Every finding on record at Life Care Center Of Charleston

Based on a review of facility policy, observations, interviews, and record review, the facility failed to send quarterly statements to the resident and the resident's representative for Residents (R)42, R78, R118, R101, and R120.Findings include:Review of the facility's policy titled, Personal Needs Account, revised 12/15/16, revealed, All residents are eligible, but not required, to participate in the personal needs account. This allows the resident to place money in an interest-bearing checking account, which they can access for personal needs.Procedure:5. The resident will receive an account summary on a quarterly basis or at more frequent intervals at his/her request.Review of R42's electronic medical record (EMR) revealed R42 was admitted to the facility on [DATE]. Review of an undefined Minimum Data Set (MDS) revealed R42's Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating normal cognitive function.During an interview on 01/06/2026 at 01:15 PM, R42 stated, I do not have or receive any statements of funds. I know I get $30, but it goes to my bill.During an interview on 01/07/2026 at 12:37 PM, the Business Office Manager (BOM) stated, The Resident Representative (RR) gets the quarterly statement. If they are alert and oriented, the residents get their statements, and sometimes the RP. Some of the alert and oriented (A&O) residents don't get their statement, but the RR always gets the statement by mail.Review of R78's EMR revealed R78 was admitted on [DATE]. Review of an undefined MDS revealed R78's BIMS score of 03 of 15, indicating severe cognitive impairment.During an interview on 01/08/2026 at 2:22 PM, R78's RR called and stated, They are not receiving quarterly statements of personal funds. They stated they receive a lot of EOBs [explanation of benefits].A review of R120's facesheet revealed R120 was admitted to the facility on [DATE]. Review of an undefined MDS revealed R120 has a BIMS score of 14 of 15, indicating intact cognitive function.During an interview on 01/08/2026 at 02:35 PM, R120 stated, I don't think I have any money here.Review of R96's EMR revealed R96 was admitted on [DATE]. Review of an undefined MDS revealed R96's BIMS score of 11 of 15, indicating moderate cognitive function.During an interview on 01/08/2026 at 02:35 PM, R96 stated, No, I do not receive any statements.A review of R101's facesheet revealed R101 was admitted to the facility on [DATE]. Review of an undefined MDS revealed R101's Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating intact cognitive function.During an interview on 01/08/2026 at 03:04 PM, R101 stated, I do not receive any quarterly statements for my account.During an interview on 01/08/2026 at 04:40 PM, the BOM stated, I do not have proof of the quarterly statements I sent. I do not keep a log of the quarterly statements that I send to the RR. I can start doing that.During an interview on 01/08/2026 at 04:55 PM, the Administrator stated, I anticipate going forward to keep a log of the quarterly statements, the date and time, and who they were sent to. I will have the field controller educate on the proper way to keep records. We will be educated by corporate.

Based on review of facility policy, record review, and interview, the facility failed to initiate a Significant Change of Status Minimum Data Set (MDS) to reflect Resident (R)88's election for Hospice Services, for 1 of 2 residents reviewed for Hospice.Findings include:Review of the facility policy titled Resident Assessment Instrument and Care Plan Development with a reviewed date of 08/29/25, documented, Procedure The Resident Assessment Instrument is composed of the MDS, Care Area Assessments, and Utilization Guidelines . 2. MDS assessments are completed at a minimum upon admission, quarterly, annually, and with a significant change in patient status . 4. The Care Area Process begins with the Care Area Triggers are completed with the admission MDS, annual MDS, and with a significant change in patient status assessment. 5. The Care Area Triggers are derived from the information coded on the MDS that identify patients who have or at risk for developing specific functional problems that require further assessment . 8. The information identified using the MDS and Care Area Assessment process is used to develop an individualize person-centered Care Plan .Review of the facility policy titled Area of Focus: Hospice with a reviewed date of 12/02/25, documented, What Hospice Care: means a comprehensive set of services . identified and coordinated by an interdisciplinary group (IDG) to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill resident . How . Accurate and thorough assessment of the resident is fundamental in determining the resident's need for hospice services. The resident must receive a comprehensive assessment to provide direction for the development of the resident's care plan to address the choices and preferences of the resident who is nearing the end of life.Review of CMS's RAI Version 3.0 Manual dated [DATE], documented, . An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or change hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election .Review of R88's Face Sheet revealed R88 was admitted to the facility on [DATE], with diagnoses including, but not limited to, Alzheimer's Disease, anxiety disorder, major depressive disorder, single episode, purulent endophthalmitis, bilateral, pseudobulbar affect, and gross hematuria.Review of R88's Annual MDS with an Assessment Reference Date (ARD) of 12/02/25 revealed R88 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating R88 had severe cognitive impairment. Further review of the MDS did not indicate that R88 was receiving Hospice Services.Review of R88's 06/15/24 Quarterly MDS, 09/12/24 Quarterly MDS, 12/09/24 Annual MDS, 03/05/25 Quarterly MDS, 06/04/25 Quarterly MDS, and 09/03/25 Quarterly MDS, did not indicate R88 was receiving Hospice Services.Review of R88's Physician Order revealed, Interim Hospice admit date : [DATE] DX: Alzheimer's disease Review of R88's Care Plan with a review start date of 12/04/25 and a completed date of 12/09/25, documented, The resident has a terminal prognosis and receives hospice services through Interim.Review of R88's Referral Order dated 07/29/24, revealed, .HOSPICE & PALLATIVE MEDICINE REFERRAL. Will refer to hospice to admit to case load if appropriate w/ Interim hospice.Review of R88's Hospice admission Consent & Election of Hospice Services dated 07/30/24, documented, the effective date of election was 07/30/24.During an interview on 01/08/26 at 9:31 AM, the MDS Director stated, When we are notified, we open a significant change MDS for the resident. If someone goes on Hospice today, we start significant change of status with a 14-day ARD. We streamline the process, we talk about it in a meeting with the IDT team, once the eval is completed social services lets me know by email or text, and we look for the order, and I get started on the MDS. That's probably one that got missed. I don't see it.During an interview on 01/08/26 at 9:42 AM, the Administrator and Director of Nursing (DON) stated there was a lack of communication during that time frame. But now we have a process in place that ensures that is done. Now it's a whole discussion whenever a resident goes on hospice.

Based on review of the facility policy, record review, observations, and staff interviews, the facility failed to identify, assess, and implement appropriate care-planned interventions to address 1 of 1 resident's known behavior of manipulating prescribed oxygen flow rates. This failure placed the resident at risk for receiving oxygen inconsistent with physician orders, and increased the risk for potential respiratory complications, including but not limited to oxygen toxicity or masking of changes in the resident's condition. Findings include:Record review of the Facility Policy titled, Oxygen Administration (Infection Control, Safety, & Storage last revised on 09/30/2025 and reviewed on 09/24/2024 revealed The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences, and 483.65 of this subpart.Record review of Resident (R)18's Face Sheet revealed that R18 was admitted to the facility on [DATE] with diagnoses including but not limited to congestive heart failure and chronic obstructive pulmonary disorder. Review of R18's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15, which indicates that she is cognitively intact. Further review of the admission MDS revealed that R18 receives Respiratory Therapy, as a special treatment. During a resident interview on 01/06/2026 at 10:41 AM, R18 stated that her Oxygen (O2) concentrator in her room is malfunctioning and the facility had to provide her with a portable tank. A portable tank was observed on the back of R18's wheelchair. Additionally, the control knob on the oxygen regulator of the portable tank was observed to be set at 3L (liters)/minute. R18 further complained that her tank ran out of O2 and no one realized it. She went on to explain that staff had to increase her O2 level to more than what she needed to get her back to a comfortable state.During a second interview with R18 on 01/07/2026 at 03:35 PM, R18 stated that her O2 level is at 3L and she prefers it that way. R18 further explained that her O2 Concentrator is working, but just does not feel as good as her portable tank. When R18 was advised that her O2 order was for 2L, R18 offered no further comment. Again, R18's oxygen rate was observed 3L/PM via a portable tank placed on the back of her wheelchair. Additionally, her O2 concentrator with a humidifier bottle (labeled 01/04/2026) was sitting by her bedside. During an interview on 01/07/2026 at 03:55 PM, Licensed Practical Nurse (LPN)4 stated the R18's oxygen level on her portable tank was set at 2L earlier in the day. When LPN4 was advised that the Liters Per Minute (LPM) was currently at 3LPM, LPN4 explained that she has attempted to explain to the resident that the prescribed O2 level is to be maintained per physician's order, but R18 has not cooperated and has remained non-compliant. Record review on 01/07/2026 at 04:23 PM of R18's Care Plan revealed two (2) respiratory-related care plans:1. The resident has an altered respiratory status/difficulty breathing related to CHRONIC RESPIRATORY FAILURE WITH HYPOXIA. The resident will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Administer medication/puffers as ordered. Maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions. Observe for changes in orientation, increased restlessness, anxiety, and air hunger.2. The resident has Emphysema/COPD. The resident will display optimal breathing patterns daily through review date. Avoid extremes of hot and cold. Give aerosol or bronchodilators as ordered. Observe for any side effects and effectiveness. Observe for difficulty breathing (Dyspnea) on exertion. Remind resident not to push beyond endurance. OXYGEN SETTINGS: O2 via n/c as ordered.Record review on 01/07/2026 at 04:36 PM revealed R18 had a Physician's Order dated 12/23/2025 for oxygen continuously at two liters per minute via nasal cannula. Record review on 01/08/2026 at 09:53 AM revealed R18 also had an order for Oxygen on an Order Summary Report-(Active Orders As of: 01/06/2026): Oxygen at 2 liters/minute continuously per nasal cannula. Document every shift. Order Date: 12/23/2025, Start Date: 12/23/2025, End Date: NONE.Record review on 01/08/2026 at approximately 09:54 AM revealed an updated order for Oxygen on an Order Summary Report-(Active Orders As of: 01/08/2026): Oxygen at 3 liters/minute continuously per nasal cannula. Document every shift. Order Date: 01/07/2026, Start Date: 01/07/2026, End Date: NONEDuring an interview with the Director of Nursing on 01/08/2026 at 01:37 PM, it was stated that her expectation is for Oxygen therapy to be provided according to physician's orders.

Based on review of the facility's policy, observations, interviews, and record review, the facility failed to ensure ostomy care was provided in accordance with professional standards, as no physician order for ostomy care was in place for 1 of 1 resident.Findings Include: Review of the policy titled, Colostomy and Ileostomy Care last revised on 09/20/2021 and reviewed on 09/04/2025 revealed on page 1 of 12 that, A physician's order will be obtained for ostomy care to include specific physician preference regarding appliance, skin barrier, and skin care. Record review of R129's Face Sheet revealed he was admitted on [DATE] with the diagnoses including but not limited to congestive heart failure, atrial fibrillation, dementia, insomnia, hyperlipidemia, colostomy, and need for assistance with personal care. Record review of R129's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/2026 revealed that R129 has the Brief Interview of Mental Status (BIMS) score of 12 out of 15, which indicates moderate cognitive impairment. Further review of the admission MDS revealed that R129 was admitted with an Ostomy Appliance under Section H of the Bladder and Bowel section. During an observation and interview on 01/07/2026 at 10:07 AM, R129 was observed lying in bed with no apparent distress. During a brief interview on 01/07/2026 at 10:08 AM, R129 stated that his ostomy was not understood and the staff member that attempted to change it did not know exactly how to manage it. During an interview on 01/07/2026 at approximately 01:30 PM with both Licensed Practical Nurse (LPN)4 and LPN3, R129's ostomy care was discussed. LPN4 stated that R129 is receiving ostomy care but was unable to locate an order. LPN3 further explained that R129's stool is very loose and that the ostomy appliance was leaking at the bottom.he will eat and then go fill it right up. Upon further discussion and an observation of LPN4 reviewing the chart, LPN4 stated, I don't see anything from Wound Care Nursing (WOCN) or an order for ostomy care.where is it? No, I don't see anything from wound care? When asked what type of supplies were used for R129's ostomy care, LPN4 stated that the facility uses their own supplies usually, but that most recently, she used his supplies that are in his drawer and the supplies he came with. During an interview on 01/08/2026 at 01:37 PM, the Director of Nursing (DON) was unable to verify a physician's order for ostomy care. The DON went on to explain, I'll make sure that order gets in. We have our own wound nurse here that I can have speak with you right away. During an interview on 01/08/2026 at approximately 01:39 PM with LPN5, the Wound Care Nurse (WOCN) stated that ostomy care is usually addressed when they do their rounds. The WOCN further stated, I don't see orders. Ostomy appliances are usually checked and changed every shift and/or changed on an as needed basis. When asked to walk through the admission and ostomy appliance care process, LPN4 (WOCN) stated that usually report is called into the receiving LPN, but the facility does not know definitively until the resident arrives at the facility. After arrival, orders are usually placed, as appropriate. Then ostomy care is provided based on the order that usually entails a good cleaning, skin prep, and then a wafer and bag. LPN4 (WOCN) went on to explain how it is changed once weekly depending on the type of bag system and checked every shift. LPN4 (WOCN) also stated, I am always open to teaching them. R129's Medication Administration Record/Treatment Administration Record (MAR/TAR) was initially reviewed and printed on [DATE] at 12:25:44 EST. It was dated from 1/1/26 to 1/31/26. It revealed only two (2) references to Ostomy care-No Ostomy Care indicated (OLD):Medical Condition: COLOSTOMY STATUS (Z93.3)Enhanced Barrier Precautions Diagnosis: Colostomy every shift -Order Date [1]01/07/2026 1603

Based on observations, record review, and interviews, the facility failed to provide proper supervision for Resident (R)97, resulting in R97 eloping from the facility. Specifically, a resident pulled a fire alarm, resulting in R97 evacuating the facility alone, without staff knowledge. This resulted in R97 falling, while in the facility's unsecured courtyard, and suffering a fractured clavical. On 12/19/24 at 12:45 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 10/05/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 12/19/24 at 5:00 PM, the facility provided an acceptable IJ Removal Plan. On 12/20/24, the survey team, validated the facility's corrective actions and removed the IJ, as of 12/20/24. The facility remained out of compliance at F689 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Recertification Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility policy titled Fire Procedures reviewed on April 2024, documented, Departmental Fire Procedures III. If Alarm Sounds from Elsewhere in Building: -close all doors in area. -remain in your area and await further instructions. If not in area, report back. -If with residents, remain with them and provide reassurance. -Account for all residents and staff in your area and be prepared to report results to Control Station. Review of R97's Face Sheet revealed R97 was admitted to the facility on [DATE], with diagnoses including but not limited to: metabolic encephalopathy, vascular dementia, unspecified severity, with mood disturbance, type 2 diabetes mellitus, unsteadiness on feet, history of falling, cognitive communication deficit. Review of R97's Physician Progress Notes dated 10/07/24, documented, Follow-up: Fall . Family at beside reports they were called by the facility where she is currently getting rehab to report she had an unwitnessed fall and they think she might have hit her head so they were sending her to the ED for evaluation . Pt had fall with significant bruising with pooling to L clavicle/ shoulder area. abnormality noted at time of exam. Will order stat xray to r/o fx . 1. Fall - Per nursing staff, s/p fall on 10/5 now with c/o Left shoulder/clavicle pain. Will order Xray 2 views Left Clavicle and Left shoulder to r/o fx post fall. Review of R97's Incidents Follow-up and Recommendation Form with an incident date of 10/05/24, documented, Summary of Investigative Facts: Resident became anxious during fire alarm and went into courtyard (locked) and layed [sic] on ground. Recommendations/Actions Taken: Resident offered non skid socks - xray obtained 10/7/24. Review of R97's Un-witnessed Fall document dated 10/05/24, documented, During a fire alarm this nurse noticed the resident lying on the ground on her left side with a blanket under her head as a pillow. Resident was dressed in pants, shirt, had on a clean dry brief with no socks or shoes. Review of R97's Trident Health Patient Visit Information dated 10/07/24, revealed, You were seen today for: Fracture of left clavicle. Collarbone Fracture received 10/07/24. Review of Accuweather.com revealed that on 10/05/24, the high was 80 degrees Fahrenheit and the low was 74 degrees Fahrenheit. During an interview on 12/17/24 at 11:17 AM, R97's Husband stated that R97 fell and fractured her shoulder the second night she was here, when she made it outside after the fire alarm went off. During an interview on 12/18/24 at 2:55 PM, Licensed Practical Nurse (LPN)3 revealed that a resident on another hall pulled the fire alarm which caused all the doors to be opened and the Certified Nursing Assistant (CNA) left the unit to go assist manning the doors on the Dayspring unit. LPN3 stated they left the unit to go to Dayspring to reset the fire alarm and once they returned to the unit, they were notified that R97 was not in their bed. LPN3 further stated that R97 was the only resident that went out during the alarm and that R97 was found outside in the courtyard, right off the unit, lying on the ground with her blanket under their head and the resident stated that they were trying to get away from the fire. During an interview on 12/19/24 at 9:16 AM, CNA1 stated that a resident on the Dayspring Unit pulled the fire alarm, and they had to leave the Pebble Creek unit to help man the doors on Daysprings. CNA1 stated that after they did their rounds on Daysprings they went back to Pebble Creek and the nurse left the unit to go turn off the alarm. CNA1 stated that it was possibly about 5 minutes before the nurse found the resident outside in the courtyard. CNA1 further revealed that they did not complete a head count on the Pebble Creek unit during the fire alarm. During an observation and interview on 12/19/24 at 9:52 AM, the Maintenance Director (MD), revealed the path used by R97 to evacuate the facility. R97 exited the facility through a secured door on the Pebble Creek Unit. The MD stated, when the fire alarm is activated, the doors are no longer secured. The door leads to a gated courtyard. Further observation revealed, two gates located to the left and right of the courtyard. Both gates were not secured. The MD stated the gates are never secured. During an interview on 12/19/24 at 8:53 AM, the MD revealed there are fire alarm pull stations next to the exit doors. The resident room doors as well as the hallway doors are three-hour fire doors. There is an employee stationed on every door. There is enough staff to man each door even at night. The MD stated all staff report to the location of the fire. All staff are assigned a job at this point. No staff member is preassigned a particular door to be stationed at. The MD further stated no one is going to fuss at the staff if they choose to evacuate the hall. They may choose to take the residents behind the fire doors, or they may choose to evacuate the residents outside the facility. The MD further stated, the only incident that I am aware of in October occurred on October 12, 2024 at 9:30 AM, when a resident pulled the pull station outside of room [ROOM NUMBER]. There have been no other Incidences in October. The MD concluded, I was not informed that a resident was found outside during this incident on 10/05/24. On 12/19/24 at 5:00 PM, the facility provided an acceptable IJ Removal Plan, which included the following: 1. How correction action will be accomplished for those residents found to have been affected by the deficient practice. On 10/5/2024 resident MR#209959 exited the facility unsupervised sustaining a fracture. The resident ambulated with the Charge Nurse back inside the facility denying any pain. On 10/5/2024, the Charge Nurse completed a skin assessment with no injuries or bruising. On 10/5/2024, an Incident Report and notifications were made to the family and MD. On 10/5/2024, a Fall risk evaluation was completed and the patient identified as a risk with a score of 16. The Executive Director, Director of Nursing and Interdisciplinary Team completed a Root Cause Analysis (RCA) on 12/19/2024. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice. On 10/5/2024, the Charge Nurses completed a head count for all patients inside the facility. All patients were accounted for. 3. What measure will be put into place or systemic changes made to ensure that the deficient practice will not recur? During the monthly PI committee meetings, the following will be reviewed: -The Executive Director and Maintenance Director will be responsible for ensuring compliance with supervision when drills/fire alarm sounds. -The Director of Nursing will be responsible for reviewing the Event Management System for trends and patterns. -The Staff Development Director will be responsible for reviewing the education completion of associations on: Departmental Fire Procedures policy, Incident and Reportable Event Management Policy, and Fall Management Policy. On 12/19/2024, the Regional Director of Clinical Services provided education to the Executive Director (ED) and the Director of Nursing (DON) on the following: Departmental Fire Procedures policy, Incident and Reportable Event Management Policy, and Fall Management Policy. The ED, DON, Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC) and/or licensed nurse will provide education to all facility staff on the following: Departmental Fire Procedures policy, Incident and Reportable Event Management Policy, Fall Management Policy. Any associate who has not completed training by 12/19/2024 will not be allowed to provide direct resident care until training is completed. The Executive Director (ED), Director of Nursing (DON), Staff Development Coordinator (SDC), and/or licensed nurse will provide education to all new associates upon hire during orientation. Medical Director reviewed and agreed with this plan of removal on 12/19/2024. AD Hoc QAPI meeting was held 12/19/2024 regarding this plan of removal. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The ED and/or Maintenance Director will complete fire drills weekly x8 weeks. The DON will review Event Management System for trends and patterns daily x8 weeks. Associate Education will be continued until all associates have been educated on Departmental Fire Procedures policy, Incident and Reportable Event Management Policy, and Fall Management Policy. 5. Date when corrective action will be completed. 12/20/2024

