Every finding on record at Life Care Center of Hilton Head

Based on review of the facility policy, record review, and interviews, the facility failed to ensure Resident (R)26 was free from sexual abuse by R56. Due to both residents' cognitive status and diagnoses, the survey team utilized The Reasonable Person Approach when addressing this noncompliance.On 07/15/2025 at 8:38 PM, the State Agency determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations had caused or was likely to cause serious harm, psychosocial harm, serious impairment or death.On 07/15/2025 at 8:38 PM, the Administrator was notified that the failure to protect Resident (R)26 from sexual abuse by R56 constituted Immediate Jeopardy (IJ) at F600.On 07/15/2025 at 8:38 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 07/09/2025. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation.On 07/16/2025 at 5:41 PM, the facility provided an acceptable IJ Removal Plan. On 07/17/2025, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F600 at a lower scope and severity of D.An extended survey was conducted in conjunction with the Recertification Survey and Complaint Survey for non-compliance at F600, constituting substandard quality of care.Findings Include:Review of the facility's policy, with a reviewed date of 05/06/2025, titled, Abuse-Prevention, states, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation. Establishing a safe environment that supports, to the extent possible, a resident' consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as the identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship . Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as: Sexually aggressive behavior, and residents that require extensive nursing care and/or totally dependent on staff for the provision of care. Review of R56's Face Sheet revealed R56 was admitted to the facility on [DATE] with a readmission date of 02/17/25, with diagnoses including, but not limited to, metabolic encephalopathy, vascular dementia, and adult failure to thrive. Review of R56's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/24/25, revealed he had a Brief Interview for Mental Status (BIMS) of 5 out of 15, indicating he had severe cognitive impairment. Review of R56's Progress Note dated 07/09/25 at 9:13 PM revealed, Observed this resident masturbating in front of a female resident, (room [ROOM NUMBER]-A) in the hallway. Resident was standing beside the female resident, his penis visible and actively masturbation actions movement observed. Instructed the male resident to return to his room. Questioned the female resident, did he, (male resident), touch you? The female resident said, No, he was showing me his penis. Regional Director of Clinical Services was notified at 08:30 PM. Review of R56's Progress Note dated 07/10/25 at 3:06 AM revealed, Resident on 1:1 supervision per care plan intervention related to inappropriate behavior. No acute change in mental status/mood. Cooperative. Review of R26's Face Sheet revealed R26 was admitted to the facility on [DATE], with diagnoses including but not limited to, Huntington's Disease, depression, anxiety, and insomnia. Review of R26's Quarterly MDS with an ARD of 04/16/25, indicated she had a BIMS score of 7 out of 15, indicating she had severe cognitive impairment. During an interview on 07/15/25 at 3:12 PM, Registered Nurse (RN)1 revealed, there was an incident on [NAME] of Tuesday or Wednesday last week where a gentleman, R56, came out of his room and started playing with his genitals and was standing beside another resident, R26.RN1 stated that R56 did not touch R26 and he did not have his genitals in the direction of her.There were no other residents in the hall at the time.The event was intercepted by the nurse on duty, and I was considered a witness.We all had to complete a witness statement and there was an incident report written for the incident. RN1 further stated that R26 was not affected and did not know anything about it or was not in distress, as she has a debilitating disease, Huntington's, and she doesn't remember things sometimes. During an interview on 07/15/25 on 4:34 PM, with the Regional Director of Clinical Services revealed, R56 is confused, and she was notified by the charge nurse on 07/09/25 at 8:30 PM, that he went into R26's room and exposed himself.They both stated that R56 did not touch R26.She stated that they immediately completed a skin assessment and did not identify any new areas.It was a head-to-toe assessment of which we paid close attention to genital areas for any bruising or scratches. They put R56 on 1 to 1 supervision and frequent monitoring, but unsure for how long. During an interview on 07/15/25 at 6:30 PM, the Social Services Director (SSD) stated that to her knowledge she does not know of anyone that has an assessment for consensual sexual activity in this facility. She stated that R26 was, very with it and she could make her needs known, and that she understands and is sometimes understood. The SSD stated that the facility does a Mini Mental State Exam, on every resident every three months. I asked about the assessment for sexual activity again and she stated, she knows they have to provide a space for residents that verbalize they want to participate in sexual activity but did not provide a copy of the assessment that is completed for each resident that wishes to participate. During an interview on 07/15/25 at 7:16 PM, Licensed Practical Nurse (LPN)1 stated she was familiar with both R56 and R26. She stated she was coming out of another resident's room and R56 was standing beside R26, actively masturbating. R26 was laying in her Broda chair reclined, and R56 was standing by her face. LPN1 immediately told R56, Go to your room and asked R26 if R56 had touched her. R26 stated, No, he was showing me his penis. She then called the Corporate Director of Nursing (DON) and they took care of it. She was given two sheets of paper for the witness statements and then they began interviewing the residents to see if they had been touched or had any trauma. A Certified Nursing Assistant (CNA) was placed with R56 for 1:1 observation. She stated it would be classified as sexual abuse because R56 was exposing his private parts. She stated it was not classified as sexual during the in-services, it was only stated as abuse. LPN1 stated the incident wasn't consensual, but R26 was aware of what R56 was doing. During an interview on 07/15/25 at 7:50 PM with the Executive Director (ED) revealed she received a call from her Regional Clinical Director, and she came right over to the facility. At that time, they completed questionnaires and an investigation about the incident that occurred between R56 and R26. R26 stated R56 had came in her room and exposed himself. During the investigation, they provided education about abuse, but this incident was not classified as abuse because both residents stated they were fine and were not abused.On 07/16/2025 at 5:41 PM, the facility provided an acceptable IJ Removal Plan, which included the following:On 7 /9/25, the Licensed Practical Nurse (LPN) immediately separated Resident (R) 56 and Resident (R) 26.On 7/9/25, the Licensed Practical Nurse (LPN) completed a risk management on (R) 56. Notification was made to the Executive Director (ED), Regional Director of Clinical Services (RDCS), physician/Medical Director. A new intervention for 1:1 observation was initiated. No new orders were received from the physician.On 7/9/25, the Regional Director of Clinical Services (RDCS) completed risk management on (R) 26. Notifications were made to the Executive Director (ED), Regional Director of Clinical Services (RDCS), and physician/Medical Director.On 7/9/25, the Social Services Director completed a psychosocial interview with Resident (R) 26 and the resident did not appear to be in distress or anxious. Notification to resident representative was attempted by leaving a voicemail for a return call. On 7/10/25, the Social Services Director notified the resident representative about the incident. On 7/16/25, the Social Services Director completed a PHQ2to9 Psychosocial assessment and Resident ( R) 26 did not appear to have any anxiety, changes in mood or distress.On 7/9/25, the Director of Nursing (DON) completed a skin assessment on (R) 26. **No new skin issues were identified and no signs of abuse identified.On 7/9/25, the Regional Director of Clinical Services completed a Pain assessment on (R) 26. **No pain identified.On 7/11 /25, Resident (R) 56 was assessed by the physician. A new order received for Paxil for depression.On 7/15/25, the licensed practical nurse (LPN) received an order from the physician for Resident (R) 56 to be sent to the emergency room for evaluation. **No new orders were received. No indication for further psychiatric evaluation.On 7 /15/25, the Social Services Director reviewed and updated Resident (R) 56's behavior care plan.On 7/15/25, the Regional Director of Clinical Services (RDCS) added the intervention for Resident (R) 56 to be placed on 1:1 observation when he returns from the Emergency Room.On 7/16/25, Resident (R) 56's room was changed to the other Unit (Boyd Hall). Notifications were made to the following local and state agencies: The Medical Director was notified of the incident again by the Executive Director on 7/15/25. The local ombudsman was notified of the incident by the Executive Director on 7/16/25 The local police department was notified of the incident by the Executive Director on 7/16/25. The state survey agency was completed by the Executive Director on 7/16/25.The Executive Director (ED), Director of Nursing (DON), and Interdisciplinary Team completed a Root Cause Analysis (RCA) on 7/16/2025. The Root Cause Analysis identified: **The facility associates require re-education on Abuse policies and procedures, and behavior management policies to ensure the safety of residents from non-consensual sexual advances and potential of psychological harm related to unwanted sexual advances.All residents have the potential to be affected by the alleged deficient practice.All residents on [NAME] with a BIMS of 9 or higher were interviewed for any allegations of abuse/Neglect/Misappropriation by the Social Services Director and/or the Executive Director on 7/9/25. **No allegations of Abuse were identified.All residents on [NAME] with BIMS of 8 or less had a skin assessment completed to identify any potential unreported abuse by the Regional Director of Clinical Services (RDCS) and/or the Director of Nursing (DON) on 7/9/25. **No allegations of Abuse were identified.All resident Comment and Concern cards for the past 90 days were reviewed for any allegations of abuse/Neglect/Misappropriation by the Executive Director on 7/15/25. **No allegations of Abuse were identified.All resident council minutes for the past 90 days were reviewed for any concerns regarding allegations of abuse/neglect/misappropriation by the Executive Director on 7/10/25. **No allegations of Abuse were identified.The Regional Director of Nursing (RDCS) and Licensed Registered Nurse (RN) identified all residents with behaviors and ensured behavior Care Plans/Kardex were updated as indicated. This was completed on 7/16/25.On 7/16/2025, the Regional Director of Clinical Services provided education to the Executive Director (ED), Director of Nursing (DON), Staff Development Coordinator, and Social Services Director (SSD) on the following policies to ensure the safety of residents from non-consensual sexual advances and potential of psychological harm related to unwanted sexual advances:-Abuse - Identification of Types-Protection of Residents: Reducing the threat of Abuse and Neglect-Abuse Prevention-Abuse - Coordination with the QAPI Program and QAA Committee -Elder Justice Act Fact Sheet-Incident and Reportable Event Management-Person Centered Care Planning-Behavioral Health ServicesThe Director of Nursing (DON), Staff Development Coordinator (SOC), and/or licensed nurse will provide education to all associates on the following to ensure the safety of residents from non-consensual sexual advances and potential of psychological harm related to unwanted sexual advances:-Abuse - Identification of Types-Protection of Residents: Reducing the threat of Abuse and Neglect-Abuse Prevention-Abuse - Coordination with the QAPI Program and QAA Committee-Elder Justice Act Fact Sheet-Incident and Reportable Event Management-Person Centered Care Planning-Behavioral Health ServicesEducation was initiated on 7/9/25.As of 7/15/25, the facility has educated 81 out of 82 associates. *Any associate who has not completed training by (07/16/2025) will not be allowed to provide direct resident care until training is completed. The Executive Director (ED), Director of Nursing (DON), Staff Development Coordinator (SOC), and/or licensed nurse will provide education to all new associates upon hire during orientation, annually, and as needed.The Executive Director (ED) provided abuse and abuse reporting education to the resident council on 7/10/25. This education included sexual abuse education.Signage was posted by time clock identifying all allegations are to be reported to the Executive Director (ED) immediately, with her contact number. It also included a second person, the Director of Nursing (DON), and her contact number to be notified, when Executive Director (ED) cannot be reached. This was completed on 7/10/25.The Director of Nursing (DON) and/or licensed nurse will review (audit) (Audit #4 A Changes in behavior) all residents with changes in behavior during clinical grand rounds to identify potential causative factors, notify the physician and resident representative, and update the care plan/ Kardex as indicated to ensure the safety of residents from non-consensual sexual advances and potential of psychological harm related to unwanted sexual advances, five (5) times a week for four (4) weeks, then three (3) times a week for four (4) weeks, then one (1) time a week for four (4) weeks.The Medical Director reviewed and agreed with this plan of removal on 7/16/2025.The Acceptance of Compliance completion date is 7/16/2025.AD Hoc QAPI meeting was held on 7/16/25 regarding this plan of removal. Attendees were Executive Director (ED), Medical Director, Director of Nursing (DON), Staff Development Coordinator/Infection Preventionist Nurse (SDC/IPN), Social Services Director (SSD), Director of Rehab (DOR), and Health Information Manager (HIM).

Based on observation, record review, interview and manufacturer labelling, the facility failed to ensure that medications were securely stored on 1 of 4 medication carts observed during medication pass and further failed to ensure that expired and outdated medications were removed from 4 of 4 medications carts and 2 of 2 treatments carts.Findings include: Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals revised on 08/01/24 states, Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, dated 12/01/2007 and the latest revision date of 08/01/2024, states as the procedure under, General . 10. Facility should ensure medications and biological's that: 1) Have an expired date on the label; 2) Have been retained longer than recommended by the manufacturer or supplier guidelines; or 3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier . 22. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals . On 07/17/25 at approximately 7:57 AM, multiple bottles of over-the-counter medications (Acetaminophen 325 mg (milligram), Magnesium Oxide 400 mg, Multivitamin - Once A Day, Ferrous Sulfate 325 mg, Vitamin D3 1,000 mg, Vitamin B-12 1,000 mcg (micrograms) and Cranberry 500 mg) were sitting atop the unattended [NAME] 100 Hall medication cart next to the medication station with two wandering residents passing by and no one at or near the nursing station. On 07/17/25 at approximately 8:13 AM, Registered Nurse (RN)2 acknowledged that these medications were atop the medication cart and were unsecured. On 07/17/25 at approximately 11:52 AM, the Director of Nursing (DON) was informed of this finding and stated she expected all medications to be securely locked when not in use or being directly observed by a nurse. During an observation on 07/17/2025 at 10:32 AM, of the medication cart for the 400 Hall revealed: Bisacodyl Suppositories 10 milligrams (mg) with Lot #CZAKT013, 83 suppositories had expired on 06/25/2025. One can of Imperial Instant Food Thickener with the distributer as Sysco with Lot #3325 A4713 was expired on 06/23/2025. The expired biologicals were confirmed by the Director of Nursing (DON) and removed from storage. During an observation on 07/17/2025 at 10:55 AM, of the medication cart on Hall 500 revealed: Olopatadine Hydrochloride 0.1% eye drops with Lot #A230012 had expired on 12/2024. Spironolactone 25 mg tablets, 81 tablets, manufactured by Zydus Pharmacy, with RX#406817725 has a use by date of 07/15/2025. The expired medications were confirmed by the DON and removed from the cart. During an observation on 07/17/2025 at 11:15 AM, of the Hall 400 and 500 treatment cart revealed: One tube of Surgilube, Surgical Lubricant Sterile Bacteriostatic Cream with Lot #56314, Ref #281020537 was expired on 11/30/2023. The Surgilube expiration date was confirmed by the DON and removed from the treatment cart. During an observation on 07/17/2025 at 11:15 AM, of the 200 Hall medication cart revealed: Alprazolam 0.25 mg with Lot #100449895, 21 tablets was expired on 06/30/2025. The expired medication was confirmed by the DON and removed from the cart. During an observation on 07/17/2025 at 11:30 AM, of the 100 Hall medication cart revealed: Bisacodyl Suppositories with Lot #CZAK13, 85 suppositories were expired on 06/2025. One container of Sun [NAME] Fiber Powder, 19 ounces, 48 servings with Lot #4029625 was expired on 04/2025. The biologicals were confirmed as expired by the DON and removed from storage. During an observation on 07/17/2025 at 11:48 AM, of Hall 100 and 200 treatment cart revealed one tube of Fluocinonide Cream 0.05%, 30 grams with Lot #AD32357 was expired on 05/2025. Five Econolux 4 x 4 gauze sponges, Ref#416-105, Lot #99801007 expired on 06/01/2025. Boudreaux's Butt Paste one tube, Ref #281020537 with Lot #C21027 was expired on 09/2024. Surgilube 1 tube, Ref #281020537 with Lot #56314 was expired on 11/30/2023. The medications and biologicals were confirmed as expired by the DON and removed from storage.

