Every finding on record at Magnolia Manor - Inman

Based on observations, interviews, and policy review, the facility failed to ensure food stored in the kitchen was properly labeled, dated and covered, and failed to maintain kitchen food preparation and service equipment in a clean condition for one of one kitchen. These failures had the potential to promote bacterial growth, impede identification of expired or unsafe food products, and increase the risk of food-borne illness for 165 residents who consumed food prepared from the facility's kitchen.Findings include: Review of the facility's policy titled, Food Safety in Receiving and Storage, dated 10/15/25, indicated Policy: Food will be received and stored by methods to minimize contamination and bacterial growth. Procedures.12. Refrigerated, ready to eat Time/Temperature Control for Safety Foods (TCS) are properly covered, labeled, dated with a use-by-date, and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. Review of the facility's policy titled, Safe Food Preparation, dated 10/15/25, indicated Policy: During the food production process, will be handled by methods to minimize contamination and bacterial growth to prevent food borne illness. Procedures.2. All working surfaces, utensils, and equipment are cleansed thoroughly and sanitized after each period of use. 1. Observation during the initial kitchen inspection on 08/02/26 from 9:10 AM to 9:40 AM, alongside the [NAME] and then Assistant Dietary Manager (ADM) at 9:30 AM, revealed the following concerns with food storage: The kitchen's reach in refrigerator contained one previously opened and undated five-pound container of chicken salad and two large previously opened, undated, and uncovered packages of processed American cheese. One of the opened and uncovered packages of cheese contained cheese slices that were discolored and had started to harden. During an observation and interview on 08/02/26 at 9:15 AM, the cook confirmed the previously opened and undated five-pound container of chicken salad and the two undated and uncovered previously opened packages of processed America cheese were stored in the kitchen's reach-in refrigerator. The cook stated food should be labeled, dated, and completely covered when stored. 2. Further observations during the initial kitchen inspection on 08/02/26 from 9:10 AM to 9:40 AM, alongside the cook and then ADM at 9:30 AM, revealed the following unclean food preparation and service equipment: a. 10 of 10 metal food service and preparation pans, which were stored as clean and checked for cleanliness, were unclean with food and/or grease residue on them. The 10 pans also had moisture on their inner and outer surfaces and were stored stacked directly on top of each other. b. The kitchen's stove-top spill pan was unclean with a heavy accumulation of dried food and burned food spills. c. The kitchen's food processor's bowl attachment was stored unclean with food residue and moisture inside the bowl. d. Two large mixing bowls, which were stored stacked on together, were unclean with food residue and moisture on them. During an observation and interview on 08/02/26 at 9:26 AM, the cook confirmed the stored food service, and preparation pans were not clean and wet. The cook stated the food preparation pans should be clean when stored for use and began taking the unclean pans to the kitchen's three compartment sink to wash them. During an observation and interview on 08/02/26 at 9:35 AM, the ADM confirmed the stored food preparation and service pans, mixing bowls, and food processor's bowl attachment were unclean and wet when stored. The ADM stated the pans, mixing bowls, and food processor's bowl attachment should be clean when stored for use. The ADM also stated the food preparation pans and bowls should not be stored directly on top of each other to allow them to air day. During an observation and interview on 08/02/26 at 9:38 PM, the ADM confirmed the kitchen's stove top spill pan was unclean with a heavy accumulation of dried food and burned food spills. The ADM stated staff should clean the spill pan every week and more often if needed.

Based on observations, interviews, record review, and policy review, the facility failed to honor a resident's preferred time to get out of bed each morning for one of two residents (Resident (R) 76) reviewed for choices out of a sample of 44 residents. This failure had the potential to diminish residents' quality of life, self-determination, and opportunities for social interaction. Findings include: Review of the facility's policy titled, Patient/Resident Rights, dated 10/01/20, indicated Policy: The facility employes measures to ensure patient and resident personal dignity, well-being, and self determination are maintained and will educate patients and residents regarding their rights and responsibilities.The facility provides care for each resident in a manner that promotes, maintains, or enhances quality of life, recognizing each resident's individuality. Review of R76's quarterly Minimum Data Set (MDS) located under the RAI [Resident Assessment Instrument] tab in the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 06/02/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R76 was cognitively intact. The MDS also assessed R76 as being dependent on transfers. During an interview on 08/02/26 at 12:45 PM, R76 stated that each day she wanted to be out of bed by 9:00 AM and staff were aware of this preference, but on some days, staff were unable to transfer out of bed until 10:00 AM or later because there were not enough staff available. The resident explained that she required two staff to transfer out of bed and on some mornings her Certified Nursing Assistant (CNA) was unable to find another available staff member to help transfer her out of bed until 10:00 AM or later. The resident stated this resulted in her missing scheduled morning activities that she enjoyed including coffee and muffin time, games like trivia, and church services. The resident stated that on average the staff did not get her out of bed until after 10:00 AM three to four times a week. The resident specified on the prior Sunday (07/26/26) staff did not get her out of bed until well after 10:00 AM and she missed the Sunday morning church service. During an observation and interview on 08/03/26 at 9:04 AM, R76 was observed in bed. R76 stated that she was waiting for staff to transfer her out of bed and staff should have already had her up by now. Observation on 08/03/26 at 9:44 AM, revealed one unidentified CNA was overheard in the hallway asking another CNA if she could help with assisting R76 out of bed. Observation on 08/03/26 at 10:03 AM revealed that R76 was still in bed, and staff were observed taking a shower stretcher into the resident's room. Observation on 08/03/26 at 10:12 AM revealed that staff were rolling R76 up the hallway on the shower stretcher. During an observation and interview on 08/04/26 at 9:35 AM, R76 was observed out of bed. R76 stated that yesterday (08/03/26) staff again did not transfer her out of bed until after 10:00 AM, which was too late, because a second CNA was not available to assist with transferring her out of bed. R76 stated as a result she did not get to attend any of the morning activities that were scheduled on 08/03/26. During an interview on 08/04/26 at 9:50 AM, CNA9 stated that she often cared for R76 during the 7:00 AM to 3:00 PM shift. CNA9 stated R76 was a two person assist with transfers and that she was aware R76 wanted to get out of bed each morning before 9:00 AM. CNA9 stated that on some mornings R76 was not transferred out of bed until after 10:00 AM or later because there was not another CNA available to assist her with transferring the resident out of bed. CNA9 explained that on some days it took time to find another available staff member to help her with the transfer. During an interview on 08/04/26 at 12:50 PM, the Director of Nursing (DON) stated R76 was a two-person assist with transfers and staff should be transferring her out of bed by 9:00 AM each morning. The DON stated she would check with the staff working on the hallway to ensure two staff were available to help with two person assist resident transfers when needed. During an interview on 08/04/26 at 4:40 PM, the Activity Director (AD) stated R76 enjoyed participating in the scheduled facility activities including church services and playing games like bingo and trivia. The AD reviewed R76's activity participation record and stated on 08/03/26 R76 did not participate in the scheduled 10:00 AM coffee and chat activity or the scheduled 11:00 AM Hangman game activity. The AD also confirmed by review of the resident's activity participation record that on 07/26/26, R76 did not attend the scheduled 10:00 AM church service activity.

Based on interview, record review, and facility policy review, the facility failed to ensure an allegation of staff-to-resident abuse was reported to the State Agency within two hours of the allegation being made for one of one resident (Resident (R) 118) reviewed for abuse reporting of 44 sample residents. This failure had the potential to prevent other resident incidents from being reported timely to the administrator and to the state agency. Findings include: Review of the facility's policy titled, Leadership Policies and Procedures III: Organizational Ethics Subject: Abuse, Neglect, Exploitation, or Mistreatment revealed Policy: .2. The Facility shall report immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse. Review of R118's Face Sheet tab of the electronic medical record (EMR) revealed R118 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included displaced supracondylar fractures of the right and left femur, chronic pain, dysphagia, cognitive communication deficit, rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis, polyneuropathy, diabetes mellitus, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/26 and located under the RAI [Resident Assessment Instrument] tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Review of the Care Plan tab of the EMR, revised 07/09/26, identified R118 was at risk for negative psychosocial outcomes related to perceived aggressive care by staff. Interventions included having two staff members present while providing care. Review of a behavioral care plan revealed staff were to communicate calmly, explain care before beginning tasks, provide one-step directions, avoid arguing with the resident, and allow extra time for communication. During an interview on 08/02/26 at 1:53 PM, R118 stated that approximately one to two months earlier, a Certified Nursing Assistant (CNA) came into her room during the night and pushed the side of her face down into the pillow. R118 stated the CNA made derogatory remarks, had a knee in her back, and that she screamed and attempted to get away. R118 stated her roommate yelled at the CNA to get off of her, after which the CNA left the room. R118 stated she did not know the CNA's identity because it was dark. R118 further stated she developed soreness in her shoulder and pain in her back following the incident. During an interview on 08/04/26 at 2:33 PM and review of the facility's reporting documentation on 08/04/26, the Director of Nursing (DON) and Administrator confirmed the alleged incident occurred on 04/26/26 during the night shift. The DON stated the allegation was reported to the State Agency on 04/27/26 at 2:18 PM via the two-hour report. The Administrator and DON stated Social Services received the allegation from the resident and daughter on 04/27/26 at approximately 9:00 AM and reported it to the Administrator at 9:01 AM. During an interview on 08/04/26 at 2:38 PM, the DON and Administrator stated Social Services was notified by R118 and her daughter on 04/27/26 at approximately 9:00 AM regarding the allegation. During an interview on 08/04/26 at 2:45 PM, the DON stated Social Worker reported the allegation to the Administrator on 04/27/26 at 9:01 AM. During an interview on 08/04/26 at 7:07 PM, the Administrator stated he was disappointed that the allegation was not reported to him in time for submission of the required two-hour report.

Based on record review and staff interviews, the facility failed to ensure the comprehensive assessment accurately reflected smoking for one of one (Resident (R) 90) residents reviewed for smoking in the sample of 44 residents. This failure had the potential to lead to a lack of supervision and intervention. Findings include: Review of R90's Face Sheet located under the Resident tab of the electronic medical record (EMR) indicated R90 was admitted on [DATE] with diagnoses which included dementia and lack of coordination. Review of R90's Care Plan located under the RAI [Resident Assessment Instrument] tab of the EMR dated 08/29/24 indicated the resident was a smoker/vaper. Review of R90's Smoking Risk (Acuity) assessment located under the Resident tab of the EMR, dated 04/26/26, indicated R90's smoking materials were cigarettes. Review of R90's annual Minimum Data Set (MDS), located under the RAI tab of the EMR with an Assessment Reference Date (ARD) of 06/17/26, indicated the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15, reflecting moderate cognitive impairment. Additionally, under Section J – Health Conditions, R90 was marked as No for current tobacco use. During an interview on 08/04/26 at 7:01 PM, Minimum Data Set (MDS) Coordinator confirmed R90 was a smoker and that his annual MDS did not reflect the resident was a smoker. She confirmed the MDS drove the resident care.

Based on record review and interview, the facility failed to ensure the Pre-admission Screen and Resident Review (PASARR) level one screen was resubmitted when a new diagnosis of mental illness (MI) was diagnosed for one of two residents (Resident (R) 15) reviewed for PASARR of 44 sample residents. This created a potential failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate prior to admission. Findings include: Review of R15's Face Sheet located under the Resident tab of the electronic medical record (EMR) indicated the resident was admitted on [DATE] and had a diagnosis of schizophrenia dated 08/23/24. Review of R15's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/19/26 and located under the RAI [Resident Assessment Instrument] tab revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 indicating R15 had severe cognitive impairment. The MDS indicated the resident had a diagnosis of schizophrenia. Review of R15's Care Plan located under the RAI tab of the EMR, dated 03/30/20 with an edit date of 06/25/26, indicated R15 had a diagnosis of schizophrenia. Review of R15's Preadmission Screening and Resident Review (PASARR) located under the Resident Documents tab of the EMR, dated 03/11/20, revealed the resident did not have a mental illness. It revealed the resident was admitted with dementia with aggression. Review of R15's Active Orders located under the Resident tab of the EMR revealed the resident was prescribed quetiapine (antipsychotic medication) 50 milligram (mg) oral tabletat bedtime for schizophrenia, start date 07/16/26. During an interview on 08/03/26 at 3:24 PM, Social Services Assistant (SSA) confirmed if a resident had a previous PASARR level one that was negative for MI, was later diagnosed with MI, and had an active order for medications related to MI; a new PASARR level one should be submitted for review for PASARR level two.

Based on observation, record review, staff interviews, and policy review, the facility failed to ensure individual and group activities were provided per individual preferences for 1 of 1 resident reviewed for activities, (Resident (R) 160). This failure had the potential to contribute to decreased social stimulation, decreased cognitive abilities, decreased psychosocial stimulation, and a decline in physical functioning abilities. Review of the Face Sheet tab of the electronic medical record (EMR) revealed R160 was admitted to the facility on [DATE], with the latest return on 03/14/26. Diagnoses included vascular dementia, severe, with anxiety; unspecified dementia, severe, with anxiety; traumatic subdural hemorrhage without loss of consciousness; cerebral infarction; hemiplegia affecting the right dominant side; major depressive disorder, recurrent, severe with psychotic symptoms; psychotic disorder with delusions due to known physiological condition; anxiety disorder; visual loss; sensorineural hearing loss, bilateral; muscle weakness; and type two diabetes mellitus. An EMR review of the entire record did not reveal any activity assessment or preference documentation for R160. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/20/26 and located under the RAI [Resident Assessment Instrument] tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 99. The resident's cognitive status and diagnoses indicated that the resident required staff assessment, encouragement, and assistance to participate in meaningful activities. Review of the quarterly MDS with an ARD of 07/21/26 revealed a BIMS was not conducted and coded as zero. Review of the Care Plan tab of the EMR revealed the activity care plan, initiated 04/22/22 and edited 07/24/26, documented R160 preferred to go by her first name and was independently active in group activities of choice. The goal, with a target date of 10/31/26, was for the resident to be an active participant in group activities of choice, including group discussions, exercise, bingo, arts, and crafts. Interventions directed staff to check in with the resident for activity-related needs, encourage participation in group activities of choice, discuss and observe the resident's preferences, encourage activities of interest including church, movies, music, socials, bingo, crafts, board games, cards, cultural events, current events, news, dominoes, educational programs, family/friend visits, group discussions, radio, reading, religious services, religious studies, sports, and television, provide in-room activities as needed, remind and encourage the resident to attend activities, and assist to activities as needed and required. Review of the Progress Notes tab of an activity progress note, dated 04/24/26 at 4:31 PM, documented R160 was out of bed daily in her wheelchair, needed assistance getting to and from activities of current interests, was escorted to group activities such as church services and musical programs, was an active participant in one-to-one visits, enjoyed having her nails done, enjoyed naps throughout the day, and enjoyed talking with staff and other residents daily. The note further documented activities staff will continue the current plan of care until the next review date. There was no June 2026 Activity Participant Log provided by the Activity Director. Review of R160s Activities Charting Report for July 2026 revealed she participated in worship services on 07/08/26, a one-to-one visit on 07/23/26, and was offered a hydration cart on 07/04/26. Observation on 08/02/26 at 12:22 PM revealed R160 was at the nurses' station in her recliner chair with her feet extended, legs crossed, and helmet on. She was talking in jumbled non sensical words about her boys. There was no observed activity engagement between the staff at the nurses' station and R160. Observation on 08/03/26 at 10:57 AM revealed R160 was seated in a Geri chair with feet elevated and pink helmet on at the nurses' station. There was no interaction by nursing staff at the nurses' station and no observed activity engagement. R160 was talking in non sensical word salad to herself. Observation on 08/03/26 at 3:14 PM revealed R160 was at the nurses' station in her recliner chair with her feet extended, legs crossed, and helmet on. There was no observed activity engagement documented during this observation between R160, the nurses, and Certified Nursing Assistants (CNA). Observation on 08/04/26 at 9:53 AM revealed R160 was seated in a recliner chair with legs extended and crossed and her pink helmet on, and she was restless. A CNA offered to take R160 for a stroll in the building. Observation on 08/04/26 at 10:13 AM revealed R160 was at the 400 hall nurses' station near nursing staff in her recliner chair with her feet elevated while church music was being played on the piano in the dining room. R160 was not observed attending or participating in the church activity despite the resident's care plan and progress note identifying church and music as activities of interest and documenting that she needed assistance getting to and from activities. Observation on 08/04/26 at 4:04 PM revealed R160 was seated at the nurses' station in her recliner chair with her pink helmet on. A movie was ending in the Main Dining Room, with credits and music playing, but R160 did not attend. During interview on 08/04/26 at 4:21 PM, the Activity Director (AD) stated she had started approximately one month earlier and stated R160 participated in group church four times in January 2026, attended church and bingo, and received one-to-one visits. She stated that in July 2026, R160 participated in church on time, a one-to-one visit once, and hydration cart once. The AD stated, We try to engage her to come out more, and that her expectation was for [R160] to come to all activities. She stated she did not know R160's care plan or preferences. During interview on 08/04/26 at 4:45 PM, the Director of Nursing (DON) stated, everyone should go to group activities or receive one-to-one activities and that staff should do activities with [R160] daily. The DON stated staff should determine R160's interests, such as church or group program. I saw staff bring [R160] to the nurses' station every day. During an interview on 08/04/26 at 4:49 PM, the Administrator stated, I expect they attempt to determine activity preferences with her, interview family members for interest in hobbies and enjoyed activities. I expect her to participate in activities once a day. Review of the facility's policy titled, Activity Policies and Procedures: Activity/Recreation Programming, revision date of 11/04/24, documented the Activity/Recreation Director and staff were to provide an ongoing Activity/Recreation program based on the comprehensive assessment, individualized care plan, and resident preferences to support resident choice of facility-sponsored group, one-to-one, and independent activities designed to meet the resident's interests and support physical, intellectual, psychosocial, emotional, and spiritual well-being. The policy documented the resident's expressed needs, interests, hobbies, and cultural preferences were to be included in the development of programs, and the care team was to assist activity staff in developing a person-centered activity care plan that considered the resident's needs, interests, hobbies, cultural preferences, attention span, and level of function/ability. The policy further documented Activity/Recreation programs were to be based on resident leisure interests, hobbies, and cultural preferences; individuals with dementia were to have programs designed that were personal and customized based on previous lifestyle, preferences, and comforts; residents who could not participate in a group setting were to be provided one-to-one/individual activities; programming included large groups, small groups, one-to-one visits, and independent opportunities; programs were to take place mornings and afternoons, seven days per week, including holidays and evenings; documentation at least quarterly was to note resident progress, response, and outcome; and intervention strategies were to be developed as needed to address unsatisfactory outcomes.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure portable oxygen cylinders were stored safely and in accordance with professional standards of practice for one of one resident (Resident (R) 80) reviewed for oxygen therapy of 44 sample residents. This deficient practice created the potential for resident injury related to unsecured oxygen equipment. Findings include: Review of the facility's policy titled, Respiratory Policies and Procedures, Subject: Oxygen (O2), Complete Manual Revision, dated 02/12/24, revealed the policy required oxygen cylinders to be stored in racks with chains, sturdy portable carts, or approved stands. The policy further stated oxygen cylinders shall not be stored in patient/resident rooms or living areas and shall never be left freestanding. Review of the Face Sheet tab of the electronic medical record (EMR) revealed R80 was admitted to the facility on [DATE] with diagnoses including acute on chronic systolic congestive heart failure, heart failure, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, pneumonia, anxiety disorder, muscle weakness, abnormalities of gait and mobility, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) located under the RAI [Resident Assessment Instrument] tab of the EMR with an Assessment Reference Date (ARD) of 06/23/26 revealed R80 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. During an observation on 08/02/26 at 9:40 AM, R80's room was observed with two tall portable oxygen tanks standing unsecured near the roommate's bed. R80 was observed in a wheelchair with another portable oxygen cylinder located in the pocket behind the wheelchair and an oxygen concentrator next to the bed. During an interview on 08/02/26 at 9:42 AM, Registered Nurse (RN) 3 stated the portable oxygen tanks should not be stored unsecured in the resident room. During an interview on 08/02/26 at 9:43 AM, Certified Nursing Assistant (CNA) 3 stated portable oxygen tanks should be stored in a storage room and not unsecured in a bedroom. During an interview on 08/02/26 at 9:45 AM, CNA8 stated portable oxygen tanks should be stored in rollers and should not be standing freely in the room.

Based on interview, record review, and policy review, the facility failed to ensure the residents' code status preference was honored in that the physician's order did not match the code status preference on the residents' Physician Order for Life Sustaining Treatment (POLST) document for two (Resident (R)9 and R77) of five residents reviewed for code status. This failure had the potential to result in the residents not receiving lifesaving cardiopulmonary resuscitation (CPR).Findings include:Review of the facility's policy titled Advance Directives revised on [DATE] revealed, The facility's staff will inform the patient/resident about formulating an advance directive and will maintain written policies and procedures regarding advanced directives and Physician Order for Life Sustaining Treatment (POLST), or similar documents where applicable, including information on decisions involving resuscitative services and life-sustaining treatments.8. Obtain primary physician orders for the patient/resident advance directives, A POLST and some of the other forms are recognized as a valid physician's order, where applicable under state law. 9. POLST - Physician Orders for Scope of Treatment. All are the same concept as the POLST (Physician's Orders for Life- Sustaining Treatment) paradigm.1. Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] located in the Resident Assessment Instrument (RAI) tab of the electronic medication record (EMR) revealed an admission date of [DATE], a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R9 was cognitively intact, and diagnoses of tracheostomy status, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, and schizoaffective disorder, bipolar type.Review of R9's POLST dated [DATE] located in the EMR under the Resident Document tab revealed Attempt Resuscitation/CPR and Full Treatment were checked, and the form was signed by R9.Review of R9's Progress Note dated [DATE] located in the EMR under the Progress Note revealed Code Status: Full Code/Scope of Treatment. Review of R9's Orders dated [DATE] located in the EMR under the Order tab revealed Code Status: DNR [do not resuscitate]. Review of R9's Care Plan dated [DATE] located in the EMR under the RAI tab revealed Advanced Care Planning I DNR with an approach of Resident has completed the following advanced directives (x) DNR.During an interview on [DATE] at 5:40 PM, R9 was asked if her heart should stop, did she want someone to give her CPR to start it again. R9 stated, Yes, she wanted CPR.During an interview on [DATE] at 5:45 PM, the Social Services Assistant (SSA)2 was asked should the POLST and physician's order for code status match. The SSA2 stated, Yes. SSA2 was asked why R9's POLST code status did not match R9's physician order for code status. SSD2 reviewed the EMR and stated she wasn't aware of the discrepancy.During an interview on [DATE] at 5:50 PM, Licensed Practical Nurse (LPN)1 was asked what happens if a resident codes (found without a pulse). LPN1 stated she would check the Medication Administration Record (MAR) for the resident's code status and follow the physician's order. LPN1 was asked if they had a hard chart she would reference or check the POLST form. LPN1 stated there were no hard charts to check. LPN1 stated she was agency, and she didn't know what a POLST form was or where to find it.During an interview on [DATE] at 5:52 PM, LPN2 was asked what she would do if R9 coded. LPN2 stated she would check the code order in the computer and have someone else check the POLST form as she wasn't sure where it was located. 2. Review of R77's quarterly MDS with an ARD date of [DATE] located in the RAI tab of the EMR revealed an admission date of [DATE], a BIMS score of 15 out of 15, indicating R77 was cognitively intact and diagnoses of heart failure, chronic kidney disease, and hypertension. Review of R77's POLST dated [DATE] located in the EMR under the Resident Document tab revealed Attempt Resuscitation/CPR and Limited Treatment were checked. The form was signed by R77.Review of R77's Care Plan dated [DATE] located in the EMR under the RAI tab revealed Advanced Care Planning: Code Status DNR.Review of R77's Orders dated [DATE] located in the EMR under the Order tab revealed Code Status: DNR.During an interview on [DATE] at 6:14 PM, R77 was asked if her heart stopped, did she want someone to use CPR to start it again, as that was on her paperwork. R77 stated, Yes, CPR is okay, but not much more. R77 then asked if her paperwork was correct. R77 was informed that her POLST did list her wishes for CPR with limited treatment. During an interview on [DATE] at 6:52 PM, the Director of Nursing (DON) was asked how staff initially obtained a resident's code status. The DON stated upon admission, whether a resident came from the hospital or home, they would have a discussion with the resident or their representative about advance directives. The DON stated the social worker completes the POLST, and the resident or representative and physician sign the form. The DON stated a POLST should be signed regardless of whether a resident was a full code or DNR. The DON further stated for new admissions the unit manager adds the order to the EMR or the floor nurse if the code status changes during their stay. The DON stated the code status order should include a POLST and the physician's order. The DON was asked if a resident coded/found not breathing, what should staff do? The DON stated staff should check the code status in the order and at the top of the EMR profile. The DON was asked if the POLST should be checked as well or was it necessary. The DON stated, Not if they are a DNR, and they know that because they had already seen the order. The DON was asked if she was aware that the POLST did not match the order for R9 and R77. The DON stated, No. The DON was asked if it was possible that the POLST and code status order did not match. The DON stated, Yes, if someone made a mistake. The DON was asked how the mistake could be prevented. The DON stated, Make sure they match. The DON confirmed staff need to ensure the POLST and the code status order reflect the resident's wishes. During an interview on [DATE] at 7:20 PM, SSA1 was asked how staff initially obtained a resident's code status. SSA1 stated the resident, or their representatives, are asked, and their decision is added to an order and the face sheet. SSA1 stated once the order was in the EMR, the POLST was uploaded into the EMR.

Based on interview, record review, and facility policy review, the facility failed to report blood sugar levels (BS) below 60 mg/dl (milligrams per deciliter) to the physician and failed to follow physician orders to hold insulin when the BS was below 100 mg/dl for one (Resident (R)87) of one resident reviewed for laboratory services.Findings include:Review of the facility policy titled Physician and other Communication/Change in Condition, revised 05/05/23, revealed, To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. Procedures: 1. Complete assessment of the patient/resident which may include but is not limited to: . E. Blood Glucose . 3. Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record.Review of the facility policy titled Laboratory Testing, revised on 05/05/23, revealed, . 2. The attending physician or physician extender shall be promptly notified of abnormal, critical, or stat [immediately] test results. 3. The charge nurse receiving the test results shall be responsible for notifying the physician or physician extender of such test results in a timely manner.Review of the facility policy titled Medication Management Program, revised on 01/15/25, revealed, . 3. Prior to administering medications, the nurse is responsible for: A. Obtaining and recording any necessary vital signs . 5. The authorized staff member validates the following information is documented on the MAR [Medication Administration Record]: A. Correct physician's order and diagnosis for each medication . 13. The authorized staff member administers medications according to accepted standards of practice and incompliance with regulatory requirements.Review of R87's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/04/25, located in the Resident Assessment Instrument (RAI) tab of the electronic medication record (EMR), revealed an admission date of 01/18/21 and a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating R87's cognition was severely impaired and had a diagnosis to include but not limited to diabetes mellitus.Review of R87's Orders located in the EMR under the RAI tab revealed the following order: Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL [millilitre] (3 mL); amt [amount]: 16 units; subcutaneous Special Instructions: Hold if fsbs [finger stick blood sugar] < [less than] 100 Every 12 Hours 08:00 AM, 08:00 PM, dated 07/10/25. Notify provider if less than 60 or greater than 450. Once A Day 06:00 AM, originally ordered on 07/26/22.Review of R87's Care Plan revised on 08/04/25, located in the EMR under the RAI tab revealed, [R87] is at risk for Hyper/Hypoglycemia secondary to Diabetes. Interventions included Medication adjustment per provider order and Give meds [medications] per order, labs [laboratory] per order and report abnormals [sic] to MD [physician].Review of R87's Progress Note dated 07/10/25, located in the EMR under the Progress Note tab revealed NP [Nurse Practitioner] increased resident's Lantus to 16u [unit] from 14u because of elevated A1C (a blood test that measures a person's average BS levels over the past 2-3 months).Review of R87's Progress Note dated 08/13/25, located in the EMR under the Progress Note tab revealed bg [blood glucose] low, snack x2 given.Review of R87's August 2025 Medication Administration Report (MAR) located in the EMR under the Order tab revealed at 6:00 AM, nine blood sugar (BS) levels were documented to be below 100 mg/dl and on one occasion no BS was documented. Insulin was documented as administered at 8:00 AM on these days. No BS was recorded for the PM insulin administration. Furthermore, BS levels below 60 included no documentation the physician was notified.These included:On 08/02/15 at 6:00 AM at 62 mg/dl,On 08/05/25 at 6:00 AM at 76 mg/dl,On 08/06/25 at 6:00 AM at 63 mg/dl,On 08/07/25 at 6:00 AM at 61 mg/dl,On 08/08/25 at 6:00 AM at 67 mg/dl,On 08/09/25 at 6:00 AM at 56 mg/dl,On 08/10/25 at 6:00 AM no BS was recorded,On 08/11/25 at 6:00 AM at 78 mg/dl,On 08/12/25 at 6:00 AM at 69 mg/dl,On 08/13/25 at 6:00 AM at 49 mg/dl.During an interview on 08/13/25 at 2:06 PM, Regulatory Specialist (RS) was asked if R87's insulin was administered when her BS was documented below 100, when her order instructed the nurse to not administer the insulin if her BS was below 100. RS was also asked why the BS was blank for 08/10/25 but insulin was documented as given. At 3:48 PM the RS stated she didn't find anything more than what was reviewed earlier for R87.During a telephone interview on 08/13/25 at 5:10 PM, the Clinical Pharmacist (CPh) was asked about R87's insulin being administered without a BS check in the PM when the insulin was administered twice daily, in the AM and PM. The CPh stated, It's best practice to match dosing schedule with the sticks.During an interview on 08/13/25 at 5:45 PM, Licensed Practical Nurse (LPN)1 was asked if she administered R87's insulin on 08/13/25, 08/12/25, and 08/11/25. LPN1 stated, Yes. LPN1 was asked if R87's insulin order included to not administer insulin if R87's BS was less than 100. LPN1 then reviewed the EMR and confirmed the order. LPN1 was shown the BS levels on the MAR were below 100 on 08/13/25, 08/12/25, and 08/11/25 and LPN1 was asked if the insulin should have been administered. LPN1 stated she didn't check the BS as it was another nurse at 6:00 AM. LPN1 stated she rechecked R87's BS before she gave the insulin on 08/13/25 this morning at 8:00 AM and it was okay to administer. LPN1 stated, however, she didn't document her BS because there was no place to record it.During an interview on 08/14/25 at 1:45 PM, the Director of Nursing (DON) was asked about R87's insulin given when the BS was low and the order instructed to not administer if the BS was below 100. The DON reviewed the EMR and confirmed it was not followed, stating, The order was a bad one. The DON stated she was not aware of R87's BS at 49 on 08/13/25 but confirmed the physician should have been called. The DON stated a new order for BS was given.During an interview on 08/14/25 at 5:28 PM, Unit Manager (UM)2 stated the nurse who took the BS should have called the physician. UM2 was asked what the BS parameters were for R87. UM2 stated, the parameters were 60/450 but the order was discontinued on 08/13/25 for unknown reasons.During a telephone interview on 08/14/25 at 6:29 PM, the Nurse Practitioner (NP) was asked if she had been informed about R87's BS at 49 on 8/13/25. The NP stated she had not been informed. the NP was asked if she should have been notified about the BS. The NP stated, Yes, she should have received a call. The NP stated the nurses should be calling her for BS less than 60 or greater than 450. The NP stated the nurse was supposed to check R87's BS twice daily because the Lantus order is every 12 hours, and this included holding the insulin if BS was less than 100. The NP was asked if she was aware of R87's BS at 56 on 08/09/25 and the NP stated she was not aware. The NP stated she was not aware of any time the insulin was given when R87's BS was less than 100, and she was also not aware R87's BS parameters were discontinued on 08/13/25.During a follow up interview on 08/14/25 at 6:37 PM, the DON was asked about R87's BS parameters being discontinued. The DON stated she was not aware, and the parameters should not have been discontinued.

