Every finding on record at NHC Healthcare - Laurens

Based on review of facility policy, review of manufacturer's recommendation, record review, observation, and interview, the facility failed to ensure a medication administration error rate of less than 5 percent for 2 out of 27 opportunities for error. Specifically, the Fiasp Pen (a pre-filled, disposable insulin delivery device) was not primed according to the manufacturer's recommendations for Resident (R)105 and additionally failed to ensure R161 received an eye medication as ordered. The medication error rate was 7.41 percent. Findings include: Review of the facility policy titled Insulin Administration states under the procedure section D. Overview for insulin pens the following: a) Attach pen needle to pen. Prime pen by dialing up 2 units and hold the pen with the needle pointing upwards. Tap the pen gently to remove air bubbles and then push the injection button until a drop of insulin appears at the tip of the needle. Review of the manufacturer's recommendations for administration via a FIASP (insulin aspart) injection pen revealed, Priming your FIASP FlexTouch Pen: . Step 7: Turn the dose selector to select 2 units. Step 8: Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top. Step 9: Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps 7 to 9, no more than 6 times. If you still do not see a drop of insulin, change the needle and repeat steps 7 to 9. Review of the facility policy titled, Medication Administration-General Guidelines under the Procedures section states, A. Preparation-1 Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to prepare and administer medications. 4) Before administering a medication, the nurse should assure he/she is administering to the correct patient, verify the medication, dose, time and route. Expiration date of medication should be checked before administration. Patient's allergies should be checked before the first administration of a medication. Review of R105's Face Sheet revealed the facility admitted R105 with diagnoses including, but not limited to, Type 2 Diabetes Mellitus with Hyperglycemia and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. During an observation on 06/23/26 at 11:30 AM, revealed Licensed Practical Nurse (LPN)1, after obtaining R105's blood sugar, preparing to give 6 units of FIASP insulin. After attaching the needle to the pen, LPN1 dialed the insulin pen to 6 units and turned to enter the resident's room. This surveyor asked LPN1 if there was anything that should be done to the insulin pen prior to administering the insulin. LPN 1 indicated s/he should prime the pen. At that time, after removing the cap, LPN1 held the insulin pen in a slanted position and primed the pen. LPN1 did not tap the pen for possible air bubbles or hold the pen upward per the manufacturer's recommendations. During an interview with LPN1 on 06/23/26 at 5:32 PM, LPN1 stated s/he had not been taught to hold the insulin pen upright to prime the pen. Review of R161's Face Sheet revealed the facility admitted R161 with diagnoses including, but not limited to, age-related cataract, primary open-angle glaucoma, right eye, stage unspecified. Review of the current physician's order revealed an order for Brimonidine-Timolol Drops 0.2-0.5%, one drop to left eye twice a day. During an observation and interview on 06/23/26 at 8:37 AM, revealed LPN2, after donning gloves, placed one drop into R161's right eye. After exiting the resident's room, LPN2 was asked which eye did s/he administer the eye drop. LPN 2 stated the eye drop was placed in the resident's right eye. When asked which eye the medication should have been administered into, LPN2 confirmed the eye drop should have been administered into the left eye.

Based on review of facility policy, review of manufacturer's recommendation, record review, observation, and interview, the facility failed to ensure a Fiasp Insulin Pen (a pre-filled, disposable insulin delivery device) was primed correctly prior to administering insulin for Resident (R)105. Specifically, the nurse failed to ensure the needle was pointed upward to ensure the air was removed from the pen and the resident received the correct amount of insulin as ordered for 1 of 1 resident observed receiving insulin. In addition, the facility failed to ensure R161 received an eye medication as ordered for 1 of 1 resident observed for eye medications.Findings include: Review of the facility policy titled Insulin Administration states under the procedure section D. Overview for insulin pens the following, a) Attach pen needle to pen. Prime pen by dialing up 2 units and hold the pen with the needle pointing upwards. Tap the pen gently to remove air bubbles and then push the injection button until a drop of insulin appears at the tip of the needle. Review of the manufacturer's recommendations for administration via a FIASP (insulin aspart) injection pen revealed, Priming your FIASP FlexTouch Pen: . Step 7: Turn the dose selector to select 2 units. Step 8: Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top. Step 9: Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps 7 to 9, no more than 6 times. If you still do not see a drop of insulin, change the needle and repeat steps 7 to 9. Review of the facility policy titled, Medication Administration-General Guidelines, under the Procedures section states, A. Preparation-1) Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to prepare and administer medications. 4) Before administering a medication, the nurse should assure he/she is administering to the correct patient, verify the medication, dose, time and route. Expiration date of medication should be checked before administration. Patient's allergies should be checked before the first administration of a medication. Review of R105's Face Sheet revealed the facility admitted R105 with diagnoses including, but not limited to, Type 2 Diabetes Mellitus with Hyperglycemia and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. During an observation on 06/23/26 at 11:30 AM, revealed Licensed Practical Nurse (LPN)1, after obtaining R105's blood sugar, preparing to give 6 units of FIASP insulin. After attaching the needle to the pen, LPN1 dialed the insulin pen to 6 units and turned to enter the resident's room. This surveyor asked LPN1 if there was anything that should be done to the insulin pen prior to administering the insulin. LPN1 indicated s/he should prime the pen. At that time, after removing the cap, LPN1 held the insulin pen in a slanted position and primed the pen. LPN1 did not tap the pen for possible air bubbles or hold the pen upward per the manufacturer's recommendations. During an interview with LPN1 on 06/23/26 at 5:32 PM, LPN1 stated s/he had not been taught to hold the insulin pen upright to prime the pen. Review of R161's Face Sheet revealed the facility admitted R161 with diagnoses including, but not limited to, age-related cataract, primary open-angle Glaucoma, right eye, stage unspecified. Review of the current physician's order revealed an order for Brimonidine-Timolol Drops 0.2-0.5%, one drop to left eye twice a day. During an observation and interview on 06/23/26 at 8:37 AM, revealed LPN2, after donning gloves, placed one drop into R161's right eye. After exiting the resident's room, LPN2 was asked which eye did s/he administer the eye drop. LPN2 stated the eye drop was placed in the resident's right eye. When asked which eye the medication should have been administered into, LPN2 confirmed the eye drop should have been administered into the left eye.