Based on review of facility policy, observation, interview, and record review, the facility failed to ensure residents were provided showers or baths for 5 out of 5 residents and nail care for 1 of 5 residents reviewed for activities of daily living. Findings include:Review of the facility policy titled, Activities of Daily Living (ADL) with a reviewed date of 09/10/24, revealed, Residents will receive assistance as needed for completing ADLs. Additionally, A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of the facility policy titled, Refusal of Care or Treatment with a reviewed date of 09/05/24, revealed, If the resident refuses other care activities such as bathing, the facility should speak with the resident and/or resident representative to determine if the preference or tolerance for this activity has changed. The interdisciplinary team should work with the resident and/or resident representative to develop alternative options to provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care, and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. The policy also stated, Documentation of the refusal and above notifications should be present in the resident's medical record.1. Review of Resident (R)22's Face Sheet revealed she was admitted to the facility on [DATE]. Her diagnoses included, but was not limited to, encephalopathy (brain disorder), Type 2 diabetes mellitus, memory deficit, muscle weakness, hemiplegia (weakness) and hemiparesis (paralysis) affecting her dominant right side, and need for assistance with personal care.Review of R22's Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/25 revealed her Brief Interview for Mental Status (BIMS) score to be 9 out of 15, indicating moderate cognitive impairment. Rejection of care, including ADL care, was documented as, Behavior not exhibited. She needs partial/moderate assistance with showering/bathing self and supervision with personal hygiene.Review of R22's Care Plan revealed a focus of ADL assistance needed to maintain or attain highest level of function. Interventions included assisting with ADLs and shaving as needed.Review of R22's point of care records revealed she was scheduled for bathing on Tuesdays and Fridays. In July 2025, no documentation was found showing R22 had a shower from 07/01/25 - 07/17/25. In June 2025, she received a shower on 06/03/25, 06/06/25, and 06/10/25. In May 2025, R22 received a shower on 05/09/25, 05/13/25, and 05/30/25.2. Review of R23's Face Sheet revealed she was admitted to the facility on [DATE]. Her diagnoses included, but are not limited to, malignant neoplasm of endometrium (cancer of the uterus), muscle weakness, hemiplegia and hemiparesis of her left non-dominant side, depression, anxiety, and need for assistance with personal care.Review of R23's quarterly MDS with an ARD of 06/17/25 revealed her BIMS score to be 6 out of 15, indicating she has severe cognitive impairment. Rejection of care, including ADL care, was documented as, Behavior not exhibited. No data was found for functional abilities showing the assistance R23 needs for bathing.Review of R23's Care Plan revealed a focus of ADL assistance needed to maintain or attain highest level of function. Interventions included assisting with ADLs and shaving as needed.Review of R23's point of care records revealed she was scheduled for bathing on Mondays and Thursdays. In July 2025, R23 received a tub bath on 07/14/25. In June 2025, she received a tub bath on 06/02/25 and 06/05/25. She refused bathing on 06/19/25.3. Review of R44's Face Sheet revealed she was admitted to the facility on [DATE]. Her diagnoses included, but are not limited to, fracture of left humerus (upper arm bone), fracture of left wrist, stage 2 pressure ulcer, muscle weakness, neuritis and neuralgia (disorder of the nerves causing pain), unsteadiness on feet, and need for assistance with personal care.Review of R44's quarterly MDS with an ARD of 05/22/25 showed she has a BIMS score of 14 out of 15, indicating she has no cognitive deficit. Rejection of care, including ADL care, was documented as, Behavior not exhibited. She needs substantial/maximal assistance with showering/bathing self and supervision with personal hygiene.Review of R44's Care Plan revealed a focus of ADL assistance to maintain or attain highest level of function. Interventions included assisting with ADLs as needed and offering shaving if facial hair is visible.Review of R44's point of care records revealed she was scheduled for bathing on Mondays, Wednesdays, and Fridays. In July 2025, no documentation is found showing R44 received a shower or tub bath. R44 refused bathing on 07/16/25. In June 2025, no documentation is found showing R44 received a shower or tub bath. The point of care records for April 25 and May 25 do not include a section for bathing.4. Review of R56's Face Sheet revealed he was admitted to the facility on [DATE]. His diagnoses included, but are not limited to, metabolic encephalopathy (changes to brain function), chronic kidney disease, malnutrition, repeated falls, vascular dementia (cognitive impairment from decreased blood flow to the brain), high blood pressure, and need for assistance with personal care.Review of R56's quarterly MDS with an ARD of 06/24/25 revealed he has a BIMS score of 5 out of 15, indicating he has severe cognitive deficit. Rejection of care, including ADLs, is documented as, Behavior not exhibited. No data was found for functional abilities showing the assistance R56 needs for bathing.Review of R56's Care Plan revealed a focus of ADL assistance needed to maintain or attain highest level of function. Interventions included assisting with ADLs, offering to shave when needed, and notifying nurse if resident refuses.Review of R56's point of care records revealed he was scheduled for bathing on Thursdays and Saturdays. In July 25, R56 refused bathing on 07/10/25 and 07/12/25, and received a shower on 07/16/25. In June 2025, R56 refused bathing on 06/05/25, 06/19/25, and 06/21/25, and received a shower on 06/26/25. In May 2025, R56 received a shower on only 05/01/25. R56 refused bathing on 05/10/25, 05/15/25, 05/17/25, 05/22/25, 05/24/25, 05/29/25, and 05/31/25. In April 25, R56 received a shower on only 04/03/25 and 04/05/25. R56 refused bathing on 04/24/25.No documentation was found in the progress notes from 4/01/25 - 07/17/25 indicating the nurses were notified of R56's refusal for a shower or bath on the dates notated on the point of care records.5. Review of R61's Face Sheet revealed she was initially admitted to the facility on [DATE] with a readmission date of 05/16/19. Her diagnoses included, but are not limited to, multiple sclerosis (disease affecting the central nervous system), compression fracture of the lumbar vertebra, history of falling, muscle weakness, chronic pain syndrome, foot drop of left foot, bipolar disorder, depression, and need for assistance with personal care.Review of R61's quarterly MDS with an ARD of 05/15/25 revealed she has a BIMS score of 15 out of 15, indicating she has no cognitive deficit. Rejection of care, including ADL care, was documented as, Behavior not exhibited. She needs setup assistance with showering and bathing self and tub/shower transfer.Review of R61's Care Plan revealed a focus of, The resident has an ADL self-care performance deficit r/t multiple sclerosis, impaired balance, chronic pain syndrome, muscle weakness, monoplegia of lower limb, hx of fractures, overreactive bladder. Interventions included offering to shave facial hair when visible, washing hair/drying hair once a week on shower day, and providing a sponge bath when a full bath or shower cannot be tolerated. Additionally, she requires supervision to limited assistance with setup for bathing/showering.Review of R61's point of care records revealed she was scheduled for bathing on Wednesdays and Saturdays during day shift. In July 2025, R61 received a shower on 07/02/25, 07/09/25, 07/12/25, and 07/16/25. In June 2025, R61 received a shower on only 06/11/25. In May 2025, R61 received a shower on 05/03/25, 05/07/25, 05/10/25, 05/14/25, 05/17/25, 05/28/25. In April 2025, R61 received a shower on 04/02/25, 04/05/25, 04/09/25, 04/12/25, and 04/16/25.During an observation on 07/15/25 at approximately 11:00 AM, R56's fingernails were long and had grown over the tip of his fingers and thumbs. His thumb nail on his left hand was approximately 0.5 cm above the tip of his thumb.During an observation on 07/17/25 at 11:15 AM, R56 showed the surveyor his hand. His nails were unchanged from 07/15/25 and were approximately 0.5 cm longer than the tips of his fingers and thumbs.During an interview with R56 on 07/15/25 at approximately 11:00 AM, he stated he had asked staff members to cut his nails numerous times over the past 2-3 weeks, but no one had returned to cut them.During an interview for Resident Council Meeting on 07/16/25 at 3:00 PM, residents revealed dissatisfaction with bathing/showering frequency. R44 stated, We have to beg like a dog for a shower. R22 stated she had not had a shower for two months. Other residents stated the frequency is supposed to be two times per week; however, they all agreed this does not happen. R22, R23, and R61 stated the staff will find any reason to say they (the residents) refused their showers. The residents stated there should be a shower schedule that is adhered to. When asked if they have shared their concerns with anyone at the facility, all revealed they have voiced their concerns to everyone every day.During an interview with Certified Nursing Assistant (CNA)3 on 07/17/25 at 11:25 AM, she revealed she has worked at the facility for 6-6 1/2 years. My duties today are to be the 1:1 person for R56 and to encourage him to take a shower today. Sometimes, he is not very cooperative, but most times, he will do what we ask. CNA3 stated she noticed R56's nails were long. Her plan was to ask the nurse to cut his nails. She stated, They don't like the CNAs to cut the residents' nails because some of the residents are diabetic. So, usually, we let the nurse know when a resident needs their nails cut, and the nurse will come in and cut them. CNA3 also revealed, We document showers in the chart under the point of care section. Residents usually get showers twice a week. If a resident refuses, we can document it in there, and we also let the nurse know because this can become a behavior problem, and the residents' hygiene is important. If a resident refuses to bathe, I usually will offer to do the shower later in the day.During an interview with Registered Nurse (RN)1 on 07/17/25 at 2:11 PM, she revealed, If a resident is on Hospice, the Hospice CNAs do nail care. As for our CNAs, they say they don't have the stuff to cut nails. RN1 also revealed, When residents refuse showers, I will try to help. For example, there is one resident who refuses a shower constantly, but because she likes me, I will ask her and offer to help. The responsibility is the Director of Nursing's (DON) to talk to the resident when they refuse showers to see about shower time changes.During an interview with CNA1 on 07/17/25 at 3:50 PM, she was shown the point of care record for R22 showing blank bathing entries. She revealed, If it (the point of care record) is blank like that, it means nothing was recorded. It probably means nothing was done, and the person did not get a bath that day. Sometimes we have trouble with the tablets too, so we can't document what we did.During an interview with CNA2 on 07/17/25 at 3:55 PM, she revealed, We record everything in this tablet. We can't see a running look at the month to see what has been done. If we give a bath, we have to show we did it in the chart by recording in this tablet.During an interview with the DON on 07/17/25 at 2:35 PM, she revealed, The expectations of the CNAs for documenting showers/bathing is to document every shift what they did for the residents. It is part of their job. It will be mine and the ADON's responsibility to ensure documentation is completed. If it's not documented, it's not done. The DON revealed they have not been using shower sheets in this facility, and she plans to implement this to ensure showers are being done. For residents who refuse showers, she revealed the resident has a right to refuse, but the CNA needs to notify nurse. Maybe they need to change the person giving the shower. They need to document the refusal and offer an alternative. If it happens repeatedly, we need to let the Medical Director know because it could be a behavior issue that needs to be addressed. DON also revealed, I honestly don't know who is responsible for nail care at this facility. I will find out.During an interview with the Executive Director (ED) with the ED2 present on 07/17/25 at 3:33 PM, she revealed, When a resident refuses bathing, CNAs are supposed to chart in the point of care record to say the resident refused. Some residents will continue to refuse. The CNA should go back and try to coax them into bathing especially if incontinent. The refusal should be charted in the point of care record. They should also be telling the nurse if the resident refuses. If the resident is not diabetic, the activities staff may be who cuts the resident's nails. However, we have not had an activities person until a few weeks ago.During a follow-up interview with the ED on 07/17/25 at 4:00 PM, she reviewed the point of care record for R22 showing blank bathing entries. She stated, The blanks in the chart doesn't mean the bathing wasn't done. It means no one documented it. We can't prove it was done though.

Based on review of facility policy, record review, and interviews, the facility failed to ensure an allegation of abuse was reported in a timely manner. Specifically, the facility was notified of an allegation of sexual abuse on 07/09/25 and did not report the allegation of abuse to the State Agency until 07/16/25.Findings include:Review of the facility's policy, with a reviewed date of 09/05/24, titled, Incident and Reportable Event Management, states, 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 2hours 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 to 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.Review of R56's Face Sheet revealed R56 was admitted to the facility on [DATE], with a readmission date of 02/17/25, with diagnoses including, but not limited to, metabolic encephalopathy, vascular dementia, and adult failure to thrive.Review of R56's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/24/25 revealed he has a Brief Interview of Mental Status (BIMS) of 5 out of 15, indicating he had severe cognitive impairment.Review of R56's Progress Note dated 07/09/25 at 9:13 PM revealed, Observed this resident masturbating in front of a female resident (room [ROOM NUMBER]-A) in the hallway. Resident was standing beside the female resident, his penis visible and actively masturbation actions movement observed. Instructed the male resident to return to his room. Questioned the female resident, did he, (male resident), touch you? The female resident said, No, he was showing me his penis. Regional Director of Clinical Services was notified at 08:30 PM. Review of R26's Face Sheet revealed R26 was admitted to the facility on [DATE] with diagnoses including but not limited to, Huntington's Disease, depression, anxiety, and insomnia. Review of R26's Quarterly MDS with an ARD of 04/16/25 indicated she had a BIMS score of 7 out of 15, indicating severe cognitive impairment. During an interview on 07/15/25 at 3:12 PM, Registered Nurse (RN)1 revealed that there was an incident on [NAME] on Tuesday or Wednesday last week where a gentleman, R56, came out of his room and started playing with his genitals and was standing beside another resident, R26. RN1 stated that R56 did not touch R26 and he did not have his genitals in the direction of her. There were no other residents in the hall at the time. The event was intercepted by the nurse on duty, and I was considered a witness. RN1 stated that R26 was not affected and did not know anything about it or was not in distress, as she has a debilitating disease, Huntington's, and she doesn't remember things sometimes. During an interview on 07/15/25 at 4:34 PM, the Regional Director of Clinical Services revealed R56 is confused, and she was notified by the charge nurse on 07/09/25 at 8:30 PM that R56 went into R26's room and exposed himself. They both stated that R56 did not touch R26. She stated that they immediately completed a skin assessment and did not identify any new areas. It was a head-to-toe assessment of which we paid close attention to genital areas for any bruising or scratches. They put R56 on 1 to 1 supervision and frequent monitoring but were unsure for how long. The Regional Director of Clinical Services stated that since they did not touch each other, they opted to not report the incident to the state. They had completed a thorough investigation which was completed by 3:00 AM, and the findings were unsubstantiated. She further stated that she is aware that abuse reporting is within two hours or immediately, but since they had completed an investigation, they opted not to report the incident.During an interview on 07/15/25 at 7:16 PM, Licensed Practical Nurse (LPN)1 stated she was familiar with both R56 and R26. She stated she was coming out of another resident's room, and R56 was standing beside R26, actively masturbating. R26 was lying in her Broda chair reclined, and R56 was standing by her face. LPN1 immediately told R56, Go to your room, and asked R26 if R56 had touched her. R26 stated, No, he was showing me his penis. LPN1 stated she then called the Corporate Director of Nursing (DON), and they took care of it. LPN1 further stated it would be classified as sexual abuse because R56 was exposing his private parts. LPN1 stated the incident wasn't consensual, but R26 was aware of what R56 was doing. LPN1 concluded that management is responsible for reporting once they are made aware. During an interview on 07/15/25 at 7:50 PM the Executive Director (ED) revealed she received a call from her Regional Clinical Director, and she came right over to the facility. At that time, they completed questionnaires and an investigation about the incident that occurred between R56 and R26. During the investigation, they provided education about abuse, but this incident was not classified as abuse because both residents stated they were fine and were not abused.

Based on review of facility policy, observation, record review, and interview, the facility failed to ensure that a nutritional supplement was accurately measured as to volume as specified in physician orders for 1 of 5 residents observed during medication pass administration.Findings include:Review of the facility policy titled Administration of Medications reviewed on 09/16/24 states, Right Dose. Check the MAR (Medication Administration Record) and the doctor's order before medicating. Use standard measuring devices such as syringes, graduated cups, or scaled droppers.Review of Resident (R)6's Face Sheet revealed R6 was admitted to the facility on [DATE], with diagnoses including but not limited to, protein-calorie malnutrition.On 07/17/25 at approximately 8:18 AM, during medication pass observations for R6 revealed Registered Nurse (RN)2 poured Med Pass 2.0 Vanilla into a plastic cup without measuring the amount. When asked how much she had poured into the plastic cup, RN2 stated she had no way of measuring and did not know how much she had poured. On 07/17/25 at approximately 8:33 AM, RN2 administered medications and the Med Pass 2.0 Vanilla nutritional supplement to R6 without determining the amount of Med Pass 2.0 Vanilla being administered. On 07/17/25 at approximately 8:38 AM, RN2 acknowledged that she had not measured the amount of Med Pass 2.0 Vanilla that she had administered to R6. On 07/17/25 at approximately 10:15 AM, a review of the Physician Orders for July 2025 revealed an order dated 07/16/25, which specified, 2 Cal Med Pass Supplement three times a day give 120 ml (milliliter) tid (three times daily) and a review of the EMR (electronic medical record) MAR (medication administration record) revealed the same Physician Order for the amount to be administered. On 07/17/25 at approximately 10:28 AM, a review of the Care Plan for R6 revealed, The resident has unplanned/unexpected weight loss r/t (related) Poor food intake [Nutrition/Weight Loss], Resident will consume sufficient caloric intake to sustain adequate nutritional needs. and Give the resident supplements as ordered. Further review of the Care Plan revealed, Resident at risk for weight fluctuation r/t heart failure, h/o (history of) edema, and diuretic regimen in place. Resident has experienced a significant weight loss, Resident will consume sufficient caloric intake to sustain nutritional needs. and Give the resident supplements as ordered. Alert nurse/dietician if not consuming on a routine basis. On 07/17/25 at approximately 10:53 AM, review of the EMR revealed, 7/11/25 RAR meeting held; currently resident is at 131.4 lbs (pounds), which is a decrease of 3% (percent) in one month. PO (oral) intake of her regular diet is at 50% of all meals. Resident is written for and provided Med pass 120 ml tid. Will continue to monitor weights weekly. On 07/17/25 at approximately 11:52 AM, the Director of Nursing was informed of this finding, and she stated she expected all medications to be measured correctly before administered to a resident and showed that there were graduated medicine cups on the Hall 100 medicine cart.

Based on review of facility policy, record review, and interview, the facility failed to accurately document Resident (R)510's advance directives, for 1 of 2 residents. Specifically, R510 had orders and signed documentation requesting Do Not Resuscitate (DNR), however R510's Care Plan documented Full Code. Findings include: Review of the facility policy titled, Advance Directives and Advance Care Planning with a reviewed date of [DATE], documented, Residents have the right to self-determination regarding their medical care. This includes the right of an individual to direct his or her own medical treatment, including the right to execute or refuse to execute an advance directive . Procedure 15. Documentation in the Minimum Data Set (MDS) should reflect the appropriate advance directives . 16. Do Not Resuscitate (DNR) - . all Life Care Centers of America's residents receive full resuscitative measures unless a DNR is written in the resident's medical record and is identified in the resident's advance directive . The following procedures are to be enforced: c. DNR order is flagged appropriately on the resident's chart to alert staff as to status. f. The DNR order is incorporated into the resident's care plan . Review of R510's Face Sheet revealed R510 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, hyperlipidemia, and erythematous condition. Further review of the Face Sheet revealed R510's code status was documented as Do Not Resuscitate/Comfort Measures Only. Review of R510's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed R510 had a Brief Interview for Mental Status Score (BIMS) of 3 out of 15, indicating R510 had severe cognitive impairment. Review of R510's Physician Orders revealed an order with a start date of [DATE] which documented Do Not Resuscitate/Comfort Measures Only. Review of R510's Hard Chart (binder containing paper copies of medical records) revealed a document titled SC Physician Orders for Scope of Treatment dated [DATE], revealed code status of R510 was DNR, comfort measures only. Review of R510's Hard Chart revealed a document titled SC Emergency Medical Services dated [DATE] indicated R510's code status was DNR. Review of R510's Hard Chart revealed a written order dated [DATE], which documented, Resident's son request DNR/Comfort Measures Only. Review of R510's Baseline Care Plan signed on [DATE], indicated Advance Directives: Full Code. Review of R510's Care Plan initiated on [DATE], revealed, Resident has Advance Directives . CPR - Full Code, with a goal indicating, Resident's Advance Directives will be honored. Intervention in this Care Plan with a date initiated of [DATE], revealed, Code status will be reviewed on a quarterly basis and PRN (as needed). Another intervention with a date initiated of [DATE] and a revision date of [DATE], revealed, Resident has decided to remain a Full Code. During an interview on [DATE] at 2:17 PM, Licensed Practical Nurse (LPN)1 stated, Her family never came back to complete the admission process. I didn't do her care plan. If something were to happen and we did the opposite of what was documented, it would not be good. During an interview on [DATE] at 2:26 PM, the Director of Nursing (DON) stated, She has dementia and is a wanderer. When a patient is first admitted they will automatically be full code, until we verify their code status. If the family is not present, then we have to wait until we can confirm. The staff doesn't follow the care plan when it comes to advance directives. If someone is coding, we run and get the hard chart to verify the status. Care plans get updated quarterly and as needed. The care plan should have been updated immediately when the DNR was verified. During an interview on [DATE] at 3:08 PM, Registered Nurse MDS Coordinator (RN)1 revealed, At that time we had a care plan meeting with the family, the family decided to do the DNR. The care plan meeting was done on Monday. Baseline, I do within 48 hrs. If the family is not available, we make a note of that. Quarterly, Annual and as needed, significant change. Advance directives should be updated immediately, this was my mistake.

Based on observation, interview, record review, and review of facility policy, the facility failed to revise Resident (R)4's Care Plan to reflect refusal of Activities of Daily Living (ADL) care in a timely manner, for 1 of 3 residents reviewed for Care Plans related to ADL Care. Findings include: Review of the facility policy titled Comprehensive Care Plans and Revisions last revised on 08/22/23 revealed, The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. Procedure includes: the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery this can include; additional interventions on existing problems; updating goal or problem statements; adding a short-term problem, goal, and interventions to address a time limited condition. Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia with psychotic disturbance, muscle weakness, anxiety disorder, and major depressive disorder. Review of R4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/24, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicates R4 had moderate cognitive impairment. Review of R4's Care Plan last revised on 12/06/23 revealed, [R4] has an ADL self-care performance deficit related to limited mobility, dementia, impaired balance, non-ambulatory status, depression, anxiety, anemia, and morbid obesity. Interventions include the resident is to be up and dressed, and in her wheelchair after lunch for two hours daily. During an observation on 06/04/24 at 10:47 AM, revealed R4 was asleep in her bed in a night gown with facial hair noted to the resident's upper lip. An attempted interview was declined by R4. During an observation on 06/04/24 at 12:15 PM, revealed R4 in bed asleep, in night gown, with facial hair noted to her upper lip. During an observation on 06/04/24 at 2:24 PM, revealed R4 in bed asleep, in night gown, with facial hair noted to her upper lip. During an interview on 06/04/24 at 3:51 PM, R4's Resident Representative revealed that R4 has been sleeping more during the day but would like the resident to get out of bed and dressed appropriately at least for a few hours during the day when possible. During an observation and interview on 06/05/24 at 8:50 AM, revealed R4 still had facial hair noted to her upper lip. R4 was awake and in bed, in night gown alert but pleasantly confused. An attempted interview with R4 revealed that she has cognitive impairment, during the attempted interview R4 began to pick at her facial hair when questioned about it. During an observation on 06/06/24 at 8:15 AM, revealed R4 with facial hair noted to her upper lip, R4 was finished with breakfast and laying in bed in a nightgown. During an interview on 06/06/24 at 1:20 PM, Certified Nursing Assistant (CNA)4 revealed that R4 often refuses to get out of bed during the day and is awake during the morning most days but likes to go back to sleep after lunch. CNA4 stated that she was unaware that R4's Care Plan states that she is to be dressed after lunch and out of bed in her wheelchair. During an interview on 06/06/24 at 3:14 PM, CNA6 revealed they are the resident's assigned CNA for today and was the resident's CNA on 06/05/24, and provided R4 with a shower on 06/05/24. CNA6 stated that the resident is often resistive to care but was able to redirect the resident on 06/05/24 and make her more agreeable to a shower. CNA6 stated that they have nowhere to document if a resident refuses to be shaved in their system, so they tell nursing staff and it is documented in the nurses notes. During an interview on 06/06/24 at 3:39 PM, the Director of Nursing (DON) revealed staff are required to update changes with resident within 7 days after the comprehensive assessment and as needed with resident changes. The DON further stated that she expects staff to document refusal in the EMR within 48 hours so that the MDS coordinator and IDT team can revise the resident care plan to reflect their behaviors. The IDT team also involve family and make them agreeable with the plan of care before finalizing the care plan, but care plans are updated on a as needed basis.