Based on record review, interview, and facility policy review, the facility failed to ensure the physician documented that the Clinical Pharmacist (CPh) recommendations regarding the use of a PRN (as needed) medications were reviewed and failed to document the action taken or not taken to address the irregularities for one (Resident (R)13) of five residents reviewed from a sample of 43 residents. This failure had the potential to lead to unwarranted medication side effects or improperly treated symptoms.Findings include:Review of the facility policy titled Pharmacy Services Policies and Procedures dated 04/17/24 revealed, The facility will ensure that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, psychological wellbeing. The Facility will comply with all Federal, State and Local regulations regarding unnecessary drugs . 6. For non-Urgent recommendations, the Facility and Attending Physician must address the recommendation(s) in a timely manner that meets the needs of the resident. Upon receipt of the written Consultant Pharmacist Report of non-urgent recommendations, the DON or facility designee shall provide the report to the attending physician(s) or their designee during their next regularly schedule facility visit or within 5 business days, whichever should come first . 9. If the Attending Physician or their agent fails to address a recommendation or document a rationale for declining a recommendation: A. The Director of Nursing or facility designee will alert the Medical Director where MRR's [Medication Regimen Review] are not addressed timely or completely by the attending physician. Review of R13's Resident Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R13 was admitted to the facility on [DATE] with diagnosis including but not limited to anxiety. Review of R13's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/11/25 and located under the MDS tab of the EMR revealed R13 had severe cognitive impairment as assessed by staff. Review of R13's Orders located under the Orders tab of the EMR revealed a Prescription Order dated 06/17/25 for lorazepam (antianxiety medication) 1 milligram (mg) every 6 hours as needed with the End Date on the Prescription Order indicated Open Ended; an order for buspirone (antianxiety medication) 7.5 mg three times a day dated 06/10/22 with an End Date of Open Ended; and Lexapro (escitalopram) (antidepressant medication) 10 mg three tablets once a day dated 12/18/24 (renewal date) and an End Date of Open Ended. Review of R13's Note to Attending Physician/Prescriber signed by the facility's nurse practitioner (NP) on 07/24/25 revealed the CPh had recommended, Resident has a PRN order for an anxiolytic, lorazepam 1 mg Q6H (every 6 hours) which has been in place for greater than the 14-day observation period without a projected stop date or duration of therapy . Please consider discontinuing the PRN order or if the medication cannot be discontinued at this time, CMS requires that the prescriber document the indication for use, the intended duration of therapy and the rationale for the extended time period. On the Note to Attending Physician/Prescriber the NP response read, No longer on board. Review of R13's Note to Attending Physician/Prescriber dated 08/27/24 revealed the CPh had recommended This resident is currently receiving antidepressant therapy with escitalopram 20 mg QD. This dose has been in place for some time, and a review of the resident chart does not reflect a worsening of depression. To reach the minimal effective dose, may I suggest an attempt at a dose reduction? The facility NP responded on 09/16/24 with Resident on hospice. All med [medication] changes made by them.Review of R13's Note to Attending Physician/Prescriber dated 08/27/24 revealed the CPh had recommended This resident is currently receiving antidepressant therapy with buspirone 7.5 mg TID. This dose has been in place for some time, and a review of the resident chart does not reflect a worsening of depression. To reach the minimal effective dose, may I suggest an attempt at a dose reduction? The facility NP responded on 09/10/24 with Resident on hospice. All med changes made by them.Review of R13's Resident Documents in the EMR revealed no other provider communication related to the CPh's recommendations. Review of R13's Progress Notes revealed no other provider communication related to the CPh's recommendations.Review of R13's hardcopy hospice provider notes in the facility hospice binder revealed no notes related to the CPh's recommendations.During an interview on 08/13/25 at 3:15 PM, the Director of Nursing (DON) stated the pharmacy recommendations are emailed to her and then forwards to the facility NP for review. For residents on hospice services, the hospice agency providers managed the medications and so should receive the pharmacy recommendations. During an interview on 08/13/25 at 4:20 PM, the Team Coordinator (TCAH) for the hospice agency stated their agency did not receive pharmacy recommendations from the facility for R13. The TCAH stated normally a facility sends the pharmacy recommendations directly to the agency, then they are sorted and sent to the appropriate provider for consideration.During an interview on 08/13/25 at 4:50 PM, the CPh stated if the resident was under hospice services, the hospice provider was responsible for medication management and should have received the pharmacy recommendations. The CPh stated if the hospice provider does not respond, then it was the facility's responsibility to then communicate the recommendations to the facility providers for consideration.During an interview on 08/14/25 at 5:33 PM, the facility NP stated she did not manage medications for residents on hospice services. She expected the facility staff to forward the recommendation to the hospice provider. During an interview on 08/14/25 at 3:30 PM, the DON stated the lorazepam, escitalopram and buspirone pharmacy recommendations should have been communicated to the hospice provider for consideration.During an interview on 08/14/25 at 3:45 PM, Unit Manager (UM)1 stated the hospice provider should have been contacted either over the phone or on their next visit because once a resident is on hospice services it was the hospice provider that manages the medications. She reviewed R13's EMR and stated there were no notes indicating the facility had communicated the pharmacy recommendations to the hospice agency for consideration after the facility NP responded that she was not managing R13's medications.

Based on review of facility policy, interview and record review, the facility failed to ensure that Resident (R)1 was provided appropriate supervision to prevent 2 separate elopements from the facility on 04/28/25. On 06/03/25 at 5:53 PM, the Administrator and the Director of Nursing were notified that the failure to ensure that Resident (R)1 was free from two separate elopement incidents from the facility on 04/28/25, constituted Immediate Jeopardy (IJ) at F689. On 06/03/25 at 5:53 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility that IJ existed as of 04/28/25. The IJ was related to 42 CFR 483.25 - Quality of Care. On 06/04/25 at 11:54 AM, the facility provided an acceptable IJ Removal Plan. On 06/04/25 at 12:28 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F689 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings Include: Review of the facility policy titled Elopement with a complete revision 11/01/2017 states, To safely and timely redirect patients/residents to a safe environment. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: restlessness and agitation, Schizophrenia, anxiety disorder, conversion disorder with seizures or convulsions, and moderate intellectual disabilities. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/25, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicates she was severely cognitively impaired. Further review of the MDS revealed that R1 had no wandering behaviors during the assessment period. Review of R1's Progress Note dated 04/28/25, revealed, 3:29 PM-Resident was seen going out of door 5 she was immediately followed by staff we did not see her anywhere in the parking lot. I went back in to get more nurses once back outside I saw the resident laying in the middle of the road I called for her to be sure it was her as it was dark and I could not see after getting no response I went in the road and it was [R1] so me and 2 other nurses talked to her and got her to get up and follow us inside where she continued to try to escape so me and a certified nursing assistant (CNA) kept her at the nurses station and when we no longer could do so she got to her room where a CNA sat outside the door to watch her. The DON [Director of Nursing] and unit manager were alerted at the time of the incident. Review of R1's Progress Note dated 04/28/25 at 7:09 PM, revealed, Resident noted missing after alarm was sounding on unit 2 and staff checked her room. She was noted walking in the staff parking lot on the side of the building heading to the front of the building. After running to catch up with her, she put herself on the ground and started yelling and kicking staff as several assisted her onto a wheelchair (WC), and she slid herself back onto the ground. The Nurse Practitioner (NP) and unit manager notified and per NP order received to transport resident to the ER for evaluation. Resident remained alert, no injuries noted at that time. Review of the INTERACT Nursing Home to Hospital Transfer Form/Situation Background Assessment Recommendation (SBAR) dated 04/28/25 at 4:43 PM, from Magnolia Manor, unit 2, revealed the reason for the transfer states - Elopement, Combative. Usual functional status- Ambulates independently. Risk alerts- Agitation with risk to harm to self or others, may attempt to exit, and seizures. Review of Quarterly Nursing - Elopement Risk Observation dated 03/11/25 at 1:10 PM, revealed R1 has a history of wandering, has attempted to leave the health care center, has expressed a desire to leave the health care center, and has a diagnosis that requires supervision. During an interview with the Nurse Consultant in the presence of the current Administrator on 06/03/25 at 12:09 PM, revealed she is aware of the incident with R1 eloping from the building. The Nurse Consultant stated she heard this from either the Director of Nursing or the previous Administrator, however, she can't recall. The Nurse Consultant stated she was told R1 got out of the building while being in line of sight, R1 then placed herself on the ground, and was able to be re-directed back in the building. During an interview with the current Administrator on 06/03/25 at 12:11 PM, revealed that he has been in his role since last week, 05/28/25 and was unaware of this event. During a phone interview with Licensed Practical Nurse (LPN)1 on 06/03/25 at 12:38 PM, revealed she came in at 7:00 AM on 04/28/25, she was getting a report from LPN2 related to R1's elopement that occurred at 1:00 AM, and that R1 went out the back door on unit 2, was found in the street lying on the ground (main road). LPN1 revealed that while getting the report, R1 successfully eloped again around 7:00 AM. The alarms were going off, and another staff member went and checked R1's room; she was not there. Staff started looking for her, and R1 was found in the parking lot within line of sight and was redirected back to the building. LPN1 stated that CNA1 was able to redirect R1 into the building via a non-mechanical wheelchair. LPN1 confirmed that R1 successfully eloped the building twice on 04/28/25. During an interview with LPN2 on 06/03/25 at 1:04 PM, LPN2 stated on 04/28/25, around midnight, R1 was wandering throughout the building. That night, she exited door 5, which is located in unit 2, which is 4-5 rooms down from her room. The alarm goes off. She and the agency CNA (unable to recall name) split up and looked for her. R1 was not found on the premises, staff came back in the building, got more staff, 2 nurses from stations 3 & 4, and went back out the front door. LPN2 stated she saw a dark shadow on the main road. LPN2 stated she called R1's name out, and she would not respond. LPN2 walked up to the dark shadow and confirmed that it was R1; she was found alert/responsive, and ignoring LPN2. LPN2 stated staff tried talking to her, told her she can't lay in the middle of the road because it's dark and dangerous. During an interview with the Director of Nursing (DON) on 06/03/25 at 3:35 PM, revealed that she is aware of the incident related to R1. The DON stated she found out from the nurses, LPN2 specifically, and an agency nurse. The DON was told she got out, and staff looked for her and found her laying on the main road. The DON stated she was also told R1 eloped again, right before she arrived at her shift at around 7:00 AM. On 06/04/25 at 11:54 AM, the facility provided an acceptable IJ Removal Plan, which included the following: Resident #1 was placed on room supervision after elopement attempt on 4/28/25 at approximately 1am. Room supervision consisted of visual observation of resident's room and supervision was interrupted during change of shift. Resident #1 was sent to emergency department for evaluation after elopement attempt at 7am. Upon return placed on 1:1 supervision remains on 1:1 supervision. Staff education provided regarding Resident Exit Seeking and Elopement Prevention on 4/30/25. Elopement Risk evaluations done in the past 90 days on current residents inhouse will be reviewed by Director of Nursing/Designee for accuracy by 6/3/25. Residents identified at risk will be reviewed for appropriate interventions including placement in the Elopement Binder and validated care plans have interventions listed. The Director of Nursing was reeducated by the Clinical Consultant on 6/3/25 on Accidents and Incidents including: -elopement process and the elopement binder -elopement risk assessment process and putting interventions in place based on risks identified. All Facility Staff will be reeducated by 6/4/25 by the Director of Nursing/Designee on Accidents and Incidents including: -elopement process and the elopement binder Licensed Nurses will be reeducated by 6/3/25 by the Director of Nursing on the elopement risk assessment process and putting interventions in place based on risks identified. Any staff not receiving this education by 6/4/25 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation. The Director of Nursing will randomly interview a minimum of 2 staff daily to validate understanding of elopement risk and elopement binder. Interviews will continue for 30 days then 2 staff 3 times per week for an additional 60 days. Results of the audits will be review monthly during QAPI meeting. The Director of Nursing/Designee will review the facility activity report beginning 6/4/25 in clinical morning meeting to identify documentation and/or elopement risk assessments that may suggest a resident is exit seeking. If identified, the Director of Nursing/Designee will validate interventions are appropriate and care plan is updated. The Director of Nursing/Designee will review new admission elopement risk assessments in Clinical Morning Meeting beginning 6/4/25 for accuracy and interventions validated if indicated, including placement in the elopement binder and education to staff. The Medical Director was notified on 6/3/25 of the Immediate Jeopardy. An Ad Hoc Quality Assurance and Performance Improvement Meeting was held on 6/4/25 to discuss contents of this plan. Administrator will oversee compliance of this plan. Allegation of Compliance: 6/4/25

Based on review of the facility policy, record review, and interview, the facility failed to report an allegation of elopement that occurred on 04/28/25. Specifically, Resident (R)1 eloped two separate times from the facility on 04/28/25 and the facility failed to report the elopement. Findings include: Review of the facility policy titled Elopement with a complete revision date of 11/01/2017, documents, To safely and timely redirect patients/residents to a safe environment. The Director of Nursing or designee notifies the Administrator/designee and notifies the appropriate agencies, attending physician, and the patient's/resident's legal representative. The Facility leadership contacts their Regional [NAME] President of Operations and their Clinical Services Director for recommendations at the time of the elopement. Review of R1's Progress Notes dated 04/28/25, revealed, 3:29 PM-Resident was seen going out of door 5 she was immediately followed by staff we did not see her anywhere in the parking lot I went back in to get more nurses once back outside I saw the resident laying in the middle of the road I called for her to be sure it was her as it was dark and I could not see after getting no response I went in the road and it was [R1] so me and 2 other nurses talked to her and got her to get up and follow us inside where she continued to try to escape so me and a certified nursing assistant (CNA) kept her at the nurses station and when we no longer could do so she got to her room where a CNA sat outside the door to watch her. The DON and unit manager were alerted at the time of the incident. Review of R1's Progress Note dated 04/28/25 at 7:09 PM, revealed, Resident noted missing after alarm was sounding on unit 2 and staff checked her room. She was noted walking in the staff parking lot on the side of the building heading to the front of the building. After running to catch up with her, she put herself on the ground and started yelling and kicking staff as several assisted her onto a wheelchair (WC), and she slid herself back onto the ground. The Nurse Practitioner (NP) and unit manager notified and per NP order received to transport resident to the ER for evaluation. Resident remained alert, no injuries noted at that time. Review of the INTERACT Nursing Home to Hospital Transfer Form/Situation Background Assessment Recommendation (SBAR) dated 04/28/25 at 4:43 PM, from Magnolia Manor, unit 2. The reason for transfer revealed, Elopement, Combative. Usual functional status- Ambulates independently. Risk alerts- Agitation with risk to harm to self or others, may attempt to exit, and seizures. An attempt to contact R1's Resident Representative (RP) on 06/03/25 at 12:02 PM, was unsuccessful, the number was not in service. During an interview with the Administrator on 06/03/25 at 12:11 PM, revealed he has been in his role since last week, 05/28/25. The Administrator stated he was unaware of this event, and he has no facility investigation related to R1 and the events that occurred in April 2025. During a phone interview with Licensed Practical Nurse (LPN)1 on 06/03/25 at 12:38 PM, revealed she came in at 7 AM on 04/28/25, she was getting a report from LPN2 related to R1's elopement that occurred at 1:00 AM, and that R1 went out the back door on unit 2, was found in the street lying on the ground (main road). LPN1 revealed that while getting the report, R1 successfully eloped again around 7:00 AM. The alarms were going off, and another staff member went and checked R1's room; she was not there. Staff started looking for her, and R1 was found in the parking lot within line of sight and was redirected back to the building. LPN1 stated that CNA1 was able to redirect R1 into the building via a non-mechanical wheelchair. LPN1 further stated protocol is to report to the Director of Nursing (DON) and Administrator. LPN1 confirmed that R1 successfully eloped the building twice on 04/28/25. During an interview with LPN2 on 06/03/25 at 1:04 PM, LPN2 stated that on 04/28/25, around midnight, R1 was wandering throughout the building. That night, she exited door 5, which is located in unit 2, which is 4-5 rooms down from her room. The alarm goes off. She and the agency CNA (unable to recall name) split up and looked for her. R1 was not found on the premises. Staff came back in the building, got more staff, 2 nurses from stations 3 & 4, and went back out the front door. LPN2 stated she saw a dark shadow on the main road. LPN2 stated she called R1's name out, and she would not respond. LPN2 walked up to the dark shadow and confirmed that it was R1; she was found alert/responsive and ignoring LPN2. LPN2 stated staff tried talking to her, told her she can't lie in the middle of the road because it's dark and dangerous. LPN2 stated that following the incident, the unit manager was contacted, and DON, who instructed her to do a body audit, a full skin assessment. No injuries were noted following the incident. A progress note and Sbar were completed. R1 did not go out to the hospital at that time; however, she was sent after she eloped again at 7:00 AM, for behaviors. LPN2 concluded she was told to do a witness statement and which was given to the previous Administrator. An attempted phone interview with the previous Administrator on 06/03/25 at 1:45 PM, was unsuccessful, call forwarded to voicemail. A detailed message was left for a return phone call. During an interview with the Unit Manager (UM) on 06/03/25 at 1:57 PM, revealed, I am the Unit Manager. However, I have no knowledge about this. I got notified by [LPN2] that [R1] got out at 1:00 AM, I was not physically in the building. I told her to notify the DON and to make sure the resident was brought back in the building, and someone was to sit with the resident until we can come together as a team and see how the situation can be corrected, and she became 1 on 1. During an interview with the Director of Nursing (DON) on 06/03/25 at 3:35 PM, revealed she is aware of the incident. The DON stated she was notified when she arrived for her shift. The DON was told R1 got out, staff heard the door, staff looked for her, and staff found her lying on the main road. The DON stated she was also told R1 eloped again, right before she arrived for her shift. The DON stated she had notified her Administrator at the time and thought the situation was reported. The DON also stated she and the Administrator at the time spoke with the Nurse Consultant, who told them that the incident was not to be reported because there is a fine line between federal and state regulations. The DON followed the chain of command. The DON stated she did what she could to protect the resident at the time. The DON stated the facility should have reported both incidents. The DON further stated she cannot override the chain of command; the Administrator at that time could have overridden the Nurse Consultant's decision. During an interview with the facility's Regional Regulatory Compliance Consultant, RRCC on 06/03/25 at 4:03 PM, revealed she had no knowledge of the event regarding R1, she was told about it when she arrived. The RRCC stated as consultants, they can only go by what information is given to them. It could have been a life-or-death situation. The RRCC stated staff need to follow the policy, investigate, and determine why or why not they didn't do what they were supposed to do. The understanding from staff is that R1 was within line of sight, which is why it was not reported. The facility is its own entity, so the facility does not have to consult with consultants when it comes to reporting.

Based on review of the facility's policy, record review, and interview, the facility failed to provide documentation to that a proper investigation was conducted regarding an incident that occurred on 04/12/2025 involving an allegation of staff-to-resident abuse concerning Resident (R2). Findings include: A review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment states: Investigations are prompt, comprehensive, and responsive to the situation and contain founded conclusions. The investigation may include but is not limited to, the following: Identification and removal of the alleged perpetrators. Identification of the alleged victim. Type of alleged abuse. Where and when the incident occurred. Written summaries of interviews with individuals having first-hand knowledge of the incident. NOTE: Employees/witnesses are not to write out statements. Employees/witnesses will be interviewed by designated facility staff, and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer. Resolution/outcome. Measures taken to prevent future incidents. All documents pertaining to the investigation must be compiled and stored in the administrator's office. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including, but not limited to: Cerebral Palsy, adult failure to thrive, cortical blindness, and epilepsy. Review of R2's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/14/25, revealed R2's Brief Interview for Mental Status (BIMS) could not be assessed due to R2 never/rarely being understood. Review of R2's Progress Notes documented by Licensed Practical Nurse (LPN)4 revealed, 04/12/2025 05:56 PM -Resident alert place in wheelchair. Writer was made aware by staff that resident mother not supposed to be in the resident room visiting with her due to Past history and that the visitation should be supervise by staff. After ADL's writer administer resident Meds., and proceeded to transport resident to the area to visit with her Mother. Writer begun to apologized letting mother know that medication needed to be administer then she started yelling what did you all did to her arm. Writer stated i don't know what happen but I could find out for you. Mother stated in a accusative voice you know exactly what happen. Writer told the mother let me get someone to supervise with you. I took resident away from by her due her aggressiveness, before walking off. Later returning to the nurses station writer was told that mother was contacting the Police. During an interview with the current Administrator on 06/04/25 at 9:59 AM, in the presence of the Regional Regulatory Compliance Consultant (RRCC) revealed that there is no investigative file found related to R2 and the incident that occurred on 04/12/25. The Administrator stated that all he could locate and provide was the 5-Day Follow-up, and to follow up with the Director of Nursing (DON) since she has been in her role longer. The Administrator stated his expectation is for all reportable files to be investigated thoroughly and for all reportable files to remain in the building for situations like this. Multiple attempts to interview R2's Resident Representative (RP), which is also her R2's mother, on 06/04/25 at 11:00 AM and 11:22 AM were unsuccessful. The phone number was disconnected and is no longer in service. Multiple attempts to interview Licensed Practical Nurse (LPN)4 on 06/04/25 at 11:10 AM, 1:05 PM, and 1:18 PM, were unsuccessful. Voicemail box was full and unable to leave a detailed message. An additional attempt was made on 06/05/25 at 10:55 AM, which was unsuccessful. Multiple attempts to interview R2's Department of Social Services Caseworker, RP/Emergency Contact 2, on 06/04/25 at 11:27 AM and 11:32 AM, was unsuccessful, a detailed message was left for a return call. During an interview with the DON on 06/04/25 at 10:03 AM, revealed that she is familiar with R2 and the incident that occurred on 04/12/25. The DON stated facility staff are aware that R2's mother is not allowed to visit the resident unsupervised. R2 is overseen by a DSS caseworker due to mistreatment at home prior to admission. R2's mother visited her on 04/12/25 and saw scratches and redness on R2's left upper arm. R2's mother alleged that the scratches and redness on R2's left arm were the result of abuse by a staff member. Law enforcement was notified, and the case ended up being unfounded and closed. There were no witnesses to the alleged event. R2 is care planned for involuntary movements to the UE (Upper Extremity) and has a history of scratching herself. The physician was notified, but there were no changes in medications or treatments. The DON stated that regarding the reportable file, the previous administrator had the reportable file. It is unknown why we can't find it. All reportables were kept in the administrator's office. The DON stated she could not provide any documentation related to the investigation.

Based on review of facility policy, record review, and interview, the facility failed to ensure Resident (R)4 was free of accidents for 1 of 4 residents review for accident hazards. Findings include: Review of the facility policy with a revision date of May 5, 2023, titled Fall Management revealed in the policy the definition of a fall, Fall refers to the unintentionally coming to rest on the ground, floor, or other lower level, but not because of an overwhelming external force. Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE], with diagnoses that included but was not limited to: pressure ulcer sacrum, hypertensive heart disease with heart failure, dementia, type 2 diabetes mellitus and major depressive disorder. Review of R4's Annual Minimum Data Set (MDS) with an Assessment Reference Date of 02/27/25, revealed a Brief Interview for Mental (BIMS) score of 13 out of 15, indicating R4 was cognitively intact. Additionally, the MDS revealed R4 required substantial/maximum assistance with bed mobility. Review of R4's Physician Orders revealed an order dated 01/27/20, for assistance of 2 with bed mobility. Review of R4's Progress Notes dated 03/04/25 at 7:10 AM, stated, Writer was doing wound care on resident at 6:55 am. When resident was laying over on her right side, she slides out of bed onto the floor. Writer was right there when it happened and tried to slow down her fall to the floor. Writer called Nurse Practitioner (NP). Resident states she is having a little right hip pain. NP was notified about that as well. Review of R4's Progress Note dated 03/05/25 at 8:11 AM, revealed, Writer called and spoke with resident's nurse at hospital. Resident was admitted with a right femoral fracture. Resident will be undergoing a right total hip replacement today or tomorrow. Review of R4's Progress Note dated 03/11/25 at 3:35 PM, revealed, Resident returned to facility at 1524 from hospital. Surgical sutures are on the left hip with a bordered gauze covering the area . Review of Department of Public Health (DPH) Five Day Self Report for R4 recorded under the details of reportable incident, On 03/04/2025 nurse was performing a dressing change. He pulled her toward him and turned her over. Her legs started sliding off the air mattress. Nurse quickly attempted to get to the other side of her bed to stop her from sliding. He attempted to hold her legs up but could not so he lowered her to the floor. He went and got 3 Certified Nurse Assistants (CNA's) to manually lift her to the bed because the batteries for the Hoyer were dead. There was no injury noted at the time. She was sent out to the hospital for x-rays and a fracture of the left femur was found. Intervention prior to reportable incident recorded, Resident was a 2 person assist for bed mobility, Immediate corrective action/assessment following reportable incident recorded, Nurse was disciplined for failure to complete duties as assigned. Review of a Corrective Action Form dated 03/04/25, revealed Licensed Practical Nurse (LPN)1 was given a verbal warning for a performance behavior. It recorded, Failure to complete duties as assigned. [R4] was a 2 person for bed mobility and employee did not have a 2nd person for treatment change, resulted in resident fall out of bed. Resident resulted with fracture to femur. During an interview on 04/21/25 at 1:30 PM, LPN1 stated, I was doing patient care, changing a dressing on [R4's] bottom. She was fidgeting with her legs. She was on her left side. She has an air mattress. Her leg was beginning to slide, I put it back. It happened again, both legs. I was holding her legs. I gently lowered her to the ground. I went and got help. At the time I did not know she was a 2 assist with bed mobility. During an interview on 04/21/25 at 1:59 PM, The administrator stated, He should have had a second person assist. He took accountability for his action.

Based on review of facility policy, observation, record review, and interview, the facility failed to protect Resident (R)1 from misappropriation of more than $600.00 from her personal bank account, for 1 of 1 residents reviewed for misappropriation. Findings include: Review of the facility policy with a revision date of 10/23/19, titled, Abuse, Neglect, Exploitation, or Mistreatment documents in the policy, The facility's Leadership prohibits neglect, mental, physical and or verbal abuse . and misappropriation of a resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation . including misappropriation of resident property, and are reported immediately. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Review of R1's Facesheet revealed R1 was admitted to the facility on [DATE], with diagnoses that include but not limited to: hypertension, anemia, major depressive disorder and chronic respiratory failure with hypoxia. Review of R1's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R1 was cognitively intact. Review of R1's Medical Chart revealed a Progress Note dated 02/24/25 at 4:32 PM, Social Services along with administrator checked in on [R1] to see how she was doing. [R1] stated she's ok, she just don't understand how she can't trust people [R1] was educated on where to keep her funds and who she needs to inform upon her having funds on her persons. [R1] was also educated and offered a lock box that she can have in the event she have funds. [R1] stated, that's ok I keep my money in the bank [R1] stated she will never offer money and she did not read the patient handbook that was given to her. Review of the facility investigation and Department of Public Health (DPH) 5- Day Follow Up report dated 02/26/25, revealed an allegation of misappropriation. It reported R1 called social services (SS) and stated, I gave a Certified Nurse Assistant (CNA) a check for $12,000.00 on 01/25/2025 to deposit into my bank account. I also told the CNA I was going to bless her with $200.00 for doing this for me. After depositing the check, the CNA told me she was not able to withdrawal the $200.00 due to my account having a negative balance. I told CNA to hold onto my card until she could withdrawal the $200.00 . on 02/27/2025 I checked my bank account and statement and seen where the $200.00 was taken out my banks ATM. I also noticed two other withdrawals on 01/31/2025 of $202.50 each, totaling $405.00. Both of these withdrawals were at the same ATM. I questioned CNA through text messages asking her did she take anymore money and if she needed it all she had to do was ask me for it and I would have given it to her . once I told her that I was going to report her, she stopped responding to me. SS and the Director of Nurses interviewed CNA who admits taking $200.00 from ATM, but denies taking the extra $400.00. In summary of report, facility alleges substantiated abuse of misappropriation of resident property. Review of R1's Care Plan dated 02/26/25 revealed a problem for Psychosocial Well-Being, [R1] is at risk for negative outcomes of her psychosocial well-being related to alleged misappropriations of her personal funds. The goal recorded R1 will experience no long-term negative outcomes related to their psychosocial well-being through the next assessment period as evidenced by no sustaining negative outcomes such as reduction in socializations, good eating patterns, adequate sleep, and physical signs of anxiety or fear or sadness is not observed. During an interview on 04/21/25 at 10:50 AM, R1 stated, When I first came here she, (name of alleged perpetrator) cared for me. Then she wasn't here, then she came back. We became really close. The hospital gave me that check. In all, she (CNA1) got more than $600.00 dollars. She was only supposed to get $200.00, I told her that was my blessing to her for depositing the check for me. Then she went and took an additional $400.00, I did not approve that. The facility told me they can't discuss it with me any further, they turned it over to the people they needed to. I'm in charge of everything myself, I have a right to know. During an interview on 04/21/25 at 3:01 PM, CNA1 confirmed she worked for an agency and was still working. CNA1 stated, [R1] gave me a check to deposit for her, her bank card and the PIN number. It (the check) was for $12,000.00. She didn't want the facility to know she had the check. I deposited it for her at her bank. She told me to withdraw $200.00. I wasn't able to get the money that day. A few days later when I was back to work, on a Saturday, she told me to stop and get the money before I came to work. I went to her banks ATM. I brought her the receipt, the card, and the deposit slip. Somebody else called me from the facility and asked me about it. I work with a staffing agency. An officer never called me and my agency never called me about this and I continue to work, just not there. During an interview on 04/21/25 at 3:20 PM, the Administrator revealed the CNA was suspended or DNR'd (do not return) here, meaning she cannot return back to this facility. We called the Sheriff's office and reported this to them. A detective came. He said [CNA1] will be charged. When I spoke to the agency, they said they will DNR her. I personally told [R1] the outcome when she asked me. If I have any updates I tell her. I told her the CNA will be charged. During a follow up interview on 04/21/25 at 3:43 PM, R1 stated she was able to send the facility copies of the transaction from her phone. She pulled up her bank withdrawal transactions of three $200.00 withdrawals, from her February bank statement and the transaction of the deposit of $12,500.00, all dated in January 2025. During an interview on 04/21/25 at 4:21 PM, the Social Worker (SW) stated R1 told me she received a check, asked the CNA to deposit it for her and she will bless her with $200.00. R1 gave her the bank card. She had to wait to get the $200, for the check to clear. I called CNA1 and she agreed she took the $200.00, but said she did not take additional monies. There were other ATM's at different locations where the money was withdrawn. That CNA was not employed here. I did not call her agency to report this. I do not have a copy of the withdrawal. She pulled it up on her cell phone so I could verify it. The date she reported it to me was 02/21/25. R1 has asked about the outcome. I told her I did not know. I told this to the Mobile DON that was here at the time. R1 said, she is her own responsible party, she does not want her family notified for anything, she will notify them is she wishes.

Based on review of facility policy, record review, and interviews, the facility failed to protect Resident (R)11 from neglect, by failing to administer (R)11's physician ordered antibiotics, resulting in loss of limb. On 12/19/24 at 10:10 AM, the Administrator was notified that the failure to administer physician ordered antibiotics as treatment for a Pressure Ulcer (PU)/Pressure Injury (PI), constituted IJ at F600. On 12/19/24 at 10:10 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 11/21/24. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 12/19/24, the facility provided an acceptable IJ Removal Plan. On 12/19/24, 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 Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility's policy titled, Medication Management Program revised on 05/05/23, documented, The facility implements a Medication Management Program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. The following scope and rules included: 1.The facility's Medical Director will have an active role in the oversight of medication management, achieved in a variety of ways including medical record reviews, consultation, recommendations from pharmacy consultants and/or recommendations through the Quality Assurance and Performance Improvement process. 2. Licensed Independent Practitioners, licensed nurses, consulting pharmacists, and pharmacy service providers collaborate and review medication orders to ensure medical and clinical necessity and appropriateness. The primary mechanism for this validation is an initial and ongoing medication reconciliation process. 3. Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life. Review of R11 's Face Sheet revealed R11 was admitted to the facility on [DATE], with diagnoses including but not limited to: Type 2 Diabetes Mellitus with a foot ulcer (Admission), PVD (peripheral vascular disease), Chronic Kidney Disease (CKD), Stage 3b (CMS/HCC) s/p unilateral above knee amputation, pain in left ankle and joints of left foot, acquired absence of right leg above knee. Review of R11's Wound Measurement dated 11/14/24, revealed a wound on her left lateral ankle; left heel: Wound size [Length (L) x Width (W) x Depth (D)] 2.7 x 4.5 x 0.3 Surface Area 12.15 cm2 Exudate: Moderate Sero-Sanguinous Thick adherent black necrotic tissue (Eschar) 70% Slough 10% Other Viable tissues 20% (SubQ Muscle) Review of R11's Wound Measurements dated 11/21/24, revealed a diabetic wound of the left heal, full thickness: Wound Size (L x W x D) 3.0 x 4.4 x 0.3 cm Surface Area 13.20 cm2 Exudate Moderate Sero-sanguinous Thick adherent black necrotic tissue (eschar) 70% Other viable tissue 20% Review of a VOHRA Wound Physicians Wound Evaluation & Management Summary dated 11/21/24, revealed, Recommendation: Augmentin 875/125 mg BID x 14 days. Probiotics TID x 45 days. Review of R11's Medication Administration Record (MAR), did not reveal an order for Augmentin 875/125 mg. Review of R11's Physician Orders did not reveal an order for Augmentin 875/125 mg BID x 14 days or Probiotics TID x 45 days. Review of R11's Care Plan with a start date of 06/09/17, documented, At risk for *IMPAIRED SKIN INTEGRITY* Related To (R/T): *Bowel and Bladder incontinence *Assist. with toileting needs *Assist. in bed mobility *Assist with toileting needs *Risk of developing pressure ulcer *Diagnosis (Dx). of PVD *Dx. of Contracture rt hand *Dry skin *Sciatica. Further review of the Care Plan revealed the following approach, [R11] will maintain skin integrity As Evidence By (AEB) no skin breakdown or signs of skin breakdown through target date. Notify Medical Doctor (MD) of any significant changes in skin integrity. During an interview on 12/18/24 at 11:24 AM, Licensed Practical Nurse (LPN)1 stated, [R11] already had an Above the Knee Amputee (AKA) who developed wounds to her left heel and her left lateral ankle malleolus. Routinely we were keeping ithe wounds stable. [R11's] interventions included an air mattress and wound boots from the start. After a few weeks we started to see additional break down of those wounds. [R11's] periwounds became inflamed and angry. [R11] had the trifecta of wound healing issues. [R11] had a diagnosis of Diabetes Mellitus (DM), Peripheral Vascular and Arterial Disease so we were working with her aggressively. When we noticed draining of the wounds the MD ordered an antibiotic because she was concerned an underlying infection was starting due to [R11's] high risk comorbidities. On Thursdays every week we round on the residents. I try my best to have her orders and measurements entered into the computer. If I don't, I will try to wrap up on Fridays. I will admit I missed entering the antibiotic order in Matrix (electronic medical record). I feel awful about it. The wound care MD noticed the antibiotic was not entered in Matrix the following week. I totally missed it. The MD was concerned so she sent [R11] out to [local hospital] because the wound looked worse, in lieu of interventions of using the wound boots and air mattress. I have conducted in-services with 4 nurses, unfortunately it has been numerous times when dressings have come off or have not been changed or replaced. When I am off on leave the primary nurses are responsible for wound care. I usually have 15 to 20 plus patients a day for wound changes. During an interview on 12/18/24 at 12:46 PM, R11's Resident Representative (RR) stated, They called me about her wound. The facility stated they thought it needed to be looked at and they needed more medication to treat her wound. Then I noticed she had a hole in her left leg. Since she has been at that facility, she now has had both legs amputated. Her left leg was amputated on November 22, 2024. We spoke with [local hospital] and they made the decision to remove the left leg on that day or the next day. They ended up going above the knee to amputate. I think they ended up doing the surgery on November 23rd or 24th. The first text I received from [LPN1] was November 21st. [R11] went to the hospital the same day. It was 2 days before that, they called. A telephone number kept coming up, but it came up as spam. The spam number did not leave a message. It was [LPN1] the wound care specialist who told me about the wounds they were treating, and they needed to give her antibiotics. [LPN1] stated they had to send her to the hospital to give the antibiotics since they couldn't administer it there at the facility. During an interview on 12/18/24 at 1:24 PM, the Interim Director of Nursing (DON) stated, I heard about it. I know [R11] went to the hospital. The wound was healing, but day after day it got worse. During an interview on 12/18/24 at 2:18 PM, the MD stated, The week before I ordered Augmentin. I entered the note, and I guess it was not entered. I don't know what happened. The next week I assessed [R11] and observed the wound was getting worse. I decided to send her to the hospital. I am subcontracted out for services. We are unable to enter orders into their system. The wound deteriorated and had exudate, so we covered [R11] with a broad-spectrum antibiotic. I think we did a culture on her at that time. The wound deteriorated, I can't say by not receiving the antibiotic what [R11's] outcome would be. I can't answer that question without knowing the updates on her progress. During an interview on 12/18/24 at 2:50 PM, the Nurse Practitioner (NP) stated, The way the wound doctor functions is she uploads her notes in Matrix and the Wound Nurse is responsible for putting the orders in Matrix. I don't know who the Wound MD is in the facility. The old Wound MD would let me know who they vistited, but the new Wound MD doesn't let me know of any interactions between her and the Wound Nurse. The only way I find out about any new orders is reviewing the Wound MD's note that is entered into Matrix. The only thing I did notice was they were not entering orders in Matrix. I informed the old DON of orders not being entered into the system. I have noticed orders being missed on other residents as well. During an interview on 12/18/24 at 3:09 PM, RR stated, This visit to the hospital prior to Magnolia Manor - [NAME] were to treat her for wounds on her foot. I was notified by the [NP] about the wound. The wound was still not healing, and it turned black. [R11] should have had care before she received wound #2. Wound #2 was open to the bone. The bone was exposed. Something should have been done prior to them sending her to the hospital. She doesn't complain of pain. But [R11] will groan. That is how I know she is in pain. When at the hospital the hospital doctors stated the wound was infected and they needed to remove the leg. We had a conversation prior to this occurring with Magnolia Manor - [NAME] to ensure [R11] established a team to work with her that knows her. So that she can receive consistent care. I had the meeting with the staff that included the head of nursing. The RR was unable to state the others who attended the meeting. RR continued, We established a protocol so we shouldn't have to go through this again after the amputation of the first leg. Now it has happened again. I don't understand why this has happened again. The first wound wasn't doing what it should be doing. If the first wound wasn't healing and clearing up appropriately. Especially since she is diabetic, the second wound should have been aggressively treated so this would not happen again. I found out about wound #2 at the hospital. The last email from the NP was September 23, 2024. They amputated [R11's] leg on November 25, 2024. During an interview with the Administrator on 12/18/24 at 5:35 PM, the Administrator stated, My expectations going forward is to get an exit interview with the Wound MD every visit. I was not aware this was going on. I will get updated from both the Wound Physician and NP on all interventions. I will look at all reports of treatments and orders and ensure they are carried out as expected. On 12/19/24, the facility provided an acceptable IJ Removal Plan, which included: Resident #11 no longer resides in the facility. An audit of notes from the wound physician's current resident list was completed by The Director of Nursing/Designee on 12/18/2024 to identify new physician orders. None identified. An audit of medication administration was completed by the Director of Nursing/Designee on 12/18/2024 for medications and treatments 12/01/2024 through 12/18/2024 to identify missed medications and/or treatments. None identified. Licensed nurses were reeducated on Abuse and Neglect, transcribing and following physician orders including notifying responsible party of new orders by the Director of Nursing/Designee on 12/18/2024. Licensed Nurses not receiving this education by 12/19/2024 will receive prior to their next scheduled shift and this will be completed in New Hire and agency orientation. Director of Nursing/Designee will review wound physician's notes in clinical morning meeting Monday - Friday beginning 12/20/2024 until 01/10/2025 to validate recommend orders have been transcribed, implemented, responsible party notified, and care plan updated. Director of Nursing/Designee will review wound physician's notes in clinical morning meeting Monday - Friday beginning 12/20/2024 until 01/10/2025 to validate updated wound measurements have been documented in the medical record, responsible party notified and care plan updated. These weekly audits will be monitored by the Administrator and brought for review to the next Quality Assurance and Performance Committee meeting for recommendations and this will continue for 2 additional months. Ad Hoc QAPI will be held on 12/19/2024. The Medical Director was notified of the Immediate Jeopardy on 12/19/2024. Allegation of Compliance Date is 12/19/2024.