Based on review of the facility policy, record review, observations, and interviews, the facility failed to ensure that Resident (R)2, a resident with a previous history of elopement, had adequate supervision to prevent the resident from eloping from the facility on 05/19/25 at approximately 10:00 PM. R2 was found by law enforcement, lying down near trees, in a wooded area approximately 75 feet away from the building, on facility property at approximately 3:00 AM - 3:30 AM on 05/20/25. On 05/22/25 at 8:14 PM, the Administrator and Director of Nursing (DON) were notified that the failure to ensure Resident (R)2, a resident with a previous history of elopement, had adequate supervision to prevent the resident from eloping from the facility on 05/19/25 at approximately 10:00 PM. R2 was found by law enforcement lying down near trees, in a wooded area approximately 75 feet away from the building on facility property at approximately 3:00 AM - 3:30 AM on 05/20/25. This elopement constituted Immediate Jeopardy (IJ) at F689. On 05/22/25 at 8:14 PM, the survey team provided the Administrator and DON with a copy of the CMS IJ Template and informed the facility the IJ existed as of 05/19/25. The IJ was related to S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 05/23/25, the facility provided an acceptable IJ Removal Plan/Allegation of Compliance. On 05/23/25 at 2:07 PM, the survey team validated the facility's corrective action and removed the IJ as of 05/23/25 at 2:07 PM. At this time, the scope/severity was lowered to a D. An extended survey was conducted in conjunction with the Complaint Survey due to the identification of substandard quality of care. Findings include: Review of facility policy titled Section E: Emergency Procedures for Specific Events 'Missing Resident' dated September 2017, revealed Upon discovery of a missing resident: Alert all staff on the unit. Conduct a quick but thorough search of the unit and logical places where resident may have gone. If a resident cannot be located, the Nurse in charge of the area shall be responsible for notifying the Administrator. The Administrator will advise all units/departments and ensure immediate attempts shall be made to determine where the resident was last seen and what the resident was wearing. This information should be indicated on the INFORMATION ON MISSING RESIDENT form and given to the Command Center. Upon receiving notification of a missing resident do the following: The search of each area will be done by staff normally assigned to that area. If Building Lockdown is ordered, observe exit doors in your assigned work area. Staff searching within the building should visually identify residents in each room. Staff should also be certain to check rooms thoroughly, including empty beds, bathrooms, closets and behind/under beds. Once an assigned area has been searched, the results should be reported to the Charge Nurse/Department Supervisor. As the search of a department/unit is completed, this should be relayed to the Command Center, if activated. Staff assigned to search outside should check areas behind shrubbery, parked cars, etc. Staff searching at night should carry a flashlight and a means of communicating with the Command Center (radio, cell phone, etc.). During cold weather, staff should also carry a blanket for the resident. A picture of the missing resident should be provided to search teams, if available. Page 2 of the policy indicates: If resident is not located after search of building and immediate outside area: Notify [Name of County] Police Department (911). Provide them with a description of the missing resident. Charge Nurse and/or Administrator to notify family/responsible party. If it becomes necessary to call outside authorities, the [Name of State Agency] should also be notified. Record review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE] with diagnoses including but not limited to urinary tract infection, difficulty in walking, dependence on supplemental oxygen, anxiety disorder, and encounter for adjustment and management of a vascular access Peripherally Inserted Central Catheter (PICC Line). Record review of R2's In-Progress Admission Minimum Data Set (MDS) dated [DATE] revealed R2 has a Brief Interview of Mental Status (BIMS) score of 12 out of 15, which indicates that he is moderately, cognitively impaired. Further review of the Admission MDS revealed in R2's admission mobility assessment, he requires partial/moderate assistance with sit to stand. Substantial/maximal assistance with walking 10 feet - 150 feet; R2 utilized a manual wheelchair during his admission assessment. Record review of R2's Admission Elopement assessment dated [DATE] at 8:09 PM revealed R2 was at risk for elopement, an electronic monitoring device was placed on his lower left leg. Record review of R2's Discontinued Physician Orders for May 2025 revealed an order with a start date of 05/16/25 - 05/20/25 electronic monitoring device placement, instructions include check placement and site location each shift left ankle, Lot #124109876. Record review of R2's May 2025 Medication Administration Record (MAR) revealed a Physician Order with a start date of 05/16/25 - 05/20/25 electronic monitoring device placement, instructions include check placement and site location each shift left ankle Lot #124109876. Review of the MAR revealed there was no documentation of the device on 05/16/25, 05/17/25, and 05/18/25. Record review of R2's May 2025 Physician Orders revealed an order with a start date of 05/15/25 for Oxygen 3-4 liters (L)/minute (min) every shift. There was also an order with a start date of 05/15/25 for PICC line dressing and flush maintenance. Record review of R2's Progress Notes dated 05/20/25 at 9:00 AM revealed Resident returned form Emergency Department (ED) on stretcher with Emergency Medical Staff (EMS) being assisted to bed. R2 noted to be drowsy but easily aroused, when awake he is alert and talking with staff in room vital signs completed, no voiced complaints of pain, noted with small scratches to scalp, scratches to bilateral arms, small blood-filled blisters to left third and fifth fingers , bruise to right fourth finger, scratches to back, abrasions and scratching to bilateral knees and lower extremities with no issues of complaints of pain. Electronic monitoring device noted to left lower extremity ((Lot# KNKTX0003 A20080903 Exp: 12/27). Neurological checks performed with no issue noted, returned with Foley catheter in place, per EMS he was noted with urinary retention, nurse and therapist assisted him dressing and transferred to Geri chair therapist escorted him to therapy gym. Record review of R2's Progress Notes dated 05/20/25 at 9:30 AM revealed On 05/19/25 this writer received a call from station three nurse stating she entered into R2 room and found the window open with the screen lying on the ground. His roommate [R5] stated he went of the window; this nurse alerted all staff on each nursing station of the missing resident and a thorough search was initiated. This writer arrived at the facility within one minute and contacted the Administrator, Law enforcement, R2 Resident Representative (RR), and Medical Director. The RR stated, oh no, give me a call when you find him. The available staff began to search the premises. Law enforcement arrived and asked staff to cease the premises search and return inside the facility to initiate second search. Law enforcement was given missing person detail information to include a color photo of the resident. Resident was later located on the facility's premises behind the therapy area within 75 feet from the building. He was lying on the ground. He was able to stand and ambulate with limited assist from law enforcement. The resident was assisted to the stretcher and assessed in the EMTs. Resident was taken to ED for a well care evaluation. RR and on-call MD updated on current events. The resident returned to the facility from the ED with a Foley catheter due to possible obstruction. There was a care plan meeting scheduled for today, the RR requested that we reschedule the meeting due to the recent events. The Interdisciplinary Team (IDT) agreed, resident currently in bed being assessed by nurse and therapist. Record review of R2's Progress Note dated 05/20/25 at 11:00 AM revealed Interview with R2 entered into resident's room, this writer observed him lying in bed, with both eyes open. Alert to name. When ask if he recalled what happen last night? He replied Yes. When asked where was he attempting to go? He replied, to a friend's house (a big house with a lot of money), but when I got out there, I realized it was too far. When asked if this friend was a family member? He stated, no he is a friend. The writer asked how did you get outside? He demonstrated (while lying in bed) how he got dressed, pulled up the blinds, pulled the window back, and pushed the screen out. I put one leg out the window and then the other one. Asked why did he exit through the window? He stated, It was the fastest way out. The writer informed the resident that she was out there looking for him. He replied, it was more out there than just me and you. I continued the conversation telling him that I was calling his name. He replied, I heard you. I asked why didn't you answer me? He stated because I didn't want y'all to know where I was, it was too many people out there (as he smiled). The resident was very pleasant during this interview. Record review of R2's Health and Physical Hospital Discharge Summary dated 05/11/25 revealed R2 is an [AGE] year-old who presents with concerns over altered mental status. At the time of evaluation R2 with his Resident Representative (RR) at bedside. R2 is a very pleasant male with a longstanding history of tobacco abuse totaling greater than [AGE] years as a result he does have Congestive Obstructive Pulmonary Disease (COPD), depression, narcolepsy with cataplexy and some concerns over cognitive impairment. Today he was brought to the hospital when he was found sleeping on his neighbor's front porch. When R2 arrived at the hospital he was lethargic but would arouse to a loud voice and could not explain how he got there other than stating he may have been related to his narcolepsy. His RR said however gives a history of extremely worrisome findings over the last few weeks. R2 has been confused in terms of time and sometimes will ask repetitive questions to his son of things he would normally know. Last week he apparently crawled out of his window and ended up at his neighbor's place because he was hallucinating and thought that he may be under attack. He did see his primary care Physician about ten days ago and his Seroquel was stopped. His son states he has still remained intermittently confused since that time. Here in the ED his workup is worrisome for him having some hypoxia and hypercapnia from COPD exacerbation. He was started on BiPaP in the emergency room . He also has evidence for a UTI; he has been referred to the medical service for admission for the same. Record review of R2's Care Plan with a start date of 05/20/25 revealed R2 had an episode of wandering and exit seeking. Interventions include equip with a device alarm (left ankle), check for proper functioning of device every day and check for placement every shift; maintain a calm environment and approach to him; provide 1:1 supervision; when he begins to wander, assess for and provide for basic needs. Review of a Police Department Incident Report with an incident date of 05/19/25 revealed On the incident date and time, police department staff responded to the incident in reference to a missing person. Upon arrival I found multiple facility staff members walking around the rear of the building with flashlights. Police department staff made contact with a facility staff who informed that a patient had climbed out of the window in his room and they were unable to locate him. Facility staff informed the police department that R2 suffered from dementia, had issues with oxygen levels and was a risk for cardiac issues, and is narcoleptic. Immediately upon learning that R2 would be missing/endangered the police department staff asked that all facility staff members clear the area surrounding the window and the rear of the building. Police department staff then requested a bloodhound. Police department staff had a facility staff member to walk to R2's room where they secured clothing of R2 to use a scent article. R2's roommate (R5) stated that he had been gone for approximately an hour . the police department had to reach out to a different law enforcement agency, [state law enforcement]) to assist with the search of R2. Upon arrive [sic] of [state law enforcement] bloodhounds, both police departments initiated a track (search for R2) which was unsuccessful. A reverse 911 call was issued for a four-mile radius and [NAME] were requested from Emergency Services. While waiting for the [NAME], several people began to search a wooded area to the rear of the facility. Down a hill behind a wooded fence, officers located R2 sleeping in the woods, he had removed his pants and was using them as a pillow. R2 had several scratches but seemed to be in decent condition considering the circumstances. R2 was able to walk to the wood line with assistance (up a hill nearby the facility), he was then secured on stretcher and turned over to Emergency Medical Services (EMS) personnel and then transported to the hospital. Record review of R5, (R2's Roommate), Face Sheet revealed R5 was admitted to the facility on [DATE] with the diagnosis including but not limited to epilepsy, anxiety disorder, major depressive disorder, and insomnia. Record review of R5's Quarterly MDS dated [DATE] revealed that R5 has a BIMS score of 13 out of 15, which indicates that he is cognitively intact. An interview on 05/22/25 at 10:02 AM with R5 revealed that he observed R2 successfully elope from the facility out of their window, in their room a few nights ago (05/19/25). R5 stated that R2 unlocked the window and then kicked the window screen to elope. R5 stated he tried to call for help to get staff to stop him, but it took a few minutes before anyone came. R5 was unsure specifically how long R2 was missing from the facility but stated he was gone for a few hours, and the police had to use tracking dogs to find R2. An observation and interview with R2 on 05/22/25 at 11:47 AM revealed that he was unable to recall recently eloping from the facility. R2 was pleasantly confused, an electronic monitoring device was observed on R2's left leg at this time. A phone interview on 05/22/25 at 12:38 PM with R2's Resident Representative (RR) revealed that the facility notified him of R2's elopement on 05/19/25 at 10:56 PM and was notified that the resident was found on 05/20/25 at 3:00 AM by Law Enforcement officials/facility staff. During the interview with R2's Resident Representative, he stated, R2 has a history of elopement and eloped from his home on 05/10/25. R2 was found by his neighbors, which initiated the resident being hospitalized and then admitting to the facility on [DATE]. The RR then stated that facility informed them that R2's window is now screwed shut to prevent the resident from eloping again. A phone interview was attempted on 05/22/25 at 1:02 PM with R2's Nurse from the night of 05/19/25. However, it was unsuccessful. The voicemail was full and surveyor was unable to leave a message. An observation and interview on 05/22/25 at 1:32 PM with the Maintenance Director revealed that they have placed a barricade at the top of the resident's window to prevent it from opening fully. The Maintenance Director stated that he initiated this intervention on 05/20/25, after the resident eloped from the facility from his window. A phone interview on 05/22/25 at 3:14 PM with Certified Nursing Assistant (CNA)1 revealed that they were working on the night of 05/19/25 when R2 eloped from the facility from out of his window. CNA1 stated, Earlier that evening before R2 eloped, he was attempting to stand without assistance, so staff put him at the nurse's station for supervision to prevent R2 from falling. CNA1 stated that they last observed the resident at the nurse's station with other staff but was unsure of what time specifically. CNA1 stated that she was providing another resident with a shower when she overheard someone call out on the intercom, Code Purple (elopement). CNA1 stated that she was unsure who was specifically assigned to R2, but he was not exhibiting exit-seeking behaviors with her, only that R2 was attempting to stand without assistance. CNA1 stated that staff began to search for the resident both inside and outside of the facility until Law Enforcement arrived at the facility and told everyone to go back inside. CNA1 stated that she was unsure of what time R2 was found and brought back to the facility but was approximately between 2:30 AM - 3:00 AM. Lastly, CNA1 revealed that she was unaware of R2's exit seeking behaviors and she knows to identify residents with elopement risks by observing their behaviors and observing for a electronic monitoring devices. During an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 05/22/25 at 3:22 PM, the DON stated that she unaware of R2's history of elopement/elopement prior to being admitted to the facility. DON stated, he was taking out his PICC line a lot, so the Registered Nurse (RN) was checking on him every 15 minutes. She checked on him at 9:55 PM because she heard a noise during this observation, he was opening up a piece of candy. She went back at 10:10 PM. When the RN went to check on R2 again, he was missing, and she observed that the window was open, and the window screen was on the ground outside. I immediately came to the facility and saw that staff were outside looking and calling his name. I could see where the screen was on the ground outside. I got a color photo so the police could look for him. The Administrator was called; I then started looking in the therapy area. His room is facing that patio in that parking lot. I called the police after I called the Administrator. The police told us to stay close so the resident's scent wouldn't get mixed up with our scent. We had some of our staff drive up and down the road to see if we saw him. After the police arrived, they took over the search. We also looked up on the roof to see if we could see him. When we found him, he was behind the therapy center and behind a bush. He took his pants off and rolled it up and used it as a pillow. We did call the RR to let them know about what happened. He got up from lying on the ground. They brought the stretcher to him. He walked to the stretcher and EMS took him to the ER. He returned about 08:30 AM. They found him about 3:00 AM in the morning. I wished the police would have let us continue to search for him in the back. The police got a pair of shoes, so the dogs could smell his scent. The interventions we put into place included getting him a 1 on 1 sitter that is assigned to him at nighttime. During the day, we kept him at the desk. We placed a second lock on the window and a window stop. This prevents him from opening the window. R2 told me when he returned here, he was going to visit his friend. He said, the big house and big money. He told me his friend was in [the next town over]. He told me how he left. He pulled the window out and pushed it. He told my daughter he didn't want his jeans on. So, he put his jeans back on and socks. He told me he seen me and heard me call his name, but he didn't want me to know where he was. He continued his antibiotics with the PICC line. He should be finishing up. So, he will probably get his PICC line out. He told me he put his leg over the air condition unit to get over it. He said he saw us, but it was too many people out there for me. We recently had a meeting with the family members, and it would have been nice to know he was an elopement risk. The son stated he sees people, but he doesn't talk to them. We had the fire department, the police, and [state law enforcement]. It was a lot of people. Our psych services comes in the first Wednesday in every month. We have some people who have a wanderguard on. I asked him why he chose to go out of the window, and he stated that was the fastest way to get out. The nurse checks the wanderguard. The wanderguard has an expiration date. I expect the staff to check the wanderguard prior to leaving the facility, in order to make sure it is in place. It can go on their wrist. The wanderguard is mostly placed on the ankle, and a check is completed by using 2 fingers, to ensure there is proper circulation. The DON stated, We have training on Relias. The rest of the staff is trained. I haven't had 100% training yet., but my goal is to have 100% completed on checking who to call first if an elopement occurs. I want to go in the assessment to make sure they understand what makes them an at-risk person and acting quickly. A phone interview on 05/22/25 at 4:21 PM with RN1 revealed that they were the resident's assigned nurse on 05/19/25, on the night shift. RN1 stated, R2 was exhibiting the behavior of standing without assistance and staff had to constantly re-direct him to prevent him from falling. R2 was placed at the nurse's station for supervision related to this behavior. RN1 stated that they asked the resident if he was ready for bed and R2 was agreeable, RN1 assisted the resident to bed and took off his pants then R2 shortly fell asleep. RN1 stated that she was frequently rounding on the resident because he previously attempted to pull out his PICC line. RN1 stated she last observed the resident on 05/19/25 at approximately 10:00 PM and the resident was in bed, now awake and eating a candy bar. RN1 stated that approximately 15 minutes later, she observed that R2 was missing, the window was open, and the screen of the window was on the ground outside. RN1 immediately notified other staff, the DON, and appropriate parties. RN1 stated that R2 was found by Law Enforcement approximately 75 feet from the facility. Law Enforcement recognized the resident from his previous elopement prior to being admitted to the facility and was able to instruct the resident/make him agreeable to returning to the facility. RN1 was unsure of what specific time the resident was located by Law Enforcement but stated it was approximately 2:30 AM-3:00 AM on 05/20/25. RN 1 then stated that they have not worked a shift at the facility since this incident, but an in-service was completed during her shift/after the resident was located by facility staff. An interview with the Administrator on 05/22/25 at 4:50 PM revealed I got a call from nursing on 05/19/25 at 10:25 PM notifying me that R2 was missing from the facility, I live less than a mile from the facility and arrived at the facility shortly after being called. When I arrived, the DON was here, and the police pulled up about the same time that I arrived. The police requested that facility staff enter back inside the building to allow Law Enforcement to take-over the search process. The facility is paved all the way around and the resident's room is tucked in a corner. Then you have a patio, a parking lot and the therapy center. We set up a command center in the parking lot closest to therapy center. Law Enforcement allowed me to go look at R2 room from the inside. Outside, it was already dew on the ground. Law Enforcement brought the dog in from [state law enforcement]. The dog immediately picked-up the footprints, I don't know the timeframe of how long they were out with the dog, but it was approximately 20 minutes. Law Enforcement had difficulty tracking a scent from R2 because there were also deer in the nearby woods and the dogs picked up on their scent as well. Law enforcement had to allow the tracking dog time reset from the different scents, during this time facility staff went on the roof with flashlight to help search for R2. When they put the dogs back out where the sidewalk goes around the building and the Woodline with a few trees [state law enforcement] said I wasn't to look at the Woodline. [state law enforcement] asked me to give them information on R2. By the time we walked to the office they called me and said they got him (R2), and he was in the Woodline, this was approximately 3:00 AM - 4:00 AM (unsure of time) I went out with [state law enforcement] and saw him as he got up without assistance to started walking to be assessed by EMS. Law Enforcement and EMS staff asked R2 if he was hungry, he said yes and he got up and walked out. R2 is alert and oriented, he had times of confusion with the UTI. R2 was taken to the hospital for further evaluation and returned to the facility on [DATE] around mid-day. When R2 returned to the facility, staff interviewed him and asked did her remember what happened/why did he exit the facility. In interview with facility staff (nurse and therapy) R2 stated I wanted to leave; I got up put my clothes on and step out of the window. I wanted to go to my friend's house. When I got out, he said it was too far. The Administrator stated, During an interview with the resident, staff questioned R2 about the reasoning behind leaving the facility from the window and R2 stated that he heard staff calling his name and saw people looking for him, but he didn't want to be found. R2 is a conscious person, he knew he couldn't go out of the door because he had an alarm on (electronic monitoring device). R2 left the facility Against Medical Advice (AMA), and I don't consider this an elopement because residents have a right to make decisions to discharge/leave. Eloping is when they (a resident) do not know what they are doing. R2 consciously decided upon himself to leave the facility from the window and told facility staff what he did/demonstrated to staff how he exited the facility. R2 also consciously avoided Law Enforcement and facility staff by rolling in the ground to avoid the tracking dog from picking him up. After the incident, we met with R2's Resident Representative for a Care Plan meeting and were informed by his RR that the resident has had other attempts to elope/leave his home. We have now put a window stop in R2 window, and we keep him out of his room as much as possible during the day at the nurse's station for supervision. At night, we have someone sitting with him for supervision. R2 had an electronic monitoring device placed on him on admission because he made a comment to staff that he wanted to go home. Lastly, the Administrator stated, The facility was unable to prevent the resident from leaving the facility because he made the decision to leave on his own because the resident's decisions were calculated (avoiding Law Enforcement, tracking dogs, facility staff, etc.). A phone interview on 05/23/25 at 11:57 AM with Medical Doctor (MD1) revealed they assessed R2 on admission and R2 spoke about wanting to go home. R2, on admission, was oriented x 3 (aware of name, location, approximate time). MD1 later stated that he was not included in the decision to place an electronic monitoring device on R2 related to his wandering and that was a facility staff decision. An interview on 05/23/25 at 12:40 PM with R2's Social Worker (SW) revealed On admission, R2 had a BIMS of 12 (moderate cognitive impairment) initially, but when I spoke with R2 after the incident (elopement), his BIMS was a 10 (moderate cognitive impairment). The next day, I spoke to R2 and his BIMS was back to a 12. In conversations with R2, he spoke about wanting to go home, R2's Resident Representative is now looking into placing R2 on a locked unit after he discharges from the facility, due to his wandering/exit seeking behaviors and history of elopement. Prior to admission, R2's Resident Representative supervised R2 by bringing him to work daily. The SW indicated, Our discharge plan is currently to assist R2's RR with home health services, if they are not able to find a locked/secure unit for R2. A phone interview on 05/23/25 at 2:03 PM with MD2 revealed that they were notified of R2's elopement at 2:00 AM and that staff and the police department were searching for the resident in the woods. MD2 stated, R2 has a history of exit seeking/elopement behaviors and facility staff notified him appropriately when the resident was located. The facility's removal plan for the IJ related to F689 included Immediate Actions Taken: 1. Implemented 1:1 supervision for this resident when he is not in group settings. Implemented upon his return to the facility on Tuesday, 05/20/25 and will remain for this resident for the duration of his stay at [the facility]. Compliance will monitored by Department Heads along with the Administrator and Director of Nursing. 2. Installed a double lock/window stop system on his patient room window to increase safety. The system was installed at 8:10 AM on 05/20/25 (prior to the resident returning to the facility). Window lock/stops will be checked for proper operation twice daily for the duration of R2's stay at the facility. The lock/stop system has been installed on all patient room windows and will be monitored quarterly. Compliance will be monitored by the Director of Plant Maintenance. 3. Reeducated the staff on the facility's Emergency Procedure for a Missing Resident. education began during and immediately after the search on 05/20/25 and concluded on 05/23/25. Education will continue for all employees quarterly on each shift. Compliance will be monitored by the Department Heads along with the Administrator and Director of Nursing. 4. A Quality Assurance Performance Improvement (QAPI) was initiated on 05/20/25 to ensure that R2 and other facility resident have appropriate supervision and assuasive devices in place to prevent accidents, especially those with exit seeking behaviors. Compliance will be monitored by Department Heads along with Administrator and Director of Nursing.