Based on the facility policy, observations and interviews, the facility failed to ensure expired, outdated or discontinued medications were removed and not stored with resident medications in use in 3 of 5 medication carts and 1 of 1 treatment carts. The facility additionally failed to ensure a medication cart was locked, and medications were not left on top of the med cart unattended on Morning Star Unit, medication cart #2. Findings include: Review of the facility policy titled, Drug Storage Guide, states under, Medication Cart Check, The MAR/EMR are covered when unattended. The medication care is locked when unattended. Expired controlled substances are not present. The drug storage guide did not include expired medications and biologicals, or medications unsecured and on the top of the med cart. The facility's drug storage guide did not mention the storing of discontinued medications in the medication cart. An observation on 12/17/2024 at 10:32 AM of the medication cart 2 on the Dayspring Unit revealed: Risperidone 1 milligam (mg), 20 tabs with Lot #8198-4007 were discontinued and stored on the medication cart. Acetaminophen 325 mg with Lot#J074J, Manufactured by Timely, 6 tablets were expired on 07/30/2024. The stored and expired medications were verified by Licensed Practical Nurse (LPN)1 and removed from storage. An observation on 12/19/2024 at 10:40 AM of the Meadow Ridge medication cart 2 revealed: Elder Tonic Lot# 20709 16 fluid ounces was expired on 07/2024. The expired medication was verified by LPN5 and removed from storage. An observation on 12/19/2024 at 10:50 AM of the Meadow Ridge treatment cart revealed: One tube, 20 ounces of Hemorrhoidal Ointment, manufactured by SunMark had expired on 11/20/2024. The expiration date was confirmed by LPN1 and the medication was removed from storage. An observation on 12/19/2024 at 11:10 AM of the Rosewood medication cart 1 revealed: Vitamin E 180 mgs with Lot #752W01 was expired on 11/2024. The expired medication was confirmed and removed from storage by Registered Nurse (RN)1. Oxycodone 5 mgs with Lot#18202A, 26 tablets were discontinued and stored on the medication cart. These stored narcotics were confirmed by RN1 and removed from storage on the medication cart. An observation on 12/19/2024 at 11:24 AM of the Morning Star Unit revealed a medication cart 2 in the hallway unlocked and unattended with a stack of a resident's medication blister packs, which contained pills lying on the top of the cart. The computer screen was open to a resident's private information. The nurse was in a resident's room, doors down from the cart. During an interview on 12/19/2024 at 11:26 AM, LPN6 confirmed the findings and stated that she had just walked away from the cart leaving the cart unlocked, medications on top and the computer screen open to a resident's private information.

Based on observation, staff interviews, and a review of facility dietary policies, the facility failed to ensure proper sanitization of kitchen equipment, failed to discard expired foods past use by date in 1 of 1 main cooler, and failed to label and date open items in 1 of 1 freezer. These deficiencies could potentially affect 119 residents who reside in the facility and who consume food from the kitchen. Additionally, the facility failed to ensure Certified Nursing Assistants (CNA) properly sanitized their hands during meal service. The findings include: A review of facility policy titled Use by Date Guide states:Life Care may require s shorter time frame on a food item to reduce the number of items under refrigeration. For Example, the food code indicates that leftovers may be kept up to 7 days, however, Life Care guidelines are for 3 days (72 hours). A review of facility policy titled Food Safety with a revision date of [DATE] states: Page 5, Leftovers are dated properly and discarded after 74 hours unless otherwise indicated. A review of the facility policy titled Cleaning Schedule with a revision date of [DATE] states: The Director of Food and Nutrition Services develops a cleaning schedule to include all equipment and areas to be cleaned. Designated Cleaning tasks are assigned to each position. The Director of Food and Nutrition Services monitors the cleaning schedule to ensure the tasks are completed timely and appropriate. Initial walk-through of the facility kitchen on [DATE] at 10:45 AM alongside the Dietary Manager (DM) confirmed the findings below: Cooler: Two (2), 4-inch-deep stainless steel quarter pans, 1 containing Puree eggs with no preparation date, handwritten use by date [DATE]. The second pan contained Puree bread with no preparation date, a handwritten use by date of [DATE]. Freezer: Two (2) 18x24 pans of frozen dough, 95 frozen rolls, not in original packaging, with no open date, or use-by date. An observation of the facility's industrial stove revealed a heavy accumulation of old food/grease debris was observed on the side and backsplash of the stove. There was an accumulation of grime observed around the knobs and along the front side of the stove. An observation of a full-height 2-door heated hotbox being opened by the Dietary [NAME] revealed dry yellow and brown grease drippings on both interior doors. There was also an accumulation of liquid stains and build-up surrounding the knobs on the tray line. The deep fryer's side panel had a heavy accumulation of old grease mixed with crumbs observed on the side and backsplash of the stove. 7 out of 14 fans, located in the kitchen ceiling had dust buildup surrounding it. A follow up walk-through of the facility kitchen on [DATE] at 11:33 AM and [DATE] at 12:50 PM revealed the equipment was in the same condition. An interview with the Dietary Manager (DM) on [DATE] at 11:04 AM stated Her expectation is for all staff to look at the items in coolers and ensure all items that are expired or close to expiration are thrown out. DM stated Her expectation is for all staff who are responsible for dating leftovers to accurately fill out the stickers. DM states it is everybody's responsibility to look. DM states main cooking methods are deep fryers, stoves, and ovens. Cleanings are daily, after each meal. She states deep cleans are done weekly, which includes breaking down equipment. DM states she utilizes a cleaning sheet that breaks down by item, who is to clean it, and the staff member is to initial when done. DM states she goes behind every staff member to ensure cleanliness. DM confirmed the findings and stated the floor tech is responsible for wiping ceiling fans down once a month. DM also stated she can't remember the last time he cleaned the ceiling fans. DM stated she was unable to provide documentation related to cleaning logs. An interview with the Director of Nursing (DON) on [DATE] at 1:00 PM revealed she expects to have no expired food in the kitchen and for dietary staff to be deep cleaning and wiping down kitchen equipment. DON stated The kitchen staff should be auditing that stuff like we have to do medicines. The Registered Dietician completes mock surveys, so it's surprising to me. 47075 Findings include: Review of the facility's policy Hand Hygiene, revised [DATE] showed Procedure: 2. Associates perform hand hygiene (even if gloves are used) in the following situations. a. Before and after contact with a resident; c. After contact with objects and surfaces in the resident's environment; During a dining observation on the Pebble Creek unit on [DATE] at 12:09 PM, Licensed Practical Nurse (LPN)7 came from behind the desk and pulled a tray from the food cart without performing proper hand hygiene. LPN7 placed the tray on top of the food cart. While speaking with a resident representative, LPN7 touched her face, the hand rail, and her hair before removing the tray from the top of the food cart and putting the tray back inside the cart. During further observation on [DATE] at 12:12 PM, LPN3 was observed pulling the food cart down hall to room [ROOM NUMBER] while touching her hair. She then opened the food cart and pulled another tray from the cart and took the tray to a resident room and placed the tray on the resident's overbed table, all without using proper hand hygiene before or after entering room [ROOM NUMBER]. She then came back out and pulled the cart to room [ROOM NUMBER]. LPN7 continued to pull trays from the food cart and enter and exit rooms 50 at 12:14 PM, then room [ROOM NUMBER], then room [ROOM NUMBER] at 12:15 PM and room [ROOM NUMBER], setting up resident trays without performing proper hand hygiene. During an interview on [DATE] at 12:18 PM with LPN7 revealed that while serving dining trays she should wash hands before serving residents and not touch the resident's food. LPN7 further revealed that she should sanitize her hands between serving each resident. During an interview on [DATE] at 3:05 PM with the Infection Preventionist (IP), LPN3 revealed that the facility has a policy regarding hand hygiene and training is done annually at the skills fair. LPN3 explains that performance improvement -hand hygiene has been part of facility in-services are done as well. Hand hygiene is done annually and as part of our performance improvements. CNA hand hygiene when passing trays are as follows: wash hands before taking tray off cart, sanitizing between patients CNA should sanitize before she gets each tray out and between each resident. 49818

Based on the facility policy, observations, and interviews, the facility failed to ensure the proper priming of insulin pens, and correct administration on insulin via an insulin pen, therefore could not ensure 3 of 3 residents (R) received the correct dosage of insulin. Findings include: Review of the facility policy titled Insulin Pen Administration, revised 08/30/2023 and reviewed 09/17/2024, states: Policy: The facility will ensure residents with orders for insulin administration through the use of a pen delivery device is performed in accordance with current standards or practice with manufacturer's guidance. Procedure: 4. The insulin pen should be primed prior to each use (in accordance with manufacturer's guidelines) to prevent the collection of air in the insulin reservoir. a. General guidance for priming an insulin pen in the absence of manufacturer's guidance; i. Dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat the procedure until at least one drop appears. 6. To verify that all insulin is injected, keep the pen needle in the subcutaneous fat layer for 6 to 10 seconds after the injection with the thumb remaining on the push button plunger. An observation during med pass on 12/18/2024 at 08:20 AM for R39 revealed Licensed Practical Nurse (LPN)1 administering 10 units of Glargine Insulin without first priming the insulin pen. During an interview on 12/18/2024 at 08:30 AM, LPN1 confirmed that she did not prime the insulin pen and stated that she was not aware that she needed to prime the insulin pen. LPN1 could not confirm that R39 received the correct dosage of insulin. An observation on 12/18/2024 at 09:25 AM of the administration of Glargine Insulin revealed LPN2 priming the pen holding it horizontal with the needle cap on the the pen. LPN2 then administered the ordered 23 units of insulin for R8. During an interview, LPN2 confirmed that she had primed the insulin pen horizontally with the needle cap still on the pen and could not confirm that R8 received the correct dosage of insulin. An observation on 12/19/2024 at 08:06 AM revealed LPN3 preparing to give R1 Glargine Insulin via a flex pen. LPN3 held the pen horizontally and with the needle cap still applied and attempted to prime the pen. LPN3 then proceeded to administer the insulin after preparing the site for the injection LPN3 stuck the needle in and pushed the plunger and immediately removed the needle. During an interview with LPN3, she confirmed the observations and could not ensure that R1 had received the correct dosage of insulin.

Based on the facility policy, observations and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent to include 4 of out 26 opportunities for error. The facility additionally failed to ensure an ordered medication for Resident (R)39 was administered timely. The medication administration error rate is 15.38 percent. Findings include: Review of the facility policy titled, Insulin Pen Administration, revised 08/30/2023 and reviewed 09/17/2024, states: Policy: The facility will ensure residents with orders for insulin administration through the use of a pen delivery device is performed in accordance with current standards or practice with manufacturer's guidance. Procedure: 4. The insulin pen should be primed prior to each use (in accordance with manufacturer's guidelines) to prevent the collection of air in the insulin reservoir. a. General guidance for priming an insulin pen in the absence of manufacturer's guidance; i. Dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat the procedure until at least one drop appears. 6. To verify that all insulin is injected, keep the pen needle in the subcutaneous fat layer for 6 to 10 seconds after the injection with the thumb remaining on the push button plunger. An observation during med pass on 12/18/2024 at 08:20 AM for R39 revealed Licensed Practical Nurse (LPN)1 administering 10 units of Glargine Insulin without first priming the insulin pen. LPN1 also failed to administer Sertraline 100 milligrams (mg) at 9:00 AM medication by mouth. During an interview on 12/18/2024 at 08:30 AM, LPN1 confirmed that she did not prime the insulin pen and stated that she was not aware that she needed to prime the insulin pen. LPN1 also stated that the Sertraline 100 milligrams was not in the med cart with R39's other AM medications, so she would have to order the medication from the pharmacy. She stated that if she ordered the medication before 5:00 PM, the medication would be delivered from the pharmacy later today. Review of the Medication Administration Record (MAR) revealed, the Sertraline was not given for 12/18/2024 at 09:00 AM. During an interview on 12/19/2024 at 11:45 AM, the Director of Nursing (DON) confirmed that the ordered Sertraline 100 milligrams was in the facility pyxis and should have been given on 12/18/2024 and on time. An observation on 12/18/2024 at 09:25 AM of the administration of Glargine Insulin revealed LPN2 priming the pen holding it horizontal with the needle cap on the the pen. LPN2 then administered the ordered 23 units of insulin for R8. LPN2 confirmed that she had primed the insulin pen horizontally with the needle cap still on the pen. An observation on 12/19/2024 at revealed at 08:06 AM, LPN3 was preparing to give R1, Glargine Insulin via a flex pen. LPN3 held the pen horizontally and with the needle cap still applied attempted to prime the pen. LPN3 then proceeded to administer the insulin. LPN3 prepared the resident's site for the injection then stuck the needle in and pushed the plunger and immediately removed the needle. During an interview with LPN3, she confirmed that she had primed the pen horizontally with the cap on the pen and then after administering the insulin removed the needle quickly, and stated she should have held it in place for at least 10 seconds. She could not confirm that R1 had received the correct dose of insulin.

Based on the facility policy, observations, record reviews and interviews, the facility failed to maintain dignity for Resident (R)39 during the administration of an insulin injection for 1 of 3 residents observed receiving an insulin injection. Findings include: Review of the facility policy titled, Dignity, issued 05/06/2019 and reviewed 09/26/2024 states: Policy, Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as, honor and value their input. Respect and Dignity. The resident has a right to be treated with respect and dignity. The facility admitted R39 on 10/08/2024 with diagnoses including, but not limited to diabetes mellitus type 2 without complications, morbid obesity, and long term use of insulin. During an observation on 12/18/2024 at 08:00 AM of insulin administration for R39, Licensed Practical Nurse (LPN)1 assisted R39 onto the bed. R39 was wearing a dress, socks, and a brief. She kept asking for a blanket to cover herself with. The room door was open and her roommate was sitting at the doorway, facing the resident on the bed. LPN1 did not provide a blanket or privacy. LPN1 pulled up R39's dress, unfastened her brief, and injected the insulin into her abdomen. The nurse then refastened R39's brief, and pulled her dress down, still not providing a blanket for R39 or a top cover for R39. During an interview on 12/18/2024 at 08:07 AM with LPN1, she confirmed that she had not provided privacy and maintained dignity for R39 during the insulin injection.

