Every finding on record at Martha Franks Baptist Retirement Center

Based on review of facility policy, record reviews and interviews, the facility failed to ensure Resident (R)1, was free from physical abuse. Specifically, on 02/20/26, R1 had her hands held down and was slapped with an open hand in the face by Certified Nursing Assistant (CNA)3. Findings include:Review of the facility policy titled Abuse, Neglect and Exploitation, with no revision date, states that Physical Abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment.Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to, major depressive disorder and dementia with agitation.Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/25 revealed R1's Brief Interview for Mental Status (BIMS) score was 7 out of 15, indicating severe cognitive impairment. In addition, R1 was independent with toileting and transfers.Review of an Incident Report dated 02/20/26, completed by the Director of Nursing (DON), revealed: [CNA3] reported to the nurse that while attempting to clean the resident's bathroom, the resident [R1] became agitated and combative, spitting, hitting, and punching at the staff member. The staff member stated she held the resident's hands down and 'smudged' the resident in the face with her hand. The staff member reported the incident immediately to the nurse and requested to go home. R1 had no visible injuries.Review of CNA3's Change of Status form dated 02/20/26 revealed the reason for termination as investigation of alleged abuse, self-reported.Review of a local county Police Department incident report dated 02/20/26 revealed the following narrative: Abuse of a Vulnerable Adult. The CNA is reported to have admitted to staff that she assaulted the resident with dementia by means of an open-hand slap during the course of a physical altercation. The CNA was subsequently terminated, and the resident is in no current danger of continued abuse or retaliation. CNA3 was subsequently booked into the county jail.During a phone interview on 03/12/26 at 12:32 PM, R1's RP reported that the facility called to inform her that R1 had an accident and was cleaning herself when the CNA entered the room to assist. The RP stated that the resident spit on the aide and struck the aide in the face with a wet washcloth containing bowel movement (BM), and the aide retaliated against R1. She further reported that the employee was dismissed immediately following the incident. The RP stated that she believed the facility handled the situation appropriately, noting R1's dementia, and confirmed that law enforcement and the physician were notified and that R1 was assessed with no visible injuries.An attempt to interview R1 on 03/12/26 at approximately 1:30 PM was unsuccessful, as she was unable to specifically recall the events involving CNA3 on 02/20/26.During a phone interview on 03/12/26 at 12:16 PM, LPN1 reported that she works on Unit 3, which she described as the locked dementia unit. LPN1 stated that on Friday, 02/20/26, CNA3 was assigned to R1. At the time, LPN1 was monitoring the dining room and observing residents. She asked CNA3 to check on R1. LPN1 reported that CNA3 entered R1's room and observed bowel movement in the bathroom area. LPN1 remained in the dining room while CNA3 exited the resident's room. According to LPN1, CNA3 appeared panicked and stated she needed to go home. When asked why, CNA3 reported that R1 had spit on her and hit her in the face with a wet washcloth containing bowel movement. CNA3 reportedly made a motion with her hand and stated, I did this, indicating she had put her hands on the resident. LPN1 stated she immediately notified the DON and Administrator. CNA3 was asked to remain in sight until the DON and Administrator arrived. LPN1 reported that when she checked on R1, the resident appeared visibly upset but had no visible marks. R1 was observed cleaning the toilet and is generally independent, disliking others invading her space. LPN1 stated that CNA3 was escorted off the unit and out of the building within minutes of the incident. LPN1 noted that this behavior was not typical for CNA3, and residents generally interacted well with her.During an interview on 03/12/26 at 12:53 PM, Social Services (SS) stated that she was notified by the DON regarding the incident involving CNA3 and R1. It was reported that CNA3 self-reported the incident. According to SS, CNA3 stated that she entered R1's room to assist the resident with cleaning bowel movement (BM) on the floor. CNA3 reported that R1 became agitated and combative toward her. SS stated that, at some point during the interaction, CNA3 retaliated and made contact with the resident's face. SS noted she was unable to determine exactly how the contact occurred. SS reported that R1 was assessed for psychosocial concerns following the incident. She stated that R1 is severely cognitively impaired and alert and oriented only to self. When asked about the incident, R1 did not recall the events but indicated that someone had made her angry. SS reported that the resident received multiple follow-up visits, with no signs of emotional distress observed, and continued to participate in activities as usual. SS further stated that R1 was asked if she feared for her safety, if anyone had hurt her, or if she was afraid to be in the facility. According to SS, R1 denied these concerns and stated that she was fine.During an interview on 03/12/26 at 1:23 PM, The DON stated that on Friday, 02/20/26, LPN1 called to report an issue on the unit involving CNA3, who had stated that she just put hands on R1. The DON instructed LPN1 to keep CNA3 at the nurses' station, assess the resident immediately, and ensure R1 was okay. LPN1 confirmed that R1 had been assessed and was unharmed. The DON immediately notified the Administrator and instructed LPN1 to send CNA3 to the Administrator's office while she made her way to the facility. The DON met CNA3 at the Unit 3 exit and escorted her to the Administrator's office, where she and the Administrator interviewed CNA3. CNA3 reported that she had entered R1's room while looking for another resident and observed that R1 appeared to have experienced bowel incontinence, leaving the bathroom soiled. CNA3 stated that R1 was attempting to clean the bathroom and that she began assisting. During the interaction, CNA3 observed a BM-soiled washcloth in R1's hand, and the resident became agitated, spitting and hitting CNA3 with the washcloth. CNA3 stated that she held R1's hands above her head to prevent further hitting and then whopped/smudged the resident's face with an open hand. The DON clarified that CNA3 meant whopped as a slap and described it as smudging the resident's face. When asked what she should have done differently, CNA3 stated, I should have walked away, but I was upset, acknowledging that she was aware R1 had dementia. The Administrator informed CNA3 that her actions constituted abuse, were unacceptable, and terminated her employment. The DON escorted CNA3 to Unit 3 to collect her belongings, clock out, and exit the building. The DON reported that R1's responsible party (RP) and physician (MD) were notified. The MD and a nurse practitioner (NP) who were in the building that day both assessed R1, and no injuries were noted. The DON stated this was the only occurrence involving CNA3.Attempts to interview CNA3 on 03/12/26 at 2:13 PM, 3:00 PM, and 4:55 PM were unsuccessful.The facility provided a Corrective Action Plan, which included the following:On 2/20/2026, CNA reported to Charge Nurse that while assisting the resident in cleaning up her bathroom, the resident became agitated and spit in CNAs face and also slung a washcloth that contained bowel movement onto CNA. CNA stated she held the hands of the resident and struck the resident in the face with her open hand. CNA was immediately removed from the area, interviewed, and terminated by the Administrator and DON.Law Enforcement was made aware of the incident. The report was submitted to the Regional Ombudsman. Nursing Assessment and body audit were completed immediately by nursing staff, and no injuries were revealed. Family was notified of the incident by the Administrator and DON. No policies and procedures were violated by CNA prior to the incident, and CNA was in good standing. CNA employee files contain no disciplinary issues, and CNA has prior abuse training. Residents were monitored for any psychosocial distress or changes by nursing staff as well as Social Services. 1:1 re-education was immediately initiated for staff working in skilled nursing, which included abuse and appropriate response/intervention as well as workplace fatigue. Investigation revealed no physical evidence that abuse occurred. The social worker immediately interviewed all residents who reside in Unit 3 regarding abuse and whether any abuse had been witnessed or experienced. Questions were also asked as to whether or not residents felt safe in the facility. The social worker proceeded to ask all residents of other skilled units as well.MD visited, as well as the PA. MD gave new medication orders, and PA checked on the resident. The social worker contacted the family, who gave consent for a psychiatric evaluation. Family has visited the resident at the facility and walked the resident around and has reported no changes in mood, behavior, or psychosocial status. The social worker has checked in on the resident at least twice weekly and has not observed or been informed of any changes in the resident. The resident continues her normal daily routines.Education immediately began in-house with all staff working in Skilled Nursing. Education consisted of types of abuse and definitions of each, dementia with abuse prevention, de-escalation of behaviors, and how to appropriately avoid these situations. Staff were reeducated regarding who the Abuse Coordinator is and how to notify the Abuse Coordinator of any concerns. The abuse policy was reviewed. Statements were obtained by all staff who work in Skilled Nursing as well.Education is ongoing and will continue until 05/20/26. Nursing Management (DON, ADON, and Unit Managers staff will continue with weekly rounding and audit for any signs of abuse.QAPI is held weekly and will be updated.Allegation of compliance: 02/21/26At the time of the survey, the facility was no longer out of compliance. The deficiency identified has been reviewed and determined to constitute Past Noncompliance (PNC).

Based on observations, staff interviews, and a review of facility policy, the facility failed to properly label and discard expired food items in the main kitchen (1 of 1). This failure to follow proper food storage protocols presents a potential risk to the health and safety of the 79 residents who consume food prepared in the facility's kitchen. Findings include:A review of the facility's policy, titled Food Storage with a Copyright date of 2017, revealed, All stock must be rotated with each new order received, and that rotating stock is essential to assure the freshness and highest quality of all foods. The policy requires that old stock is always used first (first-in - first out method) and that the person designated to put stock away must be supervised to ensure stock is rotated properly. The policy further states that food should be dated as it is placed on shelves if required by state regulation, and that high-risk, ready-to-eat, time/temperature control for safety foods must have visible date marking to indicate the date or day by which the food should be consumed, sold, or discarded. In addition, food items must be stored and handled in a way that maintains the integrity of packaging until ready for use. Leftover food must be stored in covered containers or securely wrapped, clearly labeled, and dated before refrigeration. Refrigerated foods are to be stored upon delivery, and careful rotation procedures are to be followed.On September 16, 2025, at 10:21 AM, an initial entrance was made to the kitchen. The Certified Dietary Manager (CDM) and the CDM in Training were present and confirmed all findings. In the main cooler, one 1-gallon Ziplock bag of shredded cheese was observed not in its original packaging, unlabeled, and marked with a date of 9/17. One 5-lb (pound) bag of sundried tomatoes had been opened with no open date. Two 5-lb bags of shredded carrots had a use-by date of 09/04/2025, and six 5-lb bags of coleslaw mix had a use-by date of 08/25/2025. In the salad/bar cooler, one metal pan of spinach was observed covered with no label; the CDM confirmed the item and a date of 9/5. Additionally, a 1-gallon bag of shredded cheese was present with no label; the CDM confirmed a date of 9/5. In the dry storage closet, one Ziplock bag of croutons, not in original packaging and not labeled, was confirmed by the CDM to have a date of 9/5.An interview with the CDM, in the presence of the CDM in Training, was conducted on September 16, 2025, at 10:55 AM. The CDM stated that the facility receives food from US Foods and PFG, with deliveries occurring twice per week. All dietary staff are responsible for inspecting food storage areas and ensuring that leftover items are properly labeled and stored. The CDM reported that monthly in-service training is held for dietary staff, during which food safety practices are reviewed. The CDM stated that leftovers are stored for no more than three days. An interview with the Administrator, conducted on September 16, 2025, at 1:36 PM, revealed that her expectations for the kitchen include ensuring that all food items are free from expiration and that all leftover food is properly labeled and dated.

Based on review of the facility's policy, observations, and interviews, the facility failed to ensure the proper handling and transport of resident linens in a manner that prevents cross-contamination. This lapse in infection control practices poses a potential risk to resident health and safety by increasing the likelihood of infectious agents spreading.Findings include:Review of the facility's policy titled, Handling Soiled Linens: revised 08/20/2025 stated2. All used linen should be handled using standard precautions (i.e., gloves) and treated as potentially contaminated. Other protective equipment may be required. Examples of linen that may require special handling include, but are not limited to:a. Visibly soiled with blood or large amounts of body fluidb. Residents with contagious conditions such as chicken pox, herpes zoster, or other skin lesions.c. Residents with infectious drainage not contained by dressings or other supplies.d. Residents with infections transmitted by contact (e.g., MRSA, VRE, Clostrioides difficile).Review of facility policy titled Laundry Policy Explanation and Compliance Guidelines: revised 08/20/2025 stated,2. The facility's laundry area will provide hand-washing facilities and products as well as PPE [Personal Protective Equipment].12. Laundry staff will be in-serviced on handling linens and laundry on a regular basis.During an observation of the Laundry Aide (LA) on 09/17/25 at approximately 9:23 AM, revealed the LA was observed not doffing [removing] the washable blue gown, gloves, and/or washing her hands after retrieving dirty laundry from the barrel, in the soiled utility room. The LA attempted hand washing in the soiled laundry area, however, she stated, There is a little bit of soap, but no paper towels, and was observed to be unable to complete the handwashing technique. The LA was then observed walking through hallways, back to the laundry room still wearing the soiled gloves and a washable blue gown. The Surveyor then asked the LA, How often she washed the blue gown? in which the LA stated, After every two laundry washes, did I do something wrong?On 09/17/25 at approximately 9:47 AM, the LA was observed folding and placing a soiled blue gown under the laundry table, in the clean area of the laundry room. Disposable PPE was observed underneath the table, in the clean laundry area.During an interview with the Housekeeping Supervisor (HKS) on 09/18/25 at 8:44 AM, the HKS reported that laundry staff have online education classes through Healthcare Academy. The HKS revealed and acknowledged that the LA had cross-contaminated after retrieving soiled laundry. The HKS reported that the LA knows the procedure for picking up dirty laundry from the soiled utility is as follows: Gown and glove up using yellow disposable gowns, retrieve laundry, doff gown and gloves, wash hands. HKS stated, She knows to doff dirty blue gown, gloves, and wash hands. HKS reported all laundry staff had education on taking dirty laundry to the laundry room in January/February 2025, and staff will have training again regarding the transport of dirty/clean laundry procedures beginning today.During an interview on 09/18/25 at approximately 12:00 PM with the Maintenance/Environmental Director revealed he heard one of his staff did not handle laundry transport correctly. The Maintenance/Environmental Director reported, I just don't know why she does this. The facility does education all the time regarding the transport of soiled laundry, but some don't seem to get it. I have been telling them we're in the window for DHEC and educating, but some still don't get it.