Based on record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately complete a resident assessment. This failure affected 1 of 32 sampled residents, (Resident (R)114). Findings Include: Review of the October 2024 Resident Assessment Instrument (RAI) Manual, page L-1 stated, Health-related Quality of Life -Poor oral health has a negative impact on: --quality of life --overall health --nutritional status -Assessment can identify periodontal disease that can contribute to or cause systemic diseases and conditions, such as aspiration, malnutrition, pneumonia, endocarditis, and poor control of diabetes. Planning for Care -Assessing dental status can help identify residents who may be at risk for aspiration, malnutrition, pneumonia, endocarditis, and poor control of diabetes. Page L-2 stated, Steps for Assessment 1. Ask the resident about the presence of chewing problems or mouth or facial pain/discomfort. 4. Conduct exam of the resident's lips and oral cavity with dentures or partials removed, if applicable. Use a light source that is adequate to visualize the back of the mouth. Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek lining. Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The assessor should use their gloved fingers to adequately feel for masses or loose teeth. 5. If the resident is unable to self-report, then observe them while eating with dentures or partials, if indicated, to determine if chewing problems or mouth pain are present. 6. Oral examination of residents who are uncooperative and do not allow for a thorough oral exam may result in medical conditions being missed. Referral for dental evaluation should be considered for these residents and any resident who exhibits dental or oral issues. Review of R114's Face Sheet from the electronic medical record (EMR) under the Resident tab showed a facility admitted [DATE]. Review of R114's Progress Notes from the EMR under the Resident Tab dated 01/22/25, revealed the resident was observed with missing teeth and poor dentation. Review of R114's Admission Observation from the EMR under the Resident Tab, dated 01/22/25, revealed under the dental assessment section the following options: -Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose). -Inflamed or bleeding gums or loose natural teeth. -No natural teeth or tooth fragment(s) (edentulous) . -Mouth or facial pain, discomfort, or difficulty with chewing. -Abnormal mouth tissue(ulcers, masses, oral lesions, including under denture or partial if one is worn). -Unable to examine. -Obvious or likely cavity or broken natural teeth. -None of the above were present. Further review of the Admission Observation revealed, None of the above were present was the only option checked. Review of R114's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/25, the dental assessment section had the same options as the Admission Observation with the same option checked of None of the above were present. Review of R114's Physician Progress Notes from the EMR under the Resident tab showed on 03/04/25, the physician wrote, Reporting pain with eating in bottom front area of mouth. Tells me pain is from area where he does not have a tooth. However, he does report pain with palpation of both adjacent teeth. Extremely poor dentition overall. Several missing teeth and several remaining teeth are loose. I do not see any abscess. Will provide PRN [as needed] orajel. Add to list for dentist to evaluate. Reason for acute care visit: Toothache. During an interview on 03/25/25 at 3:52 PM, R114 stated, My teeth are gone; they are there just bad because of time overseas with the military, and I would like them worked on. During an interview on 03/27/25 at 9:57 AM, the MDS-2 Coordinator confirmed she completed R114's Admission MDS. When asked about the dental status, MDS-2 stated, I don't recall if I looked or not. He was not as cooperative as he is now. MDS-2 reviewed her notes and found nothing regarding looking at his dental status; MDS-2 reviewed the Admission Observation and stated, the observation is linked directly to the MDS coding and that is probably how it was coded. MDS-2 reviewed the admission Progress Notes and confirmed it did not match the observation or assessment. During an interview on 03/27/25 at 2:53 PM, the Director of Nursing (DON) stated the facility did not have a policy regarding MDS accuracy, We use the RAI Manual. During an interview on 03/27/25 at 4:54 PM, the DON stated it was an expectation that MDS assessments would be coded correctly 100% of the time.

Based on observation, record review, interview, and facility policy review, the facility failed to document 1 of 32 sampled residents' skin condition (Resident (R)114). The failure to have all the information in a medical record could affect the planning and receipt of necessary care and treatment. Findings include: Review of the facility policy titled Accidents and Untoward Occurrences, dated 11/2023, stated: . Skin Tears -Use Skin Tear/Laceration Skin Integrity Event located in the EHR [electronic health record]. -Description of what happened, if witnessed or patient's statement about what happened, if not witnessed. If the patient states that a specific object caused the skin tear, document what the patient said in quotes. -Description of the skin tear, including location, size, and depth (in centimeters), discoloration, bleeding, swelling, general condition of skin prior to injury (i.e., tissue paper-like skin, etc.) -First aid treatment rendered. -Notification of physician/provider and document content of discussion. -Notification of patient representative, including time, who you spoke with, response of patient representative -Patient's reaction to injury. -Initial Alert Charting: Notes should include assessment of the skin tear, interventions, if any, and responses to interventions, if any. The policy did not address skin scabs. Review of R114's Face Sheet from the electronic medical record (EMR) under the Resident tab showed a facility admitted [DATE], with medical diagnoses including but not limited to: hypertensive heart and chronic kidney disease, congestive heart failure, and type II diabetes. Review of R114's 03/21/25, Skin Assessment located in the EMR under the Observation tab revealed no documentation regarding the hand scab or the dressing on the left forearm. Review of R114's Progress Notes from the EMR Resident tab showed nothing about an incident or the treatment of a wound in the past two weeks. During an interview and observation on 03/25/25 at 4:09 PM, scabs were observed on the back of R114's right hand and a bordered dressing on R114's left forearm. R114 stated the scabs were a result of his diabetes and the dressing was over an area he caught on the door latch going through the door, but was not sure when it happened. During an interview on 03/27/25 at 9:45 AM, the Unit Manager (UM)3 confirmed R114's skin assessment showed no wounds. At 9:50 AM, UM3 observed R114 in the Therapy department and confirmed the scab and wound dressing. During an interview on 03/27/25 at 4:54 PM, the Director of Nursing (DON) stated an expectation was that, Staff should be following the guideline making sure we know what is [sic] with the skin, notify the physician, make sure we get treatment orders, and carry out the orders. Skin should be monitored and documented as ordered.

