA closed the door to his room and replied to my brother and I, when I make him. R73's daughter further stated, I thought that was kind of strange the way he said it. His name is [CNA1's first name]. My dad was abused at the previous facility by staff, and this just rubbed me the wrong way when he said that. During an interview on 09/19/24 at 12:39 PM, LPN4 revealed, CNA1 was starting to act unusual, and nervous, with his bookbag. It was almost like he knew something was up. LPN4 stated she let him go after telling CNA1 he was under investigation, for an allegation of abuse, and someone would be contacting him including police and administrative staff. LPN4 further stated the facility Administrator gave phone orders, to call the police and have them come to the facility to do a report. LPN4 stated he told him to pack his things, and he needed to call someone to pick him up because he could not be on the property. LPN4 stated CNA1 was asking questions such as What did I do, and that's all he said, he didn't argue, he called his mom and left. LPN4 stated as soon as CNA1 left she ran in the building and locked the door. The deputy came onsite and interviewed LPN4 as to why he was being dispatched. The deputy interviewed all witnesses separately. LPN4 stated all the residents involved were not cognitive enough to replay the encounter with the alleged perpetrator. During an interview on 09/19/24 at 1:30 PM, with the Administrator and Director of Nursing (DON). The Administrator revealed a call was received from LPN4, stating that CNA3 and CNA4 had reported that CNA1 tapped several residents on the head. At that time, the tap was reported on R73 and R10. The Administrator stated she asked LPN4 what do the staff mean by tap, LPN4 replied, I'm not sure, however, the witnesses are in the office. The Administrator stated she requested CNA3 to get on the phone and CNA3 described tap as a punch. The Administrator told LPN4 to try to keep CNA1 in the building and call law enforcement to have them come out to the facility. The Administrator stated that CNA1 was gone when law enforcement arrived. The deputy interviewed all witnesses, separately. The Administrator further stated she doesn't believe the abuse occurred and to her knowledge, there was no bad blood within the CNAs. CNA1 denied the physical abuse, however, confirmed that he did provide care to the three residents. On 09/20/24 at 2:40 PM, the facility provided an IJ Removal Plan, which included the following: 1. Residents #10, #73, and #479 were assessed by the Assistant Director of Nursing and another License Nurse on 8/2/2024 to verify injury. No signs or symptoms of abuse were present . CNA1, the accused, was removed from the facility on 08/02/2024 and has not been in the facility since then. He was placed on immediate suspension pending the results of the investigation. On 08/05/2024, CNA1, who was on a probationary period, was terminated from employment related to work performance. 2. The facility has determined that all residents have the potential to be affected by alleged abuse. All residents with who had ever been assigned to or near the accused CNA were interviewed on 8/3/2024 by the Administrator to assess any further allegations of abuse. There were no further concerns reported by any residents. On 8/2/2024, body audits were completed by the Assistant Director of Nursing and a Licensed nurse to assess all residents for any signs or symptoms of abuse, with no findings of injury. 3. On 8/3/2024, an in-service education program was conducted by the Director of Nursing Services and the Administrator with all direct care staff regarding abuse prevention, including the types of abuse, and burnout, as well as addressing circumstances that require reporting including appropriate timeframes. On 8/7/2024, after completion of the investigation, CNAs 3 and 4 were provided additional one-to-one education and disciplinary actions regarding failure to report a suspicion or allegation of abuse immediately. Both CNAs expressed an understanding of this requirement. 4. The Director of Nursing Services, or designee, will continue to conduct audits of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any allegations of abuse are identified, properly investigated and reported to the appropriate people. Further feedback and assurance will be solicited via the facility grievance process and Resident Council. Any findings, allegations, or suspicions of abuse will be immediately reported and investigated per Federal and State regulations. Results of audits and resident feedback will be monitored by the facility QAPI team to ensure compliance is maintained. Corrective action completion date: 8/7/2024.

Based on review of facility policy, observations, interviews and record review, the facility failed to implement interventions outlined in Resident (R)1's Care Plan, for 1 of 1 resident reviewed for falls. Specifically, Certified Nursing Assistant (CNA)1 was providing care to R1. R1 fell out of bed and suffered a laceration and bruising to the forehead. Findings include: Review of the undated facility policy titled, Incidents and Accidents revealed, Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to; dysuria, gout, depression, anxiety, diabetes, chronic kidney disease, dementia, muscle weakness, and cognitive communication deficit. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 04/20/23 revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating R1 has severe cognitive impairment. Further review of the MDS revealed under functional abilities and goals, R1 requires a two-person physical assist with bed mobility, transfer, toileting, and bathing. Review of R1's Care Plan with an ongoing date of 11/14/22 documented, Falls: Resident is at risk for falls with fall related injury to Alzheimer's, dependent transfers, poor safety awareness, vitamin D deficiency. Goal: Residents risk for falls/injury will be minimized with intervention. Interventions: . 10/5/22 with pressure reducing cushion; Hoyer lift or two person assist transfers; and 2 staff for ADL's requiring bed mobility/transfers updated 06/19/23. Review of R1's Progress Note dated 06/18/23 revealed, CNA (Certified Nursing Assistant) called Nurse to room stating while doing [R1] care she rolled out of the bed. CNA attempted to catch her to stop the fall but [R1] hit her head on the frame of the bed and sustained a small laceration to the left eyebrow. The area was cleaned with wound cleanser, dressing and ice pack was applied. The Medical Doctor was made aware, order received to transfer resident to emergency room . Resident representative was made aware. Neuro check started and was within normal limit. [R1] was transferred to [local hospital] emergency room via 911. [R1] left via rescue awake, verbally responding. Review of R1's Progress Note dated 06/19/23 (Late entry 06/18/23) revealed, [R1] returned from [local hospital] with the following diagnosis: 1.) Head injury 2.) Laceration to forehead. [R1] had clear dressing to left forehead above eye with approximately 5 sutures. [R1] left forehead was black and blue with some swelling. [R1] complained about eye pain. In an interview on 09/20/23 at 12:15 PM, CNA1 stated she was changing R1. R1 rolled over and her glove got stuck, and the bed/mattress began to slide. CNA1 further stated R1's head fell forward and hit the post of her roommate's bed, but she held the rest of R1's body and lowered R1 to the floor. CNA1 concluded that R1 has always been a 1- person assist. In an interview on 09/20/23 at 12:19 PM, LPN1 revealed she was called in the residents room by CNA1, who stated R1 had fell . LPN1 stated when she went into the room, R1 was already back in bed. LPN1 further stated she was familiar with R1's care and R1 was a 1- person assist at the time of fall.