Based on review of facility policy, record review and interviews, the facility failed to prevent accidents/hazards for 1 of 3 Residents (R)1 reviewed. Specifically, on 8/30/23, R1 had a successful elopement from the facility. R1 was placed at an increased risk of serious harm with the potential of being struck by a vehicle and/or suffering a heat related illness. On 08/31/23 at 3:35 PM the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 08/31/23 at 3:35 PM, the Administrator was notified that the failure to protect Resident (R)1 from having a successful elopement from the facility constituted Immediate Jeopardy (IJ) at F689. On 08/31/23 at 3:35 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 08/30/23. The IJ was related to 42 CFR 483.25 Quality of Care. On 09/01/23 at 11:23 AM, the facility provided an acceptable IJ Removal Plan. On 09/01/23 at 11:23 AM, the facility provided an acceptable IJ Removal Plan. On 09/01/23, the survey team, validated the facility's corrective actions and determined the facility made good faith attempts at correcting the non-compliance before the start of the survey. The IJ is considered at Past Non-Compliance as of 08/31/23. The survey team concluded all corrective actions were put into place prior to their arrival onsite. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility policy titled Unsafe Wandering and Elopement Prevention with a reviewed date of 09/29/22 revealed, The facility will ensure that residents are assessed to determine risk for elopement in accordance with current standards and implement interventions as appropriate to mitigate the risks identified. Definitions. Elopement- this occurs when a resident leaves the premises or a safe area without authorization (i.e., and order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential too experience) heart or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Unsafe wandering - It can be associated with an increased risk for falls and injuries. Wandering may become unsafe when a resident becomes overly tired or enters and area that is physically hazardous or that contains potential safety hazards (e.g., chemicals, tools, and equipment, etc.) entering into another resident's room may led to an altercation or contact with hazardous items. Wandering if random or repetitive locomotion. This movement may be goal-directed (e.g., the person appears to be searching for something such as an exit0or [sic] may be non-goal-directed or aimless. Review of the facility policy titled Missing Residents/Actual Elopement Event with a revised date of 04/05/23 revealed, It is the responsibility of all associates to report any resident who is suspected of being missing to the nurse manager immediately. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to dementia, coronary artery disease, cardiovascular accident/transient ischemic attack, hypertension, diabetes mellitus and hyperlipidemia. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/09/23 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 5 out of 15, which indicated R1 has severe cognitive impairment. Review of R1's Elopement assessment dated [DATE] and 06/23/23, revealed R1 was not at risk for wandering and elopement. Review of a facility statement dated 08/30/23 revealed, Registered Nurse (RN)1 stated R1 had been out of her room in the day room at 11:30 PM and came to the nursing desk at 12:15 AM because of nausea. R1 sat at the nursing station with another resident for approximately 30-45 minutes and around 1:30 AM I pushed her back to her room. R1 came out of room again at approximately 2:30 AM, back to the day room and I pushed her back to her room. RN1 stated she last saw R1 around 4:30 AM in dayroom. RN1 further stated while doing my final rounds and checking blood sugars she went into R1's room and she was not in her room or bathroom. RN1 rechecked the day room and went through all rooms and bathrooms on Morning Star and Day Spring units and still could not find R1. All other units came to assist with the search. RN1 concluded she went outside the perimeter of the facility and noticed R1 was in the parking lot and returned R1 to the unit. A body assessment was conducted with no injuries. Review of a facility statement dated 08/30/23, revealed Certified Nursing Assistant (CNA)1 stated R1 was in tv room around 2:00 AM and went to nursing station. I went on break at 2:30 AM and nurse had pushed her back to her room. The resident self-propelled herself back to day room around 4:30 AM, nurse was looking for resident and unable to locate on Morning Star or Dayspring. R1 was found sitting in parking lot at around 5:00 AM and returned to facility. Review of a facility statement dated 08/30/23, revealed CNA2 stated I saw [R1] last at 2:40 AM at nursing station before I started doing rounds. [R1] had been alternating between watching TV in day room and the nursing station since 12:30 am. During an interview on 08/31/23 at 10:30 AM, the Administrator stated R1 was a resident on the Morning Star unit and was last seen at approximately 4:30 AM in the Morning Star Day Room across from the nursing station. R1 was found in the parking lot near the main entrance in her wheelchair at approximately 4:50 AM and had been outside approximately 20 minutes. The Administrator further stated R1 passed through the main hallway into the Lobby and exited through the front door which will open when pushed because it is an egress door. It was a warm night and it was not raining. During an interview on 08/31/23 at 11:12 AM, the Director of Nursing (DON) stated R1 had been on the dementia unit and had been transferred to the Morning Star unit several months ago because the other residents on the dementia unit were bothering her. The DON further stated R1 was last assessed for elopement risk on 06/23/23 and found not to be at risk for elopement. During a follow up interview on 08/31/23 at 11:33 AM, the Administrator stated there is no video footage since the system does not work. The Administrator further stated R1 had recently been started on Trulicity once a week and staff and her daughter had noticed some changes in her behavior and nausea. During an interview on 08/31/23 at 2:52 PM, the Maintenance Director (MD) stated the front entrance door through which R1 eloped does not presently signal elsewhere in the facility when it is opened. On 08/31/23, attempts were made to contact the Resident Representative, Licensed Practical Nurse (LPN)1, Certified Nursing Assistant (CNA)1 and CNA2 with no success. The facility's Removal Plan for included the following: Life Care Center of [NAME] takes quality assurance and quality control very seriously. It is extremely important that we provide a safe, clean environment for our residents, family members, staff, and the community we serve. On August 30, 2023, Life Care Center of [NAME] notified DHEC of an event pertaining to the elopement of resident # I (MR#206990). Immediate risk mitigation started with a Root Cause Analysis (RCA) which was completed the same day, August 30, 2023. l. On 8/30/23, resident# l (MR #206990) was assisted back into the facility by a licensed nurse. A skin assessment, pain assessment, and an elopement risk assessment were completed by a licensed nurse and no injuries were noted. Resident was placed on l: l supervision by a licensed nurse. A licensed nurse completed an event management report. A licensed nurse notified the physician, responsible party, Director of Nursing and Executive Director. A licensed nurse reviewed and updated resident #1 'scare plan and Kardex. Resident was placed on the secure unit and assessed by the attending physician. New medication orders were received. 2. On 8/30/23, The Executive Director reported the incident to the Medical Director, SC DHEC, and the Tri-County Regional Ombudsman. 3. On 8/30/23, a licensed nurse completed head count of all residents and all residents were in facility. A licensed nurse completed elopement risk assessments for all residents and updated all care plans and Kardex's for residents identified at risk for elopement. A licensed nurse updated At Risk for Elopement notebooks. The At Risk for Elopement notebooks were placed at the nurse's stations and the reception desk. The Director of Nursing also placed signage for awareness of exit seeking residents at nurses' stations and reception desk. 4. On 8/30/23, the Interdisciplinary team completed a Root Cause Analysis (RCA) on the elopement to re-evaluate the systemic approached to resident elopement. 5. On 8/30/23, the Maintenance Director ensured the front door was secured/locked and will remain secured unless receptionist or staff is present. 6. On 8/30/23 , the Director of Nursing (DON), Assistant Director of Nursing (ADON), Director of Rehab (DOR) and/or Infection Preventionist (IP) nurse-initiated education to all associates on: Abuse Policies Unsafe Wandering and Elopement Prevention Missing Residents/Actual Elopement Event Resident Assessment Instrument and Care Plan Any Associate that did not complete training on 8/30/23, will receive training before working their next shift. 7. On 8/30/23, the Maintenance Director conducted an elopement drill and provided educational overview for the participants. The Maintenance Director will conduct Elopement Drills monthly for three months. Results will be presented by the Director of Maintenance to the monthly QAPI committee. Then resume to quarterly schedule. 8. A licensed nurse will review elopement risk assessment (UDA's) to ensure residents at risk for elopement are appropriately care planned and a picture is placed in elopement notebooks. This will be completed 5 times/week for 4 weeks, 3 times /week for 4 weeks and 1 time/week for 4 weeks. Results will be presented by the DON to the monthly QAPI (Quality Assurance and Performance Improvement) committee for 3 months. QAPI committee members may make recommendations as appropriate for changes to managing this clinical system. All corrective actions were completed on 8/30/23. The facility alleges compliance on 8/31/23 as a past noncompliance immediate jeopardy. Timeline of events: 01/27 /22 Resident #206990 (R1) admitted to facility on the rehab unit. Her admitting diagnoses include: Metabolic Encephalopathy, CVA with left-sided hemiparesis/hemiplegia, and DM 03/04/22 Resident (R1) became long term care and moved to secured unit. 04/07/22 Family concerned of resident's (R1) decline being on the secured unit. She was then moved to Morning Star, a unit that is not secured. Elopement assessments indicated she was not an elopement risk. Resident thrived on Morning Star, moving freely around the unit, to the dayroom, to the dining room, etc. Never any issues. 08/15/23 New order for Trulicity to be administered every Tuesday. 08/30/23 Third dose of Trulicity administered at approx. 1600. 08/29/23 2300 Shift began. CNA 1 reports resident in her bed. 2300 Nurse (LPN 1) states resident sitting in dayroom. 08/30/23 0015 Nurse (Licensed Practical Nurse 1)states resident propelled herself to the nurse's station and c/o nausea, suspected cause was the Trulicity injection. She sat at the nurse's station for a period of time (unsure how long). 0030 CNA (Certified Nursing Assistant) 1 saw resident transfer herself out of bed. She then alternated between sitting in the dayroom/watching tv/propelling back and forth to her room. 0200 CNA 2 saw resident between nurse's station and dayroom. 0230 CNA 2 states she saw resident rolling herself into dayroom. Nurse (LPN 1) pushed resident back to her room. 0240 CNA 1 states resident noticed at the nurse's station when she was about to begin her last round of the shift. 0430 Nurse (LPN 1) making rounds and checking blood sugars. Noticed resident wasn't in her room . (Resident is a diabetic and needed blood sugar checked.) CNA 2 believes she saw resident propel herself to the dayroom at approximately this time. 0430 Search for resident began on Morning Star and Dayspring (these two units are near one another) 0500 Resident (R1) found sitting in w/c in parking lot. Registered Nurse (LPN 1) asked resident what she was doing and she stated she was looking for her medicine. Registered nurse (LPN 1) immediately returned resident to her unit. Body audit, pain assessment and incident report completed. Facility provider/ED (Executive Director)/DON/ADON (Assisteant Director of Nursing) notified. 0800 ED completed Reportable 0900 Facility provider assessed resident as soon as she arrived to facility. Provider states in her note resident has no recollection of the incident earlier in the morning. Vital signs within normal limits at time of evaluation. Resident (R1) states to provider that she feel nauseous. Provider suspects the Trulicity is causing this and order is discontinued. 0900 ED spoke with resident's RP (Resident Representative) and it was agreed resident should be on secured unit for her safety. Move not made immediately because waiting on other resident to discharge. 1300 Resident (R1) moved to room on secured unit. 08/31/23 Facility provider ordered CBC (complete blood count), CMP (comprehensive metabolic panel), U/A (urinalysis) C&S (culture and sensitivity) r/t (related to) resident with increased confusion.

Based on observations, interviews, and facility policy review, the facility failed to ensure that food was protected from contamination during delivery to resident rooms. Specifically, the facility failed to ensure that food was covered during delivery to 1 (Morning Star Unit) of 3 nursing units. This deficient practice has the potential to affect 31 residents who occasionally or regularly ate in their rooms on the Morning Star Unit. Findings include: A review of the facility policy, Resident Dining Services, revised 04/26/2023, revealed, When meals are assembled in the kitchen and then delivered to residents' rooms or dining areas to be distributed, covering foods is appropriate, either individually or in a mobile food cart. The policy further indicated, Flatware will be wrapped, and food, desserts, salads, and beverages will be covered before transported throughout the facility. Observation of the lunch meal service on 05/08/2023 at 1:02 PM, revealed the covered meal tray delivery cart parked near the Morning Star Unit nursing station. Certified Nursing Assistant (CNA)1 removed a resident's meal tray from the covered cart and delivered the meal tray with the uncovered cornbread muffin past seven resident rooms to room [ROOM NUMBER], which was approximately 80 feet from the covered meal tray delivery cart. Observation on 05/08/2023 at 1:05 PM, revealed an uneaten resident meal tray sat on top of the nursing station, with the uncovered cornbread muffin. At 1:13 PM, a CNA returned a dirty meal tray and placed it on the nursing station, approximately two feet away from the uneaten meal tray. The CNA then took another resident meal tray down the hall and left the uneaten meal tray at the nursing station. At 1:14 PM, CNA4 took the uneaten meal tray from the nursing station and delivered it past seven resident rooms to room [ROOM NUMBER], which was approximately 80 feet from the nursing station. Observation of the lunch meal service on 05/09/2023 at 12:38 PM, revealed the covered meal tray delivery cart parked at the Morning Star Unit nursing station. At 12:39 PM, Licensed Practical Nurse (LPN)7 removed Resident (R)21's meal tray from the covered cart. The cheesecake dessert was uncovered on the tray. LPN7 set the tray on the nursing station and went to get ice and beverages for the tray. At 12:41 PM, LPN7 took the tray past four resident rooms, the shower room, and the physical therapy gym to R21's room, which was approximately 90 feet from the nursing station. Observations on 05/09/2023 at 12:42 PM revealed CNA5 removed a resident's meal tray from the covered cart and walked down the hall with the uncovered dessert. CNA5 delivered the tray past seven resident rooms to room [ROOM NUMBER], which was approximately 80 feet from the nursing station. In an interview on 05/09/2023 at 12:44 PM, CNA5 stated that the covered meal tray cart kept the food warm and protected the food from germs. CNA5 stated when a meal tray was removed from the covered cart and walked down the hall with items uncovered the food was exposed to germs. CNA5 stated the staff were supposed to roll the covered cart down the hall to the resident rooms. In an interview on 05/09/2023 at 12:52 PM, CNA4 stated the purpose of the covered meal tray delivery cart was to keep the food warm and protected from germs. CNA4 stated if staff took the food out uncovered, the food would get cold and be exposed to germs. CNA4 stated the staff were supposed to roll the cart down the hallway to each resident room as the staff delivered the residents' meal trays. In an interview on 05/09/2023 at 12:55 PM, CNA6 stated that if something was uncovered on the tray, the staff should cover it before the food item was removed from the cart. In an interview on 05/09/2023 at 2:42 PM, LPN7 stated she had noticed the dessert was uncovered when she delivered the tray to R21 after she was already down the hall with the tray. LPN7 stated the food should be covered so that it was kept warm and protected it from germs. In an interview on 05/09/2023 at 2:47 PM, the Certified Dietary Manager (CDM) stated the staff should take the cart down the hall to the individual residents' rooms, and not leave the cart parked at the nursing station. In an interview on 05/09/2023 at 2:58 PM, the Registered Dietitian (RD) stated he sometimes observed the meal delivery process. The RD stated he expected carts to be taken down the hall to each room and the meal tray to be taken directly from the cart into the resident room. The RD stated staff should not leave the cart at the nursing station and carry uncovered food down the hall. In an interview on 05/09/2023 at 3:09 PM, the Executive Director (ED) stated she expected staff to follow proper infection control protocol when food was delivered to resident rooms. The ED stated the facility was going to start ensuring all items on the meal tray was individually covered. Per the ED, the staff would be in-serviced to take the meal tray delivery cart down the hall to the resident room before the meal tray was removed from the cart. In an interview on 05/09/2023 at 3:27 PM, the Director of Nursing stated she expected the food to be covered when it was delivered to the resident's room.

Based on record review, document review, facility policy review, and interviews, the facility failed to timely report an allegation of abuse for 1 (Resident (R)217) of 1 resident reviewed for abuse. Findings include: Review of the policy, Abuse-Reporting and Response - Suspicion of a Crime, dated 10/04/2022, indicated, Policy - The facility will ensure reporting reasonable suspicion of crimes against a resident or individual receiving care from the facility within prescribed timeframes to the appropriate entities, consistent with Section 1150B of the Elder Justice Act. The policy specified, Each covered individual shall repot immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. A review of R217's Admission Record revealed the facility admitted the resident on 04/26/23 with diagnoses to include fracture of the upper and lower end of the left fibula, displaced comminuted fracture of the shaft of the right tibia, fractures of the lower end of the left radius, fractures of the lower end of the right radius, type III traumatic spondylolisthesis of the second cervical vertebra, displaced fracture of the seventh cervical vertebra, and multiple fractures of the ribs, bilaterally. Review of the admission Minimum Data Set with an Assessment Reference Date of 04/28/23, revealed R217 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. During an interview on 05/08/23 at 10:21 AM, the family member of R217 stated the nurse who had taken care of the resident on 05/05/23 at night refused to crush the resident's medication, and the certified nursing assistant (CNA) picked up the resident's leg to reposition it and dropped the resident's leg on the bed. The family member stated they wanted to talk with the Executive Director (ED). On 05/08/23 at 10:43 AM, R217's family member shared with the ED, in the presence of the surveyor, that on the night of 05/05/23, the nurse refused to crush R217's medication and the CNA, the same night, picked up the resident's leg and dropped it. During a telephone interview on 05/08/23 at 3:50 PM, Licensed Practical Nurse (LPN)10 stated R217 did mention to her about the medications and their leg incident to her on Saturday 05/06/23. LPN10 stated she wrote a statement, left it for management, and informed the manager on duty, the Activities Director (AD). Review of the MOD [Manager on Duty] Report for 05/06/23, revealed R217 verbalized a concern that the night nurse refused to crush their medication, and the night CNA lifted their broken leg and dropped it to the bed. During an interview on 05/08/23 at 4:01 PM, the ED stated the facility had not done a two-hour report because in conversation with staff, the facility did not see any intent to harm the resident. During an interview with the AD on 05/09/23 at 7:45 AM, she stated she was the manager on duty on 05/06/23. She had talked to the nurse on day shift and the nurse stated something happened the night of 05/05/23 with R217, and the resident wanted to talk to the manager on duty about the concern. The AD then stated R217 informed her that the night nurse refused to crush their medication, and the CNA picked up their leg and dropped it on the bed. The AD stated she telephoned the Director of Nursing (DON) and the ED because what had happened was not okay. In an interview on 05/09/23 at 2:18 PM, the ED stated she only heard that a resident reported they did not receive their medication as they wanted it. During an interview with the DON on 05/09/23 at 3:10 PM, she stated the AD had called her on Saturday, 05/06/23 and said there was a concern about a resident's medication not being crushed. She stated she did not remember hearing about the resident's leg being dropped. Per the DON, she told the AD to notify the ED and the matter would be addressed when she and the ED returned to work on Monday, 05/08/23. In a follow-up interview with the ED on 05/10/23 at 11:50 AM, she stated the allegation should have been reported within two hours of when the allegation was told to her. A review of the Initial 2/24-Hour Report, dated 05/08/23, indicated on 05/05/23 during the 11:00 PM - 7:00 AM shift, R217 reported LPN11 refused to crush their medications per the resident's request and CNA8 dropped the resident's leg during care and caused the resident pain. Per the report, staff involved were immediately suspended, witness statements were obtained, and the police were notified. The report further indicated the state agency was notified of the allegation of physical and mental abuse on 05/08/23 at 5:13 PM, greater than two hours after the facility became aware of the allegation.