Based on observations, interview, record review, and review of facility policy, the facility failed to offer/provide Resident (R)4, a dependent resident, with Activities of Daily Living (ADL) care related to facial hair, for 1 of 3 residents reviewed for ADL care. Findings include: Review of facility policy titled Activities of Daily Living: last revised 02/12/24 revealed The resident will receive assistance as needed to complete ADLs. Any change in the ability to perform ADLs will be reported to the nurse. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services that ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that a resident who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene. Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia with psychotic disturbance, muscle weakness, anxiety disorder, and major depressive disorder. Review of R4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/24, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicates R4 had moderate cognitive impairment. Review of R4's Care Plan last revised on 12/06/23 revealed, [R4] has an ADL self-care performance deficit related to limited mobility, dementia, impaired balance, non-ambulatory status, depression, anxiety, anemia, and morbid obesity. Interventions include the resident is to be up and dressed, and in her wheelchair after lunch for two hours daily. During an observation on 06/04/24 at 10:47 AM, revealed R4 was asleep in her bed, in a night gown, with facial hair noted to the resident's upper lip. An attempted interview was declined by R4. During an observation on 06/04/24 at 12:15 PM, revealed R4 in bed asleep, in night gown, with facial hair noted to her upper lip. During an observation on 06/04/24 at 2:24 PM, revealed R4 in bed asleep, in night gown, with facial hair noted to her upper lip. During an interview on 06/04/24 at 3:51 PM, R4's Resident Representative revealed that R4 has been sleeping more during the day but would like the resident to get out of bed and dressed appropriately at least for a few hours during the day when possible. During an observation and interview on 06/05/24 at 8:50 AM, revealed R4 with facial hair noted to her upper lip, awake in bed, in night gown, alert but pleasantly confused. An attempted interview with R4 revealed that she has cognitive impairment, during the attempted interview R4 began to pick at her facial hair when questioned about it. During an observation on 06/06/24 at 8:15 AM, revealed R4 with facial hair noted to her upper lip, R4 was finished with breakfast and laying in bed in a nightgown. During an interview and observation on 06/06/24 at 1:20 PM, Certified Nursing Assistant (CNA)4 revealed that CNA's are responsible for trimming residents facial hair, and it is completed on an as needed basis. CNA4 further stated that they trim facial hair when it reaches a certain length, and agreed that R4 had enough facial hair for staff to trim at this time. During an interview on 06/06/24 at 2:42 PM, the Director of Nursing (DON) revealed that CNA's are responsible for providing residents with ADL care such as shaving/grooming residents on an as needed basis and should be offered to residents at least two times a week during their shower days. The DON further stated that if a resident refuses to have ADL care performed, the CNA's are responsible for informing nursing staff so it can be documented in the resident's record. During an interview on 06/06/24 at 3:14 PM, CNA6 revealed they are the resident's assigned CNA for today and was the resident's CNA on 06/05/24, and provided R4 with a shower on 06/05/24. CNA6 stated that the resident was resistive to care yesterday but she eventually was able to redirect the resident and make her agreeable to take a shower, due to the resident's agitation CNA6 did not offer to trim R4's facial hair but told the nurse. CNA6 stated that they have nowhere to document if a resident refuses to be shaved in their system, so they tell nursing staff and it is documented in the nurses notes.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that medications were properly stored and secured for Resident (R)15, for 1 of 1 residents reviewed. Findings include: Review of facility policy titled, , Storage and Expiration Dating of Medication, Biologicals with an effective date of 12/01/07, revealed, Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Facility should store bedside medications or biologicals in a locked compartment within the resident's room. Facility should ensure that only Facility representatives and the appropriate resident maintains the keys, access cards, electronic codes, or combinations which open the locked compartment. Review of R15's Face Sheet revealed R15 was admitted to the facility on [DATE], with diagnoses including but not limited to: type 2 diabetes, chronic obstructive pulmonary disease, hypertension, and heart disease. Further review of R15's Face Sheet documented, Special Instructions: Please do not order medications from Omnicare. Resident will receive medications from CHAMPVA Med-By-Mail East- 1(866)229-7389. Medications will be mailed to son and he will deliver them to the facility. Medications will come in 3 month supply. Fax number to CHAMPVA (MBM) 1-(303) [PHONE NUMBER] for medication changes or any new medications. PLEASE CALL CHAMPVA WHEN MEDICATIONS ARRIVE AND LET THEM KNOW WE RECEIVE MEDICATIONS AND THEY WILL START REFILL PROCESS. Review of R15's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/26/24, revealed R15 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R15 was cognitively intact. Review of R15's Medication Self Administration Review with an agreement date of 04/18/22, revealed R15 is capable of self administering the following medications: Tylenol 325 Q6H PRN (every 6 hours as needed), hair skin and nails vitamin 2 tabs daily, stopain extra strength roll for muscle pain, menthol 2.5% muscle rub cream. Further review of the Self Administration Review revealed a comment stating, only the medications listed above . During an observation & interview on 06/04/24 at 11:25 AM, revealed R15's room contained two plastic bins containing medications. The plastic bins were stored above a wardrobe closet in R15's room. Observation of the plastic bins revealed the bins were not locked or secured. The plastic bins contained the following medications: Meclizine HCL 25 MG Chew TAB 90 Lisinopril 20 MG Tab 60 Metoprolol Succinate 100 MG SA Tab 90 Gabapentin Capsules USP 300 MG 270 Pantoprazole NA 40 MG EC Tab 90 Losartan 25 MG Tab 90 Dapagliflozin 10 MG Tab 8 bottles 30 Amlodipine Besylate 10 MG Tab 90 Loperamide HCL 2 MG Cap 2 bottles 30 Furosemide 20 MG Tab 5 bottles 90 Albuterol Inhaler 90 mcg-1 box Premarin 0.625mg-1 box Combivent Inhaler 100 20mcg-9 boxes Fluticasone 100/50-1 box Finger stick lancets-3 boxes R15 stated, They didn't have enough room in the drawer to keep all my meds, so they keep it in here. During an interview on 06/06/24 at 8:53 AM, the Director of Nursing (DON) revealed, R15 gets her meds delivered from Veterans Administration (VA), R15's son is a physician and he is scared that she will run out of medication. R15's son put them (medications) up there where R15 couldn ' t reach it. The DON further stated, We do room rounds every day and the staff never mentioned it. Based on our policy, the medication has to be stored in a secured location, and it was up high to where she couldn't reach it. The bins are clipped shut. The resident is a special case and she gets anxiety. We did what we thought was fit, by keeping it up high and clipping them shut. During an interview on 06/06/24 at 8:57 AM, License Practical Nurse (LPN)1 revealed, R15's son always comes in bringing stuff. And he wont tell us what he bringing in. During an interview on 06/06/24 at 9:04 AM, Certified Nursing Assistant (CNA)5 stated, I never paid attention to it. There was medication inside the closet. The medication was in boxes. During a follow up interview on 06/06/24 at 9:06 AM, R15 stated, I keep my meds in here for about 8 months. They [facility staff] said they didn't have anywhere to put it [medications]. It used to be in paper boxes, my son bought the plastic bins. They never had zip ties or locks on it.

Based on National Pressure Injury Advisory Panel, record review, interview, and observation, the facility failed to failed to provide physician supervision of a pressure ulcer for Resident (R)49's right foot, for 1 of 4 residents reviewed for pressure ulcers. Findings include: Review of the National Pressure Injury Advisory Panel, titled, Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide, dated 2019 revealed under recommendation, Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage 3: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an unstageable Pressure Injury. Review of R49's Face Sheet revealed the facility admitted R49 on 02/07/24, with diagnoses including but not limited to: hip fracture, pressure ulcer of right heel unstageable, weakness, and orthostatic hypotension. Review of R49's skin/wound note dated 02/07/24 at 3:14 PM, revealed, [R49] admitted today with a dehisced surgical wound on his left buttock due to a debridement of a wound as well as a abscess. Resident also has a DTI on right heel measuring 5x6.4cm. and is dry eschar with some granulation tissue noted on the dorsal side. Medical Doctor (MD) is aware of present treatments for these wounds. Review of Nursing Wound Observation dated 02/07/24, recorded R49's right heel as an unstageable pressure ulcer with necrotic tissue to 75% of the wound bed. Review of Nursing Wound Observation dated 03/20/24, recorded R49's right heel as unstageable deep tissue injury improving with 60% necrotic tissue. Review of Nursing Wound Observation dated 04/24/24, recorded R49's right heel as a stage 2 after surgeon debrided the wound. Review of Nursing Wound Observation dated 05/08/24, recorded R49's right heel as a stage 2 improving with granulation tissue present. No slough was recorded. Review of Nursing Wound Observation dated 05/15/24, recorded R49's right heel as a stage 2 improving, with slough 10% and granulation tissue. Serous drainage was noted. Apply aquacell AG (an absorbant dressing with ionic silver, a proven broad spectrum antimicrobial) to right heel, cover with mepore dressing Monday, Wednesday, Friday. Review of Nursing Wound Observation dated 05/29/24, recorded R49's right heel as a stage 2, unchanged with 10% slough noted. Apply gauze moistened with Dakins solution to right heel wound, apply mepore dressing and float heels when in bed. Review of Nursing Wound Observation dated 06/05/24, recorded R49's right heel as a stage 2 unchanged, with 10% slough. Apply gauze moistened with Dakins solution to right heel wound, apply mepore dressing and float heels when in bed. During an observation on 06/05/24 at 11:41 AM, of R49's right heel wound with Licensed Practical Nurse (LPN)2, revealed the heel presents as a large open wound, observed with thick black necrotic tissue covering approximately 60% of the open area. There was also tan slough, throughout the remaining area with some red beefy tissue. No odor was noted. The heel had redness and some inflammation. Review of Physician Progress Notes, since R49's admission revealed the following: 02/12/24 with diagnosis cellulitis left buttock, continue Augmentin and doxycycline for wound infection. Seen by wound nurse, discussed case with her. 02/23/2024 cellulitis left buttock, Seen by wound nurse, discussed case with her. 02/14/2024 cellulitis left buttock, Seen by wound nurse, discussed case with her. 02/15/2024 cellulitis left buttock, Seen by wound nurse, discussed case with her. 02/19/2024 cellulitis left buttock, Seen by wound nurse, discussed case with her. 02/20/2024 sacral decubitus ulcer improving, no infection, I examined [R49] with [LPN2], his wound is improving, look clean. Continue Augmentin and doxycycline for wound infection. Seen by wound nurse, discussed case with her. 02/21/24 sacral decubitus ulcer improving, no infection. I examined [R49] with [LPN2], his wound is improving, look clean 02/21. Continue Augmentin and doxycycline for wound infection. Seen by wound nurse, discussed case with her. 02/22/24 sacral decubitus ulcer improving, no infection. I again discussed with [R49] that his sacral wound would not heal unless he spent more time of the bed offloading his weight off of the wound. I examined [R49] with [LPN2], his wound is improving, look clean 2/21. Continue Augmentin and doxycycline for wound infection. Seen by wound nurse, discussed case with her. 02/23/24 sacral decubitus ulcer improving, no infection. I remind [R49] and nursing staff and therapy to offload his weight from the wound, I again discussed with [R49] that his sacral wound would not heal unless he spent more time of the bed offloading his weight off of the wound. I examined [R49] with [LPN2], his wound is improving, look clean 2/21. Continue Augmentin and doxycycline for wound infection. Seen by wound nurse, discussed case with her. 02/26/24 sacral decubitus ulcer improving, no infection. MRSA in the buttock wound. I remind [R49] and nursing staff and therapy to offload his weight from the wound, I again discussed with [R49] that his sacral wound would not heal unless he spent more time of the bed offloading his weight off of the wound. I examined [R49] with [LPN2], his wound is improving, look clean 2/21. I asked [R49] to spend the day in his chair, bed only to sleep. Explained this will help his wound healing. Continue Augmentin and doxycycline for wound infection. Seen by wound nurse, discussed case with her. 02/27/24 sacral decubitus ulcer improving, no infection. I remind [R49] and nursing staff and therapy to offload his weight from the wound, I again discussed with [R49] that his sacral wound would not heal unless he spent more time of the bed offloading his weight off of the wound. I examined [R49] with [LPN2], his wound is improving, look clean 2/21. I asked [R49] to spend the day in his chair, bed only to sleep. Explained this will help his wound healing. Continue Augmentin and doxycycline for wound infection. Seen by wound nurse, discussed case with her. 02/28/24 sacral decubitus ulcer improving, no infection. I debrided his sacral wound at bedside 2/28, 20 min. Continue to speand more time off the bed to help offloading weight from his wound. I remind [R49], nursing staff and therapy to offload his wound. 02/29/24 sacral decubitus ulcer improving, no infection. I debrided his sacral wound at bedside 2/28, 20 min. Continue to speand more time off the bed to help offloading weight from his wound. I remind [R49], nursing staff and therapy to offload his wound. 03/01/24 sacral decubitus ulcer improving, no infection. I debrided his sacral wound at bedside 2/28, 20 min. Continue to speand more time off the bed to help offloading weight from his wound. I remind [R49], nursing staff and therapy to offlaod his wound. 03/04/24 sacral decubitus ulcer improving, no infection. I debrided his sacral wound at bedside 2/28, 20 min. Continue to speand more time off the bed to help offloading weight from his wound. I remind [R49], nursing staff and therapy to offlaod his wound. 03/05/24 sacral decubitus ulcer improving, no infection. I debrided his sacral wound at bedside 2/28, 20 min. Continue to speand more time off the bed to help offloading weight from his wound. I remind [R49], nursing staff and therapy to offlaod his wound. 03/06/24 sacral decubitus ulcer improving, no infection. I debrided his sacral wound at bedside 2/28, 20 min. Continue to speand more time off the bed to help offloading weight from his wound. I remind [R49], nursing staff and therapy to offlaod his wound. 03/22/24 sacral decubitus ulcer improving, no infection. I started Augmentin twice a day for 7 days. I will send him back to surgery for an incision and drainage. Continue to speand more time off the bed to help offloading weight from his wound. I remind [R49], nursing staff and therapy to offlaod his wound. 04/01/24 sacral decubitus ulcer improving, no infection. Cellulitis left buttock. I started Augmentin twice a day for 7 days. I will send him back to surgery for an incision and drainage. Continue to speand more time off the bed to help offloading weight from his wound. I remind [R49], nursing staff and therapy to offlaod his wound. [R49] had a recent sacral abcess. Went to went to outside physician who felt abcess resolved, completed course of ABT. Spoke with LPN 2 from wound care. 04/24/24 I will send him back to surgery for an incision and drainage. Continue to speand more time off the bed to help offloading weight from his wound. I remind [R49], nursing staff and therapy to offlaod his wound. [R49] had a recent sacral abcess. Went to went to outside physician who felt abcess resolved, completed course of ABT. Spoke with [LPN2] from wound care. 04/25/24 Status post IV fluids for dehydration, no dizziness. I will send him back to surgery for an incision and drainage. Continue to speand more time off the bed to help offloading weight from his wound. I remind [R49], nursing staff and therapy to offlaod his wound. [R49] had a recent sacral abcess. Went to went to outside physician who felt abcess resolved, completed course of ABT. Spoke with[LPN2] from wound care. 04/29/24 Status post normal saline 1 Liter 4/25. I will send him back to surgery for an incision and drainage. Continue to speand more time off the bed to help offloading weight from his wound. I remind [R49], nursing staff and therapy to offlaod his wound. [R49] had a recent sacral abcess. Went to went to outside physician who felt abcess resolved, completed course of ABT. Spoke with [LPN2] from wound care. 04/30/24 Status post normal saline 1 Liter 4/25. I will send him back to surgery for an incision and drainage. Continue to speand more time off the bed to help offloading weight from his wound. I remind [R49], nursing staff and therapy to offlaod his wound. [R49] had a recent sacral abcess. Went to went to outside physician who felt abcess resolved, completed course of ABT. Spoke with [LPN2] from wound care. 05/01/24 Status post normal saline 1 Liter 4/25. I will send him back to surgery for an incision and drainage. Continue to speand more time off the bed to help offloading weight from his wound. I remind [R49], nursing staff and therapy to offlaod his wound. [R49] had a recent sacral abcess. Went to went to outside physician who felt abcess resolved, completed course of ABT. Spoke with [LPN2] from wound care. 06/06/24 a noted was added, written as a late entry from 06/03/24. Saw [R49] wound rounds. Has a left heel wound stage two. 60% necrotic, 20% slough 20% granulation. Wound is improving. During an interview on 06/06/24 at 10:54 AM, the Medical Doctor (MD) stated, When I round, I round with [LPN2], the wound nurse. [R49] has 2 wounds, one on his sacrum and one on his left heel. I saw the heel either earlier this week or last week. The wound on his heel is fairly new to me, I was told about it a week ago. I said it is a stage 2. A stage 2 is a wound that is past the superficial skin into the dermis, typically, it depends. [R49] has some necrosis to the wound. I may not have documented on the heel because I've been observing his sacral wound. All the notes that are written are for the sacrum. It may be that the wound on the heel has got worse recently. [LPN2] mentioned the wound to me yesterday but I did not see it yesterday.