Based on observation, interview, and facility policy review, the facility failed to ensure the floor in the kitchen was free of debris, staff appropriately wore a hair restraint, food items were labeled and dated, expired food items were discarded, and personal items were not stored in the nourishment room. These deficient practices had the potential to affect all residents who received food from the kitchen. Findings included: 1. A facility policy titled, Cleaning and Sanitation of Dining and Food Service Areas, with a copyright date of 2017 revealed, Policy: The nutrition and food services staff will maintain the cleanliness and sanitation of the dining and food services areas through compliance and a written, comprehensive cleaning schedule. In an observation of the second dry storage room on [DATE] at 9:07 AM, there was one individual packet of a sugar substitute and one individual packet of mayonnaise on the floor. During a concurrent observation of the freezer on [DATE] at 9:12 AM, there was a dirty wet towel on the floor at the entrance of the freezer. The Director of Food Services pointed at the wet towel lying on the floor by the freezer and stated it could be a hazard. In an observation of the kitchen on [DATE] at 9:16 AM, there was a cart near the refrigerator that had dirt and a dried yellow stain. In an interview on [DATE] at 11:56 AM, the Director of Nursing stated the kitchen should be kept clean, swept, and mopped. 2. On [DATE] 8:49 AM, Dietary Aide (DA) #8 was observed in the kitchen near the dishwasher area. DA #8's shoulder length hair hung out of the side of the hat. In an interview on [DATE] at 8:50 AM, the Director of Food Services stated DA #8 was not in compliance and, she should not have her hair on the side like that. In an interview on [DATE] at 3:27 PM, the Administrator stated all staff assigned to the kitchen, or staff that went into the kitchen, should have a hairnet because they would not want someone's hair in their food. In an interview on [DATE] at 11:56 AM, the Director of Nursing stated kitchen staff must wear hairnets. 3. A facility policy titled Food Storage with a copyright date of 2017, indicated, 4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables and broken lots of bulk foods. All containers must be legible and accurately labeled and dated. During a concurrent observation and an observation of the first dry storage room on [DATE] at 9:05 AM, there were two large undated plastic containers of rice and an opened, undated bag of pasta. The Director of Food Services (DFS) stated the items should have been labeled. Per the DFS, the staff assigned to label had been out. During a concurrent interview and observation of the second dry storage room on [DATE] at 9:08 AM, there was an undated, unlabeled large container of white substance on the bottom shelf with a scoop in it. The DFS stated the white substance was thickener, it should have been labeled and dated, and the scoop should not have been left in it. During an observation of the walk-in refrigerator on [DATE] at 9:10 AM, there were three undated bags of romaine lettuce and one opened, undated bag of onion. During an observation of the kitchen on [DATE] at 9:16 AM, there was one large unlabeled and undated container of yellow powder, that resembled cornmeal, with a scoop at the bottom of the container. During concurrent interview and observation of the nourishment room on Unit 1 on [DATE] at 9:04 AM, there were individual boxes of cereal with no expiration dates. The Director of Food Services stated items without expiration dates, like the cereal, could result in a resident getting sick. During an observation of the nourishment room on Unit 3 on [DATE] at 9:49 AM, there were individual boxes of cereal with no expiration dates. During an observation of the nutrition room on Unit 3 on [DATE] at 9:50 AM, there was an unlabeled and undated plastic bag that contained red velvet cake and chocolate marble cake. During an observation of the nourishment room on Unit 3 on [DATE] at 9:51 AM, there were two cartons of nonfat milk with expiration date of [DATE]. During an observation of the nutrition room on Unit 2 on [DATE] at 9:55 AM, there was an unlabeled and undated bottle of creamer and a unlabeled and undated bottle of turkey gravy. During an observation of the nourishment room on Unit 2 on [DATE] at 9:56 AM, there were individual boxes of cereal with no expiration dates. In an interview on [DATE] at 3:27 PM, the Administrator stated items with no expiration should not be in circulation and all food products must be dated and labeled. In an interview on [DATE] at 11:56 AM, the Director of Nursing (DON) stated the dietary staff must make sure items were dated and labeled and expired food items were discarded. The DON stated if a resident received the expired milk, gastro-intestinal problems could have been a potential adverse outcome. During an interview on [DATE] at 2:19 PM, the Dietary Manager (DM) stated the dietary aides were supposed check daily for expired items and discard them. The DM stated if any the resident had received any expired food items, sickness like food poisoning was a possible adverse outcome. 4. During an observation of the nourishment room on Unit 3 on [DATE] at 9:35 AM, there were personal items to include a hairbrush, a comb with matted and dusty hair, one pair of glasses, one bottle of hand body lotion, and one bottle of nail polish remover. In an interview on [DATE] at 3:27 PM, the Administrator stated the personal items, should not have been in the pantry. In an interview n [DATE] at 11:56 AM, the Director of Nursing stated the nail polish was not supposed to be in the nourishment room.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure nail care was provided to a dependent resident for 1 (Resident (R)26) of 2 residents reviewed for activities of daily living (ADL). Findings included: A facility policy titled, Fingernails/Toenails, Care of, revised 02/2018, revealed, 1. Nail care includes weekly cleaning and regular trimming as tolerated. The policy revealed, 1. Notify the supervisor if the resident refuses the care. A Resident Face Sheet indicated the facility admitted R26 on 05/21/2018. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of Alzheimer's disease, diabetes mellitus, and dementia with behavioral disturbance. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/2024, revealed R26 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for personal hygiene. R26's Care Plan included a problem statement initiated on 01/25/2022 that indicated the resident required assistance with ADLs due to weakness, cognitive impairment, impaired mobility, impaired balance, and decreased endurance. Interventions directed staff to provide fingernail care as ordered (initiated 01/25/2022). During an observation on 07/29/2024 at 10:01 AM, R26 was in bed and had untrimmed fingernails with peeled nail polish and dark debris underneath their fingernails on both hands. During an observation on 07/29/2024 at 12:35 PM, R26 was in the common area eating. Staff were near the resident giving verbal encouragements. R26's fingernails were uncleaned with dark debris underneath. During an observation on 07/30/2024 at 9:43 AM, R26 was in the common area with dirty fingernails and chipped nail polish on nails with a dark brown unknown substance. On 07/30/2024 at 9:46 AM, Certified Nursing Assistant (CNA)1 stated checking the resident's nails should be done at least every day. CNA1 stated R26 received a shower that morning. On 07/30/2024 at 10:15 AM, CNA2 confirmed R26 had a shower that morning. CNA2 stated that morning he checked the resident's nails to see if there was anything on them. CNA2 stated the resident was a diabetic and CNAs were not able to cut the residents nails, the nurse would. CNA2 stated he would not cut the residents nails but would clean them with a washcloth or wipe. During an observation on 07/30/2024 at 10:19 AM with CNA2 of R26's fingernails, CNA2 looked at the resident's hands and stated he saw a back substance under the resident's fingernails. CNA2 stated the resident's fingernails were long and probably needed to be cut. On 07/30/2024 at 10:23 AM, Licensed Practical Nurse (LPN)3 stated R26's fingernails were not cleaned and needed to be cut. LPN3 stated the resident's fingernails should have been cleaned during the resident's shower that morning. LPN3 stated she was not notified that the resident refused nailcare that morning and the CNA should let her know if the resident had refused. During a follow-up interview on 07/30/2024 at 10:28 AM, CNA2 stated he would not have cut R26's nails because the resident was a diabetic, but he should have let the nurse know and he did not. On 07/31/2024 at 3:21 PM, the Director of Nursing (DON) said nail care was part of the resident's shower. The DON stated her expectation was that nursing staff performed nail care and hand hygiene before eating. On 07/31/2024 at 3:33 PM, the Administrator said her expectation was that the residents were clean and neat to include their nails. She stated nail hygiene and cleaning should be part of the resident's regular shower routine. The Administrator stated the CNA should have reported to the nurse if nail care was not completed.

Based on interview, record review, and facility policy review, the facility failed to develop a care plan to address the wandering behavior of 1 (Resident (R)172) of 22 sampled residents. Finding included: A facility policy titled Care Plans, Comprehensive Person-Centered, revised 03/2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical psychosocial and functional needs is developed and implemented for each resident. A Resident Face Sheet revealed the facility admitted R172 on 03/27/24. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of lack of coordination, muscle weakness, difficulty in walking, falls, Alzheimer's disease, and dementia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/24, revealed R172 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. R172's Resident Progress Notes, dated 04/08/24 at 11:23 AM, revealed the resident often wandered around the unit aimlessly and into other residents' rooms. R172's Resident Progress Notes, dated 04/13/24 at 4:54 PM, revealed at times the resident had to be redirected to stay on the unit and not wander too far. R172's Resident Progress Notes, dated 04/26/24 at 11:08 AM, revealed R172 wandered into other residents' room. R172's Resident Progress Notes, dated 04/28/24 at 5:58 PM, revealed R172 was noted twice during the shift pushing on the patio door or the keypad to try to get outside. The note revealed staff redirected the resident and the resident continued to wander the halls. In an interview on 07/31/24 at 9:22 AM, Certified Nurse Assistant (CNA)18 stated R172 had dementia, was confused, and required redirection. CNA18 stated the resident wandered frequently. In an interview on 07/31/24 at 9:10 AM, Registered Nurse (RN)17 stated she recalled R172 utilized a walker and wandered In an interview on 08/02/24 at 10:08 AM, MDS Coordinator #24 stated R172 wandered on the unit and then the resident started to wander past the therapy hall. She stated they discussed the resident's behavior during a meeting. The MDS Coordinator stated R172 should have had a care plan in place for wandering. In an interview on 07/31/24 at 1:54 PM, the Director of Nursing (DON) reported she remembered R172 began wandering and had to be redirected to stay on the unit and not to wander too far. In a follow-up interview on 07/31/24 at 2:02 PM, the DON stated as soon the staff saw the resident's wandering behavior, a care plan should have been implemented. In an interview on 07/31/24 at 2:42 PM, the Administrator stated she expected to see a care plan with interventions in place related to wandering for the resident.

Based on observation, interview, record review, review of the Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the status for 1 (Resident (R)31) of 22 sampled residents. Specifically, the facility failed to ensure R31's MDS accurately reflected the resident's fall status. Findings included: A facility policy titled, Resident Assessments, revised 03/2022, revealed 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments - conducted for all residents in the facility. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, dated 10/2023, indicated that according to 2. If this is not the first assessment, the review period is from the day after the ARD [Assessment Reference Date] of the last MDS assessment to the ARD of the current assessment. 3. Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment. All relevant records received from acute and post-acute facilities where the resident was admitted during the look-back period should be reviewed for evidence of one or more falls. 4. Review nursing home incident reports and medical record (physician, nursing, therapy, and nursing assistant notes) for falls and level of injury. 5. Ask the resident, staff, and family about falls during the look-back period. Resident and family reports of falls should be captured here, whether or not these incidents are documented in the medical record. A Resident Face Sheet indicated the facility admitted R31 on 08/16/2021. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of Alzheimer's disease, muscle weakness, and lack of coordination. A quarterly MDS, with an ARD of 05/24/2024, revealed R31 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had no falls since admission/entry or reentry or the assessment (which was a quarterly MDS with an ARD of 02/23/2024). R31's Care Plan included a problem initiated 02/14/2022, that indicated the resident was at risk for falls due to weakness, decreased mobility/endurance, pain, and cognitive impairment. An Event Report, dated 02/25/2024 at 9:49 AM, revealed R31 had a witnessed fall in the dining room. An Event Report, dated 03/21/2024 at 11:11 PM, revealed R31 had a fall on their buttocks in their bathroom. During an interview on 07/29/2024 at 2:08 PM, R31 stated they had a fall this year in the dining room. During an interview on 07/30/2024 at 2:02 PM, R31 stated they did have a second fall, which was in their bathroom. During an interview on 07/31/2024 at 2:59 PM, MDS Coordinator #7 stated she pulled incident (event) reports for reference to code the MDS correctly for falls. MDS Coordinator #7 stated the resident's 05/24/2024 MDS should have been coded for two falls. During an interview on 08/01/2024 at 3:36 PM, the Director of Nursing (DON) stated her expectation was for the MDS Coordinator to do their research and examine event reports, progress notes, observation reports, and post-fall assessments to reference and code the MDS accordingly and correctly. During an interview on 08/02/2024 at 10:53 AM, the Administrator stated her expectation was for the resident falls to be included on the MDS. The Administrator stated the two falls R31 had should have been included on the resident's 05/24/2024 MDS.

Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure staff wore personal protective equipment (PPE) for 1 (Resident (R)27) of 5 sampled residents reviewed for infection control, who was on enhanced barrier precautions (EBP). Findings included: A facility policy titled, Enhanced Barrier Precautions with a revision date of 08/2022, indicated, 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). The policy revealed 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing brief or assisting with toileting; g. device care of use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc. [et cetera, and other similar things]); and h. wound care (any skin opening requiring a dressing). According to the policy, 5. EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO [multi-drug-resistant organism] colonization. A Resident Face Sheet revealed the facility admitted R27 on 03/06/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of urinary tract infection, retention of urine, obstructive and reflux uropathy, bladder neck obstruction, and presence of urogenital implants. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/31/2024, revealed R27 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS also indicated the resident had an indwelling catheter. R27's Care Plan included a problem dated 03/06/2024, that indicated the resident had an indwelling urinary catheter related to urinary retention/obstructive uropathy. Interventions directed staff to provide EBP because the resident had an indwelling urinary catheter and to wear gloves and a gown with high contact activities (initiated 06/13/2024). R27's Order History revealed an order dated 06/13/2024, for EBP due to an indwelling urinary catheter, for gloves and gown to be worn with high contact activities, and to make sure a precaution hanger and sign were on the door. An observation on 07/29/2024 at 10:02 AM, revealed Certified Nurse Assistant (CNA)22 entered R27's room and provided the resident a shower. CNA22 wore gloves during the provision of the resident's shower. CNA22 did not wear a gown. During an interview on 07/29/2024 at 10:35 AM, CNA22 stated during R27's shower she only wore gloves. She stated she should have also worn a gown because the resident was on EBP due to having a urinary catheter. During an interview on 08/02/2024 at 11:24 AM, the Director of Nursing (DON) stated she expected the staff to abide by the policy and procedures the Infection Preventionist taught them for EBP. She stated the staff should wear a gown and gloves when they assisted residents with bathing who were on EBP. During an interview on 08/02/2024 at 11:50 AM, the Administrator stated she expected the staff to wear PPE as required.

Based on review of the facility policy, record review and interview, the facility failed to report an alleged violation within 24 hours for 1 of 4 residents reviewed (Resident (R)3. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating states 3.b. Immediately is defined as within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Record review on 12/5/2023 at 10:30 AM revealed the facsimile stapled to the 24 Initial Report was dated 7/26/2023 at 1456 (2:56 PM). The Date/Time of the Reportable Incident was dated 7/24/2023 at 11:30 AM. Review of the progress note dated 7/24/2023 at 11:30 AM revealed discovery of R3 bleeding from her forehead and 911 was called. An interview was conducted with the Administrator on 12/5/2023 at 12:50 PM. She stated, There was a time lapse for the reporting of stitches. She said she was made aware the next morning and went ahead and reported it. She said the Director of Nurses didn ' t think it was a reportable for stitches. She said she in-serviced all the house supervisors on 8/15/2023 in the monthly meeting.

Based on interview and record review, the facility failed to report an allegation of sexual abuse involving Resident (R)3 and unidentified female residents. On 09/15/2022 at approximately 3:55 PM, Licensed Practical Nurse (LPN)2 documented in R3's progress notes that he had been touching female residents inappropriately and that two of the female residents were upset by this. The facility did not report this allegation to state health authorities, and R3 was involved in another allegation of sexual abuse on 12/27/2022. On 01/12/2023 at approximately 10 AM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. The administrator was notified that the failure to report the 09/15/2022 sexual abuse allegations involving R3 constituted immediate jeopardy (IJ) at F609 beginning on 09/15/2022. On 01/12/2023 at approximately 5 PM, the facility provided an acceptable IJ removal plan. On 01/13/2023 at approximately 12 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F609 at a lower scope and severity of D. Findings include: Review of the facility's undated abuse policy revealed It is the responsibility of our employees . to promptly report any incident or suspected incident of neglect or resident abuse Employees must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to, stage 4 chronic kidney disease, type 2 diabetes mellitus, major depressive disorder, and hypothyroidism. The resident scored a Brief Interview for Mental Status (BIMS) of 14/15 as of 12/12/2022, indicating he is cognitively intact. Review of R3's progress notes revealed that, on 09/15/2022, LPN2 noted that R3 had been touching female residents inappropriately - two of the female residents were upset by his actions - he knows he shouldn't be doing this. LPN2 also noted that his actions were reported to Social Services, the responsible party, and the medical doctor. A follow-up note authored by the current Director of Nursing (DON) on 09/16/2022 revealed that the on-call MD ordered an increase in Prozac and required staff to provide supervision to the resident at all times while in public areas with surrounding female residents. Interview with Social Services Director on 01/09/2022 at approximately 4:30 PM revealed she could not remember LPN2 reporting the 09/15/2022 allegation of sexual abuse involving R3. Interview with Medical Director (MD)1 on 01/11/2023 at approximately 2:25 PM confirmed that there was an incident involving R3 in September. On reviewing the 09/15/2022 note, he recalled the notification but could not remember details. Interview with Administrator on 01/12/2023 at approximately 10:15 AM revealed that she could not find the 09/15/2022 incident of R3 inappropriately touching female residents in the facility reportables. Interview with the current DON on 01/12/2023 at approximately 10:17 PM revealed she did not know who LPN2 reported the incident to. When she learned of it the following day, she informed the previous DON as well as the Medical Director. Interview with Social Services Director on 01/12/2023 at approximately 10:52 AM revealed the 09/15/2022 allegation of sexual abuse should have been reported to state health authorities. Multiple unsuccessful attempts were made to interview LPN2 and the previous DON over the course of the survey. The facility's removal plan included: The Licensed Nursing Home Administrator (LNHA) and Social Services Director (SSD) interviewed all interviewable residents for sexual harassment incident notifications or concerns back to 09/15/2022. This was completed on 01/13/2023. The DON completed a medical record review of all non-interviewable resident medical records for identification of inappropriate sexual harassment incidents back to September 15, 2022. Abuse policies were reviewed / updated to include all sources of abuse, including resident - resident. All staff on duty were re-educated by end of day 01/12/2023. SDC provided abuse re-education to all community staff by end of day Friday 01/13/2023. Abuse investigation procedure and documentation process were reviewed by LNHA and DON. DON and designee continued to re-educate Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation was monitored by Social Services Director or designee and care plans were updated as indicated. Staff educated on new interventions either verbally or in writing. 1:1 supervision of resident during waking hours while social services works on possible discharge planning for resident. 1:1 supervision initiated at 8 PM 01/11/2023. Resident placed on 1:1 supervision when out of room. Resident moved to private room on another unit and 1:1 continued. Behavior monitoring documentation as well as all investigations to be reviewed at all QAPI meetings.