Based on observation, record review, interview, and review of the facility's policies entitled Hand Hygiene and Cleaning and Disinfection of Non-Critical Patient Care equipment, the facility failed to ensure staff performed proper hand hygiene before and after resident care for 2 (two) of 2 (two) residents (Residents #1 and #2.); cleaned community equipment before and after use for 2 (two) of 2 (two) residents (Residents #1 and #2.); and maintained social distancing of residents during a meal service for 8 (eight) of 8 (eight) residents (Resident #1 and 7 unsampled residents.) The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's latest Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was not conducted as the resident was rarely/never understood. She required extensive assistance with Activities of Daily Living (ADL's). Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was diagnosed with [REDACTED]. The resident's latest MDS dated [DATE] revealed the resident had a BIMS of 99 which indicated she was moderately cognitively impaired. She required extensive assistance with ADL's. During an observation of the evening meal on 9/22/20 at 5:00 pm, on the locked unit's dining room, 8 (eight) residents were present in the small room with a bed side table in front of each of them. Social distancing was not practiced and residents were less than 6 (six) feet apart. On 9/22/20 at 5:15 pm, during an interview with CNA #1, she stated she was aware the residents in the dining area were not social distanced at least 6 feet apart. She also stated she had received education on social distancing. During the same observation, Certified Nurse Assistant (CNA) #1 was observed taking a blood pressure for Resident #1 in the far back left corner of the room. The blood pressure cuff was observed on the resident's right wrist area. When the procedure was completed, without cleaning the cuff, the CNA placed the cuff into a blue bag on the resident's bed side table and obtained a no-touch thermometer. The CNA checked the resident's temperature. The thermometer was then placed into the blue bag without being cleaned. Without sanitizing her hands or the resident's bed side table, the CNA retrieved the bag and left the dining area. Just outside the dining area in the hallway Resident #2 was observed in her wheelchair. CNA #1 retrieved the unclean blood pressure cuff from the blue bag, and placed the cuff on Resident #2's wrist. After she took the resident's blood pressure, the CNA placed the blood pressure cuff back into the blue bag without cleaning it. The CNA then retrieved the thermometer and began to check the resident's temperature. The resident swatted the thermometer away and refused to have her temperature checked. The CNA placed the thermometer back in the bag without cleaning it. Again, CNA #1 did not sanitize or wash her hands after the procedure. During the interview on 9/22/20 at 5:15 pm with CNA #1, she stated she had been educated on hand hygiene, but confirmed she had not sanitized her hands before and after contact with Resident #'s 1 and 2. She confirmed she had not cleaned and sanitized the blood pressure cuff and thermometer between residents. She stated Sometimes the cuffs we have here don't work right, so I bring mine from home. She confirmed the blood pressure cuff she used for Residents #'s 1 and 2 was her personal equipment. She stated I spray it down with Lysol in my car before I bring it in (the facility). On 9/22/20 at 5:35 pm, during an interview with the Senior Executive Director, she stated it was her expectation social distancing should be practiced, hand hygiene should be performed before and after resident care, and shared equipment should be cleaned before and after use. She stated it was not her expectation for staff to bring personal equipment from home for resident use. On 9/23/20 at 1:00 pm, during an interview with the Director of Nursing (DON), she stated she observed the evening meal on 9/22/20 and confirmed residents were not social distanced in the dining room. The DON indicated she had educated staff there was to be no communal dining at the facility and residents should eat in their rooms. She stated she expected staff to perform hand hygiene before and after resident care, and shared equipment should by cleaned before and after resident care. The facility's policy Hand Hygiene revised 5/7/2020 read, When to perform proper hand hygiene with (ABHR (Alcohol Based Hand Rub)) and with soap and water .Before and after all resident care. The facility's policy Cleaning and Disinfection of Non-Critical Patient Care Equipment effective date 3/6/19; reviewed 7/25/19 read .assuring that non-critical reusable patient care equipment (defined by the CDC (Centers for Disease Control) as items that come into contact with intact skin but not mucous membranes) is cleaned daily and before and after reuse. Examples of non-critical items include, but are not limited to: Stethoscopes, blood pressure cuffs .

Based on record review, interview, and policy review, the facility failed to follow the plan of care for transfers to ensure for one of five sampled residents (Resident #1), the resident was free from neglect. This deficient practice had the potential to affect the 93 residents in the facility. Findings include: Review of Resident #1's electronic medical record (EMR) admission record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Fall Risk Assessment found in Resident #1's EMR, dated 12/31/19, identified the resident was a high risk for falls. The Fall Risk Assessment noted the resident's mobility status was confined to a chair. Under a section on this same form, titled Balance, it was noted that the resident was not able to attempt transfers without physical assistance. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/19, specified Resident #1 had a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated the resident was severely cognitively impaired. Review of Section G, Functional Status, revealed the resident was totally dependent on staff for transfers from the bed to a chair or wheelchair, with the assistance of two staff. Review of the EMR Care Plan, dated 03/11/19 through 03/23/20, revealed Resident #1 was totally dependent on staff for transfers via a mechanical lift with the assistance of two staff members. On 03/23/20 the care plan was updated to reflect a third staff member was now needed to transfer the resident via a mechanical lift. The third staff member was directed to support the leg of Resident #1 during all transfers. Review the nursing Progress Notes, dated 02/17/20, located in the EMR, identified Resident #1 had [MEDICAL CONDITION] and the left knee was painful to touch. The area was also noted as warm. The EMR nursing Progress Notes identified Resident #1 grimaced and made sounds when the left leg/knee was moved or touched. The physician was immediately notified and ordered an x-ray of the left leg. The results of the x-ray confirmed Resident #1 had a left femur fracture and the resident was transferred to the hospital for an evaluation and treatment. Review of the paper physician progress notes [REDACTED].#1 had a left femur fracture. The progress note revealed the results of a single view lateral film (limited study) and noted what exactly happened to Resident #1 was unclear. The progress note continued, by noting the bones of Resident #1 were likely brittle and [MEDICAL CONDITION] was likely a component of the fracture. Review of a facility paper History and Physical dated 02/19/20, noted Resident #1 had an inoperable femur fracture and the x-ray showed osteopenia and [MEDICAL CONDITION]. During a telephone interview on 08/04/20 at 1:33 PM with CNA #9, who no longer works at the facility, confirmed that he/she transferred Resident #1 without using the mechanical lift per the care plan on 02/16/20. CNA#9 stated that it was a quick way to do it. CNA#9 stated that after the resident was transferred from the bed to the chair, the resident did not show any signs of being in pain. CNA#9 stated that he/she transferred Resident #1 without the use of a mechanical lift on numerous occasions in the past and never had any problems. CNA#9 stated that he/she was aware Resident #1 required the use of a mechanical lift but said it was quicker not to use the mechanical lift. CNA#9 stated that he/she did not share this information with the facility during the facility's investigation of Resident #1's injury of unknown origin. CNA#9 stated that he/she worked the day shift on 02/16/20, but denied putting Resident #1 back to bed at the end of his/her shift. A subsequent interview was conducted with CNA #9 on 08/04/20 at 1:43 PM. CNA#9 stated he/she pulled the resident from the bed and to the chair when transferring without the mechanical lift. CNA#9 stated that he/she would put the chair next to the resident's bed to do the transfer. CNA#9 confirmed Resident #1 was not weight bearing and could not stand. CNA#9 confirmed that he/she did not use a gait belt during the transfer of the resident from the bed to the chair on 02/16/20. During an interview conducted on 08/04/20 at 1:20 PM, with Licensed Practical Nurse (LPN) #10, the staff member confirmed he/she was the nurse who was alerted by a CNA, regarding Resident #1's knee on 02/17/20. LPN#10 stated he/she was not aware of any nurse aide who was not using a mechanical lift to transfer Resident #1. LPN#10 stated that Resident #1 always required the use of a mechanical lift. During an interview on 08/04/20 at 2:25 PM, the Director of Nursing (DON) said that he/she did not have any knowledge that CNA#9 was transferring Resident #1 without the required mechanical lift. During an interview conducted on 08/05/20 at 8:19 AM, the Administrator stated that the facility investigation could not determine the cause of Resident #1's injury of unknown origin. There was no evidence to show what caused the femur fracture. During interview with the DON and the Administrator on 08/05/20 at 11:38 AM, the DON stated that the definition of neglect included when residents are not being care for, not turning them in bed, not following the care plan and Kardex. The DON and Administrator stated that if they were aware that Resident #1 was not being transferred per the plan of care (mechanical lift) it would be reported (to State Agency), would require termination of the employee, and report the nurse aide to the nursing board. Review of CNA#9's personnel record revealed mechanical lift training was provided on 08/07/18, the date of hire. The employee file included an orientation packet that had CNA#9's signature on a form titled, Associate Pledge. Under this title, it revealed, . Being the most I can be for daily safety because I want to be injury free.Being protective of residents and associates at all times because I want us to be safe at work and I want residents to always remain free from harm. Review of the facility's policy titled, Event Management & Emergency Procedures, dated as revised 04/15/19 revealed, .The resident has the right to be free from.neglect.Neglect - means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect may be the result of patterns of failure or many be the resident of one or more failures involving one resident and one staff member.

Based on observation, record review, interview, and review of manufacturer labeling, the facility failed to assure that expired medications were removed from 1 of 8 medication carts and 1 of 5 treatment carts (cross refer F755). The findings included: On 12/11/19 at approximately 8:12 AM, inspection of the Morning Star medication cart #1 revealed one [MEDICATION NAME] Inhaler belonging to Resident #64, which had been dated by the facility as opened 2/1/19. The manufacturer's labeling stated Discard 3 months after insertion of cartridge into inhaler. On 12/11/19 at approximately 8:17 AM, Licensed Practical Nurse #1 verified the expired medication finding and stated I didn't realize it should be discarded and don't recall the resident using it. On 2/11/19 at approximately 9:51 AM inspection of the Meadow Ridge treatment cart revealed in the bottom drawer one opened and partially empty 250 milliliter screw cap bottle of Sterile Normal Saline, USP (United States Pharmacopoeia) labeled Intended for single patient use. This bottle had been dated by the facility as opened 12/10. Additional manufacturer's labeling stated Contents STERILE in unopened or undamaged package. and CAUTION: Not for injection. No antimicrobial or other substance added. On 12/11/19 at approximately 9:52 AM this finding was verified by Registered Nurse #1 who stated that it was being used to treat wounds and that he/she did not realize that is could not be used again after opening.

Based on observation, interview, and review of the facility policy titled Laundry Services, the facility failed to follow infection control procedures during the laundry observation. Staff was observed reaching into barrels without personal protective equipment (PPE) to the arms; clean clothes bins were in close proximity to washers and soiled bins; staff touched clean bin with soiled gloved hand; and after loading washer, washer door was closed and machine started with staff's soiled, gloved hand (one of one observation of the laundry). The findings included: During the laundry observation on 12/13/19 at 11:42 AM, Laundry Staff #2 was observed reaching down into a soiled barrel to retrieve items. Laundry staff #2 was observed with a long sleeve shirt but no PPE to protect his/her clothing. Laundry Staff #1 was observed reaching down into a soiled barrel wearing short sleeves and wrist gloves. After retrieving the soiled items, Laundry Staff #1 was observed to wash his/her hands but not his/her forearms. After entering into the soiled side of the laundry, staff sorted items and entered into the washer/dryer room to load the washer. Observation of the laundry revealed four clean bins making two rows between the washers and dryers. Laundry Staff #1 was observed to move a clean cart with his/her soiled, gloved hand to make room for the soiled cart. After loading the washer, Laundry Staff #2 closed the washer door, locked the door into place, and started the washer using his/her soiled gloved hand. The Director of Housekeeping was asked to measure the distance between the soiled carts and clean carts which measured 4 feet 31/2 inches. After the above observation, concerns were shared with the Housekeeping Director, Laundry Staff #1 and Laundry Staff #2. During an interview on 12/13/19 at approximately 11:55 AM, Laundry Staff #1 was unaware of moving the clean bin with soiled gloved hands. S/he also stated at the end of the shift washers and soiled bins were wiped down with a cleaning agent. Review of the facility policy titled Laundry Services, revealed the following: 1) Facility staff should handle all used laundry as potentially contaminated and use standard precautions. 2) .The use of separate rooms, closets, or other designated spaces with a closing door provides the most secure methods for reducing the risk of accidental contamination. 3) Dirty linen should be clearly separated from areas where clean linen is handled. 4) Gloves and gowns must be used while sorting soiled linen.

Based on interview and record review, the facility failed to report resident to resident abuse timely for Residents #9 and #82 in one of one resident altercations reviewed. The findings included: The facility admitted Resident #9 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's BIMS (brief interview of mental status) was 99. The facility admitted Resident #82 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #82's BIMS was 99. A record review on 12/10/2019 at approximately 3:00 PM revealed a quarterly progress note dated on 12/05/2019 that on 11/21/2019 at 15:30 a resident was sitting in a chair in the hallway near the nurses station when another resident came up to her (Resident #82). The other resident was in her (Resident #9's) personal space and when she went to move her out of it, the resident (Resident #9) proceeded to kick this resident in her right shin. During an interview on 12/11/2019 with Social Services regarding the quarterly assessment progress note dated on 12/05/2019 about Resident #9 kicking another resident, the staff member stated that s/he did not witness the event then directed the surveyor to the nurse who wrote the note. The Social Services staff noted that Resident #82 does not like people in his/her personal area, and Resident #9 often wanders around on unit and tries to help straighten up other residents or push them in their wheelchairs. On 12/11/2019 at 2:16 PM, a phone interview with Licensed Practical Nurse (LPN) #2 revealed that the incident took place and that Resident #9 was attempting to straighten up Resident #82 and then became irritable and moved away from Resident #9. Resident #9 then kicked Resident #82 in the shin then staff members pulled the two residents apart from each other. LPN #2 then reported the incident to RN #2, the unit nurse on duty at the time of the incident. On 12/11/2019 at 2:54 PM, an interview with LPN #2 revealed that once s/he was notified about the incident with Residents #9 and #82, s/he examined the resident, and reported it to the Director of Nursing (DON), Physician, and the family. On 12/11/2019, during review of an incident report revealed that on 11/21/2019, resident was sitting in chair at the nurses' station when another resident came and kicked them in the right shin. The resident had a large skin tear with bruising to the right front leg (shin). The facility conducted a shift report, 24 hour report, and follow up investigation. An interview on 12/11/2019 with the DON revealed that the facility is to report to the state survey agency only after they investigate and determine that an incident was abuse. The DON stated both residents have dementia and no other incident has occurred with the two residents and since the incident took place the facility has kept the two residents apart, and a full investigation and follow up was completed about the incident.

Based on observation, record review, interview, and review of manufacturer labeling, the facility failed to assure that expired medications belonging to Resident #64 were removed from 1 of 8 medication carts (cross refer F761) The findings included: On 12/11/19 at approximately 8:12 AM, inspection of the Morning Star medication cart # 1 revealed one [MEDICATION NAME] Inhaler belonging to Resident #64 prescribed for as needed use, which had been dated by the facility as opened 2/1/19. The manufacturer's labeling stated Discard 3 months after insertion of cartridge into inhaler. On 12/11/19 at approximately 8:17 AM, Licensed Practical Nurse #1 verified the expired medication finding and stated I didn't realize it should be discarded and don't recall the resident using it. On 12/11/19 at approximately 10:15 AM during medication reconciliation, the medication administration records for Resident #64 were reviewed from 2/1/19 to 12/11/19 and did not show that that any doses had been administered. Further review of the pharmacy monthly inspection reports from (MONTH) to December, 2019 did not show that [MEDICATION NAME] Inhaler had been identified as outdated for Resident #64. On 12/12/19 at approximately 3:12 PM these findings were verified by the Director of Nursing.

Based on interview and record review, the facility failed to implement the abuse policy in reporting resident to resident abuse timely for Residents #9 and #82 in one of one resident altercations reviewed. The findings included: The facility admitted Resident #9 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's BIMS (brief interview of mental status) was 99. The facility admitted Resident #82 to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #82's BIMS was 99. A record review on 12/10/2019 at approximately 3:00 PM revealed a quarterly progress note dated on 12/05/2019 that on 11/21/2019 at 15:30 a resident was sitting in a chair in the hallway near the nurses station when another resident came up to her (Resident #82). The other resident was in her (Resident #9's) personal space and when she went to move her out of it, the resident (Resident #9) proceeded to kick this resident in her right shin. During an interview on 12/11/2019 with Social Services regarding the quarterly assessment progress note dated on 12/05/2019 about Resident #9 kicking another resident, the staff member stated that s/he did not witness the event then directed the surveyor to the nurse who wrote the note. The Social Services staff noted that Resident #82 does not like people in his/her personal area, and Resident #9 often wanders around on unit and tries to help straighten up other residents or push them in their wheelchairs. On 12/11/2019 at 2:16 PM, a phone interview with Licensed Practical Nurse (LPN) #2 revealed that the incident took place and that Resident #9 was attempting to straighten up Resident #82 and then became irritable and moved away from Resident #9. Resident #9 then kicked Resident #82 in the shin then staff members pulled the two residents apart from each other. LPN #2 then reported the incident to RN #2, the unit nurse on duty at the time of the incident. On 12/11/2019 at 2:54 PM, an interview with LPN #2 revealed that once s/he was notified about the incident with Residents #9 and #82, s/he examined the resident, and reported it to the Director of Nursing (DON), Physician, and the family. On 12/11/2019, during review of an incident report revealed that on 11/21/2019, resident was sitting in chair at the nurses' station when another resident came and kicked them in the right shin. The resident had a large skin tear with bruising to the right front leg (shin). The facility conducted a shift report, 24 hour report, and follow up investigation. On 12/11/2019, during a review of the facility's policy tilted, Protection of Residents Rights: Reducing the Threat of Abuse & Neglect revealed under the Reporting and Response section the following facilities must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. If the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. Failure to do so will mean that the facility is not in compliance with the federal regulations. The 5 day report: Facilities must satisfy the federal requirement to report the results of an investigation within 5 working days from the date of the incident (or knowledge of the incident). Any report after that time will be considered out of compliance with regulation. An interview on 12/11/2019 with the DON revealed that the facility is to report to the state survey agency only after they investigate and determine that an incident was abuse. The DON stated both residents have dementia and no other incident has occurred with the two residents and since the incident took place the facility has kept the two residents apart, and a full investigation and follow up was completed about the incident.