Based on observation, interview, and record review, the facility failed to provide meals at regular times comparable to normal mealtimes and resident preferences for 3 of 4 stations (station two, three, and four) in the facility. Findings include: During an observation of a Tray Delivery Schedule contained in a plastic stand-up holder at each of the four nurses' stations, the following times and stations were posted for residents, staff, and visitors to observe: Breakfast 7:15 AM - Station 1; 7:35 AM - Station 2; 7:55 AM - Station 3; 8:15 AM - Station 4. Lunch 11:45 AM - Early Trays; 12:00 PM - Restorative Dining (Therapy). 12:00 PM - Station 1; 12:30 PM - Station 2; 12:50 PM - Station 3; 1:10 PM - Station 4; Supper 4:50 PM - Early Trays (All Stations); 5:15 PM - Station 1; 5:35 PM - Station 2; 5:55 PM - Station 3; 6:15 PM - Station 4 Trays to be delivered +/- 15 minutes of scheduled time. During a lunch observation of station two on 02/20/24 at 12:33 PM, residents were observed to have placemats on the table and were leaned over and resting their heads on the table while waiting for their meals. The meals were scheduled for delivery at 12:30 PM. The meal cart arrived at 12:40 PM. Room trays were passed before the residents in the dining room were served. Resident (R)107 was observed to receive her tray, in her room, at 12:43 PM. At 12:45 PM, R7 was observed in her room with her meal on an over bed table. During an observation and interview of station two on 02/20/24 at 12:48 PM, the meal cart was placed outside the dining room. No one attempted to pass the trays to the residents seated in the dining room. Staff stated that they were waiting for the second cart to pass all the room trays before passing the dining room trays. At 12:53 PM, the second cart arrived on the unit and staff started to pass room trays. At 12:59 PM, another meal cart arrived in the dining room and meals were then passed to the residents seated in the dining room. During a lunch observation of station three on 02/20/24 at 1:45 PM, thirteen residents were observed in the dining room. The last tray was delivered at 1:54 PM, 64 minutes after the meals were scheduled to be delivered to station three. During an observation and interview of station four on 02/20/24 at 12:59 PM, 1:15 PM, and 1:36 PM, there were no meal carts on station four. At 1:40 PM, the first meal cart arrived at station four. Four certified nurses' assistants (CNA's) were observed at the cart along with the Registered Nurse Supervisor (RN)2. When asked, CNA1 stated there's no silverware. RN2 stated there's no silverware, we cannot pass the trays until we get silverware. During an observation on 02/20/24 at 2:00 PM, R18 was seated in her wheelchair in the doorway to her room. R18 said I'm hungry, just waiting for the girls to bring my lunch, we have to wait our turns. During an observation on 02/20/24 at 2:00 PM, R86 was seated in his wheelchair in the hall outside his room. R86 stated I'm hungry too. During an observation on 02/20/24 at 2:04 PM, R33 was seated in station four dining room. R33 received her tray and stated, this looks good, I'm so hungry. Only two residents were seated in the dining room for lunch, all other residents received their meals in their rooms. R30 was served her tray, in her room, at 2:14 PM. The last room tray to be served was observed at 2:19 PM, 69 minutes after the meals were scheduled to be delivered. During a lunch observation on 02/21/24 at 1:18 PM, the meal cart arrived on station four. At 1:40 PM, R33 was served lunch in the dining room, 30 minutes after the posted time of meal delivery. During a breakfast observation on 02/22/24 at 8:30 AM, the meal cart was observed to arrive at station four. Four staff members were delivering trays. The last tray was delivered at 9:07 AM, 52 minutes after the trays were scheduled to be delivered. A resident group interview was held on 02/21/24 at 11:00 AM with four alert and oriented residents chosen by the facility staff, who regularly attended the facility's monthly resident council meetings. During the interview, all four residents (R200, R75, R77, and R128), stated timing of meals can be up to 30-45 minutes late, we have complained, but how can you fix short staff in the kitchen? The residents stated, this has been going on for months. R75 stated, it's just the way it is, you have to wait. During an interview on 02/22/24 at 9:44 AM, CNA1 stated delivery depends on when the kitchen sends the trays, how late they are, we're always ready. CNA1 was on duty, on station four, all three days of survey. During an interview on 02/22/24 at 11:03 AM, the Registered Dietician (RD) confirmed the tray delivery schedule is the expected time for the meal cart to be delivered to the four stations for staff to deliver to each resident. During an interview on 02/22/24 at 12:53 PM, the Social Worker (SW)2 confirmed that residents had voiced grievances about the late meal delivery in resident council. SW2 did not know how the staff had responded to the resident grievances. During an interview on 02/22/24 at 1:34 PM, the Dietary Manager (DM) stated, when we start, we start at rehab, the last cart should be at Station 4 no later than 1:20 PM. The DM stated her expectation of her staff was I expect to start on schedule, remain on schedule and be delivered on schedule. When asked what would cause a delay in the meal delivery, the DM stated, I haven't had that problem with trays being late, so I have not had to communicate this issue to my staff.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure residents who self-administered medications had a self-administration of medications assessment, a physician's order, and a care plan completed for 1 of 1 resident reviewed for self-administration of medications. The failure to properly assess and care plan, Resident (R)108, for self-administration of medications increases the potential of medication errors. Findings include: Review of the facility's policy titled, Self-Administration of Medications, revised 01/01/19, revealed, In order to maintain the resident's high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescribe's order to self-administer. Review of R108's Face Sheet revealed R108 was admitted to the facility on [DATE] and had diagnoses which included but was not limited to: bipolar, anxiety, obsessive compulsive disorder (OCD), and traumatic brain injury (TBI). Review of R108's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/24, revealed R108 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R108 was cognitively intact. During an observation on 02/20/24 at 10:00 AM, after walking into R108's bedroom, there were five clear plastic cups stacked together, on R108's overbed table. One clear cup had two brown capsules and one round dark pink pill. One cup had three round white pills and one dark pink round pill. One cup had a dark pink pill. R108 grabbed these medication cups with his left hand and placed them on the bed with his left hand over the medication cups. R108 declined to speak about the medications other than saying they were throw away pills. During an interview on 02/20/24 at 10:10 AM, Registered Nurse (RN)1 stated that R108 had a mood disorder and could be difficult with his behaviors. RN1 was asked if medications should have been at his bedside, and she stated no. After the interview, RN1 left the area and went into R108's room. At 10:13 AM, RN1 came walking out with medication cups in her hand, confirming the cups should not have been in his room. Review of R108's Physician Order Report: 02/01/24 - 02/22/24, revealed acetaminophen tablet; 325 milligrams (mg); amount: two tablets (total 650 mg); oral. Special Instructions: take two tablets (650 mg) every four hours as needed (PRN) for general pain, fever of 100.4 oral/101.4 rectal/99.4 axillary; cranberry tablet; 450 mg; amount: two tablets; oral once a day; 08:00 AM; and turmeric-turmeric root extract capsule; 450-50 mg; amount: one capsule; oral twice a day (BID); 08:00 AM, 5:00 PM. Review of R108's Medication Administration Record (MAR) 02/01/24-02/22/24, revealed acetaminophen 650 mg every four hours PRN was given on the following dates 02/05/24, 02/08/24, 02/10/24, 02/12/24, 02/16/24, 02/19/24, and 02/21/24; cranberry tablet 450 mg two tablets was documented as given daily and turmeric-turmeric root extract 450-50 mg, one capsule was documented as given BID. Review of R108's Progress Notes dated February 2024, revealed no evidence of R108 being assessed for self-administering his own medications. During a follow up interview on 02/20/24 at 12:30 PM, RN1 confirmed that R108 did not have an order to self-administer his own medication. At 12:45 PM, RN1 brought an educational counseling paperwork to the conference room where she had educated the nurse passing medication this morning. At this time RN1 was asked what medications were in the cups, and she confirmed that the dark pink pill was cranberry, the brown capsules were R108's turmeric medication, and the white pills were Tylenol. Review of the Educational Counseling dated 02/20/24, revealed Morning medications were discovered today at a resident's bedside. [Licensed Practical Nurse (LPN) 1] is the current floor nurse for this resident. The medications were safely removed by the nurse manager after the resident refused to accept them. This supervisor explained the importance of following [name of corporation] standards of medication administration. [name of corporation] standards of medication administration should include the five rights: Patient, drug, time, dose, and route. This is to include documenting the administration after the resident has received the medications. The resident does deserve the right to refuse medications at any given time and the documentation must correlate this right. It is unacceptable to leave medication at the resident's bedside, unless the resident has been given the privilege to self-administer medication. During an interview on 02/21/24 at 11:30 AM, the Director of Nursing (DON) stated that she expected nurses not to leave medication with residents and confirmed that R108 did not have a self-administer assessment for taking his own medications. At 4:20 PM, the DON stated she was unaware that LPN1 had been leaving R108's medications at bedside unattended. During an interview on 02/21/24 at 3:50 PM, LPN1 confirmed that she did leave R108's medications at his bedside yesterday except for the Tylenol, she did not give him Tylenol. LPN1 stated that R108 had behaviors and only let certain people into his room, and R108 would let her know what medications he would take and would not take. LPN1 confirmed that she knew not to leave medications with residents; however, LPN1 stated that before this incident, she left R108's medications with him when he refused to take them for her. LPN1 confirmed that R108 had not been assessed to administer his own medication. During an interview on 02/22/24 at 11:00 AM, the Administrator indicated that he was aware of this incident and confirmed that staff had not assessed R108 for self-administering his own medication. The Administrator stated that R108 was a physician, had behaviors, and sometimes refused to do things; however, the Administrator confirmed that did not give nurses the right to leave R108's medications with him. During a follow up interview on 02/22/24 at 11:20 AM, the DON stated that she had spoken with R108's physician, and he did not feel that R108, due to his illness, would be a good candidate for self-administering his own medication.