Based on review of the facility policy, observation, and interview, the facility failed to follow infection control standards during wound care of Resident (R)49, for 1 of 4 residents reviewed for pressure ulcers. Findings include: Review of the undated facility policy titled, Wound Care Treatment Clean Dressing Change Skills Evaluation revealed under policy, Wound Care; gently remove the old dressing and place in the trash, discard soiled gloves, clean hands. Hand hygiene; hand washing or hand sanitizer per policy. Review of R49's Face Sheet revealed the facility admitted R49 on 02/07/24, with diagnoses including but not limited to: hip fracture, pressure ulcer of right heel unstageable, weakness and orthostatic hypotension. During an observation of a dressing change for R49 on 06/05/24 at 11:41 AM, Licensed Practical Nurse (LPN)2 gathered all the supplies needed for the dressing change and placed them on a clean tray, lined with a barrier. LPN2 knocked on the door and entered the room and closed the door. R49 gave consent for an observation of the dressing change. R49 was positioned on his right side facing the door. LPN2 explained the procedure to R49 and after placing the tray on his overbed table, she washed her hands at the sink. LPN2 donned gloves and proceeded to remove the soiled dressing from R49's right heel. LPN2 removed the gloves and donned another pair of gloves. LPN2 did not wash her hands or sanitize her hands before donning the second pair of gloves. The wound was observed with thick hard black eschar covering approximately 60% of the wound bed, with additional tan slough marbled with beefy red tissue. The was also inflammation and some redness on the outer portion of the heel. There was no odor present. LPN2 then cleaned the wound with normal saline and applied Calmoseptine with a q-tip on the outer perimeter of the wound, as she stated, To protect the outer skin. LPN2 removed her gloves, sanitized her hands from the hand sanitizer located on the wall in the room. After donning a 3rd pair of gloves, LPN2 used a skin prep pad and applied it outside the perimeter of the Calmoseptine. LPN2 then applied a 2x2 dressing soaked in Dakin's solution (a diluted hypochlorite solution used as an antiseptic) directly on the wound bed. LPN2 then applied the outer dressing, and dated and initialed it. During an interview on 06/05/24 at 11:55 PM, LPN2, after R49's dressing change of his right heel, stated, I thought I sanitized my hands after removing the soiled dressing and changing gloves, but I cannot remember. I know I sanitized after applying the Calmoseptine with the q-tip. During an interview on 06/06/24 at 12:25 PM, the Director of Nurses (DON)stated, For a dressing change, remove the old dressing, remove gloves, hand sanitize, then put gloves on. 48835

Based on record review, observations, interviews, and facility policy reviews, the facility failed to report an allegation of abuse timely for 1 of 1 allegation of abuse reviewed involving two residents (Resident #4 and Resident #5). Findings included: The facility's policy, titled, Abuse- Identification of Types, dated 10/04/2022, indicated the Risk Factors that May Provoke Reactions in Residents, Staff, or Visitors revealed, The risk for abuse may increase when a resident exhibits a behaviors(s) that may provoke a reaction by staff, residents, or others, such as: Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; Taking, touching or rummaging through other's property. The facility's policy, titled, Abuse - Reporting and Response - Suspicion of a Crime, dated 10/04/2022, Reporting Procedures 4. Written notification to the State Survey Agency and Law Enforcement must then also be made within the specified timeframes. A review of Resident #4's Admission Record revealed the facility admitted the resident on 09/11/2020 with diagnoses that included dementia without behavioral disturbances, bipolar disorder, and rhabdomyolysis (when damaged muscle tissue releases its proteins and electrolytes into the bloodstream). A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/13/2022, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #4 had no behaviors, was independent with activities of daily living (ADLs), had no range of motion limitations, was steady on their feet, and used no mobility devices. A review of Resident #4's Care Plan, revised on 07/01/2020, indicated Resident #4 had staff assistance with planning and initiating activities of choice daily. Interventions included that the resident enjoyed watching television with their headphones on. Resident #4 had no care plan related to behaviors prior to 12/24/2022. A review of Resident #5's Admission Record revealed the facility admitted the resident on 11/28/2022 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysarthria muscle weakness (difficulties with speech), and unsteadiness on their feet. A review of the admission MDS, with an ARD of 12/05/2022, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #5 had no behaviors and was independent or required set up help only for all ADLs. The resident had no range-of-motion impairment to the upper or lower extremities and used a walker for ambulation. A review of Resident #5's Care Plan revealed Resident #5 did not have a care plan for behaviors prior to 12/24/2022. Review of the incident report, dated 12/24/2022, revealed that at 6:10 PM, Resident #4 exited their room yelling. Resident #5 was the roommate. Resident #4 was bleeding from their lip, and Resident #5 was sitting on the floor and could not get up on their own. Resident #5 was assisted up off the floor to a standing position. Resident #5 was alert, oriented, and calm. The resident denied any pain or discomfort. A full physical was then performed, only to find a small abrasion to the left knee; no bleeding or bruising was noted. The right knee was abnormal when walking, but the resident stated this happened with their stroke and that was why they used a walker. Resident #5 stated that Resident #4 had misplaced his/her TV remote for (a paid streaming application), and Resident #4 stated the remote belonged to him/her. Resident #5 had found the remote and Resident #4 slapped Resident #5 on their left shoulder, so Resident #5 hit Resident #4 with their hand. When Resident #5 hit Resident #4, Resident #5 fell backwards, and Resident #4 was on top of Resident #5. Resident #5 then rolled Resident #4 off them, and Resident #4 grabbed the remote and walked out of the room. Both residents declined to go to the emergency room for further assessment. Resident #4 was asked to remain out of the room, and Resident #5 was asked to remain in the room. The Director of Nursing (DON) and the Executive Director were called. The sheriff's office was also called and arrived at 6:50 PM. Both residents were interviewed. The residents' physicians were notified. Resident #5 was moved to another room, and Resident #4 remained in the same room. Review of the County Sheriff's Office incident report, dated 12/24/2022, revealed officers were dispatched to the facility related to two residents who engaged in a verbal and physical altercation (Resident #4 and Resident #5). The residents were interviewed separately. During the interview with Resident #5, the resident stated that Resident #4 accused them of stealing their remote. Resident #5 stated they did not steal it, and that was when Resident #4 attempted to punch Resident #5 and missed. Resident #5 then punched Resident #4, causing Resident #4's lip to bleed. Resident #4 was interviewed and stated their roommate, Resident #5, tried to snatch the TV remote from their hand. Resident #4 moved to prevent this from happening, and they both fell to the floor. Resident #4 believed Resident #5 accidently struck them. Neither party wished to file any charges. A review of the Accident/Incident Reporting Form Bureau of Health Facilities Licensing, dated 12/25/2022, indicated the state survey agency was notified of the abuse allegation on 12/25/2022 at 1:26 PM, which was not submitted to the state survey agency within the required 2-hour timeframe. Review of the Progress Notes, dated 12/26/2022, revealed Resident #5 had an altercation with Resident #4 over the roommate's television remote control, both putting the blame on each other. The residents were moved to separate rooms and all personal remote controls were labeled to reflect proper ownership. A (brand name) remote was provided in the general day room for all residents to use. Review of the Progress Notes, dated 12/27/2022, revealed Resident #5 was moved to another room as requested. The resident was happy about the move. During an interview on 04/24/2023 at 7:48 PM with Registered Nurse (RN) #4, she stated that on 12/24/2022 around 6:00 PM, Resident #5 had the television remote and Resident #4 stated the remote belonged to him/her because they went to the day room and paid for (brand name streaming service) to be able to watch. She stated both residents had different stories of who started what, but Resident #5 was on the floor and Resident #4 was on top of him/her. Resident #4 had a bloody lip. Neither resident wanted to go to the emergency room for evaluation. The staff separated the residents right away, and Resident #5 was moved to another room. The sheriff's office was called and interviewed both residents. She further stated neither resident had any history of this type of behavior, and they got along well. During an interview with RN #1 on 04/24/2023 at 11:25 AM, she stated the residents had an altercation about the TV remote, and Resident #5 hit Resident #4. Neither was seriously hurt, and both refused to go to the emergency room for evaluation. They were separated, and Resident #5 was moved to another room. During an interview with the Executive Director on 04/25/2023 at 8:39 AM, she stated there was an argument about a TV remote and it resulted in a fall. She stated the remote belonged to Resident #4, and Resident #5's remote was missing. Resident #5 grabbed Resident #4's remote to change the channels, and they both fell in the process. She stated, Had they not fallen we would not have even submitted a concern because it was a misunderstanding and we replaced Resident #5's remote. The staff moved the resident to another room to ensure there would not be any further misunderstandings. Resident #4 had a skin tear to the lip. She said there was no intent to hurt each other. The Executive Director sated there was no serious bodily injury; therefore, the incident was not reported within the two hours but within 24 hours.

Based on interview, record review, and policy review, the facility failed to ensure accurate resuscitation code status documentation was maintained in both the electronic medical record (EMR) and paper medical record for one resident (Resident (R) 98) of 24 sampled residents. Findings include: Review of a policy provided by the facility titled Advance Directives and Advance Care Planning, dated 10/20/21, indicated . The ability of a person to control decisions about medical care and daily routines has been identified as one of the key elements of quality of care at the end of life. The process of advance care planning is ongoing and affords the resident, family, and others on the resident's interdisciplinary health care team as opportunity to reassess the resident's goals and wishes as the resident's medical condition changes . Review of a document provided by the facility titled Emergency Medical Services Do Not Resuscitate (a directive not to perform cardiopulmonary resuscitation and to allow natural death) Order, dated 06/09/21, indicated R98 requested no resuscitative measures were to be provided to her. Review of a document provided by the facility titled Informed Decision Regarding Nursing Facility Admission and Acknowledgement of Admission Agreement, dated 02/10/22, was signed by R98's representative and indicated an Advance Directive was executed and a copy of the Do Not Resuscitate (DNR) was on file with the facility. Review of R98's EMR undated Admission Record, located under the Profile tab, indicated R98 was admitted on [DATE]. Review of R98's EMR Clinical Physician Orders, located under Orders tab and dated 02/10/22, indicated R98 was a Full Code (to implement chest compressions, intubation [placement of a tube into windpipe], and possible defibrillation [electric shock to the heart]). During an interview on 02/15/22 at 11:17 AM, the Director of Nursing (DON) stated the code status was addressed during the admission process. The DON stated R98 had been in and out of the facility for respite care. During a subsequent interview on 02/16/22 at 8:27 AM, the DON stated R98 was admitted on a Friday, code status needed to be confirmed through review of R98's Medical Records, and all residents were considered Full Code until the facility could verify the code status from the resident's previous admissions.

Based on observations, interviews, and policy review, the facility failed to ensure one Certified Nursing Assistant (CNA)9 was provided needed competency training for oxygen administration and maintenance. As a result, CNA9 failed to recognize that an oxygen canister required for care of a resident (Resident (R)9) was empty and needed to be replaced. This failure had the potential to cause physical and/or psychosocial harm to residents requiring oxygen therapy administration. Findings include: Review of a document provided by the facility titled Oxygen Administration/ Safety/ Storage/ Maintenance, reviewed on 08/02/21, reflected under Training Requirements: All facility staff will be educated on Oxygen Administration, Safety and Storage upon hire, annually, and as indicated thereafter. The same policy noted Procedure: This facility will utilize the following Lippincott Procedures: Oxygen Administration Procedure: Oxygen Administration Competency Skills Checklist: with embedded links to the Lippincott Manual (the standard manual of care for nursing procedures). During an observation on 02/14/22 at 12:55 PM, CNA9 was observed assisting R9 in the resident's bathroom. Further observation revealed R9 had in place a nasal cannula/oxygen tubing that was attached to an oxygen tank that was on a wheelchair in the resident's bathroom. R9 was complaining that she was not getting enough air, and CNA9 did not recognize that R9's oxygen canister regulator said empty. CNA9 assisted R9 to her bed and CNA10 came into the room, stated that the canister was empty, and immediately moved R9's oxygen line to the oxygen concentrator at the resident's bedside. During an observation and interview on 02/14/22 from 1:02 PM until 1:10 PM, after CNA10 connected the oxygen tubing to the oxygen concentrator, R9 stated that she felt better and was receiving enough air. Review of R9's Profile, located in the electronic medical record (EMR) revealed that R9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R9's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/02/21 reflected a Brief Interview for Mental Status (BIMS) score of 11 indicating R9 had impaired cognition. This MDS revealed that R9 required extensive to total assistance with one person support with Activities of Daily Living (ADLs) and daily oxygen administration. Review of R9's Care Plan, located in the facility EMR Care Plan section, reflected that R9 was care planned for oxygen therapy on 12/02/21 with interventions including Oxygen Settings: O2 [oxygen] via n c [nasal cannula] at four [4] liters [L] continuously. Review of R9's Orders, dated 11/25/21 and located in the facility EMR Orders section reflected physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 02/14/22 at 1:16 PM, CNA10 stated that she had been trained on oxygen administration and oxygen canisters. During an interview on 02/15/22 at 2:00 PM, CNA9 stated that she had received training on oxygen cylinders on 02/14/22. During an interview on 02/15/22 at 4:15 PM, the Director of Nursing (DON) stated that CNA9 had been trained on oxygen cylinders on 02/14/22 and that all CNAs were to be retrained on oxygen cylinders. During an interview on 02/16/22 at 1:30 PM, CNA4 stated that she was still in orientation and that she had been trained on oxygen canisters. Review of CNA9's employee file indicated she was hired on 01/27/22 as a CNA. There was no evidence included in CNA9's employee file indicating she had been trained in oxygen administration or maintenance prior to 02/14/22. During an interview on 02/16/22 at 10:00 AM, the DON confirmed that all trainings were in the employee files. Review of a document provided by the facility titled Staff Development and Education, revised 11/08/21, reflected A staff development program consisting of a planned and organized system of training begins with orientation and continues throughout the duration of employment for all associates . A facility must develop, implement, and maintain an effective training program for all new and existing staff . consistent with their expected roles . A facility must ensure that staff members are educated on the rights of the resident and the responsibilities of the facility to properly care for its residents . The Staff Development Coordinator (SDC) [sic] or designee plans and directs an effective orientation, training, and evaluation program, which includes, but is not limited to, resident care policies specific to resident's identified care needs, resident care requirements based upon assignments and duties including types of services and treatments required for each resident, and other interventions necessary to meet residents' needs . The training programs include orientation for new associates and in-service education for all associates as required by Federal and State guidelines . The Staff Development Coordinator or designee maintains records of all training classes . an individual training record is maintained for each associate to include date of each training class attended . subject of the class . instructor of the class . All training records will be made available to Federal and State surveyors upon request. During an interview on 02/16/22 at 1:45 PM, the Assistant Director of Nursing (ADON) stated that she had previously been the SDC, and that the facility did quarterly trainings with rotating clinical subjects. The ADON said that there had been skills checkoffs during orientation that included oxygen canisters. The ADON stated that she no longer was the SDC and that she did not know where training records were kept.

Based on interview, record review, and policy review, the facility failed to ensure one of five residents (Resident (R) 30) reviewed for unnecessary medications had a documented rationale for declining pharmacy recommendations. Findings include: Review of the facility policy Pharmacy Services and Medication Regimen Review, dated 11/18/21, revealed, Procedure: Unless otherwise required, the facility will utilize the Omnicare 09.01 Medication Regimen Review procedures for handling Drug Regimen Reviews. Review of Omnicare 9.1 Medication Regimen Review, dated 11/28/16, revealed Applicability: This Policy 9.1 sets forth procedures relating to the medication regimen review (MRR). Procedure: 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendation contained in the MRR. 7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 7.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 7.2.1 If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record. Review of the monthly pharmacy reviews for R30 for October 1, 2021, through October 31, 2021, and December 28, 2021, revealed pharmacy recommendations to Please consider reevaluating continued use if appropriate of [MEDICATION(S)] (an antihistamine). Further review of the recommendation revealed I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below being marked by the physician. There was no documented rationale from the physician for declining the recommendation. Review of R30's undated Admission Record, located in R30's electronic medical record (EMR) under the Profile tab, revealed R30 was admitted to the facility on [DATE] and readmitted on [DATE]. On 02/15/21 at approximately 2:30 PM an interview with the Director of Nursing (DON) was conducted. The DON stated, the physician does not like doing the monthly pharmacy reviews, doesn't understand the purpose of the review. The Medical Director has not addressed the reviews with him. They [the physicians] don't always provide a reason for declining the recommendation from the pharmacist. On 02/16/22 at 9:50 AM an interview was conducted with the Attending Physician (AP). The AP stated, the resident is a long-term resident who knows his medications and refuses to have de-escalation of his medications. Since he had been here so long, I made an assumption that everybody knew the reasoning for declining the recommendation.

Based on observation, interview, policy review, and review of Center for Disease Control and Prevention (CDC) guidance, the facility failed to ensure: 1. one of one resident (Resident) R99 reviewed for new admissions was placed under quarantine. R99 was unvaccinated for COVID-19. and 2. a catheter bag was kept off the floor for one of one resident (Resident (R) 19) in a total sample of 24 residents. The failure to quarantine an unvaccinated new admission increased the risk of transmission of COVID-19 to other residents. The failure to keep a catheter bag off the floor increased the risk for R19 developing a urinary tract infection. Findings include: 1. Per CDC website titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated February 2, 2022, revealed Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection indicated . HCP (healthcare personnel) caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (personal protective equipment) (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator) . Ideally, a resident with suspected [CONDITION(S)]-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending . In general, it is recommended that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. This is especially important for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection being cared for outside of the COVID-19 care unit. However, in some circumstances (e.g., memory care units), keeping the door closed may pose resident safety risks and the door might need to remain open. If doors must remain open, work with facility engineers to implement strategies to minimize airflow into the hallway. In general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission . COVID-19 vaccination should also be offered . Review of policies provided by the facility titled Coronavirus (COVID-19) ([CONDITION(S)]-CoV-2) dated 02/07/22, . Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator) . Residents can be removed from Transmission-Based Precautions after day 10 following the exposure (day 0) if they do not develop symptoms . In general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions, should be placed in quarantine, even if they have a negative test upon admission, and should be tested as outlined in the COVID-19 Resident Testing Policy; COVID-19 vaccination should also be offered . All recommended COVID-19 PPE should be worn during care of residents under quarantine, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles, or a disposable face shield that covers the front and sides of the face). gloves, and gowns . Review of R99's electronic medical records (EMR) indicated R99 was admitted to the facility on [DATE]. Review of R99's EMR revealed R99 was not vaccinated against COVID-19 prior to his admission to the facility. Observation on 02/14/22 at 10:56 AM, revealed no PPE (personal protective equipment) or posting of transmission-based precautions on the outside of R99's room. Observation on 02/14/22 at 4:47 PM, revealed R99 entered the main dining room of the facility. R99 was not wearing a face mask. At 5:06 PM, the Director of Nursing (DON) entered the dining area and spoke with kitchen staff and then left at 5:07 PM. Observation continued until 5:41 PM and revealed R99 remained seated at a table in the main dining room and completed his meal. During this observation staff continued to pass meal trays to the other residents in the dining room. No staff member approached R99 to remind him to go back to his room or to don (put on) a face mask. Further observation on 02/14/22 at 6:00 PM, revealed no PPE outside of R99's room. In addition, there was no transmission-based precaution sign posted to instruct visitors and staff what PPE was required when entering R99's room. During an interview on 02/14/22 at 5:57 PM, the Assistant Director of Nursing (ADON), who was also the Infection Control Preventionist (ICP), stated if a resident was unvaccinated the resident was to be offered the COVID-19 vaccine. The ADON/ICP stated the resident was then to be placed under a 14-day quarantine and monitored for signs and symptoms. The ADON/ICP confirmed R99 was admitted within the past 14 days. During an interview on 02/14/22 at 5:53 PM, the Administrator confirmed R99 was unvaccinated for COVID-19. During an interview on 02/14/22 at 6:03 PM, the ADON/ICP confirmed R99 was unvaccinated for COVID-19. During an observation on 02/15/22 at 8:15 AM, Personal Protective Equipment (PPE) was noted to be in a cart and Transmission Based Precautions (TBP) signage was on the open door of R99's room. Certified Occupational Therapy Assistant (COTA) 8 walked into R99's room, said hello, shook the resident's hand, and said good morning. COTA 8 did not don PPE before going in R99's room. Observation on 02/15/22 at 9:00 AM, R99 was quarantined to his room, had PPE stored on the outside of his room, and had a sign posted on his door for transmission-based precautions. During an interview on 02/15/22 at 9:02 AM, the Physical Therapist Assistant (PTA) 11 confirmed R99 was not under quarantine when he was admitted and therefore PTA11 did not don a gown or a N95 mask when entering R99's room. PTA 11 stated he first screened R99 for therapy services on 02/11/22 and did not wear a gown or N95 mask. During an interview on 02/15/22 at 9:04 AM, the Certified Occupational Therapist Assistant (COTA) 8 stated he has seen R99 walk the hallways and he had redirected the resident back to his room. COTA 8 confirmed he previously had entered the room of R99 without first donning a gown and a N95 mask. COTA 8 stated he followed the direction provided by the facility. During an interview on 02/15/22 at 8:30 AM, Registered Nurse (RN) 5 stated residents who are newly admitted and are unvaccinated are to stay in their rooms. RN5 stated that new unvaccinated admissions were tested for COVID the first day and again the fifth day of the stay. RN5 stated R99 was the only resident currently on TBP. During an interview on 02/15/22 at 9:42 AM, Certified Nursing Assistant (CNA) 1 confirmed she provided care to R99 without first donning a gown and a N95 mask. During an interview on 02/15/22 at 9:44 AM, the Director of Rehabilitation Services (DRS) confirmed she screened R99 and did not wear a gown or N95 mask. The DRS verified R99 wandered. During an interview on 02/15/22 at 9:49 AM, the Director of Nursing (DON) stated it would be detrimental to R99 to remain in his room. The DON stated the facility did a risk verse benefit on R99 since he wandered and was at risk for falls and [the DON] did not want R99 to break a hip. When the DON was asked about R99 and dining during the dinner meal on 02/14/22, the DON stated R99 was at risk for nutrition and needed to eat and did not want to disrupt him. The DON was unable to provide any information regarding a risk verses benefit assessment for not placing R99 under quarantine and not requiring staff to wear full PPE while providing care to R99. During an interview on 02/15/22 at 12:39 PM, COTA8 stated that he went into R99's room that morning without PPE because he had seen R99 trying to get up from his recliner, and COTA8 was concerned that R99 would fall. COTA8 stated that if he were doing therapy, he would have donned full PPE. During an observation on 02/15/22 at 12:41 PM, R99's room door was closed, and the PPE cart was by the door. The Minimum Data Set (MDS) coordinator (MDSC) was at the nurse's station and stated that R99 was in the room. 2. Review of the facility policy Urinary Incontinence and Indwelling Urinary Catheter (Foley) Management, dated 07/17/2021, revealed Policy: Each resident will be identified and assessed for urinary incontinence and/or indwelling catheter upon admission, quarterly, and with significant change in urinary status . This facility will utilize the Lippincott procedures: Incontinence management, urinary, long-term care. Clinical alert: Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of CAUTI (catheter-associated urinary tract infection). However, don't place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI. Observation of R19 on 02/15/22 at 1:50 PM, revealed R19 in his room, lying supine (on his back) in bed sleeping, with the bed in its lowest position. R19's catheter bag was observed lying on the floor next to his bed. The catheter bag was covered by a fall mat which was next to the bed. On 02/15/22 at 2:00 PM, an interview with Licensed Practical Nurse (LPN) 2 was conducted. LPN2 stated, the catheter bag is on the floor and the fall mat is lying on top of it. The bag should not be on the floor. Review of R19's undated Admission Record, located in R19's electronic medical record (EMR) under the Profile tab, revealed R19 was admitted to the facility on [DATE]. Review of R19's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/31/22 indicated R19 had a Brief Interview Mental Status (BIMS) score of 11 out of 15, which indicated moderately impaired cognition. This MDS assessment documented R19 had a prognosis of six months or less and was receiving hospice services.