Based on review of the facility policy, observations, and interview, the facility failed to maintain an effective pest control program. Specifically, roaches were in a resident's (Resident) R28) oxygen concentrator and on R49's wall in his room. The facility's deficient practice had the potential for roaches to infest the facility and affect all 66 resident's residing in the facility. Findings include: Review of an undated policy titled, Pest Control revealed . Our facility shall maintain an effective pest control program . Maintenance services assist, when appropriate and necessary, in providing pest control services . During a medication administration observation on 08/16/22 at 4:27 PM in R49's room, four roaches were observed crawling up R49's wall next to his television. During an observation on 08/16/22 at 4:44 PM with the Unit Manager (UM) in R28's room, the UM confirmed that when R28's oxygen concentrator was moved up several roaches scattered underneath it. The UM stated he would inform the maintenance department regarding the roaches. During an interview on 08/17/22 at 2:18 PM, the Maintenance Director (MD) stated he was aware of roaches in R28's and R49's rooms and that the exterminator sprayed both rooms on 08/17/22. The MD confirmed the exterminator sprayed certain rooms monthly for roaches, but not the entire facility. During a second observation on 08/17/22 at 2:30 PM with MD in R28's room, R28's oxygen concentrator was moved, and several roaches scattered and ran on the floor. The MD verified the observation of roaches. On 08/17/22 at 2:53 PM, while the MD moved R28's oxygen concentrator, which was next to the nurses' station and medication cart, to outside the building, roaches were observed coming out of R28's oxygen concentrator onto the floor and running down the hallway. The MD verified this observation. During an interview on 08/17/22 at 3:14 PM, the Housekeeping Director (HD) stated R49 had roaches in his clothes, in his room closet and that he reported it to the MD. The HD was unsure of the day he reported to the MD. During an interview on 08/17/22 at 3:29 PM, Housekeeping (HK)1 confirmed she saw roaches in R28's and in R49's rooms (approximately on 08/15/22 ) that week. Review of a facility provided document, dated 08/17/22, titled CUSTOMER SERVICE REPORT revealed . Rooms serviced today: 106,111,112,128,134, 137,140, 141 . No cockroach activity was noted during the inspection and/or service . TARGET PEST: cockroaches APPLICATION METHOD: Spot . Further review of this document revealed both R28 and R49's rooms were treated for roaches on 08/17/22. During an interview on 08/17/22 at 4:37 PM, the Director of Nurses (DON) confirmed the roaches in R28's oxygen concentrator increased his risk for respiratory infections. The DON confirmed the pest control service spot spraying certain rooms and not the entire facility was not controlling the roach problem. During an interview on 08/17/22 at 6:08 PM, the Administrator confirmed she was made aware of R28's infestation of roaches in his oxygen concentrator. The Administrator confirmed the facility should not have roach infestations in resident's oxygen concentrators or any other area of the facility. The Administrator confirmed the facility's pest control company services were not controlling the facility's pest problem.

Based on observations, interviews, record review, and policy review, the facility failed to maintain clean oxygen concentrator equipment, specifically filters, for 1 (Resident (R28) of 2 residents reviewed for respiratory services in a total sample of 19 residents. The facility's deficient practice had the potential to expose R28 to respiratory irritants and/or respiratory distress. Findings include: Review of the undated policy, titled, Oxygen Concentrator revealed An oxygen concentrator is a medical device that [MEDICATION(S)] oxygen from room air by filtering out or separating the nitrogen from the oxygen. The oxygen passes through a filter within the device for delivery based on the flow meter setting . follow manufacturer recommendations for frequency of cleaning filters . Review of the undated document titled Preventive Maintenance revealed . Clean or replace gross particle (cabinet) filters on both side of the cabinet . Perform this procedure as needed depending on the environment the concentrator is used in . Review of R28's undated Face Sheet revealed R28 was admitted to the facility on [DATE]. Review of R28's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 08/15/22 at 2:30 PM, R28 was receiving oxygen administered via nasal cannula. Observation of the two filters (right side and left side) on R28's oxygen concentrator revealed the filters were not clean and were covered with dust particles. During a second observation on 08/16/22 at 11:50 AM, R28 was receiving oxygen administered via nasal cannula. Observation of the two filters (right and left side) on R28's oxygen concentrator revealed the filters were not clean and were covered with dust particles. During a third observation on 08/16/22 at 4:44 PM with the Unit Manager (UM), the UM confirmed the two filters on R28's oxygen concentrator were not clean and were covered with dust. The UM confirmed the nursing staff were expected to clean the resident's oxygen concentrator filters weekly and as needed. The UM stated the night shift nursing staff were responsible for cleaning R28's oxygen concentrator filters. Review of R28's Orders tab Current eMar [electronic medication administration record]/eTAR [electronic treatment administration record] Report August 2022 revealed . OXYGEN 2-4 LITERS VIA N/C CONTINUOUS . and no directive for cleaning oxygen filters. Review of R28's physician's Orders tab in the EMR revealed . OXYGEN 2-4 LITERS VIA N/C CONTINUOUS 12/13/20 . CHANGE O2 TUBING AND HUMIDIFIER BOTTLE WEEKLY ON SUNDAY 10/25/20 . but no order for maintaining/cleaning R28's oxygen concentrator filters. Review of R28's Care Plan tab revealed a Comprehensive Care Plan that included . RISK OF RESP DISTRESS WILL BE MINIMIZED . CHANGE O2 HUMIDIFIER Q 7 DAYS WHILE IN USE 12/01/22 . Oxygen 2-4 liters via n/c continuous 12/01/20 . but no intervention for cleaning or changing oxygen concentrator filters. On 08/16/22, the UM verified R28's electronic medical record (EMR) Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The UM verified R28's EMR under the Order tab had no physician's order to clean R28's oxygen concentrator filters. UM verified R28's Care Plan in his EMR under the Care Plan tab did not have an intervention to clean R28's oxygen concentrator filters. During an interview on 08/17/22 at 4:37 PM, the Director of Nursing (DON) confirmed nursing staff were responsible for cleaning oxygen concentrator filters once a week and as needed. DON confirmed the potential risk (for the facility not cleaning residents' oxygen concentrator filters) was improper function of the oxygen concentrator and resident's exposure to respiratory irritants and respiratory distress.