Based on observations, record reviews, interviews, and review of the facility policy, the facility failed to ensure that standards of clinical practice related to drug storage and administration established by the pharmaceutical company FDA (Food and Drug Administration) approved package inserts, and facilities' policy for 2 of 5 units reviewed professional standards. The Day Spring and Morningstar nursing staff did not act on improper temperature controls. It was determined on 7/31/17 at 4:50 PM that Immediate Jeopardy existed in the following areas starting 7/1/17 when the facility staff first identified and recorded the improper temperature controls with medication storage. The facility Executive Director/Administrator was present on 7/31/2017 at 4:50 PM when advised by the Team Leader that Immediate Jeopardy had been identified by the survey team after conferring with the State Agency. The findings included: On 7/31/17 at 11:15 AM, an observation of the Day Spring medication storage room with Licensed Practical Nurse (LPN) #1 revealed the temperature of the refrigerator was 32 degrees of Fahrenheit (F) which was verified on the thermometer by LPN #1. The medication in the refrigerator was: 1.) (1) 10 ml. vial of [MEDICATION NAME] (Lot #6F230A) 2.) (1) 10 ml. vial of Humalog insulin (Lot # C 8C) 3.) (2) 10 ml. vials of [MEDICATION NAME] R insulin (Lot #GZF1239) 4.) (1) 10 ml. vials of [MEDICATION NAME] (Lot #7F4443A) 5.) (2) 30 ml. bottles of Lorazapam 2 ml. (Lot # B124) and (Lot # 025A) Following the observation of the refrigerator, a review of the July 2017 refrigerator temperature log attached to the front door which stated, Refrigerator temps should be between 36-46 degrees and had (15) recorded dates below 36 degrees and as low as 29 degrees. On 7/31/17 at 11:25 AM, an observation of the Morningstar medication storage room with LPN #2 revealed the temperature of the refrigerator was 32 degrees of F which was verified on the thermometer by LPN #2. The medication in the refrigerator was: 1.) (23) 20 mcg. /2 ml. vials of [MEDICATION NAME] (Lot #7A94) 2.) (3) 5TU/0.1 ml. vials of [MEDICATION NAME] Purified Protein Derivative (PPD) 3.) (1) 10 ml. vial of [MEDICATION NAME] R insulin (Lot #GZF0046) 4.) (1) 10 ml. vial of [MEDICATION NAME](Lot #GZF1056) 5.) (2) 2 mg/ml vials of Lorazapam (Lot # 2) and (Lot # 8) 6.) (1) 1/3 full opened bottle of [MEDICATION NAME] oral solution Following the observation of the refrigerator, a review of the July 2017 refrigerator temperature log attached to the front door which stated, Refrigerator temps should be between 36-46 degrees and starting on 7/1/17 (21) recorded dates were below 36 degrees and as low as 24 degrees. (8) dates had no temperature recording. On 7/31/17 at 11:26 PM, during an interview with LPN #2, s/he stated, I have seen 1 vial of [MEDICATION NAME] frozen and notified the pharmacy. S/he further stated, I did know the temperature the medication should be stored at. On 7/31/17 at 1:15 PM, a review of the facility policy, Medication Storage & Security in the Facility states under procedure (14.) Medications requiring refrigeration or temperatures between 2 C (36 degrees F) and 8 Celsius (46 degrees of F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications that require storage in a cool place are refrigerated unless otherwise directed on the label. Also, procedure (16.) General Insulin Storage Guidelines bullet (2) states, Specific storage guidelines by the manufacture are followed. On 7/31/17 at approximately 1:20 PM, a review of the FDA approved manufacturer package inserts and manufacturer package labeling revealed that the Insulin, Lorazapam, [MEDICATION NAME] and [MEDICATION NAME] should be stored 36-46 degrees F. On 7/31/17 at 5:10 PM, an interview with the Pharmacy Director, s/he stated, Medication refrigerators are to be kept according to the facility policy and manufacture specifications typically between 36 and 46 degrees. On 8/2/17 at 3:00 PM, a review of the facility Medication Room Audit forms for the Day Spring and Morningstar units dated 7/1/17 to 7/27/17 revealed the medication refrigerators temperatures and logs were checked and no concerns were noted. Based on observation, record reviews, and interviews, facility nurses failed to seek guidance from the Pharmacy and or Physician as to the safety of administering medications improperly stored. This action resulted in the potential for harm for residents who were ordered by their physicians to receive the medications which were improperly stored and subsequently administered. Medications which are improperly stored may lose efficacy or potency, therefore compromising the desired effect. It was determined that the Immediate Jeopardy existed starting 7/1/17 when the facility was first recorded improper temperature controls. The facility submitted and the survey team accepted an Allegation of Compliance effective 8/1/17 which stated: The Pharmacy Manager, was contacted by the Executive Director to discuss the medication room refrigerator temperatures noted for July on Morning Star and Day Spring. It was decided to log all current medications and discard them. One resident received [MEDICATION NAME] that was opened. All other medications had not been opened. All medications were discarded and new medications ordered. The Pharmacy manager also stated that he would research and provide a list of other patients receiving medications that were to be refrigerated from July 1 to present. He stated that when unopened, the cooler temps would not change the medication enough to cause the residents harm. Once opened they can be maintained at room temperature. All residents receiving insulin or coeds requiring refrigeration in the month of July were reviewed today. It was determined that one resident from each unit, Day Spring and Morning Star, received medications that had been stored during the time improper temperatures were recorded. No adverse effects were noted by either patient. An incident report (IDA) was completed for each resident. The family and physician were notified. Medications were immediately discarded for Resident # from the Day Spring unit and new medication was ordered. Medications were immediately discarded for resident # from the Morning Star unit and new medication was ordered. All residents who were admitted and/or discharged in the month of July were reviewed today. On Day Spring, 15 residents were discharged , but only one was diabetic. This resident was actively expiring and physician orders were received for no sliding scale insulin. On Morning Star, 6 residents were discharged and none were diabetic. A master list of all refrigerators in the facility and their location was developed. The ADON and unit managers assisted in checking and recording all temperatures at 4 p.m. today. All temperatures were between 36-46 degrees. The Administrator called an Emergency Performance Improvement meeting. In attendance was the Medical Director, Director of Nursing, Assistant Director of Nursing, and Staff Development Director. Plans were discussed to immediately provide shift to shift oversight on refrigerator temperatures to ensure proper temperatures are checked daily, that they are within the proper temperature guidelines, and recorded accurately. Our Human Resources Director ran a list of all licensed nurses. The Staff Development Director immediately began education with them on Medication Storage and Security in the facility. Currently 62% of our nurses have been educated. All remainder licensed nurses will be educated before working. All newly hired licensed nurses will be educated on Medication storage and Security in the facility. Records of education are kept in the Staff Development Office (SDC). The ED ensures all licensed nurses will be provided training before returning to work. The temp log record for the medication refrigerators on each unit has been changed from daily checks to shift to shift checks. It has also been added on the form that if temperatures are not within the range of 36- 46 degrees, to immediately contact maintenance, and find a refrigerator with proper temperatures until the refrigerator is repaired or replaced. This shift to shift temp log started on the 3-11 shift today. Daily checks of Medication Room refrigerator checks will be completed each morning by the RN unit managers and reported and recorded on our grand rounds report. Grand Rounds is an interdisciplinary team that goes from unit to unit each a.m. to discuss resident/family concerns, changes of condition, admissions, discharges, etc. A master log of all refrigerators in the building has been developed. The Executive Director (ED), DON, or SDC will complete a check of all refrigerator temps daily. This master log was completed at 4:00 p.m. today. The daily logs will be kept in the ED office. An update of all progress related to this plan will be reviewed by the ED to the PI committee each month for (3) months. The PI committee will determine at that time what reporting needs to continue to ensure compliance with proper refrigerator temperatures. Our allegation of compliance date is August 1, 2017. The Immediate Jeopardy was removed upon verification of implementation of the Allegation of Compliance by the survey team on 8/1/17 prior to exit. Verification was determined by observation, review of records and interviews. At that time the citations remained but were lowered to a scope and severity of E.

Based on observations, record reviews and interviews the pharmacy failed to ensure that medications were stored in 2 of 5 medication room refrigerators at temperatures specified by FDA (Food and Drug Administration) approved package inserts, manufacturer package labeling and the Facility's policy. Medication was being stored on the Morningstar and Day Spring unit below manufacture specifications. It was determined on 7/31/17 at 4:50 PM that Immediate Jeopardy existed in the following areas starting 7/1/17 when the facility staff first identified and recorded the improper temperature controls with medication storage. The facility Executive Director/Administrator was present on 7/31/2017 at 4:50 PM when advised by the Team Leader that Immediate Jeopardy had been identified by the survey team after conferring with the State Agency. The findings included: On 7/31/17 at 11:15 AM, an observation of the Day Spring medication storage room with Licensed Practical Nurse (LPN) #1 revealed the temperature of the refrigerator was 32 degrees of Fahrenheit (F) which was verified on the thermometer by LPN #1. The medication in the refrigerator was: 1.) (1) 10 ml. vial of Lantus insulin (Lot #6F230A) 2.) (1) 10 ml. vial of Humalog insulin (Lot # C 8C) 3.) (2) 10 ml. vials of Novolin R insulin (Lot #GZF1239) 4.) (1) 10 ml. vials of Lantus Solostar (Lot #7F4443A) 5.) (2) 30 ml. bottles of Lorazapam 2 ml. (Lot # B124) and (Lot # 025A) Following the observation of the refrigerator, a review of the July 2017 refrigerator temperature log attached to the front door which stated, Refrigerator temps should be between 36-46 degrees and had (15) recorded dates below 36 degrees and as low as 29 degrees. On 7/31/17 at 11:25 AM, an observation of the Morningstar medication storage room with LPN #2 revealed the temperature of the refrigerator was 32 degrees of F which was verified on the thermometer by LPN #2. The medication in the refrigerator was: 1.) (23) 20 mcg. /2 ml. vials of Perforomist (Lot #7A94) 2.) (3) 5TU/0.1 ml. vials of Tuberculin Purified Protein Derivative (PPD) 3.) (1) 10 ml. vial of Novolin R insulin (Lot #GZF0046) 4.) (1) 10 ml. vial of Levemir insulin (Lot #GZF1056) 5.) (2) 2 mg/ml vials of Lorazapam (Lot # 2) and (Lot # 8) 6.) (1) 1/3 full opened bottle of Vancomycin oral solution Following the observation of the refrigerator, a review of the July 2017 refrigerator temperature log attached to the front door which stated, Refrigerator temps should be between 36-46 degrees and starting on 7/1/17 (21) recorded dates were below 36 degrees and as low as 24 degrees. (8) dates had no temperature recording. On 7/31/17 at 11:26 PM, during an interview with LPN #2, s/he stated, I have seen 1 vial of Perforomist frozen and notified the pharmacy. S/he further stated, I did know the temperature the medication should be stored at. On 7/31/17 at 1:15 PM, a review of the facility policy, Medication Storage & Security in the Facility states under procedure (14.) Medications requiring refrigeration or temperatures between 2 Celsius (C) (36 degrees F) and 8 Celsius (46 degrees of F) are kept in a refrigerator with a thermometer to allow (temperature monitoring. Medications that require storage in a cool place are refrigerated unless otherwise directed on the label. Also, procedure (16.) General Insulin Storage Guidelines bullet (2) states, Specific storage guidelines by the manufacture are followed. On 7/31/17 at approximately 1:20 PM, a review of the FDA approved manufacturer package inserts and manufacturer package labeling revealed that the Insulin, Lorazapam, Tubersol and Perforomist should be stored 36-46 degrees F. On 7/31/17 at 5:10 PM, an interview with the Pharmacy Director, s/he stated, Medication refrigerators are to be kept according to the facility policy and manufacture specifications typically between 36 and 46 degrees. On 8/1/17 at approximately 9:05 AM, a review of the Morningstar Medication Room Audit Report (completed by the Consulting Pharmacy Technician) and submitted to the facility which identified that the Morningstar Medication Nursing Station refrigerator was reviewed and the following criteria was marked with a check as Met : 14.)Medications stored per manufacture's specifications, 19.) Temperature between 36-46 degrees currently, 20.) Medication refrigerator log is completed daily (twice daily if vaccines are stored). There was no immediate action documented which indicated the Pharmacy assessed the improperly stored medications at the time of the Audit, educated the nursing staff as to the proper procedure to follow nor documented follow up to assure the concern was immediately corrected. On 8/01/17 at 3:30 PM, during an interview with the Medical Director (MD), the storage temperature logs were discussed indicating recorded temperatures and a temperature as low as 24 degrees. The MD stated, The improper storage of medications could affect the potency of the medication. On 8/01/17 at 3:30 PM, during an interview with the Medical Director (MD), the storage temperature logs were discussed indicating recorded temperatures and a temperature as low as 24 degrees. The MD stated, The improper storage of medications could affect the potency of the medication. On 8/3/17 at approximately 10:57 AM, during a telephone interview the Consulting Pharmacy Technician, S/he verified that on 7/6/17 s/he conducted a Medication Room Audit on the Morningstar unit and reviewed the refrigerator temperature log and stated, I look at the temperature logs, but not at the temperatures recorded. Based on record review and interviews, the facility's Consulting Pharmacist failed to assure that the Pharmaceutical service oversight for which it was contracted to provide, continued to identify, evaluate and prevent the improper storage of medications. There was no immediate action documented which indicated the Pharmacy assessed the improperly stored medications, educated the nursing staff as to the proper procedure to follow nor documented follow up to assure a concern was immediately corrected. It was determined that the Immediate Jeopardy existed starting 7/1/17. The facility submitted and the survey team accepted an Allegation of Compliance effective 8/1/17 which stated: The Pharmacy Manager, was contacted by the Executive Director to discuss the medication room refrigerator temperatures noted for July on Morning Star and Day Spring. It was decided to log all current medications and discard them. One resident received vancomycin that was opened. All other medications had not been opened. All medications were discarded and new medications ordered. The Pharmacy manager also stated that he would research and provide a list of other patients receiving medications that were to be refrigerated from July 1 to present. He stated that when unopened, the cooler temps would not change the medication enough to cause the residents harm. Once opened they can be maintained at room temperature. All residents receiving insulin or coeds requiring refrigeration in the month of July were reviewed today. It was determined that one resident from each unit, Day Spring and Morning Star, received medications that had been stored during the time improper temperatures were recorded. No adverse effects were noted by either patient. An incident report (IDA) was completed for each resident. The family and physician were notified. Medications were immediately discarded for Resident # from the Day Spring unit and new medication was ordered. Medications were immediately discarded for resident # from the Morning Star unit and new medication was ordered. All residents who were admitted and/or discharged in the month of July were reviewed today. On Day Spring, 15 residents were discharged , but only one was diabetic. This resident was actively expiring and physician orders were received for no sliding scale insulin. On Morning Star, 6 residents were discharged and none were diabetic. A master list of all refrigerators in the facility and their location was developed. The ADON and unit managers assisted in checking and recording all temperatures at 4 p.m. today. All temperatures were between 36-46 degrees. The Administrator called an Emergency Performance Improvement meeting. In attendance was the Medical Director, Director of Nursing, Assistant Director of Nursing, and Staff Development Director. Plans were discussed to immediately provide shift to shift oversight on refrigerator temperatures to ensure proper temperatures are checked daily, that they are within the proper temperature guidelines, and recorded accurately. Our Human Resources Director ran a list of all licensed nurses. The Staff Development Director immediately began education with them on Medication Storage and Security in the facility. Currently 62% of our nurses have been educated. All remainder licensed nurses will be educated before working. All newly hired licensed nurses will be educated on Medication storage and Security in the facility. Records of education are kept in the Staff Development Office (SDC). The ED ensures all licensed nurses will be provided training before returning to work. The temp log record for the medication refrigerators on each unit has been changed from daily checks to shift to shift checks. It has also been added on the form that if temperatures are not within the range of 36- 46 degrees, to immediately contact maintenance, and find a refrigerator with proper temperatures until the refrigerator is repaired or replaced. This shift to shift temp log started on the 3-11 shift today. Daily checks of Medication Room refrigerator checks will be completed each morning by the RN unit managers and reported and recorded on our grand rounds report. Grand Rounds is an interdisciplinary team that goes from unit to unit each a.m. to discuss resident/family concerns, changes of condition, admissions, discharges, etc. A master log of all refrigerators in the building has been developed. The Executive Director (ED), DON, or SDC will complete a check of all refrigerator temps daily. This master log was completed at 4:00 p.m. today. The daily logs will be kept in the ED office. An update of all progress related to this plan will be reviewed by the ED to the PI committee each month for (3) months. The PI committee will determine at that time what reporting needs to continue to ensure compliance with proper refrigerator temperatures. Our allegation of compliance date is August 1, 2017. The Immediate Jeopardy was removed upon verification of implementation of the Allegation of Compliance by the survey team on 8/1/17 prior to exit. Verification was determined by observation, review of records and interviews. At that time the citations remained but were lowered to a scope and severity of E.