Based on review of the facility policy, interviews, and record review, the facility failed to ensure Resident (R)1 was free from physical abuse by facility staff, 1 of 3 reviewed for abuse. On August 17, 2022 at 3:30 PM, the Administrator was presented with an Immediate Jeopardy (IJ) Template indicating F600 was identified at the level of Past-noncompliance. On July 17, 2022, approximately between the hours of 2:00 AM and 4:00 AM, Resident (R)1 was physically abused by Certified Nursing Assistant (CNA)1. CNA1 was recorded by the cell phone video of CNA2, striking R1 on the top of her head with an open hand. Witness statement revealed CNA1 escorted R1 back to her room. R1 was later found on the floor of her room with the following injuries:left hand was observed as swollen and a skin tear was noted to her left forearm. Petechiae was noted to her left cheek and under her right eye. A small abrasion was noted to her right upper lip and behind her right ear. There was a skin tear to her left shin and a small bruise was noted to her right shoulder. It is unknown whether the injuries were a result of a potential fall or the physical abuse. R1 with a BIMS of 3 revealed to the day shift nurse that, She beat me. When asked who, she stated, that black woman. Review of the facility's documentation revealed CNA1 was not immediately removed from resident care following the incident. When CNA2 made LPN1 aware of the incident, CNA1 was still allowed to provide care to other residents. When the Director of Nursing (DON) was made aware of the incident at approximately 4 AM, staff was instructed to send CNA1 home after 4 AM. R1 was noted to have been agitated throughout the night of 7/17/22 and combative with staff. Staff did not immediately remove R1 from the presence of CNA1. Review of the facility's investigative file identified the facility began an investigation and implemented a plan of correction as of July 18, 2022. Findings include: Review of the facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation last revised 12/11/17 revealed: Abuse, Neglect, Misappropriation of Patient Property and exploitation, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members, or legal guardians, friends, visitors, or any other individual in this center. The patient has the right to be free from abuse, neglect, misappropriation of patient property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Additional review of the facility's policy indicated under Protection Policy,: 1. Any individual found to be in danger of injury will be removed from the source of the suspected abusive behavior. 2. Medical and emotional support will be made immediately available to any individual suffering either alleged abuse, neglect, misappropriation of patient property of exploitation. A phone interview on 08/04/22 at 4:30 PM with R1's Resident Representative (RR) revealed they had visited R1 on 07/18/22 because a nurse called and told them that R1 had a fall on a previous shift. They believed R1 had had more than a fall because she had new bruises on her legs and arms, that were not there previously when they last visited the resident, which was recently. RR further stated the bruises on R1 seemed suspicious, which made them keep reaching out to the nurses at the facility. RR then stated, On 07/20/22, I found out about the abuse from the DON and the facility transferred R1 to the hospital to follow up on her bruises and I later decided to bring her home with me and discharge completely from the facility. This situation has been terrible not only for R1, but on our family because now we have to watch her 24/7, but I do not trust putting her into another nursing home placement. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/13/22 revealed R1 has a Brief Interview of Mental Status (BIMS) score of 03 out of 14, which indicates she is cognitively impaired. Record review on 08/04/22 of R1's Progress Note dated 07/17/22 at 2:48 AM revealed Resident at the desk in her wheelchair, very agitated and angry to the point of slapping at Nursing and CNA and at the nurse even grabbing things off the desk and hitting staff with them. Kept asking for grandson when explained he is not here, she becomes angry all over again. Slapping and trying to get out of the building and when pulled away from the doors becomes very combative all over again. Record review on 08/04/22 of R1's Progress Note dated 07/17/22 at 10:08 AM revealed Resident still sleeping in bed after being up most of the night. Bandage to elbow still clean and intact. According to night nurse, resident had another fall last night around 4:00 AM and got another skin tear to lower leg. Resident's vitals were great this morning and resident has no complaints of pain or anything at this time. Will continue to monitor. Record review on 08/04/22 of R1's Progress Note dated 07/17/22 at 11:52 AM revealed Spoke to R1 Resident Representative about the possible altercation last night. She voices understanding. Record review on 08/04/22 of R1's Progress Note dated 07/17/22 at 12:31 PM revealed Bruising to bilateral hands and arms, left and right forearms, elbows and upper arms. Left hand is swollen and left forearm has skin tear. Petechiae (pinpoint, round spots that appear on the skin as a result of bleeding) noted to left cheek right under eye and very small abrasion to right upper lip. Bruise noted on left shoulder. Bruising also noted to left and right inner thighs and shin. Left shin has skin tear as well. Abrasion noted behind right ear. Dressing applied to left skin and steri strips and dressing applied to left forearm, will continue to monitor. Record review on 08/04/22 of R1's Progress Notes dated 07/18/22 at 3:26 PM revealed Social Worker (SW) spoke with R1's Resident Representative about the situation with R1. Explained that SW is here for both the family and R1. Resident Representative voiced understanding, explained policy and procedure for the situation and gave the Resident Representative cell phone number if they have any questions after hours. SW will follow up with resident and family. Record review on 08/04/22 of R1's Progress Note dated 07/19/22 at 2:00 PM, revealed Spoke with Resident Representative about ongoing inquiry. Record review on 08/04/22 of R1's Progress Note dated 07/20/22 at 12:22 PM revealed Arranged transportation for R1 to go to hospital for full physical exam to [sic] meet law enforcement at hospital. Spoke with Resident Representative about transfer to hospital. Record review on 08/04/22 of R1's Progress Note dated 07/20/22 at 12:30 PM revealed Resident left facility via stretcher with Emergency Medical Staff (EMS) to hospital. Record review on 08/04/22 of R1's Progress Note dated 07/20/22 at 5:57 PM revealed Received a phone call from staff stating that a Social Services member of the hospital is requesting to speak with someone in administration pertaining to this resident. Gave instruction to staff to give her my cell number. Nurse called this nurse asking a series of questions that Medical Director had pertaining to this resident current health status and the on-going investigation. After all questions were answered, Hospital nurse stated that a complete assessment had been made and the resident will be returning back to facility soon. This nurse was grateful for being updated on the resident's return to the facility. Record review on 08/04/22 of R1's Progress Note dated 07/20/22 at 8:34 PM revealed Resident returned via stretcher by EMS, resident arrived approximately 8:04 PM Doctor provided brace for left arm, EMS told nurse they put it on twice but resident kept taking it off. When resident got settled before eating nurse put on brace. Brace currently still on per discharge summary doctor wants brace left on till follow up hand surgery has been set up. Order states to call primary care provider tomorrow. Resident referred to hand center, Resident Representative has been notified approximately 8:40 PM, and stated that she will come to the facility tomorrow for a visit. Record review on 08/04/22 of R1's Care Plan with a start date of 08/10/21 revealed R1 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 has a BIMS score of 3, severely impaired with her cognition. R1 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 08/04/22 at 4:30 PM with the Administrator and DON revealed CNA1 had been terminated from the facility on 07/18/22. CNA2 and Licensed Practical Nurse (LPN)1 were on paid-leave until the investigation was completed along with re-education on abuse and cell-phone usage policy. The Administrator and DON further stated that there is a video of the incident on 07/17/22 that was recorded by a staff member on their cell-phone. An interview with R1's former roommate, R2, on 08/04/22 at 5:15 PM revealed she remembered R1, but never saw any staff members get physically rough with her and that she has never been abused at the facility. An interview with the DON on 08/04/22 at 5:45 PM revealed that on the night of the incident, 07/17/22, they were informed of CNA1 and R1 having a physical altercation and instructed the Unit Manager to send CNA1 home, immediately. A phone interview with CNA1 was attempted on 08/04/22 at 7:14 PM with no success. A voicemail with contact information was provided. A phone interview with CNA2 was attempted on 08/04/22 at 7:16 PM with no success. The phone number was no longer in service. A phone interview was attempted with LPN1 on 08/04/22 at 7:19 PM with no success. A voicemail with contact information was provided. Review of R1's Weekly Skin Observation dated 07/14/22 at 1:57 AM, (week prior to incident), revealed no documentation of surgical wounds, bruising/discoloration, skin tear/ lacerations, abrasions, skin desensitization, dry/flaky skin, swelling or other skin conditions for R1. Review of R1's Weekly Skin Observation dated 07/21/22 at 2:53 AM revealed bruising/discoloration in the following areas for R1: 1. Face 2. Shoulder, Left 3. Arm, Right and Left 4. Hand, Right and Left 5. Fingers, Right and Left 6. Leg, Right and Left Skin Tear/ Laceration in the following areas for R1: Arm, Left. Review of CNA1's personnel and education files revealed no concerns. She has previously received training in abuse and neglect. Review of the facility's internal investigation revealed CNA1's Witness Statement dated 07/17/22. It stated, I was sitting at the desk, when R1 got up out of her bed and walked toward the desk. I got her wheelchair because I know her to be unsteady when she walks. I offered to help her back to bed, but she refused to get back in bed. So I proceeded to offer her something to snack on, it was a chicken sandwich and juice. After she was done eating, I offered to help her to bed again. She said she was ready to go to bed. So [sic] help her back to bed. I was doing my Matrix on the computer and noticed her coming out of her room again. She refused to go to bed. I was in the hall doing my rounds when I heard the back door. She tried to open the door and refused to stay at the desk or in the bed. I decided to stay at the desk with her. She smacked me twice, she tried to hit me and the nurse several times. She got so violent with me I had to get up and get behind several times to hold her hands down so she wouldn't hit me. She was pointing her finger in my face and repeatedly tried to hit me. I did not chase her or do anything to put her in harm's way. I did chart her behaviors in Matrix. Review of LPN1's Witness Statement dated 07/17/22 revealed At 11:00 PM, CNA1 came in and on her first round she found R1 going out the dining room door. When we got her back in the door we brought her to the desk, she was agitated and wanting to see her grandson. I kept telling her that he was not there. She pulled the blue fan off the desk and hit me just above my knee. She slapped CNA1 in the face twice and scratched my arm. She kept standing up from her wheelchair and we would sit her back down. She would try to hit us with anything, stapler, tape dispensary, etc. which we moved out her reach. 2:00 AM CNA1 made a round I sat with her at the desk she continued to be agitated we talked with her but she kept saying, I need to see my grandson. I again explained to her the grandson is not here. 4:00 AM I was on station 1 with another nurse (LPN2) and CNA2 came to us and said That girl has hit R1 twice. We went to Station 2 and found R1 sitting in the floor beside her bed. After talking with CNA1, I attempted to call the DON at 4:21 AM with no answer, and 4:25 AM, I notified a Unit Manager, at 5:02 AM she texted back to send CNA1 home. I pulled CNA1 from patient care and she sat at the desk and wrote her statement. She handed me the statement and clocked out and went home. Review of CNA2's 1st witness statement dated 07/17/22 at 6:22 AM revealed, From 2:42 AM to 3:15 AM R1 was agitated. I told LPN1 and CNA1 that I thought she has a urinary tract infection ([CONDITION(S)]) because she didn't want to go to bed and she couldn't sit still. R1 was upset and I feel like they both (CNA1 and LPN1) made her worse. They both tugged and wrestled with her, which is why I feel that CNA1 felt comfortable enough to take it farther after LPN1 left to keep provoking R1 then R1 hit CNA1. CNA1 hit R1 back and grabs R1 around her neck. Then they both were hitting each other R1 smacked CNA1 in the face and called her a derogatory word and then asked CNA1 for a cup of coffee. CNA1 told R1 that she wasn't getting her anything and she should get it herself. I went to Station 3 to get LPN2 and when we got back CNA1 had taken R1 to her room, but we found R1 on the floor in a wet brief, bloody skin tears on her arm and leg with bruises. Review of CNA2's 2nd witness statement dated 07/18/22 at 2:45 PM revealed My first witness statement was me upset and telling what I thought happened, this is a statement of what I saw happen to R1. I saw R1 got back up out of bed after CNA1 already put her to bed. CNA1 put R1 in her wheelchair and brought her to the dining room. R1 wouldn't stay in the dining room and she wanted to wander and CNA1 kept bringing her back until she decided to take her to the nurse's station and would keep her there at the desk. Then CNA1 and LPN1 kept R1 at the desk and wouldn't let her move away from the desk. I did not see CNA1 give R1 a snack or try to do anything to calm her down. I saw CNA1 and LPN1 both sitting at the desk beside R1 provoking her and fussing at her. I then told LPN1 that R1 probably had a [CONDITION(S)] because she didn't act like this unless something is wrong, but they didn't do anything to help defuse the situation only agitated her more. LPN1 sat in a chair behind R1 for a long period of time, R1 wanted to move back away from the desk. R1 kept swinging at LPN1 then LPN1 leaves the desk with CNA1. R1 and CNA1 sat at the desk for a long period of time tugging and pushing. I saw CNA1 push R1 head and shove her and I went to get help, I went to Station 1 to get LPN2, but she was outside talking with LPN1. I ran back to our station (Station 2) and CNA1 was still arguing with R1 and they were scuffling with each other, so I went back to Station 1 to get LPN1, I told her that CNA1 was hitting R1. Me, LPN1 and LPN2 went back to Station 2 and found R1 in her room on the floor bleeding from tears on her arm, leg. There was scratching and bruising on R1 and I called my DON to let them know what was going on. After the original survey exit date of 08/04/22, CNA2 returned the phone call on 08/15/22 at 7:54 AM. CNA2 revealed, I was working that night I saw CNA1 hitting R1. On that night I saw R1 walking down the hallway coming from her room and CNA1 gave her a wheelchair and put the resident in the dining room several times. R1 did not want to stay in the dining room, so eventually CNA1 put her at the nurse's station with her and LPN1. I told LPN1 and CNA1 that I thought R1 had a [CONDITION(S)] because she normally goes to bed with no issues at night. They both ignored me and kept making the resident irritable. Eventually, CNA1 leaves R1 at the nurses station with LPN1 and LPN1 held R1's wheelchair, so she couldn't leave the nurses station. When CNA1 got back from doing rounds, LPN1 left and that is when CNA1 started to get more aggressive with R1. I started to record because I knew the Administrators wouldn't have believed me, I have previously told my supervisors about CNA1's behavior in the past, but was ignored. I did not post the video anywhere, but kept it on my phone for proof. I have on video CNA1 pushing and hitting R1 in the head and restraining the resident from leaving the nurses station. I took a short video and went to the other hall to get LPN2, but she was outside talking with LPN1. When I went back to the unit, I saw R1 and CNA1 hitting each other, so I went back to the other station and got LPN2. LPN1, LPN2, and I went back to the station and couldn't find R1. We later found her in her room, on the floor and bleeding. I think CNA1 threw her to floor, when she pushed her back into her room. We called the DON and she made CNA1 leave, and the next day I had to come back to the facility and was forced to write second witness statement. They also attempted to get me to delete the video from my phone, but I didn't because I wanted law enforcement to see it first. After that, I went back home and around 5 or 6 I was expecting law enforcement to get in contact with me, but they didn't. So I went down to the police station on 07/20/22 and showed them the video and was told they were unaware of the abuse case at the facility. A phone interview with LPN2 on 08/15/22 at 10:00 AM revealed that the facility has instructed them not to speak with anyone related to this situation. An interview with the Administrator and Regional Vice President (RVP) on 08/17/22 at 11:50 AM revealed, CNA1 bearhugged R1 and hit her on the top of the head with an open hand. Law enforcement was notified on Sunday morning (07/17/22), but did not respond until the following Tuesday. The RVP then stated, It is not uncommon for law enforcement to come later, as they do not take it as seriously as we do. During an interview with the DON on 08/17/22 at 1:04 PM, she stated her expectation was for staff to immediately protect the resident. When asked if staff was able to remove an employee from the facility after witnessing abuse, in order to ensure resident protection, she stated, Yes, anyone can remove staff who is abusing residents, and it would be her expectation that they are immediately removed. The DON also stated she did not immediately contact the family due to the time of the incident. She stated she called R1's RR approximately 30 minutes after she wrote the nursing notes. She notified the state agency via telephone around 5 AM, but was unable to leave a message and called the local police a little before she called the family. She stated she could not verify the time she called the police, because she used her personal cell phone and the call was already gone from her call log. During review of CNA1's timecard with the Administrator, he stated, she did not clock out, so the system clocked her out. He stated she was not immediately removed from the facility because only management staff can remove an employee, that is why staff had to wait for the DON to send CNA1 home following the witnessed abuse. When asked what his expectation was related to CNA2 not immediately removing R1 from CNA1's presence, he stated, She was probably fearful for her own life and asked that the survey team define the term immediate. During an interview with LPN3 on 08/17/22 at 2:33 PM, she stated, We woke up R1 and took her to the bathroom. We noticed the bruises on her arm. She (R1) told us straight away what happened. She said, that black lady tried to kill me last night. She kept saying, she beat me, she beat me. This was around 10:30 AM, right before lunch. Before my shift started at 7 AM, we got a report from the night shift that R1 had been combative and had scratched the nurse's arm. We were told R1 had had a fall in her room. After R1's allegation, I sent a CNA to call the DON, and the DON stated she was already aware of the incident. When asked if she were to witness physical abuse occuring, what she would do, she stated, I would immediately protect the resident. The facility's plan of correction to prove compliance contained: 1. CNA1 was terminated from employment with NHC Healthcare effective 07/18/22. 2. CNA2 was suspended from work during the investigation and disciplinary action period. CNA2 received disciplinary action including a written warning and required re-education prior to returning to work. During the suspension, CNA2 will complete the following re-education: -Abuse Policy/Handling Resident Aggressive Behavior- Inhouse Education -Recognizing, Reporting, and Preventing Abuse- Relias Training Course -About Care Giver Conduct- Relias Training Course -Challenging Behaviors in Dementia Care- Relias Training Course -Cellular Phone/Camera Equipped Mobile Devices Policy- Relias Training Course 3. LPN1 was suspended from work during the investigation and disciplinary action period. LPN1 received disciplinary action including a written warning and required re-education prior to returning to work. During the suspension, LPN1 will complete the following re-education: -Abuse Policy/Handling Resident Aggressive Behavior- Inhouse Education -Recognizing, Reporting, and Preventing Abuse- Relias Training Course -About Care Giver Conduct- Relias Training Course -Challenging Behaviors in Dementia Care- Relias Training Course -Cellular Phone/Camera Equipped Mobile Devices Policy- Relias Training Course -Refresher Course on Basic Supervision 4. Inservice Education assigned to all employees is as follows: -Abuse Policy/Handling Resident Aggressive Behavior- Inhouse Education -Recognizing, Reporting, and Preventing Abuse- Relias Training Course -About Care Giver Conduct- Relias Training Course -Challenging Behaviors in Dementia Care- Relias Training Course -Cellular Phone/Camera Equipped Mobile Devices Policy- Relias Training Course