Based on interview, record review and review of facility policy and procedure the facility failed to ensure the availability of a prescribed narcotic for one of five residents reviewed for unnecessary medications. (Resident #5) The findings are: On 05/19/21 at 09:54 am record review of Resident #5 was admitted with the diagnoses including but not limited to [CONDITION(S)], Unspecified [CONDITION(S)], Elevated blood-pressure reading, Anxiety disorder, unspecified [CONDITION(S)], Difficulty in walking, Arthropathy, [CONDITION(S)], Heart failure, Unsteadiness on feet, Muscle weakness, and unspecified dementia without behavioral disturbance. On 05/19/21 at 10:00 am review of the electronic medication administration record (E-MAR) revealed an order for [MEDICATION(S)] 12 mcg (microgram)/hr (hour) patch apply one patch to skin every three days/72 hrs (hours) as ordered. Rotate application sites and remove old patch before placing new one. Review of the E-MAR denoted that on 04/20/2021 the [MEDICATION(S)] patch was not administered with no nursing documentation for the non administration. Review of the narcotic inventory record revealed the resident received a patch on 04/17/2021 and then again on 04/23/2021. On 05/19/21 at 12:43 pm interview with Registered Nurse #1 revealed the nurse should have documented by the medication why it was not given. Further information also revealed that the order for the medication was not received and filled at the pharmacy until 04/21/2021. Facility policy, Medication Administration-General Guidelines, D. Documentation. 7. If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the MAR for that dosage administration is initialed and circled if using a paper MAR, if electronic MAR follow manual's direction for documentation of such. An explanatory note is entered on the MAR. If there is consistent incident of medication being withheld, refused, not available or given at the time scheduled the physician should be notified of such. The reporting and instruction should be documented in the resident's medical record .

Based on observation and interview, the facility failed to provide the residents with a dignified and homelike environment during dining. The facility used styrofoam bowls, also known as a monkey dish, during meal service. This affected 74 out of 85 residents who ate during meal times. The findings included: On 11/01/19 at 12:49 PM, lunch meal service was observed in the main dining room. Residents' dessert and bread were each in their own separate styrofoam bowl while the main meal was on china. On 11/01/19 at approximately 5:25 PM, the dinner trays were observed to have dessert and bread each in their own styrofoam bowl. On 11/02/19 at 12:25 PM, resident trays were observed to have styrofoam bowls, one with a dessert and one with a roll. On 11/03/19 at approximately 10:20 AM, the Certified Dietary Manager (CDM) was interviewed. The CDM stated that the facility was using the styrofoam bowls when she started about a year ago and that she never thought to change it. She didn't know why they used styrofoam bowls. On 11/03/19 at 12:30 PM, the Administrator (NHA) was interviewed. The NHA stated that at one time they used the china bowls, but that she was unaware as to when the kitchen stopped using them and why.

Based on observation, interview and record review, the facility failed to ensure proper food handling, food safety, proper handwashing, proper use of hair nets, and proper drying techniques. This affected approximately 74 out of 85 residents who ate their meals from the kitchen. The findings included: 1a. On 11/03/19 beginning at 10:07 AM the following kitchen observations were made: Dietary Aid (DA) #21 was observed picking a food thermometer off the floor and placed it on the edge of the steam table. DA #21 was not wearing gloves and did not wash her hands before moving on to the next task of removing food from the oven. DA #21 was interviewed, she agreed that she had not washed her hands after she picked the thermometer off the floor and then removing food from the oven. DA #21 stated that she should not have left the dirty thermometer on the steam table without having it properly sanitized and then should have washed her hands. 1b. On 11/03/19 at approximately 10:20 AM, Cook #5 was observed preparing a sandwich with gloved hands. Cook #5 dropped the knife she was using on the floor, picked it up, removed her gloves and returned to the preparation area without gloved hands to put away the bread and pimento cheese. Cook #5 then took out a clean knife and put on a new pair of gloves. She did not wash her hands after picking up the knife that fell on the floor and prior to putting on a new pair of gloves. 1c. On 11/03/19 at approximately 10:25 AM, DA #22 was observed rolling silverware into napkins with gloved hands. DA #22 was asked by the Certified Dietary Manager (CDM) to help with another task. DA #22 was observed removing her gloves and immediately putting on a new pair of gloves without washing her hands. On 11/03/19 at approximately 10:27 AM, the CDM was interviewed. CDM stated the dietary staff are trained to wash their hands every time they change their gloves and when they change tasks. The policy for Dietary Services: Sanitization was reviewed. #10 read, Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. 2a. On 11/03/19 at approximately 10:25 AM, DA #22 was observed rolling silverware that was still wet from the dish washer. DA #22 was observed banging off the excess water prior to rolling the silverware into a napkin. The CDM was interviewed on 11/02/19 at approximately 10:27 AM. CDM stated that utensils were wet and should not have been used. CDM stated that it was their policy to air dry all utensils prior to use. 2b. On 11/03/19 beginning at 11:50 AM, lunch service tray line was observed. The insulated plate bases were stacked for use. More than 12 bases were observed to be wet and a plate was placed in them and used for service. After being made aware of the wet bases on 11/03/19 at 12:00 PM, CDM removed the remaining wet insulated bases from use. CDM stated that all equipment should be air dried prior to use. 3. On 11/03/19 during tray line service at 12:07 PM, DA #4 entered the kitchen from the dining room. She was not wearing a hair net and proceeded to go straight to the walk-in refrigerator. Once out of the refrigerator, her co-workers told her to put on a hair net. At 12:17 PM, DA #24 entered the kitchen through the dining room. DA #24 had long hair, approximately halfway down her back that was not restrained. She walked through the kitchen, and past the tray line prior to putting her hair in a hair net. On 11/03/19 at approximately 1:00 PM, the CDM was interviewed and stated that they did not have a formal policy on which door to enter the kitchen, but that it was her expectation that the staff would enter the kitchen through the service hallway door because that is where the hairnets and hand washing sink were located. 4. On 11/03/19 at 12:20 PM, the temperature log book was reviewed. The lunch that was being served did not have temperatures recorded. The CDM stopped the tray line to take temperatures. DA #21 calibrated the thermometer, took the temperature of a food item and sanitized the thermometer with an alcohol wipe. Instead of allowing the thermometer to air dry, DA #21 use a paper napkin to wipe off the thermometer and inserted it into the next food item. DA #21 was observed sanitizing with the alcohol wipe and then dried off the thermometer after temping each item with the same paper napkin. The temperature log book was reviewed for September, (MONTH) and (MONTH) 2019. The following meals were served without recording temperatures: 09/24/19 - lunch, 09/30/19 - breakfast and lunch, 10/22/19 - dinner, 10/25/19 - dinner, 10/28/19 - lunch, 10/29/19 - breakfast, 10/31/19 - breakfast and lunch, 11/02/19 - dinner, and 11/03/19 - lunch. On 11/03/19 at approximately 1:00 PM, the CDM was interviewed and stated that it was the expectation that temperatures were taken and recorded prior to the tray line beginning and that when taking temperatures, the dietary staff should first use an alcohol wipe to sanitize, allow the thermometer to air dry and then insert into the thickest part of the food. The policy for Safe Food Temperatures was reviewed. Under the Procedure section, #1. Prior to the beginning of the tray line the temperature of all food being served is taken and recorded appropriately on the temperature control form. The policy for Proper Use of Thermometers was reviewed. Under the Procedure section, #1 read in part, . clean and sanitize the thermometer, clean the thermometer with clean soapy water, sanitize with an alcohol wipe, insert into the thickest part of the product .