Based on observations, record reviews, interview, and review of the facility policy and manufactures' specifications, the facility failed to follow a procedure to ensure that medication was stored at proper temperatures in accordance with manufacture specifications in 2 of 5 medication rooms on 2 of 5 units reviewed for medication storage. Medications were stored at a temperature below manufactures specifications on the Morningstar and Day Spring units. It was determined on 7/31/17 at 4:50 PM that Immediate Jeopardy existed in the following areas starting 7/1/17 when the facility staff first identified and recorded the improper temperature controls with medication storage. The facility Executive Director/Administrator was present on 7/31/2017 at 4:50 PM when advised by the Team Leader that Immediate Jeopardy had been identified by the survey team after conferring with the State Agency. The findings included: On 7/31/17 at 11:15 AM, an observation of the Day Spring medication storage room with Licensed Practical Nurse (LPN) #1 revealed the temperature of the refrigerator was 32 degrees of Fahrenheit (F) which was verified on the thermometer by LPN #1. The medication in the refrigerator was: 1.) (1) 10 ml. vial of Lantus insulin (Lot #6F230A) 2.) (1) 10 ml. vial of Humalog insulin (Lot # C 8C) 3.) (2) 10 ml. vials of Novolin R insulin (Lot #GZF1239) 4.) (1) 10 ml. vials of Lantus Solostar (Lot #7F4443A) 5.) (2) 30 ml. bottles of Lorazapam 2 ml. (Lot # B124) and (Lot # 025A) Following the observation of the refrigerator, a review of the July 2017 refrigerator temperature log attached to the front door which stated, Refrigerator temps should be between 36-46 degrees and had (15) recorded dates below 36 degrees and as low as 29 degrees. On 7/31/17 at 11:25 AM, an observation of the Morningstar medication storage room with LPN #2 revealed the temperature of the refrigerator was 32 degrees of F which was verified on the thermometer by LPN #2. The medication in the refrigerator was: 1.) (23) 20 mcg. /2 ml. vials of Perforomist (Lot #7A94) 2.) (3) 5TU/0.1 ml. vials of Tuberculin Purified Protein Derivative (PPD) 3.) (1) 10 ml. vial of Novolin R insulin (Lot #GZF0046) 4.) (1) 10 ml. vial of Levemir insulin (Lot #GZF1056) 5.) (2) 2 mg/ml vials of Lorazapam (Lot # 2) and (Lot # 8) 6.) (1) 1/3 full opened bottle of Vancomycin oral solution Following the observation of the refrigerator, a review of the July 2017 refrigerator temperature log attached to the front door which stated, Refrigerator temps should be between 36-46 degrees and starting on 7/1/17 (21) recorded dates were below 36 degrees and as low as 24 degrees. (8) dates had no temperature recording. On 7/31/17 at 11:26 PM, during an interview with LPN #2, s/he stated, I have seen 1 vial of Perforomist frozen and notified the pharmacy. S/he further stated, I did know the temperature the medication should be stored at. On 7/31/17 at 1:15 PM, a review of the facility policy, Medication Storage & Security in the Facility states under procedure (14.) Medications requiring refrigeration or temperatures between 2 Celsius (C) (36 degrees F) and 8 Celsius (46 degrees of F) are kept in a refrigerator with a thermometer to allow (temperature monitoring. Medications that require storage in a cool place are refrigerated unless otherwise directed on the label. Also, procedure (16.) General Insulin Storage Guidelines bullet (2) states, Specific storage guidelines by the manufacture are followed. On 7/31/17 at approximately 1:20 PM, a review of the FDA approved manufacturer package inserts and manufacturer package labeling revealed that the Insulin, Lorazapam, Tubersol and Perforomist should be stored 36-46 degrees F. Review of the manufacture specifications for Lorazapam Intensol Oral Concentrate USP 2 mg per mL states under, Protect From Light, Store at Cold Temperature-Refrigerate 2 degrees Celsius to 8 degrees Celsius (36 degrees F to 46 degrees F) Review of the manufacture specifications for Novolin R insulin state under How should I store Novolin R?, Unopened Novolin R, Unopened Novolin R should be kept in the refrigerator between 36 to 46 degrees of Fahrenheit (2 to 8 degrees of Celsius). Review of the manufacture specifications Lantus Solostar 100 Units/ML under section Storage, states, Store all unopened insulin containers in the refrigerator between 36-46 degrees. Review of the manufacture specifications for Tuberculin Purified Protein Derivative, (Mantoux) (PPD) (Tubersol) states under section Storage, Store at 2 degrees to 8 degrees of Celsius (35 to 46 degrees of Fahrenheit). Do not freeze. Discard product if exposed to freezing. Review of the manufacture specifications for Perforomist Inhalation Solution states under How should I store Perforomist Inhalation Solution? bullet (1) Store Perforomist Inhalation Solution in a refrigerator between 36 degrees to 46 degrees F (2 degrees to 8 degrees C) in a protective foil pouch. Protect from heat or light. On 7/31/17 at 5:10 PM, an interview with the Pharmacy Director revealed s/he indicated that medication refrigerators are to be kept according to the facility policy and manufacture specifications typically between 36 and 46 degrees. Based on observation, record reviews and interviews, the failure of facility staff apply medication temperature control related to medication storage and administered medications put residents at risk for serious harm. The standard for medication storage per the code of Federal Regulations states: All prescription drugs shall be stored at appropriate temperatures and under appropriate conditions in accordance with requirements, if any, in the labeling of such drugs, or with requirements in the current edition of an official compendium, such as the United States Pharmacopeia/ National Formulary (USP/NF). It was determined that the Immediate Jeopardy existed starting 7/1/2017 when the facility recorded improper temperatures and failed to take any action on the improperly stored medication. The facility submitted and the survey team accepted an Allegation of Compliance effective 8/1/17 which stated: The Pharmacy Manager, was contacted by the Executive Director to discuss the medication room refrigerator temperatures noted for July on Morning Star and Day Spring. It was decided to log all current medications and discard them. One resident received vancomycin that was opened. All other medications had not been opened. All medications were discarded and new medications ordered. The Pharmacy manager also stated that he would research and provide a list of other patients receiving medications that were to be refrigerated from July 1 to present. He stated that when unopened, the cooler temps would not change the medication enough to cause the residents harm. Once opened they can be maintained at room temperature. All residents receiving insulin or coeds requiring refrigeration in the month of July were reviewed today. It was determined that one resident from each unit, Day Spring and Morning Star, received medications that had been stored during the time improper temperatures were recorded. No adverse effects were noted by either patient. An incident report (IDA) was completed for each resident. The family and physician were notified. Medications were immediately discarded for Resident # from the Day Spring unit and new medication was ordered. Medications were immediately discarded for resident # from the Morning Star unit and new medication was ordered. All residents who were admitted and/or discharged in the month of July were reviewed today. On Day Spring, 15 residents were discharged , but only one was diabetic. This resident was actively expiring and physician orders were received for no sliding scale insulin. On Morning Star, 6 residents were discharged and none were diabetic. A master list of all refrigerators in the facility and their location was developed. The ADON and unit managers assisted in checking and recording all temperatures at 4 p.m. today. All temperatures were between 36-46 degrees. The Administrator called an Emergency Performance Improvement meeting. In attendance was the Medical Director, Director of Nursing, Assistant Director of Nursing, and Staff Development Director. Plans were discussed to immediately provide shift to shift oversight on refrigerator temperatures to ensure proper temperatures are checked daily, that they are within the proper temperature guidelines, and recorded accurately. Our Human Resources Director ran a list of all licensed nurses. The Staff Development Director immediately began education with them on Medication Storage and Security in the facility. Currently 62% of our nurses have been educated. All remainder licensed nurses will be educated before working. All newly hired licensed nurses will be educated on Medication storage and Security in the facility. Records of education are kept in the Staff Development Office (SDC). The ED ensures all licensed nurses will be provided training before returning to work. The temp log record for the medication refrigerators on each unit has been changed from daily checks to shift to shift checks. It has also been added on the form that if temperatures are not within the range of 36- 46 degrees, to immediately contact maintenance, and find a refrigerator with proper temperatures until the refrigerator is repaired or replaced. This shift to shift temp log started on the 3-11 shift today. Daily checks of Medication Room refrigerator checks will be completed each morning by the RN unit managers and reported and recorded on our grand rounds report. Grand Rounds is an interdisciplinary team that goes from unit to unit each a.m. to discuss resident/family concerns, changes of condition, admissions, discharges, etc. A master log of all refrigerators in the building has been developed. The Executive Director (ED), DON, or SDC will complete a check of all refrigerator temps daily. This master log was completed at 4:00 p.m. today. The daily logs will be kept in the ED office. An update of all progress related to this plan will be reviewed by the ED to the PI committee each month for (3) months. The PI committee will determine at that time what reporting needs to continue to ensure compliance with proper refrigerator temperatures. Our allegation of compliance date is August 1, 2017. The Immediate Jeopardy was removed upon verification of implementation of the Allegation of Compliance by the survey team on 8/1/17 prior to exit. Verification was determined by observation, review of records and interviews. At that time the citations remained but were lowered to a scope and severity of E.

Based on record review and interviews, the facility failed to administer medication as ordered by the physician for 1 of 4 resident's reviewed for medication transcription. Resident #1 did not receive ordered medication, which resulted in respiratory difficulty and hospitalization . The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed the physician examined the resident and wrote orders for IM (intramuscular) [MEDICATION NAME] on 3/20/15. The resident did not receive the [MEDICATION NAME] and was admitted to the hospital with [REDACTED]. Resident #1 was moved from one unit to another on 3/20/15. The chart was not available to the new unit. On 3/20/15 the physician wrote orders, which were not transcribed or followed until 3/22/15. Review of the physician progress notes [REDACTED]. The progress note stated under the [DIAGNOSES REDACTED]. (creatinine) 3.1, half of the admitting baseline. but s/he is very [MEDICAL CONDITION], more so than on arrival. weight creeping up, and per daughter up 40 pounds from baseline. saw nephrology this week, and per daughter again in 2 weeks. feel I have no choice but to give IM (intramuscular) [MEDICATION NAME] tonight. s/he is wheezy, has taught [MEDICAL CONDITION]. The progress note and orders were written on the 3-11 shift on 3/20/15. The orders were not noted until 3/22/15 on the 3-11 shift. The resident went 7 hours on the 3-11 shift, 8 hours on the 11-7 shift on 3/20/15, 24 hours on 3/21/15 without ordered treatment; the ordered treatment was not discovered until 3/22/15. Review of the Nurse's Notes of 3/20/15 at 12:41 PM stated, Resident transferred to. unit to room. Alert and oriented, pleasant and cooperative. Denies pain or distress. Oriented to new staff and unit. Daughter at resident's side. Vital signs stable and afebrile. Nurse's Note of 3/22/15 at 10:13 PM stated, res A&O (alert and oriented) throughout the shift. at 5:30 PM pt (patient) demonstrated SOB (shortness of breath) and wheezing. O2 sat at 79% on 2L O2 (2 liters of oxygen) HHN (hand held nebulizer) tx (treatment) tolerated well and O2 sats rose to 96%. Around 9 pm patient started having more difficulty breathing and louder wheezing, pitting noted to BLE (bilateral lower extremities) from thighs to toes at 1-2+. O2 sat at 88%. BP 182/88. MD notified. New order to send to ER (emergency room ) for evaluation of [MEDICAL CONDITIONS] exacerbation, [MEDICAL CONDITIONS](hypertension), and SOB, family with patient. Left via 911 around 9:30 pm. The hospital chest x-ray report for 3/22/15 at 10:51 PM stated, Impression: [MEDICAL CONDITIONS] with moderate bilateral pleural effusions and compressice atelectasis. On 5/26/15 at approximately 1:30 PM Licensed Practical Nurse (LPN) #1 was interviewed by the surveyor. The nurse stated that Resident #1's physician normally made rounds early in the morning around 7:00 AM and sometimes returned around 1:00 PM. The physician writes orders and flags the orders. S/he will type up a progress note too. The nurse on the unit was responsible for taking off the orders. The physician made rounds by her/himself. The doctor would leave the chart flagged on the desk. As we have time throughout the day we take them off. There are 2 nurses on each unit on days. The night shift nurse does a chart check to make sure all orders orders have been taken off throughout the day. On 5/26/15 at approximately 1:46 PM, LPN #2 was interviewed by the surveyor. S/he stated the nurse on duty was responsible for transcribing orders. The MD flags the orders and the orders won't be put back. They stay at nurses station . The nurse on duty writes down the order and faxes to the pharmacy. The night nurse checks orders to make sure transcribed correctly and orders not missed. On 5/27/15 at approximately 8:45 PM, Licensed Practical Nurse (LPN) #3 was interviewed via phone by the surveyor. On Friday (3/20/15) the off going nurse told me that she couldn't find Resident #1's chart. S/he had something to file in the chart. I found her/his labs and called the doctor between 2 and 3 AM. The doctor said the labs were normal for her/him. They found the chart sometime on Saturday. On Sunday evening I came in and the morning shift nurse and I found the new orders together. I came to work at 11:00 PM on Friday. The chart was missing, didn't see the chart all night. All I saw was the lab report. Saturday, 7P to 7A was an uneventful shift. I don't remember seeing her/his chart that night. Nurse's Notes are in the computer. Don't believe doctor came in on Saturday that I can recall. I believe s/he (Resident # 1) was having some breathing issues- but that was her norm (normal). Sunday, in at 7 P and told the resident was not feeling well all day. The family was there. The chart was looked at when I got there. S/he did not go out until my shift. S/he was new to me of Friday night. She had been moved from another unit. I called the different units to see where the chart was. The nurse before me , LPN # 1 had checked for chart and so did I. On 5/28/15 at approximately 12:18 PM, LPN # 1 was re-interviewed by the surveyor via phone. LPN #1 stated, I believe I was the nurse who received Resident #1 (when moved to another unit). I did not receive the chart. Sometimes the doctor takes the chart into her/his office. I had her/his (Resident #1's ) MAR (Medication Administration Record). We have information in the computer, a demographic sheet that gives information of family and insurance. Not aware when the chart was located. I gave in report that chart was not on unit. On the 3-11 shift if chart is not available, go through the building, if can't find it notify the supervisor. Not sure what protocol would be on nights. I would think they would call the doctor at home to see if they had left it in the doctor's office. Dr.'s office locked but maintenance would be available at night and would be available on nights and have a key. At approximately the Director of Nursing (DON) was interviewed by phone by the surveyor. When asked about the missing chart the DON stated, Sign out sheet on each unit. Whoever takes it signs it out. I don't recall being told Resident #1's chart was not available. If chart is not available, look for it. I would check the departments and check on each unit. This is the first that I have heard the chart was not available. The doctor would have had it and s/he would have brought it back to the unit. The doctor does not leave charts in her/his office. S/he knows the residents' record has to be available. LPN #1 was the 3-11 nurse when the resident was moved.

Based on record review and interviews, the facility failed to ensure resident medical records were accessible to the nurses to provide ordered medications for 1 of 4 residents reviewed for transcribed orders. Resident #1 was moved from one unit to another without the medical record. The medical record contained new orders. The findings included: Cross refer to F333, significant med error. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed the physician examined the resident and wrote orders for IM (intramuscular) [MEDICATION NAME] on 3/20/15. The resident did not receive the [MEDICATION NAME] and was admitted to the hospital with [REDACTED]. Resident #1 was moved from one unit to another on 3/20/15. The chart was not available to the new unit. On 3/20/15 the physician wrote orders which were not transcribed or followed until 3/22/15. Review of the physician progress notes [REDACTED]. The progress note stated under the [DIAGNOSES REDACTED]. (creatinine) 3.1, half of the admitting baseline. but s/he is very [MEDICAL CONDITION], more so than on arrival. weight creeping up, and per daughter up 40 pounds from baseline. saw nephrology this week, and per daughter again in 2 weeks. feel I have no choice but to give IM (intramuscular) [MEDICATION NAME] tonight. s/he is wheezy, has taught [MEDICAL CONDITION]. The progress note and orders were written on the 3-11 shift on 3/20/15. The orders were not noted until 3/22/15 on the 3-11 shift. The resident went through 7 hours of the 3-11 shift, 8 hours of the 11-7 shift on 3/20/15, 24 hours on 3/21/15 and was not discovered until 3/22/15. On 5/27/15 at approximately 8:45 PM, Licensed Practical Nurse (LPN) #3 was interviewed via phone by the surveyor. On Friday (3/20/15) the off going nurse told me that she couldn't find resident #1's chart. S/he had something to file in the chart. I found her/his labs and called the doctor between 2 and 3 AM. The doctor said the labs were normal for her/him. They found the chart sometime on Saturday. On Sunday evening I came in and the morning shift nurse and I found the new orders together. I came to work at 11:00 PM on Friday. The chart was missing, didn't see the chart all night. All I saw was the lab report. Saturday, 7P to 7A was an uneventful shift. I don't remember seeing her/his chart that night. Nurses Notes are in the computer. Don't believe doctor came in on Saturday that I can recall. I believe s/he (Resident # 1) was having some breathing issues- but that was her norm (normal). Sunday, In at 7 P and told the resident was not feeling well all day. The family was there. The chart was looked at when I got there. S/he did not go out until my shift. S/he was new to me of Friday night. She had been moved from an other unit. I called the different units to see where the chart was. The nurse before me , LPN # 1 had checked for chart and so did I. On 5/28/15 at approximately 12:18 PM, LPN # 1 was re-interviewed by the surveyor via phone. LPN #1 stated, I believe I was the nurse who received resident #1 (when moved to another unit). I did not receive the chart. Sometimes the doctor takes the chart into her/his office. I had her/his (resident #1's ) MAR (Medication Administration Record). We have information in the computer, a demographic sheet that gives information of family and insurance. Not aware when the chart was located. I gave in report that chart was not on unit. On the 3-11 shift if chart is not available, go through the building, if can't find it notify the supervisor. Not sure what protocol would be on nights. I would think they would call the doctor at home to see if they had left it in the doctor's office. Dr.'s office locked but maintenance would be available at night and would be available on nights and have a key. At approximately 12:45 PM, on 5/28/15 the Director of Nursing (DON) in a telephone interview with the surveyor was asked about the missing chart she stated, There's a Sign out sheet on each unit. Whoever takes it signs it out. I don't recall being told Resident #1's chart was not available. If chart is not available, look for it. I would check the departments and check on each unit. This is the first that I have heard the chart was not available. The doctor would have had it and s/he would have brought it back to the unit. The doctor does not leave charts in her/his office. S/he knows the residents' record has to be available. LPN #1 was the 3-11 nurse when the resident was moved.