Based on record review, interview, and policy review, the facility failed to ensure four out of 25 sampled residents (Resident (R) 74, R27, R73, and R104) were protected from abuse and free from fear of retaliation. Specifically, R74's allegations that staff were rough during cares were not identified as potential abuse and were not investigated by the facility. Additionally, R27, R73, and R104 stated they were fearful of retaliation from staff for expressing concerns. On 10/28/21 at 7:00 PM, the Administrator was provided an Immediate Jeopardy template and notified that an Immediate Jeopardy was identified at F600 related to the facility's failure to prevent abuse. F600 was determined to be at a scope and severity of J. The Immediate Jeopardy was determined to first exist on 09/10/21 when the facility failed to implement their abuse policy and failed to thoroughly investigate and report R74's allegations of abuse. R74 made multiple allegations to different staff member, none of R74's allegations were investigated. The facility provided an acceptable plan for removal of the immediate jeopardy on 10/29/21 at 6:50 PM. The survey team validated that the immediate jeopardy was removed on 10/29/21 at 7:50 PM following the facility's implementation of the plan for removal of the immediate jeopardy. FACILITY RESPONSE/REMOVAL PLAN for F600 A1. Facility was notified by surveyor on 10/28/21 that R74 made an allegation of sexual assault and had feeling of being scared about retaliation of staff. This facility was not made aware of any allegation of sexual assault or any feelings of retaliation of staff by R74, nor psychiatrist, or any other party prior to the surveyor communicating this to facility staff. A2. The facility immediately reported the allegation of abuse on 10/28121 to DHEC Certification, Ombudsman, and law enforcement. [NAME] City Police Department responded to call and interviewed resident. A3. The resident was offered a transfer from this facility by [NAME] City Police during their interview with the resident on 10/28/21 and the resident declined. A4. On 10/28/21 the two CNAs who were alleged to be abusive were removed from the work schedule immediately and will remain on suspension pending outcome of the investigation. B1. Facility was notified of additional interviews during resident council meeting of R27, R73,and Rl04 with surveyor about other residents being afraid of retaliation. This facility was not made aware of any concerns of residents being afraid of retaliation prior to 10/28/21. B2. Facility staff interviewed R27, R73, Rl04 on 10/29/21 to gain more feedback and reassure them they have the right to voice grievances without reprisal. B3. All cognitive residents from each station were interviewed by the DON and Social Services on 10/28/21-10/29/21 for feedback regarding Resident rights and their comfort level with voicing concerns. During the process residents were reassured that any and all concerns are welcome and will be addressed without the threat of reprisal. Cl. On 10/28/21-10/29/21, the facility is conducting Staff inservices regarding abuse prevention to include what abuse is. i.e., perceived rough care, reporting and residents right to voice grievances without fear of reprisal. Reinforced to staff the patient does not have to claim or say abuse for an event to be abuse. C2. On 10/28/21-10/29/21, the facility is conducting counseling with all staff members on the appropriate and timely response and the consequences of failure to adhere to facility abuse and neglect policies, and how to identify and report abuse. C3. Any staff member not currently working will be inserviced and upon return to work. As of 2:50 PM on 10/29/21, l1l of 155 (71%) staff members have been inserviced. C4. On 10/28/21-10/29/21, the facility RN nurse managers initiated inservices, counseling, and education for all staff on abuse and neglect that will continue on an ongoing basis. Dl. On 10/28/21 the Center's policy on Abuse and Neglect was reviewed by the Administrator and Regional [NAME] President with no changes needed at this time. E1. A QAPI meeting was held on 10/28/21 with the Administrator, DON, Assistant DON, Nurse Managers, Regional VP, Regional Nurse, Social Workers, Regional Social Worker, Regional HIM Director, and Regional Activities/Wellness Director. The alleged events were discussed in detail and processes that need to be completed and implemented to assure resident safety from situations of abuse and to assure allegations of abuse are followed up on appropriately. The processes will be communicated to all partners through the inservice listed above. E2. Conferenced with the Medical Director on the morning of 10/29/21 was held to inform him of the alleged events and discussed the appropriate response to assure the utmost in patient care and safety. The Medical Director will share information regarding the alleged events with other medical staff members and discuss the appropriate response for resident safety. F1. Assistant Director of Nursing will monitor staff compliance with the facility abuse and neglect policy, including identification and timeliness of reporting. She will also monitor the grievance log for any concerns related to abuse or neglect. Audit ten percent of the records monthly for six months, for any patient care concerns in nurse's notes, psych notes, and any other health care contractor notes and to assure records are accurate and no concerns are found. The review began on 10/28/21. The removal was validated by observations and interviews of steps taken by the facility to protect residents from abuse. These measures included: Quality Assurance and Performance Improvement review for monitoring and auditing recognition and proper reporting of any/all allegations of abuse; reviews of updated policies and implementation of the policy updates; and a review of the enhanced education/training for all staff related to recognizing and reporting all allegations of abuse. The Immediate Jeopardy was removed on 10/29/21 at 7:50 PM with approval from the State Survey Agency. The deficient practice remained at a D (isolated with the potential for more than minimal harm) scope and severity upon removal of the immediate jeopardy. Findings Include: Review of the Resident Face Sheet located in the Electronic Medical Record (EMR), revealed R74 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant, hypertension, and presence of cardiac pacemaker. Review of R74's most recent Minimum Data Set (MDS) with an Assessment Reference Date of 09/20/21 revealed the resident scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. Review of a facility's document titled, Service Recovery Case Report Form, provided by the facility, dated 09/10/21, indicated R74 was not comfortable with the care she received. The report stated the concerns were addressed with the Director of Nursing (DON) and the resident. R74 requested the information to meet with the ombudsman. The resolution was for the resident to meet with the ombudsman. Review of a facility's document titled, Service Recovery Case Report Form, provided by the facility, dated 09/22/21, revealed R74 reported to Social Worker (SW) 2 that R74 had concerns with her care. The document stated, This was addressed with nursing and spoke with CNAs. Review of a psych note, dated 10/06/21, found in the EMR, documented, Staff reports [R74] thinks other people are talking about her and mistreating her. She is cognitively intact. but. she has a difficult time getting out of bed and silting up. This is why she is in a nursing home. She talked freely and openly. She said she has had several bad experiences in the facility and other facilities. She says the aide, 'put her finger up my butt.' Ln [sic] other aide, 'pushed my legs apart so hard she left handprints on my thighs.' She told her primary physician last week that she is concerned if something happens to her and she dies that it, 'would not be an accident.' She asked to have an autopsy be done. She tells me that she is crying, and she is, 'scared.' She is scared to go to sleep for fear that somebody might do something to her. She denies being depressed. She denies any thoughts of wanting to die. She denies any suicidal thoughts. She did give me permission to talk to nursing staff about this: however, she is concerned that there will be retribution. During an interview on 10/28/21 at 1:24 PM, R74 stated that she had reported to the social worker that two of aides on the night shift grabbed her by the groin while putting her brief on and told her how she needs to behave. R74 stated it has gotten to the point where one night the CNA came at her through the curtain and was coming at her aggressively until the nurse realized there was another nurse in the room and witnessed the CNA's actions. R74 stated, another time a CNA put her fingers in my [rectum] as punishment, it was so bad I could not turn over. R74 stated, the CNA stated I was constipated, and they were trying to get it out. On another night a second CNA came in my room from somewhere with a staff member who never worked with me before and did not have a name tag. The staff member was tall when asked who she was she stated it was none of her business. R74 stated after the staff left, she called Registered Nurse (RN) 2 and reported it. During an interview on 10/28/21 at 1:59 PM in the presence Corporate Nurse, the DON (the facility's Abuse Coordinator), stated R74 reported to her that staff had been a little rough during care but felt as though it may be regarding caring for a bigger person. The DON stated she interviewed the residents and staff on the 200-Hall and no one had any abuse concerns so she did not document the event and did not report it to the state. The DON stated she did not investigate any allegation of abuse and there was no documentation of any allegations of abuse. During an interview on 10/28/21 at 2:15 PM, the Director of Social Services revealed R74 has asked me to make referrals to move to other facilities and asked to speak to the ombudsman in regard to care concerns. [R74] felt as though some of the aides did not care for her. The Director of Social Services stated [R74] and some of the aides had a personality conflict; [R74] reported that the CNA's were against her or they did not like her. The Director of Social Services stated R74 had reported that at times she felt the CNAs were rough with her; and she reported the allegation to the 200 Hall charge nurse (RN 2). The Director of Social Services stated the charge nurse would then report concerns to the DON. The Director of Social Services stated the concern was documented in the grievance log. The Director of Social Services stated R74 never named a particular aide it was the night aide and did not give specific dates. The Director of Social Services stated, If any resident in the facility stated staff was rough with them, I would take that as an abuse allegation. During an interview on 10/28/21 at 3:17 PM, the Administrator stated he spoke to [R74] and prior to today the resident never mentioned abuse until today. [R74] never stated to me she had been abused. First, [R74] stated two nurse assistants hurt her when they turned her and that is how it was approached to me. I told the resident we would be more gentle[sic]. I approached this as a customer relations standpoint. [R74] is a big lady and the CNA [Certified Nurse Aide] is small lady so it would be hard to turn to the resident. The Administrator stated today,10/28/21, he asked R74 if she felt staff abused her and the resident stated, Oh yes. In regards to the resident alleging a staff member put a digit up her rectum, the Administrator stated he could not remember the exact wording but R74 stated, the staff told her she was impacted, and they tried to help me, and it hurt. During an interview on 10/28/21 at 7:00 PM with the DON, Administrator, Regional [NAME] President of Operations, the DON acknowledged she had not reviewed the psych note prior to the surveyors expressed the concerns. Follow up interview with the Administrator on 10/29/21 at 9:00 AM, the Administrator stated the Medical Director had spoken to R74 and was under the impression that the resident recently experienced the abuse and the Medical Director ordered the resident to be sent to the ER for an evaluation of any trauma. During an interview on 10/29/21 at 9:20 AM, the Medical Director stated, I did not personally assess her [R74]. I spoke with the head nurse, and she gave me the impression was recent [the alleged abuse]. The Medical Director also stated he had not personally reviewed the psychiatric note from the psychiatrist, dated 10/6/21, or spoken with the psychiatrist regarding his evaluation/assessment. The Medical Director stated the psychiatrist did not document in EMR and prefers to go back to his office and document and then sends his visit note over. The Medical Director stated during the interview, based on the information he just received that the incident actually occurred in September 2021, he did not feel the resident still needed to be sent out for an abuse evaluation. During an interview on 10/29/21 at 9:46 AM, in regard to notifying facility staff of R74's concerns following the 10/06/21 visit, the Psychiatrist stated, to the best of my recollection I did not notify nursing staff. The psychiatrist stated, If I talked to someone at the facility, I would have documented I notified staff. The psychiatrist stated, if I took the allegation of abuse seriously, I would have notified the facility. I do not feel as though something [R74's concerns] truly happened. When asked why did he not report it to the facility, the psychiatrist stated the resident informed him that she had spoken to her physician so he assumed the physician reported it to the facility. The psychiatrist stated he did not document in the facility's EMR. He stated he dictated his notes, then faxed them to the facility, which took a couple days to complete. The psychiatrist was unable to state when the note had been sent to the facility. During an interview on 10/29/21 at 10:18 AM, RN1 stated she was the routine Monday-Friday on the 200 Hall and R74 had been on her station for a couple months. RN1 stated R74 would say something about weekend staff turning her but she complained about staff every shift. RN1 stated a few weeks ago R74 complained about staff being rough with her so she reported it to the Nurse Manager. RN1 stated she reported to staff to be gentle with R74 during care, to have a witness when working with her, and to have someone to back them up. RN1 stated, if there was an allegation of abuse, I would change the aide and talk to the patient to see what happened and notify the nurse managers. RN1 stated, usually we would document in the chart especially if there is an outcome. In regard to the psychiatrist's visit she stated, she saw the psychiatrist prior to the psychiatrist seeing the resident and indicated R74 had a behaviors (accusing staff and telling untruths) so he increased R74's medication. RN1 stated she told the psychiatrist to go in and talk to R74 by herself so the resident may open up more. When asked did the resident have hallucinations she stated, No. When asked did the facility have any Behavior Monitoring for the resident documented in the chart she stated, No. RN1 reiterated the that she did not speak to the psychiatrist after his visit and that the order was given prior to his visit with the resident. RN1 stated R74 has never said anything about abuse allegations. She stated the behaviors R74 exhibited were complaining about staff and telling untruths, meaning R74 would say someone did something to me. During an interview on 10/29/21 at 10:50 AM, the DON along with the Assistant DON stated the psych notes were received via fax and then information would be given to the DON to review. The ADON stated sometimes Social Services would receive the document and once it was reviewed the document is then sent to Medical Records and it scanned in the record. During an interview on 10/29/21 at 10:57 AM, Medical Records stated she received R74's psych note on 10/27/21 from the Director of Social Worker and it was scanned the same day. During an interview on 10/29/21 at 3:08 PM, R74's Primary Care Physician stated he was not aware of any concerns regarding R74 alleging staff being rough with her. During the Resident Council Meeting on 10/28/21 at 1:18 PM, R27, R73, and R104 were asked if they felt safe reporting any complaint or incident to the facility. All three residents stated no. All three residents confirmed they were concerned about retaliation from the staff. When asked what kind of retaliation? R27 replied, well just like once before a nurse stopped talking to me because she thought I said something. R73 and R104 did not answer and confirmed they did not feel comfortable answering. Review of the facility policy titled, Patient Protection and Response Policy for Allegation/Incidents of Abuse Neglect, Misappropriation of Property and Exploitation, revised 12/11/17, documented, The patient has the right to be free from abuse, neglect. B. Policy. The center will seek and accept complaints from patients, families, and partners without reprisal. Procedure 1. The right to report a concern or incident is not limited to a formal written grievance process but includes any verbalized complaint to any center partner. 2. Prompt efforts will be made to resolve concerns. 4. The center will not retaliate against any partners who make a report, cause lawful report to be made, or takes steps in furtherance of making a lawful report. All events reported as possible abuse, neglect. will be investigated to determine whether the alleged abuse, neglect. did or did not take place. The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident. Procedure: a. The investigation is conducted immediately under the following circumstances: i. When it is identified that an alleged incident may have occurred. ii. As soon as any partner has knowledge and reports an alleged event. **When there is a question as to whether to conduct an investigation, it is best to do so. An accurate summary reporting of all investigations conducted by the center will be maintained as a working document in the QA committee.