Based on review of the facility policy, record reviews and interviews, the facility failed to protect 1 of 7 residents from sexual abuse. Resident (R)3 inappropriately touched R4 on 12/27/2022 at approximately 5:15 PM. This was observed by multiple staff members. After the incident, R3 was left unsupervised in his room, which resulted in R3 touching R4 inappropriately, again. On 01/11/2023 at approximately 3:50 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. The Administrator was notified that the allegation of sexual abuse constituted immediate jeopardy (IJ) at F600 beginning on 12/27/2022. On 01/12/2023 at approximately 5 PM, the facility provided an acceptable IJ removal plan. On 01/13/2023 at approximately 12 PM, 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. Findings include: Review of the facility's undated abuse policy revealed, Sexual abuse was defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to, stage 4 chronic kidney disease, type 2 diabetes mellitus, major depressive disorder, and hypothyroidism. The resident scored a Brief Interview for Mental Status (BIMS) score of 14/15 as of 12/12/2022, indicating he was cognitively intact. R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Parkinson's disease, type 2 diabetes mellitus, muscle weakness, vascular dementia, and cerebral infarction due to thrombosis of unspecified cerebral artery. The resident scored BIMS score of 07/15 as of 10/12/2022, indicating mild cognitive impairment. Review of R3's care plan revealed he was care planned for sexually inappropriate behaviors / actions. An intervention added on 09/16/2022 required staff to provide supervision to the resident at all times while in public areas with surrounding female residents. Review of facility investigation of sexual abuse allegation involving R3 and R4 revealed that on 12/27/2022 at approximately 5:15 PM, R3 woke from a nap and needed to be changed. He grabbed his Certified Nursing Assistant (CNA) during care between her legs and on her breast. Another CNA assisted but he started touching her as well. A third CNA was brought in for redirection. After care was finished, R3 left his room. He approached R4 as she was walking toward the dinner table and grabbed her between the legs. LPN1 intervened and separated them. The Administrator, Emergency Medical Services, and police were notified. The resident refused hospitalization , and the police warned him that his actions could warrant legal repercussions. Review of CNA2's statement revealed she went into R3's room to find he had soiled his bed. As she tried to clean him, he grabbed her breast and buttock. She told him to stop. Review of CNA1's statement revealed she heard a fell ow CNA needed help with changing R3 because he was inappropriately touching her. She went in to assist, but when the resident was inappropriate with her as well, she went to get a male CNA. Interview with R4 on 01/09/2023 at approximately 12:17 PM and 1:37 PM revealed that on 12/27/2022 at approximately suppertime, she came out of her room to go to the nurse's station. She heard someone call her name. Turning around, she saw R3 who then grabbed her between the legs. Interview further revealed that R4 was alright but she didn't think she would ever be alright with R3 around anymore. During an interview with CNA1 on 01/09/2023 at approximately 12:45 PM, she confirmed her statement. She entered R3's room to assist CNA2 in changing him - since the resident was groping her. He started doing the same thing to her. She was able to find a male CNA who could calm the resident. She then left to pass out supper trays. At this time, R4 was walking in the hallway to come up for dinner. R3 was also in the hallway and grabbed her between the legs. CNA1 told R3 he cannot do that and tried to separate them. CNA3 took R3 to his room, then went to help the rest of the staff pass out meal trays. CNA1 observed R3 grab R4 again in the main dining area before he was separated again. R4 was upset about the incident and how R3 was still on the unit and gets to get away with it. The facility now requires that R3 be supervised at all times if he is outside of his room. During an interview with CNA2 on 01/09/2023 at approximately 1:07 PM, she confirmed her statement. R3 was grabbing her while she tried to provide care during supper. The resident had a history of grabbing people. She later observed R3 grab R4 between the legs. This happened a few times that day, and she was able to confirm that she witnessed R3 grab R4 a second time while she was in the dining area. Interview with Administrator on 01/09/2023 at approximately 1:20 PM revealed Licensed Practical Nurse (LPN)1 was in the hallway passing medications when R3 was going to supper. Staff had just gotten R3 up. He was put in a wheelchair which he can self-propel. He rolled up to R4 and grabbed her between the legs. LPN1 notified the Administrator at this time. Staff consoled R4 and took her to the dining room while CNA3 took R3. The Administrator told R4 she would try to get R3 out of the building. During an interview with LPN1 on 01/09/2023 at approximately 1:30 PM, she confirmed her statement. R4 was using a walker while R3 approached her with his wheelchair. He grabbed her between the legs. LPN1 told him to stop and separated them, then notified the Administrator. Interview with CNA1 on 01/09/2023 at approximately 2:10 PM confirmed that CNA1 witnessed R3 grope R4 on two occasions: once in the hallway while R3 was on her way to supper and again during supper in the dining area when CNA3 was helping to pass out trays. Interview with CNA2 on 01/09/2023 at approximately 4:04 PM also confirmed that R3 groped R4 twice. The first time was in the hallway and the second time was in the dining room. Interview with Psychiatric Consultant (PC)1 on 01/09/2023 at an unspecified time, revealed she saw R3 after the incident. R3 has tested alert and oriented since she first saw him as a patient. He has been on antidepressants for mood and inappropriate sexual behaviors. The resident at times downplays the incident. At other times, R3 denies the incident occurred. The resident has been warned that he is crossing into legal territory, but he has disregarded this. Interview with Medical Doctor (MD)1 on 01/09/2023 at an unspecified time, revealed that R3 has not denied his behaviors. The resident has been reminded that his behavior could be criminal and require intervention from law enforcement or expulsion from the facility. The resident has acknowledged this. MD1's assessment is that while, at times, R3's health conditions and kidney failure might impair his capacity, the resident is overall able to understand the difference between right and wrong and the implications of his decisions. It is possible that his health conditions have unmasked bad behaviors and lowered inhibitions, but these behaviors place other facility residents at risk. Interview with Administrator on 01/11/2023 at approximately 12:05 PM revealed that CNA3 left R4 unsupervised in his room to assist staff passing out trays. This occurred minutes after he had groped R3 in the hallway. She denied that R3 touched R4 a second time, however, revealing that CNA1 intervened in the dining room before he touched R4. Interview with CNA1 on 01/11/2023 at approximately 12:25 PM confirmed the Administrator's recount of events on 12/27/2022. CNA1 stated that she was misunderstood about whether R3 succeeded in touching R4 a second time. Multiple unsuccessful attempts were made to interview LPN2 and the previous DON over the course of the survey. The facility's removal plan included: The Licensed Nursing Home Administrator (LNHA) and Social Services Director (SSD) interviewed /assessed residents in neighborhood with BIMS scores of 9 and above for potential abuse. Concerns were not identified. Nursing supervisors and SSD and designee updated resident behavior monitoring sheets to describe specific behaviors and staff response. Resident evaluated and continues to be evaluated by primary care provider. Resident continues to have monthly and PRN therapy scheduled with licensed mental health professional. 1:1 supervision of resident during waking hours while social services works on possible discharge planning for resident. 1:1 supervision initiated at 8 PM on 01/11/2023. Resident will not be seated near female resident(s) at activities, dining, etc. when at all possible. IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions. Care plan revisions and interventions communicated to front line staff caring for resident on 12/28/2022. LNHA immediately re-educated staff on duty re: abuse on day of event. Abuse policies were reviewed / updated to include all sources of abuse, including resident - resident. Staff Development Coordinator (SDC) provided abuse re-education to all community staff by end of day Friday 01/23/2023. Abuse investigation procedure and documentation process were reviewed by LNHA. Abuse policies were reviewed/updated to include all sources of abuse, including resident - resident. All staff on duty were re-educated by end of day 01/12/2023. SDC provided abuse re-education to all community staff by end of day Friday 01/13/2023. Abuse investigation procedure and documentation process were reviewed by LNHA and DON. DON and designee continued to re-educate Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation was monitored by Social Services Director or designee and care plans were updated as indicated. Staff educated on new interventions either verbally or in writing. 1:1 supervision of resident during waking hours while social services works on possible discharge planning for resident. 1:1 supervision initiated at 8 PM on 01/11/2023. Resident placed on 1:1 supervision when out of room. Resident moved to private room on another unit and 1:1 continued. Behavior monitoring documentation as well as all investigations to be reviewed at all QAPI meetings.

Based on interview, record review and review of the facility policy, the facility failed to ensure that the use of an PRN (as needed) psychoactive medications was not continued beyond the 14 days without documentation from the resident's physician the indication for continued use for one of five residents (R)59 reviewed for unnecessary medications, resulting in the potential for adverse side effects from an unnecessary medications. Findings include: Review of R59's Face Sheet (undated) located in the Electronic Medical Record (EMR) under the Resident tab indicated R59 was admitted to the facility on [DATE] with diagnoses of dementia in other diseases classified elsewhere without behavioral disturbance and generalized anxiety disorder. Review of R59's Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 03/22/22 located in the EMR under the RAI tab revealed R59, that a Brief Interview for Mental Status (BIMS) had not been completed, indicating the resident was severely impaired-never/rarely made decisions. Review of R59's Physician's Orders dated March 22, 2022, located in the EMR under the Orders tab revealed that R59 was prescribed [MEDICATION(S)] (antipsychotic medication) oral concentrate two milligrams (mg) per milliliter (ml) and to give 0.5-1ml by mouth every four hours as needed (PRN) for restlessness and agitation. Review of R59's Medication Administration Record (MAR) dated March 2022 located in the EMR under the Orders tab revealed R59 began taking [MEDICATION(S)] 0.5 -1 ml by mouth every 4 hours PRN on 03/22/22 and the justification for use was .for restlessness and agitation . Review of R59's MAR dated April 2022, revealed R59 had taken [MEDICATION(S)] every day through 04/22/22. During an interview with the Pharmacy Consultant on 04/22/22 at 12:21 PM, she verified that she was in the facility on 04/19/22 and had not looked at R59's [MEDICATION(S)] order. She stated that it is the facility's responsibility to let her know when a medication should be reviewed. During an interview with the facility's Medical Director on 04/22/22 at 1:40 PM, the Medical Director stated that he doesn't use [MEDICATION(S)] as a long-term medication for residents. Review of the undated facility's policy titled, Medication Monitoring and Management, indicated, .Evaluate the use of current PRNs and discuss with MD continued need .

Based on interview, record review, and review of the facility policy, the facility failed to ensure that the consulting pharmacist identified during the monthly medication regimen review all irregularities. Specifically, a resident had an order for an as needed (PRN) antipsychotic medication and there was no indication of a 14 day stop date or that the consulting pharmacist identified this issue for one resident (R)59 of 5 residents reviewed for unnecessary medications, resulting in the potential for adverse side effects from an unnecessary medication. Findings include: Review of R59's Face Sheet (undated) found in the Electronic Medical Record (EMR) under the Resident tab indicated R59 was admitted to the facility on [DATE] with diagnoses of dementia in other diseases classified elsewhere without behavioral disturbance and generalized anxiety disorder. Review of R59's Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 03/22/22 found in the EMR under the RAI tab revealed R59 did not have a Brief Interview for Mental Status (BIMS) completed, indicating the resident never/rarely made decisions. Review of R59's Physician's Orders dated March 22, 2022, located in the EMR under Orders tab revealed that R59 was prescribed [MEDICATION(S)] (antipsychotic medication) oral concentrate two milligrams (mg) per milliliter (ml) and to give 0.5-1ml by mouth every four hours as needed (PRN) for restlessness and agitation. Review of R59's Medication Administration Record (MAR) dated March 2022 located in the EMR under the Orders tab revealed R59 began taking [MEDICATION(S)] 0.5 -1 ml by mouth every 4 hours PRN on 03/22/22 and the justification for use was .for restlessness and agitation . Review of R59's MAR dated April 2022, revealed R59 had taken [MEDICATION(S)] every day through 04/22/22 Review of R59's Progress Notes from March 2022 to April 2022 in the EMR under the Progress Notes tab, revealed no pharmacy reviews, or recommendations, regarding the use of [MEDICATION(S)]. During an interview with the Pharmacy Consultant on 04/22/22 at 12:21 PM, she stated that she was aware that a PRN antipsychotic should have a 14 day stop date and should have been reviewed by the doctor for recommendation to continue or discontinue using the medication. During an interview with the facility Medical Director on 04/22/22 at 12:40 PM, the Medical Director stated that he doesn't use [MEDICATION(S)] long term. He also stated that he would follow protocol and review the medication after 14 days of the medication being used. Review of the undated facility's policy titled, Medication Monitoring and Management, indicated, .PRN orders for antipsychotic drugs are limited to 14 days. Orders cannot be renewed unless physician evaluates the resident for continued appropriateness of medication .

Based on observation, interview and review of the facility policy titled, Used Grease and Dumpster Policy, the facility failed to ensure the grease pit was not overflowing with old grease, and trash was put into the dumpsters and not on the cement around the dumpsters. The facility further failed to ensure a light colored thin substance was not leaking from any of 4 dumpsters. The findings included: An observation on 1/13/2021 at approximately 8:00 AM of the grease pit revealed old black grease running down the front of the receptacle and onto the cement. Further observation on 1/13/2021 at approximately 8:00 AM of the facility's 4 dumspters revealed trash around the dumpsters on the cement and not inside the receptacles, and a light colored thin substance was on the cement around the dumpsters. An interview on 1/13/2021 at approximately 8:00 AM with the Infection Control nurse verified the findings and he/she stated that he/she was not why the grease pit was running over, the trash was outside the dumpsters and he/she did not what the thin, light colored substance was leaking from the dumpsters. Review on 1/13/2021 at approximately 8:45 AM of the facility policy titled, Used Grease and Dumpster Policy, states, Food Service Director has a monthly calendar to check grease area for spilled grease on the first of each month and to keep area cleaned accordingly. Food Service Director checks the dumpsters along with the grease area on the first of the month. Regarding the dumpsters, areas checked are dumpster lids, plugs and cleanliness. All areas needing attention will be addressed immediately.

Based on observations, interviews and review of the facility policy titled, Food Storage, Food Service Department, Dress Code, and Satellite Kitchen Cleaning Policy, the facility failed to ensure foods are stored, prepared and served under sanitary conditions in 1 of 1 kitchens and 1 of 3 satellite kitchens reviewed. The findings included: During initial tour of the kitchen on [DATE] at approximately 11:30 AM revealed the Dietary Manager with no hair restraint and moving about the kitchen. Further review of the kitchen during initial tour revealed: a. A piece of cake wrapped in plastic had no date in the reach in cooler. b. A bottle of lemon juice opened with no date in the reach in cooler. c. A container of cooked bacon and a container of cookedeggs covered in plastic with no date in the walk in cooler. d. A carton of milk that was expired in the reach in cooler. e. A container of Ambrosia in the reach in cooler was expired. f. Food was stacked in boxes on the upper shelves in the freezer 2 - 3 inches from the ceiling. An interview on [DATE] at approximately 12:01 PM the dietary manager confirmed the findings. An observation on [DATE] at approximately 1:35 PM of the satellite kitchen on Unit 2 revealed: a. An ice scoop in the holder with a small amount of water and a black substance in the bottom. The scoop container had no drainage. b. A moderate amount of dried spillage/splatter on all 4 sides of the microwave. c. The ice machine had a build up of a black substance around the inner rim. d. A piece of chocolate pie wrapped in plastic wrap inside the unit refrigerator with no date. An interview on [DATE] at approximately 1:35 PM with the Dietary Manager confirmed the findings. Review on [DATE] at approximately 2:30 PM fro the facility policy titled, Food Storage, states under Procedure #11, Food will be stored a minimum of 6 inches above the floor, 18 inches from the ceiling and 2 inches from the wall on clean racks or other clean surfaces, and is protected from splashes, overhead pipes, or other contamination, (ceiling sprinklers, sewer/waste, disposal pipes, vents, etc.). Further review of the Food Storage policy states under #13, Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Left over food is used within 7 days or discarded . Review on [DATE] at approximately 3:00 PM of the facility policy titled, Food Services Department, Dress Code, states under, Hair Restraints, All employees engaged in food service prep, serving or kitchen work need to wear a hair restraint. Review on [DATE] at approximately 3:00 PM of the facility policy titled, Satellite Kitchen Cleaning Policy, states, Ice Machine - The maintenance department empties and cleans and sanitizes all parts semi-annually. Ice scoop and scoop holder - All ice scoop holders that are not equipped with drainage holes are to have drainage holes drilled.