Based on record review and interview, the facility failed to review and revise the resident's comprehensive plan of care. Resident #2 was noted with five falls during a two month period. The resident's care plan included an intervention for the resident to request assistance prior to ambulation, which was unrealistic due to the resident's cognitive status and did not meet the resident's needs. One of two residents reviewed for falls. The findings included: Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the resident's Initial Minimum (MDS) data set [DATE] indicated the resident had a Brief Interview for Mental Status score of 3. S/he required extensive assistance of one person for dressing, toileting, personal hygiene and locomotion on/off the unit; a walker/wheelchair was used for locomotion. Review of the resident's care plan revealed potential for falls was identified as a problem area on 05/09/14. Interventions and approaches were listed on the care plan and included to "...Provide environmental adaptations *Low/platform bed *Call light within reach *Adequate glare free lighting *Area free of clutter *Fall mats at bedside; Provide resident/family teaching to include *Safety measures to reduce fall risk *What to do if a fall occurs; Provide/observe use of adaptive devices *Walker/cane *Wheelchair; Remind resident and reinforce safety awareness *Educate/remind resident to request assistance prior to ambulation; Side rails as an enabler; Provide verbal and tactile safety cues and reminders..." 5/26/14 a care plan updated indicated "pad siderails". An update dated 6/25/14 stated, "post signage to stop and ask for (A) (assistance) before toileting". A note on the care plan dated 6/29/14 stated, "res (resident) sent to hosp (hospital) will review upon readmission". The care plan dated 7/5/14 indicated the resident was to be in a supervised area when out of bed to wheelchair. Review of Resident #2's Incident Follow-Up & Recommendation Form dated 5/1/14 indicated a family friend noted the resident on the floor in his/her room. The family friend stated the resident stood up and attempted to remove his/her clothes but lost his/her balance and fell to the floor. Actions taken included encourage the resident to use the call bell for ADLs (Activities of Daily Living). Review of Resident #2's Incident Follow-Up & Recommendation Form dated 5/10/14 indicated a staff member found the resident sitting on the floor in the hallway with the wheelchair behind him/her. Review of Resident #2's Incident Follow-Up & Recommendation Form dated 5/26/14 indicated a staff member noted a skin tear to the resident's right elbow and a bruise to the right index finger. Resident #2 stated s/he fell but could not remember what day. The resident's care plan was updated with an intervention to pad siderails. Review of Resident #2's Incident Follow-Up & Recommendation Form dated 6/25/14 indicated the CNA (certified nurse aide) responded to the resident's call light. Resident #2 was sitting on the side of the bed and the CNA noted a skin tear to the resident's right arm. The bathroom floor was soiled with urine. Resident #2 stated s/he fell in the bathroom. Actions taken included to educate the resident to stop and ask for assistance before toileting. The resident's care plan was updated to post signage to stop and ask for assistance before toileting. Review of Resident #2's State Reportable Accident/ Incident Report dated 6/29/14 indicated another resident sitting at the nurse's station yelled out "emergency". The nurse saw Resident #2 lying on his/her right side on the floor approximately 10 feet away from the wheel chair by the nurse's station. Resident #2 was admitted to the hospital with [REDACTED].#2 had a right superior and inferior ramus fracture. The resident was noted to have [MEDICAL CONDITION] while in the hospital and Psychiatry recommended [MEDICATION NAME] treatment and comfort care. The resident's care plan was updated on 7/5/14 to keep the resident in a supervised area when out of bed to the wheelchair. In an interview with the surveyor on 8/27/14 at approximately 1:15 PM, the Director of Nursing (DON) stated that resident's care plans are updated in the events meeting in the mornings. The events team reviews incidents and implements interventions. The Director of Nursing, the Assistant Director of Nursing, the Clinical Coordinator and Therapy attend the events meeting. The DON stated that the intervention of placing a resident in a supervised area consists of an area that is visible by staff such as the nurse's station or dining room. If a resident is at the nurse's station the nurse may not necessarily see a resident fall but staff will know right away since in a visible area. Hopefully staff can prevent a fall.

Based on review of facility files and interview, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. Resident #2 was noted to have five falls at the facility during a two month period. Interventions put in place were not appropriate based on the resident's cognitive status. One of two residents reviewed for falls. The findings included: Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the resident's Initial Minimum (MDS) data set [DATE] indicated the resident had a Brief Interview for Mental Status score of 3. S/he required extensive assistance of one person for dressing, toileting, personal hygiene and locomotion on/off the unit; a walker/wheelchair was used for locomotion. Review of Resident #2's Nursing Notes from 5/12/14 through 6/29/14 revealed a note dated 5/14/14 at 3:37 AM "...resident continues to be noncompliant with (his/her) call bell. (s/he) will walk up hall when or after using the bathroom. (s/he) is confused. (s/he) is led back to (his/her) room to toilet and given instructions to use (his/her) call bell when (s/he) needs any sort of assistance. resident states (s/he) understands but suffers from dementia..." On 6/4/14 at 8:04 AM "...still non complient (sic) with call bell use at times. about half and half." On 6/6/14 at 8:19 PM "...Needs supervision for safety. Also needs constant cues and direction... " On 6/9/14 at 10:56 AM "CNA reported to nurse urine found on resident's floor and trash can. Resident unable to follow simple commands and has increase confusion this evening..." On 6/16/14 at 1:36 AM "...Does not understand how to use call bell for assistance. Call bell attached to shirt and within reach...". On 6/17/14 at 10:24 PM "... call bell is within reach at all times resident lacks the understanding of how to use it..." On 6/23/14 at 1:38 AM "...Poor safety awareness at times, will catch (him/her) walking to toilet. Call bell in place resident cannot perform a return demonstration..." On 6/25/14 at 3:47 PM "...Resident has experienced increased tearfulness and increased episodes of getting out of bed or out of chair unassisted. Spoke with Dr. regarding changes. No new orders at this time." On 6/28/14 at 1:43 AM "...Resident has poor safety awareness and will ambulate and toilet self on own....". On 6/29/14 at 3:32 AM "...Resident has poor safety awareness, will toilet self and walk hallways unassisted..." Review of Resident #2's Incident Follow-Up & Recommendation Form dated 5/1/14 indicated the resident was noted by a family friend to fall on the floor in his/her room. The family friend stated the resident stood up and attempted to remove his/her clothes but lost his/her balance and fell to the floor. Actions taken included encourage the resident to use the call bell for ADLs (Activities of Daily Living). Review of Resident #2's Incident Follow-Up & Recommendation Form dated 5/10/14 indicated a staff member found the resident sitting on the floor in the hallway with the wheelchair behind him/her. Review of Resident #2's Incident Follow-Up & Recommendation Form dated 5/26/14 indicated a staff member noted a skin tear to the resident's right elbow and a bruise to the right index finger. Resident #2 stated s/he fell but could not remember what day. Review of Resident #2's Incident Follow-Up & Recommendation Form dated 6/25/14 indicated the CNA (certified nurse aide) responded to the resident's call light. Resident #2 was sitting on the side of the bed and the CNA noted a skin tear to the resident's right arm. The bathroom floor was soiled with urine. Resident #2 stated s/he fell in the bathroom. Actions taken included to educate the resident to stop and ask for assistance before toileting. Review of Resident #2's State Reportable Accident/ Incident Report dated 6/29/14 indicated another resident sitting at the nurse's station yelled out "emergency". The nurse saw Resident #2 lying on his/her right side on the floor approximately 10 feet away from the wheel chair by the nurse's station. Resident #2 was admitted to the hospital with [REDACTED].#2 had a right superior and inferior ramus fracture. The resident was noted to have delirium while in the hospital and Psychiatry recommended Restoril treatment and comfort care. The resident's care plan was updated on 7/5/14 to keep the resident in a supervised area when out of bed to the wheelchair. In an interview with the surveyor on 8/27/14 at approximately 1:15 PM, the Director of Nursing (DON) stated that the intervention of placing a resident in a supervised area consists of an area that is visible by staff such as the nurse's station or dining room. If a resident is at the nurse's station the nurse may not necessarily see a resident fall but staff will know right away since in a visible area. Hopefully staff can prevent a fall.

On the days of the complaint and extended survey based on record reviews, observations and interviews, the Administration failed to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The Administration was not informed by the nursing and social services staff that Resident #1, a male resident, was observed fondling a female resident's breast and kissing her sometime during the month of December 2013. The findings included: Cross refer to F-157 as it relates to the failure of the facility to notify the physician and/or legal representative of a change in Resident #1's psychosocial status, 1 of 4 sampled residents observed with behaviors. Cross refer to F-250 as it relates to the failure of the facility to provide medically-related social services to maintain the highest practicable psychosocial adjustment for 1 of 4 sampled residents observed with behaviors. Resident #1 was observed by multiple staff fondling a female resident's breast and kissing her. There was no evidence of a thorough assessment of Resident #1's behaviors; no evidence of communication with Resident #1's family regarding behaviors and no evidence Resident #'1 behaviors were monitored by Social Services. Cross refer to F-280 as it relates to the failure of the facility to review and revise the care plan for Resident #1 observed by multiple staff fondling a female resident's breast and kissing her. Cross refer to F-319 as it relates to the failure of the facility to ensure residents that display mental or psychosocial adjustment difficulty received appropriate and timely treatment to assist in treating the problem for 1 of 4 sampled residents observed with behaviors. Resident #1 was observed by multiple staff fondling Resident #2's breast and kissing her. In an interview with the surveyor on 1/17/2014 at approximately 7:15 PM the Director of Nurses and Administrator in Training stated they were unaware of the incident and that no one had told them about the incident with Resident #1. In an interview with the surveyor on 1/18/2014 at approximately 11:20 AM the Administrator stated she did not remember anyone telling her about the incident. On 01/17/2014 at approximately 7:30 PM the Director of Nurses and Administrator in Training were notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F-157, F-250, F-280, F-319 and F-490 at a scope and severity of "J". The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility related to the failure of the facility to assess Resident #1's behaviors, formulate a plan of care, notify the physician/ personal representative, and document Resident #1's inappropriate sexual behavior during the month of December 2013. An Allegation of Compliance (AOC) was submitted by the facility on 1/18/2014. The actions listed in the AOC included the following: "...Corrective Action for resident/s found to be affected: Effective 1/17/14, Resident #1 has been provided 24-hr 1:1 observation by a Life Care Associate and will continue 24-hr 1:1 observation by a Life Care Associate until a psychiatric evaluation is completed by psychiatrist and determines he no longer requires 1:1 observation. This evaluation will be completed by 1/23/14. Physician notification of incident on 1/18/14; no orders received. Family notified by nursing staff on 1/18/14. His individualized behavior management plan, care plan, was reviewed and revised on 1/18/14 by the Assistant Social Worker. Revisions on behavior management plan includes praise for good behavior, let resident know when exhibits inappropriate behavior, and observe resident's interactions with others. The care plan was revised by an MDS nurse on 1/18/14 to read, "Can also be verbally aggressive; one episode on 1/5/14 and socially inappropriate (resisted care) or disruptive"; due to behaviors 1:1 observation 24/7 until seen by psychiatrist. On 1/18/14, our Medical Director notified a psychiatrist for psychiatric consult to be completed by 1/23/14. How other residents have been identified with the potential to be affected: 29 residents on the dementia unit have the potential to be affected. A skin integrity data collection report was completed on 1/17/14 by a licensed nurse for each resident on the dementia unit. No concerns noted. Social Services completed a new Social Service Assessment for all residents on the dementia unit on 1/18/14 to ensure the identity of potential resident behaviors. The DON will ensure that residents with behaviors will receive a psychological assessment with behavior recommendations by a psychiatrist. Appointments have been scheduled and all will be completed 1/31/14. Behavior interventions will be listed on the resident's individualized plan of care by 1/18/14 by Social Services staff. Staff on each shift will be aware of each resident's behavioral intervention by 1/18/14. The Charge Nurse ensures that behavioral interventions are followed daily by documenting on the behavioral monitoring sheets for each resident, each shift effective 1/18/14. In-service education r/t residents with behaviors, interventions, monitoring and documentation was provided by DON or ADON on and 1/18/14 to all staff, all shifts, who work on the dementia unit. Education will be provided to all shifts daily on the dementia unit starting 1/19/14 until all staff has been provided training prior to work. New staff hired will also be provided training. The Executive Director has informed Social Services staff of the issues involved with complete and accurate Behavioral Assessments, interventions, monitoring and staff training on 1/18/14. The Executive Director reviewed policies and procedures with Social Services staff on 1/18/14. The Social Service staff completed Social Service Assessments on all residents on the dementia unit on 1/18/14. All behaviors identified have been updated on each resident's behavior management plan and plan of care by Social Services staff..." Date of Compliance: 1/18/2014 Observations, interviews, and review of policy revealed the AOC submitted by the facility on 1/18/2014 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff and social work staff had been educated and was knowledgeable of the care needs of residents with behaviors, the importance of timely interventions, monitoring, documentation and reporting. The Administrator was informed of this on 1/18/2014 at 7:00 PM. The Immediate Jeopardy at F-490 was removed but the citations remained at a lower scope and severity of "D".

On the days of the complaint and extended survey based on record reviews, observations and interviews, the facility failed to provide medically-related social services to maintain the highest practicable psychosocial adjustment for 1 of 4 sampled residents observed with behaviors. Resident #1 was observed by multiple staff members fondling a female resident's breast and kissing her. There was no evidence of a thorough assessment of Resident #1's behaviors; no evidence of communication with Resident #1's family regarding behaviors and no evidence Resident #'1 behaviors were monitored by Social Services. The findings included: Cross refer to F-319 as it relates to the failure of the facility to ensure residents that display mental or psychosocial adjustment difficulty received appropriate and timely treatment to assist in treating the problem for 1 of 4 sampled residents observed with behaviors. Resident #1 was observed by multiple staff members in the dayroom on the Daysprings hall, fondling Resident #2's breast and kissing her Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident with a BIMS (Brief Interview for Mental Status) of "6" indicating short and long-term memory problems; poor decision making skills. Behaviors noted were physical and verbal. The resident was housed on the locked dementia unit, was ambulatory and was designated a wanderer by the facility. A review of the resident's clinical record from November 2013 through January 2014 revealed no documentation related to the December 2013 incident described by multiple staff members. A Nurse's Note dated 1/06/2014 at 1:34 AM stated, "late entry 1-5-14 @813pm: Nurse was coming around corner and observed Resident #1 kissing the forehead of another resident. Nurse told this resident to stop and he did..." A social service note dated 12/19/2013 stated, "Residents Q assessment completed... able to make needs known. ...has short term memory problems. ...scored 6 on BIMS and 3 on mood. He may be verbally and physically abusive toward other residents. He may also be sexually inappropriate towards other female residents at times... Res (ident) spends most of his time in his room or walking around unit..." Review of the Care Plan updated 12/23/2013, signed by a representative from nursing and social service failed to address Resident #1's inappropriate sexual behavior. Review of a Behavior Management Plan dated 12/06/2013 stated, "Problem: Res (resident) may be sexually inappropriate i.e. kissing, hand holding..." Approaches included re-direct, re-approach, praise good behavior, let resident know when inappropriate, watch resident interactions with others..." This plan was not part of the care plan updated 12/23/2013. In an interview with the surveyor on 1/18/2014 at 1:00 PM the Social Service Assistant stated that s/he was told sometime in December (2013) about the incident in the dayroom with Resident #1. S/he stated s/he didn't remember who told her/him but s/he asked the first nurse s/he saw and s/he told her/him about the incident. When asked by the surveyor if s/he spoke to anyone else about the incident s/he stated, "No". When asked by the surveyor if s/he spoke to nursing about the incident s/he stated, "No, they were the ones who told me so I thought they knew". The surveyor asked if there were any notes about the incident, s/he stated, they would be in the notes on the computer. In an interview with the surveyor on 1/18/2014 at 2:00 PM the Director of Social Services stated that s/he was aware Resident #1 would hold hands with other residents. S/he stated that s/he was told about the incident with Resident #1 in the dayroom by the Social Service Assistant sometime around the 2nd or 3rd week of December. S/he confirmed s/he did not discuss the incident with the Director of Nursing. On 01/17/2014 at approximately 7:30 PM the Director of Nurses and Administrator in Training were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-250, F-280, F-319 and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility related to the failure of the facility to care plan, notify the physician/ personal representative, and document Resident #1's inappropriate sexual behavior in the facility dayroom during the month of December 2013. An Allegation of Compliance (AOC) was submitted by the facility on 1/18/2014. The actions listed in the AOC included the following: "...Corrective Action for resident/s found to be affected: Effective 1/17/14, Resident #1 has been provided 24-hr 1:1 observation by a Life Care Associate and will continue 24-hr 1:1 observation by a Life Care Associate until a psychiatric evaluation is completed by psychiatrist and determines he no longer requires 1:1 observation. This evaluation will be completed by 1/23/14. Physician notification of incident on 1/18/14; no orders received. Family notified by nursing staff on 1/18/14. His individualized behavior management plan, care plan, was reviewed and revised on 1/18/14 by the Assistant Social Worker. Revisions on behavior management plan includes praise for good behavior, let resident know when exhibits inappropriate behavior, and observe resident's interactions with others. The care plan was revised by an MDS nurse on 1/18/14 to read, "Can also be verbally aggressive; one episode on 1/5/14 and socially inappropriate (resisted care) or disruptive"; due to behaviors 1:1 observation 24/7 until seen by psychiatrist. On 1/18/14, our Medical Director notified a psychiatrist for psychiatric consult to be completed by 1/23/14. How other residents have been identified with the potential to be affected: 29 residents on the dementia unit have the potential to be affected. A skin integrity data collection report was completed on 1/17/14 by a licensed nurse for each resident on the dementia unit. No concerns noted. Social Services completed a new Social Service Assessment for all residents on the dementia unit on 1/18/14 to ensure the identity of potential resident behaviors. The DON will ensure that residents with behaviors will receive a psychological assessment with behavior recommendations by a psychiatrist. Appointments have been scheduled and all will be completed 1/31/14. Behavior interventions will be listed on the resident's individualized plan of care by 1/18/14 by Social Services staff. Staff on each shift will be aware of each resident's behavioral intervention by 1/18/14. The Charge Nurse ensures that behavioral interventions are followed daily by documenting on the behavioral monitoring sheets for each resident, each shift effective 1/18/14. In-service education r/t residents with behaviors, interventions, monitoring and documentation was provided by DON or ADON on and 1/18/14 to all staff, all shifts, who work on the dementia unit. Education will be provided to all shifts daily on the dementia unit starting 1/19/14 until all staff has been provided training prior to work. New staff hired will also be provided training. The Executive Director has informed Social Services staff of the issues involved with complete and accurate Behavioral Assessments, interventions, monitoring and staff training on 1/18/14. The Executive Director reviewed policies and procedures with Social Services staff on 1/18/14. The Social Service staff completed Social Service Assessments on all residents on the dementia unit on 1/18/14. All behaviors identified have been updated on each resident's behavior management plan and plan of care by Social Services staff..." Date of Compliance: 1/18/2014 Observations, interviews, and review of policy revealed the AOC submitted by the facility on 1/18/2014 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the care needs of residents with behaviors, the importance of timely interventions, monitoring, documentation and reporting. The Administrator was informed of this on 1/18/2014 at 7:00 PM. The Immediate Jeopardy at F-250 was removed but the citations remained at a lower scope and severity of "D".