Based on observations, record review, and resident and staff interviews, the facility failed to provide an appropriate call light for 1 of 1 resident reviewed for accommodation of needs (Resident #233). Specifically, Resident #233 had difficulty using a standard push button call light due hand deformities. The findings included: According to the Face Sheet, Resident #233 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment, dated 09/26/19, Resident #233 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 12 out of 15. He required extensive to total assistance with all activities of daily living (ADL). He had functional limitation in range of motion to both of his upper and lower extremities. Resident #233 was interviewed and observed on 11/02/19 at 9:45 AM. He was laying in his bed. His hands were observed to be disformed and they flexed down at the wrist. His fingers were flexed towards his palm and forearm. He was able to move some fingers slightly, but it was limited. His call light was observed. He had a regular push button call light. The call light was observed to be clipped to his pillow and the call light was above his left shoulder, which was out of his reach. The resident's care plan was reviewed. According to the ADL care plan dated 09/26/19, Resident #233 required total care with all ADL's related to the inability to use his hands due to gouty arthritis. Staff does most of his feeding due to deformities of hands. Resident #233 was interviewed and observed on 11/04/19 at 10:24 AM. His call light was not visually seen. When asked where his call light was, he said he didn't know. He said he was looking for it and couldn't find it. At 10:26 AM, the Nursing Home Administrator (NHA) entered the room, along with the resident's family. The NHA was asked to find Resident #233's call light. The NHA looked for the call light and it was tucked underneath his sheets, which made it difficult for the resident to find. Resident #233 told the NHA that he couldn't find his call light. Resident #233 was interviewed and observed on 11/04/19 at 2:53 PM. He was asked to press his call light. The resident was laying in his bed and his call light was laying on his lap. He moved his left hand to try and press the push button. He had extreme difficulty with grasping the call light in order to be able to press the button. He had thought he pressed the button, but the call light did not turn on. The call light was functional. He agreed that the call light was difficult for him to use. He said he didn't press the button hard enough. He said that his call light wasn't always in reach. He said sometimes it was on the floor. Unit Manager #114 was interviewed on 11/04/19 at 3:07 PM. She said Resident #233 could use the call light if it was placed in his hand. Otherwise, it was more difficult for him to use the light. She was not aware the facility had any other type of call light besides the standard push button call light. She then spoke with the Director of Nursing (DON). She said they had call lights that were a flat pad, or pancake pad, that could be pressed. She did not know the resident had difficulty pressing the call light, as his call light would go off at times. She agreed that a pancake call light would be much easier for him than the standard call light, due to his hands. On 11/04/19 at 3:14 PM, Resident #233 had the pancake call light hooked up in his room. Unit Manager #114, the DON, and the Assistant Director of Nursing (ADON) were all in the resident's room. They said he was able to press the light with no problems. Resident #233 said the new call light would be much easier for him to use. Unit Manager #114 was interviewed on 11/04/19 at 4:25 PM. She said the new call light was much better for him. The DON was interviewed on 11/04/19 at 5:21 PM. She said the new call light was much better for him. The NHA as interviewed on 11/04/19 at 5:46 PM. She said the pancake call light would be much better for him. She agreed that with his hands, the normal call light would have been difficult to use.

Based on observations and resident and staff interviews, the facility failed to respond timely to a resident's request. Specifically, the facility failed to assist Resident #233 to sit on the side of the bed in a timely manner. This affected one of one resident. The findings included: According to the Face Sheet, Resident #233 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment, dated 09/26/19, Resident #233 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 12 out of 15. He required extensive to total assistance with all activities of daily living (ADL). Resident #233 was interviewed on 11/02/19 at 9:37 AM. He said the staff did not check on him or provide the care that he should get. He said staff did not change him. He said sometimes it could be hours before he would see someone. Resident #233 was interviewed and observed on 11/04/19 at 2:53 PM. During the interview, Certified Nurse Aide (CNA) #55 came into the room at 2:57 PM. She was making her rounds since she just came on shift. Resident #233 requested to sit on the side of the bed. She said she needed to get help and she would be back. After she left, Resident #233 made the comment that she would not be back. He said the staff never come back when they say they will. He said they never come and help him. Resident #233's room continued to be monitored. CNA #55 had not gone back to the room after 15 minutes. There was no one else that entered the room either. At 3:11 PM, Unit Manager #114 was informed the CNA had not gone back into Resident #233's room after he requested to sit on the side of the bed. Unit Manager #114, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) all went down to Resident #233's room. At 3:14 PM, the room was observed. Unit Manager #114, the DON, and the ADON were in the room. Resident #233 was requesting to sit on the side of the bed. They got the nurse to assist with sitting him up. CNA #55 was interviewed on 11/04/19 at 3:20 PM. When asked about why she did not return to Resident #233's room, she said she was not assigned to him and she was waiting for his assigned CNA to get in. She said she had just spoke with the assigned CNA and she said Resident #233 was not allowed to sit on the side of the bed without support. When she came into Resident #233's room, she was the only CNA there at the time of shift change and she was checking in on everyone. She always did that when she came on shift. She said she would assist residents that she wasn't assigned to, but she was not very familiar with Resident #233. She said she struggled to find someone to assist her and it was probably 15 to 20 minutes before she saw his assigned CN[NAME] She said she should have gone straight back to his room and communicated that she was unable to help him at that time. Unit Manager #114 was interviewed on 11/04/19 at 4:25 PM. She said they were able to get Resident #233 up and he sat on the side of the bed for a short period. She said Resident #233 needed two staff to assist him. She said CNA #55 should have grabbed the first person she saw to assist her with sitting him up. She could have grabbed the nurse, another CNA, or she could have asked her as well. She said all staff have been told that every resident is theirs and they need to assist every resident; not just the residents they are assigned to. She said if the CNA could not have found anyone to help her, then she should have gone back to the room and at least explained the situation. The DON was interviewed on 11/04/19 at 5:21 PM. She said that requests from residents should be taken care of in a timely manner. If staff need another person, then they need to find someone that can help. CNA #55 could have gotten the nurse, another CNA, the Unit Manager, or herself to help. She said residents should be assisted as soon as possible. It could take a few minutes to find someone, but anyone could assist.