Based on review of facility policy, record review and interviews, the facility failed to provide treatment, consistent with professional standards of practice for Resident (R)11's Pressure Ulcer (PU)/Pressure Injury (PI). Specifically, the facility failed to administer an antibiotic to treat R11's wounds, resulting in a loss of limb. On 12/19/24 at 10:10 AM, the Administrator was notified that the failure to provide treatment, consistent with professional standards of practice, to a Pressure Ulcer (PU)/Pressure Injury (PI), constituted IJ at F686. On 12/19/24 at 10:10 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 11/21/24. The IJ was related to 42 CFR 483.25 Quality of Care. On 12/19/24, the facility provided an acceptable IJ Removal Plan. On 12/19/24, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F686 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F686, constituting substandard quality of care. Findings include: Review of the facility's policy title, Wound Care Policies and Procedures Reference dated 09/2024, documented, All treatments should be in conjunction with a physician's order . Physician Orders will still be Required for Wound Care . Review of the facility's policy titled, Medication Management Program, revised 05/05/2023, revealed, The facility implements a Medication Management Program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. The following scope and rules included: 1.The facility's Medical Director will have an active role in the oversight of medication management, achieved in a variety of ways including medical record reviews, consultation, recommendations from pharmacy consultants and/or recommendations through the Quality Assurance and Performance Improvement process. 2. Licensed Independent Practitioners, licensed nurses, consulting pharmacists, and pharmacy service providers collaborate and review medication orders to ensure medical and clinical necessity and appropriateness. The primary mechanism for this validation is an initial and ongoing medication reconciliation process. 3. Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life. Review of R11's Face Sheet revealed R11 was admitted to the facility on [DATE], with diagnoses including but not limited to: Type 2 Diabetes Mellitus with a foot ulcer (Admission), PVD (peripheral vascular disease), Chronic Kidney Disease (CKD), Stage 3b (CMS/HCC) s/p unilateral above knee amputation, pain in left ankle and joints of left foot, acquired absence of right leg above knee. Review of (R)11's Physician Orders revealed the following: Sodium hypochlorite solution (Dakins apply once daily for 30 days. Use 1/4 Dakin's, lightly wet gauze for Wet to Dry (WTD). Do not wet to remove. Remove dry bandage quick like a band aid with necrotic tissue attached. Acetic acid apply once daily for 30 days clean wound with acetic acid. Secondary Tape (retention) apply once daily for 23 days; Gauze roll (stretch) 6 apply once daily for 23 days wrap from beneath toes to mid-calf to attempt to keep resident from being able to remove; Super absorbent gelling fiber pad apply once daily for 9 days. Review of a VOHRA Wound Physicians Wound Evaluation & Management Summary dated 11/14/24, order revealed dressing treatment plan (Diabetic Wound of Left, Lateral Ankle Full Thickness). Sodium (Na) hypochlorite solution (Dakins) apply once daily for 30 days; Use 1/4 Dakins, lightly wet gauze and cover wound with wet gauze for WTD. Do not wet to remove. Remove dry bandage quick like a band-aid with necrotic tissue attached. Acetic acid apply once daily for 30 days clean wound with acetic acid. Review of a VOHRA Wound Physicians Wound Evaluation & Management Summary dated 11/21/24, revealed the following: Recommendation: Augmentin 875/125 mg Twice a Day (BID) x 14 days. Probiotics Three times a day (TID) x 45 days. Review of R11's Wound Measurement dated 11/14/24, revealed a wound on her left lateral ankle; left heel: Wound size [Length (L) x Width (W) x Depth (D)] 2.7 x 4.5 x 0.3 Surface Area 12.15 cm2 Exudate: Moderate Sero-Sanguinous Thick adherent black necrotic tissue (Eschar) 70% Slough 10% Other Viable tissues 20% (SubQ Muscle) Review of R11's Wound Measurements dated 11/21/24, revealed a diabetic wound of the left heal, full thickness: Wound Size (L x W x D) 3.0 x 4.4 x 0.3 cm Surface Area 13.20 cm2 Exudate Moderate Sero-sanguinous Thick adherent black necrotic tissue (eschar) 70% Other viable tissue 20% Review of R11's Medication Administration Record (MAR), did not reveal an order for Augmentin 875/125 mg. Review of R11's Physician Orders did not reveal an order for Augmentin 875/125 mg BID x 14 days or Probiotics TID x 45 days. Review of R11's Care Plan with a start date of 06/09/17, documented, At risk for *IMPAIRED SKIN INTEGRITY* Related To (R/T): *Bowel and Bladder incontinence *Assist. with toileting needs *Assist. in bed mobility *Assist with toileting needs *Risk of developing pressure ulcer *Diagnosis (Dx). of PVD *Dx. of Contracture rt hand *Dry skin *Sciatica. Further review of the Care Plan revealed the following approach, [R11] will maintain skin integrity As Evidence By (AEB) no skin breakdown or signs of skin breakdown through target date. Notify Medical Doctor (MD) of any significant changes in skin integrity. During an interview on 12/18/24 at 11:24 AM, Licensed Practical Nurse (LPN)1 stated, [R11] already had an Above the Knee Amputee (AKA) who developed wounds to her left heel and her left lateral ankle malleolus. Routinely we were keeping the wounds stable. [R11's] interventions included an air mattress and wound boots from the start. After a few weeks we started to see additional break down of those wounds. [R11's] periwounds became inflamed and angry. [R11] had the trifecta of wound healing issues. [R11] had a diagnosis of Diabetes Mellitus (DM), Peripheral Vascular and Arterial Disease so we were working with her aggressively. When we noticed draining of the wounds the MD ordered an antibiotic because she was concerned an underlying infection was starting due to [R11's] high risk comorbidities. On Thursdays every week we round on the residents. I try my best to have her orders and measurements entered into the computer. If I don't, I will try to wrap up on Fridays. I will admit I missed entering the antibiotic order in Matrix (electronic medical record). I feel awful about it. The wound care MD noticed the antibiotic was not entered in Matrix the following week. I totally missed it. The MD was concerned so she sent [R11] out to [local hospital] because the wound looked worse, in lieu of interventions of using the wound boots and air mattress. I have conducted in-services with 4 nurses, unfortunately it has been numerous times when dressings have come off or have not been changed or replaced. When I am off on leave the primary nurses are responsible for wound care. I usually have 15 to 20 plus patients a day for wound changes. During an interview on 12/18/24 at 12:46 PM, R11's Resident Representative (RR) stated, They called me about her wound. The facility stated they thought it needed to be looked at and they needed more medication to treat her wound. Then I noticed she had a hole in her left leg. Since she has been at that facility, she now has had both legs amputated. Her left leg was amputated on November 22, 2024. We spoke with [local hospital] and they made the decision to remove the left leg on that day or the next day. They ended up going above the knee to amputate. I think they ended up doing the surgery on November 23rd or 24th. The first text I received from [LPN1] was November 21st. [R11] went to the hospital the same day. It was 2 days before that, they called. A telephone number kept coming up, but it came up as spam. The spam number did not leave a message. It was [LPN1] the wound care specialist who told me about the wounds they were treating, and they needed to give her antibiotics. [LPN1] stated they had to send her to the hospital to give the antibiotics since they couldn't administer it there at the facility. During an interview on 12/18/24 at 1:24 PM, the Interim Director of Nursing (DON) stated, I heard about it. I know [R11] went to the hospital. The wound was healing, but day after day it got worse. During an interview on 12/18/24 at 2:18 PM, the MD stated, The week before I ordered Augmentin. I entered the note, and I guess it was not entered. I don't know what happened. The next week I assessed [R11] and observed the wound was getting worse. I decided to send her to the hospital. I am subcontracted out for services. We are unable to enter orders into their system. The wound deteriorated and had exudate, so we covered [R11] with a broad-spectrum antibiotic. I think we did a culture on her at that time. The wound deteriorated, I can't say by not receiving the antibiotic what [R11's] outcome would be. I can't answer that question without knowing the updates on her progress. During an interview on 12/18/24 at 2:50 PM, the Nurse Practitioner (NP) stated, The way the wound doctor functions is she uploads her notes in Matrix and the Wound Nurse is responsible for putting the orders in Matrix. I don't know who the Wound MD is in the facility. The old Wound MD would let me know who they visited, but the new Wound MD doesn't let me know of any interactions between her and the Wound Nurse. The only way I find out about any new orders is reviewing the Wound MD's note that is entered into Matrix. The only thing I did notice was they were not entering orders in Matrix. I informed the old DON of orders not being entered into the system. I have noticed orders being missed on other residents as well. During an interview on 12/18/24 at 3:09 PM, RR stated, This visit to the hospital prior to Magnolia Manor - [NAME] were to treat her for wounds on her foot. I was notified by the [NP] about the wound. The wound was still not healing, and it turned black. [R11] should have had care before she received wound #2. Wound #2 was open to the bone. The bone was exposed. Something should have been done prior to them sending her to the hospital. She doesn't complain of pain. But [R11] will groan. That is how I know she is in pain. When at the hospital the hospital doctors stated the wound was infected and they needed to remove the leg. We had a conversation prior to this occurring with Magnolia Manor - [NAME] to ensure [R11] established a team to work with her that knows her. So that she can receive consistent care. I had the meeting with the staff that included the head of nursing. The RR was unable to state the others who attended the meeting. RR continued, We established a protocol so we shouldn't have to go through this again after the amputation of the first leg. Now it has happened again. I don't understand why this has happened again. The first wound wasn't doing what it should be doing. If the first wound wasn't healing and clearing up appropriately. Especially since she is diabetic, the second wound should have been aggressively treated so this would not happen again. I found out about wound #2 at the hospital. The last email from the NP was September 23, 2024. They amputated [R11's] leg on November 25, 2024. During an interview with the Administrator on 12/18/24 at 5:35 PM, the Administrator stated, My expectations going forward is to get an exit interview with the Wound MD every visit. I was not aware this was going on. I will get updated from both the Wound Physician and NP on all interventions. I will look at all reports of treatments and orders and ensure they are carried out as expected. On 12/19/24, the facility provided an acceptable IJ Removal Plan, which included the following: Resident #11 no longer resides in the facility. An audit of notes from the wound physician's current resident list was completed by The Director of Nursing/Designee on 12/19/2024 to identify new physician orders. None identified. An audit of current wound treatment orders and wound physician notes will be completed on 12/19/2024 by the Director of Nursing/designee to validate wound treatments have been implemented as recommended by wound physician. An audit of medication administration was completed by the Director of Nursing/Designee on 12/1/2024 for medications and treatments 12/01/2024 through 12/18/2024 to identify missed medications and/or treatments. None Identified. Licensed nurses were reeducated on Abuse and Neglect, transcribing and following physician orders including notifying responsible party of new orders by the Director of Nursing/Designee on 12/18/2024. Licensed nurses will receive reeducation on wound care by the Director of Nursing/Designee by 12/19/2024 including: -Transcribing physician wound treatment orders from wound physician notes -Providing treatment and care per physician's order Licensed Nurses not receiving this education by 12/19/2024 will receive prior to their next scheduled shift and this will be completed in New Hire and agency orientation. Director of Nursing/Designee will review wound physician's notes in clinical morning meeting Monday-Friday beginning 12/20/2024 through 01/10/2025 to validate any recommended orders have been transcribed, implemented, responsible party notified, and care plan updated. Director of Nursing/Designee will review wound physician's notes in clinical morning meeting Monday-Friday beginning 12/20/2024 through 01/10/2025 to validate updated wound measurements have been documented in the medical record, responsible party notified, and care plan updated. These weekly audits will be monitored by Administrator and brought for review to the next Quality Assurance and Performance Committee meeting for recommendations and this will continue for 2 additional months. Ad Hoc QAPI will be held on 12/18/2024. The Medial Director was notified of the Immediate Jeopardy on 12/18/2024. Allegation of Compliance Date is 12/19/2024

Based on observations, interviews, record review and review of facility policy, the facility failed to ensure that medications belonging to Resident (R)15 were properly stored, secured, and/or administered prior to staff leaving the room for 1 of 2 residents reviewed. Findings include: Review of the facility policy titled, Pharmacy Services, Policies and Procedures- Section 8: Medication Storage, with a revision date of 04/17/24, documented, 1. Medications and biologicals are stored safely, securely and properly following the manufacturer's recommendations or those of the supplier. In accordance with State and Federal laws, the facility will store all drugs and biologicals in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. 2. The medication and biological supply are only accessible to licensed nursing personnel, pharmacy personnel or authorized staff members. Review of the facility policy titled, Nursing Policies and Procedures- Medication Management Program with a revision date of 05/05/23, documented, 7. Medications are administered no more than one hour before to one hour after the designated medication pass time. 10. The authorized staff member or licensed nurse must remain with the resident while the medication is swallowed. Never leave medication in a resident room without order to do so. Review of R15's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to: respiratory failure, lymphedema, chronic venous hypertension of right lower extremity, and cirrhosis of liver. Review of R15's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/01/24 revealed R15 had a Brief Interview of Mental Status (BIMS) score of 15 of 15, indicating that the resident was cognitively intact. Review of R15's Medication Administration Record (MAR) for December 2024, Physician Orders dated 12/18/24, revealed an administration record for 9:00 AM of Budesonide -formoterol HFA aerosol inhaler; 160/4.5, Coreg 6.25 mg tab, Multi Vite 400-50-500mg capsule, Ferrous Sulfate 325mg tab, Furosemide 40 mg tab, Lactulose solution 10gr/15ml syrup, Lidocaine Adhesive Patch 4%, Mucinex 600mg tab, Protonix 40mg capsule, Potassium Chloride 20 mg capsule, Prostat 30ml syrup, Spironolactone 25mg tab, Ventolin HFA inhaler 90mcg, and Rifaximin 550mg tab. Further review of the MAR revealed Licensed Practical Nurse (LPN)3 signed off for administration on 12/18/24, as a late entry for medications at 10:30 AM. Review of R15's Physician Orders did not include an order for self-administration of medication. During an observation on 12/18/24 at 11:00 AM, during the initial tour of R15's room, revealed, two clear medicine cups at the right side of bed on the overbed table. One cup contained multiple-colored pills. The other cup contained a light brown liquid. Both cups were not labeled as to the contents. There were also medications that were in boxes and packages on the overbed table. During an interview on 12/18/24 at 11:23 AM, Certified Nursing Assistant (CNA)1 revealed that she was aware of the medications on the overbed table for R15. CNA1 stated she noticed the pills at 11:15 AM. CNA1 stated she left the pills there and went to the nurse's station to notify Licensed Practical Nurse (LPN)3, but LPN3 was at lunch. CNA1 further stated she didn't address this issue with anyone else; therefore, the medication remained on the overbed table at bedside as she exited the room. During an interview on 12/18/24 at 11:29 AM, LPN2 verified the medications on the overbed table in R15's room, LPN2 confirmed the finding of one empty medicine cup, and the other medicine cup with the light brown liquid inside, along with a Lidocaine Patch 700mg, Fluticasone nasal spray and Budesonide 160/4.5mg inhaler. LPN2 stated R15 was not his resident and he had not been in the room today. LPN2 confirmed that LPN3 was the nurse caring for R15, but she was on lunch. During an interview on 12/18/24 at 1:57 PM, LPN3 confirmed she was the nurse caring for R15. LPN3 stated his BIMS is 15, and he told her to leave the medicine, and she thought he would take it right then. LPN3 stated her normal procedure includes looking at the medication list, checking the medication dosage, pulling medication from the packages, knocking on the door and telling the residents she's coming in to give them their medication. She has the resident's medication ready when she walks in. LPN3 stated that everything she takes in the room with her, she brings back out after usage. LPN3 further stated she was going to double back to R15's room but got sidetracked. LPN3 states R15 always takes his medicine, and most of the time he comes to the cart and takes his medicine. LPN3 stated, I know I shouldn't have left the medications by his bed, but I felt he would have taken his medicine. LPN3 concludes that she understands that medication can not be left at bedside because someone else could have gotten it. During an interview on 12/19/24 at 9:38 AM, the Interim Director of Nursing (DON) stated that during medication administration she has the MAR in front of her to check the five routes of medication administration. Also, identifying the patient and staying there as long as it takes to ensure the resident takes all medication. The DON revealed the expectation for staff is to follow policy that medication should be administered at bedside and watched. The DON stated she wants to ensure the resident doesn't choke or pocket the medication. She also wants to ensure wanderers don't take the medication. The timeframe for medicine administration is one hour before and one hour after the prescribed order time. The facility does keep some over-the-counter medications at bedside that are labeled with the resident's name on it. The DON also includes if there is a disgruntled resident that doesn't want to take their medicine right then, she advises them that she can't leave the medication unattended in the room and there is a certain amount of time that she has before they are discarded. Late entries are only documented when medications are given late. The DON explains that her expectations are for staff to always follow policy.

Based on interview, record review, and review of facility policy, the facility failed to ensure that Resident (R)2 was free from physical abuse by Licensed Practical Nurse (LPN)2, for 1 of 19 residents reviewed for abuse. Findings include: Review of the facility policy titled Leadership Policies and Procedures Organizational Ethics Abuse, Neglect, Exploitation, or Mistreatment last revised on 10/23/19, documented, the facility's leadership prohibits neglect, mental, physical, and or verbal abuse, use of a physical of chemical restraint not required to treat medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient/resident property and/or funds and ensures violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or mental anguish. Abuse also includes the deprivation by an individual, including 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. Willful as used in the individual means the individual must have acted deliberately, not that individual must have intended to inflict injury or harm. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including but not limited to: dementia with moderate anxiety, major depressive disorder, generalized anxiety disorder and, dysphasia. Review of R2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 11/01/24, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 99, which indicates that R2 was not cognitively intact and was unable to complete the interview. Review of a Witness Statement written by LPN1, dated 10/31/24, documented, I [LPN2] was sitting at the nurses station on Unit 1 at 6:35 AM. The resident (R2) came up to the nurses station asking the third shift nurse (LPN2) for a 'puff' of her inhaler several times. [LPN2] kept ignoring [R2] at first but later began to argue with the resident about the inhaler. [R2] became upset and said that she was going to call 911. The resident then proceeded to walk around to the phone and lifted it up and started dialing the number. [LPN2] then tried to snatch the telephone from the resident, and they began tussling with the phone. I asked [LPN2] to let the resident have the phone, once [LPN2] let go of the telephone the resident reared back with the phone and hit [LPN2] hard in the face with the telephone. [LPN2] then snatched the telephone back from the resident and hit her gently in the face. [LPN2] then went around the nurses stations towards the resident and the resident turned and walked towards me [LPN1]. I then stepped between both of them, the resident winked at this nurse [LPN1], then closed her eyes and slid to the floor. After assisting the resident back up, this nurse escorted the resident back to her room and called to notify the Director of Nursing (DON). Review of a Witness Statement written by LPN2, dated 10/31/24, documented, At 6:45 AM the resident came up to the nurses station for an inhaler. I let the resident [R2] know that she did not have an inhaler until later in the day. Resident then went around to the phone and picked up the phone and I touched the cord. When I did, [R2] hit me hard in the face. She then went around to [LPN1] and when I walked to her she said oh and fell in my arms. I placed the resident on the floor for a few minutes and then [LPN1] ambulated her back to her room. Review of a Conclusion Summary dated 10/31/24, documented, At 6:45 AM [LPN1] employed by the facility witnessed [LPN2], an agency LPN strike a resident in the face with a telephone. The altercation occurred because the resident had asked to be given an inhaler, which was prescribed for her to given PRN (as needed). The nurse responded to the resident, you don't have one and the resident proceeded to pick up the phone to call 911. [R2] and [LPN2] tussled with the phone and the nurse was able to grab the phone from the resident. Resident then walked away from the desk and proceeded to use another phone on the hall and [LPN2] attempted to take that phone away from [R2] as well. Aggravated, [R2] hit [LPN2] in the face with the phone and [LPN2] hit the resident back in the face with the phone. Eyewitness who was present immediately called the DON to report this incident and escorted the resident to her room and remained with her until the other nurse had left the unit as that nurse had instructed her to do. After administrative investigation concluded it revealed that the allegation of physical abuse is substantiated. During an interview on 11/19/24 at 3:10 PM, LPN1 revealed that they witnessed LPN2 hit R2 while at the nurses station on Unit 1. R2 came to the nurses station to ask for her PRN (as needed) inhaler and requested her nurse for the day, R2 requested the inhaler from LPN2 several times. LPN2 refused to give R2 her inhaler and stated that she did not have a Physician Order for an inhaler but made no attempts to look at R2's medical record or in the medication/treatment carts. LPN2 and R2 began to argue with each other, then R2 attempted to call 911 with the phone at the nurses station. LPN2 refused to allow R2 to use the phone and the two started tugging back and forth with the phone then I (LPN1) intervened by trying to deescalate the situation by telling LPN2 to let go of the phone. LPN1 stated eventually LPN2 let go of the phone and R2 hit LPN2 hard in the face with the phone, LPN2 retaliated and hit R2 back in the face with phone (but not as hard). LPN1 further stated, she got between the resident and LPN2 to stop them from fighting anymore. R2 then slid herself to the ground (purposely), I had to find someone to help me assist the resident up from the floor. After finding help with assisting the resident back into her wheelchair, I assisted the resident to her room and instructed her to stay there for a while because I didn't want R2 and LPN2 to cross paths again. I then went outside to notify the Director of Nursing (DON) of the situation. LPN1 further stated, R2 did not have any injuries due to the incident and LPN2 was not allowed to return back to the facility as an agency nurse. LPN1 stated that LPN2 previously worked at the facility as a staff nurse but was eventually terminated due to behavioral issues/customer service. LPN1 stated that LPN2 often had anger issues but mostly with tone/verbally. LPN1 stated that she never witnessed LPN2 be physically abusive to a resident in the past but has overheard LPN2 be rude to residents/other staff members. An attempted interview on 11/19/24 at 3:50 PM, with R2 was unsuccessful due to her cognitive status, a phone call was made to her Resident Representative and a message was left with contact information. An attempted interview with LPN2 on 11/20/24 at 11:06 AM, was unsuccessful, a voicemail message was left with callback information. During a phone interview on 11/20/24 at 12:12 PM, with the Agency Staffing Coordinator revealed that they were not allowed to disclose any information at this time related to LPN2's employment status. The Agency Staffing Coordinator stated that the Administrator of Staffing Agency will call back when they return in the office and provided call back information. A call back was never received from the Agency Staffing company. A second attempt on 11/20/24 at 12:30 PM, was made to LPN2 but was unsuccessful. A third attempt on 11/20/24 at 12:46 PM, LPN2 stated that they are not at liberty to speak with the state agency related to this matter at this time and provided information to their lawyer. During an interview on 11/20/24 at 4:48 PM, the Assistant Director of Nursing (DON) revealed that the abuse allegation was substantiated and LPN2 was put on a do not return list. The DON stated they were notified around 7 that morning that LPN1 witnessed LPN2 hit R2. When they arrived to the facility, R2 was in her room and they assessed the resident and found no injury. LPN2 was at the nurses station completing medication count with another nurse so they could exit the facility. I notified the resident representative along with the medical director and law enforcement. Law enforcement was able to interview the resident and LPN1 and both confirmed that LPN2 hit R2 with a phone. The last updates that I have for the incident was that law enforcement was pursing LPN2, and she should have a court date soon.

Based on observation, interview and review of the facility policy, the facility failed to maintain an effective pest control program to remain free of pests/rodents, in 1 of 4 units. Findings include: Review of the facility policy revised on June 20, 2023, titled Pest Control states, Facility will maintain an effective pest control program to prevent or eliminate infestation of pests and rodents. 1. Contracted pest elimination service will provide monthly service for the most common pests such as rodents, cockroaches and other crawling invaders. This includes a sanitation and structural inspection to identify any issues conducive to pest activity and proactive monitoring. 5. Proper sanitation will be maintained, and clutter reduced to prevent food and harborage for pests. During an observation 09/24/2024 at 10:31 AM, a roach like insect was observed on a CPAP machine. During an observation on 09/24/2024 at 10:35 AM, a dead spider was observed on the window seal in room [ROOM NUMBER]. During an observation on 09/24/2024 at 10:42 AM, a nurse was walking around the nurses' desk and hit the water machine, which resulted in multiple roach like insects scatter. Additionally, a roach like insect was observed in the bathroom and a waterbug like insect was turned over dead at the nurses' station on the 200 Hall. Review the Pest Control Logs on 09/24/2024 at 3:50 PM, revealed all pest control activity logs compared to Ecolab service areas revealed no activity was found. During an interview on 09/24/2024 at 10:15 AM, Resident (R)1 stated, It was six roaches in my CPAP machine. This place is infested with roaches. During an interview on 09/24/2024 at 10:25 AM, Housekeeper 2 stated, I see roaches in certain rooms. We use bleach cleaner spray and shackle spray. During an interview on 09/24/2024 at 10:44 AM, Certified Nursing Assistant (CNA)1 stated, I am prn [as needed] mostly on first shift. I see roaches them everywhere. I have only seen pest control once. They were at the nursing station. I see them throughout the day. Next door when I came in today the room [ROOM NUMBER], they [roaches] were running everywhere. During an interview on 09/24/2024 at 10:40 AM, Licensed Practical Nurse (LPN)1 stated, The roaches are everywhere. During an interview on 09/24/2024 at 10:46 AM, Housekeeper 1 stated If we see a bug we talk to maintenance to come spray. They tell us afterwards so after they spray we can come in and clean behind them. We do try our best to clean up immediately. I informed the staff to let me know immediately. We have logs to record at each nurses' station to document the date time, location and type of pests they have seen. Everyone is responsible for reporting. My team is willing to do whatever. We have isolated rooms where we have sprayed and then return them to their rooms. During an interview on 09/24/2024 at 10:59 AM, the Administrator stated, I just was made aware of the problem today. I have called maintenance. During an interview on 09/24/2024 at 11:36 AM, the Administrator stated, We are getting her a new CPAP machine, it should be here within an hour. During an interview on 09/24/2024 at 11:07 AM, Maintenance 1 stated, The biggest issue is their (residents) nightstand is stored with food in it. First thing is they need to have that clean and then we can treat their rooms. If I don't know about it I can't fix the problem. We have a maintenance log at each nursing station. I reviewed Pest Control Log for Unit 200. Ecolab guy should come out this week. They come out monthly. If additional visits are needed especially roach treatment they will come out at no additional charge. During an interview on 09/24/2024 at 3:47 PM, Maintenance 1 compared the log to service in the areas that were spray over the three months. Maintenance 1 stated, EcoLab comes in and review the logs and will spray the rooms with activity.