Based on record review, staff interview, and facility policy review, the facility failed to notify the responsible party of a change in condition for 1 (Resident #1) of 3 sampled residents. Findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1 was discharged from the facility on 11/13/2020. A facility policy, titled, Changes in Resident's Condition or Status, dated 05/05/2020, indicated, This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify consistent with his or her authority, the resident representative(s) when there is- (B) A significant change in the resident's physical, mental or psychosocial status (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). 1. a. Resident #1 had a physician's orders [REDACTED]. A review of a Nurse Progress note dated 11/09/2020 at 3:02 AM revealed that Licensed Practical Nurse (LPN) #1 wrote that a certified nursing assistant asked LPN #1 to evaluate Resident #1 after Resident #1 had loose stools. When LPN #1 looked at the stool, it was documented to be watery, and maroon-dark red in color. LPN #1 also noted that while being cleaned, Resident #1 had another bowel movement that was bright red. The note indicated that the Nurse Practitioner (NP) was called. The NP ordered laboratory work and for the [MEDICATION NAME] to be held. There was no documentation that Resident #1's responsible party was notified. An interview was completed with the Director of Nurses (DON) on 01/07/2021 at 1:29 PM. The DON said that the physician would be notified of a resident with rectal bleeding. Normally we would call the family about that, but (LPN #1) wouldn't have to. If I was the family, I would want to know, but it could be that it got missed in the documentation. The nurse (LPN #1) that wrote the note wasn't the one who found the bleeding. It would have been passed on to the night nurse (LPN #1) by the day shift nurse. The nurse didn't write a note and s/he doesn't work with us anymore. On 01/07/2021 2:30 PM, an interview was completed with LPN #1. LPN #1 was asked to help clean Resident #1 after the resident had a loose bowel movement. LPN #1 said the stool was watery and maroon in color. LPN #1 said that the NP was called, and the anticoagulant was ordered to be held. LPN #1 said that the responsible party was not called. As far as I'm used to, especially on night shift, I would only call the family for an emergency like a fall or if (Resident #1) needed to be sent to the hospital. I would have waited to call the family after lab results came back. 1.b. The Nursing Admission assessment dated [DATE] for Resident #1 was reviewed. Resident #1 was not noted to have any open wounds to the sacrum or coccyx. On 11/07/2020 at 3:41 AM, Licensed Practical Nurse (LPN) #1 documented in the Nurse Progress notes that Resident #1 had a red open area to the skin on the coccyx. There were no progress notes before 11/07/2020 indicating a wound to the coccyx. A review of the physician's orders [REDACTED].#1's coccyx area. No documentation was found in the medical record indicating that Resident #1's family was notified of the wound. On 01/07/2021 at 2:30 PM, an interview was completed with LPN #1. LPN #1 stated that when the area to Resident #1's coccyx was seen, LPN #1 thought there was a dressing on the area already, so the responsible party was not notified.

Based on record review and interview, the facility failed to implement its' policy of reporting an alleged incident. This affected one out of 12 sampled residents. Resident #1 reported missing money to Receptionist #86 on 02/11/19 and it was not reported to the abuse coordinator. The findings included: Review of the clinical record revealed that Resident #1 had an initial admission date of [DATE] with a readmission date of [DATE]. The quarterly Minimum Data Set (MDS) assessment, dated 04/03/19, documented the resident had no memory impairment. The survey team entered the facility on 07/22/19 with one Facility Reported Investigation (FRI) to investigate for misappropriation of funds involving Resident #1. On 02/26/19, the facility reported that Resident #1 had reported to the Nursing Home Administrator (NHA) that she was missing $50.00. On 07/24/19 at 12:27 PM, the NHA was interviewed. The NHA stated that the initial report of the missing money was reported to the facility's receptionist who did not inform him of the alleged incident. The NHA stated that he was out of the facility when the initial report was made. On 07/24/19 at 12:35 PM, Receptionist #86's written statement was reviewed. The statement documented that Receptionist #86 received the phone call from Resident #1 on 02/11/19. Receptionist #86 documented that the resident did not want the alleged missing money reported to the NHA. On 07/24/19 at 12:50 PM, Receptionist #86 was interviewed. She stated that Resident #1 had called asking to talk with the NHA. She informed Resident #1 that the NHA was out of the facility and could she take a message. Resident #1 told Receptionist #86 about missing $50.00. Receptionist #86 stated that Resident #1 did not mention anything about not telling the NHA, but that she forgot all about it. Receptionist #86 stated that she was trained on proper reporting of alleged incidents and that she knew she should have called her NHA immediately. Receptionist #86 stated that she took full responsibility for the lack of reporting because she forgot all about it. On 07/24/19 at 1:04 PM, Resident #1 was interviewed. Resident #1 stated that she had called the receptionist to speak with the NHA and he was out of the facility. Resident #1 had assumed that the receptionist had reported to the NHA and was waiting for a follow up. On 02/26/19, the NHA was informed of the alleged incident while visiting with Resident #1. Resident #1 stated that she was the first person to inform the NHA. She stated that she had the phone call with Receptionist #86 about two weeks prior to informing the NHA.

Based on record review and interview, the facility failed to implement its' policy of reporting an alleged incident. This affected one out of 12 sampled residents. Resident #1 reported missing money to Receptionist #86 on 02/11/19 and it was not reported to the abuse coordinator. The findings included: Review of the clinical record revealed that Resident #1 had an initial admission date of [DATE] with a readmission date of [DATE]. The quarterly Minimum Data Set (MDS) assessment, dated 04/03/19, documented the resident had no memory impairment. The survey team entered the facility on 07/22/19 with one Facility Reported Investigation (FRI) to investigate for misappropriation of funds involving Resident #1. On 02/26/19, the facility reported that Resident #1 had reported to the Nursing Home Administrator (NHA) that she was missing $50.00. On 07/24/19 at 12:27 PM, the NHA was interviewed. The NHA stated that the initial report of the missing money was reported to the facility's receptionist who did not inform him of the alleged incident. The NHA stated that he was out of the facility when the initial report was made. On 07/24/19 at 12:35 PM, Receptionist #86's written statement was reviewed. The statement documented that Receptionist #86 received the phone call from Resident #1 on 02/11/19. Receptionist #86 documented that the resident did not want the alleged missing money reported to the NHA. On 07/24/19 at 12:50 PM, Receptionist #86 was interviewed. She stated that Resident #1 had called asking to talk with the NHA. She informed Resident #1 that the NHA was out of the facility and could she take a message. Resident #1 told Receptionist #86 about missing $50.00. Receptionist #86 stated that Resident #1 did not mention anything about not telling the NHA, but that she forgot all about it. Receptionist #86 stated that she was trained on proper reporting of alleged incidents and that she knew she should have called her NHA immediately. Receptionist #86 stated that she took full responsibility for the lack of reporting because she forgot all about it. On 07/24/19 at 1:04 PM, Resident #1 was interviewed. Resident #1 stated that she had called the receptionist to speak with the NHA and he was out of the facility. Resident #1 had assumed that the receptionist had reported to the NHA and was waiting for a follow up. On 02/26/19, the NHA was informed of the alleged incident while visiting with Resident #1. Resident #1 stated that she was the first person to inform the NHA. She stated that she had the phone call with Receptionist #86 about two weeks prior to informing the NHA.

Based on review of the grievance file, review of the facility's abuse policies and procedures, and interview, the facility failed to implement policies developed related to identification of abuse, investigation of abuse, resident protection, and reporting allegations of abuse to the State Agency, for four of four residents' allegations of abuse/neglect reported to the facility involving 3 staff members via the facility's grievance process. Resident A was told to go to the bathroom in her/his brief, causing anxiety, fear, and humiliation. Resident B reported neglect and threats to delay [MEDICAL CONDITION] care. Resident #9 reported rough handling, humiliation, and verbal abuse and was visibly upset. Resident #529 reported verbal abuse and humiliation. The findings included: Review of the Grievance File on [DATE] at 4 PM revealed that the following incidents were reported to the facility via the grievance process: (1) On [DATE], two residents complained that Certified Nursing Assistant (CNA) #2 had neglected their needs resulting in anxiety and psychological harm. Licensed Practical Nurse (LPN) #2 wrote the following: This morning [DATE] when this nurse went to give (Resident A) her medication she appeared anxious. This nurse spoke with her about what she was so anxious about. She stated she wanted to go to the hospital. During further conversation about what she was feeling and why she wanted to go to the hospital, she shared with me that she was upset because last night when she would ask to go to the bathroom, she was told by the CNA to just go in her brief. (Resident A) is continent and this upset her. She then told the same story to her daughter when she arrived. The daughter then approached me in the early afternoon about what she needs to do to take her mom home. She stated that her mom was just very anxious and upset and she doesn't feel she will improve here in this setting . DON (Director of Nursing) and ED (Executive Director) notified. Licensed Practical Nurse (LPN) #2 provided this written statement on [DATE]: At shift change from ,[DATE] to ,[DATE] I answered her call light. (Resident B) was inquiring about who her CNA was going to be this evening. When she was informed it was (CNA #2), she adamantly requested that (CNA #2) not care for her. When this nurse asked her why, she stated that (CNA#2) was very solemn and short with her and she had asked (CNA #2) to empty her [MEDICAL CONDITION] on more than one occasion because she thought it was very full and (CNA #2) kept putting her off. At one point (CNA #2) told her she would be in about 2 AM and (Resident B) informed her she did not want to be awakened at 2 in the morning, so (CNA #2) told her she would wait until 6 AM. She at this point asked to see (LPN #5) and she had to completely change the [MEDICAL CONDITION] because it was so full. She also states that (CNA #2) slammed her door shut every time she left the room last night. DON notified. Review of the Facility Investigation and Response form revealed no staff member was designated to investigate the concern. Actions taken to Resolve/Respond to concern included only CNA not to work with these residents. Statements were obtained from CNA #2 related to the two incidents but no investigation was conducted. No statements were obtained from roommates, other residents, or staff on duty, especially LPN #5. The incident was not reported to the State Agency as required. There was no evidence that other residents were protected from further abuse/neglect. During an interview with the DON and Administrator on [DATE] at approximately 5 PM, the DON verified that no further investigation had been completed, the incidents had not been reported, and that the only intervention had been to remove the CNA from caring for these individual residents. (2) On [DATE] (no time specified), LPN #3 reported to the DON: Resident (#9) stated that the night person came into her room to change her was rough, push(ed) her over to change her. When she told her that she was going to report her, the person stated nobody (was) going to believe her because she (was) crazy (and) she was tired of changing her. The DON spoke to the resident on [DATE] (no time specified) at which time the resident was visibly upset and kept reporting the story without deviation of details. I was able to calm resident and assured her that I would investigate further. No visible injuries were noted and resident had no complaints of acute/new pain. The Administrator was notified. On [DATE], LPN #6 wrote a statement at 8:30 PM confirming that on that date, Resident #9 was complaining of right arm pain. She stated that the CNA from 11p-7a last night ([DATE]) pulled her L(eft) arm first then pulled her bad side (right side) . (The resident) also stated that the CNA told her she was tired of changing her pissy ass and she should be ashamed of herself, and to get her ass up and go the bathroom the next time. (The resident) also stated that the CNA told her she could tell whoever she wanted to because no one would believe her 'crazy ass'. There were no other statements in the file other than the alleged perpetrator. Review of the Facility Investigation and Response form revealed that the Administrator determined that no abuse had occurred. Actions taken to Resolve/ Respond to concern included Associate given customer service education. Associate to not work with resident again. Upon conclusion of the investigation, the Suspension Pending Investigation form noted that the allegation was unsubstantiated and CNA #3 was returned to work on [DATE]. During an interview with the DON and Administrator on [DATE] at approximately 5 PM, the DON verified that no further investigation had been completed, the incident had not been reported, and that the CNA had been suspended and removed from caring for this individual resident. (3) Review of a Concern and Comment form dated [DATE] revealed that Resident #529's family member reported to the DON: On Sunday (MONTH) 12th at 8:53 PM, the resident left a message stating the aide made an inappropriate remark to him when she came into give him care. The aide stated, 'If you weren't playing with yourself you wouldn't be wetting the bed so much.' The (family member) said this was an isolated incident but feels there's some truth to it . The Facility Investigation and Response form noted that the DON spoke (with) resident who relayed same information. The DON's written statement also included that the Resident expressed concern that this comment was made in front of his wife who is also a resident. He is concerned that a rumor will be started about him . The investigation included only a statement by the alleged perpetrator (CNA #4). Actions taken to Resolve/Respond to concern included CNA and DON went to resident and CNA apologized to resident for delivery of statements. Resident accepted apology. There was no evidence that the incident was reported to the State Agency or thoroughly investigated. There was no evidence that this or other residents were protected from further abuse/neglect. During an interview with the DON and Administrator on [DATE] at approximately 5 PM, the DON verified that no further investigation had been completed and that the incident had not been reported to the State Agency. A copy of the facility's policy entitled Protection of Residents: Reducing the Threat of Abuse & Neglect was provided by the Administrator. The Identification section of the policy stated: It is the policy of this facility to identify abuse, neglect . Possible indicators of abuse may include but are not limited to: .Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place or feelings of guilt or shame . Abuse is defined as The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse .and mental abuse . Verbal Abuse-The use of oral . language that willfully includes disparaging and derogatory terms to residents . regardless of their age, ability to comprehend, or disabilities . Mental Abuse includes,but is not limited to, humiliation, harassment, threaten of punishment or deprivation. (MONTH) occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Under the Investigation and Protection section, the Procedure included a 2 .'psychosocial assessment, if needed . 4. The administrator/designee will. utilize the Incident Investigation Questionnaire Form to document the investigation . 6. If it is determined that alleged abuse and neglect. has occurred, the administrator, director of nursing, or his/her designee will promptly notify officials in accordance with state laws .7. The written summary of the investigation should include, but is not limited to: . Interviews with any witnesses to the incident .A review of the residents medical record Interviews with staff members on all shifts having contact with the resident at the time of the incident . Interviews with the resident's roommate, family, and/or visitors who may have information regarding the incident. Interviews with other residents who received care and services from the alleged perpetrator . 8. If the accused individual is an employee, the alleged perpetrator will be removed from resident care areas immediately and placed on suspension pending results of the investigation . 14. The results of the investigation will be recorded on the Incident Investigation Questionnaire. Any additional documents including interviews and record reviews will be attached to the Incident Follow-Up & Recommendation Form . Review of the policies and investigation files provided by the Administrator revealed that (a) the facility failed to identify that abuse/neglect occurred based on definitions found in the policy, (b) perpetrators were not suspended to protect other residents from potential abuse as delineated in the policy, (c) the incidents were not reported to the State Agency as required by state law and as stipulated in the policy and (d) the investigation was not thorough and conducted per the policy. On [DATE] at 2:15 PM the Administrator, Director of Nursing, and the Regional Director of Clinical Services were notified that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on [DATE] and was identified at a scope and severity of K. Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of K in the following areas: 42 CFR 412(b)(1)(2) F607 The facility failed to implement policies developed related to identification, investigation, resident protection, and reporting allegations of abuse to the State Agency. 42 CFR 483.12(c) F609 The facility failed to report four residents' allegations of abuse/neglect to the State Agency when reported to the facility via the facility's grievance process. 42 CFR 483.12(c)(2)(3) F610 The facility failed to identify and thoroughly investigate four of four residents' allegations of abuse/neglect reported to the facility via the facility's grievance process. 42 CFR 483.70 F835 The facility failed to be administered in a manner that protected residents from abuse. The Administrator's and Director of Nursing's inaction and decisions following allegations of abuse placed other residents in their care in danger of neglect as well as physical, verbal, and emotional abuse. The Administrator and DON failed to implement abuse policies developed related to identification, investigation, resident protection, and reporting of allegations of abuse to the State Agency. The Administrator and Regional Director of Clinical Services were notified that the Immediate Jeopardy was removed on [DATE] at 5:15 PM and the scope and severity was lowered to an E following acceptance and verified implementation of the following Allegation of Compliance: 1. Residents A & B no longer reside in the facility. Both were discharged and have since expired in the community. Certified Nursing Assistant (CNA) #2 is no longer employed by the facility. The incidents were reported to the State Agency on [DATE]. 2. Residents #9 and #529 had unremarkable skin assessments reviewed on [DATE] by unit nurses. Physician was notified on [DATE] by the Director of Nurses (DON). Both resident incidents were reported to the State Agency on [DATE] and an investigation initiated. CNAs #3 and #4 were suspended on [DATE] pending investigation. 3. The Social Services Director, Executive Director (Administrator/ED), and Activities Assistant will interview all residents with a Brief Interview for Mental Status (BIMS) score of 8 or higher for any allegations of abuse/neglect by [DATE]. 4. The DON, Assistant DON (ADON), Wound Care Nurse and/or Unit Managers will review skin assessments on all residents with BIMS of 7 or below to identify any potential unreported abuse by [DATE]. 5. The DON and Regional Director of Clinical Services will review all resident comment and concern cards for the past 90 days for any allegations of abuse by [DATE]. 6. Findings from the above will be reported to the appropriate State Agencies and investigated per state regulations by the Executive Director (ED) and/or DON. 7. The Regional Director of Clinical Services will provide education on the abuse policy which includes: Protection of Resident Rights/Reducing the Threat of Abuse and Neglect, identifying abuse, investigation and protection, reporting and response, photography and social media, Elder Justice Act, and reporting obligations to the ED, DON, and the ADON to ensure that abuse policies are implemented. 8. The ED, DON, and/or ADON will provide education to all associates on the abuse policy which includes contents listed in #7 above. Any associate that has not been inserviced by [DATE] will not be allowed to work until insurance is completed. All newly hired associates will be educated on the abuse policy during orientation. 9. All resident comment and concern cards will be reviewed for allegations of abuse during daily stand-up meetings. The ED will be responsible for ensuring appropriate identification 'reporting per regulations, conducting a thorough investigation and implementing facility abuse policies. 10. All resident skin assessments will be conducted weekly and reviewed during daily clinical meeting for potential abuse. The DON will be responsible for notifying the ED and initiating the investigation. 11. Signage with contact numbers will be posted by the time clock identifying all allegations are to be reported to the ED or secondary contact immediately. 12. The Regional voice President and Regional Director of Clinical Services will be notified of any allegation of abuse and/or neglect at the time the ED or DON are notified and provide documentation that allegation(s) have been reported as required. Prior to submitting final investigations to required agencies, a member of the Divisional/ Regional Team will review investigations to ensure a thorough investigation was completed. The Regional Vice President and/ Regional Director of Clinical Services will review the abuse reporting log and investigations during facility visits.