Based on observations, interviews and policy reviews, the facility failed to utilize proper handwashing techniques during wound care for 1 of 2 nurses observed. The facility failed to maintain infection control practices during medication pass for 3 of 5 nurses observed. The findings included: 1. On 11/03/19 at 10:38 a.m., Nurse #74's handwashing technique was observed during wound care observation for Resident #3. Nurse #74 turned on the water faucet with his unwashed hands. He washed his hands with soap and water, then used his clean hands to turn off the water faucet. He then pressed the lever on the paper towel dispenser to dispense a towel to dry his hands. He repeated this technique each time he washed his hands during wound care. After the wound care observation, the nurse was asked about his handwashing technique. Nurse #74 responded by demonstrating his handwashing technique, and again used his clean hands to turn off the water faucet and press the lever to dispense a paper towel to dry his hands. When questioned about the last time he was checked off on handwashing, he stated it had been more than 1 year. During an interview on 11/04/19 at 9:19 a.m., the Director of Nursing (DON) stated the correct handwashing procedure would be to dispense a paper towel, perform handwashing, dry the hands, then use the elbow to dispense another towel to turn off the faucet. A review of the facility's policy for Handwashing/Hand Hygiene, revised 8/2015, indicated, Washing hands, 1. Vigorously lather hands with soap and rub them together .2. Rinse hands thoroughly 3. Dry hands thoroughly with paper towels and then turn off the faucet with a clean, dry paper towel. 2a. During an observation and interview on 11/03/19 at 8:43 a.m., Nurse #64 was observed administering an insulin injection to Resident #25. Nurse #64 placed the syringe in his own mouth, prepped the injection site with alcohol, then administered the injection. He did not wear gloves during the procedure. When questioned, he stated it was the facility's policy to wear gloves during injections. When asked about placing the syringe in his mouth, he stated old army habits. The facility's undated policy for Injectable Medication Administration, indicated, Bring supplies to bedside or beside resident and maintain a clean space. Put on gloves. Expose the area to be injected and clean with an alcohol wipe. After administering the medication, the policy indicated, Dispose of syringe in sharps container and supplies in appropriate waste container. Remove & discard gloves. 2b. During a medication pass observation and interview on 11/4/19 at 8:20 a.m., Nurse #73 entered Resident #7's room to administer her morning medications. The nurse began by washing his hands. He turned the faucet on with his unwashed hands, washed his hands with soap and water, turned the faucet off with his arm, then used his clean hands to press the lever on the paper towel dispenser to dispense a towel to dry his hands. While he was washing his hands, in reference to handwashing, he stated, It isn't a good system. As he touched the paper towel dispenser lever to dispense a paper towel, he stated, Even this is dirty. He was questioned about his handwashing technique. He proceeded to demonstrate his handwashing technique, and once again used his clean hands to dispense a paper towel. When asked what he could do to prevent contaminating his hands while dispensing a paper towel, he stated his previous employer had tissues available that he used to dispense a paper towel. During an interview on 11/04/19 at 10:19 a.m., the DON stated the correct handwashing procedure would be to first dispense a paper towel, wash and dry the hands, then use the elbow to dispense another towel to turn off the faucet. A review of the facility's policy for Handwashing/Hand Hygiene, revised 8/15, indicated, Washing hands, 1. Vigorously lather hands with soap and rub them together .2. Rinse hands thoroughly 3. Dry hands thoroughly with paper towels and then turn off the faucet with a clean, dry paper towel. 2c. On 11/4/19 at 8:20 a.m., Nurse #73 entered Resident #7's room to administer her morning medications. He had prepared the medications and placed them in a plastic tray. Nurse #73 took the tray into the resident's room and placed it directly on the resident's table. After administering the medications, he returned to the medication cart with the plastic tray. He did not clean the tray. During a follow up interview on 11/04/19 at 9:55 a.m., Nurse #73 stated he didn't usually use the plastic tray with medication pass. He stated he had never been instructed to clean the tray in between use with each resident. During an interview on 11/4/19 at 10:05 a.m., the Clinical Nurse Coordinator stated the staff don't usually use the plastic trays with medication pass. She indicated if the nurses use the trays with medication pass, it should be cleaned in between each resident use with bleach wipes that are available on the medication carts.

Based on record review and staff interviews, the facility failed to properly communicate with hospice regarding code status for 1 of 1 resident (Resident #6). Specifically, the facilities records indicated a Full Code and the hospice records indicated a Do Not Resuscitate (DNR). The findings included: According to the Face Sheet, Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment, dated 10/01/19, Resident #6 was unable to complete the Brief Interview of Mental Status (BIMS). She had a short term memory and long term memory problem. She required supervision to extensive assistance with all activities of daily living (ADL). Resident #6's clinical record was reviewed on 11/02/19 at 11:05 AM. The facility's chart had a code status of Full Code. This was signed on 10/04/18. The physician's orders [REDACTED]. Resident #6 was admitted to hospice on 01/22/19. The hospice chart had a code status of DNR. Registered Nurse (RN) #64 was interviewed on 11/02/19 at 11:21 AM. He said Resident #6 was a DNR and said she was on hospice. He did not assume someone was a DNR because they're on hospice. He said he would look in the chart, if he needed to know the code status for a resident. There was a form in the front of the chart that he would look at. According to Resident #6's care plan, the resident was receiving hospice services due to terminal stage of illness. Approaches included coordinating care and services with hospice provider. Unit Manager #114 was interviewed on 11/02/19 at 12:06 PM. She said the nurses would go to the hospice chart and look to see which code status a resident was. She said code status should be in both the hospice and facility charts and they should match. She said hospice would normally update the facility chart. She said the Social Services Director (SSD) was the one that goes over code status and would coordinate with hospice. She called the SSD on 11/02/19 at 12:09 PM. She said the resident's code status did not change to DNR when she went on hospice. She said the hospice chart was wrong. She remembered a conversation with the son, who was the Power of Attorney (POA), and the resident wanted to remain a full code to be around for her grandchildren. The SSD and Unit Manager looked at both charts. She confirmed the facility chart had a Full Code order and the hospice agency had a DNR order. She said the hospice order was signed by the daughter, who was not the PO[NAME] The SSD was not aware of the DNR order. She said they always called the family when something happened and the family always wants her sent out. She said the communication with the hospice agency was not good. They never informed her about the order, which they should have. The SSD said the nurses would go to the facility chart to look for code status and would not go to the hospice chart. RN #64 was interviewed on 11/02/19 at 12:32 PM. He said he would look in the facility's chart to determine a resident's code status. He would not look in the hospice chart. He does not assume a code status for anyone. He said he would always look at the chart to determine the resident's wishes. The SSD was interviewed on 11/03/19 at 3:48 PM. She confirmed that the communication from hospice was poor. She said they hardly ever talked to anyone. Sometimes hospice would come and no one knew they were there. She did not know the DNR order was in the hospice chart because no one told her. She did not know when that paperwork would have been placed in the chart. It was signed during her admission to hospice, but that didn't mean that was when it was placed in the chart. She was not sure why the hospice agency did not consult with the son, who was the PO[NAME] Unit Manager #114 was interviewed on 11/04/19 at 4:25 PM. She said the communication with paperwork being placed in the chart had not been good. The hospice agency did not tell them when they put something in the hospice chart. She said the hospice agency goes through the chart to ensure everything is in there. She thought it would be a good idea for them to start looking at the chart to ensure what was in there. She confirmed she was not aware of the DNR order in the hospice chart. She said when the hospice staff come, they are good about speaking with the facility staff. The Director of Nursing (DON) was interviewed on 11/04/19 at 5:21 PM. She said if the hospice agency obtained a DNR order, then they should have communicated that to the facility. She was not sure how the miscommunication happened. She said hospice should be communicating changes with the facility staff.