Based on observations, record reviews and interviews the facility failed to have physician orders [REDACTED]. Resident # 10 was admitted to the facility on [DATE] and reentered the facility on 8/6/2020 with [DIAGNOSES REDACTED]. Cross reference F656. The findings include: On 1/11/2021 at approximately 11:52 AM Resident # 10, who was unable to speak clearly, showed the bloody top of his/her head to the Surveyor. During a follow-up visit with Resident # 10 on 1/13/2021 at approximately 11:35 AM he/she removed cap revealing approximately 2-3-inch streaks of dried blood atop his/her head. A review of the resident's physician orders [REDACTED].# 1 failed to show an order for [REDACTED].# 1 stated that the resident was known to pick the top of his/her head, that there had been an order for [REDACTED].# 1 stated that Certified Nursing Assistants should have noted any concern after the resident's bath on 1/12/2021. LPN # 1 proceeded to create the following order Cleanse red area to top of head with ns (normal saline), apply abt (antibiotic) ointment, cover with gauze and secure with tape, change every night and PRN (as needed) until healed.

Based on observations, record reviews and interview the facility failed to assure that expired medications were removed from active drug storage in 1 of 3 medication rooms. The findings include: On 1/11/2021 at approximately 12:05 PM inspection of the Hall 100 Medication Room revealed: -one opened and undated 15 ml (milliliter) bottle of Refresh Tears by Allergan belonging to Resident # 47. The manufacturer labeling states: Discard 90 days after opening. -the medication room refrigerator revealed one bottle of Magic Mouthwash #1 belonging to Resident # 53 that had been labeled by pharmacy discard after 12/17/2020. On 1/11/2021 at approximately 12:17 PM Registered Nurse # 1 verified and acknowledged these findings.

Based on observation, interview, and review of the facility's policy titled Handling Cold Foods for Trayline, the facility failed to ensure that foods were held at the correct temperature before serving. Tuna salad on lettuce was not held at a temperature of 41 degrees or cooler in 1 of 3 dining rooms observed with food served in the dining room. The findings included: On 05/01/19 at 12:04 PM, observations of food temperatures revealed one tuna salad on top of lettuce that had a temperature of 48.3 degrees sitting on top of ice in a plastic tub. The Dietary Aide and the Dietary Technician were both aware of the temperature of the tuna salad. The Dietary Technician instructed the Dietary Aide to place the salad back on the ice. At 12:34 PM, the Dietary Aide plated an item from the tray line and a Certified Nursing Assistant picked up the tuna salad and placed it on the tray to be served. Delivery of the tray was stopped by the surveyor. During an interview at that time, the Dietary Technician confirmed the temperature had been 48.3 degrees. When asked, the Dietary Technician knew the tuna salad had to be maintained at a temperature of 41.0 degrees or less and had not stopped the Dietary Aide from placing the salad on a tray to be served. Review of the facility's policy titled Handling Cold Foods for Trayline, revealed 3. Cold temperatures will be taken and recorded prior to and halfway through service to assure foods are (less than or equal to) 41 (degrees) F (Fahrenheit).

Based on interview and review of the facility's documentation, the facility failed to monitor results of a Performance Improvement Plan (PIP) to determine if changes were effective at ensuring foods were at the appropriate holding temperature or if the interventions should be revised. The findings included: On 05/02/19 at approximately 02:45 PM, the Nursing Home Administrator (NHA) provided a PIP (Performance Improvement Plan) related to recording of food temperatures and ensuring they were within regulations. Further review revealed the PIP was documented as completed on 03/29/19. Other issues also identified related to food service included in the PIP were documented as completed on 04/04/29. During an interview on 05/02/19 02:53 PM, the Nursing Home Administrator (NHA) confirmed the PIP was completed and that there was no plan in place for monitoring to ensure continued compliance. The NHA confirmed the PIP had been ineffective.

Based on record review and interview the facility failed to provide the required written notice of transfer to the resident/ resident representative for Resident's #12, #51, #35 and # 22 at the time of a facility initiated transfer. 4 of 5 reviewed for transfer to the hospital. The findings included: Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. muscle weakness, [MEDICAL CONDITION],chronic pain, history of UTI's, [MEDICAL CONDITIONS],Essential Hypertension, [MEDICAL CONDITION], Gastro-[MEDICAL CONDITION] Reflux disease, overactive bladder, urinary incontinence, abnormal weight loss, Cognitive communication on deficit, Wedge compression fracture of first lumbar vertebra, Major [MEDICAL CONDITION], lack of coordination, shortness of breath, pain in unspecified knee and [MEDICAL CONDITION]. During record review there was no documentation that the Resident/ Resident's Representative was notified of the transfer to the hospital as soon as practicable. During an interview on 05/15/18 at approximately 03:45 PM, the Director of Nursing (DON) stated, We have not provided written notification to the resident/ Resident's Representative of the transfer to the hospital. On 05/16/18 at approximately 10:46 AM the Unit Manager confirmed and stated, We make the Residents Representative (RR) aware at the time of a transfer to the hospital, but we have not given written notification to the RR. The facility admitted Resident #22 on 4/4/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Progress Note dated 3/21/18 at 1:28 PM indicated, Sent to ER as ordered by Nurse Practitioner, (RP) notified . The Progress Note dated 3/21/18 at 10:49 PM indicated, This writer spoke with LCMH staff Nurse and informed resident admitted to Hospital 2nd floor with Dx: UTI. Called residents (RP) to inform but already aware . There was no documentation in the medical record to indicate the resident and/or resident's Responsible Party was provided with a written notification of the reason for the transfer to the hospital. The facility admitted Resident #12 on 01/30/17 with [DIAGNOSES REDACTED]. At 1:23 PM on 05/16/2018, review of the Nursing Progress Notes revealed on 04/26/18 Nurse called into residents room by concierge due to resident not responding appropriately. Upon entering room resident was observed to have slow response. Mental status checked and responses were as follows (sic) where are you resident stated Martha Stewart, year 1977, no response when asked who our current president was. O2 (oxygen) saturation was 78% via NC (nasal canula) 3L/min (liters per minute). Resident was unable to follow simple breathing technique instructions. Lung sounds were clear upper and lower right lobe but diminished in left upper and lower lobe. Resident observed using accessory muscles. Vital signs were obtained and were as follows: B/P (blood pressure) 143/67 Temp (temperature) 97.9 Pulse 110 Resp (respirations) 21 O2 saturations fluctuating between 78-90%. Due to unstable o2 saturations ems (sic) was called at 7:38 pm. Resident left via stretcher at 8:20pm en route to Greenville per request of POA ( .). Resident #12 was admitted to the hospital and returned on 04/30/18. There was no documentation that written notice of transfer was provided to the resident or the resident's representative. The facility admitted Resident #35 with [DIAGNOSES REDACTED]. On 05/15/18 at 10:10 AM, review of the Electronic Health Record revealed Resident #35 was hospitalized from 3/9-3/19/18 following a fall resulting in a [MEDICAL CONDITION]. Further review revealed Resident #35 was also hospitalized from 05/07-05/09/18. On 05/15/18 at 10:12 AM, review of Nursing Progress Notes revealed on 3/09/18 the resident's roommate cam outside of the room calling for help. The nurse entered the room and observed the resident on the floor on the left side of the bed. The resident said the left hip hurts a lot when touched. The NP was notified and order received for hip x-ray 2 views and pelvic x-ray. At 9:46 PM, the nurse documented X-ray results were as follows: There is a comminuted left intertrochanteric fracture with impaction. The joint shows no dislocation. Conclusion: Acute left [MEDICAL CONDITION]. EMS (Emergency Medical Service) was called and the resident left via stretcher at 8:00 PM and the resident was admitted to the hospital. The RP was notified by phone of the transfer but there was no documentation that written notice of transfer was provided to the resident or resident representative. At 9:21 AM on 05/16/2018, further review of the Nursing Progress Notes revealed on 05/07/18 the CNA (Certified Nursing Assistant) observed the resident exhibiting [MEDICAL CONDITION] activity and called the nurse. Vital signs were taken, the MD (Medical Doctor) was notified and a new order received to send the resident to the emergency room for evaluation. The Responsible Party was notified by phone. There was no documentation that the resident or resident representative received written notice of the reason of transfer.

Based on review of facility files and interview, the facility failed to ensure each resident remained free from abuse and neglect. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. LPN #1 was attempting to cut Resident #1's finger nails and the resident resisted. CNA #1 and CNA #2 held the resident down while LPN #1 cut the resident's finger nails. The tips of the resident's fingers were nicked and the resident's arms and hands were bruised during the incident. One of three residents reviewed for incidents. The findings included: The facility reported alleged abuse for Resident #1. Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area herself/himself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 2. The Quarterly MDS coded Resident #1 as rejecting care and having physical behaviors toward others 1-3 days during the assessment period. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said h/she would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. In an interview with the surveyor on 2/14/18 at approximately 2:10 PM, the Healthcare Manager stated s/he found out about the incident the next morning. S/he was on the way to a conference out of town and the DON informed him/her about the incident. The DON was riding with the Healthcare Manager on the way to the meeting. The DON told him/her the nurse the day before had clipped Resident #1's fingernails and cut the tips of his/her fingers. The DON said there was an old skin tear that had reopened and a lot of bruising to that arm. The DON stated s/he was going to have to investigate and report the incident. It was about 7:00 AM when the DON told him/her about the incident. The DON had not reported it at that point. The DON called the number to report the incident and left a message, sometime between 7:00-7:30 AM. The DON started his/her investigation when they got back that afternoon. The Healthcare Manager saw the resident's fingers the next day when the nurse manager had unbandaged the fingers and was redressing them. The pinky fingers had a good bit nipped off the end of the fingers. All 5 fingers on one hand and the pinky of the other all had clipped areas on the cuticles. The pinky was still bleeding on one hand. There was bruising on one arm and was the same that had the most of the clips on it. It was bruised all the way up to the elbow, dark purple. The Healthcare Manager talked with the resident's son /daughter on 1/10/18 and told her/him it had been reported to law enforcement. S/he asked if it had been reported to DHEC and they said yes. Review of CNA #1's Status Change Form dated 1/10/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #1's Time Card revealed s/he worked 6:45 AM to 3:09 PM on 1/8/18 and 6:46 AM to 1:18 PM on 1/10/18. Review of CNA #2's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #2's Time Card revealed s/he worked 6:43 AM to 2:38 PM on 1/8/18 and 6:59 PM to 3:13 PM on 1/9/18. Review of LPN #1's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of LPN #1's Employee Time Card revealed s/he worked 6:40 AM to 7:22 PM on 1/8/18. Review of the facility's Abuse Investigations Policy revealed all reports of resident abuse, neglect and injuries of unknown source shall be thoroughly and promptly investigated by facility management. Employees of this facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. Review of the facility's Abuse Prevention Program revealed residents have the right to be free from abuse and neglect. Policy Interpretation and Implementation included the protection of residents during abuse investigations.

Based on review of facility files and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. The resident was noted to have the behavior of refusing care. Resident #1's care plan was not followed related to how staff should respond to the resident's behavior. Resident #2's care plan was not followed by CNA #3. Resident #2 was noted to require 2 staff for ADL care and CNA #3 provided care to the resident without additional staff and heard a pop sound while providing care to the resident. Two of three residents reviewed for care. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #2. Review of the facility's Five-Day Follow-Up Report dated 10/11/17 indicated Resident #2's fracture was identified on 10/6/17 at approximately 10:00 PM. The DON (Director of Nursing) was notified of the fracture at 10:15 PM. A complete body audit was performed. The left shoulder was pink and swollen with no other injury identified at that time. Statements revealed that on 10/4/17 the CNA taking care of the resident reported to the nurse that the resident had a popping sound. Interview with the CNA revealed that while performing incontinent care, when s/he went to position Resident #2 over on his/her side using the pad the CNA heard the resident's left arm pop. The CNA alerted the nurse. The nurse confirmed that on 10/4/17 between 8:00 PM-8:30 PM s/he was told about the popping sound when the CNA moved the resident. The nurse assessed the resident's arm and at that time there was no evidence of an abnormality or injury. Further statements revealed that on 10/5/17 the resident did have pain in the left arm and the nurse was notified by the CNA. The nurse assessed the resident and medicated him/her for pain. On 10/6/17 the resident complained of pain in the left arm when touched. This is when the nurse practitioner was asked to see the resident and s/he ordered an x-ray. After consulting with the medical director, it was felt that with the resident's history and frailty ([CONDITION] and [MEDICAL CONDITION] with allergies [REDACTED]. Routine incontinent care was being delivered on 10/4/17 when the CNA, providing care alone, heard a pop. The resident is care planned for the assistance of 2 with bed mobility and toileting. The CNA was counseled for not following the plan of care. Review of the Nurses' Progress Notes revealed there was no entry on 10/4/17 related to the CNA reporting the popping sound and the nurse assessing the resident. Further review of Resident #2's Nurses' Notes dated as a late entry on 10/10/17 for 10/5/17 indicated LPN #2 was notified by CNA that was assisting another CNA while doing a brief change on resident. Resident was complaining of much pain with any movement of left arm or touching arm. Checked resident's left arm and did not see anything. Left arm warm to touch, left arm up on pillow. Resident history of unable to move arm his/herself. Resident was given a pain pill at that time. The Progress Note documented by the Nurse Practitioner dated 10/6/17 at 1:37 PM revealed Resident #2 complained of left arm pain when touched or arm moved. States that it is his/her entire arm. Unable to tell where it is coming from. S/he yells and says don't move it with any amount of movement. No obvious deformity, no redness or [MEDICAL CONDITION]. Plan was for an x-ray of the left shoulder. A late entry on 10/7/17 for 10/6/17 by LPN #2 indicated the physician was notified about the x-ray report. New order to check pulse in left arm and medicate as needed for pain. Apply sling to left arm and position arm for comfort. If pulse changes or hand cold or increase in pain send to ER for evaluation of fracture. Review of the Radiology Report dated 10/6/17 revealed Resident #2 had a humeral fracture with slight displacement. Review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #2 as having a Brief Interview for Mental Status score of 10. The Quarterly MDS coded the resident as having verbal behavior 1-3 days during the assessment period. Review of Resident #2's care plan revealed ADL deficit related to dementia and impaired mobility was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included staff to provide assistance as needed with bed mobility x 2 assist and hygiene x 2 assist. Review of Resident #2's Resident Profile revealed the resident was coded as requiring 2 staff for bed mobility and hygiene with a start date of 1/14/16. LPN #3's facility-obtained statement indicated CNA #3 reported s/he heard some popping sounds when s/he moved Resident #2. LPN #3 went and looked at the resident. There was no swelling or discoloration. Resident #2 said it didn't hurt. CNA #4's facility-obtained statement dated 10/9/17 indicated on 10/5/17 s/he helped another CNA change Resident #2's brief one time. Resident #2 was screaming and complaining of pain in his/her arm like I have never heard him/her do before. CNA #4 was not assigned to the resident that night but Resident #2's behavior alarmed him/her so much that s/he immediately went to the nurse, LPN #2 and told him/her how Resident #2 was acting. CNA #4 expressed to LPN #2 how serious s/he thought it may have been. CNA #3's facility-obtained statement indicated s/he had Resident #2 on 10/4/17 and reported that the resident had a popping sound. Review of the Education Counseling form for CNA #3 dated 10/11/17 revealed the subject was following plan of care using appropriate assistance with bed mobility. Comments included to always use appropriate assistance with bed mobility. This information can be found in the kiosk under resident profile. Use your need to know books. In an interview with the surveyor on 2/14/18 at approximately 2:30 PM, the Healthcare Manager stated that s/he was told they heard a pop while giving care to the resident. The CNA reported it. The Healthcare Manager stated s/he did not know anything about what happened with the CNA being suspended. In an interview with the surveyor on 2/14/18 at approximately 2:40 PM, the unit 1 manager stated Resident #2 had been complaining about mouth soreness for a while. The resident was transported to the dentist on 10/3/17. All of a sudden, the resident started complaining about left shoulder pain out of nowhere. Resident #2 was moved to Unit 3 on 9/30/17 to accommodate an infection control issue, moved to Unit 2 on 10/2/17, and returned to his/her original room on Unit 1 on 10/4/17. The unit 1 manager did not hear about the resident's complaints of pain until the weekend. The unit 1 manager stated s/he did not know about the CNA hearing a pop until the investigation began. The unit 1 manager stated the pop was not documented by the nurse when it happened, it should have been. The unit 1 manager received a call about the x-ray report and s/he called the DON. The x-ray revealed a fracture. The unit 1 manager called the DON the night of 10/6/17. During the investigation they learned about CNA #3 hearing a pop while providing care. CNA #3 was providing care by him/herself and the resident is supposed to have 2 people for bed mobility. Resident #2 can't move one side, s/he is bedbound, and s/he refuses to get up. That information is on the resident profile on the kiosk. The DON educated CNA #3 that the resident required 2 people and the profile had that information. CNA #3 worked with Resident #2 a good bit. Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area himself/herself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 2. The Quarterly MDS coded Resident #1 as rejecting care and having physical behaviors toward others 1-3 days during the assessment period. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come in assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said h/she would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. In an interview with the surveyor on 2/14/18 at approximately 2:10 PM, the Healthcare Manager stated s/he found out about the incident the next morning. S/he was on the way to a conference out of town and the DON informed him/her about the incident. The DON was riding with the Healthcare Manager on the way to the meeting. The DON told him/her the nurse the day before had clipped Resident #1's fingernails and cut the tips of his/her fingers. The DON said there was an old skin tear that had reopened and a lot of bruising to that arm. The DON stated s/he was going to have to investigate and report the incident. It was about 7:00 AM when the DON told him/her about the incident. The DON had not reported it at that point. The DON called the number to report the incident and left a message, sometime between 7:00-7:30 AM. The DON started his/her investigation when they got back that afternoon. The Healthcare Manager saw the resident's fingers the next day when the nurse manager had unbandaged the fingers and was redressing them. The pinky fingers had a good bit nipped off the end of the fingers. All 5 fingers on one hand and the pinky of the other all had clipped areas on the cuticles. The pinky was still bleeding on one hand. There was bruising on one arm and was the same that had the most of the clips on it. It was bruised all the way up to the elbow, dark purple. The Healthcare Manager talked with the resident's son/ daughter on 1/10/18 and told him/her it had been reported to law enforcement. S/he asked if it had been reported to DHEC and they said yes.