Based on review of the grievance file, review of the facility's abuse policies and procedures, and interview, the facility failed to identify, report to the State Agency, and thoroughly investigate four of four residents' allegations of abuse/neglect reported to the facility involving 3 staff members via the facility's grievance process. Resident A was told to go to the bathroom in her/his brief, causing anxiety, fear, and humiliation. Resident B reported neglect and threats to delay [MEDICAL CONDITION] care. Resident #9 reported rough handling, humiliation, and verbal abuse and was visibly upset. Resident #529 reported verbal abuse and humiliation. The findings included: Review of the Grievance File on [DATE] at 4 PM revealed that the following incidents were reported to the facility via the grievance process: (1) On [DATE], 2 residents complained that Certified Nursing Assistant (CNA) #2 had neglected their needs resulting in anxiety and psychological harm. Licensed Practical Nurse (LPN) #2 wrote the following: This morning [DATE] when this nurse went to give (Resident A) her medication she appeared anxious. This nurse spoke with her about what she was so anxious about. She stated she wanted to go to the hospital. During further conversation about what she was feeling and why she wanted to go to the hospital, she shared with me that she was upset because last night when she would ask to go to the bathroom, she was told by the CNA to just go in her brief. (Resident A) is continent and this upset her. She then told the same story to her daughter when she arrived. The daughter then approached me in the early afternoon about what she needs to do to take her mom home. She stated that her mom was just very anxious and upset and she doesn't feel she will improve here in this setting . DON (Director of Nursing) and ED (Executive Director) notified. Licensed Practical Nurse (LPN) #2 provided this written statement on [DATE]: At shift change from ,[DATE] to ,[DATE] I answered her call light. (Resident B) was inquiring about who her CNA was going to be this evening. When she was informed it was (CNA #2), she adamantly requested that (CNA #2) not care for her. When this nurse asked her why, she stated that (CNA#2) was very solemn and short with her and she had asked (CNA #2) to empty her [MEDICAL CONDITION] on more than one occasion because she thought it was very full and (CNA #2) kept putting her off. At one point (CNA #2) told her she would be in about 2 AM and (Resident B) informed her she did not want to be awakened at 2 in the morning, so (CNA #2) told her she would wait until 6 AM. She at this point asked to see (LPN #5) and she had to completing change the [MEDICAL CONDITION] because it was so full. She also states that (CNA #2) slammed her door shut every time she left the room last night. DON notified. Review of the Facility Investigation and Response form revealed no staff member was designated to investigate the concern. Actions taken to Resolve/ Respond to concern included only CNA not to work with these residents. Statements were obtained from CNA #2 related to the two incidents but no investigation was conducted. No statements were obtained from roommates, other residents, or staff on duty, especially LPN #5. The incident was not reported to the State Agency as required. There was no evidence that other residents were protected from further abuse/neglect. During an interview with the DON and Administrator on [DATE] at approximately 5 PM, the DON verified that no further investigation had been completed, the incidents had not been reported, and that the only intervention had been to remove the CNA from caring for these individual residents. (2) On [DATE] (no time specified), LPN #3 reported to the DON: Resident (#9) stated that the night person came into her room to change her was rough, push(ed) her over to change her. When she told her that she was going to report her, the person stated nobody (was) going to believe her because she (was) crazy (and) she was tired of changing her. The DON spoke to the resident on [DATE] (no time specified) at which time the resident was visibly upset and kept reporting the story without deviation of details. I was able to calm resident and assured her that I would investigate further. No visible injury were noted and resident had no complaints of acute/new pain. Then Administrator was notified. On [DATE], LPN #6 wrote a statement at 8:30 PM confirming that on that date, Resident #9 was complaining of right arm pain. She stated that the CNA from 11p-7a last night ([DATE]) pulled her L(eft) arm first then pulled her bad side (right side) . (The resident) also stated that the CNA told her she was tired of changing her pissy ass and she should be ashamed of herself, and to get her ass up and go the bathroom the next time. (The resident) also stated that the CNA told her she could tell whoever she wanted to because no one would believe her 'crazy ass'. There were no other statements in the file other than the alleged perpetrator. Review of the Facility Investigation and Response form revealed that the Administrator determined that no abuse had occurred. Actions taken to Resolve/ Respond to concern included Associate given customer service education. Associate to not work with resident again. Upon conclusion of the investigation) the Suspension Pending Investigation form noted that the allegation was unsubstantiated and CNA #3 was returned to work on [DATE]. During an interview with the DON and Administrator on [DATE] at approximately 5 PM, the DON verified that no further investigation had been completed, the incident had not been reported, and that the CNA had been suspended and removed from caring for this resident. (3) Review of a Concern and Comment form dated [DATE] revealed that Resident #529's family member reported to the DON: 0n Sunday (MONTH) 12th at 8:53 PM, the resident left a message stating the aide made an inappropriate remark to him when she came into give him care. The aide stated, 'If you weren't playing with yourself you wouldn't be wetting the bed so much.' The (family member) said this was an isolated incident but feels there's some truth to it . The Facility Investigation and Response form noted that the DON spoke (with) resident who relayed same information. The DON's written statement also included that the Resident expressed concern that this comment was made in front of his wife who is also a resident. He is concerned that a rumor will be started about him . The investigation included only a statement by the alleged perpetrator. Actions taken to Resolve/Respond to concern included CNA and DON went to resident and CNA apologized to resident for delivery of statements. Resident accepted apology. There was no evidence that the incident was reported to the State Agency or thoroughly investigated. During an interview with the DON and Administrator on [DATE] at approximately 5 PM, the DON verified that no further investigation had been completed and that the incident had not been reported. A copy of the facility's policy entitled Protection of Residents: Reducing the Threat of Abuse & Neglect was provided by the Administrator. The Identification section of the policy stated: It is the policy of this facility to identify abuse, neglect . Possible indicators of abuse may include but are not limited to: .Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place or feelings of guilt or shame . Abuse is defined as The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse .and mental abuse . Verbal Abuse-The use of oral . language that willfully includes disparaging and derogatory terms to residents . regardless of their age, ability to comprehend, or disabilities . Mental Abuse includes,but is not limited to, humiliation, harassment, threaten of punishment or deprivation. (MONTH) occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Under the Investigation and Protection section, the Procedure included a 2 .'psychosocial assessment, if needed . 4. The administrator/designee will. utilize the Incident Investigation Questionnaire Form to document the investigation . 6. If it is determined that alleged abuse and neglect. has occurred, the administrator, director of nursing, or his/her designee will promptly notify officials in accordance with state laws .7. The written summary of the investigation should include, but is not limited to: . Interviews with any witnesses to the incident .A review of the residents medical record Interviews with staff members on all shifts having contact with the resident at the time of the incident . Interviews with the resident's roommate, family, and/or visitors who may have information regarding the incident. Interviews with other residents who received care and services from the alleged perpetrator . 8. If the accused individual is an employee, the alleged perpetrator will be removed from resident care areas immediately and placed on suspension pending results ofth investigation . 14. The results of the investigation will be recorded on the Incident Investigation Questionnaire. Any additional documents including interviews and record reviews will be attached to the Incident Follow-Up & Recommendation Form . Review of the policies and investigation files provided by the Administrator revealed that (a) the facility failed to identify that abuse/neglect occurred based on definitions found in the policy, (b) the stipulated forms were not used during the investigation, (c) the incidents were not reported to the State Agency as required by state law and as stipulated in the policy and (d) the investigation was not thorough and conducted per the policy. On [DATE] at 2:15 PM the Administrator, Director of Nursing, and the Regional Director of Clinical Services were notified that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on [DATE] and was identified at a scope and severity of K. Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of K in the following areas: 42 CFR 412(b)(1)(2) F607 The facility failed to implement policies developed related to identification, investigation, resident protection, and reporting allegations of abuse to the State Agency. 42 CFR 483.12(c) F609 The facility failed to report four residents' allegations of abuse/neglect to the State Agency when reported to the facility via the facility's grievance process. 42 CFR 483.12(c)(2)(3) F610 The facility failed to identify and thoroughly investigate four of four residents' allegations of abuse/neglect reported to the facility via the facility's grievance process. 42 CFR 483.70 F835 The facility failed to be administered in a manner that protected residents from abuse. The Administrator's and Director of Nursing's inaction and decisions following allegations of abuse placed other residents in their care in danger of neglect as well as physical, verbal, and emotional abuse. The Administrator and DON failed to implement abuse policies developed related to identification, investigation, resident protection, and reporting of allegations of abuse to the State Agency. The Administrator and Regional Director of Clinical Services were notified that the Immediate Jeopardy was removed on [DATE] at 5:15 PM and the scope and severity was lowered to an E following acceptance and verified implementation of the following Allegation of Compliance: 1. Residents A & B no longer reside in the facility. Both were discharged and have since expired in the community. Certified Nursing Assistant (CNA) #2 is no longer employed by the facility. The incidents were reported to the State Agency on [DATE]. 2. Residents #9 and #529 had unremarkable skin assessments reviewed on [DATE] by unit nurses. Physician was notified on [DATE] by the Director of Nurses (DON). Both resident incidents were reported to the State Agency on [DATE] and an investigation initiated. CNAs #3 and #4 were suspended on [DATE] pending investigation. 3. The Social Services Director, Executive Director (Administrator/ED), and Activities Assistant will interview all residents with a Brief Interview for Mental Status (BIMS) score of 8 or higher for any allegations of abuse/neglect by [DATE]. 4. The DON, Assistant DON (ADON), Wound Care Nurse and/or Unit Managers will review skin assessments on all residents with BIMS of 7 or below to identify any potential unreported abuse by [DATE]. 5. The DON and Regional Director of Clinical Services will review all resident comment and concern cards for the past 90 days for any allegations of abuse by [DATE]. 6. Findings from the above will be reported to the appropriate State Agencies and investigated per state regulations by the Executive Director (ED) and/or DON. 7. The Regional Director of Clinical Services will provide education on the abuse policy which includes: Protection of Resident Rights/Reducing the Threat of Abuse and Neglect, identifying abuse, investigation and protection, reporting and response, photography and social media, Elder Justice Act, and reporting obligations to the ED, DON, and the ADON to ensure that abuse policies are implemented. 8. The ED, DON, and/or ADON will provide education to all associates on the abuse policy which includes contents listed in #7 above. Any associate that has not been inserviced by [DATE] will not be allowed to work until insurance is completed. All newly hired associates will be educated on the abuse policy during orientation. 9. All resident comment and concern cards will be reviewed for allegations of abuse during daily stand-up meetings. The ED will be responsible for ensuring appropriate identification 'reporting per regulations, conducting a thorough investigation and implementing facility abuse policies. 10. All resident skin assessments will be conducted weekly and reviewed during daily clinical meeting for potential abuse. The DON will be responsible for notifying the ED and initiating the investigation. 11. Signage with contact numbers will be posted by the time clock identifying all allegations are to be reported to the ED or secondary contact immediately. 12. The Regional voice President and Regional Director of Clinical Services will be notified of any allegation of abuse and/or neglect at the time the ED or DON are notified and provide documentation that allegation(s) have been reported as required. Prior to submitting final investigations to required agencies, a member of the Divisional/ Regional Team will review investigations to ensure a thorough investigation was completed. The Regional Vice President and/ Regional Director of Clinical Services will review the abuse reporting log and investigations during facility visits.

Based on review of the grievance file, review of the facility's abuse policies and procedures, and interview, the facility failed to identify, report to the State Agency, and thoroughly investigate four of four residents' allegations of abuse/neglect reported to the facility involving 3 staff members via the facility's grievance process. Resident A was told to go to the bathroom in her/his brief, causing anxiety, fear, and humiliation. Resident B reported neglect and threats to delay [MEDICAL CONDITION] care. Resident #9 reported rough handling, humiliation, and verbal abuse and was visibly upset. Resident #529 reported verbal abuse and humiliation. The findings included: Review of the Grievance File on [DATE] at 4 PM revealed that the following incidents were reported to the facility via the grievance process: (1) On [DATE], 2 residents complained that Certified Nursing Assistant (CNA) #2 had neglected their needs resulting in anxiety and psychological harm. Licensed Practical Nurse (LPN) #2 wrote the following: This morning [DATE] when this nurse went to give (Resident A) her medication she appeared anxious. This nurse spoke with her about what she was so anxious about. She stated she wanted to go to the hospital. During further conversation about what she was feeling and why she wanted to go to the hospital, she shared with me that she was upset because last night when she would ask to go to the bathroom, she was told by the CNA to just go in her brief. (Resident A) is continent and this upset her. She then told the same story to her daughter when she arrived. The daughter then approached me in the early afternoon about what she needs to do to take her mom home. She stated that her mom was just very anxious and upset and she doesn't feel she will improve here in this setting . DON (Director of Nursing) and ED (Executive Director) notified. Licensed Practical Nurse (LPN) #2 provided this written statement on [DATE]: At shift change from ,[DATE] to ,[DATE] I answered her call light. (Resident B) was inquiring about who her CNA was going to be this evening. When she was informed it was (CNA #2), she adamantly requested that (CNA #2) not care for her. When this nurse asked her why, she stated that (CNA#2) was very solemn and short with her and she had asked (CNA #2) to empty her [MEDICAL CONDITION] on more than one occasion because she thought it was very full and (CNA #2) kept putting her off. At one point (CNA #2) told her she would be in about 2 AM and (Resident B) informed her she did not want to be awakened at 2 in the morning, so (CNA #2) told her she would wait until 6 AM. She at this point asked to see (LPN #5) and she had to completing change the [MEDICAL CONDITION] because it was so full. She also states that (CNA #2) slammed her door shut every time she left the room last night. DON notified. Review of the Facility Investigation and Response form revealed no staff member was designated to investigate the concern. Actions taken to Resolve/ Respond to concern included only CNA not to work with these residents. Statements were obtained from CNA #2 related to the two incidents but no investigation was conducted. No statements were obtained from roommates, other residents, or staff on duty, especially LPN #5. The incident was not reported to the State Agency as required. There was no evidence that other residents were protected from further abuse/neglect. During an interview with the DON and Administrator on [DATE] at approximately 5 PM, the DON verified that no further investigation had been completed, the incidents had not been reported, and that the only intervention had been to remove the CNA from caring for these individual residents. (2) On [DATE] (no time specified), LPN #3 reported to the DON: Resident (#9) stated that the night person came into her room to change her was rough, push(ed) her over to change her. When she told her that she was going to report her, the person stated nobody (was) going to believe her because she (was) crazy (and) she was tired of changing her. The DON spoke to the resident on [DATE] (no time specified) at which time the resident was visibly upset and kept reporting the story without deviation of details. I was able to calm resident and assured her that I would investigate further. No visible injury were noted and resident had no complaints of acute/new pain. Then Administrator was notified. On [DATE], LPN #6 wrote a statement at 8:30 PM confirming that on that date, Resident #9 was complaining of right arm pain. She stated that the CNA from 11p-7a last night ([DATE]) pulled her L(eft) arm first then pulled her bad side (right side) . (The resident) also stated that the CNA told her she was tired of changing her pissy ass and she should be ashamed of herself, and to get her ass up and go the bathroom the next time. (The resident) also stated that the CNA told her she could tell whoever she wanted to because no one would believe her 'crazy ass'. There were no other statements in the file other than the alleged perpetrator. Review of the Facility Investigation and Response form revealed that the Administrator determined that no abuse had occurred. Actions taken to Resolve/ Respond to concern included Associate given customer service education. Associate to not work with resident again. Upon conclusion of the investigation) the Suspension Pending Investigation form noted that the allegation was unsubstantiated and CNA #3 was returned to work on [DATE]. During an interview with the DON and Administrator on [DATE] at approximately 5 PM, the DON verified that no further investigation had been completed, the incident had not been reported, and that the CNA had been suspended and removed from caring for this resident. (3) Review of a Concern and Comment form dated [DATE] revealed that Resident #529's family member reported to the DON: 0n Sunday (MONTH) 12th at 8:53 PM, the resident left a message stating the aide made an inappropriate remark to him when she came into give him care. The aide stated, 'If you weren't playing with yourself you wouldn't be wetting the bed so much.' The (family member) said this was an isolated incident but feels there's some truth to it . The Facility Investigation and Response form noted that the DON spoke (with) resident who relayed same information. The DON's written statement also included that the Resident expressed concern that this comment was made in front of his wife who is also a resident. He is concerned that a rumor will be started about him . The investigation included only a statement by the alleged perpetrator. Actions taken to Resolve/Respond to concern included CNA and DON went to resident and CNA apologized to resident for delivery of statements. Resident accepted apology. There was no evidence that the incident was reported to the State Agency or thoroughly investigated. During an interview with the DON and Administrator on [DATE] at approximately 5 PM, the DON verified that no further investigation had been completed and that the incident had not been reported. A copy of the facility's policy entitled Protection of Residents: Reducing the Threat of Abuse & Neglect was provided by the Administrator. The Identification section of the policy stated: It is the policy of this facility to identify abuse, neglect . Possible indicators of abuse may include but are not limited to: .Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place or feelings of guilt or shame . Abuse is defined as The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse .and mental abuse . Verbal Abuse-The use of oral . language that willfully includes disparaging and derogatory terms to residents . regardless of their age, ability to comprehend, or disabilities . Mental Abuse includes,but is not limited to, humiliation, harassment, threaten of punishment or deprivation. (MONTH) occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Under the Investigation and Protection section, the Procedure included a 2 .'psychosocial assessment, if needed . 4. The administrator/designee will. utilize the Incident Investigation Questionnaire Form to document the investigation . 6. If it is determined that alleged abuse and neglect. has occurred, the administrator, director of nursing, or his/her designee will promptly notify officials in accordance with state laws .7. The written summary of the investigation should include, but is not limited to: . Interviews with any witnesses to the incident .A review of the residents medical record Interviews with staff members on all shifts having contact with the resident at the time of the incident . Interviews with the resident's roommate, family, and/or visitors who may have information regarding the incident. Interviews with other residents who received care and services from the alleged perpetrator . 8. If the accused individual is an employee, the alleged perpetrator will be removed from resident care areas immediately and placed on suspension pending results ofth investigation . 14. The results of the investigation will be recorded on the Incident Investigation Questionnaire. Any additional documents including interviews and record reviews will be attached to the Incident Follow-Up & Recommendation Form . Review of the policies and investigation files provided by the Administrator revealed that (a) the facility failed to identify that abuse/neglect occurred based on definitions found in the policy, (b) the stipulated forms were not used during the investigation, (c) the incidents were not reported to the State Agency as required by state law and as stipulated in the policy and (d) the investigation was not thorough and conducted per the policy. On [DATE] at 2:15 PM the Administrator, Director of Nursing, and the Regional Director of Clinical Services were notified that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on [DATE] and was identified at a scope and severity of K. Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of K in the following areas: 42 CFR 412(b)(1)(2) F607 The facility failed to implement policies developed related to identification, investigation, resident protection, and reporting allegations of abuse to the State Agency. 42 CFR 483.12(c) F609 The facility failed to report four residents' allegations of abuse/neglect to the State Agency when reported to the facility via the facility's grievance process. 42 CFR 483.12(c)(2)(3) F610 The facility failed to identify and thoroughly investigate four of four residents' allegations of abuse/neglect reported to the facility via the facility's grievance process. 42 CFR 483.70 F835 The facility failed to be administered in a manner that protected residents from abuse. The Administrator's and Director of Nursing's inaction and decisions following allegations of abuse placed other residents in their care in danger of neglect as well as physical, verbal, and emotional abuse. The Administrator and DON failed to implement abuse policies developed related to identification, investigation, resident protection, and reporting of allegations of abuse to the State Agency. The Administrator and Regional Director of Clinical Services were notified that the Immediate Jeopardy was removed on [DATE] at 5:15 PM and the scope and severity was lowered to an E following acceptance and verified implementation of the following Allegation of Compliance: 1. Residents A & B no longer reside in the facility. Both were discharged and have since expired in the community. Certified Nursing Assistant (CNA) #2 is no longer employed by the facility. The incidents were reported to the State Agency on [DATE]. 2. Residents #9 and #529 had unremarkable skin assessments reviewed on [DATE] by unit nurses. Physician was notified on [DATE] by the Director of Nurses (DON). Both resident incidents were reported to the State Agency on [DATE] and an investigation initiated. CNAs #3 and #4 were suspended on [DATE] pending investigation. 3. The Social Services Director, Executive Director (Administrator/ED), and Activities Assistant will interview all residents with a Brief Interview for Mental Status (BIMS) score of 8 or higher for any allegations of abuse/neglect by [DATE]. 4. The DON, Assistant DON (ADON), Wound Care Nurse and/or Unit Managers will review skin assessments on all residents with BIMS of 7 or below to identify any potential unreported abuse by [DATE]. 5. The DON and Regional Director of Clinical Services will review all resident comment and concern cards for the past 90 days for any allegations of abuse by [DATE]. 6. Findings from the above will be reported to the appropriate State Agencies and investigated per state regulations by the Executive Director (ED) and/or DON. 7. The Regional Director of Clinical Services will provide education on the abuse policy which includes: Protection of Resident Rights/Reducing the Threat of Abuse and Neglect, identifying abuse, investigation and protection, reporting and response, photography and social media, Elder Justice Act, and reporting obligations to the ED, DON, and the ADON to ensure that abuse policies are implemented. 8. The ED, DON, and/or ADON will provide education to all associates on the abuse policy which includes contents listed in #7 above. Any associate that has not been inserviced by [DATE] will not be allowed to work until insurance is completed. All newly hired associates will be educated on the abuse policy during orientation. 9. All resident comment and concern cards will be reviewed for allegations of abuse during daily stand-up meetings. The ED will be responsible for ensuring appropriate identification 'reporting per regulations, conducting a thorough investigation and implementing facility abuse policies. 10. All resident skin assessments will be conducted weekly and reviewed during daily clinical meeting for potential abuse. The DON will be responsible for notifying the ED and initiating the investigation. 11. Signage with contact numbers will be posted by the time clock identifying all allegations are to be reported to the ED or secondary contact immediately. 12. The Regional voice President and Regional Director of Clinical Services will be notified of any allegation of abuse and/or neglect at the time the ED or DON are notified and provide documentation that allegation(s) have been reported as required. Prior to submitting final investigations to required agencies, a member of the Divisional/ Regional Team will review investigations to ensure a thorough investigation was completed. The Regional Vice President and/ Regional Director of Clinical Services will review the abuse reporting log and investigations during facility visits.