Based on observation, interviews, and facility policy review, the facility failed to provide proper safety protocols for 5 out of 5 residents who smoke/vape, Residents (R)1, R2, R3, R4, and R5. Additionally, the facility failed to conduct smoking assessments for 2 out of 5 residents who smoke/vape, R4 and R5. Specifically, residents were smoking vapes in the facility and sharing vapes with other residents. On 04/30/2024 at 09:34 AM, the Administrator was notified that the failure to conduct assessments on residents who smoke/vape and failing to provide proper safety protocols for residents who smoke/vape constituted Immediate Jeopardy (IJ) at F689. On 04/30/2024 at 09:34 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 04/30/2024. The IJ was related to 42 CFR 483.25 - Quality of Care. On 04/30/2024 at 2:30 PM, the facility provided an acceptable IJ Removal Plan. On 05/01/2024 at 02:30 PM, the survey team validated the facility's corrective actions and removed the IJ, as of 05/01/2024. The facility remained out of compliance at F689 at a lower scope and severity of E. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility's policy titled, Smoking Regulation, dated 11/1/2017, revealed, It is highly encouraged that the Facility retains a smoke free environment. If the Facility chooses not to retain a smoke-free environment (Smoking Facility), the Facility's Leadership will establish an appropriate and safe environment for smoking in the Facility to reduce risks to patients/residents who smoke, reduce risks of passive smoking for others, and reduce the risk of fire. The procedures included: 1. Staff is prohibited from smoking on facility's property except for those areas specifically designated for smoking. 2. If the Facility provides long-term care and is a Smoking Facility, a policy is established by the Leadership that permits patients/residents to smoke without written authorization from a licensed independent practitioner. This policy designates locations that are environmentally separate from all patient/resident care areas. 3. The Smoking Facility's Leadership will institute a smoking policy for patients/residents, that: A. Establishes where smoking can occur on facility property. B. Minimizes the smoke to the greatest extent possible. C. Discourages all such smoking. D. Provides education and options for smoking cessation activities. 4. The Smoking Facility's staff will complete the Safety Evaluation for Smoking Care Plan form (Assessment) for the patient's/resident's need for adaptive equipment upon admission, quarterly, and annually. When completed, the record is filed in the patient's/resident's medical record. 6. Patients/Residents will not smoke without direct supervision. This facility is a smoke-free environment. There are no designated smoking areas inside the building. Residents wishing to smoke during their stay will be permitted to do so only with staff supervision and only in designated areas. Smoking is strictly prohibited in any other areas of the facility and/or its property, without exception. Residents must utilize protective gear/apparatus (flame retardant smoking aprons, gloves, etc.) provided for in their safety evaluation and/or care plan, if applicable. Tobacco products are limited to tobacco and/or clove cigarettes, cigars and/or pipes. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with a diagnosis including but not limited to, calculus of kidney due to nephrostomy catheter. R1's MDS Quarterly Review dated 02/08/2024 revealed R1 has a Brief Interview of Mental Status (BIMS) score of 15, indicating they are cognitively intact. Review of R1's smoking assessment revealed, Smoking materials: disposable vape observation dated 03/21/2024. Frequency of use: less than daily. Smokes in unauthorized areas: Minimal Problem. Mobility: Minimal Problem Review of R1's Electronic Medical Record (EMR) did not reveal documentation that R1 was assessed for acknowledgement of smoking policy. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE] with a diagnosis including but not limited to, hypoxemia. Review of R2's Quarterly MDS dated [DATE] revealed R2's BIMS score was 15. Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE] with diagnoses including but not limited to, paraplegia and chronic obstructive pulmonary disease (copd). Review of R3's Quarterly MDS dated [DATE] revealed R3's BIMS score was 15. Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE] with a diagnosis including but not limited to, seasonal allergic rhinitis. Review of R4's Quarterly MDS dated [DATE] revealed R4's BIMS was 15. Review of R4's EMR did not reveal documentation that R4 was assessed for smoking/vaping. Review of R5's Face Sheet revealed R4 was admitted to the facility on [DATE] with diagnoses including but not limited to: nondisplaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, copd, and tobacco use. Review of R5's Quarterly MDS dated [DATE] revealed R5's BIMS score was 15. Review of R5's EMR, did not reveal documentation that R5 was assessed for smoking/vaping. During an interview on 04/29/24 at 1:48 PM, License Practical Nurse (LPN)1 stated to the surveyor, I just caught [R1] vaping in the room. He is keeping it in his gown. During an interview on 04/29/24 at 1:51 PM, R1 admitted to vaping in his room. During an interview on 04/29/24 at 3:05 PM, R1 stated, I gave the vape back to my roommate. We share the vape, it's not mine, it is his. During an interview on 04/29/24 at 3:11 PM, the Assistant Director of Nursing (ADON) stated, We have talked to the family members about supplying those (vapes) to the resident. We have educated the family members. During an observation and interview on 04/29/24 at 3:12 PM, R2 was vaping in the courtyard area of the facility and was unsupervised. When asked if he shares his vape with his roommate, R2 responded, I don't know what you are talking about. When asked does he vape in the room R2 responded, I don't know what you are talking about. During an interview on 04/29/24 at 4:53 PM, LPN2 stated, When I first came here to work it was a smoking facility. Then it was a non-smoking facility. Now, I am unsure. But yes, we have a problem with residents vaping. During an interview on 04/30/24 at 9:34 AM, the Administrator stated, We are a smoke free facility. We do not have a vaping policy. When we see or discover they are vaping, we confiscate the vape. They have noted they mail order them in the facility, they have them delivered with outside food via uber. We have educated the families not to bring in vapes for the residents. During an interview on 04/30/24 at 12:30 PM, R3 stated, A nurse told me I could smoke in the bathroom, but she was suspended for 2 to 3 days. Now we can only vape in the courtyard. I keep my vape in my drawer or locked in my bag, so it won't get stolen. The staff allow us to keep it on us. During an interview on 4/30/24 at 12:40 PM, the Administrator stated, On admission, they sign the no smoking document. During an interview on 04/30/24 at 12:56 PM, Registered Nurse (RN)1 stated, [R3] vapes, I am unsure how she gets her vapes, that is a mystery. The residents are good with the rules as far as I know. I am usure of a policy pertaining to vaping. During an interview on 04/30/24 at 2:06 PM, R4 stated, I vape. I just came from outside using my vape. I keep it locked in my book bag. I usually order it, and it comes in the mail. We are only allowed to vape in the courtyard. During an interview on 04/30/24 at 2:00 PM, R5 revealed that she smokes and has been for a long time. R5 stated that the facility does not allow people to smoke, so she started vaping instead. R5 further stated that she typically goes to the back yard to vape because it's easier to hide. Both she and her roommate vape in the facility. R5 continued, her roommate does vape in the room and conceals the vapors by blowing the smoke down her shirt. R5 revealed that someone who works in the facility buys her and her roommate vapes. R5 stated, I do not want to say her name because she might get fired. R5 revealed that the staff member was a nurse, but would not specify their name or give a description. R5 concluded that once she gets money in her account, she will typically give the nurse some money to buy vapes for her and her roommate and that they take turns buying vapes from the same nurse, this has been going on for a while now. During an interview on 04/30/24 at 4:00 PM, the Director of Nursing (DON) stated, We checked the smoking assessments, I was not aware of [R4] and [R5] vaping. We do not have smoking assessment for those residents. The facility's accepted removal plan revealed: Magnolia Manor [NAME] Plan of Removal F689_ 4/30/2024 Residents #1, #2, #3, #4, #5 smoking assessments were completed on 04/30/2024. Residents #1, #2, #3, #4, and #5 turned in their smoking material to the nurse for secure storage on 04/30/2024. The Administrator reviewed with the identified residents the smoking policy including: -All residents are prohibited from keeping any type of smoking materials, including electronic cigarette vapes in their rooms or on their person. These materials must be turned into a nurse for secured storage. -Residents may only smoke/vape in designated areas that have been approved and identified as a designated smoking area. -Residents will be supervised by facility staff while smoking/vaping during the entirety of the time. -Assigned facility staff will accompany residents wishing to smoke/vape to the designated smoking area at the times outlined in the smoking schedule. -No other person, including but not limited to residents, families and visitors may directly provide smoking materials including vapes to any resident. -Designated staff members, Social Services and Activity staff, may purchase, using the resident's personal funds, smoking material/vapes for residents allowed to smoke as requested. Facility will keep a log for each resident on what is purchased and kept in the secured area. Receipts will be kept for record keeping and reconciliation. Residents currently residing in the facility were asked by facility leadership if they currently use vapes or are smokers on 04/30/2024. An additional 11 residents identified as smokers/vapers. Those 11 self-identified as smokers, including the use of vapes will have a smoking acuity (assessments) completed by a licensed nurse on 04/30/2024 to determine any additional supervision the resident may require when smoking /vaping. The Administrator will review on 04/30/2024 with the residents, that have self-identified as smoker/vapers, and Facility Staff the smoking guidelines policy including: -All residents are prohibited from keeping any type of smoking materials, including electronic cigarette vapes in their rooms or on their person. These materials must be turned into a nurse for secured storage. -Residents may only smoke/vape in designated areas that have been approved and identified as designated smoking area. -Residents will be supervised by facility staff while smoking/vaping during the entirety of the time. -Assigned facility staff will accompany residents wishing to smoke/vape to the designated smoking area at the times outlined in the smoking schedule. -No other person, including but not limited to residents, families and visitors may directly provide smoking materials including vapes to any resident. -Designated staff members, social Services and Activity staff, may purchase from the resident's personal funds, smoking material/vapes for residents allowed to smoke as requested. Facility will keep a log for each resident on what is purchased and kept in the secured area. Receipts will be kept for record keeping and reconciliation. Residents who had smoking materials have turned in those smoking materials to the nurse for storage in a secured area on 04/30/2024. Smoking Cessation products will be offered to any resident that has identified as a smoker. If they chose to utilize smoking cessation products, the physician will be notified and orders obtained on 04/30/2024. Any staff not receiving this smoking guidelines policy education on 05/01/2024 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation and for agency staff. The Director of Nursing will validate in clinical meeting Monday- Friday that Smoking Acuity (Assessment) has been completed for newly admitted residents identifying as a smoker/vaper. The Director of Nursing will randomly interview a minimum of 2 staff and 2 interviewable residents weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with the smoking guidelines. Administrator/designee will round in resident rooms 2 times per day for 5 days, then daily for 3 additional weeks then monthly for 2 additional months to validate there are no smoking materials in residents' rooms or on their persons. Any concerns will be addressed at time of discovery. The Medical Director was notified on 04/30/2024 of the Immediate Jeopardy. Ad Hoc Quality Assurance Performance Improvement Meeting was held on 04/30/2024 to discuss contents of this plan.

Based on observations, record reviews, interviews, review of the Facility Reported Incident (FRI), the facility failed to ensure one of 15 sampled residents (Resident (R)1), who had a physician order for a pureed diet and nectar thickened liquids received adequate supervision to remain free from accident hazards. Specifically, R1 obtained a pimento cheese sandwich from the evening snack cart and consumed some of the sandwich, as a result, R1 was found unresponsive while seated in a wheelchair in his room. Staff immediately initiated cardiopulmonary resuscitation (CPR). The nurse staff found pieces of the pimento cheese sandwich in R1's mouth. This failure placed the resident at risk causing serious injury, serious harm, and death. On [DATE] at 7:18 PM, the survey team provided the Administrator and Director of Nursing (DON) a copy of the CMS Immediate Jeopardy (IJ) Template and notified them that an IJ existed on [DATE] and constituted Substandard Quality of Care (SQC). The IJ and SQC were related to 42 CFR 483.25 - Accidents (F689). On [DATE] at 9:00 AM, the facility presented a copy of their Corrective Action Plan dated [DATE]. On [DATE] at 4:02 PM, the survey team validated that the facility removed the IJ as of [DATE], before the survey entrance. IJ at F689, severity J, cited as Past Non-compliance. Findings include: Review of R1's electronic face sheet located in the face sheet tab revealed R1 was admitted to the facility on [DATE] and had a readmitted [DATE] with diagnoses including cerebral infarction, dysphagia following cerebral infarction (History of) and unspecified convulsions. Review of the resident's electronic physician's orders located on the orders tab revealed R1 had an order for honey thickened liquids, at risk for swallowing/choking, assist with feeding, pureed meals, and Speech Therapy (ST) to evaluate and treat for dysphagia. Review of the electronic annual Minimum Data Set (MDS) located under the MDS tab dated [DATE] revealed R1 has a BIMS score of 2 out of 15, which indicated the R1 was severely impaired, required supervision/one person assist while eating, and no speech therapy triggered at this time. The electronic Care Plan located under the care plan tab dated [DATE] identified R1 as having episodes of insomnia as manifested by not sleeping well at night, unable to stay asleep, and is at risk for alteration in nutrition related to dementia, weight loss, dysphagia with modified texture diet speech therapy related to dysphagia as needed. Review of the Incident Report, dated [DATE], revealed, R1 was identified by Licensed Practical Nurse (LPN)1 in his room in his wheelchair appearing to be asleep. LPN1 identified R1 was unresponsive and immediately called a code blue upon confirming R1's code status. LPN1 identified R1 to have pieces of a pimento cheese sandwich in his mouth when CPR was initiated. R1 was on a pureed diet with nectar thick liquids and was severely, cognitively impaired, and not capable of making safe decisions. During an interview on [DATE] at 12:14 PM, the Administrator stated that on [DATE] at 3:25 AM, a Certified Nurse Aide (CNA)1 on 200 hall saw R1 at the nurses' station sitting in his wheelchair and then observed R1 propel himself to his room. The Administrator stated that on [DATE] at 3:42 AM, LPN1 was walking down the hall and passed the resident's room and noticed the resident appeared to be asleep sitting up in his wheelchair. LPN1 entered the room and tried to wake R1, so that he could be transferred to the bed to rest. LPN1 noticed that R1 didn't respond. LPN1 determined that R1's skin was warm to touch, body movements were flaccid and no signs of a struggle. The Administrator stated that LPN1 realized that the resident didn't respond to physical stimulation and was unresponsive. LPN1 verified the resident's code status, by reviewing R1's face sheet, and initiated a code blue. CNA1 called 911. LPN2 came from the 300 hall to assist LPN1 with the code blue. The Administrator stated LPN1 identified R1's mouth was opened while initiating CPR, and observed a piece of a pimento cheese sandwich in R1's mouth. LPN1 removed the sandwich and CPR was initiated until EMS arrived. EMS arrived on [DATE] around 3:54 AM and EMS took over the code and called the time of death at 4 AM on [DATE]. Continued interview with the Administrator revealed the nurse stated the resident somehow got the half pimento cheese sandwich from the snack cart for bedtime. Some of the sandwich was found behind R1 in his wheelchair. During an interview on [DATE] at 1:01 PM, LPN1 confirmed being the nurse on the 200 unit for the night and that she saw R1 around the nurses' station on [DATE] around 2:50 AM asking for more food. LPN1 confirmed R1 was on a pureed diet with nectar thick liquids. She stated she gave R1 the apple sauce off the snack cart. LPN1 stated she was getting ready to go to a different nurses' station when she went down the hall around 3:40 AM. LPN1 noticed R1 was in his wheelchair and appeared to be asleep. LPN1 stated his body was limp, skin was warm to touch, and body was flaccid. LPN1 checked his pulse on his wrist and neck and checked the resident for breathing. LPN1 stated she ran to the nurses' station to identify resident's code status and immediately called the LPN2 on unit 3 for assistance. LPN1 stated she got the crash cart and went to R1's room around 3:43 AM. LPN1 alerted the CNAs of the code blue being performed on the resident. LPN1 stated she and CNA1 were able to get the resident on the bed to perform CPR. There was another CNA who called 911 around 3:45 AM and told 911 it appeared that resident had probably aspirated. LPN1 stated she removed the sandwich from the resident's mouth. She confirmed she started doing compressions and suctioned food from the resident's mouth. LPN1 stated EMS arrived around 3:55 AM and took over CPR. The EMS connected R1 to an AED (Automated external defibrillator) and called R1's time of death around 3:58 AM. LPN1 stated she typically keeps snacks behind the nurse's station. She stated one of the CNAs blocked off the nurse's station to keep the resident from going to the snacks. She stated one of the CNAs later indicated the item used to block the nurse's station was pushed back and it appeared someone had moved it. LPN1 stated she doesn't particularly know where R1 got the sandwich. LPN 1 indicated R1 would ask for snacks, and this is why they would block the nurse's station at night. During an interview on [DATE] at 1:37 PM, CNA1 stated she was working with another CNA. CNA1 confirmed that she did not feed R1 any food or snacks. CNA1 stated that she was unaware of R1's diet. CNA1 stated she saw him by the nurses' station around 2:30 AM, completed rounds around 3:25 AM and later observed LPN1 running with the crash cart to R1's room. CNA1 stated she saw the resident in his wheelchair with head back and mouth open. She stated she called 911 immediately. EMS arrived and called R1's time of death. During an interview on [DATE] at 2:44 PM, the Director of Speech (DOS) stated that R1 was on speech therapy's caseload from [DATE] - [DATE]. She stated the resident was last screened [DATE] and there were no changes to R1's diet as it was already pureed with nectar thick liquids and was still appropriate at the time of screening. During an interview on [DATE] at 5:36 PM, the Administrator stated the snack cart would be placed right near the nurse's station with bedtime snacks. The snacks are labeled and dated. The Administrator stated that CNA1 indicated the snacks were placed on the cart during the ice pass and she forgot to remove the snacks after completing the ice pass. The Administrator stated during that time of the night the snacks should be placed behind the nurse's station. During an interview on [DATE] at 5:44 PM, the DON confirmed there are other residents who are on a pureed diet, but they do not take food. During an interview on [DATE] at 5:48 PM, the Dietary Manager (DM) confirmed the bedtime snacks consisted of half sandwiches peanut butter and jelly, egg salad sandwiches and pimento cheese. Other snacks include pudding cups, applesauce, and fruit cups. She stated there are 18 residents who have a physician's order for pureed diet and snacks provided for the puree residents are pudding cups, puree fruit (available upon request), and apple sauce. During an interview on [DATE] at 5:51 PM, CNA2 stated she has been educated on resident's diet. She stated the snacks were kept behind the nurse's station after being passed out to residents. She stated the residents have meal cards to identify the resident's diet and if there are no meal cards available, she will refer to the nurse for the resident's diet. During an interview on [DATE] at 5:57 PM, Registered Nurse (RN1) stated the resident's diet is listed on the diet sheet and on the 24-hour report. She stated the snacks are kept behind the nurse's station or in the medication room. She stated the snacks are passed out by the direct care staff and leftovers are placed behind the nurse's desk or in the medication room. She stated that R1 would always let staff know when he wanted a snack. She stated the resident would always have a snack off of the snack cart which included pudding, applesauce, or jello. She stated the resident was supervised each time for feeding including meals. She was educated after the incident, on placing the snacks in the medication room and reviewing resident's diet before providing the resident a snack. During an additional interview on [DATE] at 6:06 PM, the Administrator stated during the investigation process for R1, residents who were identified as wanders, diet was compared, and behaviors were reviewed. The facility determined that there are no current residents at risk for wandering and consuming food not appropriate to their diet. The Administrator indicated that all staff have been trained to store the snack cart in the medication room. The facility's Corrective Action Plan dated [DATE] included the following: Summary of Incident: On [DATE], R1 was identified to have a pimento cheese sandwich in his mouth when CPR was initiated. R1 was on a pureed diet with nectar thick liquids. R1 was severely, cognitively impaired, and was not capable of making safe decisions. Immediate Action: On [DATE], the DON immediately implemented education on not leaving snack carts unattended, placing all snacks in the nourishment room, and monitoring all residents during mealtimes, snack times and activities including food/drink items. On [DATE], the DON investigated and conducted a root cause analysis of the incident. The investigation revealed R 1 was identified to be warm to touch flaccid with no bluish discoloration around mouth or gums on initial encounter. CNAs interviews with the DON established R1 was able to retrieve the pimento cheese sandwich from the snack cart and the nurses confirmed sandwich bag underneath resident when R1 was transferred from the wheelchair. Identification of others: Between [DATE] to [DATE], similar residents were assessed and were confirmed to not be at risk for wandering and retrieving food items. No other residents were affected by the deficient practice. Action taken: Interview on [DATE] at 10:57 AM, LPN2 confirmed being educated on Monday, [DATE] about monitoring all resident with meals, and when snacks are brought out to lock up all snacks, no drinks are allowed at the nurse's station, personal items and staff was also educated on reviewing resident's diet or meal ticket prior assisting residents with snacks or meals. Interview on [DATE] at 11:22 AM, RN2 confirmed being educated on supervising meals, any snack drinks etc. must be placed away so that it's not in the resident's reach. Educated on Monday morning, [DATE]. Interview on [DATE] at 11:24 AM, the CNA/payroll and staffing confirmed when snacks come to the hall, all snacks need to be placed in a locked room. All residents are to be supervised during snack and mealtimes. Educated on identifying the resident diet order by looking at the meal ticket before assisting with meals. Interview on [DATE] at 11:45 AM, Dietary1 stated anyone with minced/pureed diets, snacks must be put away, so no residents have access to the snacks. The dietary hands the snacks to the nurses and the nurses are to place the snacks in the medication room and lock the door. Interview on [DATE] at 11:49 AM, CNA3 stated that all residents are to be supervised; snacks are to be kept in a locked room. Educated on learning the resident's diet and verifying diet prior to meal, snacks, or activities. When meals or any food is out staff is to remain in visible sight of residents especially residents with altered diets to ensure safety. Nursing and dietary staff will continue to check placement of snacks to be safely secured and all meals and activities involving meals to be monitored by staff. Documentation was reviewed and verified during the survey. There was Quality Assurance and Performance Improvement a (QAPI) meeting held on [DATE] at 10:00 AM. The facility will continue to review residents at risk for choking accident hazards and revise the Corrective Action Plan as needed.

Based on state reported incident report review, clinical record review, facility policy review and staff interview, the facility failed to provide basic life support including cardiopulmonary resuscitation (CPR) to a resident who elected to be designated as full code. The facility did not follow physician's orders [REDACTED].#1). Closed record review revealed Resident #1 had a full code status and the failure to follow physician's orders [REDACTED]. The facility immediately implemented corrective actions and removed the noncompliance by [DATE]. The findings include: Review of the facility's policy titled,CPR Guidance During the COVID-19 Pandemic, ([DATE]) was conducted. The policy noted: Please also consider each patient's goals of care, long before the need for CPR might arise. Early discussion of advance directives, as well as code status, can help ensure that resident's goals are met, without creating unnecessary risk and exposure to staff during CPR. Review of the facility's policy titled, Cardiopulmonary Resuscitation, Emergency Code Blue, ([DATE]; revised [DATE]) was conducted. The Procedures section of the policy noted: Follow practice guidelines for CPR by initiating Resuscitation with and without Automatic External Defibrillator (AED), as appropriate, etc. in accordance with patient/resident Advance Directives. The Procedures section of the policy also noted: Call 911 for emergency transfer to an acute care center, unless the patient/resident is coding, and staff has determined that the patient/resident is a DNR (Do Not Resuscitate).; Continue CPR efforts as appropriate, etc. in accordance with patient/resident Advance Directives, until advanced rescue team arrives or until spontaneous respirations, pulse and blood pressure return. Review of Resident #1's closed record revealed an admission date of [DATE] and a discharge date of [DATE]. The resident was admitted with [DIAGNOSES REDACTED]. Further record review revealed that the resident expired in the facility on [DATE]. Review of Resident #1's record revealed the physician's orders [REDACTED]. Further review of the resident record revealed that the resident's chart included an insert indicating that the resident was a full code. Review of the resident's Admission Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment for determining the resident's attention, orientation and ability to register and recall new information was conducted. The resident scored two (2) out of 15, indicating that the resident was severely cognitively impaired. The resident was coded as requiring extensive assistance with bed mobility and transfers. The resident was care planned on [DATE] for: Advanced Care Planning; Resident will be informed of his/her right to complete advanced directives to direct his/her medical care and make his/her values and treatment goals known. Resident's stated desires will be honored. The approaches included: Advanced directives of resident's choice completed and placed on medical record under advanced directive tab and Resident has completed the following advanced directives Full code. Review of the facility's Incident Report dated [DATE], revealed that on [DATE] at 6:35 a.m., Resident #1 expired in the facility following a brief period of illness. Later in the day, on [DATE], the Director of Nursing (DON) was alerted via telephone that the Registered Nurse (RN) #1 assigned to Resident #1, may not have responded to Resident #1's passing in accordance with her wishes and physician's orders [REDACTED]. At the time of the notification to the DON, RN #1 had already concluded her shift and was not present in the facility. The Incident Report indicated that all required agencies and parties, including RN #1's staffing agency, were notified of this allegation and an immediate investigation was initiated. The DON provided documentation that the following entities were notified of the incident: the Ombudsman, State of South Carolina Department of Health and Environmental Control (SCDHEC), Medical Director, Nurse Practitioner, Director of Nursing, Resident #1's family, the Coroner, local law enforcement and the State Board of Nursing. The conclusion of the facility's investigation identified CPR was not administered to Resident #1 whose current code status was listed based on physician's orders [REDACTED]. According to the Nurse's Note, dated [DATE] at 6:35 a.m., Resident appeared to take a small breath. Pulse radial and apical absent. DON notified per DON, notify coroner and Nurse Practitioner (NP). NP notified. An interview was conducted with the DON on [DATE] at approximately 1:16 p.m. An inquiry was made regarding the incident that occurred involving the death of Resident #1. The DON recalled that RN #1 contacted her by phone regarding Resident #1 expiring. An inquiry was made regarding the time that RN #1 contacted her. The DON stated that she couldn't recall the exact time but that it was soon after the incident occurred. The DON stated that she instructed RN #1 to contact the Coroner and family. An inquiry was made whether the DON asked RN #1 if s/he verified Resident #1's code status. The DON stated that s/he wasn't in the facility at the time of the incident and that s/he did not ask RN #1 about the code status. The DON stated that s/he was not aware that the resident was a full code. The DON stated that RN #1 should have checked the resident's status. The DON stated that s/he was contacted by the NP later that day and was informed that Resident #1 had full code status and RN #1 did not follow the protocol for full code. An interview was conducted with the Administrative staff on [DATE] at approximately 9:25 a.m. The staff, including the Interim Administrator and an assisting Administrator stated that they were not in the facility at the time of the incident involving Resident #1. The staff confirmed that RN #1 was not allowed back into the building and had not worked in the facility since the incident. The staff provided copies of the reportable information, current and revised policies, as well as all in-service training conducted for the staff to prevent reoccurrences. A review of the materials revealed that RN #1 was reported to the State licensing board and law enforcement was notified. An interview was conducted with the Medical Director on [DATE] at 10:43 a.m. The Medical Director confirmed that he was not present during the incident but was informed that Resident #1 was full code and did not receive the elected services. The Medical Director stated that he would expect a nurse to check the resident's status to prevent an incident of such nature to occur. An interview was conducted with the Interim Administrator on [DATE] at approximately 10:55 a.m. An inquiry was made regarding the identification of residents with full code status. The Interim Administrator stated that information for residents regarding code status was located in residents' charts and in a book in the nurse's station. The administrative staff added that all staff were in-serviced and all agency staff were required to take training prior to starting work in the facility to prevent future occurrences and the policies were updated to reflect the new training requirements.

Based on record review and interview, an incorrect method of providing mobility for Resident #7 resulted in injury for 1 of 3 reportable's reviewed for falls. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. The resident had a BIMS (Brief Interview for Mental Status) of 15 denoting ability to make own decisions. The Minimum Data Set (MDS) documented that this resident was a total care resident needing total lift with 2 person assist for mobility and transfers. The Physicians Order read: 2 Certified Nursing Assistant (CNA) Hoyer Lift. On 10/14/18 resident was seated in a gerichair. The CNA proceeded to try to transfer the resident from the gerichair to the bed by herself. While lifting resident in gerichair to place lift pad under the resident, the resident slipped and fell to the floor. The CNA later stated the resident slipped and resident was eased down to the floor. The resident stated in an interview on 12/20/18 at 8 AM that the (staff) dropped her. Licensed Practical Nurse (LPN) # 5 assessed the resident after the fall and in his/her opinion did not see any injury. The Physician was notified and stated, Let the Nurse Practitioner (NP) check the resident in the morning. The resident asked to go to the hospital. The resident continued to complain and asked for his/her leg to be X-rayed. The Nurse told the resident s/he could not call for an X-Ray. In a late entry on 10/16/18 at 1 AM clarification note, the Nurse told the resident s/he could not order an X-Ray without calling the doctor, but the resident could send himself/herself out. The Nurse told the resident to let his/her meds take effect and see the NP in the morning. The family called Emergency Medical Services (EMS) to do a welfare check. EMS came to facility and assessed the resident. EMS wanted to take him/her to the emergency room (ER), but the resident refused. They called a doctor at the ER to see what to do. Since the resident refused, the ER doctor advised them to leave him/her at the facility. There was no documentation of the NP checking the resident. The resident went to [MEDICAL TREATMENT] on 10/15/18 and was transferred to the hospital from there. A scan was done and the resident was found to have a fractured right ankle. The resident was treated and returned to the facility on [DATE] with a splint to the right foot and leg. Five CNA's were interviewed about care of residents with a fall risk and transfers. All of the CNA's knew to look in the resident profile in the kiosk for instructions on how to lift residents and the number of staff needed. The Physician was interviewed via telephone twice on 12/20/18. At 7:45 AM, the Physician could not remember anything about the incident, except the nurse did call him. About 8:15 AM, the Physician called back and made a statement corresponding to the information given by the facility related to the incident.

Based on observation, record review and interview, the facility failed to identify a risk of falling when turning in a geri-chair with 1 staff member for Resident #7 and failed to use a bed alarm as ordered for Resident #94 (2 of 4 reviewed for accidents/falls). The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. The resident had a BIMS (Brief Interview for Mental Status) of 15 denoting ability to make own decisions. The Minimum Data Set (MDS) documented that this resident was a total care resident needing total lift with 2 person assist for mobility and transfers. The Physicians Order read: 2 Certified Nursing Assistant (CNA) Hoyer Lift. On 10/14/18 resident was seated in a gerichair. The CNA proceeded to try to transfer the resident from the gerichair to the bed by herself. While lifting resident in gerichair to place lift pad under the resident, the resident slipped and fell to the floor. The CNA later stated the resident slipped and resident was eased down to the floor. The resident stated in an interview on 12/20/18 at 8 AM that the (staff) dropped her. Licensed Practical Nurse (LPN) # 5 assessed the resident after the fall and in his/her opinion did not see any injury. The Physician was notified and stated, Let the Nurse Practitioner (NP) check the resident in the morning. The resident asked to go to the hospital. The resident continued to complain and asked for his/her leg to be X-rayed. The Nurse told the resident s/he could not call for an X-Ray. In a late entry on 10/16/18 at 1 AM clarification note, the Nurse told the resident s/he could not order an X-Ray without calling the doctor, but the resident could send himself/herself out. The Nurse told the resident to let his/her meds take effect and see the NP in the morning. The family called Emergency Medical Services (EMS) to do a welfare check. EMS came to facility and assessed the resident. EMS wanted to take him/her to the emergency room (ER), but the resident refused. They called a doctor at the ER to see what to do. Since the resident refused, the ER doctor advised them to leave him/her at the facility. There was no documentation of the NP checking the resident. The resident went to [MEDICAL TREATMENT] on 10/15/18 and was transferred to the hospital from there. A scan was done and the resident was found to have a fractured right ankle. The resident was treated and returned to the facility on [DATE] with a splint to the right foot and leg. Five CNA's were interviewed about care of residents with a fall risk and transfers. All of the CNA's knew to look in the resident profile in the kiosk for instructions on how to lift residents and the number of staff needed. The Physician was interviewed via telephone twice on 12/20/18. At 7:45 AM, the Physician could not remember anything about the incident, except the nurse did call him. About 8:15 AM, the Physician called back and made a statement corresponding to the information given by the facility related to the incident. The facility admitted Resident #94 on 07/29/2014 with [DIAGNOSES REDACTED]. During the initial tour on Unit 200, Resident #94 was out of the room. A bed alarm box without batteries was noted on the roommates over table. The bed alarm sensor pad was noted on resident #94's bed and the cord for the box was under the bed. Further observations 12/16/18 at 12:30 PM revealed the alarm box remained on the roommates over table with no batteries. New batteries were applied and alarm was functioning at 4:00 PM when tested Record Review revealed that resident #94 had a Physicians Order for bed alarm to bed at all times with function and placement checked every shift. During an interview on 12/16/2018 at approximately 10:43 AM, CNA #1 confirmed that the box had no batteries and was not connected to the sensor pad cord. On 12/16/2018 at 3:50 PM, Registered Nurse #1 stated, I saw the last 2 days that the bed alarm was not in place and that is why I circled it on the treatment flowsheet.