Based on review of facility files and interview, the facility failed to provide services that meet professional standards of quality. CNA (Certified Nursing Aide) #3 heard a pop sound from Resident #2 while providing ADL care. The CNA reported the incident to the resident's nurse. The nurse failed to document the incident in the resident's medical record. Resident #1 was held down by LPN #1 and CNA #1 and #2 and his/her fingernails cut when s/he resisted care. Two of three residents reviewed for professional standards. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #2. Review of the facility's Five-Day Follow-Up Report dated 10/11/17 indicated Resident #2's fracture was identified on 10/6/17 at approximately 10:00 PM. The DON (Director of Nursing) was notified of the fracture at 10:15 PM. A complete body audit was performed. The left shoulder was pink and swollen with no other injury identified at that time. Statements revealed that on 10/4/17 the CNA taking care of the resident reported to the nurse that the resident had a popping sound. Interview with the CNA revealed that while performing incontinent care, when s/he went to position Resident #2 over on his/her side using the pad the CNA heard the resident's left arm pop. The CNA alerted the nurse. The nurse confirmed that on 10/4/17 between 8:00 PM-8:30 PM s/he was told about the popping sound when the CNA moved the resident. The nurse assessed the resident's arm and at that time there was no evidence of an abnormality or injury. Further statements revealed that on 10/5/17 the resident did have pain in the left arm and the nurse was notified by the CNA. The nurse assessed the resident and medicated him/her for pain. On 10/6/17 the resident complained of pain in the left arm when touched. This is when the nurse practitioner was asked to see the resident and s/he ordered an x-ray. After consulting with the medical director, it was felt that with the resident's history and frailty ([CONDITION] and [MEDICAL CONDITION] with allergies [REDACTED]. Routine incontinent care was being delivered on 10/4/17 when the CNA providing care alone, heard a pop. The resident is care planned for the assistance of 2 with bed mobility and toileting. The CNA was counseled for not following the plan of care. Review of the Nurses' Progress Notes revealed there was no entry on 10/4/17 related to the CNA reporting the popping sound and the nurse assessing the resident. Further review of Resident #2's Nurses' Notes dated as a late entry on 10/10/17 for 10/5/17 indicated LPN #2 was notified by CNA that was assisting another CNA while doing a brief change on resident. Resident was complaining of much pain with any movement of left arm or touching arm. Checked resident's left arm and did not see anything. Left arm warm to touch, left arm up on pillow. Resident history of unable to move arm his/herself. Resident was given a pain pill at that time. The Progress Note documented by the Nurse Practitioner dated 10/6/17 at 1:37 PM revealed Resident #2 complained of left arm pain when touched or arm moved. States that it is his/her entire arm. Unable to tell where it is coming from. S/he yells and says don't move it with any amount of movement. No obvious deformity, no redness or [MEDICAL CONDITION]. Plan was for an x-ray of the left shoulder. A late entry on 10/7/17 for 10/6/17 by LPN #2 indicated the physician was notified about the x-ray report. New order to check pulse in left arm and medicate as needed for pain. Apply sling to left arm and position arm for comfort. If pulse changes or hand cold or increase in pain send to ER for evaluation of fracture. Review of the Nurses' Progress Notes revealed there was no entry on 10/4/17 related to the CNA reporting the popping sound and the nurse assessing the resident. Review of the Radiology Report dated 10/6/17 revealed Resident #2 had a humeral fracture with slight displacement. Review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #2 as having a Brief Interview for Mental Status score of 10. The Quarterly MDS coded the resident as having verbal behavior 1-3 days during the assessment period. Review of Resident #2's care plan revealed ADL deficit related to dementia and impaired mobility was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included staff to provide assistance as needed with bed mobility x 2 assist and hygiene x 2 assist. Review of Resident #2's Resident Profile revealed the resident was coded as requiring 2 staff for bed mobility and hygiene with a start date of 1/14/16. LPN #3's facility-obtained statement indicated CNA #3 reported s/he heard some popping sounds when s/he moved Resident #2. LPN #3 went and looked at the resident. There was no swelling or discoloration. Resident #2 said it didn't hurt. CNA #4's facility-obtained statement dated 10/9/17 indicated on 10/5/17 s/he helped another CNA change Resident #2's brief one time. Resident #2 was screaming and complaining of pain in his/her arm like I have never heard him/her do before. CNA #4 was not assigned to the resident that night but Resident #2's behavior alarmed him/her so much that s/he immediately went to the nurse, LPN #2 and told him/her how Resident #2 was acting. CNA #4 expressed to LPN #2 how serious s/he thought it may have been. CNA #3's facility-obtained statement indicated s/he had Resident #2 on 10/4/17 and reported that the resident had a popping sound. Review of the Education Counseling form for CNA #3 dated 10/11/17 revealed the subject was following plan of care using appropriate assistance with bed mobility. Comments included to always use appropriate assistance with bed mobility. This information can be found in the kiosk under resident profile. Use your need to know books. In an interview with the surveyor on 2/14/18 at approximately 2:40 PM, the unit 1 manager stated Resident #2 had been complaining about mouth soreness for a while. The resident was transported to the dentist on 10/3/17. All of a sudden, the resident started complaining about left shoulder pain out of nowhere. Resident #2 was moved to Unit 3 on 9/30/17 to accommodate an infection control issue, moved to Unit 2 on 10/2/17, and returned to his/her original room on Unit 1 on 10/4/17. The unit 1 manager did not hear about the resident's complaints of pain until the weekend. The unit 1 manager stated s/he did not know about the CNA hearing a pop until the investigation began. The unit 1 manager stated the pop was not documented by the nurse when it happened, it should have been. The unit 1 manager received a call about the x-ray report and s/he called the DON. The x-ray revealed a fracture. The unit 1 manager called the DON the night of 10/6/17. During the investigation they learned about CNA #3 hearing a pop while providing care. CNA #3 was providing care by him/herself and the resident is supposed to have 2 people for bed mobility. Resident #2 can't move one side, s/he is bedbound, and s/he refuses to get up. That information is on the resident profile on the kiosk. The DON educated CNA #3 that the resident required 2 people and the profile had that information. CNA #3 worked with Resident #2 a good bit. The facility reported alleged abuse for Resident #1. Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area himself/herself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 2. The Quarterly MDS coded Resident #1 as rejecting care and having physical behaviors toward others 1-3 days during the assessment period. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said h/she would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. In an interview with the surveyor on 2/14/18 at approximately 2:10 PM, the Healthcare Manager stated s/he found out about the incident the next morning. S/he was on the way to a conference out of town and the DON informed him/her about the incident. The DON was riding with the Healthcare Manager on the way to the meeting. The DON told him/her the nurse the day before had clipped Resident #1's fingernails and cut the tips of his/her fingers. The DON said there was an old skin tear that had reopened and a lot of bruising to that arm. The DON stated s/he was going to have to investigate and report the incident. It was about 7:00 AM when the DON told him/her about the incident. The DON had not reported it at that point. The DON called the number to report the incident and left a message, sometime between 7:00-7:30 AM. The DON started his/her investigation when they got back that afternoon. The Healthcare Manager saw the resident's fingers the next day when the nurse manager had unbandaged the fingers and was redressing them. The pinky fingers had a good bit nipped off the end of the fingers. All 5 fingers on one hand and the pinky of the other all had clipped areas on the cuticles. The pinky was still bleeding on one hand. There was bruising on one arm and was the same that had the most of the clips on it. It was bruised all the way up to the elbow, dark purple. The Healthcare Manager talked with the resident's son/ daughter on 1/10/18 and told her it had been reported to law enforcement. H/She asked if it had been reported to DHEC and they said yes.

Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. LPN #1 was attempting to cut Resident #1's finger nails and the resident resisted. CNA #1 and CNA #2 held the resident down while LPN #1 cut the resident's finger nails. The tips of the resident's fingers were nicked and the resident's arms and hands were bruised during the incident. CNA #1 and CNA #2 continued to work at the facility during the investigation into the incident. One of three residents reviewed for incidents. The findings included: The facility reported alleged abuse for Resident #1. Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area him/herself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 2. The Quarterly MDS coded Resident #1 as rejecting care and having physical behaviors toward others 1-3 days during the assessment period. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come in assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said she/he would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. In an interview with the surveyor on 2/14/18 at approximately 2:10 PM, the Healthcare Manager stated s/he found out about the incident the next morning. S/he was on the way to a conference out of town and the DON informed him/her about the incident. The DON was riding with the Healthcare Manager on the way to the meeting. The DON told him/her the nurse the day before had clipped Resident #1's fingernails and cut the tips of his/her fingers. The DON said there was an old skin tear that had reopened and a lot of bruising to that arm. The DON stated s/he was going to have to investigate and report the incident. It was about 7:00 AM when the DON told him/her about the incident. The DON had not reported it at that point. The DON called the number to report the incident and left a message, sometime between 7:00-7:30 AM. The DON started his/her investigation when they got back that afternoon. The Healthcare Manager saw the resident's fingers the next day when the nurse manager had unbandaged the fingers and was redressing them. The pinky fingers had a good bit nipped off the end of the fingers. All 5 fingers on one hand and the pinky of the other all had clipped areas on the cuticles. The pinky was still bleeding on one hand. There was bruising on one arm and was the same that had the most of the clips on it. It was bruised all the way up to the elbow, dark purple. The Healthcare Manager talked with the resident's son/ daughter on 1/10/18 and told her it had been reported to law enforcement. S/he asked if it had been reported to DHEC and they said yes. Review of CNA #1's Status Change Form dated 1/10/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #1's Time Card revealed s/he worked 6:45 AM to 3:09 PM on 1/8/18 and 6:46 AM to 1:18 PM on 1/10/18. Review of CNA #2's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #2's Time Card revealed s/he worked 6:43 AM to 2:38 PM on 1/8/18 and 6:59 PM to 3:13 PM on 1/9/18. Review of LPN #1's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of LPN #1's Employee Time Card revealed s/he worked 6:40 AM to 7:22 PM on 1/8/18. Review of the facility's Abuse Investigations Policy revealed all reports of resident abuse, neglect and injuries of unknown source shall be thoroughly and promptly investigated by facility management. Employees of this facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. Review of the facility's Abuse Prevention Program revealed residents have the right to be free from abuse and neglect. Policy Interpretation and Implementation included the protection of residents during abuse investigations.

Based on review of facility files and interview, the facility failed to develop and implement written policies and procedures that ensure each individual reported immediately, but not later than 2 hours after forming the suspicion, for events that cause the suspicion result in serious bodily injury to the State Agency and law enforcement. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. The resident was held down by CNA #1 and CNA #2 so that LPN #1 could cut the resident's finger nails. The resident's fingers were nicked during the incident and the resident sustained [REDACTED]. One of two reportable incidents reviewed. The findings included: Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed the incident involving Resident #1 occurred on 1/8/18 at 1:30 PM. Review of the facility's investigation revealed the police were notified on 1/10/18 The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area him/herself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 2. The Quarterly MDS coded Resident #1 as rejecting care and having physical behaviors toward others 1-3 days during the assessment period. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come in assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said she would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. In an interview with the surveyor on 2/14/18 at approximately 2:10 PM, the Healthcare Manager stated s/he found out about the incident the next morning. S/he was on the way to a conference out of town and the DON informed him/her about the incident. The DON was riding with the Healthcare Manager on the way to the meeting. The DON told him/her the nurse the day before had clipped Resident #1's fingernails and cut the tips of his/her fingers. The DON said there was an old skin tear that had reopened and a lot of bruising to that arm. The DON stated s/he was going to have to investigate and report the incident. It was about 7:00 AM when the DON told him/her about the incident. The DON had not reported it at that point. The DON called the number to report the incident and left a message, sometime between 7:00-7:30 AM. The DON started his/her investigation when they got back that afternoon. The Healthcare Manager saw the resident's fingers the next day when the nurse manager had unbandaged the fingers and was redressing them. The pinky fingers had a good bit nipped off the end of the fingers. All 5 fingers on one hand and the pinky of the other all had clipped areas on the cuticles. The pinky was still bleeding on one hand. There was bruising on one arm and was the same that had the most of the clips on it. It was bruised all the way up to the elbow, dark purple. The Healthcare Manager talked with the resident's son/ daughter on 1/10/18 and told him/her it had been reported to law enforcement. H/She asked if it had been reported to DHEC and they said yes.