Based on observation and interview the facility failed to ensure that food was served and kitchen facilities maintained according to Standard Dietary Practices. In addition, based on observations and review of the facility policy titled, Assistance with Meals, the facility failed to ensure food was not handled by staff with bare hands during the lunch meal service on the Carolina Hall. The findings included: An observation of the facility kitchen on 08/16/18 at approximately 11:00 AM revealed the air conditioning vents in the ceiling to be covered in a layer of gray dust material and brown greasy stains. Subsequent observation of the heating and air return register located over the coolers revealed a thick layer of gray dust accumulated on the outside metal cover. Maintenance staff opened the vent to reveal a replaceable filter with a thick layer of gray dust material. In an interview on 08/16/18 at approximately 2:53 PM the Maintenance Director (MD) stated the filter is scheduled to be replaced monthly. The MD confirmed the filter needed to be changed more often and that going forward the filter would be inspected bi-weekly and replaced as needed. An observation of the grease trap in the facility kitchen on 08/16/18 at approximately 3:23 PM the MD opened the grease trap located in the floor kitchen. The trap was observed to be full. In a subsequent interview, the MD was unable to locate any service records for the grease trap and could not recall when it was last serviced. An observation on 8/13/2018 at approximately 12:25 PM during the lunch meal service on the Carolina Hall revealed a staff member touching a resident's dinner roll with bare hands while removing it from a plastic container. Further observation on 8/13/2018 at approximately 12:45 PM during the lunch meal service in the dining room on the Carolina Hall revealed staff touching a resident's dinner roll with bare hands while setting up the tray. Review on 8/15/2018 at approximately 10:30 AM of the facility policy titled, Assistance with Meals, states, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Under, 1. Dining Room Residents: d. Avoid handling food with bare hands. 2. Residents confined in Bed: e. Avoid handling food with bare hands. 3. Residents Requiring Full Assistance, c. Avoid handling food with bare hands. The staff member was not available for interview.

Based on record review and interview, the facility failed to ensure the CNA (Certified Nursing Assistant) most involved with the care for Resident #38 had input into the care planning process on multiple occasions for 1 of 6 residents reviewed for hospitalization . The findings included: The facility admitted Resident #38 with [DIAGNOSES REDACTED]. Review on 8/15/2018 at predominately 6:00 AM of the medical record for Resident #38 revealed a form titled, Care Plan Meeting Attendance Record, The attendance documentation on the form did not include a CNA on 3/22/2017, 6/14/2017, 9/13/2017, 11/29/2017 and 6/13/2018. Therefore the CNA most closely involved in the care for Resident #38 was not included in the care planning process for this resident. An interview on 8/16/2018 at approximately 9:45 AM with the MDS (Minimum Data Set) assessment coordinator confirmed that the CNA was not in attendance and did not have input into the care planning process for Resident #38.

Based on record reviews and interviews the facility failed to ensure Resident #1, #63, #53 and #38 and each of the residents personal representative received in writing and in a language they could understand the reason for the discharge/transfer to the hospital for 4 of 6 residents reviewed for hospitalization . The findings included: The facility admitted Resident #63 with [DIAGNOSES REDACTED]. Review on 8/14/2018 at approximately 1:37 PM of the medical record for Resident #63 revealed no documentation to ensure Resident #63 and his/her Personal Representative received in writing and in a language they could understand the reason for the transfer/discharge to the hospital. The facility admitted Resident #53 with [DIAGNOSES REDACTED]. Review on 8/15/2018 at approximately 4:11 PM of the medical record for Resident #53 revealed no documentation to ensure Resident #53 and his/her Personal Representative received in writing and in a language they could understand the reason for the transfer/discharge to the hospital. The facility admitted Resident #38 with [DIAGNOSES REDACTED]. Review on 8/15/2018 at approximately 4:11 PM of the medical record for Resident #38 revealed no documentation to ensure Resident #38 and his/her Personal Representative received in writing and in a language they could understand the reason for the transfer/discharge to the hospital. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 08/16/18 at approximately 8:43 AM revealed Resident #1 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. No written Notice of Transfer was located in the file. In an interview on 08/16/18 at approximately 1:36 PM the Social Services Director stated no written Notice of Transfer was provided to the Resident Representative and/or Resident #1.