On the days of the complaint and extended survey based on record reviews, observations and interviews, the facility failed to notify the physician and/or legal representative of Resident #1's psychosocial status, 1 of 4 sampled residents observed with behaviors. The findings included: Cross refer to F-319 as it relates to the failure of the facility to ensure residents that display mental or psychosocial adjustment difficulty received appropriate and timely treatment to assist in treating the problem for 1 of 4 sampled residents observed with behaviors. Resident #1 was observed by multiple staff members in the dayroom on the Daysprings hall, fondling Resident #2's breast and kissing her Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident with a BIMS (Brief Interview for Mental Status) of "6" indicating short and long-term memory problems; poor decision making skills. Behaviors noted were physical and verbal. The resident was housed on the locked dementia unit, was ambulatory and was designated a wanderer by the facility. A review of the resident's clinical record from November 2013 through January 2014 revealed no documentation related to the December 2013 incident described by CNA's #1, #4 and Registered Nurse #1. There was no documentation that the physician or the family of Resident #1 was notified regarding inappropriate behaviors. In an interview with the surveyor, the Administrator, Director of Nurses and the Medical Director on 1/18/2014 at 11:40 AM confirmed that the families were told about the incident for the first time on the morning of 1/18/2014. The Medical Director stated that he was also told on 1/18/2014. On 01/17/2014 at approximately 7:30 PM the Director of Nurses and Administrator in Training were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-250, F-280, F-319 and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility related to the failure of the facility to care plan, notify the physician/ personal representative, and document Resident #1's inappropriate sexual behavior in the facility dayroom during the month of December 2013. An Allegation of Compliance (AOC) was submitted by the facility on 1/18/2014. The actions listed in the AOC included the following: "...Corrective Action for resident/s found to be affected: Effective 1/17/14, Resident #1 has been provided 24-hr 1:1 observation by a Life Care Associate and will continue 24-hr 1:1 observation by a Life Care Associate until a psychiatric evaluation is completed by psychiatrist and determines he no longer requires 1:1 observation. This evaluation will be completed by 1/23/14. Physician notification of incident on 1/18/14; no orders received. Family notified by nursing staff on 1/18/14. His individualized behavior management plan, care plan, was reviewed and revised on 1/18/14 by the Assistant Social Worker. Revisions on behavior management plan includes praise for good behavior, let resident know when exhibits inappropriate behavior, and observe resident's interactions with others. The care plan was revised by an MDS nurse on 1/18/14 to read, "Can also be verbally aggressive; one episode on 1/5/14 and socially inappropriate (resisted care) or disruptive"; due to behaviors 1:1 observation 24/7 until seen by psychiatrist. On 1/18/14, our Medical Director notified a psychiatrist for psychiatric consult to be completed by 1/23/14. How other residents have been identified with the potential to be affected: 29 residents on the dementia unit have the potential to be affected. A skin integrity data collection report was completed on 1/17/14 by a licensed nurse for each resident on the dementia unit. No concerns noted. Social Services completed a new Social Service Assessment for all residents on the dementia unit on 1/18/14 to ensure the identity of potential resident behaviors. The DON will ensure that residents with behaviors will receive a psychological assessment with behavior recommendations by a psychiatrist. Appointments have been scheduled and all will be completed 1/31/14. Behavior interventions will be listed on the resident's individualized plan of care by 1/18/14 by Social Services staff. Staff on each shift will be aware of each resident's behavioral intervention by 1/18/14. The Charge Nurse ensures that behavioral interventions are followed daily by documenting on the behavioral monitoring sheets for each resident, each shift effective 1/18/14. In-service education r/t residents with behaviors, interventions, monitoring and documentation was provided by DON or ADON on and 1/18/14 to all staff, all shifts, who work on the dementia unit. Education will be provided to all shifts daily on the dementia unit starting 1/19/14 until all staff has been provided training prior to work. New staff hired will also be provided training. The Executive Director has informed Social Services staff of the issues involved with complete and accurate Behavioral Assessments, interventions, monitoring and staff training on 1/18/14. The Executive Director reviewed policies and procedures with Social Services staff on 1/18/14. The Social Service staff completed Social Service Assessments on all residents on the dementia unit on 1/18/14. All behaviors identified have been updated on each resident's behavior management plan and plan of care by Social Services staff..." Date of Compliance: 1/18/2014 Observations, interviews, and review of policy revealed the AOC submitted by the facility on 1/18/2014 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the care needs of residents with behaviors, the importance of timely interventions, monitoring, documentation and reporting. The Administrator was informed of this on 1/18/2014 at 7:00 PM. The Immediate Jeopardy at F-157 was removed but the citations remained at a lower scope and severity of "D".

On the days of the complaint and extended survey based on record reviews, observations and interviews, the facility failed to review and revise the care plan for Resident #1 observed by multiple staff fondling a female resident's breast and kissing her. The findings included: Cross refer to F-319 as it relates to the failure of the facility to ensure residents that display mental or psychosocial adjustment difficulty received appropriate and timely treatment to assist in treating the problem for 1 of 4 sampled residents observed with behaviors. Resident #1 was observed by multiple staff members in the dayroom on the Dayspring's hall, fondling a female resident's breast and kissing her. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident with a BIMS (Brief Interview for Mental Status) of "6" indicating short and long-term memory problems; poor decision making skills. Behaviors noted were physical and verbal. The resident was housed on the locked dementia unit, was ambulatory and was designated a wanderer by the facility. A review of the resident's clinical record from November 2013 through January 2014 revealed no documentation related to the December 2013 incident described by multiple staff members. A Nurse's Note dated 1/06/2014 at 1:34 AM stated, "late entry 1-5-14 @813pm: Nurse was coming around corner and observed Resident #1 kissing the forehead of another resident. Nurse told this resident to stop and he did..." Review of the Care Plan updated 12/23/2013, signed by a representative from nursing and social service failed to address Resident #1's inappropriate sexual behavior. Review of a Behavior Management Plan dated 12/06/2013 stated, "Problem: Res (resident) may be sexually inappropriate i.e.. kissing, hand holding..." Approaches included re-direct, re-approach, praise good behavior, let resident know when inappropriate, watch resident interactions with others..." This plan was not part of the care plan updated 12/23/2013. In an interview with the surveyor on 1/17/2014 at 7:15 PM the Director of Nurses and the Administrator in Training confirmed that the care plans updated 12/23/2013 did not include Resident #1's inappropriate sexual behavior. The Administrator in Training stated that the care plan in the computer included inappropriate sexual behaviors. Review of the computer care plan indicated the problems areas were identified on 6/11/2013 with a target date of 9/19/2013; the problem area identified as physical abusive and sexually inappropriate was identified on 12/06/2013 with a target date of 03/06/2014. There was no evidence this care plan in the computer was updated on 12/23/2013. On 01/17/2014 at approximately 7:30 PM the Director of Nurses and Administrator in Training were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-250, F-280, F-319 and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility related to the failure of the facility to care plan, notify the physician/ personal representative, and document Resident #1's inappropriate sexual behavior in the facility dayroom during the month of December 2013. An Allegation of Compliance (AOC) was submitted by the facility on 1/18/2014. The actions listed in the AOC included the following: "...Corrective Action for resident/s found to be affected: Effective 1/17/14, Resident #1 has been provided 24-hr 1:1 observation by a Life Care Associate and will continue 24-hr 1:1 observation by a Life Care Associate until a psychiatric evaluation is completed by psychiatrist and determines he no longer requires 1:1 observation. This evaluation will be completed by 1/23/14. Physician notification of incident on 1/18/14; no orders received. Family notified by nursing staff on 1/18/14. His individualized behavior management plan, care plan, was reviewed and revised on 1/18/14 by the Assistant Social Worker. Revisions on behavior management plan includes praise for good behavior, let resident know when exhibits inappropriate behavior, and observe resident's interactions with others. The care plan was revised by an MDS nurse on 1/18/14 to read, "Can also be verbally aggressive; one episode on 1/5/14 and socially inappropriate (resisted care) or disruptive"; due to behaviors 1:1 observation 24/7 until seen by psychiatrist. On 1/18/14, our Medical Director notified a psychiatrist for psychiatric consult to be completed by 1/23/14. How other residents have been identified with the potential to be affected: 29 residents on the dementia unit have the potential to be affected. A skin integrity data collection report was completed on 1/17/14 by a licensed nurse for each resident on the dementia unit. No concerns noted. Social Services completed a new Social Service Assessment for all residents on the dementia unit on 1/18/14 to ensure the identity of potential resident behaviors. The DON will ensure that residents with behaviors will receive a psychological assessment with behavior recommendations by a psychiatrist. Appointments have been scheduled and all will be completed 1/31/14. Behavior interventions will be listed on the resident's individualized plan of care by 1/18/14 by Social Services staff. Staff on each shift will be aware of each resident's behavioral intervention by 1/18/14. The Charge Nurse ensures that behavioral interventions are followed daily by documenting on the behavioral monitoring sheets for each resident, each shift effective 1/18/14. In-service education r/t residents with behaviors, interventions, monitoring and documentation was provided by DON or ADON on and 1/18/14 to all staff, all shifts, who work on the dementia unit. Education will be provided to all shifts daily on the dementia unit starting 1/19/14 until all staff has been provided training prior to work. New staff hired will also be provided training. The Executive Director has informed Social Services staff of the issues involved with complete and accurate Behavioral Assessments, interventions, monitoring and staff training on 1/18/14. The Executive Director reviewed policies and procedures with Social Services staff on 1/18/14. The Social Service staff completed Social Service Assessments on all residents on the dementia unit on 1/18/14. All behaviors identified have been updated on each resident's behavior management plan and plan of care by Social Services staff..." Date of Compliance: 1/18/2014 Observations, interviews, and review of policy revealed the AOC submitted by the facility on 1/18/2014 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility social work staff had been educated and was knowledgeable of the care needs of residents with behaviors, the importance of timely interventions, monitoring, documentation and reporting. The Administrator was informed of this on 1/18/2014 at 7:00 PM. The Immediate Jeopardy at F-280 was removed but the citations remained at a lower scope and severity of "D".

On the days of the complaint and extended survey based on record reviews, observations and interviews, the facility failed to ensure residents that display mental or psychosocial adjustment difficulty received appropriate and timely treatment to assist in treating the problem for 1 of 4 sampled residents observed with behaviors. Resident #1 was observed by multiple staff fondling Resident #2's breast and kissing her. The findings included: On 1/17/2014 a complaint survey was conducted at the facility related to a facility reported incident alleging that Certified Nurse Aide (CNA) #5 verbally abused Resident #1 when he grabbed her buttock when he was standing behind her. CNA #5 allegedly told the resident she would call the police. During an interview with the surveyor on 1/17/2013 at 3:40 PM CNA #4 who witnessed the incident with CNA #5 stated that this was not the first time for Resident #1, he holds hands with other resident and goes in resident rooms. CNA #4 stated that sometime in December (2013) multiple staff members saw Resident #1 playing with Resident #2's breast and kissing her. Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident with a BIMS (Brief Interview for Mental Status) of "6" indicating short and long-term memory problems; poor decision making skills. Behaviors noted were physical and verbal. The resident was housed on the locked dementia unit, was ambulatory and was designated a wanderer by the facility. Resident #1 observed by the surveyor on 1/17/2014 at 6:20 PM standing in the middle of the dayroom on the Dayspring's hall eating ice cream; he ambulated without difficulty. He stated to the surveyor that the ice cream was good; "you are looking good today". Resident #2 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident with a BIMS of "3". Behaviors noted were physical and verbal toward others. The resident was housed on the locked dementia unit and was ambulatory using a merriwalker. A review of the resident's clinical record from November 2013 through January 2014 revealed no documentation related to the December 2013 incident described by CNA #4. A Nurse's Note dated 1/06/2014 at 1:34 AM stated, "late entry 1-5-14 @813pm: Nurse was coming around corner and observed Resident #1 kissing the forehead of another resident. Nurse told this resident to stop and he did..." A social service note dated 12/19/2013 stated, "Residents Q assessment completed... able to make needs known. ...has short term memory problems. ...scored 6 on BIMS and 3 on mood. He may be verbally and physically abusive toward other residents. He may also be sexually inappropriate towards other female residents at times... Res (ident) spends most of his time in his room or walking around unit..." Review of a 12/2/2013 Incident Follow-Up and Recommendation Form stated, "...a staff member witnessed Resident A get punched in the back of the head/neck. Resident A's wheelchair turned over resulting in him lying on the floor on his right side... small skin tear... When asked what happened Resident A kept repeating, 'Did you see what he did to me?' Resident #1 stated that all day Resident A had been picking on him, but this time he pushed the wrong button..." A witness to the incident wrote in her/his statement, "I ... was sitting in my office about 4pm Wednesday afternoon when I heard a disagreement between the residents... I got up to check and found Resident #1 striking Resident A in the head, he then grabbed Resident A's wheelchair and dumped him/her out of it." In an interview with the surveyor on 1/17/2014 at 5:20 PM CNA #3 when asked about Resident #1's behaviors stated, "he likes the ladies, holds their hands". In an interview with the surveyor on 1/7/2014 at 5:25 PM CNA #2 when asked about Resident #1's behaviors stated that once while assisting the resident with a shower he stated, "This is not fair. You aren't naked, next time you take your clothes off." S/he stated s/he reported to the nurse and it had not happened again. In an interview with the surveyor on 1/17/2014 at 5:30 PM CNA #1 when asked about Resident #1's behaviors stated that sometime in December (2013) s/he was going to a meeting and walking through the dayroom on the Day springs hall when s/he saw Resident #1 kissing Resident #2 and touching her breast, "s/he had her shirt up". CNA #1 was not sure of the date or if anyone had reported the incident. S/he confirmed there were other residents and staff in the dayroom at the time of the incident. In an interview with the surveyor on 1/17/2014 at 7:00 PM Registered Nurse (RN) #1 confirmed s/he had observed the incident in the Dayspring's dayroom sometime in December (2013). S/he stated that a couple of the CNA's were giggling. RN #1 stated the resident was leaning down over Resident #2 whose top was up with her breast exposed "kissing her mouth as far as I can recall. I told him, No! I put Resident #2's top down. I went straight out to the nurse, do not remember if I relocated him or not." When asked if s/he reported the incident s/he stated, "I think" but RN #2 was unsure whom s/he reported the incident to. In an interview with the surveyor on 1/18/2014 at 3:25 PM CNA #7 stated that s/he witnessed Resident #1 "tongue kissing" Resident #2 sometime in December 2013. S/he stated that RN #1 was in the dayroom when the incident occurred, s/he was not sure who else was present. In an interview with the surveyor on 1/18/2014 at 3:20 PM CNA #6 stated that Resident #1 was "short tempered" and s/he observed the resident holding hands with other residents. S/he was not aware of any other behaviors In an interview with the surveyor on 1/17/2014 at approximately 7:15 PM the Director of Nurses and Administrator in Training stated they were unaware of the incident and that no one had told them about the incident with Resident #1. In an interview with the surveyor on 1/18/2014 at approximately 11:20 AM the Administrator stated s/he did not remember anyone telling her/him about the incident. On 01/17/2014 at approximately 7:30 PM the Director of Nurses and Administrator in Training were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-250, F-280, F-319 and F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility related to the failure of the facility to care plan, notify the physician/ personal representative, and document Resident #1's inappropriate sexual behavior in the facility dayroom during the month of December 2013. An Allegation of Compliance (AOC) was submitted by the facility on 1/18/2014. The actions listed in the AOC included the following: "...Corrective Action for resident/s found to be affected: Effective 1/17/14, Resident #1 has been provided 24-hr 1:1 observation by a Life Care Associate and will continue 24-hr 1:1 observation by a Life Care Associate until a psychiatric evaluation is completed by psychiatrist and determines he no longer requires 1:1 observation. This evaluation will be completed by 1/23/14. Physician notification of incident on 1/18/14; no orders received. Family notified by nursing staff on 1/18/14. His individualized behavior management plan, care plan, was reviewed and revised on 1/18/14 by the Assistant Social Worker. Revisions on behavior management plan includes praise for good behavior, let resident know when exhibits inappropriate behavior, and observe resident's interactions with others. The care plan was revised by an MDS nurse on 1/18/14 to read, "Can also be verbally aggressive; one episode on 1/5/14 and socially inappropriate (resisted care) or disruptive"; due to behaviors 1:1 observation 24/7 until seen by psychiatrist. On 1/18/14, our Medical Director notified a psychiatrist for psychiatric consult to be completed by 1/23/14. How other residents have been identified with the potential to be affected: 29 residents on the dementia unit have the potential to be affected. A skin integrity data collection report was completed on 1/17/14 by a licensed nurse for each resident on the dementia unit. No concerns noted. Social Services completed a new Social Service Assessment for all residents on the dementia unit on 1/18/14 to ensure the identity of potential resident behaviors. The DON will ensure that residents with behaviors will receive a psychological assessment with behavior recommendations by a psychiatrist. Appointments have been scheduled and all will be completed 1/31/14. Behavior interventions will be listed on the resident's individualized plan of care by 1/18/14 by Social Services staff. Staff on each shift will be aware of each resident's behavioral intervention by 1/18/14. The Charge Nurse ensures that behavioral interventions are followed daily by documenting on the behavioral monitoring sheets for each resident, each shift effective 1/18/14. In-service education r/t residents with behaviors, interventions, monitoring and documentation was provided by DON or ADON on and 1/18/14 to all staff, all shifts, who work on the dementia unit. Education will be provided to all shifts daily on the dementia unit starting 1/19/14 until all staff has been provided training prior to work. New staff hired will also be provided training. The Executive Director has informed Social Services staff of the issues involved with complete and accurate Behavioral Assessments, interventions, monitoring and staff training on 1/18/14. The Executive Director reviewed policies and procedures with Social Services staff on 1/18/14. The Social Service staff completed Social Service Assessments on all residents on the dementia unit on 1/18/14. All behaviors identified have been updated on each resident's behavior management plan and plan of care by Social Services staff..." Date of Compliance: 1/18/2014 Observations, interviews, and review of policy revealed the AOC submitted by the facility on 1/18/2014 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the care needs of residents with behaviors, the importance of timely interventions, monitoring, documentation and reporting. The Administrator was informed of this on 1/18/2014 at 7:00 PM. The Immediate Jeopardy at F-319 was removed but the citations remained at a lower scope and severity of "D". .