Based on review of facility files and interview, the facility failed to prevent further potential abuse and neglect while investigations were in progress and when an alleged violation was verified failed to take appropriate corrective action. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. LPN #1 was attempting to cut Resident #1's finger nails and the resident resisted. CNA #1 and CNA #2 held the resident down while LPN #1 cut the resident's finger nails. The tips of the resident's fingers were nicked and the resident's arms and hands were bruised during the incident. CNA #1 and CNA #2 continued to work at the facility during the investigation into the incident. One of three residents reviewed for incidents. The findings included: Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area him/herself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 2. The Quarterly MDS coded Resident #1 as rejecting care and having physical behaviors toward others 1-3 days during the assessment period. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come in assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said h/she would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. In an interview with the surveyor on 2/14/18 at approximately 2:10 PM, the Healthcare Manager stated s/he found out about the incident the next morning. S/he was on the way to a conference out of town and the DON informed him/her about the incident. The DON was riding with the Healthcare Manager on the way to the meeting. The DON told him/her the nurse the day before had clipped Resident #1's fingernails and cut the tips of his/her fingers. The DON said there was an old skin tear that had reopened and a lot of bruising to that arm. The DON stated s/he was going to have to investigate and report the incident. It was about 7:00 AM when the DON told him/her about the incident. The DON had not reported it at that point. The DON called the number to report the incident and left a message, sometime between 7:00-7:30 AM. The DON started his/her investigation when they got back that afternoon. The Healthcare Manager saw the resident's fingers the next day when the nurse manager had unbandaged the fingers and was redressing them. The pinky fingers had a good bit nipped off the end of the fingers. All 5 fingers on one hand and the pinky of the other all had clipped areas on the cuticles. The pinky was still bleeding on one hand. There was bruising on one arm and was the same that had the most of the clips on it. It was bruised all the way up to the elbow, dark purple. The Healthcare Manager talked with the resident's son/ daughter on 1/10/18 and told her it had been reported to law enforcement. She asked if it had been reported to DHEC and they said yes. Review of CNA #1's Status Change Form dated 1/10/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #1's Time Card revealed s/he worked 6:45 AM to 3:09 PM on 1/8/18 and 6:46 AM to 1:18 PM on 1/10/18. Review of CNA #2's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #2's Time Card revealed s/he worked 6:43 AM to 2:38 PM on 1/8/18 and 6:59 PM to 3:13 PM on 1/9/18. Review of LPN #1's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of LPN #1's Employee Time Card revealed s/he worked 6:40 AM to 7:22 PM on 1/8/18. Review of the facility's Abuse Investigations Policy revealed all reports of resident abuse, neglect and injuries of unknown source shall be thoroughly and promptly investigated by facility management. Employees of this facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. Review of the facility's Abuse Prevention Program revealed residents have the right to be free from abuse and neglect. Policy Interpretation and Implementation included the protection of residents during abuse investigations.

Based on review of facility files and interview, the facility failed to ensure each resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside the facility. Resident #1 was held down and his/her fingernails cut when s/he resisted care. LPN (Licensed Practical Nurse) #1 removed the resident from the unit dining room into the hallway outside the dining room and proceeded to cut the resident's nails even though s/he resisted. One of three resident's reviewed for dignity. The findings included: Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA (Certified Nursing Aide) #1, and CNA #2. The facility's details of the reportable incident indicated the DON (Director of Nursing) was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area herself/himself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said s/he would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. Review of the facility's Refusal of Treatment policy statement revealed the facility shall honor a resident's request not to receive medical treatment as prescribed by his or her physician, as well as care routines outlined on the resident's assessment and plan of care. Review of the facility's Resident Rights Guidelines for All Nursing Procedures revealed the purpose was to provide general guidelines for resident rights while caring for the resident. The procedures indicated that staff must have appropriate in-service training on resident rights, including resident right of refusal (medications and treatments). The general guidelines included if a resident refuses, notify your supervisor.

NOT CORRECTED On the days of the revisit, based on observations, record reviews, interviews, and review of the policy provided by the facility entitled "Policy and Procedure for Falls", the facility failed to ensure that 5 of 10 sampled residents reviewed for falls received adequate supervision and or assistive devices to prevent future falls. A wheelchair alarm was not being used as ordered and/or Care Planned for Residents #1 and #18, both with a history of falls. Residents #23 and #24 with recent falls did not have new interventions implemented to prevent falling and/or prevent injury. There was no therapy evaluation and/or recommendation relative to the appropriateness of the lift being used by facility staff for Resident #22. The findings included: The facility admitted Resident #1 on 3/18/10 with [DIAGNOSES REDACTED]. Review of cumulative Physician order [REDACTED]. Review of the facility Care Plan updated 1/3/12 revealed Resident #1 was "At risk for falls r/t (related to) a hx (history) of falls...Morse falls score-75...". Approaches listed included "Chair alarm when up in a chair". There was no documentation on the facility Care Plan that the resident used any other alarms. Review of the Documentation Record dated 3/2/12 through 3/31/12 revealed nursing staff had been checking the resident's bed alarm for functioning every shift. Further review revealed there was no documentation of nursing staff checking a chair alarm. On 3/14/12 at 12:30 PM, Registered Nurse (RN) #1 was asked to accompany the surveyor to check the resident. RN #1 introduced the surveyor to the resident's sitter who was in the hall. The three of us entered the resident's room and Resident #1 was observed sitting alongside her bed in her wheelchair. Observation revealed there was no wheelchair alarm on her chair. When asked, the nurse and sitter both verified there was no wheelchair alarm. The bed alarm was present and functioning on the bed. On 3/14/12 at approximately 12:35 PM, the facility Care Plan and the CNA (Certified Nursing Assistant) Care Plan Guide for Resident #1 was reviewed with RN #2. Review of the CNA Care Plan Guide revealed that a bed pad alarm was used for the resident. There was no documentation on the CNA Care Plan Guide that indicated a chair alarm was to be used for the resident. RN #2 verified the discrepancy with the facility Care Plan and the CNA Care Plan Guide. She verified the physician's orders [REDACTED]. When asked what alarms were supposed to be used for the resident, she stated she thought the resident needed a chair alarm due to her fall history because the resident had fallen from her chair in the past. RN #2 returned later with a chair alarm and stated that she was going to place it on the resident's wheelchair. During exit on 3/14/12 at 4:00 PM, when the concern was shared, the Director of Nursing (DON) stated the resident was supposed to have the chair alarm in place. The facility admitted Resident #22 on 8/30/07 with [DIAGNOSES REDACTED]. Record review and interviews revealed discrepant information related to the use of mechanical lifts for Resident #22. Review of Resident #22's Care Plan related to falls on 3/14/12 at 12:50 PM revealed "Use stand up lifts with transfer per Certified Nursing Assistant (CNA) communication book." The surveyor then referred to the CNA communication book/care plan which revealed a hoyer lift was to be used with the assistance of two staff members. Review of Resident #22's "Morse Fall Scale" dated 8/11/11 and 11/11/11 on 3/14/12 at 1 PM, indicated that the resident's "Gait/transferring" was with use of a stand up lift. On 3/14/12 at 1:15 PM, during an interview with CNA #1, she stated "I use the total body lift (hoyer) with two assist for (Resident #22)." During an interview with Registered Nurse (RN) #2 on 3/14/12 at 1:30 PM, she stated that the resident used a sit/stand transfer lift. Review of the facility's Plan of Correction with the correction date of 3/9/12 revealed: "The therapy department will evaluate all current residents who use lifts for appropriate use of the lift. The resident CNA Care Plan as well as the resident Care Plan will be reviewed to ensure proper documentation related to the lift use. Any discrepancies will be corrected." During an interview on 3/14/12 at 3 PM, the Director of Nursing (DON) was asked about the therapy evaluation done for all current residents who used lifts. She stated that therapy had not done this, and that she had completed audits related to the use of mechanical lifts. She provided the audit she had done. She stated she didn't know why the POC stated therapy would do the lift evaluations when she had done the audit. According to the Mechanical Lift Audit done by the DON dated 3/5/12, it stated Resident #22 used a Hoyer lift and this information was documented in the facility Care Plan and the CNA Care Plan. The DON verified this audit information was not accurate since the Hoyer lift had not been documented on the facility Care Plan. The last evaluation done (Morse Fall Scale on 11/11/11), revealed the resident used a stand up lift for transfers and not the Hoyer lift. The facility was unable to provide documentation relative to an evaluation having been done for the appropriateness of the Hoyer lift. The facility admitted Resident #23 on 5/9/11 with [DIAGNOSES REDACTED]. Review of Resident #23's "Falls Risk Assessment" dated 3/10/12, revealed Resident #23's "Mental Status" as confusion/dementia; noted she was incontinent of bowel/bladder, took diuretics; and had a fall risk score of "5" which indicated "Moderate Risk". The section "Suggestions to Prevent Falling or Injuring self" was left blank. Review of Resident #23's Nurse's Notes on 3/14/12 at 11:50 AM, revealed a fall on 3/10/12: "Resident called nurse's desk and said I have fell on bathroom floor". Review of Resident #23's "Incident/Accident Report" did not indicate any additional comments and/or steps taken to prevent recurrence. Review of the resident's Care Plan related to falls on 3/14/12 at 12 PM, revealed the interventions of "Morse fall continued" and "therapy notified." Review of the therapy notes revealed no follow up had been done regarding Resident #23's fall. Further review of the resident's medical record revealed [REDACTED]. On 3/14/12 at 12:40 PM, during an interview with a Rehab Tech, she stated, "Therapy screens residents a week or so after receiving referral due to only having three people who can do assessments." During an interview with Registered Nurse #3 on 3/14/12 at 2:40 PM, she verified therapy did not assess the resident timely and confirmed that there were no interventions in place at the time of the revisit. The facility admitted Resident #18 on 9/28/09 with [DIAGNOSES REDACTED]. During a record review on 3/14/12 at 11:30am, the current Physician Monthly Order stated that Resident #18 was to have a chair alarm on the wheelchair. During a record review on 3/14/12 at 11:55am, the Care Plan noted Resident #18 was at risk for falls and had previous falls documented. An intervention was to have a chair alarm in place when in the wheelchair. During an observation on 3/14/12 at 1:13pm, Resident #18 did not have a chair alarm in place while she was sitting in the wheelchair. During an interview and observation of the resident on 3/14/12 at 1:14pm with Certified Nursing Assistant #2, she verified that a chair alarm was not in place on Resident #18's wheelchair. The facility admitted Resident #24 on 7/22/11 with [DIAGNOSES REDACTED]. During a record review on 3/14/12 at 12:15pm, the Nurse's Note stated that Resident #24 fell out of bed at 3:18am on 3/12/12. During a record review on 3/14/12 at 3:35pm, the Incident/Accident Report, stated the steps taken to prevent recurrence included: "1-Practiced with resident to use call bell-unable to remember minutes later. 2-Continue to respond quickly to bed alarm." During a record review on 3/14/12 at 12:30pm, the Resident Care Plan did not list Resident #24's fall of 3/12/12 or any new interventions to prevent further falls. During an interview on 3/14/12 at 12:35pm, the Minimum Data Set Coordinator verified that the fall of 3/12/12 was not addressed on Resident #24's Resident Care Plan. During a record review on 3/14/12 at 3:30pm, the CNA (Certified Nursing Assistant) Care Plan Guide revealed that Resident # 24's Mental Status was alert, confused and forgetful. The policy entitled "Policy and Procedure for Falls" received on 3/14/12, stated "All falls are listed on the care plan after each occurrence with an additional intervention if possible." Also, "All incident reports will be shared with Interdisciplinary Team in morning meeting." The facility submitted a plan of correction date with a compliance date of 3/7/12 that stated: ..Therapy department will evaluate all current resident who use lifts for appropriate use of the lift. (completion date 3/7/12) The resident CNA careplan as well as the resident care plan will be reviewed to ensure proper documentation related to the lift use. Any discrepancies will be corrected. (completion date 3/7/12) During the day of the follow up survey there was evidence the plan of correction was not completed as stated.

On the days of the survey, based on observations, record reviews and interviews, the facility failed to ensure that 2 of 6 sampled residents reviewed for falls remained free from accident hazards by providing adequate supervision and assistance devices to prevent accidents. For Resident #1 the facility failed to implement interventions to prevent recurrence and reduce risk after a fall. Resident #8 sustained 3 falls resulting in a shoulder dislocation and tibial fracture on separate occasions resulting from failure of the facility to provide appropriate training, supervision, and/or changes in the care plan interventions to prevent recurrence. The findings included: The facility admitted Resident #8 on 06/12/06 with [DIAGNOSES REDACTED]. Record review on 02/07/12 at 3:30 PM revealed that an incident report was written on 12/31/11 at 10:10 PM which stated, "Resident was laying on floor in front of recliner chair. Staff attempted to use the lift to transfer, no connection was made. Resident slide out of recliner onto floor". The documented equipment being used at the time of the incident was "lift". Nurses Notes for 12/31/11 stated that Resident #8 was complaining of right knee pain, left and right ankle pain. Resident #8 was sent to the emergency room for evaluation. Nurses Notes on 1/1/12 at 3:40 AM revealed that Resident #8 returned from the emergency room with a [DIAGNOSES REDACTED]. The second incident report, for Resident #8, which was dated for 10/21/11 at 11:15 AM stated, "staff getting res (resident) off toilet on stand-up lift. Res slid out sling lowered to floor by staff. C/O (complaints of) R (right) shoulder pain, cannot move R arm and c/o R knee to ankle pain can move R leg." The documented equipment being used at the time of the incident was a stand-up lift. Nurses Notes revealed Resident #8 was sent to the emergency roiagnom on [DATE] at 12:40 PM for evaluation of right shoulder and right knee pain. Nurses Notes revealed that Resident #8 returned to the facility on [DATE] at 1:00 AM with the [DIAGNOSES REDACTED]. Continued review of the Nurses Notes dated 10/23/12 revealed that Resident #8 was wearing a sling on the right arm and mild discoloration was seen from right shoulder to neck. The third incident report for Resident #8, which was dated for 8/25/11 at 10:00 AM stated, "Staff taking res (resident) to bathroom. Started sliding out of harness. Slid to floor. no injuries noted". The documented equipment being used at the time of the incident was a stand-up lift. Review of the Nurses Notes confirmed that Resident #8 slid out of the harness of the stand-up lift while going to the bathroom and that there were no apparent injuries. Upon review of the Therapy Screening Referral dated 8/25/11, regarding Resident #8's fall, it was documented on the referral "wrong lift (sling) used for this transfer". Documented on the therapy screening referral dated 10/21/11 regarding Resident #8's fall out of stand-up lift was noted "max assist with all transfers use full body lift per safety". Documented on the Rehab Pre-Admission Worksheet dated 10/25/11 was that Resident #8 was total assistance for transfers and "total body lift staff assistance times two". There were two additional undated Rehab Pre/Admission Worksheets documenting that Resident #8 required total assistance with "stand lift for all transfers with two staff" and maximal/total assistance for transfers with "Hoyer lift for bed to chair and bed to toilet". Physical Therapy and Occupation Therapy daily notes for 10/21/11 noted Resident #8 required maximal assistance for activities of daily living and transfers. During an interview with the acting Director of Nursing (DON) on 2/7/12 at 4:30 PM the surveyor requested the facility's policy and inservice training documentation for the staff who were assigned to transfer the residents requiring either a stand-up or Hoyer lift. The inservice documentation sheets provided by the DON completed on 9/1/11, 4/1/11, and 3/2/11 did not contain the signatures of the individuals listed on the incident reports from 8/25/11, 10/21/11 and 12/31/11. The facility's policy and procedure for lifts provided by the DON included directions: "at least two people are present during transferring...". An interview was conducted on 07/08/12 at 1:45 PM with Physical Therapy Assistant (PTA) #1 regarding when Resident #8 was changed from a stand-up lift to a Hoyer lift. After record review PTA #1 stated that she could not determine since two of the Rehab Admission Worksheets had not been dated. The PTA did identify that Resident #8 was assessed for use of a Hoyer lift on 10/25/11. When asked who was responsible for training the staff regarding the proper use of the stand-up and Hoyer lift, PTA stated therapy staff does the training only when nursing staff asks the therapy department for the training. The surveyor interviewed Certified Nurses Assistant (CNA) #3 (listed on the incident report dated 10/21/11) about who she had received her training from regarding the use of the stand-up lift. CNA #3 stated she was instructed by former DON approximately one year previously. When asked who instructed CNA #3 on how to use the Hoyer lift, she stated she learned from other CNA's on the floor. The facility failed to provide evidence of initial and ongoing training related to use of resident care equipment. Record review revealed a care plan that the resident was "at risk for fall/injury" which contained two added hand written interventions. The interventions were not dated and intervention #14 stated "use appropriate lift according to therapy recommendations". The care plan was not specific as to which lift was to be used and there were no changes in interventions following the 3 falls. The care plan was not updated following the most recent fall incident dated 12/31/11. The facility admitted Resident # 1 on 2/08 and readmitted her on 3/18/10 with [DIAGNOSES REDACTED]. During record review on 2/7/12 skin sheets were noted with multiple documentation's of bruising to the resident's arms, legs, and toes. Incident reports were requested for the periods of documentation; however, only two reports were provided by the facility. A report dated 8/13/11 documented a fall in the day room with a skin tear to right hand. The report documented as steps taken to prevent recurrence : Morse Fall Scale Complete, Res.(resident) may need around the clock sitter. The Post Fall Assessment showed at the time of the fall no alarms were being used for this resident. The report noted the resident was on Lexapro 20 mg (milligrams), Trazadone 50 mg, and Lorazepam 0.5 mg. The Falls Prevention Follow-up had 2 areas checked: care plan updated to reflect fall , additional interventions added to care plan, and continue POC (plan of care). Report to Risk Committee. No other recommendations were made by the committee. Morse Fall Scale Assessments were also noted in the medical record dating back to 3/18/11. The resident scored as a high risk for falls. Sensor alarm i.e.: bed alarm and/or chair alarm initialed with low bed also initialed on the 3/18/11 assessment. Other Morse Fall Scale assessments dated 6/6/11, 6/19/11, 8/13/11, 9/18/11, and 12/18/11 also scored the resident as high risk for falls. Each of the sheets had lines drawn to include all the interventions listed for low risk and high risk, but never any new interventions. Review of the Resident's Care Plan for "risk of falls" documented falls on 6/6/11, 7/13/11, and 8/13/11. Interventions # 8, #9, #10, and #11 had been added to the care plan but there were no dates as to when the intervention had been added. A chair alarm when up in chair was added as an additional intervention. ( #10). An interview with the Unit Manager (RN #1) revealed that the resident had a bed alarm and a chair alarm. Review of the Physicians Orders only revealed and order for a bed alarm. The nurse stated an order would have been obtained in order to apply a chair alarm. Actual visual inspection at 11 AM on 2/8/11 of the resident seated in her wheel chair by the nurse and surveyor revealed no chair alarm in place. The sitter staying with the resident stated, "She has never had a chair alarm. She has a bed alarm." During the two days of the survey, the resident was always noted up in her wheel chair. Interviews revealled the sitter only stays during the day leaving the facility responsible for the resident's supervision and safety. The sitter was not oberved during the supper meal. The incident on 8/13/11 occurred at 5:30 PM and the sitter was not present.