Based on record review, interview, and policy review, the facility failed to investigate allegations of abuse for one out of 25 sampled residents (Resident (R) 74). R74's allegations that staff were rough during cares were not identified as potential abuse and were not investigated by the facility. Findings Include: Review of the Resident Face Sheet located in the Electronic Medical Record (EMR), revealed R74 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R74's most recent Minimum Data Set (MDS) with an Assessment Reference Date of 09/20/21 revealed the resident scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. During an interview on 10/28/21 at 1:24 PM, R74 stated she had reported to the social worker that two of aides on the night shift grabbed her by the groin while putting her brief on and told her how she needs to behave. R74 stated it has gotten to the point where one night the CNA came at her through the curtain and was coming at her aggressively until the nurse realized there was another nurse in the room and witnessed the CNA's actions. R74 stated, another time a CNA put her fingers in my [rectum] as punishment, it was so bad I could not turn over. R74 stated, the CNA stated I was constipated, and they were trying to get it out. On another night a second CNA came in my room from somewhere with a staff member who never worked with me before and did not have a name tag. The staff member was tall when asked who she was she stated it was none of her business. R74 stated after the staff left, she called Registered Nurse (RN) 2 and reported it. During an interview on 10/28/21 at 1:59 PM in the presence of the Corporate Nurse, the Director of Nursing (DON) (the facility's Abuse Coordinator), stated R74 reported to her that staff had been a little rough during care but felt as though it may be regarding caring for a bigger person. The DON stated she interviewed the residents and staff on the 200-Hall and no one had any abuse concerns so she did not document the event and did not report it to the state. The DON stated she did not investigate any allegation of abuse and there was no documentation of any allegations of abuse. During an interview on 10/28/21 at 2:15 PM, the Director of Social stated R74 had reported that at times she felt the CNAs were rough with her; and she reported the allegation to the 200 Hall charge nurse (RN 2). The Director of Social Services stated the charge nurse would then report concerns to the DON. The Director of Social Services stated the concern was documented in the grievance log. The Director of Social Services stated R74 never named a particular aide it was the night aide and did not give specific dates. The Director of Social Services stated, If any resident in the facility stated staff was rough with them, I would take that as an abuse allegation. During an interview on 10/28/21 at 3:17 PM, the Administrator stated he spoke to [R74] and prior to today the resident never mentioned abuse until today. [R74] never stated to me she had been abused. First, [R74] stated two nurse assistants hurt her when they turned her and that is how it was approached to me. I told the resident we would be more gentle[sic]. I approached this as a customer relations standpoint. [R74] is a big lady and the CNA [Certified Nurse Aide] is small lady so it would be hard to turn to the resident. The Administrator stated today,10/28/21, he asked R74 if she felt staff abused her and the resident stated, Oh yes. In regards to the resident alleging a staff member put a digit up her rectum, the Administrator stated he could not remember the exact wording but R74 stated, the staff told her she was impacted, and they tried to help me, and it hurt. During an interview on 10/29/21 at 10:18 AM, RN1 stated she was the routine Monday-Friday on the 200 Hall and R74 had been on her station for a couple months. RN1 stated R74 would say something about weekend staff turning her but she complained about staff every shift. RN1 stated a few weeks ago R74 complained about staff being rough with her so she reported it to the Nurse Manager. RN1 stated she reported to staff to be gentle with R74 during care, to have a witness when working with her, and to have someone to back them up. RN1 stated, if there was an allegation of abuse, I would change the aide and talk to the patient to see what happened and notify the nurse managers. RN1 stated, usually we would document in the chart especially if there is an outcome. Review of the facility policy titled, Patient Protection and Response Policy for Allegation/Incidents of Abuse Neglect, Misappropriation of Property and Exploitation, revised 12/11/17, documented, All events reported as possible abuse, neglect. will be investigated to determine whether the alleged abuse, neglect. did or did not take place. The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident. Procedure: a. The investigation is conducted immediately under the following circumstances: i. When it is identified that an alleged incident may have occurred. ii. As soon as any partner has knowledge and reports an alleged event. **When there is a question as to whether to conduct an investigation, it is best to do so. An accurate summary reporting of all investigations conducted by the center will be maintained as a working document in the QA committee.

Based on observation, interview, and review of the facility policy Manual Warewashing, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed and has the potential to affect 154 of 154 residents with ordered diets as evidenced by failing to do the following: Air dry pans, clean (stove top and equipment). The findings included: On 11/26/18 at 9:45 AM, an initial tour of the main kitchen with the Dietary Manager (DM) revealed: 1.) The stove top had a large build-up of a black charred substance, grease, and food debris around all burners. 2.) On the stove and equipment next to the stove, the was yellow/orange food spatter. 3.) On the shelf above the stove a build-up of grease and dust. 4.) On a rack facing the stove 3 hotel pans were stacked wet. On 11/28/18 at approximately 11:05 AM, an observation with the DM revealed: 1.) The stove top had a large build-up of a black charred substance, grease, and food debris around all burners. 2.) On the stove and equipment next to the stove, yellow/orange food spatter. 3.) On the shelf above the stove a build-up of grease and dust. 4.) On a rack facing the stove 4 hotel pans were stacked wet. On 11/28/18 at approximately 11:10 AM, an interview with the DM, s/he verified the build-up and food spatter on the stove/equipment and the hotel pans were stacked wet. Review of the facility policy, Manual Warewashing, states under guideline (5.) Air-dry all items. Make sure all items are completely dry before stacking to prevent wet nesting.

Based on observations, interview, and review of the manufactures recommendations, the facility failed to follow a procedure to ensure that expired medications were removed from medication storage in 1 of 8 medication carts reviewed. Expired medications (insulin) were on the 400 back hall cart after the manufactures recommended expiration date. The findings included: On 11/26/18 at 10:20 AM, an observation of the 400 back hall medication cart with LPN #1 revealed Resident #124 had (1) open vial of [MEDICATION NAME] (Lot #8F025B) with approximately 55 units of insulin remaining. An open puncture date of 10/19 and an expiration date of 11/16 was hand written on the vial. Also, (1) [MEDICATION NAME] (Lot #HZF6856) with approximately 250 units of insulin remaining had an open puncture date of 10/23 and an expiration date of 11/20 hand written on the [MEDICATION NAME]. On 11/26/18 at approximately 10:25 AM, during an interview with LPN #1, s/he verified the [MEDICATION NAME] vial and the [MEDICATION NAME] was in-use after the expiration date and indicated the insulin should have been removed from storage. Review of the [MEDICATION NAME] 100 Units/ML vial manufactures recommendations states under the section Storage: Discard all containers in use after 28 days, even if there is insulin left. Review of the [MEDICATION NAME] manufactures recommendations revealed under section How should I store [MEDICATION NAME], Bullet (2) states, Store the [MEDICATION NAME] you are currently using out of the refrigerator below 86 degrees F or 30 degrees C for up to 28 days. Furthermore, bullet (6) states, The [MEDICATION NAME] should be thrown away after 28 days, even if it still has insulin left in it.

On the days of the survey, based on observation and interview, the facility failed to maintain a medication error rate of less than 5 percent. There were 2 errors out of 25 opportunities for error resulting in a medication error rate of 8%. The findings included: Error #1 and Error #2 On 11/28/18 at approximately 8:45 AM, during an observation of Resident #137's medication pass on the 400 front hall, Registered Nurse (RN) #1 separately crushed (1) [MEDICATION NAME] 50 milligram (mg.) tablet and (4) Aspirin 81 mg. tablets and placed the medications in (2) in separate 30 milliliter (ml.) medication cups. RN #2 then combined the medications with water. Also, two other liquid medications ([MEDICATION NAME] and Levetiracetam) were placed in separate 30 ml. medication cups. Juven, a supplement was placed in a 9 oz. plastic drinking cup. RN #1 then poured the cups into Resident #137's gastric tube leaving a significant amount of medication in the Metroprolol and Aspirin cups. RN #1 and RN #2 then exited Resident #137's room with the medication cups. On 11/28/18 at approximately 9:00 AM, during an interview with RN #1 and RN #2 immediately following the observation of Resident #137's medication pass, the surveyor, RN #1 and RN #2 observed the 30 ml. medication cups which revealed a significant amount of medication remaining in both the Metroprolol and Aspirin medication cups. RN #1 and RN #2 verified the contents remaining inside of the (2) medication cups as Metroprolol and Aspirin. RN #2 then stated, Medication residue is always left behind in the cups. On 11/28/18 at approximately 9:05 AM, during an interview with the Director of Nursing (DON) and survey team, the DON verified that a significant amount medication residue was in the (2) 30 oz. medication cups.

Based on observations, interview, review of the facility policy and the Center for Disease Control Prevention safety recommendations, the facility failed to follow a procedure to ensure precautions were observed for the disposal of contaminated equipment for 1 of 1 resident observed for finger stick blood sugar (FSBS) and injection. A finger stick device and needle were not disposed of in an approved sharps container on the 400 front hall. The findings included: On 11/27/18 at 4:25 PM, during an observation of Resident #124's med pass on the 400 front hall, Licensed Practical Nurse (LPN) #1 used a finger stick device to penetrate the residents' finger producing blood to monitor the residents' blood sugar. LPN #1 then placed the finger stick device into a trash can in Resident 124's bathroom. LPN #1 then administered insulin to Resident #124 by subcutaneous needle injection, s/he then placed the needle into general trash on the medication cart. There was a puncture proof sharps container on the medication cart. On 11/27/18 at approximately 4:45 PM, during an interview LPN #1 verified the finger stick device was in the Resident #124's bathroom trash can and the injection needle was placed in the general trash on the medication cart. LPN #1 then retrieved the needle from the medication cart trash and exposed another finger stick device in the trash and indicated the device was from the resident before Resident #124. LPN #1 then indicated that the finger stick devices and needle should have been placed into the sharps container on the cart. Review of the Center for Disease Control Prevention recommendations revealed under Infection Prevention during Blood Glucose Monitoring and Insulin Administration, section Blood Glucose Monitoring, Fingerstick Devices bullet #2 states, Dispose of used lancets at the point of use in an approved sharps container. Never reuse lancets. Also, under Insulin Administration bullet (5) states, Dispose of used injection equipment at point of use in an approved sharps container. Never reuse needles or syringes. Review of the facility policy entitled, Medication, Injections-Subcutaneous revealed under procedure (15.) Dispose of needle and syringe into a puncture proof container (sharps container).