Based on record reviews and interviews, the facility failed to be administered in a manner that protected residents from abuse. The Administrator's and Director of Nursing's (DON's) inaction and decisions following allegations of abuse placed other residents in their care in danger of neglect as well as physical, verbal, and emotional abuse. The Administrator and DON failed to implement abuse policies developed related to identification, investigation, and reporting allegations of abuse to the State Agency, for four of four residents' allegations of abuse/neglect reported to the facility involving 3 staff members via the facility's grievance process. The findings included: Review of the Grievance File on [DATE] at 4 PM revealed that the following incidents were reported to the facility via the grievance process: (1) On [DATE], two residents complained that Certified Nursing Assistant (CNA) #2 had neglected their needs resulting in anxiety and psychological harm. Licensed Practical Nurse (LPN) #2 wrote the following: This morning [DATE] when this nurse went to give (Resident A) her medication she appeared anxious. This nurse spoke with her about what she was so anxious about. She stated she wanted to go to the hospital. During further conversation about what she was feeling and why she wanted to go to the hospital, she shared with me that she was upset because last night when she would ask to go to the bathroom, she was told by the CNA to just go in her brief. (Resident A) is continent and this upset her. She then told the same story to her daughter when she arrived. The daughter then approached me in the early afternoon about what she needs to do to take her mom home. She stated that her mom was just very anxious and upset and she doesn't feel she will improve here in this setting . DON (Director of Nursing) and ED (Executive Director/Administrator) notified. Licensed Practical Nurse (LPN) #2 provided this written statement on [DATE]: At shift change from ,[DATE] to ,[DATE] I answered her call light. (Resident B) was inquiring about who her CNA was going to be this evening. When she was informed it was (CNA #2), she adamantly requested that (CNA #2) not care for her. When this nurse asked her why, she stated that (CNA#2) was very solemn and short with her and she had asked (CNA #2) to empty her [MEDICAL CONDITION] on more than one occasion because she thought it was very full and (CNA #2) kept putting her off. At one point (CNA #2) told her she would be in about 2 AM and (Resident B) informed her she did not want to be awakened at 2 in the morning, so (CNA #2) told her she would wait until 6 AM. She at this point asked to see (LPN #5) and she had to completely change the [MEDICAL CONDITION] because it was so full. She also states that (CNA #2) slammed her door shut every time she left the room last night. DON notified. Review of the Facility Investigation and Response form revealed no staff member was designated to investigate the concern. Actions taken to Resolve/Respond to concern included only CNA not to work with these residents and was signed by the Administrator on [DATE]. Statements were obtained from CNA #2 related to the two incidents but no investigation was conducted. No statements were obtained from roommates, other residents, or staff on duty, especially LPN #5. The incident was not reported to the State Agency as required. There was no evidence that other residents were protected from further abuse/neglect. During an interview with the DON and Administrator on [DATE] at approximately 5 PM, the DON verified that no investigation had been completed, the incidents had not been reported, and the only intervention had been to remove the CNA from caring for these individual residents. (2) On [DATE] (no time specified), LPN #3 reported to the DON: Resident (#9) stated that the night person came into her room to change her was rough, push(ed) her over to change her. When she told her that she was going to report her, the person stated nobody (was) going to believe her because she (was) crazy (and) she was tired of changing her. The DON spoke to the resident on [DATE] (no time specified) at which time the resident was visibly upset and kept reporting the story without deviation of details. I was able to calm resident and assured her that I would investigate further. No visible injuries were noted and resident had no complaints of acute/new pain. The Administrator was notified. On [DATE], LPN #6 wrote a statement at 8:30 PM confirming that on that date, Resident #9 was complaining of right arm pain. She stated that the CNA from 11p-7a last night ([DATE]) pulled her L(eft) arm first then pulled her bad side (right side) . (The resident) also stated that the CNA told her she was tired of changing her pissy ass and she should be ashamed of herself, and to get her ass up and go the bathroom the next time. (The resident) also stated that the CNA told her she could tell whoever she wanted to because no one would believe her 'crazy ass'. There were no other statements in the file other than the alleged perpetrator. Review of the Facility Investigation and Response form revealed that the Administrator was designated to investigate and follow up with Concern. S/he determined that no abuse had occurred based solely on statements obtained by the resident and alleged perpetrator. No investigation was completed. Actions taken to Resolve/Respond to concern included Associate given customer service education. Associate to not work with resident again. The Suspension Pending Investigation form noted that the allegation was unsubstantiated and CNA #3 was returned to work by the DON on [DATE]. During an interview with the DON and Administrator on [DATE] at approximately 5 PM, the DON verified that no further investigation had been completed, the incident had not been reported, and that the CNA had been suspended and removed from caring for this individual resident. (3) Review of a Concern and Comment form dated [DATE] revealed that Resident #529's family member reported to the DON: On Sunday (MONTH) 12th at 8:53 PM, the resident left a message stating the aide made an inappropriate remark to him when she came into give him care. The aide stated, 'If you weren't playing with yourself you wouldn't be wetting the bed so much.' The (family member) said this was an isolated incident but feels there's some truth to it . The Facility Investigation and Response form noted that the DON spoke (with) resident who relayed same information. The DON's written statement also included that the Resident expressed concern that this comment was made in front of his wife who is also a resident. He is concerned that a rumor will be started about him . The investigation included only a statement by the alleged perpetrator (CNA #4). Actions taken to Resolve/Respond to concern included CNA and DON went to resident and CNA apologized to resident for delivery of statements. Resident accepted apology. There was no evidence that the incident was reported to the State Agency or thoroughly investigated. During an interview with the DON and Administrator on [DATE] at approximately 5 PM, the DON verified that no further investigation had been completed and that the incident had not been reported. A copy of the facility's policy entitled Protection of Residents: Reducing the Threat of Abuse & Neglect was provided by the Administrator. The Identification section of the policy stated: It is the policy of this facility to identify abuse, neglect . Possible indicators of abuse may include but are not limited to: .Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place or feelings of guilt or shame . Abuse is defined as The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse .and mental abuse . Verbal Abuse-The use of oral . language that willfully includes disparaging and derogatory terms to residents . regardless of their age, ability to comprehend, or disabilities . Mental Abuse includes,but is not limited to, humiliation, harassment, threaten of punishment or deprivation. (MONTH) occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Under the Investigation and Protection section, the Procedure included a 2 .'psychosocial assessment, if needed . 4. The administrator/designee will. utilize the Incident Investigation Questionnaire Form to document the investigation . 6. If it is determined that alleged abuse and neglect. has occurred, the administrator, director of nursing, or his/her designee will promptly notify officials in accordance with state laws .7. The written summary of the investigation should include, but is not limited to: . Interviews with any witnesses to the incident .A review of the residents medical record Interviews with staff members on all shifts having contact with the resident at the time of the incident . Interviews with the resident's roommate, family, and/or visitors who may have information regarding the incident. Interviews with other residents who received care and services from the alleged perpetrator . 8. If the accused individual is an employee, the alleged perpetrator will be removed from resident care areas immediately and placed on suspension pending results of the investigation . 14. The results of the investigation will be recorded on the Incident Investigation Questionnaire. Any additional documents including interviews and record reviews will be attached to the Incident Follow-Up & Recommendation Form . Review of the policies and investigation files provided by the Administrator revealed that (a) the facility management failed to identify that abuse/neglect occurred based on definitions found in the policy, (b) perpetrators were not suspended to protect other residents from potential abuse as delineated in the policy, (c) the incidents were not reported to the State Agency as required by state law and as stipulated in the policy and (d) the investigation was not thorough and conducted per the policy. When asked if the root cause analysis had been completed to determine the reason for the deficient practice on [DATE] at 5:02 PM, the Regional Director of Clinical Services stated, It came down to identification. There was a misinterpretation of what was customer service versus abuse.' On [DATE] at 2:15 PM the Administrator, Director of Nursing, and the Regional Director of Clinical Services were notified that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on [DATE] and was identified at a scope and severity of K. Immediate Jeopardy and/or Substandard Quality of Care was identified at a scope and severity of K in the following areas: 42 CFR 483.12(b)(1)(2) F607 The facility failed to implement policies developed related to identification, investigation, resident protection, and reporting allegations of abuse to the State Agency. 42 CFR 483.12(c) F609 The facility failed to report four residents' allegations of abuse/neglect to the State Agency when reported to the facility via the facility's grievance process. 42 CFR 483.12(c)(2)(3) F610 The facility failed to identify and thoroughly investigate four of four residents' allegations of abuse/neglect reported to the facility via the facility's grievance process. 42 CFR 483.70 F835 The facility failed to be administered in a manner that protected residents from abuse. The Administrator's and Director of Nursing's inaction and decisions following allegations of abuse placed other residents in their care in danger of neglect as well as physical, verbal, and emotional abuse. The Administrator and DON failed to implement abuse policies developed related to identification, investigation, resident protection, and reporting of allegations of abuse to the State Agency. The Administrator and Regional Director of Clinical Services were notified that the Immediate Jeopardy was removed on [DATE] at 5:15 PM and the scope and severity was lowered to an E following acceptance and verified implementation of the following Allegation of Compliance: 1. Residents A & B no longer reside in the facility. Both were discharged and have since expired in the community. Certified Nursing Assistant (CNA) #2 is no longer employed by the facility. The incidents were reported to the State Agency on [DATE]. 2. Residents #9 and #529 had unremarkable skin assessments reviewed on [DATE] by unit nurses. Physician was notified on [DATE] by the Director of Nurses (DON). Both resident incidents were reported to the State Agency on [DATE] and an investigation initiated. CNAs #3 and #4 were suspended on [DATE] pending investigation. 3. The Social Services Director, Executive Director (Administrator/ED), and Activities Assistant will interview all residents with a Brief Interview for Mental Status (BIMS) score of 8 or higher for any allegations of abuse/neglect by [DATE]. 4. The DON, Assistant DON (ADON), Wound Care Nurse and/or Unit Managers will review skin assessments on all residents with BIMS of 7 or below to identify any potential unreported abuse by [DATE]. 5. The DON and Regional Director of Clinical Services will review all resident comment and concern cards for the past 90 days for any allegations of abuse by [DATE]. 6. Findings from the above will be reported to the appropriate State Agencies and investigated per state regulations by the Executive Director (ED) and/or DON. 7. The Regional Director of Clinical Services will provide education on the abuse policy which includes: Protection of Resident Rights/Reducing the Threat of Abuse and Neglect, identifying abuse, investigation and protection, reporting and response, photography and social media, Elder Justice Act, and reporting obligations to the ED, DON, and the ADON to ensure that abuse policies are implemented. 8. The ED, DON, and/or ADON will provide education to all associates on the abuse policy which includes contents listed in #7 above. Any associate that has not been inserviced by [DATE] will not be allowed to work until insurance is completed. All newly hired associates will be educated on the abuse policy during orientation. 9. All resident comment and concern cards will be reviewed for allegations of abuse during daily stand-up meetings. The ED will be responsible for ensuring appropriate identification 'reporting per regulations, conducting a thorough investigation and implementing facility abuse policies. 10. All resident skin assessments will be conducted weekly and reviewed during daily clinical meeting for potential abuse. The DON will be responsible for notifying the ED and initiating the investigation. 11. Signage with contact numbers will be posted by the time clock identifying all allegations are to be reported to the ED or secondary contact immediately. 12. The Regional voice President and Regional Director of Clinical Services will be notified of any allegation of abuse and/or neglect at the time the ED or DON are notified and provide documentation that allegation(s) have been reported as required. Prior to submitting final investigations to required agencies, a member of the Divisional/ Regional Team will review investigations to ensure a thorough investigation was completed. The Regional Vice President and/ Regional Director of Clinical Services will review the abuse reporting log and investigations during facility visits.

On the days of the Recertification and Complaint Survey, based on observation, record reviews, interviews, and review of the facility's policy, Peripherally Inserted Central Catheter (PICC), the facility failed to provide dressing changes and flushes to PICC line as ordered for Resident #1, 1 of 2 residents reviewed with a PICC line. The facility also failed to administer medication as ordered for Resident #1 and #2, 2 of 9 residents reviewed for medication administration. [MEDICATION NAME] was not administered to Resident #1 for 8 days and Resident #2 did not receive [MEDICATION NAME] for pain as ordered due to the facility's failure to transcribe the orders to the Medication Administration Record. The findings included: The facility admitted Resident #1 with multiple Pressure Ulcers. On 4/7/14 at 3:55 PM, review of the Telephone Orders revealed an order dated 2/6/14 to " flush PICC line (with) 10 ml (milliliters) of NS (normal saline) before and after med(ication) administration. " Further review revealed a Telephone order dated 2/19/14 that stated the last dose of [MEDICATION NAME] was to be administered on 2/24/14. Continued review of the Telephone Orders revealed an order dated 3/25/14 "Flush PICC (with) 10 ml's of normal saline every week or Tuesdays." On 4/9/14, review of the Medication Administration Record (MAR) for 3/1-3/31/14 revealed no documentation that the PICC line had been flushed in the month of March. Further review revealed a Central Line Catheter Treatment Record for February, 2014 that indicated the last time the PICC line had been flushed was on 2/20/14. The record indicated the needleless connector and the dressing had last been changed on 2/20/14, both of which the orders indicated were to be changed weekly. Record review revealed Resident #1 also had a Telephone order dated 2/9/14 for "[MEDICATION NAME] 17 g. (grams) give by mouth daily." Review of the February MAR revealed the order was transcribed as written. Review of the March MAR revealed the medication was not administered March 1 through March 8, 2014. During an interview on 4/9/14 at 8:50 AM, Licensed Practical Nurse (LPN) #3 confirmed, after observation, that Resident # 1 did still have a PICC line in place in the right upper extremity. The LPN further confirmed that documentation indicated the connector had not been changed and that the normal saline flush had not been signed off as administered for 2 weeks in February. LPN #3 also confirmed there was no Central Line Catheter Treatment Record for the month of March and confirmed the 3/25/14 order to flush weekly had not been transcribed to the MAR. LPN #5 confirmed the normal saline flush was not on the April MAR and that the previous order to flush before and after medication administration had been discontinued on the March MAR and the 3/25/14 order had not been transcribed. LPN #5 also confirmed the [MEDICATION NAME] had not been administered for the first 8 days of March and stated "whoever made out the MAR just didn't carry it over." Review of the facility's policy entitled "Peripherally Inserted Central Catheter (PICC)" revealed "Change dressing 24 hours post insertion ..., then every week and PRN (as needed)." In addition, the policy stated the Needleless Connector was to be changed "every week and prn" and the valved catheter flushed with "10 ml NS every week." The facility admitted Resident #2, with current [DIAGNOSES REDACTED]. On 4/8/14 at approximately 10:50 am, record review of the pain scale revealed a pain level of 10/10 on 4/2/14 and 6/10 on 4/7/14 and 9/10 on 4/8/14 documented on the Medication Administration Record. During an interview with (LPN) Licensed Practical Nurse #6 on 4/8/14 10:55am, (he/she) stated the physician had ordered another pain medication for the resident last week ([MEDICATION NAME]). Record review of the Medication Administration Record revealed no transcribed entry for [MEDICATION NAME]. During the interview, LPN #6 brought a faxed prescription dated 4/3/14 at 12:45 to the surveyor and stated, "Here is the new order for the [MEDICATION NAME]. The resident needed something else for pain and the doctor told me (he/she) would fax an order over to the floor." During an interview on 4/8/14 10:55 am, LPN #6 confirmed the date on the prescription was 4/3/14 for the order date and faxed date. LPN #6 confirmed that Resident #2 had not received any [MEDICATION NAME] for pain for the month of April. There was no evidence that although the resident was complaining of significant pain, that the facility followed the new physician's orders [REDACTED].