Based on review of facility [MEDICATION NAME], record review, interviews and review of policies and procedures, the facility failed to provide written policies and procedures regarding the visitation rights of residents. There were no policies and procedures to determine the limitation or safety restrictions that the facility may need to place on such rights as clinically indicated. The facility reported an allegation of sexual abuse of Resident #1 by a visitor at the facility. The facility failed to prevent the abuse. One of 3 residents reviewed for abuse. The findings included. Resident #1 was reviewed for alleged sexual abuse following a facility reported incident received by the State Agency. Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE], indicated the resident's BI[CONDITION] (brief interview of mental status) score as 9. Review of the medical record revealed a facility form Addressing Decisional Capacity signed by one physician on [DATE] that stated, This patient DOES NOT meet all the criteria for decisional capacity, therefore is not able to make healthcare decisions for self. Furthermore, it is my opinion that due to the patient's medical condition(s), this lack of capacity is not likely to change in the immediate future. Review of the facility 5 Day Follow up investigation indicated that on [DATE] two Certified Nurse Aide (CNA) #1 and #2 entered the room of Resident #1. They asked what the visitor was doing. The visitor responded that they were okay. The visitor had shorts on with the front opened.penis was not exposed. The CNAs immediately got the nurse who questioned the visitor who identified himself and stated he had known the resident for a long time. The social worker questioned the visitor who stated the resident asked him to hump her. The resident stated the visitor was her man, but did not know his name. The social worker removed the visitor from the room and sat him at the nurses station to be supervised until authorities arrived. In a telephone interview with the surveyor on [DATE] at 11:40 AM Licensed Practical Nurse (LPN) #1 stated s/he was two doors down from Resident#1's room when two CNAs came to me running and stated, they are having sex. Running back that way (all of us) we burst in the room, pushing door open. The surveyor asked if the door was closed, LPN #1 responded, Yes. S/he stated that the CNAs pulled the door closed and ran toward her/him. The surveyor asked LPN #1 what s/he saw when s/he entered the room, her laying flat on bed, visitor sitting on side of bed with back to door, s/he was saying, 'I told you they don't like this here.' S/he moved from bed to the chair and was facing the staff. I was asking her/him if s/he was ok, s/he was confused. The visitor said we're ok. I asked him/her how s/he knew the resident? The visitor stated, 'We go way back, just friends. I knew her/him before s/he came here.' The resident said, 'That's my man'. S/he started trying to get up, s/he was undressed from waist down. LPN #1 stated that s/he told them s/he was going to call Resident #1's family. The visitor stated, 'ok to call family.' LPN #1 stated s/he stepped out in the hall to call the DON (director of nursing) and Administrator. The visitor was still in the room, left door open, CNAs might have stayed. I don't remember closing the door. The Social Worker came in just a few minutes and took over. S/he brought the visitor out of the room to the desk. LPN #1 stated that s/he had never seen the visitor and Resident #1 together before the incident. In a telephone interview with the surveyor on [DATE] at 10:05 AM Certified Nurse Aide (CNA) #1 was asked by the surveyor about the incident with Resident #1 that occurred on [DATE] while the CNA was working on Unit 3. CNA #1 stated s/he was the first person to find Resident #1 and the visitor between 1:30 and 2:00 PM. I was assigned both residents in the room. Resident #1's roommate was outside in smoking area. S/he stated s/he saw the visitor on top of Resident #1, with pants open. S/he was moving and had hands down in private area. CNA #1 asked the visitor what was going on and the visitor responded, 'we good.' I said no you're not and called the nurse. When asked by the surveyor what s/he did CNA #1 stated that s/he pulled the door up and stepped out and called LPN #1 who was two doors away. When LPN #1 was coming toward me, I opened the door and the visitor was getting back on bed. CNA #2 and LPN #1 were behind me when I opened the door. We went in, CNA #2 didn't. CNA #1 stated s/he stood outside the door with it cracked and watched the visitor, standing on the side of the bed. The social worker came in a few minutes. When asked by the surveyor what the visitor was wearing, CNA #1 stated blue jean shorts. In a telephone interview with the surveyor on [DATE] at 9:15 AM the Social Worker was read a facility obtained statement and s/he confirmed s/he had given the information to the facility. The Social Worker confirmed s/he entered Resident #1's room and the visitor was in the room, with clothes up. The visitor was in bed beside the resident, hand under the blanket holding the resident's hand. The Social Worker stated the staff was at the door when s/he arrived, the door was closed, we knocked'. No one was in the room just the two of them. When asked by the surveyor what was the time, the Social Worker stated about 2:10 PM. The Social Worker stated s/he directed the visitor to the nurses station and two staff stayed with the visitor until the police arrived, at that time the visitor was taken to the facility business office, about 2:30 PM. The Social Worker stated that when s/he first arrived on Unit 3, after asking the visitor to come out of the room, s/he directed the nurse to do a body audit. S/he stated that s/he attempted to call the Director of Nursing and the Administrator, s/he spoke with the corporate clinical nurse. S/he asked one of the nurses to call the Sheriffs Department. S/he stated the resident was unable to tell what occurred and was rambling about stuff that was not related to the questions asked. In a face-to-face interview with the surveyor on [DATE] at 3:00 PM the Social Work Assistant stated that s/he entered the room with the Social Worker and that two CNAs were standing outside the door. The door was closed, knocked and went in. The visitor was lying on the bed with the resident, the Social Worker told the visitor to get up and s/he took him/her out of the room. The Social Work Assistant stated that s/he stayed in the room with Resident #1 several minutes, during the time s/he was in the room the resident just mumbled. I walked out of the room and stayed with the visitor until we took him/her to the business office/reception area. Two CNAs watched the visitor until the police arrived. I walked back to Unit 3 and the resident was on the stretcher to go out. I asked her/him if s/he was alright. S/he said, 'Yes baby'. The Social Work Assistant stated that the visitor's aunt had been in the facility for sometime and the s/he had never received any complaints about him/her. Review of the Daily Skilled Nurse's Note dated [DATE] stated, Around 2 PM a male visitor was reported to be in res. (resident) room. Nurse went in to res. room and observed male on bed side stating, 'I told you they don't like you doing this in here'. Res. asked nurse, 'So ya'll don't let people do this in your restaurant?' Nurse observed res. undressed from waist down, visitor moved to sit in chair beside bed and states, it's ok, we been knowing each other for a long time before she came in here. CNAs at room with nurse res. states she is ok. 2:15 PM Nurse starts attempting to call management. 2:20 PM Soc. Svc. (social service) came to floor removed visitor to sit at nurse station while continuing to call management. 2:30 PM visitor taken to front office to wait for management and police dept. (department) to arrive. 3 PM staff continues to monitor res. call placed to MD (medical doctor), order given to send to ER (emergency room ) for eval. (evaluation). RP (responsible party) number one called multiple times. Party denies knowing res. but agrees number is correct. Between 3:30 and 4 PM statement given to police dept. res. leaving for ER with clothing and bedding in use sent with res. Attempt to call RP #2 spoke with at around 7:50 PM after several attempts. RP states s/he is in route to [STATE] to see mother when attempt to inform RP s/he states hospital had called and informed him/her of what happened. RP was told visitor stated s/he had been her/his friend for a long time before s/he came here. RP states that is not true 'My mother knows no one in the area'. RP then states 'the hospital is calling me and I need to answer it, thank you.' and hangs up the phone. Late entry - body audit completed at 220 PM no areas of concern were noted. Review of the Medical Record revealed a Physician order [REDACTED]. Further review revealed a SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated [DATE] that showed the physician was notified and the Res (resident) sent to ER (emergency room ) for rape test kit to be performed. And to eval (evaluate) for further tx (treatment) as needed. In a face to face interview with the surveyor on [DATE] at approximately 10:50 AM the Director of Nursing (DON) stated they have a sign in/out log that people sign and that the doors are locked from 4:00 PM until 8:00 AM Monday-Friday and at all times on the weekend. Visitors have to ring the door bell to gain access to the facility during times when the doors are locked. The surveyor asked the DON if s/he had seen the visitor at the facility before, s/he stated that s/he had seen him/her generally visiting with Resident C. Sometimes s/he would sit with Resident C for haircut, thought s/he was a son. The surveyor asked if the DON noticed any impairment of the visitor, s/he stated the only thing s/he noticed was a cigarette smoke odor. In a face to face interview with the Administrator on [DATE] s/he stated they did not have a policy and procedure regarding the visitation rights of residents. When asked how they determined who visited resident with cognitive impairments the Administrator said they do not have a policy and procedure. S/he provided an Access and Visitation Rights from the facility Admission Packet that stated, Each resident has the right to receive visitors of his/her choosing and designation (including but not limited to a spouse of the same or opposite sex, domestic partner (of the same or opposite sex), another family member or friend, subject to the resident's right to deny visitation when applicable. The facility must provide access to any resident by (1) any representative of the Secretary, (2) Any representative of the State. (3) Any representative of the Office of the State long term care ombudsman. (4) the resident's individual physician. (5) any representative of the protection and advocacy system (5) any representative of the agency responsible for the protection and advocacy system for individuals with a mental disorder, and (6) the resident representative. The facility must provide immediate access to a resident by immediate family and other relatives, and reasonable access by any entity or individual that provides health, social, legal or other services to the resident, all of which are subject to the resident's right to deny or withdraw consent at any time. In a face to face interview with the surveyor on [DATE] at 12:00 PM Resident #2 stated s/he kind of knew the visitor and had no problems with him/her. In a face to face interview with the surveyor on [DATE] at 12:10 PM Licensed Practical Nurse (LPN) #2 stated the visitor, visited with other residents in the facility, s/he stated s/he worked Monday-Friday on the first shift and the visitor was at the facility. When asked by the surveyor if s/he had seen the visitor with Resident #1, s/he stated s/he would push her/him from the dining room to her/his room or sit in the dining room with her/him. Never saw him/her go in his/her room. In a face to face interview with the surveyor on [DATE] at 1:20 PM Certified Nurse Aide (CNA) #3 stated s/he saw the visitor once or twice sitting in the dining room, s/he noted nothing alarming. S/he stated the visitor visited with everybody. S/he stated Resident #1 did most of her/his ADLs (activities of daily living) by her/himself. In a face to face interview with the surveyor on [DATE] at 9:35 AM the Activities Assistant stated that the visitor first started coming to the facility when his/her aunt was a resident and that after the resident died s/he continued to visit other residents, s/he would bring residents to the dining room. S/he was in here often, outside with the men residents. Resident C and the visitor are outside a lot. When asked by the surveyor if there was anything unusual about his/her visits s/he stated that about a year ago s/he was speaking harshly to his/her aunt and the Administrator explained to him/her s/he couldn't speak that way. About a week ago there was a problem with a resident and chicken wings that the visitor had bought for her/him. When the visitor saw me s/he went the other way. In a face to face interview with the surveyor on [DATE] at 10:40 AM LPN #3 related an incident several months ago with a resident who expired in [DATE]; the visitor came down the hallway and the resident was at the nurses station, s/he said get away from me. LPN #3 stated s/he told the visitor to leave the resident alone. The visitor replied, Mind your own business. LPN #3 responded to the visitor that s/he was going to tell the Administrator and that s/he did. LPN #3 stated s/he never bother the resident again. In a face to face interview with the surveyor on [DATE] at 1:10 PM Resident C stated that s/he met the visitor at the facility and that s/he had an aunt who had passed away (2017) at the facility. Resident C stated the visitor offered to go to the store for him/her and that little by little other residents would ask him/her to go to the store for them. Resident C stated s/he believed in tipping, the visitor would always bring the change back, never had any problems with him/her. Review of the facility visitor's log for [DATE] indicated the visitor did not sign in on the log. In a telephone interview with the surveyor on [DATE] at 11:30 AM Resident #1's physician confirmed that the resident lacked decisional capacity. I doubt very seriously s/he could consent to sex. In a telephone interview with the surveyor on [DATE] at 1:05 PM the Investigator with the Sheriffs Department stated that the alleged perpetrator had been charged with Criminal Sexual Conduct 3rd. Degree and was in jail. It was determined on [DATE] at approximately 11:55 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of [DATE] related to complaint SC 949 in the following areas. The Administrator was notified of this determination at 12:15 PM. The deficiencies involved were as follows: 4[AGE].10(f)(4) Right to Receive/deny Visitors, F0563 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to have a written policy to address visitors. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12 Freedom from Abuse, F0[AGE]0 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to ensure each resident remained free from abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12(b) Develop/Implement Abuse/Neglect Policies, F0[AGE]7 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to implement written policies and procedures that prohibit and prevent abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. The facility staff failed to protect the resident, by removing the alleged abuser from the resident care area. One of 3 residents reviewed for abuse. 4[AGE].70 Administration, F0[AGE]5 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to be administered in a manner that enables it to use resources effectively and efficiently to attain or maintain the highest practicable physical , mental, and psychosocial well-being of each resident. Resident #1 was allegedly abused sexually by a visitor at the facility The facility provided an acceptable Allegation of Compliance (AOC) Resident #1 was assessed by a licensed nurse, the physician was notified and an order was received and resident was transported to the hospital and no longer resides in the facility. Residents who reside in the facility and were in contact with the identified visitor had the potential to be affected. The facility will interview all alert and oriented residents and complete body audits on all non-alert and oriented resident to observe for any signs of abuse. Staff were interviewed by the Administrator, Director of Nursing and nursing managers on [DATE] to determine which residents the identified visitor had interaction with and if it was in or out of the resident's room. Alert and oriented residents were interviewed by the Administrator, Director of Nursing and nursing managers to determine if any unwanted touching occurred or any witness to others. Residents with a BIM score of 12 or less were assessed by a registered nurse and no other concerns were identified. These assessments were completed on [DATE]. Interviews of all Alert and Oriented residents were completed by [DATE]. Those residents were educated to notify staff of any unusual or inappropriate behaviors or if they fell afraid or unsafe. All residents with a BIM score of 12 or less were assessed by a licensed nurse by [DATE]. No other concerns were identified. All residents in the facility will be educated by [DATE] on resident safety and notifying staff of any unusual or inappropriate behavior or if they feel threatened or afraid. On [DATE] a resident council meeting was held to discuss resident safety and to notify staff of any unusual or inappropriate behavior or if they feel threatened or afraid. Facility staff was educated by the Staff Development Coordinator, the Director of Nursing and the Administrator on the following: *Facility staff was re-educated on Abuse, Neglect, Misappropriation and Exploitation including preventing, recognizing, reporting abuse, neglect, exploitation, and mistreatment and protecting the residents. *The identification of residents who should not have visitors without notification of Responsible Party. *Notation will be made in Medication Administration Record [REDACTED]. *Social Service Director will identify and maintain a list of residents with cognitive impairments. Cognitive impairment will be determined by either an incapacitation order by a court of law or a lack of decisional capacity by two physicians. *Visitor sign in log process - any visitor entering facility will sign in on log which includes the visitor name, the date, the resident being visited and relationship and will be given a visitor sticker. Visitors will sign out upon exit from the facility. From 4 PM to 8 AM and on weekends the doors are locked, visitors will ring the doorbell and staff member answering door will have visitor sign log and issue a visitor sticker. The re-education will be completed by [DATE]. Any staff member not receiving this education by this date will receive prior to next scheduled shift. This information will be presented in New Hire Orientation. A visitor sign in log and the process of issuing a visitor sticker will be implemented by [DATE]. Letters regarding the visitor sign in log and notification of anything suspicious to charge nurse will be mailed out on [DATE] by the Administrator. CNA (certified nurse aide) #1 and #2 who were agency CNAs have not been back to the facility to work since the incident. The staffing agency will be notified on [DATE] to no longer send them to the facility. The facility will report the two CNAs to DHEC as a possible abuse incident. LPN (licensed practical nurse) #1 will receive corrective action failing to ensure the resident's safety on [DATE]. This LPN will be reported to SC LLR on [DATE]. An ad hoc Quality Assurance Performance Improvement Committee Meeting was held on [DATE] and Medical Director was informed the immediate jeopardy and the content of this plan. Allegation of Compliance (AOC) [DATE] Observations, interviews, and review of the Allegation of Compliance (AOC) submitted by the facility on [DATE] revealed the implementation of the AOC and that it was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the new visitors procedure, abuse policy and the importance of protecting the residents. The Administrator was informed of this on [DATE] at approximately 3:30 PM. The Immediate Jeopardy at F0563, F0[AGE]0 and F0[AGE]7 was removed but the citations remained at a lower scope and severity of D.

Based on review of a facility reportable, record review, interviews and the Leadership Policies and Procedures (Abuse, Neglect, and Misappropriation of Property), the facility failed to implement written policies and procedures that prohibit and prevent abuse. The facility reported an allegation of sexual abuse of Resident #1 by a visitor at the facility. The facility staff failed to protect the resident, by removing the alleged abuser from the resident care area. One of 3 residents reviewed for abuse. The findings included. Resident #1 was reviewed for alleged sexual abuse following a facility reported incident received by the State Agency. Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE], indicated the resident's BI[CONDITION] (brief interview of mental status) score as 9. Review of the medical record revealed a facility form Addressing Decisional Capacity signed by one physician on 09/04/2018 that stated, This patient DOES NOT meet all the criteria for decisional capacity, therefore is not able to make healthcare decisions for self. Furthermore, it is my opinion that due to the patient's medical condition(s), this lack of capacity is not likely to change in the immediate future. Review of the facility 5 Day Follow up investigation indicated that on 09/08/2018 two Certified Nurse Aide (CNA) #1 and #2 entered the room of Resident #1. They asked what the perpetrator was doing. The perpetrator responded that they were okay. The perpetrator had shorts on with the front opened.penis was not exposed. The CNAs immediately got the nurse who questioned the visitor who identified himself and stated he had known the resident for a long time. The social worker questioned the visitor who stated the resident asked him to hump her. The resident stated the visitor was her man, but did not know his name. The social worker removed the visitor from the room and sat him at the nurses station to be supervised until authorities arrived. In a telephone interview with the surveyor on 09/12/2018 at 11:40 AM Licensed Practical Nurse (LPN) #1 stated s/he was two doors down from Resident#1's room when two CNAs came to me running and stated, they are having sex. Running back that way (all of us) we burst in the room, pushing door open. The surveyor asked if the door was closed, LPN #1 responded, Yes. S/he stated that the CNAs pulled the door closed and ran toward her/him. The surveyor asked LPN #1 what s/he saw when s/he entered the room, her laying flat on bed, visitor sitting on side of bed with back to door, s/he was saying, 'I told you they don't like this here.' S/he moved from bed to the chair and was facing the staff. I was asking her/him if s/he was ok, s/he was confused. The visitor said we're ok. I asked him/her how s/he knew the resident? The visitor stated, 'We go way back, just friends. I knew her/him before s/he came here.' The resident said, 'That's my man'. S/he started trying to get up, s/he was undressed from waist down. LPN #1 stated that s/he told them s/he was going to call Resident #1's family. The visitor stated, 'ok to call family.' LPN #1 stated s/he stepped out in the hall to call the DON (director of nursing) and Administrator. The visitor was still in the room, left door open, CNAs might have stayed. I don't remember closing the door. The Social Worker came in just a few minutes and took over. S/he brought the visitor out of the room to the desk. LPN #1 stated that s/he had never seen the visitor and Resident #1 together before the incident. In a telephone interview with the surveyor on 09/12/2018 at 10:05 AM Certified Nurse Aide (CNA) #1 was asked by the surveyor about the incident with Resident #1 that occurred on 09/08/2018 while the CNA was working on Unit 3. CNA #1 stated s/he was the first person to find Resident #1 and the visitor between 1:30 and 2:00 PM. I was assigned both residents in the room. Resident #1's roommate was outside in smoking area. S/he stated s/he saw the visitor on top of Resident #1, with pants open. S/he was moving and had hands down in private area. CNA #1 asked the visitor what was going on and the visitor responded, 'we good.' I said no you're not and called the nurse. When asked by the surveyor what s/he did CNA #1 stated that s/he pulled the door up and stepped out and called LPN #1 who was two doors away. When LPN #1 was coming toward me, I opened the door and the visitor was getting back on bed. CNA #2 and LPN #1 were behind me when I opened the door. We went in, CNA #2 didn't. CNA #1 stated s/he stood outside the door with it cracked and watched the visitor, standing on the side of the bed. The social worker came in a few minutes. When asked by the surveyor what the visitor was wearing, CNA #1 stated blue jean shorts. In a telephone interview with the surveyor on 09/12/2018 at 9:15 AM the Social Worker was read a facility obtained statement and s/he confirmed s/he had given the information to the facility. The Social Worker confirmed s/he entered Resident #1's room and the visitor was in the room, with clothes up. The visitor was in bed beside the resident, hand under the blanket holding the resident's hand. The Social Worker stated the staff was at the door when s/he arrived, the door was closed, we knocked'. No one was in the room just the two of them. When asked by the surveyor what was the time, the Social Worker stated about 2:10 PM. The Social Worker stated s/he directed the visitor to the nurses station and two staff stayed with the visitor until the police arrived, at that time the visitor was taken to the facility business office, about 2:30 PM. The Social Worker stated that when s/he first arrived on Unit 3, after asking the visitor to come out of the room, s/he directed the nurse to do a body audit. S/he stated that s/he attempted to call the Director of Nursing and the Administrator, s/he spoke with the corporate clinical nurse. S/he asked one of the nurses to call the Sheriffs Department. S/he stated the resident was unable to tell what occurred and was rambling about stuff that was not related to the questions asked. Review of the Medical Record revealed a Physician order [REDACTED]. Further review revealed a SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 09/08/2018 that showed the physician was notified and the Res (resident) sent to ER (emergency room ) for rape test kit to be performed. And to eval (evaluate) for further tx (treatment) as needed. In a telephone interview with the surveyor on 09/12/2018 at 11:30 AM Resident #1's physician confirmed that the resident lacked decisional capacity. I doubt very seriously s/he could consent to sex. In a telephone interview with the surveyor on 09/18/2018 at 1:05 PM the Investigator with the Sheriffs Department stated that the alleged perpetrator had been charged with Criminal Sexual Conduct 3rd. Degree and was in jail. Review of the facility Leadership Policies and Procedures, Section III: Organizational Ethics, Subject: Abuse, Neglect, Exploitation, or Mistreatment; page 5.Component VII: Protection 1. During the investigation, the facility protects the patient/resident, as appropriate, including but not limited to the following: A. Removal of the alleged abuser from the patient/resident care setting. It was determined on September 12, 2018 at approximately 11:55 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of September 08, 2018 related to complaint SC 949 in the following areas. The Administrator was notified of this determination at 12:15 PM. The deficiencies involved were as follows: 4[AGE].10(f)(4) Right to Receive/deny Visitors, F0563 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to have a written policy to address visitors. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12 Freedom from Abuse, F0[AGE]0 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to ensure each resident remained free from abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12(b) Develop/Implement Abuse/Neglect Policies, F0[AGE]7 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to implement written policies and procedures that prohibit and prevent abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. The facility staff failed to protect the resident, by removing the alleged abuser from the resident care area. One of 3 residents reviewed for abuse. 4[AGE].70 Administration, F0[AGE]5 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to be administered in a manner that enables it to use resources effectively and efficiently to attain or maintain the highest practicable physical , mental, and psychosocial well-being of each resident. Resident #1 was allegedly abused sexually by a visitor at the facility The facility provided an acceptable Allegation of Compliance (AOC) Resident #1 was assessed by a licensed nurse, the physician was notified and an order was received and resident was transported to the hospital and no longer resides in the facility. Residents who reside in the facility and were in contact with the identified visitor had the potential to be affected. The facility will interview all alert and oriented residents and complete body audits on all non-alert and oriented resident to observe for any signs of abuse. Staff were interviewed by the Administrator, Director of Nursing and nursing managers on 9/10/2018 to determine which residents the identified visitor had interaction with and if it was in or out of the resident's room. Alert and oriented residents were interviewed by the Administrator, Director of Nursing and nursing managers to determine if any unwanted touching occurred or any witness to others. Residents with a BIM score of 12 or less were assessed by a registered nurse and no other concerns were identified. These assessments were completed on 9/10/2018. Interviews of all Alert and Oriented residents were completed by 9/13/18. Those residents were educated to notify staff of any unusual or inappropriate behaviors or if they fell afraid or unsafe. All residents with a BIM score of 12 or less were assessed by a licensed nurse by 9/13/18. No other concerns were identified. All residents in the facility will be educated by 9/13/18 on resident safety and notifying staff of any unusual or inappropriate behavior or if they feel threatened or afraid. On 9/11/2018 a resident council meeting was held to discuss resident safety and to notify staff of any unusual or inappropriate behavior or if they feel threatened or afraid. Facility staff was educated by the Staff Development Coordinator, the Director of Nursing and the Administrator on the following: *Facility staff was re-educated on Abuse, Neglect, Misappropriation and Exploitation including preventing, recognizing, reporting abuse, neglect, exploitation, and mistreatment and protecting the residents. *The identification of residents who should not have visitors without notification of Responsible Party. *Notation will be made in Medication Administration Record [REDACTED]. *Social Service Director will identify and maintain a list of residents with cognitive impairments. Cognitive impairment will be determined by either an incapacitation order by a court of law or a lack of decisional capacity by two physicians. *Visitor sign in log process - any visitor entering facility will sign in on log which includes the visitor name, the date, the resident being visited and relationship and will be given a visitor sticker. Visitors will sign out upon exit from the facility. From 4 PM to 8 AM and on weekends the doors are locked, visitors will ring the doorbell and staff member answering door will have visitor sign log and issue a visitor sticker. The re-education will be completed by 9/13/18. Any staff member not receiving this education by this date will receive prior to next scheduled shift. This information will be presented in New Hire Orientation. A visitor sign in log and the process of issuing a visitor sticker will be implemented by 9/13/18. Letters regarding the visitor sign in log and notification of anything suspicious to charge nurse will be mailed out on 9/13/18 by the Administrator. CNA (certified nurse aide) #1 and #2 who were agency CNAs have not been back to the facility to work since the incident. The staffing agency will be notified on 9/13/19 to no longer send them to the facility. The facility will report the two CNAs to DHEC as a possible abuse incident. LPN (licensed practical nurse) #1 will receive corrective action failing to ensure the resident's safety on 9/13/18. This LPN will be reported to SC LLR on 9/13/18. An ad hoc Quality Assurance Performance Improvement Committee Meeting was held on [DATE] and Medical Director was informed the immediate jeopardy and the content of this plan. Allegation of Compliance (AOC) September 13, 2018 Observations, interviews, and review of the Allegation of Compliance (AOC) submitted by the facility on September 13, 2018 revealed the implementation of the AOC and that it was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the new visitors procedure, abuse policy and the importance of protecting the residents. The Administrator was informed of this on September 13, 2018 at approximately 3:30 PM. The Immediate Jeopardy at F0563, F0[AGE]0, F0[AGE]7 and F0[AGE]5 was removed but the citations remained at a lower scope and severity of D.

Based on review of a facility reportable, record review and interviews, the facility failed to ensure each resident remained free from abuse. The facility reported an allegation of sexual abuse of Resident #1 by a visitor at the facility. The facility failed to prevent the abuse. One of 3 residents reviewed for abuse. The findings included. Resident #1 was reviewed for alleged sexual abuse following a facility reported incident received by the State Agency. Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE], indicated the resident's BI[CONDITION] (brief interview of mental status) score as 9. S/he required assistance of one person with activities of daily living, setup help with eating; s/he used a wheelchair for long distance ambulation. S/he could walk short distances. The resident was occasionally incontinent of bladder and frequently incontinent of bowel. Further review of the medical record revealed a facility form Addressing Decisional Capacity signed by one physician on 09/04/2018 that stated, This patient DOES NOT meet all the criteria for decisional capacity, therefore is not able to make healthcare decisions for self. Furthermore, it is my opinion that due to the patient's medical condition(s), this lack of capacity is not likely to change in the immediate future. Review of the facility 5 Day Follow up investigation indicated that on 09/08/2018 two Certified Nurse Aide (CNA) #1 and #2 entered the room of Resident #1. They asked what the perpetrator was doing. The perpetrator responded that they were okay. The perpetrator had shorts on with the front opened.penis was not exposed. The CNAs immediately got the nurse who questioned the visitor who identified himself and stated he had known the resident for a long time. The social worker questioned the visitor who stated the resident asked him to hump her. The resident stated the visitor was her man, but did not know his name. The social worker removed the visitor from the room and sat him at the nurses station to be supervised until authorities arrived. In a telephone interview with the surveyor on 09/12/2018 at 11:40 AM Licensed Practical Nurse (LPN) #1 stated s/he was two doors down from Resident#1's room when two CNAs came to me running and stated, they are having sex. Running back that way (all of us) we burst in the room, pushing door open. The surveyor asked if the door was closed, LPN #1 responded, Yes. S/he stated that the CNAs pulled the door closed and ran toward her/him. The surveyor asked LPN #1 what s/he saw when s/he entered the room, her laying flat on bed, visitor sitting on side of bed with back to door, s/he was saying, 'I told you they don't like this here.' S/he moved from bed to the chair and was facing the staff. I was asking her/him if s/he was ok, s/he was confused. The visitor said we're ok. I asked him/her how s/he knew the resident? The visitor stated, 'We go way back, just friends. I knew her/him before s/he came here.' The resident said, 'That's my man'. S/he started trying to get up, s/he was undressed from waist down. LPN #1 stated that s/he told them s/he was going to call Resident #1's family. The visitor stated, 'ok to call family.' LPN #1 stated s/he stepped out in the hall to call the DON (director of nursing) and Administrator. The visitor was still in the room, left door open, CNAs might have stayed. I don't remember closing the door. The Social Worker came in just a few minutes and took over. S/he brought the visitor out of the room to the desk. LPN #1 stated that s/he had never seen the visitor and Resident #1 together before the incident. In a telephone interview with the surveyor on 09/12/2018 at 10:05 AM Certified Nurse Aide (CNA) #1 was asked by the surveyor about the incident with Resident #1 that occurred on 09/08/2018 while the CNA was working on Unit 3. CNA #1 stated s/he was the first person to find Resident #1 and the visitor between 1:30 and 2:00 PM. I was assigned both residents in the room. Resident #1's roommate was outside in smoking area. S/he stated s/he saw the visitor on top of Resident #1, with pants open. S/he was moving and had hands down in private area. CNA #1 asked the visitor what was going on and the visitor responded, 'we good.' I said no you're not and called the nurse. When asked by the surveyor what s/he did CNA #1 stated that s/he pulled the door up and stepped out and called LPN #1 who was two doors away. When LPN #1 was coming toward me, I opened the door and the visitor was getting back on bed. CNA #2 and LPN #1 were behind me when I opened the door. We went in, CNA #2 didn't. CNA #1 stated s/he stood outside the door with it cracked and watched the visitor, standing on the side of the bed. The social worker came in a few minutes. When asked by the surveyor what the visitor was wearing, CNA #1 stated blue jean shorts. In a telephone interview with the surveyor on 09/12/2018 at 9:15 AM the Social Worker was read a facility obtained statement and s/he confirmed s/he had given the information to the facility. The Social Worker confirmed s/he entered Resident #1's room and the visitor was in the room, with clothes up. The visitor was in bed beside the resident, hand under the blanket holding the resident's hand. The Social Worker stated the staff was at the door when s/he arrived, the door was closed, we knocked'. No one was in the room just the two of them. When asked by the surveyor what was the time, the Social Worker stated about 2:10 PM. The Social Worker stated s/he directed the visitor to the nurses station and two staff stayed with the visitor until the police arrived, at that time the visitor was taken to the facility business office, about 2:30 PM. The Social Worker stated that when s/he first arrived on Unit 3, after asking the visitor to come out of the room, s/he directed the nurse to do a body audit. S/he stated that s/he attempted to call the Director of Nursing and the Administrator, s/he spoke with the corporate clinical nurse. S/he asked one of the nurses to call the Sheriffs Department. S/he stated the resident was unable to tell what occurred and was rambling about stuff that was not related to the questions asked. In a face-to-face interview with the surveyor on 09/13/2018 at 3:00 PM the Social Work Assistant stated that s/he entered the room with the Social Worker and that two CNAs were standing outside the door. The door was closed, knocked and went in. The visitor was lying on the bed with the resident, the Social Worker told the visitor to get up and s/he took him/her out of the room. The Social Work Assistant stated that s/he stayed in the room with Resident #1 several minutes, during the time s/he was in the room the resident just mumbled. I walked out of the room and stayed with the visitor until we took him/her to the business office/reception area. Two CNAs watched the visitor until the police arrived. I walked back to Unit 3 and the resident was on the stretcher to go out. I asked her/him if s/he was alright. S/he said, 'Yes baby'. Review of the Daily Skilled Nurse's Note dated 09/08/18 stated, Around 2 PM a male visitor was reported to be in res. (resident) room. Nurse went in to res. room and observed male on bed side stating, 'I told you they don't like you doing this in here'. Res. asked nurse, 'So ya'll don't let people do this in your restaurant?' Nurse observed res. undressed from waist down, visitor moved to sit in chair beside bed and states, it's ok, we been knowing each other for a long time before she came in here. CNAs at room with nurse res. states she is ok. 2:15 PM Nurse starts attempting to call management. 2:20 PM Soc. Svc. (social service) came to floor removed visitor to sit at nurse station while continuing to call management. 2:30 PM visitor taken to front office to wait for management and police dept. (department) to arrive. 3 PM staff continues to monitor res. call placed to MD (medical doctor), order given to send to ER (emergency room ) for eval. (evaluation). RP (responsible party) number one called multiple times. Party denies knowing res. but agrees number is correct. Between 3:30 and 4 PM statement given to police dept. res. leaving for ER with clothing and bedding in use sent with res. Attempt to call RP #2 spoke with at around 7:50 PM after several attempts. RP states he is in route to [STATE] to see mother when attempt to inform RP he states hospital had called and informed him of what happened. RP was told visitor stated he had been her friend for a long time before she came here. RP states that is not true 'My mother knows no one in the area'. RP then states 'the hospital is calling me and I need to answer it, thank you.' and hangs up the phone. Late entry - body audit completed at 220 PM no areas of concern were noted. Review of the Medical Record revealed a Physician order [REDACTED]. Further review revealed a SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 09/08/2018 that showed the physician was notified and the Res (resident) sent to ER (emergency room ) for rape test kit to be performed. And to eval (evaluate) for further tx (treatment) as needed. In a face to face interview with the surveyor on 09/11/2018 at approximately 10:45 AM the Administrator stated that Resident #1 was no longer at the facility. S/he stated the resident was admitted to the hospital and s/he was not sure where s/he was right now, s/he stated the resident wasn't coming back. In a telephone interview with the surveyor on 09/12/2018 at 11:30 AM Resident #1's physician confirmed that the resident lacked decisional capacity. I doubt very seriously s/he could consent to sex. In a telephone interview with the surveyor on 09/18/2018 at 1:05 PM the Investigator with the Sheriffs Department stated that the alleged perpetrator had been charged with Criminal Sexual Conduct 3rd. Degree and was in jail. It was determined on September 12, 2018 at approximately 11:55 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of September 08, 2018 related to complaint SC 949 in the following areas. The Administrator was notified of this determination at 12:15 PM. The deficiencies involved were as follows: 4[AGE].10(f)(4) Right to Receive/deny Visitors, F0563 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to have a written policy to address visitors. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12 Freedom from Abuse, F0[AGE]0 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to ensure each resident remained free from abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12(b) Develop/Implement Abuse/Neglect Policies, F0[AGE]7 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to implement written policies and procedures that prohibit and prevent abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. The facility staff failed to protect the resident, by removing the alleged abuser from the resident care area. 4[AGE].70 Administration, F0[AGE]5 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to be administered in a manner that enables it to use resources effectively and efficiently to attain or maintain the highest practicable physical , mental, and psychosocial well-being of each resident. Resident #1 was allegedly abused sexually by a visitor at the facility The facility provided an acceptable Allegation of Compliance (AOC) Resident #1 was assessed by a licensed nurse, the physician was notified and an order was received and resident was transported to the hospital and no longer resides in the facility. Residents who reside in the facility and were in contact with the identified visitor had the potential to be affected. The facility will interview all alert and oriented residents and complete body audits on all non-alert and oriented resident to observe for any signs of abuse. Staff were interviewed by the Administrator, Director of Nursing and nursing managers on 9/10/2018 to determine which residents the identified visitor had interaction with and if it was in or out of the resident's room. Alert and oriented residents were interviewed by the Administrator, Director of Nursing and nursing managers to determine if any unwanted touching occurred or any witness to others. Residents with a BIM score of 12 or less were assessed by a registered nurse and no other concerns were identified. These assessments were completed on 9/10/2018. Interviews of all Alert and Oriented residents were completed by 9/13/18. Those residents were educated to notify staff of any unusual or inappropriate behaviors or if they fell afraid or unsafe. All residents with a BIM score of 12 or less were assessed by a licensed nurse by 9/13/18. No other concerns were identified. All residents in the facility will be educated by 9/13/18 on resident safety and notifying staff of any unusual or inappropriate behavior or if they feel threatened or afraid. On 9/11/2018 a resident council meeting was held to discuss resident safety and to notify staff of any unusual or inappropriate behavior or if they feel threatened or afraid. Facility staff was educated by the Staff Development Coordinator, the Director of Nursing and the Administrator on the following: *Facility staff was re-educated on Abuse, Neglect, Misappropriation and Exploitation including preventing, recognizing, reporting abuse, neglect, exploitation, and mistreatment and protecting the residents. *The identification of residents who should not have visitors without notification of Responsible Party. *Notation will be made in Medication Administration Record [REDACTED]. *Social Service Director will identify and maintain a list of residents with cognitive impairments. Cognitive impairment will be determined by either an incapacitation order by a court of law or a lack of decisional capacity by two physicians. *Visitor sign in log process - any visitor entering facility will sign in on log which includes the visitor name, the date, the resident being visited and relationship and will be given a visitor sticker. Visitors will sign out upon exit from the facility. From 4 PM to 8 AM and on weekends the doors are locked, visitors will ring the doorbell and staff member answering door will have visitor sign log and issue a visitor sticker. The re-education will be completed by 9/13/18. Any staff member not receiving this education by this date will receive prior to next scheduled shift. This information will be presented in New Hire Orientation. A visitor sign in log and the process of issuing a visitor sticker will be implemented by 9/13/18. Letters regarding the visitor sign in log and notification of anything suspicious to charge nurse will be mailed out on 9/13/18 by the Administrator. CNA (certified nurse aide) #1 and #2 who were agency CNAs have not been back to the facility to work since the incident. The staffing agency will be notified on 9/13/19 to no longer send them to the facility. The facility will report the two CNAs to DHEC as a possible abuse incident. LPN (licensed practical nurse) #1 will receive corrective action failing to ensure the resident's safety on 9/13/18. This LPN will be reported to SC LLR on 9/13/18. An ad hoc Quality Assurance Performance Improvement Committee Meeting was held on [DATE] and Medical Director was informed the immediate jeopardy and the content of this plan. Allegation of Compliance (AOC) September 13, 2018 Observations, interviews, and review of the Allegation of Compliance (AOC) submitted by the facility on September 13, 2018 revealed the implementation of the AOC and that it was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the new visitors procedure, abuse policy and the importance of protecting the residents. The Administrator was informed of this on September 13, 2018 at approximately 3:30 PM. The Immediate Jeopardy at F0563, F0[AGE]0, F0[AGE]7 and F0[AGE]5 was removed but the citations remained at a lower scope and severity of D.