On the day of the complaint inspection, based on record review and interview, the facility failed to consult with the resident's physician when there was a significant change in the resident's condition. Resident #6 had clinical record documentation on 07/24/2010 at 0615 as sweaty, which required a linen and clothing change, later in the day he was described as lethargic. The next day (07/25/2010) at 2:00 AM it was documented that he had a temperature of 100 degrees and twitching of his extremities when touched; at 4:00 AM the twitching continued; at 6:00 AM he pulled away when care was provided and would not take fluids. The documentation indicated that the resident was lethargic at 10:50 AM and was sent to the emergency room at his daughter's request. There was no evidence the resident's physician was notified of the change in condition. (One of six sampled residents reviewed for notification) The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 10/12/2010 a review of the resident's closed medical record revealed the following Nurse's Notes from 07/24/2010 thru 07/25/2010: "07/24/2010 0615 Res (resident) has been sweaty this shift requiring linen and night clothing change. Hair damp skin cool and pale, clammy to touch. VS (vital signs) @ present BP (blood pressure) 141/72 p (pulse) 85, resp (respirations) 22 temp (temperature) 97.5 (A) (axillary), BS (blood sugar) 182. Hands to (sic) cool for O2 (oxygen) sat (saturation) to register. No s/s (signs/symptoms) of pain/discomfort. No acute apparent distress. Orderly up and showered. On top of bed resting now. Alert with eyes open. Will pass to next shift to monitor. 1:35 PM Resident was lethargic at breakfast could not wake up enough to eat. Ate 100 % of lunch. Has been holding head down and drooling excessively all day. Afebrile with VS WNL (within normal limits). Will cont. (continue) to monitor. 2300 Remains in bed. Skin cool to touch and dry at this time. No twitching of extremities. No cough or resp distress. 07/25/2010 0100 No change in condition. Opens eyes when spoken to. 0200 Temp. 100 BP (?) P 100, R 18 BS 166. O2 sat 93% on rm (room) air. Twitching extremities when touched. Oral care. Open eyes when spoken to with no awareness of staff. 0400 Eyes closed, resting quietly. Continues to have twitching episodes when touched or spoken to. 0600 Responds to tactile stimuli. T 99.9 BP 110/50 P 180 R 20 O2 93% rm air. Skin moist warm. Pulls away when care given. Unable to get resident to take fluids. 10:50 AM Resident is lethargic and unresponsive. T 97.5, BP 110/80, P 115, R 20. Sent to ... ER (emergency room ) via EMS (emergency medical service) at dgt's (daughters) request..." On 10/12/2010 at approximately 2:15PM, during an interview with the Family Nurse Practitioner she stated that the drooling was usual for the resident but that she would have expected the staff to call the physician when the resident was noted to be sweating and for sure when he first became lethargic. The Family Nurse Practitioner added that the staff was aware that he had just finished treatment for [REDACTED]. In a face-to-face interview on 10/12/2010 at approximately 12:10 PM the Unit 3 Manager stated that she was not sure why the staff failed to call the physician.

On the day of the complaint inspection, based on observations, record review, and interviews, the facility failed to ensure two of four sampled residents were assessed for transfers. Certified Nursing Assistants used a mechanical lift on Residents #1 and #2 without documented assessments as to the appropriateness of the lift device for each resident. Resident #3's CNA Care Plan Guide revealed no mention of the level of assistance required for transfers or the mode of transfer. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility, which prompted the complaint investigation. Review of the facility investigation revealed that Resident #1 had been sent to the emergency roiagnom on [DATE] for pain, swelling, warmth, decreased range of motion, and a "fading discoloration" around and below the left knee. According to the physician's statement included in those records, the resident had been admitted to the hospital on [DATE] with a [MEDICAL CONDITIONS] and tib-fib (tibia-fibula) [MEDICAL CONDITION] leg. In a letter dated 10/1/2010 from the facility's Director of Nursing (DON), the facility reported that "During the investigation it was noted that on September 25, 2010 (Resident #1's) left foot had slipped forward while being lifted with the "stand-up" lift. The lift procedure was stopped, another Certified Nursing Assistant (CNA) joined the aide caring for (Resident #1). Her left foot was moved approx.(approximately) three inches back into the proper position, and the lift and care proceeded. I had the CNAs demonstrate the procedure for me. I did not observe anything that would cause injury". Review of the closed medical record conducted on 10/12/2010 revealed the following: Review of the cumulative physician's orders [REDACTED]. During an interview at 12:15 PM, Licensed Practical Nurse #1 verified this and stated that the physician deferred the issue of transfers or the use of lifts to nursing. Review of the Admission assessment dated [DATE] revealed no mention of the amount of assistance needed for transfers or any lift devices used. Under "Assistive Aides:" wheelchair alarm and bed alarm had been checked. Review of "Weekly Nursing Assessment(s)" dated 8/22/2010 through 9/19/2010 revealed under "ADL's (Activities of Daily Living), that the resident transfers with extensive assistance with 2 person physical help". There was no documentation that the resident had been assessed for the use of a mechanical lift or that one was being used. Review of the CNA Patient Care Record (PCR) for Resident #1 dated September 2010 revealed no mention of the level of assistance required for transfers or the use of any transfer devices. Review of Nurse's Notes dated 8/16/2010 through 9/26/2010 revealed several entries that stated 2 staff assisted with transfers, but no mention of the use of a mechanical lift. Interviews with nursing staff, however, indicated that the lift had been used many times throughout the resident's stay at the discretion of the nursing staff. The following entries were noted: "8-19-10...Staff x 2 put resident to bed", "8-20-10...Staff x 2 assisted res(ident) to bed", "8-23-10...Staff x 2 assisted to bed...", "8-26-10...Staff x 2 assisted (with) hs (bedtime) care + to bed", "9-26-10...-up to w/c (wheelchair) per 2 CNAs to have haircut". During a phone interview with the surveyor on 10/12/2010 at 11:45 AM, CNA #1 stated that the lift was used for Resident #1 to get her out of bed to the wheelchair. She verified she had used the lift without other staff assistance on several occasions on 9/25/2010 because she didn't have any help. She stated she did get assistance from CNA #2 when she encountered difficulty with Resident #1's foot placement on the lift. During an interview with the surveyor on 10/12/2010 at approximately 12:15 PM, Licensed Practical Nurse #1 stated that she "knew" CNAs had used the lift on Resident #1, but that she had not actually witnessed staff using the lift until 09/25/2010 when CNA #1 had to call CNA #2 for assistance with Resident #1's foot placement. She said that normally 2 CNAs would assist with transfers for Resident #1. LPN #1 verified that the lift had been used to get the resident out of bed on 09/26/2010 and that the resident was placed back into bed with the assistance of 2 CNAs lifting the resident. LPN #1 was asked what she would tell a CNA about the type of assistance Resident #1 required to transfer from the wheelchair to the bed or wheelchair to the toilet. LPN #1 stated that when transferring from the bed to the wheelchair, she would tell them to use the lift and make sure they had someone to help. If they were taking Resident #1 to the toilet, she would tell them to "see if the resident could bear weight with 2 CNAs to assist, and if not, I don't know if they would get the lift into the toilet". During an interview with the surveyor on 10/12/2010 at 1:15 PM, CNA #2 verified she had used the lift on 09/25/10 with CNA #1 and also on 09/26/2010, when she and CNA #3 transferred Resident #1 out of the bed and into the wheelchair. She stated that they had decided to use the lift on 09/26/2010 because the resident had not been able to walk for about a week. She stated that she had used the lift before on Resident #1, due to the residents decline in ability to transfer. During an interview at 1:52 PM, CNA #3 stated that on 09/26/2010, she and CNA #2 were getting Resident #1 up out of bed. When the resident wouldn't help with the transfer, the lift was used to transfer the resident to the wheelchair. A little later when the nurse came to assess Resident #1's leg, the two CNAs transferred the resident back to bed manually using a gait belt. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had been coded under "Transfer" as a "3" requiring extensive assistance with "3" two + persons physical assist. Under "Modes of transfer" she had been coded as "Lifted mechanically". During an interview at 1:48 PM, the MDS Coordinator verified the above MDS coding information. When asked where she had gotten the information for the resident's transfer abilities, she stated she had read the Weekly Nursing Assessment and Nurse's Notes. When asked where she had gotten the information related to the use of a mechanical lift for Resident #1, she looked through the chart and then stated she had spoken with the CNAs about how they transferred the resident. When asked if it was appropriate to obtain this information from a CNA, the MDS Coordinator stated that she thought the CNAs were the best ones to assess whether a lift is needed. When asked what skills CNAs possess in order to determine that a lift is needed, she stated she didn't know- but that "they were certified". Review of the interdisciplinary Care Plan revealed that Resident #1 had the problem of "ADL Deficit, alteration in mobility r/t (related to) recent hospitalization .... transfers-extensive" indicating the amount of assistance needed for transfers. There was no mention of the use of a mechanical lift. During an interview earlier on 10/12/2010 at 9:48 AM, the DON, MDS Coordinator, and ADON were present. When asked about the Care Plan and documentation of the use of a mechanical lift, the MDS Coordinator stated that she did not Care Plan for the use of lifts. She also stated she had never seen staff chart the use of a lift. During a review of Physical Therapy Daily/Weekly Progress Notes for Resident #1 dated 08/16/2010 through 09/24/2010 with the surveyor on 10/12/2010, the Physical Therapist stated that Resident #1's transferring ability varied from day to day and ranged from Total/Maximum assistance of 2-3 staff to minimum/moderate assistance of 1 staff. She verified the following entries related to Resident #1's functional abilities dated 09/21/10 "SPT" (Stand pivot) w/c (wheelchair) toilet max(imum) (assist) x 2" and for 09/22/10 "Bed<>Chair Max(imum)/Mod(erate) x 2". After reviewing the PT progress notes, she verified there was no mention of a lift and stated she didn't recall that the resident used a mechanical lift device. When asked who determined which residents used a lift device, the Physical Therapist stated that PT and Nursing Staff discuss whether a lift is needed when a resident is admitted , but after that nursing would call PT if they had a concern. When asked if this discussion would be documented somewhere, she stated it would be documented in the PT progress notes. She stated she didn't know who made the decision to use the lift device, but that PT would suggest the lift device if a person was a good candidate. When asked if she thought that a CNA had the knowledge base to determine which resident used a lift, she stated that the CNA knew more about the resident and any changes than PT did. She stated she didn't know about CNA's making the determination. During an interview with the surveyor on 10/12/10 at 4:25 PM, the DON stated that on admission, all residents get a bed alarm and receive 2 person assistance for lifts. Therapy then comes in quickly to give their recommendations on what they think. The nurse and CNAs for that unit then come together and discuss an immediate Care Plan, which the CNA fills out. She was unable to provide a copy of the CNA Care Plan for Resident #1. The DON stated that if there are any changes in the level of assistance needed for transfers, PT is contacted and the CNAs and nurses report to each other. The DON stated Resident #1 responded well to the lift, and that she allowed the CNAs some discretion in the use of the mechanical lift. The facility admitted Resident #2 on 01/14/2009 with [DIAGNOSES REDACTED]. Record review conducted on 10/12/2010 indicated the cumulative physician's orders [REDACTED]. Review of the Weekly Nursing assessment dated [DATE] showed, under ADL's (Activities of Daily Living), the resident's transfer performance as total dependence with 2 person physical support. There was no documentation that the resident had been assessed for the use of a mechanical lift or that one was being used. Review of the CNA Care Plan Guide for Resident #2 revealed that she was a sit/stand lift with no mention of the level of assistance required for transfers. Review of Nurse's Notes dated 07/26/2010 through 10/12/2010 revealed no mention of the use of a mechanical lift. Observation on 10/12/2010 at 10:40 AM revealed CNA #2 and CNA #4 manually transferred Resident #2 from a high-backed chair to a wheelchair and wheeled her to her room for toileting. CNA #3 brought the Sara Lift into Resident #2's room and CNA #2 and CNA #3 transferred her from the wheelchair to the toilet using the lift. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had been coded under Transfer as a (3) requiring assistance with (2) one persons physical assist. Under Modes of transfer she had been coded as a manual lift. Review of the interdisciplinary Care Plan dated 07/22/2010 and updated 10/12/2010 revealed that Resident #2 had falls identified as a problem. Interventions included lowest bed position, bed alarm to bed and provide a safe environment; there was no mention of transfer needs. The facility admitted Resident #3 on 04/14/2006 with [DIAGNOSES REDACTED]. Record review conducted on 10/12/2010 indicated the cumulative physician's orders [REDACTED]. Review of the Weekly Nursing assessment dated [DATE] thru 10/09/2010 showed under ADL's (Activities of Daily Living), the resident's transfer performance as total dependence with 2 person physical support. Review of the CNA Care Plan Guide for Resident #3 revealed no mention of the level of assistance required for transfers or a mode of transfer. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] and Quarterly MDS assessment dated [DATE] revealed Resident #3 coded under Transfer as a (4) total assistance with (3) two persons physical assist. Under Modes of transfer she had been coded as a manual lift. Review of the interdisciplinary Care Plan dated 06/21/2010 and updated 09/14/2010 revealed that Resident #3 required assistance with Activities of Daily Living. Interventions included sits and transports in a Geri-chair daily; there was no mention of transfer needs.