On the days of the Complaint and Recertification Survey based on observations, record reviews and interviews the facility failed to provide appropriate wound care and implement aggressive measures to prevent the development of pressure ulcers for 4 of 6 sampled residents reviewed. The facility failed to aggressively treat Resident #10 admitted with no Pressure Ulcers who developed (1) Stage 2 Pressure Ulcer to the left heel and 1 unstageable Pressure Ulcer to the Coccyx. Observation of wound care treatment for [REDACTED].#6 revealed poor wound care technique. Resident # 2 did not receive wound treatments as ordered by the physician. The findings included: On 1/14/14 Resident #10's Pre-[MEDICATION NAME] was reported low at 16, with the normal range being 20-40 mg/dl. The lab report had been initialed by Physician (date unknown). A review of the Diet Order and Communication signed by the nurse on 1/23/14 per dietary stated to add 1/2 sandwich at bedtime as the intervention to treat the low pre-[MEDICATION NAME]. This was 7 days after the reported low pre-[MEDICATION NAME] was received by the facility. On 1/30/14 the "Resident at Risk Meeting" team recommended that Resident #10 receive a Multivitamin with minerals and Prostat once daily. Prostat 30 ml once daily (for the low [MEDICATION NAME] level) was written on 1/31/14. However, there was a time lapse between when the team recommended the daily Multivitamin (on 1/30/14) and when the order for the Multivitamin once daily had been written (on 2/4/14). Review of the Weekly Skin Integrity Data Collection documentation revealed that on 1/25/14, the nurse documented redness to the sacral area, there was no other assessments related to the sacrum until 2/6/14 when an unstageable wound to the coccyx was identified that measures 3 cm x 2 cm- depth unknown. The physician was notified with new orders for treatment given for Allevyn, air mattress to bed, and to obtain labs on the next lab day. On 2/10/14 the wound was documented to have improved and measured 3 cm x 1.5 cm with slough and a small amount of serosanguinous drainage. Resident #10 on 2/3/14 developed a stage 2 clear fluid filled blister on the left lateral heel measuring 5 cm x 7.5 cm, Allevyn was ordered for the left heel along with MVI w/minerals, float heels, and prostat. On 2/10/14, the blister measured 4 cm x 7.5 cm. On 2/11/14 Resident #10 was transferred to the emergency room . According to the ED note dated 2/11/14 at 1:41 PM, the resident's skin was hot and dry with poor skin turgor. The Inguinal area was swollen with associated signs and symptoms that included fever. A stage 4 pressure ulcer (buttock) had an absorbant dressing dated 2/10/14 that was saturated with foul dressing (drainage?). On arrival the resident's temperature was 102.6 rectally. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Resident #10 had been discharged from the facility to the hospital on [DATE], and his/her care was reviewed as part of a closed record review. A review on 4/17/14 of the Emergency Department (ED) note/hospital discharge summary provided by the facility prior to the survey exit on 4/9/14 revealed the resident had been admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. According to the ED note dated 2/11/14 at 1:41 PM, the resident's skin was hot and dry with poor skin turgor. The Inguinal area was swollen with associated signs and symptoms that included fever. A stage 4 pressure ulcer (buttock) had an absorbant dressing dated 2/10/14 that was saturated with foul dressing (drainage?). On arrival the resident's temperature was 102.6 rectally. According to the hospital discharge summary dated 2/25/14, a consultation had been made with plastic surgery to discuss possible options; and the family decided to change the goals of care to comfort. The patient was to be discharged home with hospice follow up. A review of the facility's Admission Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact at the time of the assessment. The resident was coded as requiring extensive assistance of one person for bed mobility, transfers, and walking in the room or hall; with a functional limitation in range of motion in the lower extremity of one side (left). The assessment documented the resident's height/weight as having been 69 inches and 128 pounds; having frequent incontinence of bowel and bladder and at risk for the development of pressure ulcers; with none on admission to the facility. The assessment indicated the plan was for the resident to be discharged back to the community. A review on 4/8/14 at approximately 9:50 AM of the Initial Data Collection Tool/Nursing Service (Admission Assessment) dated 1/10/14 revealed an entry for the resident's "General Skin Condition" which included a body diagram. The entry documented the skin was warm and intact with bruises, skin tears, and abrasions. There was no indication of any concerns relative to the coccyx/sacral areas or the left heel. A review of the Braden Scale for predicting pressure ulcer risk revealed entries dated 1/31/14, 2/2/14, and 2/6/14. All the entries had been coded the same, a total score of 18. A score of 15-18 indicated "at risk". A score of 13-14 indicated "moderate risk", 10-12 "high risk", and less than or equal to 9 "very high risk". Documentation on the Braden Scale prior from 1/10/14 through 1/27/14 revealed the resident had documented scores of 15 and 16, also indicating being "at risk" for pressure sores. A review on 4/8/14 of Admission Physician's Orders dated 1/10/14 revealed orders for gentle PT (Physical Therapy) exercises, with weight bearing as tolerated (WBAT). Labs that included a Pre-[MEDICATION NAME] level had also been ordered. The Pre-[MEDICATION NAME] was reported low at 16 on 1/14/14, with the normal range being 20-40 mg/dl. The lab report had been initialed by Physician (date unknown). On 1/20/14, the Certified Dietary Manager documented the [MEDICATION NAME] level along with other lab results on a Nutrition Data Collection Assessment. This assessment included information that the resident was ordered a regular diet and consumed an average of 75% of his/her meals. The Registered Dietician (RD) reviewed this information on 1/21/14 and determined that the resident should have a 1/2 sandwich at bedtime to provide additional calories and an additional 9 grams of protein to the resident's diet. The RD would monitor the nutritional parameters and follow up and assist as needed. A review of the Diet Order and Communication to add the 1/2 sandwich at bedtime revealed this communication had been signed by the nurse on 1/23/14. There was no indication from the record that the resident's low [MEDICATION NAME] level had been treated aggressively. There was a time lapse from 1/14/14 from when the low [MEDICATION NAME] level was reported until 1/23/14 when an intervention of 1/2 a sandwich at bedtime had been ordered. The RD and Dietary manager who had documented the above notes were no longer employed by the facility. A notation on the resident's Care Plan Conference Record dated 1/14/14 stated that the resident had very little appetite at that time. A review on 4/8/14 of a note dated 1/30/14 from the facility's "Resident at Risk Meeting" revealed team recommendations for Resident #10 that included a Multivitamin with minerals and Prostat once daily. an order for [REDACTED]. However, there was a time lapse between when the team recommended the daily Multivitamin (on 1/30/14) and when the order for the Multivitamin once daily had been written (on 2/4/14). A review of the Care Plan on 4/8/14 revealed an entry dated 1/10/14, "Resident is at risk for developing a pressure ulcer related to decreased mobility, incontinence, [DIAGNOSES REDACTED]." The goal was to minimize the risk for pressure ulcer development and included interventions to "Assist PRN (As Needed) to reposition/shift weight to relieve pressure, Complete Braden Scale Risk Assessment quarterly PRN, complete weekly skin assessment, Encourage use of siderails to assist turning in bed, Notify nurse immediately of any new areas of skin breakdown.., Provide diet as ordered...consult dietary PRN, Provide incontinence care after ...episodes, Provide pressure relieving or reductions device, Pressure reduction mattress, chair cushion, Refer to therapy as needed, Use lifting device, draw sheet to reduce friction." According to the resident's Admission MDS assessment, the resident required the extensive assistance of one person with bed mobility and had a functional limitation in his/her range of motion in the left lower extremity. However, there were no aggressive dated interventions noted in the care plan only PRN to address these concerns relative to the resident's pressure ulcer risk. A review on 4/8/14 of the Weekly Skin Integrity Data Collection documentation revealed that on 1/25/14, the nurse documented redness to the sacral area. There were no new orders or nursing interventions documented for the treatment of [REDACTED]. A review of the resident's Pressure Ulcer Status Record revealed that on 2/3/14, a stage 2 clear fluid filled blister was first observed to the resident's left lateral heel measuring 5 cm x 7.5 cm. The first mention of the blister in the Nursing Notes revealed an entry dated 2/4/14 at 11:04 AM. "Weekly Wound Round: ....Intact fluid filled blister to (his/her) left heel assessed and measured. MD notified with new orders ...Allevyn ...to left heel. New orders for MVI w/minerals, float heels, and prostat. See pressure ulcer status record...for wound details." A review of Physician Telephone Orders revealed corresponding orders for the same. The orders for treatment of [REDACTED]. The orders included that the resident was to have his/her heels floated while in the bed. Documentation on the Pressure Ulcer Status Record revealed that on 2/10/14, the blister measured 4 cm x 7.5 cm. On 2/6/14, an unstageable wound to the coccyx was identified. A Nursing Note dated 2/6/14 at 6:26 AM stated, "...Notified by CNA that s/he had an open area on (his/her) backside. (S/he) was assessed and noted to have an unstageable, d/t coverage of wound bed by slough, pressure ulcer to (his/her) coccyx that measures 3 cm x 2 cm- depth unknown. MD (Physician) notified with new orders for treatment with Allevyn, air mattress to bed, and to obtain labs on the next lab day....See pressure ulcer status records for wound details." A Physician's Telephone Order dated 2/6/14 stated, "Cleanse wound to the coccyx w/ns (normal saline), pat dry, skin prep peri-wound, apply Allevyn dressing every 3 days and as needed. Low air loss mattress to bed ...". On 2/10/14 the wound was documented to have improved and measured 3 cm x 1.5 cm with slough and a small amount of serosanguinous drainage. A Nursing Note dated 2/6/14 at 5:58 PM revealed a "Resident at Risk" meeting had been held due to the resident's wound and new admission week 1. (Resident #10 had been admitted [DATE]). It did not include information that this was a late entry or exactly when the meeting had been held. The note included information about the initial measurements of the left heel blister and that the resident continued on MVI w/minerals, prostat, and was eating 75% of meals. The note did not include any information about the wound to the coccyx and stated another review would be done the next week. On 4/8/14, the surveyor requested a report of the resident's intake. The Certified Dietary Manager returned later and stated there were no reports related to the resident's dietary intake, just what was documented in the chart. A review of the clinical record revealed meal intakes had not been recorded on the MARs/TARs. A Nursing Progress Note dated 1/16/14 stated the resident's intake was 100%, and a note dated 1/17/14 documented "appetite" at 50%. A review of the Care Plan revealed an entry dated 2/3/14 stating, "Resident has pressure ulcer(s), left heel stage 2, 2/6/14- coccyx unstageable." The goal was "Pressure ulcer(s) will exhibit signs of healing evidenced by decrease in size, improved appearance and be free from signs and symptoms of infection by next review date. Minimize risk for development of any new areas of skin breakdown through next review date." Handwritten additions were noted to the care plan dated 2/6/14 that indicated a low air loss mattress was in place and that the resident was to be encouraged to move about as tolerated and appropriate to encourage circulation and healing. The care plan entry included information to assist the resident every 2 hours and as needed to reposition/shift weight to relieve pressure. During an interview on 4/8/14 at 11:05 AM with the current RD; on 4/8/14 at 11:37 AM with the Assistant Director of Nursing, and on 4/8/14 at 1:00 PM with the Interim Director of Nursing, concerns related to the development of Resident #10's Pressure ulcers were discussed. The Interim DON verified that the Physician had reviewed the Pre-[MEDICATION NAME] lab report and no orders had been written at the time related to this. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Registered Nurse (RN) #3 was observed providing wound care to Resident #1 on 4/7/14 at 4:35 PM. During the observation, RN #3 removed the soiled dressing from the left hip and discarded it. After the physician assessed the wound, RN #3 cleaned the wound without changing gloves or washing/sanitizing her/his hands. The RN changed gloves and washed her/his hands then removed the soiled dressing from the sacrum and discarded it. The physician assessed the wound and RN #3 proceeded to clean the wound without changing gloves or washing or sanitizing her/his hands. RN #3 removed her/his gloves, washed her/his hands, applied a new dressing to the left hip wound and removed her/his gloves. Without washing or sanitizing her/his hands, the RN left the room, returned and removed a pair of gloves from the box and donned them without washing or sanitizing her/his hands. RN #3 then completed the dressing change. On 4/9/14 at 12:25 PM, RN #3 confirmed s/he did not change gloves or wash her/his hands after removing the soiled dressing and cleaning the wounds on both the left hip and sacrum. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Resident # 6 was observed for wound care for a Stage II sacral Pressure Ulcer on 4/8/2014 at 3:18 PM. During the wound care Licensed Practical Nurse #3 removed and discarded the soiled dressing. While LPN #3 went to wash her/his hands, Certified Nursing Assistant (CNA) #2 covered Resident #6 with the bed sheet, thereby contaminating the bed sheet. LPN #3 cleansed the wound with normal saline and gauze, then removed gloves and went to wash her/his hands. CNA #2 covered the exposed, clean wound with the contaminated bed sheet, re-contaminating the wound. LPN #3 proceeded to complete the wound care and removed her gloves. The soiled dressing, cleaning supplies and contaminated gloves were placed in a Biohazard bag. The LPN placed the Biohazard bag in a trash bag, tied the bag shut, then closed the bag of gauze, prior to hand washing or using hand sanitizer. LPN # 3 placed the contaminated bag of gauze on top of the treatment cart. LPN #3 disposed of the trash in the Biohazard Room and washed her/his hands. She/he then returned to the treatment cart and placed the contaminated bag of gauze inside the cart. During an interview on 4/9/14 at 12:00 PM, LPN #3 confirmed that CNA #2 covered the clean wound with the contaminated bed sheet. LPN #3 also confirmed that she/he contaminated the bag of gauze by handling it after wound care, prior to any hand washing and placed it back in the treatment cart with other wound care supplies. The facility admitted Resident #2, with current [DIAGNOSES REDACTED]. On 4/8/14 at approximately 11:50 am, wound treatments were performed by (LPN) Licensed Practical Nurse #6 and assisted by the Assistant Director of Nurses (ADON) for Resident #2 on 3 of 4 wounds. During the wound care observation, the wounds were not cleaned by LPN# 6 before Santyl ointment was applied to the wound bed and covered with an Allevyn dressing on the left heel and right lateral ankle. Record review of the Medication Administration Record dated 4/1/14 to 4/30/14 revealed a hand written statement to not cleanse the wound on the sacrum beside the typed in order for Dakins 0.125% to wet to dry dressing for sacrum. Record review on 4/8/14 at approximately 12:45 pm, of the Telephone Orders revealed the following orders dated 2/24/14 for wound care: "Discontinue current treatment to right lateral ankle & left heel. Begin: Cleanse wound to the right lateral ankle with Normal Saline, pat dry, apply thin layer of Santyl 250 (units/gram) to wound bed, cover with allevyn dressing, change daily & as needed." Handwritten on the March 1-31, Physician Orders was the following order: "Cleanse the Right Lateral Ankle with Normal Saline, pat dry, apply thin layer of Santyl 250 (units/gram), cover with Allevyn dressing, change every 3 days and as needed." During the record review on 4/8/14 at approximately 1:00 pm, it was noted that the telephone order was transcribed to the April Treatment Chart as "Santyl 250 (units/gram) Ointment, Apply a Thin Layer To Wound Bed Of Right Lateral Ankle and (L) Heel, Cover With Allevyn DSG-CHG Every Day & As Needed." On the Physician's Orders for 04/01/14 through 04/30/14 the order was transcribed in typed form **DX: Wounds Santyl 250 (units /gram) Ointment--"Apply a thin layer to wound bed of right lateral ankle and (l) heel, cover with allevyn dsg-Chg every day & as needed." The April Monthly Physician Orders did not include the instructions to cleanse the wound. Record review revealed no telephone order or clarification to discontinue cleaning the wounds on the right lateral ankle and left heel. An interview with LPN#6 on 4/9/14 at approximately 2:15 pm revealed "(The physician) writes his own orders. I went by the doctors orders." During an interview on 4/9/14 at approximately 12:10 pm the ADON stated, "(The physician) does not have standing orders for wound care protocol." During an interview on 4/9/14 at 4:53 pm, the ADON stated, "The printed out orders are not written verbatium and the treatment orders get jumbled up by the pharmacy with their transcription." The ADON confirmed he/she would expect a written telephone order to change a treatment. Prior to existing, The DON (Director of Nursing) provided a written statement by the physician for Resident #2 that stated, "Clarification of Order 4/1/14-There is no need to rinse wound with Normal Saline with the application of Santyl to the wound bed. Santyl is an enzymatic debrider and is in itself a cleaning/[MEDICATION NAME] agent." The statement was dated 4/9/14 and timed 1715 hours and signed by the physician. This clarification was not obtained until the concern was identified by the survey process. The manufacturer's recommendations for the use of santyl (available on santyl.com) states the area should be flushed with normal saline prior to the application of Santyl. Record review on 4/9/14, of the policy and procedure for wound cleansing revealed the policy stated: "The presence of foreign materials and devitalized tissue slows the healing process and may cause infection. Wounds are cleansed or irrigated to help separate and remove foreign materials that are not embedded or very adherent to the injured tissue or surrounding skin." The procedure for Wound Cleansing was to "Cleanse the pressure ulcer and surrounding skin at the time of each dressing change." The Policy for dressings stated : "Dressings are changed following the manufacturer's recommendations or when leakage of exudate occurs. If a dressing with a change indicator is used, the dressing should be changed when wound exudate, visible underneath the dressing, reaches the indicator line." The procedure for dressings revealed " #9 Cleanse the wound as directed and according to the Wound Cleansing policy."

On the days of the complaint inspection, based on medical record review, review of facility records, and interviews, the facility failed to ensure that a resident's legal representative was allowed to purchase copies of the resident's medical record with 2 working days advance notice for 2 of 2 requests made by family members (#1 and #2). The facility also failed to release copies of a medical record, requested by the resident, in a timely manner (#A). The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was unable to communicate. His parents were deceased . For all his time at the facility, his sister was his responsible party and made all decisions for him. She signed authorization for Do Not Resuscitate (DNR)and for vaccinations. The facility staff notified the sister about any change in condition the resident experienced. The sister attended care plan meetings and actively participated in the ongoing plan of care for her brother. She was the one who signed discharge paperwork at the facility, and it was she who authorized release of information to the resident's new facility. Review of the available medical record revealed that on [DATE], two physicians signed a form titled Authorization of Do Not Resuscitate Incompetent Resident. The physicians certified that the resident did not have the capacity to make decisions and that DNR status was appropriate for him. Resident #1's sister signed consent for the DNR order. Review of the South Carolina Health Care Consent Act revealed that a residents inability to consent must be certified by two physicians. "... Persons who may make health care decisions for patient who is unable to consent; order of priority; exceptions. ...6 an adult sibling, grandparent, or adult grandchild of the patient ..." On [DATE], the resident's sister requested copies of his medical record for the period of [DATE] to [DATE]. On [DATE], the facility sent the requested copies of the medical record to their corporate legal office. On [DATE], the facility sent a letter to the resident's sister stating " ... (Resident) was deemed as 'Incompetent' as of his admission to our facility back in 2002 according to the documentation we have on file. ..." The facility continued to say: "Our legal team has indicated to me you will have to pursue legal 'Guardianship' through the Probate Courts in order to have any documentation related to (resident's) care at our facility released to you. ..." As of [DATE], the medical record copies still had not been released to Resident #1's sister. Resident #2 lived at the facility from [DATE] to [DATE]. Her [DIAGNOSES REDACTED]. Throughout most of her stay at the facility, the resident made her own decisions. She displayed impaired cognitive status in early 2011 (,[DATE] on the Brief Interview for Mental Status, assessment date of [DATE]) and had a decline in condition which became more pronounced in mid-[DATE]. At that time, the resident was included in the facility's Butterflies Are Free program for end of life comfort care. All diagnostics were discontinued. A physician's orders [REDACTED]. On [DATE], the resident vomited a large amount of brown emesis. Facility staff contacted the physician who instructed them to call the daughter and follow her wishes. The resident expired at the facility on [DATE]. On [DATE], the resident's daughter requested copies of the medical record. The facility sent copies of the record to their corporate legal department on [DATE]. As of [DATE], the copies had not been released to the resident's daughter. Resident #A requested copies of his medical record on [DATE]. The facility sent the copies to their corporate legal department on [DATE]. The copies were released to the resident on [DATE]. During an interview with the Administrator and the Health Care Information Management Director on [DATE] at 1:25 PM, they confirmed the information concerning the three medical records noted above.