Based on review of facility [MEDICATION NAME], record review, interviews and review of policies and procedures, the facility failed to be administered in a manner that enables it to use resources effectively and efficiently to attain or maintain the highest practicable physical , mental, and psychosocial well-being of each resident. Resident #1 was allegedly abused sexually by a visitor at the facility. The facility failed to prevent the abuse. One of 3 residents reviewed for abuse. The findings included. Resident #1 was reviewed for alleged sexual abuse following a facility reported incident received by the State Agency. Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE], indicated the resident's BI[CONDITION] (brief interview of mental status) score as 9. Review of the medical record revealed a facility form Addressing Decisional Capacity signed by one physician on [DATE] that stated, This patient DOES NOT meet all the criteria for decisional capacity, therefore is not able to make healthcare decisions for self. Furthermore, it is my opinion that due to the patient's medical condition(s), this lack of capacity is not likely to change in the immediate future. Review of the facility 5 Day Follow up investigation indicated that on [DATE] two Certified Nurse Aide (CNA) #1 and #2 entered the room of Resident #1. They asked what the visitor was doing. The visitor responded that they were okay. The visitor had shorts on with the front opened.penis was not exposed. The CNAs immediately got the nurse who questioned the visitor who identified himself and stated he had known the resident for a long time. The social worker questioned the visitor who stated the resident asked him to hump her. The resident stated the visitor was her man, but did not know his name. The social worker removed the visitor from the room and sat him at the nurses station to be supervised until authorities arrived. In a telephone interview with the surveyor on [DATE] at 11:40 AM Licensed Practical Nurse (LPN) #1 stated s/he was two doors down from Resident#1's room when two CNAs came to me running and stated, they are having sex. Running back that way (all of us) we burst in the room, pushing door open. The surveyor asked if the door was closed, LPN #1 responded, Yes. S/he stated that the CNAs pulled the door closed and ran toward her/him. The surveyor asked LPN #1 what s/he saw when s/he entered the room, her laying flat on bed, visitor sitting on side of bed with back to door, s/he was saying, 'I told you they don't like this here.' S/he moved from bed to the chair and was facing the staff. I was asking her/him if s/he was ok, s/he was confused. The visitor said we're ok. I asked him/her how s/he knew the resident? The visitor stated, 'We go way back, just friends. I knew her/him before s/he came here.' The resident said, 'That's my man'. S/he started trying to get up, s/he was undressed from waist down. LPN #1 stated that s/he told them s/he was going to call Resident #1's family. The visitor stated, 'ok to call family.' LPN #1 stated s/he stepped out in the hall to call the DON (director of nursing) and Administrator. The visitor was still in the room, left door open, CNAs might have stayed. I don't remember closing the door. The Social Worker came in just a few minutes and took over. S/he brought the visitor out of the room to the desk. LPN #1 stated that s/he had never seen the visitor and Resident #1 together before the incident. In a telephone interview with the surveyor on [DATE] at 10:05 AM Certified Nurse Aide (CNA) #1 was asked by the surveyor about the incident with Resident #1 that occurred on [DATE] while the CNA was working on Unit 3. CNA #1 stated s/he was the first person to find Resident #1 and the visitor between 1:30 and 2:00 PM. I was assigned both residents in the room. Resident #1's roommate was outside in smoking area. S/he stated s/he saw the visitor on top of Resident #1, with pants open. S/he was moving and had hands down in private area. CNA #1 asked the visitor what was going on and the visitor responded, 'we good.' I said no you're not and called the nurse. When asked by the surveyor what s/he did CNA #1 stated that s/he pulled the door up and stepped out and called LPN #1 who was two doors away. When LPN #1 was coming toward me, I opened the door and the visitor was getting back on bed. CNA #2 and LPN #1 were behind me when I opened the door. We went in, CNA #2 didn't. CNA #1 stated s/he stood outside the door with it cracked and watched the visitor, standing on the side of the bed. The social worker came in a few minutes. When asked by the surveyor what the visitor was wearing, CNA #1 stated blue jean shorts. In a telephone interview with the surveyor on [DATE] at 9:15 AM the Social Worker was read a facility obtained statement and s/he confirmed s/he had given the information to the facility. The Social Worker confirmed s/he entered Resident #1's room and the visitor was in the room, with clothes up. The visitor was in bed beside the resident, hand under the blanket holding the resident's hand. The Social Worker stated the staff was at the door when s/he arrived, the door was closed, we knocked'. No one was in the room just the two of them. When asked by the surveyor what was the time, the Social Worker stated about 2:10 PM. The Social Worker stated s/he directed the visitor to the nurses station and two staff stayed with the visitor until the police arrived, at that time the visitor was taken to the facility business office, about 2:30 PM. The Social Worker stated that when s/he first arrived on Unit 3, after asking the visitor to come out of the room, s/he directed the nurse to do a body audit. S/he stated that s/he attempted to call the Director of Nursing and the Administrator, s/he spoke with the corporate clinical nurse. S/he asked one of the nurses to call the Sheriffs Department. S/he stated the resident was unable to tell what occurred and was rambling about stuff that was not related to the questions asked. In a face-to-face interview with the surveyor on [DATE] at 3:00 PM the Social Work Assistant stated that s/he entered the room with the Social Worker and that two CNAs were standing outside the door. The door was closed, knocked and went in. The visitor was lying on the bed with the resident, the Social Worker told the visitor to get up and s/he took him/her out of the room. The Social Work Assistant stated that s/he stayed in the room with Resident #1 several minutes, during the time s/he was in the room the resident just mumbled. I walked out of the room and stayed with the visitor until we took him/her to the business office/reception area. Two CNAs watched the visitor until the police arrived. I walked back to Unit 3 and the resident was on the stretcher to go out. I asked her/him if s/he was alright. S/he said, 'Yes baby'. The Social Work Assistant stated that the visitor's aunt had been in the facility for sometime and the s/he had never received any complaints about him/her. Review of the Daily Skilled Nurse's Note dated [DATE] stated, Around 2 PM a male visitor was reported to be in res. (resident) room. Nurse went in to res. room and observed male on bed side stating, 'I told you they don't like you doing this in here'. Res. asked nurse, 'So ya'll don't let people do this in your restaurant?' Nurse observed res. undressed from waist down, visitor moved to sit in chair beside bed and states, it's ok, we been knowing each other for a long time before she came in here. CNAs at room with nurse res. states she is ok. 2:15 PM Nurse starts attempting to call management. 2:20 PM Soc. Svc. (social service) came to floor removed visitor to sit at nurse station while continuing to call management. 2:30 PM visitor taken to front office to wait for management and police dept. (department) to arrive. 3 PM staff continues to monitor res. call placed to MD (medical doctor), order given to send to ER (emergency room ) for eval. (evaluation). RP (responsible party) number one called multiple times. Party denies knowing res. but agrees number is correct. Between 3:30 and 4 PM statement given to police dept. res. leaving for ER with clothing and bedding in use sent with res. Attempt to call RP #2 spoke with at around 7:50 PM after several attempts. RP states s/he is in route to [STATE] to see mother when attempt to inform RP s/he states hospital had called and informed him/her of what happened. RP was told visitor stated s/he had been her/his friend for a long time before s/he came here. RP states that is not true 'My mother knows no one in the area'. RP then states 'the hospital is calling me and I need to answer it, thank you.' and hangs up the phone. Review of the Medical Record revealed a Physician order [REDACTED]. Further review revealed a SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated [DATE] that showed the physician was notified and the Res (resident) sent to ER (emergency room ) for rape test kit to be performed. And to eval (evaluate) for further tx (treatment) as needed. In a face to face interview with the surveyor on [DATE] at approximately 10:50 AM the Director of Nursing (DON) stated they have a sign in/out log that people sign and that the doors are locked from 4:00 PM until 8:00 AM Monday-Friday and at all times on the weekend. Visitors have to ring the door bell to gain access to the facility during times when the doors are locked. The surveyor asked the DON if s/he had seen the visitor at the facility before, s/he stated that s/he had seen him/her generally visiting with Resident C. Sometimes s/he would sit with Resident C for haircut, thought s/he was a son. The surveyor asked if the DON noticed any impairment of the visitor, s/he stated the only thing s/he noticed was a cigarette smoke odor. In a face to face interview with the Administrator on [DATE] s/he stated they did not have a policy and procedure regarding the visitation rights of residents. When asked how they determined who visited resident with cognitive impairments the Administrator said they do not have a policy and procedure. S/he provided an Access and Visitation Rights from the facility Admission Packet that stated, Each resident has the right to receive visitors of his/her choosing and designation (including but not limited to a spouse of the same or opposite sex, domestic partner (of the same or opposite sex), another family member or friend, subject to the resident's right to deny visitation when applicable. The facility must provide access to any resident by (1) any representative of the Secretary, (2) Any representative of the State. (3) Any representative of the Office of the State long term care ombudsman. (4) the resident's individual physician. (5) any representative of the protection and advocacy system (5) any representative of the agency responsible for the protection and advocacy system for individuals with a mental disorder, and (6) the resident representative. The facility must provide immediate access to a resident by immediate family and other relatives, and reasonable access by any entity or individual that provides health, social, legal or other services to the resident, all of which are subject to the resident's right to deny or withdraw consent at any time. In a face to face interview with the surveyor on [DATE] at 9:35 AM the Activities Assistant stated that the visitor first started coming to the facility when his/her aunt was a resident and that after the resident died s/he continued to visit other residents, s/he would bring residents to the dining room. S/he was in here often, outside with the men residents. Resident C and the visitor are outside a lot. When asked by the surveyor if there was anything unusual about his/her visits s/he stated that about a year ago s/he was speaking harshly to his/her aunt and the Administrator explained to him/her s/he couldn't speak that way. About a week ago there was a problem with a resident and chicken wings that the visitor had bought for her/him. When the visitor saw me s/he went the other way. In a face to face interview with the surveyor on [DATE] at 10:40 AM LPN #3 related an incident several months ago with a resident who expired in [DATE]; the visitor came down the hallway and the resident was at the nurses station, s/he said get away from me. LPN #3 stated s/he told the visitor to leave the resident alone. The visitor replied, Mind your own business. LPN #3 responded to the visitor that s/he was going to tell the Administrator and that s/he did. LPN #3 stated s/he never bother the resident again. Review of the facility visitor's log for [DATE] indicated the visitor did not sign in on the log. In a telephone interview with the surveyor on [DATE] at 11:30 AM Resident #1's physician confirmed that the resident lacked decisional capacity. I doubt very seriously s/he could consent to sex. In a telephone interview with the surveyor on [DATE] at 1:05 PM the Investigator with the Sheriffs Department stated that the alleged perpetrator had been charged with Criminal Sexual Conduct 3rd. Degree and was in jail. It was determined on [DATE] at approximately 11:55 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of [DATE] related to complaint SC 949 in the following areas. The Administrator was notified of this determination at 12:15 PM. The deficiencies involved were as follows: 4[AGE].10(f)(4) Right to Receive/deny Visitors, F0563 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to have a written policy to address visitors. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12 Freedom from Abuse, F0[AGE]0 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to ensure each resident remained free from abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12(b) Develop/Implement Abuse/Neglect Policies, F0[AGE]7 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to implement written policies and procedures that prohibit and prevent abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. The facility staff failed to protect the resident, by removing the alleged abuser from the resident care area. One of 3 residents reviewed for abuse. 4[AGE].70 Administration, F0[AGE]5 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to be administered in a manner that enables it to use resources effectively and efficiently to attain or maintain the highest practicable physical , mental, and psychosocial well-being of each resident. Resident #1 was allegedly abused sexually by a visitor at the facility The facility provided an acceptable Allegation of Compliance (AOC) Resident #1 was assessed by a licensed nurse, the physician was notified and an order was received and resident was transported to the hospital and no longer resides in the facility. Residents who reside in the facility and were in contact with the identified visitor had the potential to be affected. The facility will interview all alert and oriented residents and complete body audits on all non-alert and oriented resident to observe for any signs of abuse. Staff were interviewed by the Administrator, Director of Nursing and nursing managers on [DATE] to determine which residents the identified visitor had interaction with and if it was in or out of the resident's room. Alert and oriented residents were interviewed by the Administrator, Director of Nursing and nursing managers to determine if any unwanted touching occurred or any witness to others. Residents with a BIM score of 12 or less were assessed by a registered nurse and no other concerns were identified. These assessments were completed on [DATE]. Interviews of all Alert and Oriented residents were completed by [DATE]. Those residents were educated to notify staff of any unusual or inappropriate behaviors or if they fell afraid or unsafe. All residents with a BIM score of 12 or less were assessed by a licensed nurse by [DATE]. No other concerns were identified. All residents in the facility will be educated by [DATE] on resident safety and notifying staff of any unusual or inappropriate behavior or if they feel threatened or afraid. On [DATE] a resident council meeting was held to discuss resident safety and to notify staff of any unusual or inappropriate behavior or if they feel threatened or afraid. Facility staff was educated by the Staff Development Coordinator, the Director of Nursing and the Administrator on the following: *Facility staff was re-educated on Abuse, Neglect, Misappropriation and Exploitation including preventing, recognizing, reporting abuse, neglect, exploitation, and mistreatment and protecting the residents. *The identification of residents who should not have visitors without notification of Responsible Party. *Notation will be made in Medication Administration Record [REDACTED]. *Social Service Director will identify and maintain a list of residents with cognitive impairments. Cognitive impairment will be determined by either an incapacitation order by a court of law or a lack of decisional capacity by two physicians. *Visitor sign in log process - any visitor entering facility will sign in on log which includes the visitor name, the date, the resident being visited and relationship and will be given a visitor sticker. Visitors will sign out upon exit from the facility. From 4 PM to 8 AM and on weekends the doors are locked, visitors will ring the doorbell and staff member answering door will have visitor sign log and issue a visitor sticker. The re-education will be completed by [DATE]. Any staff member not receiving this education by this date will receive prior to next scheduled shift. This information will be presented in New Hire Orientation. A visitor sign in log and the process of issuing a visitor sticker will be implemented by [DATE]. Letters regarding the visitor sign in log and notification of anything suspicious to charge nurse will be mailed out on [DATE] by the Administrator. CNA (certified nurse aide) #1 and #2 who were agency CNAs have not been back to the facility to work since the incident. The staffing agency will be notified on [DATE] to no longer send them to the facility. The facility will report the two CNAs to DHEC as a possible abuse incident. LPN (licensed practical nurse) #1 will receive corrective action failing to ensure the resident's safety on [DATE]. This LPN will be reported to SC LLR on [DATE]. An ad hoc Quality Assurance Performance Improvement Committee Meeting was held on [DATE] and Medical Director was informed the immediate jeopardy and the content of this plan. Allegation of Compliance (AOC) [DATE] Observations, interviews, and review of the Allegation of Compliance (AOC) submitted by the facility on [DATE] revealed the implementation of the AOC and that it was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the new visitors procedure, abuse policy and the importance of protecting the residents. The Administrator was informed of this on [DATE] at approximately 3:30 PM. The Immediate Jeopardy at F0563, F0[AGE]0, F0[AGE]7 and F0[AGE]5 was removed but the citations remained at a lower scope and severity of D.

Based on record review, interview and review of facility policy and contract, the facility failed to provide pain medication to meet the needs of Resident #209, 1 of 1 sampled resident reviewed for Pain. Resident #209 did not have pain medication available in a timely manner after admission to the facility. Cross refer to F309 The findings included: The facility admitted Resident #209 with [DIAGNOSES REDACTED]. Record review of hospital progress notes on 10/4/2017 at 3:50 PM revealed that Resident #209 underwent surgical procedures to the Abdominal Wall Abscess on 9/21/2017, 9/17/2017 and 9/16/2017. The notes indicated the abscessed area was 30 centimeters (cm) x 12cm, with a surgical incision 17cm in length. Record review of the nursing admission assessment on 10/4/2017 at 2:06 PM revealed the resident was admitted to the facility on [DATE] at 3:40 PM. A pain evaluation was completed as part of the assessment and indicated the resident had pain frequently over the past 5 days. A section of the pain evaluation asking the resident to rate her/his pain was not completed. The pain evaluation indicated the resident had vocal complaints of pain, specifically, incisional pain. Review of copies of faxed orders on 10/4/2017 at 12:22 PM indicated the facility faxed the pharmacy Resident #209's prescriptions at 5:53 PM on 10/2/2017. Record review of the Physician's Orders and Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The resident's pain score was 8 of 10 on the 0-10 pain scale. During an interview and observation of Resident #209 on 10/3/2017 at 2:36 PM, Resident #209 was laying in bed and appeared tense and rigid (uncomfortable). When asked to rate her/his pain on the 0-10 pain scale, Resident #209 rated her/his pain at a 10 of 10. Resident #209 stated she/he was admitted to the facility yesterday afternoon around 4:00 PM. She/he stated that she/he had pain medicine in the hospital at 12:30 PM on 10/2/2017 and did not receive pain medication in the facility until 2:00 AM today (10/3). Resident #209 stated the facility did not have her/his pain medication in the facility until then. During an interview with Licensed Practical Nurse (LPN) #2 on 10/4/2017 at 11:32 AM, LPN #2 stated Resident #209's pain medication was delivered to the facility at 12:45 AM on 10/3/2017. LPN #2 stated that facility protocol for medication acquisition after 5:00 PM is to fax the pharmacy and call the pharmacy for any medications needed as soon as possible. During an interview with the Director of Nursing (DON) on 10/4/2017 at 1:28 PM, the DON stated the facility did not have a back up pharmacy for medications needed after hours because the pharmacy they contract with is supposed to provide medications 24 hours per day, 7 days per week. During an interview with the Medical Director on 10/5/2017 at 11:21 AM, the Medical Director stated it was inexcusable for a patient to have to wait that long for pain medication. The Medical Director stated if the facility can't get medication from the pharmacy in a timely manner then maybe they need to look at getting a new pharmacy. The Medical Director stated the facility's medication acquisition process is not working if a patient has to wait that long for medication. During an interview with the DON, (with the Nurse Consultant and Nursing Home Administrator present) on 10/5/2017 at 1:00 PM, the DON stated the facility was implementing a stat box for controlled medications to ensure there would be no future delays for residents needing narcotic pain medication. Review of the facility policy entitled Physician/Prescriber Authorization and Communication of Orders to Pharmacy on 10/4/2017 at 12:22 PM revealed the policy did not identify a procedure for medication acquisition after hours. The policy did not indicate that staff needed to call the pharmacy for medications needed after hours. Review of the Pharmacy Services Agreement on 10/4/2017 at 12:22 PM revealed in the event PHARMACY cannot furnish an ordered medication on a prompt and timely basis, PHARMACY will make arrangements with another pharmacy supplier in a community local to FACILITY to promptly and timely provide such pharmaceutical products to FACILITY. In addition, the contract revealed that the facility will order medications for all residents exclusively from the contacted pharmacy. Per the Pharmacy Services Agreement, PHARMACY shall provide STAT Deliveries and pharmaceutical products on a 24-hour basis, seven days a week (including holidays)., and PHARMACY shall provide adequate backup pharmacies and suppliers to support the emergency needs of FACILITY residents.

Based on record review, interview and observation, the facility failed to provide pain management to Resident #209, 1 of 1 sampled resident reviewed for Pain. Resident #209 did not have pain medication available in a timely manner after admission to the facility. The findings included: The facility admitted Resident #209 with [DIAGNOSES REDACTED]. Record review of hospital progress notes on 10/4/2017 at 3:50 PM revealed that Resident #209 underwent surgical procedures to the Abdominal Wall Abscess on 9/21/2017, 9/17/2017 and 9/16/2017. The notes indicated the abscessed area was 30 centimeters (cm) x 12cm, with a surgical incision 17cm in length. Record review of the nursing admission assessment on 10/4/2017 at 2:06 PM revealed the resident was admitted to the facility on [DATE] at 3:40 PM. A pain evaluation was completed as part of the assessment and indicated the resident had pain frequently over the past 5 days. A section of the pain evaluation asking the resident to rate her/his pain was not completed. The pain evaluation indicated the resident had vocal complaints of pain, specifically, incisional pain. Record review of the physician's orders [REDACTED]. The MAR indicated [REDACTED]. The resident's pain score was 8 of 10 on the 0-10 pain scale. Review of copies of faxed orders on 10/4/2017 at 12:22 PM indicated the facility faxed the pharmacy Resident #209's prescriptions at 5:53 PM on 10/2/2017. During an interview and observation of Resident #209 on 10/3/2017 at 2:36 PM, Resident #209 was laying in bed and appeared tense and rigid (uncomfortable). When asked to rate her/his pain on the 0-10 pain scale, Resident #209 rated her/his pain at a 10 of 10. Resident #209 stated she/he was admitted to the facility yesterday afternoon around 4:00 PM. She/he stated that she/he had pain medicine in the hospital at 12:30 PM on 10/2/2017 and did not receive pain medication in the facility until 2:00 AM today (10/3). Resident #209 stated the facility did not have her/his pain medication in the facility until then. The resident stated she/he was upset that the facility took so long to get her/his pain medication because she/he had been taking pain medications every 3 and 4 hours in the hospital. The resident felt like her/his pain level was so high at this time because she/he had to go 13 hours without any pain medication and it was taking longer to get under control because of that. During an interview with Licensed Practical Nurse (LPN) #2 on 10/4/2017 at 11:32 AM, LPN #2 stated Resident #209's pain medication was delivered to the facility at 12:45 AM on 10/3/2017. LPN #2 stated the resident should not have had to wait that long for her/his pain medication. LPN #2 stated that facility protocol for medication acquisition after 5:00 PM is to fax the pharmacy and call the pharmacy for any medications needed as soon as possible. If the pharmacy is not called after 5:00 PM, medications may not arrive at the facility until 1:00 AM. LPN #2 stated that the admitting nurse did not call the pharmacy and request the pain medication as soon as possible. During an interview with Resident #209 on 10/4/2017 at 12:12 PM, Resident #209 stated she/he was feeling a little better, but was still having more pain than she/he was having while in the hospital. Resident #209 stated she was receiving the pain medications [MEDICATION NAME] every 3 hours and [MEDICATION NAME] every 4 hours while in the hospital. The resident stated she/he was now getting pain medication every 4 hours and rated her/his pain 8 of 10. During an interview with the Director of Nursing (DON) on 10/4/2017 at 1:28 PM, the DON stated that all nurses, including the admitting nurse, had been inserviced this past February on medication acquisition. The DON stated nurses were educated to call the pharmacy for medication needed after 5:00 PM. The DON stated the facility did not have a back up pharmacy for medications needed after hours because the pharmacy they contract with is supposed to provide medications 24 hours per day, 7 days per week. During an interview with LPN #3 on 10/4/2017 at 2:02 PM, LPN #3 confirmed she/he faxed Resident #209's prescriptions to the pharmacy, but did not call the pharmacy. LPN #3 stated she/he knew the pharmacy needed to be called for prescriptions needed after 5:00 PM, but forgot to do so. During an interview with resident #209 on 10/5/2017 at 11:02 AM, Resident #209 stated she/he was feeling much better. She/he stated she was getting her pain medication every 4 hours, as needed, and felt like her pain was under control. Resident #209 stated she/he first asked the nurse for pain medication around 5:30 PM on 10/2/1017. Resident #209 stated she/he was told she/he would have to wait until the medication was delivered by the pharmacy. Resident #209 stated she/he was told that the medication should be delivered by 9:00 PM. Resident #209 stated her/his pain level was tolerable at the time and was ok with waiting until 9:00 PM. Resident #209 stated she/he was due for pain medication at 4:30 PM based on her/his last dose from the hospital. Resident #209 stated she/he asked for her/his pain medication at 9:30 PM and was told it had not been delivered yet. Resident #209 stated she/he was told another pharmacy delivery was scheduled at 12:00 AM. Resident #209 stated she/he asked for her/his pain medication at 12:00 AM and was told it would be delivered at 1:00 AM. Resident #209 stated her pain level was outrageous by this time. During an interview with the Medical Director on 10/5/2017 at 11:21 AM, the Medical Director stated it was inexcusable for a patient to have to wait that long for pain medication. The Medical Director stated if the facility can't get medication from the pharmacy in a timely manner then maybe they need to look at getting a new pharmacy. The Medical Director stated the facility's medication acquisition process is not working if a patient has to wait that long for medication. During an interview with the DON, Nurse Consultant and Nursing Home Administrator on 10/5/2017 at 1:00 PM, the DON stated the facility was implementing a stat box for controlled medications to ensure there would be no future delays for residents needing narcotic pain medication. The Nurse Consultant confirmed the admission pain evaluation was incomplete.

Based on review of facility files and interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible. Resident #88 was found in a locked janitor's closet after being missing for approximately 4.5 hours. Facility staff failed to follow the facility's policy for missing residents. The Administrator, Director of Nursing, responsible party, sheriff's office and physician were not notified timely that the resident was missing. Housekeeping staff failed to notify their supervisor or maintenance that the locking mechanism on the janitor's closet on the unit was not working properly. One of one wanderers reviewed The findings included: The facility reported an unusual occurrence to the State Agency for Resident #88 on 6/12/16. The facility was unable to locate Resident #88 in the facility for 4.5 hours. The resident was located in the janitor's closet on the unit s/he resided on. The facility's synopsis of the elopement indicated the Administration was notified of the missing resident on 6/12/16. The Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) arrived at the facility to assist with the search for the resident. Local law enforcement was made aware of the situation along with the resident's responsible party. The search for Resident #88 continued until 3:30 AM when the resident was located in the janitor's closet. The synopsis indicated the identified door mechanism was immediately repaired and subsequently replaced. A list of chemicals present in the closet was completed at the time the resident was discovered. The items included Emerald floor cleaner, Wiwax cleaning and maintenance emulsion and Airx disinfectant cleaner. Review of the Resident Incident/Accident Investigation Worksheet dated 6/11/16 revealed the time of incident was 11:00 PM. The resident was noted not in his/her room around 11:00 PM and a Code White/Star Search was initiated. The nurse practitioner was notified at 1:30 AM and the resident's responsible party was notified at 1:30 AM. The resident was located in the facility. A body audit was completed with no apparent injuries. Review of the Weekly Skin Integrity Review revealed on 6/8/16 the resident was noted to have some old scattered discoloration. On 6/12/16 the resident was noted to have bruising, a red area to the right hip and an abrasion to the lower leg. Review of Resident #88's Risk of Elopement/Wandering Review revealed the form was last completed on 12/30/15. The instructions on the form indicated to complete the form upon admission, quarterly and at significant change. Review of Resident #88's Psychotherapy Visit note dated 6/22/16 revealed the resident was seen after being found in the closet at the facility after several hours. Resident #88 had a history of [REDACTED]. In an interview with the surveyor on 9/20/16 at approximately 1:35 PM Housekeeper #1 stated they changed the lock after the incident, it wasn't latching. Sometimes it would and sometimes it wouldn't. You would have to push on it and it would catch. The closet is supposed to lock automatically. Housekeeper #1 stated the janitor's closet is where they get their mop water, Unit 1, Unit 2 and the floor techs get their water from there. In an interview with the surveyor on 9/20/16 at approximately 1:52 PM, the Housekeeping manager stated the facility did an investigation, the conclusion was that two of the floor techs told them the door opens by itself sometimes. The staff did not tell anybody prior to the incident. The floor techs no longer work at the facility. The facility maintenance changed the lock after the incident. In an interview with the surveyor on 9/20/16 at approximately 2:30 PM, the Maintenance Director stated s/he was called at 2:00 AM that evening to help look for Resident #88. There were some doors they could not access while searching for the resident. The Maintenance Director stated s/he looked in the janitor's closet on Station 2 and found Resident #88. The resident was laying on the floor between the mop bucket and wall. The resident was on his/her back with his/her knees up, it is a small closet. Resident #88 had on a sweater and a brief. The Maintenance Director notified the nurse around the corner at the Nurses' station. Resident #88 was awake when s/he found him/her and the light was on in the closet. The Maintenance Director stated the janitor's closet door was locked and s/he had to unlock it. Once the closet was cleaned, s/he checked the locking mechanism and the door locked. Upon talking to housekeeping after the incident, they told him/her the lock wouldn't work sometimes. The Maintenance Director stated there is a maintenance book at the nurses' stations but nobody logged the lock on the janitor's closet. At the time of the incident only housekeeping and maintenance had keys to the closet. In an interview with the surveyor on 9/20/16 at approximately 3:13 PM, the Director of Nursing (DON) stated Resident #88 had Alzheimer's and liked to walk around the building constantly. The DON stated s/he received a call around 1:30 AM from the Assistant Director of Nursing(ADON). The ADON said they could not find Resident #88. The DON arrived at the facility before 2, approximately 1:50 AM. When s/he got to the facility s/he got his/her set of keys and went and checked all the offices and rooms. The DON started on the Administration hall and then went room to room to check all the residents rooms. The DON pulled on the janitor's closet door on Station 2 but did not have a key and it was locked. The police arrived a few minutes after s/he arrived at the facility. Staff called the police while s/he was on the way to the facility. Staff found the resident around 3:00 in the janitor's closet. The resident had a bowel movement and it was all over him/her. Staff called the weekend supervisor around 12:50 AM. The weekend supervisor came to the facility, and had forgotten his/her work keys. S/he went home, got the keys, came back and started opening doors s/he had keys for. The policy states the Administrator is called for a star search. They did not call the administrator or DON. The DON stated the nurse on duty stated s/he didn't know what to do. In an interview with the surveyor on 9/21/16 at approximately 10:25 AM, the DON stated elopement assessments should be done every 3 months. The last elopement assessment for Resident #88 was December 2015. In an interview with the surveyor on 9/21/16 at approximately 11:40 AM, the DON confirmed the responsible party, MD and sheriff's department were not notified timely. In an interview with the surveyor on 9/21/16 at approximately 11:48 AM, the ADON stated she completed the weekly skin integrity review right before EMS took Resident #88 out to the hospital after being located. Resident #88 had a couple of blanchable red areas to his/her right hip, s/he also had an abrasion to the left lower leg(like a strawberry, no bleeding). Staff called him/her around 1:35 AM, the resident's CNA was who called him/her. The CNA told him/her they could not locate the resident, they had already done a star search. Review of the facility's Elopement Leadership Policies and Procedures revealed once it had been established that a resident was missing, all employees should be notified immediately by paging overhead Code White. Further review of the policy revealed an immediate and thorough search of the center and surrounding grounds should be instituted. The search should include the entire unit where the resident resides or was last seen and the remainder of the facility (all rooms, closets-including storage facilities- and bathrooms). The entire search process of the facility and grounds, from the time the resident is missing, will be completed within 30 minutes. If the search fails to locate the missing resident within 30 minutes from the time the resident is found to be missing, the Administrator and/or designee contacts the appropriate community agencies (including police) and Administration, the resident's legal representative and attending physician. When the resident is located, the Charge Nurse completes a head to toe assessment. It was determined on 9/20/16 at 4:10 PM that Immediate Jeopardy and/or Substandard Quality of Care at Past Noncompliance existed in the facility as of 6/11/16 and was corrected as of 6/26/2016. The facility's Allegation of Compliance/Plan of Correction for Immediate Jeopardy included: 1. Identified resident was located inside the facility in a housekeeping closet at 3:30 am on 6/12/16. A full head to toe assessment was performed on the resident with no concerns identified. The resident was sent to Spartanburg Regional Medical Center at 3:55 am, and returned to the facility at 8:30 am in stable condition with no substantial findings. PO fluids were encouraged with intake and output ordered by resident's physician for 48 hrs. 2. Residents with wandering behaviors have the potential to be affected by this alleged deficient practice. At time resident was unable to be located by facility staff, all other facility residents were accounted for. This was completed on 6/12/16 by the Assistant Director of Nursing. All residents with wanderguards were validated to have them in place with function checked and expiration date verified, no concerns were identified. This was completed on 6/12/16 by the facility Central Supply Coordinator. All facility outer doors were validated to be functioning appropriately. All facility staff present at time of incident were interviewed to validate no door alarms sounded in the hour before the resident was unable to be located. This was completed on 6/12/16 by the facility Administrator. Identified housekeeping door mechanism was immediately repaired and subsequently replaced by the facility Maintenance Director on 6/12/16. A list of items present in the identified housekeeping closet was completed at time resident was discovered, no evidence items had been accessed by the resident. All potentially harmful items located in housekeeping closets have been removed and placed in an unaccessible area. This was completed on 6/12/16 by the Housekeeping Supervisor. The identified resident was being reviewed by social services daily for 7 days to validate no psychosocial effects of the incident persist. This was completed on 6/21/16. The identified resident has been placed on 15 minute location checks for 14 days to validate no further attempts to enter other inappropriate areas in the facility. This was completed on 6/26/16. The incident has been reported to the facility's contracted psychiatric services for resident review. Elopement drills were conducted on all 3 shifts on 6/12/16. The facility charge nurse assigned to the resident and the facility weekend supervisor were both immediately suspended pending investigation, and subsequently terminated from the facility. 3. The facility Director of Nursing/department managers has re-educated all facility staff on the facility elopement policy, the securing of all facility doors and the immediate reporting of any facility door that is not functioning properly. This re-education was completed on 6/13/16. Any staff member not receiving this re-education by this date will receive prior to next scheduled shift. This information will be presented in new hire orientation. 4. The facility Maintenance Director will monitor all facility interior doors for proper functioning daily for 14 days then monthly indefinitely. Elopement drills will be conducted on every shift 1 time per week for 4 weeks then monthly indefinitely. 5. Results of the monitoring will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for a period of 3 months or until substantial compliance is achieved and maintained. Any areas of concern identified will be addressed at time of discovery.