On the day of the complaint inspection, based on record reviews and interviews, the facility staff failed to meet professional standards of quality for 1 of 6 residents reviewed for an acute change in condition. The physician was not consulted when Resident #6, treated [MEDICATION NAME] for recurrent urinary tract infections and recently treated with a course of antibiotics for a urinary tract infection, showed evidence of a change in condition. On 07/24/2010 at 6:15 AM he was noted with sweating; blood pressure 141/72, temperature 97.5, pulse 85 and respirations 22, he was described as lethargic at breakfast there was no other documentation until 11:00 PM when it was stated that no twitching of extremities was noted. On 07/25/2010 at 2:00 AM his blood pressure was not noted, temperature 100, pulse 100, respirations 18 and twitching of extremities when touched was noted; "opens eyes when spoken to with no awareness of staff. At 4:00 AM twitching when touched was again documented; at 6:00 AM his blood pressure was 110/50, temperature 99.9, pulse 180, fluids not accepted; at 10:50 AM he was lethargic, unresponsive; his BP was 110/80, temperature 97.5, pulse 115, respirations 20. Resident #6 was transferred to the emergency room . The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 10/12/2010 a review of the resident's closed medical record revealed the following Nurse's Notes from 07/24/2010 thru 07/25/2010: "07/24/2010 0615 Res (resident) has been sweaty this shift requiring linen and night clothing change. Hair damp skin cool and pale, clammy to touch. VS (vital signs) @ present BP (blood pressure) 141/72 p (pulse) 85, resp (respirations) 22 temp (temperature) 97.5 (A) (axillary), BS (blood sugar) 182. Hands to cool for O2 (oxygen) sat (saturation) to register. No s/s (signs/symptoms) of pain/discomfort. No acute apparent distress. Orderly up and showered. On top of bed resting now. Alert with eyes open. Will pass to next shift to monitor. 1:35 PM Resident was lethargic at breakfast could not wake up enough to eat. Ate 100 % of lunch. Has been holding head down and drooling excessively all day. Afebrile with VS WNL (within normal limits). Will cont. (continue) to monitor. 2300 Remains in bed. Skin cool to touch and dry at this time. No twitching of extremities. No cough or resp distress. 07/25/2010 0100 No change in condition. Opens eyes when spoken to. 0200 Temp. 100 BP--, P 100, R 18 BS 166. O2 sat 93% on rm (room) air. Twitching extremities when touched. Oral care. Open eyes when spoken to with no awareness of staff. 0400 Eyes closed, resting quietly. Continues to have twitching episodes when touched or spoken to. 0600 Responds to tactile stimuli. T 99.9 BP 110/50 P 180 R 20 O2 93% rm air. Skin moist warm. Pulls away when care given. Unable to get resident to take fluids. 10:50 AM Resident is lethargic and unresponsive. T 97.5, BP 110/80, P 115, R 20. Sent to ...ER (emergency room ) via EMS (emergency medical service) at dgt's (daughters) request..." Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/12/2010 at approximately 2:15 PM, during a telephone interview with the surveyor the Family Nurse Practitioner stated that the drooling was usual for the resident but that she would have expected the staff to call the physician when the resident was noted to be sweating and for sure when he first became lethargic. The Family Nurse Practitioner added that the staff was aware that he had just finished treatment for [REDACTED]. In a face-to-face interview on 10/12/2010 at approximately 12:10 PM the Unit 3 Manager stated that she was not sure why the staff failed to call the physician.

On the day of the complaint inspection, based on observations, record review, and interviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Certified Nursing Assistants used a mechanical lift on Residents #1 and #2 without documented assessments as to the appropriateness of the lift device. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility, which prompted the complaint investigation. Review of the facility investigation revealed that Resident #1 had been sent to the emergency roiagnom on [DATE] for pain, swelling, warmth, decreased range of motion, and a "fading discoloration" around and below the left knee. According to the physician's statement included in those records, the resident had been admitted to the hospital on [DATE] with a Deep Vein Thromboses (DVT) and tib-fib (tibia-fibula) fracture of the left leg. In a letter dated 10/1/10 from the facility's Director of Nursing (DON), the facility reported, "During the investigation it was noted that on September 25, 2010 (Resident #1's) left foot had slipped forward while being lifted with the "stand-up" lift. The lift procedure was stopped, another Certified Nursing Assistant (CNA) joined the aid caring for (Resident #1). Her left foot was moved approx. (approximately) three inches back into the proper position, and the lift and care proceeded. I had the CNAs demonstrate the procedure for me. I did not observe anything that would cause injury". Review of the closed medical record on 10/12/2010 revealed the following: Review of the cumulative physician's orders [REDACTED]. During an interview at 12:15 PM, Licensed Practical Nurse #1 verified this and stated that the physician deferred the issue of transfers or the use of lifts to nursing. Review of the Admission assessment dated [DATE] revealed no mention of the amount of assistance needed for transfers or any lift devices used. Under "Assistive Aides:" wheelchair alarm and bed alarm had been checked. Review of "Weekly Nursing Assessment(s)" dated 08/22/2010 through 09/19/2010 revealed under "ADL's (Activities of Daily Living), that the resident transfers with extensive assistance with 2 person physical help. There was no documentation that the resident had been assessed for the use of a mechanical lift or that one was being used. Review of the CNA Patient Care Record (PCR) for Resident #1 dated September 2010 revealed no mention of the level of assistance required for transfers or the use of any transfer devices. Review of Nurse's Notes dated 08/16/2010 through 09/26/2010 revealed several entries that stated 2 staff assisted with transfers, but no mention of the use of a mechanical lift. Interviews with nursing staff, however, indicated that the lift had been used many times throughout the resident's stay at the discretion of the nursing staff. The following entries were noted: "8-19-10...Staff x 2 put resident to bed", "8-20-10...Staff x 2 assisted res(ident) to bed", "8-23-10...Staff x 2 assisted to bed...", "8-26-10...Staff x 2 assisted (with) hs (bedtime) care + to bed", "9-26-10...-up to w/c (wheelchair) per 2 CNAs to have haircut". During a phone interview on 10/21/2010 at 11:45 AM, CNA #1 stated that the lift was used for Resident #1 to get her out of bed to the wheelchair. She verified she had used the lift without other staff assistance on several occasions on 09/25/2010 because she didn't have any help. She stated she did get assistance from CNA #2 when she encountered difficulty with Resident #1's foot placement on the lift. During an interview on 10/12/2010 at approximately 12:15 PM, Licensed Practical Nurse #1 stated that she "knew" CNAs had used the lift on Resident #1, but that she had not actually witnessed staff using the lift until 09/25/2010 when CNA #1 had to call CNA #2 for assistance with Resident #1's foot placement. She said that normally 2 CNAs would assist with transfers for Resident #1. LPN #1 verified that the lift had been used to get the resident out of bed on 09/26/2010 and that the resident was placed back into bed with the assistance of 2 CNAs lifting the resident. LPN #1 was asked what she would tell a CNA about the type of assistance Resident #1 required to transfer from the wheelchair to the bed or wheelchair to the toilet. LPN #1 stated that when transferring from the bed to the wheelchair, she would tell them to use the lift and make sure they had someone to help. If they were taking Resident #1 to the toilet, she would tell them to "see if the resident could bear weight with 2 CNAs to assist, and if not, I don't know if they would get the lift into the toilet". During an interview on 10/12/2010 at 1:15 PM, CNA #2 verified she had used the lift on 09/25/2010 with CNA #1 and also on 09/26/2010, when she and CNA #3 transferred Resident #1 out of the bed and into the wheelchair. She stated that they had decided to use the lift on 09/26/2010 because the resident had not been able to walk for about a week. She stated that she had used the lift before on Resident #1, due to the residents decline in ability to transfer. During an interview at 1:52 PM, CNA #3 stated that on 09/26/2010, she and CNA #2 were getting Resident #1 up out of bed. When the resident wouldn't help with the transfer, the lift was used to transfer the resident to the wheelchair. A little later when the nurse came to assess Resident #1's leg, the two CNAs transferred the resident back to bed manually using a gait belt. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had been coded under "Transfer" as a "3" requiring extensive assistance with "3" two + persons physical assist. Under "Modes of transfer" she had been coded as "Lifted mechanically". During an interview at 1:48 PM, the MDS Coordinator verified the above MDS coding information. When asked where she had gotten the information for the resident's transfer abilities, she stated she had read the Weekly Nursing Assessment and Nurse's Notes. When asked where she had gotten the information related to the use of a mechanical lift for Resident #1, she looked through the chart and then stated she had spoken with the CNAs about how they transferred the resident. When asked if it was appropriate to obtain this information from a CNA, the MDS Coordinator stated that she thought the CNAs were the best ones to assess whether a lift is needed. When asked what skills CNAs possess in order to determine that a lift is needed, she stated she didn't know- but that "they were certified". Review of the interdisciplinary Care Plan dated 08/30/2010 revealed that Resident #1 had the problem of "ADL Deficit, alteration in mobility r/t (related to) recent hospitalization .... transfers-extensive" indicating the amount of assistance needed for transfers. There was no mention of the use of a mechanical lift. During an interview earlier on 10/12/2010 at 9:48 AM, the DON, MDS Coordinator, and ADON were present. When asked about the Care Plan and documentation of the use of a mechanical lift, the MDS Coordinator stated that she did not Care Plan for the use of lifts. She also stated she had never seen staff chart the use of a lift. During a review of Physical Therapy Daily/Weekly Progress Notes for Resident #1 dated 08/16/2010 through 09/24/2010, the Physical Therapist #1 stated that Resident #1's transferring ability varied from day to day and ranged from Total/Maximum assistance of 2-3 staff to minimum/moderate assistance of 1 staff. She verified the following entries related to Resident #1's functional abilities dated 09/21/2010 "SPT" (Stand pivot) w/c (wheelchair) toilet max(imum) (assist) x 2" and for 09/22/2010 "Bed<>Chair Max(imum)/Mod(erate) x 2". After reviewing the PT progress notes, she verified there was no mention of a lift and stated she didn't recall that the resident used a mechanical lift device. When asked who determined which residents used a lift device, the Physical Therapist stated that PT and Nursing Staff discuss whether a lift is needed when a resident is admitted , but after that nursing would call PT if they had a concern. When asked if this discussion would be documented somewhere, she stated it would be documented in the PT progress notes. She stated she didn't know who made the decision to use the lift device, but that PT would suggest the lift device if a person was a good candidate. When asked if she thought that a CNA had the knowledge base to determine which resident used a lift, she stated that the CNA knew more about the resident and any changes than PT did. She stated she didn't know about CNA's making the determination. During the interview, the Physical Therapist was asked if PT provided any training on the use of the lifts. She stated that there had been an inservice done on 09/2/2010 by PT. She stated the training was in response to a resident that was supposed to be non-weight bearing. She stated PT spoke mostly about how to transfer residents with different weight bearing statuses, body mechanics, and hip precautions (what type of care a person with a total hip replacement requires). She stated there were no demonstrations on the use of the lift, but that it was mentioned -"If they needed to use the lift, go ahead". When asked if she had received any training on the use of the lift, she stated she had not received training in this facility, but that she had in other facilities she's worked in. She stated she had not trained any staff in the use of the lift. During interviews with the nursing staff, CNAs were asked about training received on the use of the mechanical lift and how they determined the amount of transfer assistance needed for a resident. Two CNAs indicated that they had not been provided with written instructions on how to use a mechanical lift and that CNAs that trained newly orienting CNAs did not use any set check list to instruct them on lift procedures. During a phone interview on 10/12/2010 at 11:45 AM, CNA #1 was asked if she had received any training on how to use a mechanical lift. She replied that when she did clinicals at the facility, she was taught how to use them. She stated once employed by the facility, she received training in orientation where she was shown how to use the lift by another CNA. When asked how she determined which residents needed to use the lift, she replied that you could tell the ones with more weight than the others. She stated that there was no paper documentation to tell her which residents needed to use a lift, that this was common sense. During an interview on 10/12/2010 at 1:15 PM, CNA #2 stated that she had been working at the facility for [AGE] years. She stated that staff receives inservices on the use of the mechanical lift whenever they get a new one. She stated that CNAs train other CNAs in the use of the lift but that no check off sheets or written instructions are used. When asked what she would do if she didn't know how to transfer a resident, she stated she would first ask the nurse, then ask PT. When asked if she would refer to the CNA Care Plan she said she would. During an interview on 10/12/2010 at 1:52 PM, CNA #3 stated that she had been employed at the facility for approximately 2 years. She stated she had been trained on the use of mechanical lifts during orientation. She stated she did not remember the CNA who trained her, but that she had been told how to use the lift, showed how to use the lift, and had to demonstrate the lift procedure back to her trainer. She was not aware of any check off sheet related to the lift procedure that had been used or turned in. When asked how she determined what type of assistance is required with resident transfers and if a lift is used, CNA #3 stated that she would first ask the nurse or other staff. Then she would look at the CNA Care Plan, which is located in the PCR book at the nursing station. During an interview on 10/12/2010 at 4:25 PM, the DON stated that on admission, all residents get a bed alarm and receive 2 person assistance for lift. Therapy then comes in quickly to give their recommendations on what they think. The nurse and CNAs for that unit then come together and discuss an immediate Care Plan, which the CNA fills out. She was unable to provide a copy of the CNA Care Plan for Resident #1. The DON stated that if there are any changes in the level of assistance needed for transfers, PT is contacted and the CNAs and nurses report to each other. The DON stated Resident #1 responded well to the lift, and that she allowed the CNAs some discretion in the use of the mechanical lift. She verified there were no formal assessments in place for the use of mechanical lifts. When asked how CNAs were trained in the use of the mechanical lift, she stated mentor CNAs checked them off during orientation. She was unable to provide any check off sheets or policies/procedures related to the use of the mechanical lift. She was asked to provide documentation of training for the mentor CNAs but did not provide any. When asked if there was a facility designated inservice trainer, she stated that there was not one, but that the Secretary and ADON kept up with staff training. When asked if any inservices or training had been provided related to using mechanical lifts since the incident with Resident #1's broken leg, she stated that there was an inservice scheduled for October 21st. She stated the inservice was being done in response to the incident with Resident #1 and was going to address the use of lifts and fire safety. Prior to the exit conference, the DON stated she had forgotten about an inservice regarding the proper use and function of the Sara Lift and the Marissa Lift that had been done in July 2010 and provided a copy. The inservice report stated that a demonstration had been done by therapy in which "The actual lifts were brought into the room and several employees acted as residents to properly demonstrate the use and function of these lifts". The inservice sheet did not contain any checklist or written procedures that had been communicated to the staff during the inservice. The signature sheet included CNAs #1, #2, and #3. During an interview on 10/12/2010 at approximately 5:00 PM, the Assistant Director of Nurse's (ADON) stated that inservices related to the mechanical lift devices were done periodically by therapy. She stated that CNAs who have been here a long time and who were very knowledgeable about lifts train new CNAs during orientation. She stated that the licensed nursing staff does not train the CNAs on the use of the mechanical lifts. The ADON stated that "mentor" CNAs use a "Nurse's Aide Checklist For Orientation" and provided a copy for review. She stated that CNAs get checked off on the use of mechanical lifts under the heading "Safety devices" and "Comfort of patients". Review of the checklist under those headings revealed no mention of the use of a lift. When asked how the CNAs were supposed to know this information pertained to the use of a mechanical lift (since there was no mention of a mechanical lift), the ADON stated she guessed they wouldn't. She was unable to provide a check off sheet or any other documentation to show what information the mentor CNAs were using to train new CNAs regarding how the mechanical lift should be operated. Review of the PCR book, which included all the PCR's for Unit 3 revealed a communication in the front of the book dated 3/28/2006 that stated "Residents are to be lifted using one of the lifts or a gait belt. No exceptions. This is to protect the staff as well as the residents. Corrective action will be taken if this is not followed. Thank you for your cooperation!" During an interview at 5:35 PM, the DON, when asked relative to the above communication if the philosophy of the facility had been and now was to use the lift as much as possible to prevent injury, answered "yes". The facility admitted Resident #2 on 01/14/2009 with [DIAGNOSES REDACTED]. Record review conducted on 10/12/2010 indicated the cumulative physician's orders [REDACTED]. Review of the Weekly Nursing assessment dated [DATE] showed under ADL's (Activities of Daily Living), that the resident transfer performance as total dependence with 2 person physical support. There was no documentation that the resident had been assessed for the use of a mechanical lift or that one was being used. Review of the CNA Care Plan Guide for Resident #2 dated September 2010 revealed that she was a sit/stand lift with no mention of the level of assistance required for transfers. Review of Nurse's Notes dated 07/26/2010 through 10/12/2010 revealed no mention of the use of a mechanical lift. Observation on 10/12/2010 at 10:40 AM revealed CNA #2 and CNA #4 manually transferred Resident #2 from a high-backed chair to a wheelchair and wheeled her to her room for toileting. CNA #3 brought the Sara Lift into Resident #2's room and CNA #2 and CNA #3 transferred her from the wheelchair to the toilet using the lift. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had been coded under Transfer as a (3) requiring assistance with (2) one persons physical assist. Under Modes of transfer she had been coded as a manual lift. Review of the interdisciplinary Care Plan dated 07/22/2010 and updated 10/12/2010 revealed that Resident #2 had falls identified as a problem. Interventions included lowest bed position, bed alarm to bed and provide a safe environment; there was no mention of transfer needs.