On days of survey, based on observation, record review, interview and review of the facility provided policy related to medication errors, the facility failed to follow physician orders [REDACTED].# 87. The facility failed to administer a medication for Resident # 108 as ordered by the physician for two days as a result of it being incorrectly entered into the computer system. Resident # 1 did not have a consult completed as ordered by the physician. Resident # 27 did not have physician orders [REDACTED]. (1 of 3 residents reviewed with medication errors; 1 of 1 residents reviewed who did not receive medications as ordered by the physician; and 2 of 2 residents who did not receive services as ordered by the physician.) The findings included: Observation of medication administration for Resident # 87 on 11/14/13 at 8:28 AM revealed Licensed Practical Nurse #2 administered [MEDICATION NAME] 20 mg (milligrams) (2) tablets equal to 40 milligrams and [MEDICATION NAME] 25 mg (2) tablets equal to 50 milligrams in addition to other medications. Reconciliation of the physicians orders revealed the resident was ordered by the physician to receive [MEDICATION NAME] 40 mg one half tab (tablet) (or 20 milligrams) and [MEDICATION NAME] 50 mg one half tab (or 25 milligrams). The Medication error was verified by Licensed Practical Nurse # 2 and the Unit Manager. Review of the facility available Nursing 2013 Drug Hand Book, revealed that [MEDICATION NAME] has a onset time of 15 minutes; peaks in 1 hour; and has a 6-12 hour duration time. [MEDICATION NAME] has an onset time of 1 hour; peaks at 7 hours and a duration time of 24 hours. Following the identification of the medication, the physician was contacted and ordered the resident to have his/her pulse monitored. The medication error reports contained conflicting guidance. One stated "monitor v/s (vital signs) q (every) 4 hrs (hours) x 12 hrs" and the other state "Blood pressure and pulse monitored for 24 hrs". The Unit Manager who had completed the form stated the physician verbally stated 12 hours but s/he had already written 24. S/he clarified to this surveyor that the plan was to monitor the vital signs every 4 hours for 24 hours. On 11/15/13 a follow up review of the medical record was conducted. There was no documentation of the incident in the physician progress notes [REDACTED]. The medication error reports contained conflicting guidance. One stated "monitor v/s (vital signs) q (every) 4 hrs (hours) x 12 hrs" and the other state "Blood pressure and pulse monitored for 24 hrs". The Unit Manager who had completed the form stated the physician verbally stated 12 hours but s/he had already written 24. S/he clarified to this surveyor that the plan was to monitor the vital signs every 4 hours for 24 hours. The Unit Manager was asked to provide evidence that the post medication error monitoring had been completed. A vital sign monitoring sheet revealed vital signs had been obtained on 11/14/13 but no time that the vital sign was obtained was recorded. The Unit Manager stated it was obtained at approximately 11 AM (2.5 hours after the incorrect medication was administered.) The previous shift nurse was present and stated the Certified Nursing Assistants had obtained one set of vital signs at approximately 5 AM on 11/15/13. This vital sign was recorded of the vital sign flow sheet. Both nurses verified the physician's orders [REDACTED]. The physician was contacted by telephone and verified he would have expected follow up of the resident post medication error to have been completed. The facility provided policy for Medication Errors stated: "Residents receiving incorrect medication or having a drug reaction must be closely monitored, Any change in the resident's condition must be immediately reported to the Director of Nursing Services and attending physician". The following information should be documented in the medical record..The time and date of the incident, the name, strength and dosage of medication administration, the residents reaction, all assessment data obtained during the procedure, any treatment administered. It was determined on 11/15/13 at approximately 11:39 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the following areas: CFR 483.25 F-309 at a scope and severity level of "J". The Immediate Jeopardy existed on 11/15/13 when licensed nursing staff failed to follow a physician's orders [REDACTED]. Resident # 87 received two incorrect doses of medications on 11/14/13. Following the identification of the error, the residents' Physician was contacted and ordered the resident's vital signs to be monitored. The error occurred at 8:27 AM and vital signs were only obtained two times in the following 24 hour period. Vital signs were not monitored as ordered, placing the resident at risk for serious harm. The facility provided an Allegation of Compliance (AOC) that was acceptable on 11/15/13 at 5 PM and the immediacy of the Immediate Jeopardy at F-309 was removed but lowered in scope and severity to a "D". The AOC included the following: 1. The resident (#87) has been assessed by the Director of Nursing . The MD was made aware of the licensed staff failed to follow physician's orders [REDACTED]. Licensed nursing staff on duty on 11/15/13 were in-serviced by the Director of Nursing on assessment of resident's condition per MD order (checking blood pressure and pulse following an administration of blood pressure medication error) and requirements to document residents condition (BP/Pulse) per MD order following medication administration error and reporting to oncoming shifts that a medication error has occurred, physician's orders [REDACTED]. Remainder of all staff will be in-serviced on same information by 11/15/13 by DON or Unit Manager either in person or by telephone. Facility uses no agency staff. No licensed staff will work again without receiving this mandatory in-service training. 2. All residents current physicians order will be reconciled against Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Based on staff interviews, and review of documentation of in-services and audits provided by the facility, the Survey Team on 11/15/13 verified the Allegation of Compliance for the Immediate Jeopardy was in effect prior to exiting the facility. The immediacy of the Immediate Jeopardy at F-309 was removed but lowered in scope and severity to a "D". Resident #108 was admitted with a [DIAGNOSES REDACTED]. On admission the physician ordered the resident to receive Tamsulosin [MEDICATION NAME] ([MEDICATION NAME]) 0.4 milligrams every evening. On 11/14/13 at 3:53 PM, review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the medication cart identified two pills were sent to the facility on [DATE] and remained in the medication cart. Investigation by the unit manager and unit ward clerk discovered the order had been entered into the computer as a "Dietary" order rather than as a medication. Because of this error, the medication did not print onto the Medication Administration Record, [REDACTED]. The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The facility's Special Instructors Tool Resident Care sheet used by the CNA's(Certified Nursing Assistant) did not list that the resident was to have no socks. On all days of the survey, Resident #27 was observed with a sock on his/her left foot. On 11/14/13, Nurse Consultant #1 verified the resident wearing a sock to his/her left foot. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Chart review on 11/15/13 at approximately 8:54 AM revealed a physician's orders [REDACTED]. Review of the nurse's note dated 8/06/13 revealed there was no documentation to indicate resident was transported on 8/06/13 to the physician's orders [REDACTED]. A physician's orders [REDACTED].#1 was out of the facility for a pacemaker check. A physician's orders [REDACTED]." Review of nurse's note dated 9/19/13 indicated a call was made to the plastic surgeon and an appointment was made for 10/17/13 at 3:15 PM. Review of the nurse's note on 10/17/13 revealed there was no documentation to indicate the resident was transported to the scheduled 10/17/13 appointment. An interview on 11/15/13 at approximately 9:59 AM with the DON (Director of Nursing) revealed the resident's appointment was re-scheduled for 12/02/13 although there was no documentation in the chart. An interview on 11/15/13 at approximately 11:26 AM with the Director of Nursing confirmed there was no documentation to indicated why the 8/06/13 pacemaker check or the 10/17/13 plastic surgery appointment had been rescheduled. The DON further stated there should be documentation to indicate why a resident's physician's orders [REDACTED]. An interview on 11/15/13 at approximately 11:30 AM with LPN (Licensed Practical Nurse) #3 revealed the nurses are responsible for scheduling appointments and the unit clerk was responsible for arranging the transportation. LPN #3 further stated there should be documentation to indicated why and when physician's orders [REDACTED].