Based on review of facility files and interviews, the facility failed to ensure that the services provided by the facility met professional standards of care. Resident #88 was found in a locked janitor's closet after being missing for approximately 4.5 hours. Facility staff failed to follow the facility's policy for missing residents. The Administrator, Director of Nursing, responsible party, sheriff's office and physician were not notified timely that the resident was missing. Housekeeping staff failed to notify their supervisor or maintenance that the locking mechanism on the janitor's closet on the unit was not working properly. One of one wanderers reviewed The findings included: The facility reported an unusual occurrence to the State Agency for Resident #88 on 6/12/16. The facility was unable to locate Resident #88 in the facility for 4.5 hours. The resident was located in the janitor's closet on the unit s/he resided on. The facility's synopsis of the elopement indicated the Administration was notified of the missing resident on 6/12/16. The Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) arrived at the facility to assist with the search for the resident. Local law enforcement was made aware of the situation along with the resident's responsible party. The search for Resident #88 continued until 3:30 AM when the resident was located in the janitor's closet. The synopsis indicated the identified door mechanism was immediately repaired and subsequently replaced. A list of chemicals present in the closet was completed at the time the resident was discovered. The items included Emerald floor cleaner, Wiwax cleaning and maintenance [MEDICATION NAME] and Airx disinfectant cleaner. Review of the Resident Incident/Accident Investigation Worksheet dated 6/11/16 revealed the time of incident was 11:00 PM. The resident was noted not in his/her room around 11:00 PM and a Code White/Star Search was initiated. The nurse practitioner was notified at 1:30 AM and the resident's responsible party was notified at 1:30 AM. The resident was located in the facility. A body audit was completed with no apparent injuries. Review of the Weekly Skin Integrity Review revealed on 6/8/16 the resident was noted to have some old scattered discoloration. On 6/12/16 the resident was noted to have bruising, a red area to the right hip and an abrasion to the lower leg. Review of Resident #88's Risk of Elopement/Wandering Review revealed the form was last completed on 12/30/15. The instructions on the form indicated to complete the form upon admission, quarterly and at significant change. Review of Resident #88's Psychotherapy Visit note dated 6/22/16 revealed the resident was seen after being found in the closet at the facility after several hours. Resident #88 had a history of [REDACTED]. In an interview with the surveyor on 9/20/16 at approximately 1:35 PM Housekeeper #1 stated they changed the lock after the incident, it wasn't latching. Sometimes it would and sometimes it wouldn't. You would have to push on it and it would catch. The closet is supposed to lock automatically. Housekeeper #1 stated the janitor's closet is where they get their mop water, Unit 1, Unit 2 and the floor techs get their water from there. In an interview with the surveyor on 9/20/16 at approximately 1:52 PM, the Housekeeping manager stated the facility did an investigation, the conclusion was that two of the floor techs told them the door opens by itself sometimes. The staff did not tell anybody prior to the incident. The floor techs no longer work at the facility. The facility maintenance changed the lock after the incident. In an interview with the surveyor on 9/20/16 at approximately 2:30 PM, the Maintenance Director stated s/he was called at 2:00 AM that evening to help look for Resident #88. There were some doors they could not access while searching for the resident. The Maintenance Director stated s/he looked in the janitor's closet on Station 2 and found Resident #88. The resident was laying on the floor between the mop bucket and wall. The resident was on his/her back with his/her knees up, it is a small closet. Resident #88 had on a sweater and a brief. The Maintenance Director notified the nurse around the corner at the Nurses' station. Resident #88 was awake when s/he found him/her and the light was on in the closet. The Maintenance Director stated the janitor's closet door was locked and s/he had to unlock it. Once the closet was cleaned, s/he checked the locking mechanism and the door locked. Upon talking to housekeeping after the incident, they told him/her the lock wouldn't work sometimes. The Maintenance Director stated there is a maintenance book at the nurses' stations but nobody logged the lock on the janitor's closet. At the time of the incident only housekeeping and maintenance had keys to the closet. In an interview with the surveyor on 9/20/16 at approximately 3:13 PM, the Director of Nursing (DON) stated Resident #88 had Alzheimer's and liked to walk around the building constantly. The DON stated s/he received a call around 1:30 AM from the Assistant Director of Nursing(ADON). The ADON said they could not find Resident #88. The DON arrived at the facility before 2, approximately 1:50 AM. When s/he got to the facility s/he got his/her set of keys and went and checked all the offices and rooms. The DON started on the Administration hall and then went room to room to check all the residents rooms. The DON pulled on the janitor's closet door on Station 2 but did not have a key and it was locked. The police arrived a few minutes after s/he arrived at the facility. Staff called the police while s/he was on the way to the facility. Staff found the resident around 3:00 in the janitor's closet. The resident had a bowel movement and it was all over him/her. Staff called the weekend supervisor around 12:50 AM. The weekend supervisor came to the facility, and had forgotten his/her work keys. S/he went home, got the keys, came back and started opening doors s/he had keys for. The policy states the Administrator is called for a star search. They did not call the administrator or DON. The DON stated the nurse on duty stated s/he didn't know what to do. In an interview with the surveyor on 9/21/16 at approximately 10:25 AM, the DON stated elopement assessments should be done every 3 months. The last elopement assessment for Resident #88 was December 2015. In an interview with the surveyor on 9/21/16 at approximately 11:40 AM, the DON confirmed the responsible party, MD and sheriff's department were not notified timely. In an interview with the surveyor on 9/21/16 at approximately 11:48 AM, the ADON stated she completed the weekly skin integrity review right before EMS took Resident #88 out to the hospital after being located. Resident #88 had a couple of blanchable red areas to his/her right hip, s/he also had an abrasion to the left lower leg(like a strawberry, no bleeding). Staff called him/her around 1:35 AM, the resident's CNA was who called him/her. The CNA told him/her they could not locate the resident, they had already done a star search. Review of the facility's Elopement Leadership Policies and Procedures revealed once it had been established that a resident was missing, all employees should be notified immediately by paging overhead Code White. Further review of the policy revealed an immediate and thorough search of the center and surrounding grounds should be instituted. The search should include the entire unit where the resident resides or was last seen and the remainder of the facility (all rooms, closets-including storage facilities- and bathrooms). The entire search process of the facility and grounds, from the time the resident is missing, will be completed within 30 minutes. If the search fails to locate the missing resident within 30 minutes from the time the resident is found to be missing, the Administrator and/or designee contacts the appropriate community agencies (including police) and Administration, the resident's legal representative and attending physician. When the resident is located, the Charge Nurse completes a head to toe assessment. It was determined on 9/20/16 at 4:10 PM that Immediate Jeopardy and/or Substandard Quality of Care at Past Noncompliance existed in the facility as of 6/11/16 and was corrected as of 6/26/2016. The facility's Allegation of Compliance/Plan of Correction for Immediate Jeopardy included: 1. Identified resident was located inside the facility in a housekeeping closet at 3:30 am on 6/12/16. A full head to toe assessment was performed on the resident with no concerns identified. The resident was sent to Spartanburg Regional Medical Center at 3:55 am, and returned to the facility at 8:30 am in stable condition with no substantial findings. PO fluids were encouraged with intake and output ordered by resident's physician for 48 hrs. 2. Residents with wandering behaviors have the potential to be affected by this alleged deficient practice. At time resident was unable to be located by facility staff, all other facility residents were accounted for. This was completed on 6/12/16 by the Assistant Director of Nursing. All residents with wanderguards were validated to have them in place with function checked and expiration date verified, no concerns were identified. This was completed on 6/12/16 by the facility Central Supply Coordinator. All facility outer doors were validated to be functioning appropriately. All facility staff present at time of incident were interviewed to validate no door alarms sounded in the hour before the resident was unable to be located. This was completed on 6/12/16 by the facility Administrator. Identified housekeeping door mechanism was immediately repaired and subsequently replaced by the facility Maintenance Director on 6/12/16. A list of items present in the identified housekeeping closet was completed at time resident was discovered, no evidence items had been accessed by the resident. All potentially harmful items located in housekeeping closets have been removed and placed in an unaccessible area. This was completed on 6/12/16 by the Housekeeping Supervisor. The identified resident was being reviewed by social services daily for 7 days to validate no psychosocial effects of the incident persist. This was completed on 6/21/16. The identified resident has been placed on 15 minute location checks for 14 days to validate no further attempts to enter other inappropriate areas in the facility. This was completed on 6/26/16. The incident has been reported to the facility's contracted psychiatric services for resident review. Elopement drills were conducted on all 3 shifts on 6/12/16. The facility charge nurse assigned to the resident and the facility weekend supervisor were both immediately suspended pending investigation, and subsequently terminated from the facility. 3. The facility Director of Nursing/department managers has re-educated all facility staff on the facility elopement policy, the securing of all facility doors and the immediate reporting of any facility door that is not functioning properly. This re-education was completed on 6/13/16. Any staff member not receiving this re-education by this date will receive prior to next scheduled shift. This information will be presented in new hire orientation. 4. The facility Maintenance Director will monitor all facility interior doors for proper functioning daily for 14 days then monthly indefinitely. Elopement drills will be conducted on every shift 1 time per week for 4 weeks then monthly indefinitely. 5. Results of the monitoring will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for a period of 3 months or until substantial compliance is achieved and maintained. Any areas of concern identified will be addressed at time of discovery.

Based on review of facility files and interviews, the facility failed to notify the resident's family and physician of a change in status. Resident #88 was found in a locked janitor's closet after being missing for approximately 4.5 hours. Facility staff failed to follow the facility's policy for missing residents. The Administrator, Director of Nursing, responsible party, sheriff's office and physician were not notified timely that the resident was missing. Housekeeping staff failed to notify their supervisor or maintenance that the locking mechanism on the janitor's closet on the unit was not working properly. In addition, multiple physician orders [REDACTED]. (Two of 2 residents reviewed for change of condition) The findings included: The facility reported an unusual occurrence to the State Agency for Resident #88 on 6/12/16. The facility was unable to locate Resident #88 in the facility for 4.5 hours. The resident was located in the janitor's closet on the unit s/he resided on. The facility's synopsis of the elopement indicated the Administration was notified of the missing resident on 6/12/16. The Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) arrived at the facility to assist with the search for the resident. Local law enforcement was made aware of the situation along with the resident's responsible party. The search for Resident #88 continued until 3:30 AM when the resident was located in the janitor's closet. The synopsis indicated the identified door mechanism was immediately repaired and subsequently replaced. A list of chemicals present in the closet was completed at the time the resident was discovered. The items included Emerald floor cleaner, Wiwax cleaning and maintenance [MEDICATION NAME] and Airx disinfectant cleaner. Review of the Resident Incident/Accident Investigation Worksheet dated 6/11/16 revealed the time of incident was 11:00 PM. The resident was noted not in his/her room around 11:00 PM and a Code White/Star Search was initiated. The nurse practitioner was notified at 1:30 AM and the resident's responsible party was notified at 1:30 AM. The resident was located in the facility. A body audit was completed with no apparent injuries. Review of the Weekly Skin Integrity Review revealed on 6/8/16 the resident was noted to have some old scattered discoloration. On 6/12/16 the resident was noted to have bruising, a red area to the right hip and an abrasion to the lower leg. Review of Resident #88's Risk of Elopement/Wandering Review revealed the form was last completed on 12/30/15. The instructions on the form indicated to complete the form upon admission, quarterly and at significant change. Review of Resident #88's Psychotherapy Visit note dated 6/22/16 revealed the resident was seen after being found in the closet at the facility after several hours. Resident #88 had a history of [REDACTED]. In an interview with the surveyor on 9/20/16 at approximately 1:35 PM Housekeeper #1 stated they changed the lock after the incident, it wasn't latching. Sometimes it would and sometimes it wouldn't. You would have to push on it and it would catch. The closet is supposed to lock automatically. Housekeeper #1 stated the janitor's closet is where they get their mop water, Unit 1, Unit 2 and the floor techs get their water from there. In an interview with the surveyor on 9/20/16 at approximately 1:52 PM, the Housekeeping manager stated the facility did an investigation, the conclusion was that two of the floor techs told them the door opens by itself sometimes. The staff did not tell anybody prior to the incident. The floor techs no longer work at the facility. The facility maintenance changed the lock after the incident. In an interview with the surveyor on 9/20/16 at approximately 2:30 PM, the Maintenance Director stated s/he was called at 2:00 AM that evening to help look for Resident #88. There were some doors they could not access while searching for the resident. The Maintenance Director stated s/he looked in the janitor's closet on Station 2 and found Resident #88. The resident was laying on the floor between the mop bucket and wall. The resident was on his/her back with his/her knees up, it is a small closet. Resident #88 had on a sweater and a brief. The Maintenance Director notified the nurse around the corner at the Nurses' station. Resident #88 was awake when s/he found him/her and the light was on in the closet. The Maintenance Director stated the janitor's closet door was locked and s/he had to unlock it. Once the closet was cleaned, s/he checked the locking mechanism and the door locked. Upon talking to housekeeping after the incident, they told him/her the lock wouldn't work sometimes. The Maintenance Director stated there is a maintenance book at the nurses' stations but nobody logged the lock on the janitor's closet. At the time of the incident only housekeeping and maintenance had keys to the closet. In an interview with the surveyor on 9/20/16 at approximately 3:13 PM, the Director of Nursing (DON) stated Resident #88 had Alzheimer's and liked to walk around the building constantly. The DON stated s/he received a call around 1:30 AM from the Assistant Director of Nursing(ADON). The ADON said they could not find Resident #88. The DON arrived at the facility before 2, approximately 1:50 AM. When s/he got to the facility s/he got his/her set of keys and went and checked all the offices and rooms. The DON started on the Administration hall and then went room to room to check all the residents rooms. The DON pulled on the janitor's closet door on Station 2 but did not have a key and it was locked. The police arrived a few minutes after s/he arrived at the facility. Staff called the police while s/he was on the way to the facility. Staff found the resident around 3:00 in the janitor's closet. The resident had a bowel movement and it was all over him/her. Staff called the weekend supervisor around 12:50 AM. The weekend supervisor came to the facility, and had forgotten his/her work keys. S/he went home, got the keys, came back and started opening doors s/he had keys for. The policy states the Administrator is called for a star search. They did not call the administrator or DON. The DON stated the nurse on duty stated s/he didn't know what to do. In an interview with the surveyor on 9/21/16 at approximately 10:25 AM, the DON stated elopement assessments should be done every 3 months. The last elopement assessment for Resident #88 was December 2015. In an interview with the surveyor on 9/21/16 at approximately 11:40 AM, the DON confirmed the responsible party, MD and sheriff's department were not notified timely. In an interview with the surveyor on 9/21/16 at approximately 11:48 AM, the ADON stated she completed the weekly skin integrity review right before EMS took Resident #88 out to the hospital after being located. Resident #88 had a couple of blanchable red areas to his/her right hip, s/he also had an abrasion to the left lower leg(like a strawberry, no bleeding). Staff called him/her around 1:35 AM, the resident's CNA was who called him/her. The CNA told him/her they could not locate the resident, they had already done a star search. Review of the facility's Elopement Leadership Policies and Procedures revealed once it had been established that a resident was missing, all employees should be notified immediately by paging overhead Code White. Further review of the policy revealed an immediate and thorough search of the center and surrounding grounds should be instituted. The search should include the entire unit where the resident resides or was last seen and the remainder of the facility (all rooms, closets-including storage facilities- and bathrooms). The entire search process of the facility and grounds, from the time the resident is missing, will be completed within 30 minutes. If the search fails to locate the missing resident within 30 minutes from the time the resident is found to be missing, the Administrator and/or designee contacts the appropriate community agencies (including police) and Administration, the resident's legal representative and attending physician. When the resident is located, the Charge Nurse completes a head to toe assessment. It was determined on 9/20/16 at 4:10 PM that Immediate Jeopardy and/or Substandard Quality of Care at Past Noncompliance existed in the facility as of 6/11/16 and was corrected as of 6/26/2016. The facility's Plan of Correction/Allegation of Compliance for Immediate Jeopardy included: 1. Identified resident was located inside the facility in a housekeeping closet at 3:30 am on 6/12/16. A full head to toe assessment was performed on the resident with no concerns identified. The resident was sent to Spartanburg Regional Medical Center at 3:55 am, and returned to the facility at 8:30 am in stable condition with no substantial findings. PO fluids were encouraged with intake and output ordered by resident's physician for 48 hrs. 2. Residents with wandering behaviors have the potential to be affected by this alleged deficient practice. At time resident was unable to be located by facility staff, all other facility residents were accounted for. This was completed on 6/12/16 by the Assistant Director of Nursing. All residents with wanderguards were validated to have them in place with function checked and expiration date verified, no concerns were identified. This was completed on 6/12/16 by the facility Central Supply Coordinator. All facility outer doors were validated to be functioning appropriately. All facility staff present at time of incident were interviewed to validate no door alarms sounded in the hour before the resident was unable to be located. This was completed on 6/12/16 by the facility Administrator. Identified housekeeping door mechanism was immediately repaired and subsequently replaced by the facility Maintenance Director on 6/12/16. A list of items present in the identified housekeeping closet was completed at time resident was discovered, no evidence items had been accessed by the resident. All potentially harmful items located in housekeeping closets have been removed and placed in an unaccessible area. This was completed on 6/12/16 by the Housekeeping Supervisor. The identified resident was being reviewed by social services daily for 7 days to validate no psychosocial effects of the incident persist. This was completed on 6/21/16. The identified resident has been placed on 15 minute location checks for 14 days to validate no further attempts to enter other inappropriate areas in the facility. This was completed on 6/26/16. The incident has been reported to the facility's contracted psychiatric services for resident review. Elopement drills were conducted on all 3 shifts on 6/12/16. The facility charge nurse assigned to the resident and the facility weekend supervisor were both immediately suspended pending investigation, and subsequently terminated from the facility. 3. The facility Director of Nursing/department managers has re-educated all facility staff on the facility elopement policy, the securing of all facility doors and the immediate reporting of any facility door that is not functioning properly. This re-education was completed on 6/13/16. Any staff member not receiving this re-education by this date will receive prior to next scheduled shift. This information will be presented in new hire orientation. 4. The facility Maintenance Director will monitor all facility interior doors for proper functioning daily for 14 days then monthly indefinitely. Elopement drills will be conducted on every shift 1 time per week for 4 weeks then monthly indefinitely. 5. Results of the monitoring will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for a period of 3 months or until substantial compliance is achieved and maintained. Any areas of concern identified will be addressed at time of discovery. Chart review on 9/21/16 revealed a nurses note dated 9/12/16 and 9/14/16 for medication changes for resident # 219. There was no documentation that family/ responsible party had been notified. At 9/21/16 at 2 PM the Director of Nursing reviewed the chart and confirmed there was no documentation that family/ responsible party had been notified. She stated there was a line on the physician's orders [REDACTED]. Further review of the resident's record revealed orders written on 9/6, 9/2, 7/8, 7/17, 7/22, 7/27 and 6/3, 6/9, 6/21/16 also had no documentation that family/responsible party had been notified. Facility policy stated The patients's /residents family member / legal represent. will be notified of any changes in medical condition or treatment plan as indicated by HIPPA directives. Res/family/ Responsible Party will be notified of any change in condition requiring an emergent transfer to the hospital. All attempts to notify physician/ family member/legal representative will be documented in resident record.

Based on observation, record review and interviews, the facility failed to protect 1 of 1 resident's reviewed for physical abuse. Resident #5 was held down by a nurse resulting in bruises and cuts on the resident's arm. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the facility investigation of the resident's allegation of abuse stated that on 3/12/15 at approximately 12:45 AM, RN (Registered Nurse) #1 had attempted to apply a [MEDICATION NAME] Patch to the resident. The resident did not want the patch and did not want the nurse to touch him/her. The resident began striking out at the Nurse. The Nurse grabbed his/her arm. The resident stated s/he did not want to be touched and s/he became combative. "Rt (right) forearm inner aspect distal to wrist, Resident with 4 small skin tears in nail shaped pattern observed Rt forearm/wrist area with some discoloration noted. No s/s (signs/symptoms) of infection to area." Review of the Physician order [REDACTED]. Observation of the resident on 3/17/15 at approximately 9:05 AM revealed the resident's right arm displayed red blue discolorations of the back of his/her hand and inner arm over wrist. Four small crescent shaped scabs were observed on the inner right forearm. When asked what had happened to her arm, the resident stated s/he did not want to talk about it. "They took care of it". On 3/18/15 at approximately 9:00 AM, Certified Nursing Assistant (CNA) #1 was interviewed by the surveyor. The CNA stated, "Me and the other CNA was at the nurse's station. We heard the shouting. I went down to room and RN was coming out. A few minutes later (Resident #5) turned his/her light on. I went in. Resident said look what the "B" did to me. S/he showed me her/his arm. I saw blood and open areas on her/his arm. There was blood on the sheet. I went out and was telling CNA #2. I went and reported to Charge Nurse on Unit 1 (one). S/he immediately called the Director of Nursing and then went over to assess the resident. I went and told RN #1 that s/he needed to write an incident report the resident was bruised and bleeding. The Nurse said, 'well look at my arm.' She continued to pass meds until the DON came." On 3/17/15 at approximately 3:20 PM CNA #2 was interviewed by the surveyor. "Me and other CNA, (CNA #1) were working together. RN #1 was the nurse. S/he was down the hall passing meds (medications). We heard a commotion. (Resident #5) was yelling, "Get out, get out". CNA #1 went to the room, s/he was assigned to the resident. S/he came back and said the resident had a skin tear and a bruise. 'You need to go see it". CNA #1 went to get the Charge Nurse on Unit 1. I went with CNA #1 to the room. We got her/him new sheets and changed her/him. The resident was saying, 'that [***] did that to me' and complained arm was hurting. Then RN #2 and LPN (Licensed Practical Nurse) #2 went and talked to RN #1. Then the DON had shown up and talked to him/her. CNA #1 told RN #1 to write an incident report." On 3/17/15 at approximately 4:00 PM RN #2 was interviewed by the surveyor. S/he stated, " CNA #1 and CNA #2 came to Unit 1 to get me. Informed me that Resident #5 was heard yelling and screaming at the Nurse's Station on Unit 2. The two CNA's went in (resident room) and noted blood on sheet and arm with skin tears and bruises on right arm and right hand. I went to station 4 and got LPN #2. We went to station 2 to assist the resident. We noted skin tears and bruises. We dressed the skin tears. We asked the resident what happened. S/he said the nurse startled her/him. S/he said they got into a scuffle. S/he described RN #1 and said s/he (resident) did not want to see her/him (nurse) back in her/his room. The nurse was at the desk. S/he never asked us what we were doing over there or anything. S/he never got up from the desk. I notified the DON and s/he came right away." On 3/17/15 at approximately 3:05 PM LPN #1 was interviewed by the surveyor. The LPN stated, "DON called to unit and started interviewing RN #1. S/he (DON) asked RN what happened. "I tried to go in and give meds. The resident said no. S/he did not want meds and told RN to get out. So RN said s/he left and went back in and tried it again. The res. (resident) started punching at her/him. S/he grabbed the resident's arm. S/he did not know why s/he grabbed it. The DON asked why the nurse went back in the room. The nurse said that s/he thought s/he could get her/him (resident) to comply. I saw a gash on the right forearm. The area was bruised/laceration- but not bleeding. The resident was alert and oriented. When I went in the room (resident's room) s/he said the lady/man came in here and was rude to me. S/he stated squeezing, s/he wouldn't let me go."

On the days of the complaint inspection, based on record review and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. One resident received a fracture after rolling out of the bed while receiving care from staff. The resident was assessed as requiring two staff members for bed mobility and only one staff member was in the room providing care. The resident also had an intervention of fall mats at bedside and the mat had been removed. One of two resident's reviewed for falls (Resident #1). The findings included: The facility reported an incident to the State Agency related to Resident #1. On 7/1/14 at approximately 4:25 AM CNA (certified nurse aide) #1 rolled Resident #1 away from him/her resulting in the resident falling to the floor. Resident #1 sustained a right nasal bone fracture. Further review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] coded Resident #1 as requiring extensive assistance with two plus persons physical assist for bed mobility. Review of the care plan revealed at risk for accidents and injuries related to history of falls was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included 2 person to assist while giving care to resident created on 7/2/14 after the fall on 7/1/14. Review of the CNA Resident Profile for Resident #1 revealed all care is to be done with 2 people with a start date of 7/1/14. The CNA Resident Profile also indicated fall mats to the bedside related to falls with a start date of 10/11/13. Review of Resident #1's July Physician order [REDACTED]. Review of the Nurse's Notes dated 7/1/14 indicated "IDT Note. Resident fell and (s/he) will be a two person care for all care given." Review of the Resident Incident Investigation Worksheet dated 7/1/14 indicated Licensed Practical Nurse ( LPN) #1 was called into the room by the CNA related to Resident #1 lying on the floor bleeding. LPN #1 noted that the bed bolsters were intact to the bed and there was a floor mat on the left side of the resident's bed. Resident #1 was lying face down on the floor on the right side of the bed. CNA #1's facility-obtained statement dated 7/2/14 indicated s/he had asked another staff member to help him/her with Resident #1's roommate at 3:40 AM and the staff member said they would be there in a few minutes. CNA #1 decided to go ahead and do Resident #1's care on his/her own at 4:20 AM. When CNA #1 rolled Resident #1 the roll bolster just flipped off the bed, it wasn't tight like it was supposed to be. Resident #1 just flipped out of the bed. CNA #1 ran around to the other side of the bed and found Resident #1 bleeding. Resident #1 had floor mats down on one side of the bed and CNA #1 wondered why s/he only had them on one side of the bed and why they weren't down from second shift. In a telephone interview with the surveyor on 7/23/14 at approximately 1:00 PM, CNA #1 stated that the bolsters on Resident #1's bed were lose and rolled off the bed. The resident then rolled to the floor. CNA #1 stated that Resident #1 had 1/2 bolsters to the head of his/her bed. CNA #1 also stated that the resident had floor mats down on the left side of the bed but not the right side. CNA #1 stated that there were two mats stacked on each other on the left side of the bed. CNA #1 stated that s/he was standing on the mats while providing care to the resident. In an interview with the surveyor on 7/21/14 at approximately 2:00 PM, the facility administrator stated that CNA #1 rolled Resident #1 away from him/her instead of toward him/her and the resident's fall mat was not in place. CNA #1 stated that s/he knew the fall mat should have been on the floor. At the time of the fall Resident #1 only required one person for care. CNA #1 was providing morning/ incontinent care for Resident #1 at the time of the fall. The facility administrator stated that the new intervention is that care will be provided by two staff. In a telephone interview with the surveyor on 7/23/14 at approximately 10:52 AM, the facility administrator stated that she did not have anything to say about Resident #1 being coded as requiring two plus people on his/her Quarterly MDS dated [DATE] and the resident's CNA Resident Profile not reflecting that need until 7/1/14 after the resident rolled out of bed while receiving care.

On the days of the Recertification and Complaint Survey, based on record review, interviews and review of the facility's files in reference to a complaint received by this office, the facility failed to monitor Resident #27 adequately after a significant change in condition was noted. The findings included: The facility admitted Resident #27 to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] coded the resident as requiring limited supervision with bed mobility (2/2) and supervision with transferring (1/1); she/he used a walker for ambulation. On 10/1/12 at approximately 1:08 PM, record review of the Nurse's Notes revealed an entry dated 9/1/12 at 5:50 AM by LPN (Licensed Practical Nurse) #4 that stated Resident #27 was observed "with her//his legs hanging off bed unable to slide herself/himself back up into bed." "Resident does not make eye contact, and does not have good motor controll (sic)." The note further stated that the resident's oxygen saturation was 84-92% and that oxygen was started at 3 liters per minute. The resident gave no verbal response. The physician was notified and instructed the nurse to monitor the resident. There was no documentation that Resident #27 was assessed again until 8:00 AM. Continued review revealed a late entry on 9/1/12 at 6:25 PM by LPN #5 that at 8:00 AM the resident was "noted to have non-voluntary response to stimuli resident (with) eyes open, will not make eye contact. Supervisor notified." Review of the internal investigation conducted by the facility revealed that the Certified Nursing Assistant informed LPN #2 at 7:50 AM that the resident's temperature was low at 94.8 degrees and that the she/he felt cold. The nurse assessed her/him at 8:00 AM and found "her/his skin was cold and she/he was pooch breathing. I checked her/his pupils while calling her/him and I didn't get a response. I ... called (RN Supervisor) and told her/him it wasn't just a [MEDICAL CONDITION] that she/he needed to come check her/him." There was no documentation that LPN #5 assessed the resident again. The facility-obtained statement by LPN #5 during the internal investigation indicated that LPN #5 returned to her/his medication cart and finished her/his medication pass. There was no documentation that LPN #5 called the RN Supervisor again or that she/he had notified the Physician at that time. Further review revealed the RN (Registered Nurse) Supervisor (RN #2) assessed Resident #27 at 9:15 AM and documented that the resident was "unresponsive to verbal/tactile stimuli. Periodically moving Rt (right) extremities (and) lt (left) foot ((with) stimulation) but not on command." ... "Respirations are Kusmal (sic) type. BLE (bilateral lower extremities) cold to touch but not (sic) discoloration noted. Cap. (capillary) refill brisk in fingernail beds - unable to assess cap. refill in toenails r/t (related to) thickness of nails." At 9:20 AM the RN documented "NGS on-call paged" and the Nurse Practitioner returned the call at 9:25 AM and an order to send the resident to the emergency room for evaluation was received. EMS (Emergency Medical Services) was notified at 9:50 AM to transport the resident to the hospital. Review of the closed medical record revealed an Acute Care Visit dated 08/23/2012 that stated, "Chief Complaint: ... had a [MEDICAL CONDITION] arrhythmia when I saw her yesterday. Nursing staff indicated that she was having difficulty with her sleeping, that is what the original complaint was and upon seeing her, it was noted that she had a [MEDICAL CONDITION] a rate of 155 and an irregular rate. She did have an EKG which showed what appears to be in [MEDICAL CONDITION] with no P wave noted on the EKG... (Resident #27) tells me she is feeling much better. Nursing staff reports that she was up out of bed today and ate breakfast... A (Assessment): 1. [MEDICAL CONDITION]. [MEDICAL CONDITION]... P (Plan): Discontinue aspirin 81 mg (milligrams). We will start 325 mg daily. This lady is not a candidate for [MEDICATION NAME] therapy as she ambulates independently. She is unreliable, has poor safety awareness, and is hard to redirect at times. We will give her ASA 325 mg [MEDICATION NAME] coated daily. Blood pressure and pulse b.i.d. (twice a day). We will review that in two weeks... Certainly let us know see if she has chest pain or any uncontrolled heart rate associated with shortness of breath or [MEDICAL CONDITION]" During an interview on 10/1/12 at approximately 4:00 PM, the Director of Nursing (DON) stated that when the nurse received the order to monitor the resident, she/he would have expected the nurse to check the resident every 15-30 minutes and to call the physician back if there was a continued decline or no improvement in the resident's condition. She/he confirmed that the resident was "not adequately assessed." She/he further stated that she/he knew of no other place the nurse would have documented additional assessments "except, maybe on the 24 hour report." The DON was unable to locate any documentation of the resident's status on the 24 hour reports. During an interview on 10/2/12 at 11:40, the Medical Doctor stated that he did not recall being told the resident had a history of [REDACTED]. He further stated that if he had been told she had one-sided deficit or neurological deficit he would have probably sent her out. In addition, the physician stated that the resident's son was in the facility the next day and informed the nursing home administrator that his mother had had a stroke.

On the days of the Complaint and Recertification Survey, based on record review, interviews and review of the facility's files in reference to a complaint received by this office, the facility failed to provide care and services according to accepted standards of clinical practice to Resident #27 when a significant change in condition was noted. The findings included: The facility admitted Resident #27 to the facility with [DIAGNOSES REDACTED]. On 10/1/12 at approximately 1:08 PM, record review of the Nurse's Notes revealed an entry dated 9/1/12 at 5:50 AM by LPN (Licensed Practical Nurse) #4 that indicated that Resident #27 had experienced a change in her usual status. The physician was notified and instructed the nurse to monitor the resident. There was no documentation that Resident #27 was assessed again until 8:00 AM when LPN #5 noted the resident "to have non-voluntary response to stimuli resident (with) eyes open, will not make eye contact. Supervisor notified." Review of an internal investigation conducted by the facility revealed that the Certified Nursing Assistant informed LPN #2 at 7:50 AM that the resident's temperature was low at 94.8 degrees and that the she felt cold. The nurse assessed her at 8:00 AM and found "her skin was cold and she was pooch breathing. I checked her pupils while calling her and I didn't get a response." The RN Supervisor (RN #2) was notified at that time and informed she needed to come check the resident. There was no documentation that LPN #5 assessed the resident again. The facility-obtained statement by LPN #5 during the internal investigation indicated that LPN #5 returned to her medication cart and finished her medication pass. There was no documentation that LPN #5 called the RN Supervisor again or that she had notified the Physician that the resident had continued to decline. Further review revealed the RN Supervisor (RN #2) assessed Resident #27 at 9:15 AM and documented that the resident was "unresponsive to verbal/tactile stimuli. Periodically moving Rt (right) extremities (and) lt (left) foot ((with) stimulation) but not on command." ... "Respirations are Kusmal (sic) type. BLE (bilateral lower extremities) cold to touch but not (sic) discoloration noted. Cap. (capillary) refill brisk in fingernail beds - unable to assess cap. refill in toenails r/t (related to) thickness of nails." At 9:25 AM the Nurse Practitioner returned the 9:20 AM call from the RN Supervisor and an order to send the resident to the emergency room for evaluation was received. EMS (Emergency Medical Services) was not notified until 9:50 AM to transport the resident to the hospital. During an interview on 10/1/12 at approximately 4:00 PM, the Director of Nursing (DON) stated that when the nurse received the order to monitor the resident, she/he would have expected the nurse to check the resident every 15-30 minutes and to call the physician back if there was a continued decline or no improvement in the resident's condition. She/he confirmed that the resident was "not adequately assessed." She/he verified that the actions of the nurse were not consistent with what a prudent nurse would do. During an interview on 10/2/12 at 11:40, the Medical Doctor stated that he/she did not recall being told the resident had a history of [REDACTED]. The physician further stated that if he had been told the resident had one-sided deficit or neurological deficit he would have probably sent her/him out. Cross Refer 483.25 F309 related to the facility's failure to monitor the resident adequately following a change in status.

NOT CORRECTED On the day of the First Follow Up Visit based on record review, interview and review of the facility's Compliance Documents, the deficient practice was not corrected. The facility failed to update Resident #1's care plan regarding the recurrence of her tongue lesion. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes from 3/9/12-3/18/12 revealed Resident #1 had noted tongue [MEDICAL CONDITION] that were "purple and blue in color". On 3/19- 3/23, no tongue [MEDICAL CONDITION] were noted. On 3/24-3/29 the nurses were documenting no bleeding to tongue [MEDICAL CONDITION] noted and no change to tongue [MEDICAL CONDITION]. There was no evidence that the Attending Physician or the Consulting Physician were contacted regarding the tongue [MEDICAL CONDITION] recurrence. There was no evidence of any treatment to the tongue [MEDICAL CONDITION]. Review of the Care Plan dated 2/22/11 revealed a problem area of Resident has risk for open [MEDICAL CONDITION], approaches included "record location, size, color, distribution, contour, consistency with each outbreak" and "treat [MEDICAL CONDITION] per MD order." On 1/13/12 the care plan was updated with the following: "(Attending Physician) visited. No further magic mouthwash needed. Mouth/tongue healed. Will notify (Consulting Physician) if problem arises." Also a new approach was added that revealed: "Monitor for any changes in tongue [MEDICAL CONDITION], bleeding, c/o soreness/pain, any difficulty tol(erating) meals, eating, chewing." During an interview on 3/29/12, the Director of Nurses (DON) confirmed the resident's tongue [MEDICAL CONDITION] and confirmed that the care plan had not been updated with the change in tongue [MEDICAL CONDITION], and confirmed that no treatment had been initiated. Cross Refers to F-309 as it relates to the facility failure to identify Resident #1's recurrent tongue lesion and potential delay of treatment.

On the day of the complaint inspection based on record review and interview, the facility failed to ensure 4 of 6 sampled residents' care plans were periodically reviewed and revised. Resident #3, #4 and #5 had multiple falls, new and appropriate interventions were not put in place to prevent recurrence. Resident #1's care plan was not updated related to the resident's non compliance with the required foot rests. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes and Care Plan revealed Resident #3 sustained 20 falls between 9/13/2011 and 1/12/2012. The resident sustained [REDACTED]. The resident did not have new and appropriate interventions put in place after each fall to prevent recurrence of a similar fall. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Care Plan revealed the care plan was updated with 3 of the resident's 4 falls. No new and appropriate interventions were put in place after each fall to prevent recurrence. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Care Plan revealed Resident #5 sustained 11 falls from 12/2/11 through 1/5/2012. No new and appropriate interventions were updated to prevent recurrence. The care plan also had not been updated to reflect the resident's non compliance with the fall prevention devices. During an interview on 1/31/2012, the Director of Nurses confirmed that a new intervention needed to be put in place after each fall. The DON confirmed Resident #3, #4 and #5's multiple falls. The DON agreed that encouraging the use of a call light was not an appropriate intervention. She also confirmed that Resident #5 removed his devices and continued to stand up and transfer himself. The DON agreed that continuing the current interventions was not an appropriate intervention. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Nurses Notes revealed on 12/13/11 at 1 PM, "Resident was being pushed in wheelchair from therapy to nurses station and fell forward out of chair. Resident hit head on R(ight) side and lying on right side of body. Abrasion noted to R upper arm...Bruise and swelling noted to right side of forehead. Family and doctor informed of fall and condition..." At 3 PM, "Cushion for chair or other intervention requested to physical therapy to prevent falls." On 12/16 at 11 AM, "...Resident's right foot drags occasionally while in w/c (wheelchair). Foot rests on w/c required to elevate foot off floor but resident refuses foot rest d/t complaints that it's not comfortable. Different foot rests tried by therapy and resident still refuses. Family informed of this." Observation of Resident #1 on 1/31/2012 at 6 AM, 9 AM and 3 PM revealed no foot rests were attached to the resident's wheelchair. A pair of foot rests was observed under the resident's vanity in her room. The resident stated that she did not want the foot rests on her wheelchair and stated that she can use her feet to propel herself around her room. Review of the Care Plan dated 2/22/2011 revealed a problem area related to impaired physical mobility related to left [MEDICAL CONDITION] (the resident has right sided paresis), approaches included "make sure foot rests are in place on w/c whenever resident is in it." The care plan had not been updated with the resident's non compliance with the foot rests. During an interview on 1/31/2012, the Director of Nurses confirmed that foot rests were not in place on the wheelchair. She also confirmed the resident's care plan and stated that the resident did not have to have the foot rests in place. She stated that the foot rests were required only when the resident left the building with a transfer service. Cross Refer to F-323 as it relates to the facility's failure to provide each resident with the necessary supervision and assistance devices to prevent accidents.

On the day of the complaint inspection based on record review and interview, the facility failed to ensure 3 of 6 sampled residents' received the adequate supervision and assistance devices to prevent accidents. Resident #3, #4 and #5 had multiple falls; timely and appropriate interventions were not put in place to prevent recurrence. Resident #3 sustained 20 falls in 4 months with several minor injuries; appropriate interventions were not put in place after each fall. Resident #4 sustained 4 falls in a 3 month period resulting in head injuries and skin tears timely and appropriate interventions were not put in place. Resident #5 sustained 11 falls in one month. The resident was known to remove/disconnect his alarms and attempt to stand up. Timely and appropriate interventions were not put in place. The last fall on 1/5/2012 resulted in a hip fracture. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set revealed the resident scored a 6/15 on the BIMS (brief interview for mental status) assessment and was noted to require two person extensive assist with transfers. Review of the Resident's Fall Assessment revealed he was assessed as High Risks for falls. He was also noted to remove his alarms and stand unassisted. Review of the Nurse's Notes revealed Resident #5 had 11 falls from 11/9/2011 through 1/5/2012. The resident was noted on 11/14/2011 to remove his canary alarm. Further review revealed his canary alarm was to be "in use at all times." The falls are as follows: 12/2-fell , intervention was to use call light; 12/9-fell , intervention was a canary alarm (already in use); 12/11-fall, intervention was a bed alarm; 12/15-fell while attempted to go to the bathroom, the resident was encouraged to use his call bell. On 12/16/2011 at 2:30 PM, "resident placed on toilet per staff. Resident attempted to get off toilet s (without) assist. States I was going to bed. Found face down in front of toilet..." The intervention added was for "staff to stay c (with) resident while on commode." On 12/22-fell , intervention was to continue physical therapy (PT was discontinued on 12/23/2011); 12/23 "Resident observed on the floor sitting on his bottom in front of his w/c canary alarm taken off..." The intervention was for a chair mat alarm (the chair mat alarm was d/c'd on 12/30/11); 12/24-fall-the resident was encouraged to stay close to the nurses station; 12/27"Resident found sitting in floor in front of w/c. No injuries noted... Resident conts (continues) to remove tab alert from clothing..."; 12/30-fall-a self release belt was ordered. On 1/5/12 the resident removed his self release belt and fell backwards sustaining a hip fracture. The resident was sent to the hospital. Review of the Physician's Progress Notes revealed a 1/2/2012 note that stated, "...Nursing staff reports that he attempts to get up and walk. He unfastened his alarmed seatbelt with is a soft release..." Review of the Falls Care Plan dated 11/23/2011 indicated the following falls and interventions: "12-2-11 Fall - no injury; intervention "Use call light" 12-9-11 Fall - no injury; intervention "Canary Alarm" 12-11-11 Fall - no injury; intervention "Assist with toileting - Bed Alarm" 12-15-11 Fall - no injury; intervention "Re-educated to use call light" 12-16-11 Fall - no injury; intervention "Staff to stay with resident while on commode" 12-22-11 Fall - skin tear; intervention "Continue PT (physical therapy) with safety training" 12-24-11 Fall - no injury; intervention "Bring to NS (nurses station) to socialize with other residents" 12-27-11 Fall - no injury; intervention "Brought to NS to be supervised" 12-30-11 Fall - no injury; intervention "Self release belt" 1-5-12 Fall - possible fx left hip; intervention "To __Regional Medical Center" The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #3 scored a 14/15 on her BIMS assessment. The resident was also noted as requiring limited one person assistance with transfers and walking in her room. Review of the Nurses Notes and Care Plan revealed Resident #3 sustained 20 falls between 9/13/2011 and 1/12/2012. The resident sustained [REDACTED]. The resident was noted to receive physical therapy between 11/25 and 12/16/2011. The resident was then placed in a restorative ambulation program. On 9/1/11 a canary alarm was ordered. The falls are as follows: 9/13-fall from wheelchair, sustained skin tears- autolock brakes to wheelchair, 9/14, fall from wheelchair- self release belt ordered, 9/20, fall from wheelchair-self release belt replaced, 10/14, fall-continue with belt, 10/19, fall, sustained abrasions-continue interventions, 10/22, fall, sustained skin tears-therapy and maintenance to follow up on autolock brakes, 10/25, fall-canary alarm discontinued and bed mat alarm ordered, 11/4, fall-blue belt to wheelchair (soft belt restraint), 11/10, fell while transferring self-no new intervention listed, 11/15, fell while squatting-sustained skin tears-no new intervention listed, 11/17, fall, sustained skin tears-discontinued restraint and encouraged to use call light, 11/18, fall from wheelchair-Nurse Practitioner to address falls (no progress note noted), 11/25-fell while walking, sustained skin tears-therapy to evaluate and treat (picked up on caseload until 12/16/2011), 12/14, fall from wheelchair-skin tears-1: 1 discussion with resident, 12/21, fall from bed-Nurse Practitioner to evaluate medications (no changes made), 12/25, fall from wheelchair-no interventions listed, 12/30, three falls one from the wheelchair and two from the bed-on 1/2/12 changed rooms to be closer to nurses station, 1/12, fall from wheelchair, sustained skin tears-continue current interventions. The resident did not have appropriate interventions put in place after each fall to prevent recurrence of a similar fall. Review of the Progress Notes revealed no notes related to the resident's multiple falls. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident coded a BIMS of 15/15; required one person extensive assistance with transfers and bed mobility. Resident #4 ambulated with the assistance of a walker or wheelchair. Review of the Nurse's Notes revealed on 10/22/2011 the resident fell and sustained skin tears. The intervention put in place was to encourage resident to use his "reacher." On 11/18/2011 the resident fell again and sustained skin tears to his hand, no new interventions were put in place. On 1/6/2012 the resident fell going to the bathroom, hit his head and sustained skin tears, the intervention was to encourage him to use his call bell. On 1/16/2012 the resident again fell going to the bathroom, he hit his head resulting in a hematoma, the interventions put in place was a bed mat alarm ordered on [DATE]. Review of the Care Plan dated 9/30/2011 listed the following falls with interventions: "10-22-11 fell from leaning forward in w/c (wheelchair) 1/6/12 Fall with skin tear; intervention "use call light and wear fitted clothes" 1/16/12 Fall hit head; intervention "Bedmat alarm ordered..." During an interview on 1/31/2012, the Director of Nurses confirmed that intervention needed to be put in place after each fall. The above information was shared with the DON and Administrator. The DON confirmed Resident #3, #4 and #5's multiple falls. The DON agreed that the encouraging the use of a call light was not an appropriate intervention. She also confirmed that Resident #5 removed his devices and continued to stand up and transfer himself.

On the days of the survey, based on record review and interviews, the facility failed to address complaints of pain in a timely manner for one of thirteen residents reviewed for pain management. Resident #17 complained of pain upon admission to the facility on [DATE] following a [MEDICAL TREATMENT] shunt placement and intermittently thereafter, with no evidence that he was offered relief until 8-2-11. The findings included: The facility admitted Resident #17 on 7-30-11 following insertion of a new vascular access for [MEDICAL TREATMENT] in the resident's right thigh and a thrombectomy and revision of the left thigh graft. He was admitted to the facility for treatment of [REDACTED]. During an interview on 8-9-11 at 10 AM, Resident #17, who was noted as "alert and oriented X 3", stated that he had experienced a great deal of pain when first admitted after having had surgery to his upper thigh. He stated that he had not had anything for pain for "the first couple of days" until the physician had come to see him. Record review on 8-9-11 at 10:05 AM revealed hospital Inpatient Medication Records indicating that the resident had been on [MEDICATION NAME], and [MEDICATION NAME] as needed for pain prior to discharge to the skilled facility. Review of nursing facility admission orders [REDACTED]. Review of the 7-30-11 Nursing Data Collection Tool revealed that, upon admission, the resident expressed pain when asked. There was no evidence in the record that the facility addressed the resident's complant ofpain.. Review of the 7-30-11 7PM-7AM Daily Skilled Nurse's Notes revealed that the resident was in "Very Severe" pain in the "R(ight) arm, Bil(ateral) legs + thighs". On 8-1-11, under Comments/Concerns EVENING Shift", the Daily Skilled Nurse's Notes documented: "Complained of pain @ (at) [MEDICAL TREATMENT] sites. Written down in MD Book to be seen." There was no evidence in the medical record that the facility's Symptomatic Protocol (Standing Orders) for treatment of [REDACTED]. On a regularly scheduled visit to the facility on [DATE], the physician noted "Limb pain...thigh pain...sutures in place in the left inguinal area, as well as two areas on the left anterior [MEDICAL CONDITION] present on the left thigh." At that time, the physician ordered "[MEDICATION NAME] 2.5/500 PO (by mouth) QID (4 times daily)" to be routinely administered "for pain management". During an interview on 8-9-11 at 2:20 PM, the 200 Hall Unit Manager reviewed the record and confirmed that there was no evidence that the resident's pain had been treated by using the facility's Standing Orders or that the physician had been notified of the resident's discomfort. On 8-10-11 at 9:30 AM, she again stated that she had been unable to find where the resident's pain had been addressed prior to the physician's visit on 8-2-11.

On the day of the complaint inspection based on observations, record reviews and interviews the facility failed to provide the necessary care and services for 2 of 10 sampled residents. Resident #3 did not receive the appropriate interventions for respiratory distress. Resident #3 was not sent to the emergency room timely and did not have the necessary interventions put in place after his admission. There was no evidence that Resident #4 was assessed after a fall. Documentation reviewed from the report made to the State Licensing Agency revealed the resident sustained [REDACTED]. The findings included: The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #3 on [DATE] at 9:30 AM revealed the First Responders were arriving at the resident's room. The resident was observed to be pale and was pursed lip breathing. Resident #3 was observed to be on 5 L oxygen via nasal cannula. The resident's oxygen saturation was ,[DATE] %. The first responders placed a non-rebreather mask at 100 % oxygen. Resident #3's saturation slowly increased to ,[DATE]%. EMS arrived at 9:45 AM and transported the resident to the emergency room . Record review on [DATE] revealed Resident #3 did not have a Discharge Summary, Transfer Summary or History and Physical on record. The Director of Nurses located an envelope that included Transfer Orders and a Hospital Course Summary. Review of the Transfer Summary revealed Resident #3 was to have 5 L High Flow Nasal Cannula Continuously. Review of the Hospital Course Summary revealed Resident #3 had "Acute on Chronic [MEDICAL CONDITION], status [REDACTED]. Review of the Nurses Notes revealed on [DATE] at 10:35 PM, Resident #3 was "alert and pale O2 at 5 L, O2 sats ,[DATE]%. Daughter notified and agrees with resident to be sent to emergency room . Nurse Practitioner notified. Resident changed to mask and O2 sat increased to 90 %. Continues to fluctuate." At 10:46 PM, "First responders in to evaluate." At 11:00 PM, "EMS in to evaluate, O2 sats ,[DATE]% on 5 L. Resident alert and talkative, decision made per EMS, ER doc, and resident daughter and resident to remain in facility at this time." At 4:00 AM, O2 sats "fluctuating 70's and low 80's. NP notified new order received gave [MEDICATION NAME] per order. O2 sat increased to 88%." [DATE] at 7:00 AM, "vitals done on resident again O2 sats was (sic) low dtr (daughter) notified and she wanted him sent out to hospital for evaluation and treatment. Oxygen saturations were fluctuating...Ambustar called and awaiting their arrival." At 0915 AM, Ambustar arrived O2 sats were 62% on high flow O2. I informed Ambustar that I would call EMS. EMS arrived around 9:,[DATE]:25 AM. They put O2 on the resident and sats increased to 93%...he was taken via stretcher to SRMC." Review of the EMS paperwork dated [DATE] at 10:50 PM, revealed Nursing staff stated that earlier pt (patient) sat had dropped to 60 while they were changing his diaper and sheets... Partner called ER physician and Dr stated that if he was not showing any signs or symptoms then there was nothing he could do for him. After discussing with staff and pt and daughter we all determined that pt would not be transported unless something changed. Pt and staff was advised to call back if something changed." Review of the Interim Care Plan revealed no care items had been identified. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review revealed [MEDICATION NAME] Nebulizers were added. The administration times were 6 AM, 12 PM, 6 PM, and 12 AM. The 6 AM dose was initialed as given Review of the Nursing Assessment revealed no documentation of the resident's [MEDICAL CONDITION] or the recent [MEDICAL CONDITION]. During an interview on [DATE] at 10 AM, Registered Nurse #1 stated that she received report at 7 AM and she was informed that Resident #3 had dropped his O2 sats and EMS was called. RN #1 stated that she immediately went and assessed the resident. She stated that his saturations were low, in the 80's. RN #1 stated that she administered an [MEDICATION NAME] nebulizer. RN #1 stated that the resident's sats increased to 86%. She stated that she notified the Nurse Practitioner. An order was obtained to send the resident to the emergency department. The daughter and resident were in agreement. RN #1 stated that she then called Ambustar to transport the resident. RN #1 stated that the above events had taken place between 7 and 7:30 AM. RN #1 stated that after 45 min, Ambustar had not arrived and she called them back. They informed her they were in the parking lot. RN #1 then went and assessed Resident #3 again and his O2 sat was 62%. RN #1 stated that she then informed Ambustar that she would call 911. RN #1 stated that she called 911 at 9:15 AM and the first responders arrived at 9:25 AM. During an interview on [DATE], at 10:05 AM, the paramedic transporting the resident stated that if a resident dropped his oxygen saturations and had a history like Resident #3, then the resident should be transported to the ER via an ambulance not transfer service. During an interview on [DATE] at 10:10 AM, the Director of Nurses stated that she expected the nurses to have reported all of the resident's information to the nurse practitioner. The DON also stated that there should not have been a delay in time of getting Resident #3 to the ER. She also stated that residents with respiratory distress should be transported via EMS and not Ambustar. The DON also confirmed Resident #3 did not have an interim care plan developed and did not have the necessary care and services in place for Resident #3. The DON confirmed that RN #1 administered an [MEDICATION NAME] nebulizer without an order. During an interview on [DATE], the Nurse Practitioner stated that she was not aware of the resident's medical history. She stated that staff informed her that Resident #3 had a history of [REDACTED]. The NP stated that she gave the order to send the resident to the emergency room . The NP further stated that she was not aware until 4 AM on [DATE] that the resident did not go to the ER. She learned this when staff called her again. Staff reported that the resident did not go to the ER and that he was still dropping his saturations. The NP stated that she ordered [MEDICATION NAME] Nebulizers. The NP then stated that if she was made aware of the resident's history she would have been more "insistent" that he go to the ER and if needed to be sent to a different hospital for treatment. She confirmed that the nursing staff should relay all pertinent information. The NP also stated that 911 should be called for all emergencies and the Ambustar should not have been called to transport the resident to the ER. During an interview on [DATE], 4 nurses stated that if a resident exhibited respiratory distress then 911 would be called immediately. They stated that the resident would not be left alone. All four stated that if the resident's saturation dropped and was fluctuating then that would constitute an emergency and 911 should be called. All stated that Ambustar should not be called to transport a resident in distress. All four nurses stated that a resident with a change in condition should be reassessed every 15 minutes to assure that the condition did not deteriorate. Review of the facility's policy on Emergency 911 revealed the facility staff is to call 911 when the "residents condition is life threatening, in accordance with his/her advanced directives. Qualified Staff initiates the appropriate procedures i.e. oxygen, CPR...Qualified staff attempt to stabilize and monitor resident until the advance medical team arrive." The facility admitted Resident #4 on [DATE] with [DIAGNOSES REDACTED]. Review of the Incident Report dated [DATE] at 9:10 PM, revealed Resident #4 "was found on the floor in the bedroom by family. Resident lying on L (eft) side with blood on floor, face, elbow and hands." Review of the summary sent to the State Licensing Agency revealed Resident #4 sustained a fracture to his nose. Review of the closed record revealed no nurse's notes. Further review revealed no assessment of the resident's injuries after the fall and no documentation of the resident before or after the fall. Review of the Nursing Admission Assessment revealed no notes written regarding the resident's condition pre or post fall. During an interview on [DATE], the DON confirmed there were no nurse's notes in the medical record and there was no documentation of the resident's injury or the resident's condition after the fall.

On the day of the complaint inspection based on observations, record reviews and interviews the facility failed to assure nursing staff acted in accordance with professional standards of practice for 2 of 10 sampled residents. Resident #3 failed to have the necessary interventions put in place after his admission, did not have an interim care plan developed to address immediate needs after admission, did not receive the appropriate interventions for respiratory distress and was not sent to the emergency room timely. Resident #4 was not assessed after a fall that resulted in a [MEDICAL CONDITION]. The findings included: The facility admitted Resident #3 on 5/5/2011 with [DIAGNOSES REDACTED]. Observation of Resident #3 on 5/9/2011 at 9:30 AM revealed the First Responders were arriving to the resident's room. The resident was observed on 5 L oxygen via nasal cannula; pale and pursed lip breathing. The resident's oxygen saturation was 71-73 %. The first responders placed a non-rebreather mask at 100 % oxygen. Resident #3's saturation slowly increased to 91-93%. EMS arrived at 9:45 AM and transported the resident to the emergency room . Record review on 5/9/2011 revealed Resident #3 did not have a Discharge Summary, Transfer Summary or History and Physical on record. The Director of Nurses located an envelope that included Transfer Orders and a Hospital Course Summary. Review of the Transfer Summary revealed Resident #3 was to have 5 L High Flow Nasal Cannula Continuously. Review of the Hospital Course Summary revealed Resident #3 had "Acute on Chronic [MEDICAL CONDITION], status [REDACTED]. Review of the Nurses Notes revealed on 5/8/2011 at 10:35 PM, Resident #3 was "alert and pale O2 at 5 L, O2 sats 64-84%. Daughter notified and agrees with resident to be sent to emergency room . Nurse Practitioner notified. Resident changed to mask and O2 sat increased to 90 %... At 10:46 PM, "First responders in to evaluate." At 11:00 PM, "EMS in to evaluate, O2 sats 88-90% on 5 L. Resident alert and talkative, decision made per EMS, ER doc, and resident daughter and resident to remain in facility at this time." At 4:00 AM, O2 sats "fluctuating 70's and low 80's. NP notified new order received gave [MEDICATION NAME] per order. O2 sat increased to 88%." 5/9/2011 at 7:00 AM, "vitals done on resident again O2 sats was (sic) low dtr (daughter) notified and she wanted him sent out to hospital for evaluation and treatment. Oxygen saturations were fluctuating... Ambustar called and awaiting their arrival." At 0915 AM, Ambustart arrived O2 sats were 62% on high flow O2. I informed Ambustar that I would call EMS. EMS arrived around 9:20-9:25 AM. They put O2 on the resident and sats increased to 93%...he was taken via stretcher to SRMC." Review of the EMS paperwork dated 5/8/2011 at 10:50 PM, revealed Nursing staff stated that earlier pt (patient) sat had dropped to 60 while they were changing his diaper and sheets... Partner called ER physician and Dr stated that if he was not showing any signs or symptoms then there was nothing he could do for him. After discussing with staff and pt and daughter we all determined that pt would not be transported unless something changed. Pt and staff was advised to call back if something changed." Review of the Interim Care Plan revealed no care items had been identified. Review of the Nursing Assessment revealed no documentation of the resident's [MEDICAL CONDITION] or the recent [MEDICAL CONDITION]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. [MEDICATION NAME] Nebulizers were added per physician's orders [REDACTED]. Cross refers to F309 as it relates to Resident #3's need for emergency care. The facility staff failed to have necessary knowledge related to Resident #3 recent hospitalization and treatment for [REDACTED]. The facility admitted Resident #4 on 4/1/2011 with [DIAGNOSES REDACTED]. Review of the Incident Report dated 4/1/2011 at 9:10 PM, revealed Resident #4 "was found on the floor in the bedroom by family. Resident lying on L (eft) side with blood on floor, face, elbow and hands." Review of the summary sent to the State Licensing Agency revealed Resident #4 sustained a fracture to his nose. Review of the closed record revealed no nurse's notes. Further review revealed no assessment of the resident's injuries after the fall and no documentation of the resident before or after the fall. Review of the Nursing Admission Assessment revealed no notes written regarding the resident's condition pre or post fall. During an interview on 5/9/2011, the DON confirmed there were no nurse's notes in the medical record and there was no documentation of the resident's injury or the resident's condition after the fall. Cross refers to F309 as it relates to Resident #4's need for emergency care. Resident #4 fell at the facility and was injured on 4/1/11, there was no documentation regarding the injury or the resident's condition before or after the fall to provide evidence that necessary care and treatment was given to this resident.

On the days of the survey, based on record reviews, facility policy on care and assessment of Pressure Ulcers, and interview, the facility failed to ensure that a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for four of seven sampled residents reviewed for pressure ulcers. Resident # 23 was admitted [DATE] with a known pressure ulcer. treatment for [REDACTED]. Resident # 22 with a known red area to the back, receiving treatment, was not assessed weekly for changes in the area and effectiveness of treatment. Resident #1 failed to have ongoing documentation available of a pressure ulcer as it was treated to allow staff to accurately determine response to the treatment and the need for possible changes in treatment. During a pressure ulcer treatment observed on Resident #3 the licensed staff failed to implement infection control techniques to ensure healing. The findings included: The facility admitted Resident # 23 on 3/6/10 with [DIAGNOSES REDACTED]. On the weekly skin documentation form dated 3/6/10 the resident was documented by nursing to have a black area to the right heel with no further description/measurement noted. On 3/15/10 the area was documented as "soft and black." There was no physician order for [REDACTED]. ... He has a large decubitus over the right heel. It is covered by skin" . He previously had a blister and nursing staff reported that this has drained and there is some serosanguineous type drainage....Small area in the plantar surface of the right foot that is measuring approximately .5cm (centimeter) in diameter Wound bed in this area is pink, moist. This again is a very superficial area ..." The NP at this time ordered vitamin C, Prosource and Vitamin with Minerals, treatments to both areas, continued use of Podus boots, and floating of the heels while in bed. The physician saw the resident on 3/23/10 and made no changes. A care plan for the pressure ulcer to the heel was not developed until 3/18/10 During an interview with the current Unit Manager and the Unit Manager for the unit on which the resident originally resided, revealed that neither nurse could provide evidence the wound(s) noted on admission had been measured or assessed as pressure areas. There was no documentation found that the facility was providing any treatment to the heel wound from 3/6 until 3/18/10. During the interview, the unit manager stated- "It should have been skin prepped. Anything black we always skin prep to off with." On 3/22/10 a "dark area" to the bottom of the right foot was documented on the weekly assessment form. However, an order was written previously on 3/9/10 to apply skin prep to the ball of the right foot bid until healed (stage I decubitus) . There was no documentation per facility provided policy to include: " location, measurement, appearance, drainage, odor, color, presence of undermining/tunneling, healing, stage if a pressure ulcer, pain and [MEDICAL CONDITION].The resident's admission care plan noted on 3/8/10 the presence of a stage I - "ball of RH foot (?right heel) -skin prep ball of rh foot as ordered." Resident # 22 was admitted to the facility with Arthritis and Bullous Lung Disease. On 6/12/10 a weekly skin assessment noted the resident had a "pink" area to the bony prominence of the mid back and sacral area. On 6/27/10 an order was obtained for Optofoam pad, cover with [MEDICATION NAME] every three days for protection to mid back bony prominence area. On 11/15/10 at 11AM, during an interview with the Unit Manager, she stated although weekly skin assessments were completed, they were done by the weekend nurse who would be unable to see thru the Optofoam pad to visualize the area. There was no documentation that the area was measured. On 11/17/10, during an interview with the Director of Nursing, she verified that a red/pink area over a bony prominence would meet the definition of a Stage I pressure area. She stated she would have expected the area to be measured weekly and to have been included in the pressure ulcer reports submitted to her office. After checking the pressure ulcer records on file in her office, the Director of Nursing stated the resident was not and had not been included in the pressure ulcer reports. Further review of the treatment flow sheet for October 2010 revealed there were no signatures present for the application of the treatment to the back from from 10/17 to 10/29/10. On 11/15/10 at 11AM, during an interview, the Unit Manager and the nurse responsible for the application of the treatment verified there was no documentation that the dressing had been applied per the order. Resident #22 was seen by the Nurse Practitioner (NP) on 11/8/10 who commented: ..."The family was somewhat concerned.... The buttocks area and gluteal cleft are inspected. There is some pinkness in the superior aspect of the gluteal cleft. She has a very prominent coccyx, and some pinkness over these and open areas. ...Upper back approximately T8 through T 12 is pink. She has a foam dressing on, which was removed, and there is some mild what appears to be fungal -type changes to the skin, redness and pinkness, which again blanched, while there are no open areas....." The resident was diagnosed by the NP with a stage I decubitus to the Sacrococcygeal area and started on Vitamin C. The treatment to the mid back was changed at that time. The Facility provided policy for Staging pressure ulcers (Revised 6/08) stated: A stage I pressure ulcer was defined as "intact skin" and a Stage II pressure ulcer was a "partial loss of dermis..." The policy also stated that wounds will be evaluated/documented to include: " location, measurement, appearance, drainage, odor, color, presence of undermining/tunneling, healing, stage if a pressure ulcer, pain and [MEDICAL CONDITION].Treatments should be re-evaluated every 2-3 weeks. If no wound progression noted treatment change should be considered. If no change in treatment done documentation should occur as to why current treatment maintained." The facility admitted Resident #1 on 7/07/10 with [DIAGNOSES REDACTED]. Record review on 11/16/10 revealed the resident to be receiving treatments of Santyl ointment to right heel and wrap for a pressure ulcer. The last documentation found in the record was dated 9/03/10 showing a measurement of 4 cm ( centimeters) by 6 cm 1/2 sealed off pink brown lower area- 1/2 dark purple with surrounding skin normal. On 9/17/10 the wound measured .3 by .8 had scant amount of yellow drainage. An interview with RN #1 (Registered Nurse) revealed she did not do the daily dressings but measured all the wounds weekly. She stated, "I have a sheet I document all the information on and give a copy to the DON (Director of Nursing). I am supposed to transfer the information to each resident's individual Wound Treatment & Progress Record weekly. I goofed. I have not always documented weekly on the individual sheets." The nurses doing the dressings had nothing to compare with in order to make recommendations about continuing or changing treatments. The nurses assigned to do the treatments were the staff nurses on duty each day and not the same nurse each day. There was no continuity of care in treating the wound. The facility admitted Resident #3 on 6/23/10 with a [DIAGNOSES REDACTED]. During an observation of wound treatment for [REDACTED].#3 failed to wash or sanitize her hands between removal of the soiled dressing from the Stage III wound on the top of the left foot and placement of the clean dressing. LPN #3 stated that the dressing was saturated with "yellow, bloody drainage". Prior to placement of the clean dressing, the nurse removed scissors from her pocket and cut a foam dressing for use on the wound without disinfecting or cleaning the scissors prior to use. The dressing was then applied to the Stage III wound. Prior to the wound treatment to the Stage II wound on the left buttock, when the resident was positioned onto her right side, the underpad was noted to be soiled with a red tinged drainage. LPN # 3 stated, "This could be a vaginal drainage". After removal of the soiled dressing, the resident was allowed to turn back onto her back on the underpad without a dressing to the open wound on the left buttock. When the resident was turned back for placement of the clean dressing, an area of red tinged drainage the size and shape of the wound was noted on the soiled underpad. On 11-17-10 at 1:05 PM the Staff Development Coordinator (SDC) provided a facility policy entitled, "Dressing-Absorption Dressing, Application of". Step #10 stated: "Disposes of soiled dressings appropriately. Removes gloves and disposes. Washes hands." The policy then continued with the preparation and application of the clean dressing. An interview was conducted with LPN #3 on 11-17-10 at 12:40 PM. The nurse verified all the above observations and stated, "I messed up with glove changing and handwashing." The nurse stated that she cleaned the scissors prior to placing them in her pocket and she was unaware that the scissors should be cleaned prior to each use.