On days of the survey,based on observations and interviews, the facility failed to care for residents in an environment that maintains each resident's dignity. Resident # 108 was observed being told by a Certified Nursing Assistant to void in his/her brief when the resident stated he/she needed to go to the bathroom. Facility staff was observed standing while feeding (Resident # 2) ; facility staff were observed randomly applying clothing protectors without asking the resident's preference and meal trays were not served sequentially. A Hospice Nurse was randomly observed performing an assessment in a public area for Resident # 52. Resident # 107 was observed wearing the same clothes on two days of the survey. The findings included: On 11/13/13, Resident 108 was observed being fed breakfast by CNA (Certified Nursing Assistant # 3 at approximately 8:45 AM. This Surveyor was standing midway between the two resident beds in the room and was able to hear and observe both residents in the room. The CNA was seated at the resident's bedside. The resident was observed to be anxious and verbalized the need to urinate. The CNA replied: "You have a brief on, go ahead and go" and continued to feed the resident. As s/he offered the resident another spoonful of food, the resident verbally stated s/he was urinating. During an interview on 11/13/13 at 2:40 PM with CNA # 3, s/he stated she was not assigned to Resident # 108 but was assisting in feeding residents on the unit. CNA # 3 verified s/he had instructed the resident to urinate in his/her brief, even though the resident had informed him/her of the need to urinate. S/he explained that s/he did not want to stop feeding the resident. "They always say, once you stop feeding don't stop and go back to the food. When asked to identify who "they" were, s/he replied I "just heard it". The CNA further explained, we don't take (Resident 108) to the bathroom." S/he is immobile. When asked about the use of a urinal/bedpan, s/he stated I don't think they put one in his/her room. The Surveyor further inquired how a CNA would know how to care for a resident and the CNA stated there is a notebook at the desk. Review of the Special Instruction Tool (CNA Careplan) with the CNA present, revealed the area addressing toileting was not completed. The form also indicated the resident fed self. The CNA stated: We have fed him the past two days because s/he says s/he "can't see." (The care tool also did not address the resident's [MEDICAL CONDITION].) During an interview with the Director of Nursing on 11/14/13 at 2:45 PM, s/he stated the CNA careplan was completed by the admitting nurse. S/he reviewed and verified the careplan was incomplete. When asked about the facility policy related to toileting residents during meals, s/he stated s/he was unsure as s/he was still learning facility policies. However, s/he stated in his/her opinion, the resident should be toileted. If the resident was in the dining room, they should be taken back to their room. If a resident was eating in their room, they should be taken to the toilet or at least offered a urinal. When informed of the surveyors concern, s/he stated "that was not acceptable." During initial tour on 11/12/13 , Resident # 108 was noted to be in need of a shave. During random observations on 11/13/13, the resident remained in need of a shave. Although a moustache was present, addition unkempt facial hair was evident. Review of the facility photograph taken of the resident, provided further evidence of a need to shave. An interview was conducted with the assigned CNA ( #2) on 11/13/13. During the interview, the CNA explained resident's are shaved on their shower days. S/he verified the resident was clearly in need of shaving but s/he had not "gotten to it". When asked if a resident could be shaved on a day other than their assigned shower day, s/he stated yes. Upon the request of the surveyor and agreement by the resident, a shave was then completed. Observation on 11/14/13 at approximately 12:30 PM, of the dining area on the Virginia Hall revealed Resident # 52 seated in a reclined Geri-chair by a horseshoe shaped table. Other resident's and staff were in the immediate awaiting the arrival of meal trays. A person seated next to the resident, (later identified as Registered Nurse # 3) removed a stethoscope from around his/her neck and began listening to the resident's chest. S/he then palpated the resident's abdominal area, raised the resident pants and looked at the resident's lower extremities. Registered Nurse # 3 (identified as a Hospice Nurse) was then overheard to ask a CNA about the resident's bowel movement frequency in front of other residents, staff and visitors. At approximately 12:36 PM, an interview with RN # 3 was conducted and when questioned about performing an assessment in a public area, s/he stated s/he was sorry and "had not thought of that". Observation on 3 days of the survey revealed meal trays were not delivered and served sequentially to Residents residing on the Virginia Hall. Meal trays were served in the dining area by the nurses station and to individual resident rooms to residents who were able to eat independently. Once that task was completed, residents who required assistance with feeding were served. Observation in the main dining area and in resident rooms revealed resident's were seated at the same table and or residents who resided in the same room were not served meal trays at the same time. Therefore, residents without meal trays watched as others began eating until such time as their trays were delivered and they were assisted. During a random observation on 11/12/13 at approximately 12:13 PM of the day area dining delivery near Harvin Wing, revealed five dining tables set up to serve residents. Residents at three (3) tables were served and eating while two (2) other tables with 3 to 4 residents were not served or eating. An interview on 11/12/13 at approximately 12:40 PM with the DM (Dietary Manager) revealed the first food cart was for the residents who can feed themselves and the second food cart was for the residents that required staff assistance with feeding. The DM stated he/she was aware the residents who required assistance with eating would be in the dining area waiting while residents who could feed themselves were already served and eating. The DM stated the meal delivery process had been in place for some time now. A second observation on 11/13/13 at approximately 12:16 PM of the day area dining delivery near Harvin Wing revealed five dining tables set up to serve residents. Residents were observed at one (1) table served and eating. There were three (3) tables and 3 or more residents not served or eating while one (1) table in the center of the dining room had three residents served and eating. A second food cart came out at 12:40 PM and the food tray was served and uncovered in front of the residents who required staff assistance with feeding. The aroma of the food could be smelled 4 to 5 feet away. The residents seated in the dining area were less than 4 to 5 feet away from each other. Multiple residents that required assistance with feeding were seated waiting for staff assistance with feeding. The DON stated the residents that require assistance with eating are encouraged to feed themselves and then staff was to provide assistance with feeding as needed. Additionally during meal observation on all days of the survey, staff members were observed applying clothing protectors to residents who resided on the Virginia Unit without asking the resident's preference. Staff was randomly observed applying the protectors; at times while standing behind the resident and without speaking, placing the clothing protector. On 11/15/13 both the Administrator and the nurse consultant were present and did not intervene as staff placed clothing protectors without asking. During a random observation of Resident # 2 who ate his/her meals while in bed in his/her room, staff was observed standing while assisting the resident with feeding on 11/13/13 at breakfast and lunch meal observation, During an interview with the Director of Nursing,following the lunch observation, s/he stated staff should be seated when feeding residents. The facility admitted Resident #107 with [DIAGNOSES REDACTED]. A random observation on 11/13/13 at approximately 4:07 PM revealed the resident was in therapy, wearing a pink long sleeve top and below knee dark pink pleated skirt. An observation on 11/14/13 at approximately 8:43 AM revealed resident wearing pink long sleeve top and below knee dark pink pleated skirt. Review of the clothing in the resident's closet revealed a short sleeve gold top and black and white skirt. The closet consisted of several bed gowns but not street clothes. An interview on 11/14/13 at approximately 9:53 AM with the Facility Administrator revealed CNA (Certified Nursing Aide) #1 was the CNA assigned to Resident #107. An interview on 11/14/13 at approximately 9:59 AM with CNA #1 revealed residents are bathed and then they are dressed for the day. CNA #1 stated the resident required assistance with getting dressed. When asked if the resident had adequate clothing, the CNA stated the resident had adequate clothing but he/she needed to check laundry to determine when the clothing was going to be returned to the resident's room. An interview and observation on 11/14/13 at approximately 10:08 AM with Laundry Staff #1 revealed Resident #107 only had bed clothing because s/he "spent a lot of time in bed". The Operations Manager further stated 90 percent of Resident #107 clothes consisted of bed clothes. During an observation and interview on 11/14/13 at approximately 10:21 AM with the DON (Director of Nursing) s/he verified Resident #107 closet only contained a gold top and black and white skirt and bed clothing. The DON stated a sign would be in the resident's closet if family was responsible for doing the resident's laundry. The DON confirmed there was no sign in the resident's closet to indicate family did the resident's laundry. The DON confirmed the facility was then responsible for cleaning the resident's clothing. On 11/14/13 at approximately 11:58 AM the resident was seated in the day area preparing for lunch, continuing to wear the same clothing from the previous day. Review on the medical record revealed an Admission (MDS) Minimum (MDS) data set [DATE] indicated Resident #107 had a BIMS (Brief Interview Mental Status) score of 5 which noted resident was cognitively impaired. The MDS under functional status further indicated the resident required assistance with bathing and dressing.