Based on observation, record review, interview, and review of the the facility's Assessment/ Guidelines/ Staging Criteria/ Pain policy, the facility failed to accurately assess and stage pressure areas for Resident #199 and #225, 2 of 2 residents reviewed for pressure ulcers. The findings included: The facility admitted Resident #225 with [DIAGNOSES REDACTED]. On 08/26/2015 at 11:37 AM, record review of the 8/1-8/31/15 monthly cumulative physician and new/ modified orders revealed no treatment order for the pressure ulcer. 08/26/2015 at 12:15 PM, Registered Nurse (RN) #2 was observed for wound care to the resident's pressure ulcer. The wound was noted to have red [MEDICATION NAME] tissue that was blancheable. No slough or eschar was noted. The wound was not open and had no drainage. On 08/26/2015 at 12:32 PM Record Review revealed no care plan had been implemented for altered skin integrity or treatment to be provided. The care plan stated the resident has unstageable area to the sacrum. During an Interview on 8/26/2015 at 12:39 PM, Registered Nurse (RN) #2 confirmed the resident never had eschar or slough and the skin had always been intact. The RN further stated s/he was unsure what was underlying and classified as Unstageable. The RN stated the area was red, not purple, but that the area was softer than the surrounding tissue on admission. RN #2 also stated the wound blanched when admitted and had always blanched. After a review of NPUAP (National Pressure Ulcer Advisory Panel) with the RN, RN #2 confirmed the wound never met the definition of an unstageable wound. The RN stated that based on the description in the RAI (Resident Assessment Instrument) manual,the area met the definition of Unstageable related to Suspected Deep Tissue Injury(DTI) and confirmed the area should have been coded as a DTI. The RN also stated the MDS (Minimal Data Set) Coordinator coded the MDS based on the weekly wound assessment by the RN and confirmed that weekly assessment coded area as U4 - unstageable stage 4. On 08/26/2015 at 3:47 PM, the Director of Nursing (DON) provided a copy of the Assessment/ Guidelines/ Staging Criteria/ Pain policy from the facility's Skin Integrity Manual. At that time, the DON confirmed that s/he would have staged the wound as a Stage I, not an unstageable wound. The DON further stated that U4 was a term s/he used to describe a wound with U indicating unstageable and 4 indicating the presence of eschar, a U3 would be an Unstageable wound with slough and stated that that is how the nurses report the appearance of wounds to the DON. The DON confirmed the staging of U4 was not what should be documented in the record. 08/27/2015 4:37:56 PM RN #2 confirmed that the treatment [MEDICATION NAME] (with) each brief change was added to the care plan after a copy of the care plan was requested by the surveyor. The facility admitted Resident #199 with [DIAGNOSES REDACTED]. The resident was admitted with Stage IV to the sacrum and areas to bilateral heels. On 08/27/2015 at 9:06 AM, review of the Admission MDS (Minimal Data Set) dated 5/25/15 revealed the resident was coded as having 1 Stage IV and 2 Unstageable pressure ulcers on admission. On 08/27/2015 at 10:07 AM review of the weekly wound assessment for Resident #199 revealed the Bilateral Heels were documented as soft, boggy, pink, blanching, closed on admission. No documented eschar or slough. The heels were coded as Unstageable on the wound assessment and on the MDS. During an interview on 08/27/2015 at 10:38 AM, Registered Nurse (RN) #1 stated that Unit Managers usually stage wounds on admission but any RN in the building can assess and stage. The RN confirmed the resident's heels were staged as unstageable on the weekly wound assessments. The RN further confirmed both should have been coded as DTI - Deep Tissue Injury.

Based on clinical record review, observation and interview the facility failed to update care plans for 2 of 3 residents sampled for activities of daily living (ADL's). Resident #53 had a change in the amount of help needed for transfer assistance and Resident #106 had a change in the amount of assistance needed with dressing and personal hygiene. The findings included: Review of Resident #53's records revealed that the previous Minimum Data Set (MDS) coded (G0110B1) Transfer: self-performance as 0 (Independent - no help or staff oversight at any time) compared to Most Recent(excl. Adm.): 1 (Supervision - oversight, encouragement or cueing). In an interview on 08/26/2015 at 3:58 PM, MDS Coordinator #2 indicated that the resident had gotten weaker during transfer, and was requesting more assistance. Review of the Care Plan on 8/27/15 confirmed that Transfers were not addressed in the recent 7/22/15 Care Plan. In an interview on 8/27/15 at 3:17 PM, MDS Coordinator #1 confirmed that the change from independence to supervision was not addressed in the Care Plan. In an interview on 08/27/2015 3:39 PM, Resident #53 was asked if she was having to ask for staff assistance with transfers. The resident indicated that a little extra help was needed every now and then but would only ask when needed. Resident wanted to do as much for self as long as possible. In an interview on 08/27/2015 4:02 PM, Certified Nursing Assistant (CNA) #1 indicated that Resident #53 does a lot for herself. When asked about transfers, CNA #1 indicated that Resident #53 transfers herself, but will ask for help if needed. Review of Resident #106's 7/15/15 MDS on 8/26/15 revealed that the resident was coded as (0) independent with ADL except dressing and personal hygiene which was coded as (1) supervision. Review of the revised 7/2015 Care Plan on 8/26/15 revealed that the Care Plan noted that Resident #106 required extensive assistance with ADLs. In an interview on 08/27/2015 at 2:34 PM, MDS Coordinator #1 confirmed the inaccuracy of the care plan and confirmed that the resident only required assistance at times if requested.

On the days of the survey, based on observation, record review and interview, the facility failed to ensure that it was free of a medication error rate of five percent or greater. There were 3 errors out of 26 opportunities for error. The medication error rate was 11.5 percent. The findings included: ERROR # 1: On 5/27/14 at approximately 3:55 PM, during observation of medication pass, LPN (Licensed Practical Nurse) # 1 was unable to find DOC Sodium 100 mg (milligram) in the medication cart and at approximately 4:10 PM he/she withdrew one capsule of DOC Sodium 100 mg (milligram) from the Cubex (first dose supply automated dispensing machine) and then administered one capsule of DOC Sodium 100 mg to Resident A at approximately 4:16 PM. During medication reconciliation, the physicians orders for 5/1/14 - 5/31/14 revealed "DOC SODIUM 100 MG CAP (capsule) "TAKE 2 CAPSULES TWICE DAILY". ERROR # 2: On 5/27/14 at approximately 3:55 PM, during observation of medication pass, LPN # 1 removed one tablet of [MEDICATION NAME] 30 mg. from the medication cart and discovered that three more tablets were needed. On 5/27/14 at approximately 4:10 PM he/she removed three tablets of [MEDICATION NAME] 30 mg from the Cubex and at approximately 4:16 PM LPN # 1 administered four tablets of [MEDICATION NAME] 30 mg (total dose of 120 mg) to Resident A. During medication reconciliation, the physicians orders for 5/1/14 - 5/31/14 revealed an order for [REDACTED]. ERROR # 3: On 5/27/14 at approximately 3:55 PM, during observation of medication pass, LPN # 1 was unable to find [MEDICATION NAME]-S in the medication cart and at approximately 4:10 PM attempted to withdraw the medication from the Cubex. LPN # 1 was unable to locate the medication in the Cubex after using a variety of keyboard entries and called RN # 1 for assistance stating that RN # 1 had received additional training and could figure out if the medication was in the machine. RN # 1 was able to determine that [MEDICATION NAME]-S was in the machine and gave one tablet to LPN # 1 who then administered one tablet of [MEDICATION NAME]-S to Resident A at approximately 4:16 PM. During medication reconciliation, the physicians order for 5/1/14 - 5/31/14 revealed an order for [REDACTED]. During an interview on 5/27/14 at approximately 4:30 PM, LPN # 1 verified that he/she had (1) given one capsule of DOC Sodium 100 mg, not two as ordered by the physician, (2) had given four tablets of [MEDICATION NAME] 30 mg instead of [MEDICATION NAME] 24 hr CD 120 mg as ordered by the physicians orders and(3) had given 1 tablet of [MEDICATION NAME]-S instead of two as ordered by the physician. Pharmacist # 1 provided MAR (Medication Administration Record) copies for Resident A on 5/27/14 at approximately 4:48 PM and further review of the MAR indicated [REDACTED]. Further review of the Cybex transaction report on 5/28/14 at approximately 9:30 AM revealed that no [MEDICATION NAME]-S had been removed from the Cybex during that period and a review of the facility acquisition report provided by the Director of Nursing on 5/28/14 at approximately 9:20 AM from the back up pharmacy did not show that the facility had received [MEDICATION NAME]-S from that pharmacy. This finding was confirmed by Pharmacist # 1 on 5/28/14 at approximately 9:30 AM.

On the days of the survey based on observation, record reviews and interviews the facility failed to ensure that three patient rights for medication administration were followed for 1 of 10 residents, according to Clinical Nursing Skills and Techniques, 7th Edition, 2010 by Perry and Potter. The findings included: On 5/27/14 at approximately 3:55 PM, during observation of medication pass, LPN (Licensed Practical Nurse) # 1 removed one tablet of [MEDICATION NAME] 30 mg (milligram) from the medication cart and discovered that three more tablets were needed. On 5/27/14 at approximately 4:10 PM he/she removed three tablets of [MEDICATION NAME] 30 mg from the Cubex (first dose supply automated dispensing machine) and at approximately 4:16 PM LPN # 1 administered four tablets of [MEDICATION NAME] 30 mg (total dose of 120 mg) to Resident A. During medication reconciliation, the physicians orders for 5/1/14 - 5/31/14 revealed an order for [REDACTED]. On 5/27/14 at approximately 3:55 PM, during observation of medication pass, LPN # 1 was unable to find DOC Sodium 100 mg in the medication cart and at approximately 4:10 PM he/she withdrew one capsule of DOC Sodium 100 mg from the Cubex and then administered one capsule of DOC Sodium 100 mg to Resident A at approximately 4:16 PM. During medication reconciliation, the physicians orders for 5/1/14 - 5/31/14 revealed that "DOC SODIUM 100 MG CAP (capsule) "TAKE 2 CAPSULES TWICE DAILY". A review of the MAR (Medication Administration Record) on 5/27/14 at approximately 4:48 PM revealed that 7 doses of [MEDICATION NAME] CD 120 mg Capsule ([MEDICATION NAME] HCL)and 7 doses of DOC Sodium 100 mg had been documented as administered to Resident A between 5/24/14 8:00 AM and 5/27/14 8:00 AM. Further review on 5/28/14 at approximately 8:45 AM of a Cubex transaction record for Resident A, provided by Pharmacist # 1, revealed that a total of 12 tablets of [MEDICATION NAME] 30 mg (8 on 5/24/14 at 10:13 AM and 4 on 5/26/14 at 9:47 AM) and 1 capsule of [MEDICATION NAME] 100 mg (DOC Sodium 100 mg) had been removed from the machine between 5/24/14 8:00 AM and 5/27/14 8:00 AM. During an interview with Pharmacist # 1 on 5/27/14 at approximately 5:00 PM he/she stated that there was no extended-release (controlled delay) [MEDICATION NAME] stocked in the Cubex machine. The DON (Director of Nursing) provided a report on 5/28/14 at 9:20 AM which showed that no [MEDICATION NAME] 24 HR 120 mg 24 or DOC Sodium 100 mg had been obtained for Resident A from any outside pharmacy. This was confirmed by the DON at that time. A review of the facility procedures for "Ordering and receiving medications from pharmacy" on 5/27/14 at approximately 5:02 PM revealed that for: "New medications, except emergency or "stat" medications, are ordered as follows: -If needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform pharmacy of the need for prompt delivery. -Require timely delivery of new orders so that medication administration is not delayed. Use the emergency kit when the resident needs a medication prior to regular pharmacy delivery. -As a last resort contact your backup pharmacy if necessary". A review of the facility policy and procedures for "Emergency Pharmacy Service-Network Healthcare Backup" on 5/27/14 at approximately 5:02 PM revealed that when a new order is received for a medication not contained in the Emergency Box or First Dose supply and is needed before the next delivery from the pharmacy, the following procedure would apply: 1. Dial XXX at XXX-[MEDICAL CONDITION] to place orders that are required prior to XXX Healthcare's next routine delivery ( If unavailable at XXX, call XXX at XXX-[MEDICAL CONDITION]). 2. If unavailable at XXX or /XXX, call XXX Pharmacy and dial 7 for the voice mail of the pharmacist on call. Please leave a voice mail containing your name, name of facility and station, phone number and a brief message. 3. The pharmacist on call will then contact you as soon as possible. Communicate your needs to the pharmacist. 4. If you have not received a return call within a reasonable period of time, please be sure to try the above procedure again. You may also call the Pharmacist on call at their home. A listing of names and phone numbers should be posted at the nurses' station." Subsequent review of physicians orders, MAR (Medication Administration Record), Cibex transaction report revealed the following: Facility professional staff failed to administer the right medication, right dose and failed to document medications accurately. These findings were confirmed in interviews as follows: -5/27/14 at approximately 4:33 PM by LPN (Licensed Practical Nurse) # 1 -5/28/14 at approximately 12:05 PM by Pharmacist # 1 -5/28/14 at approximately 12:30 PM by RN (Registered Nurse) # 2

On the days of the survey based on observations, record reviews and interviews the facility failed to ensure that it was free of significant medication errors. There was 1 significant medication error out of 26 opportunities for error observed during medication pass and 7 significant medication errors that occurred prior to medication pass observation. (Resident A) The findings included: On 5/27/14 at approximately 3:55 PM, during observation of medication pass, LPN # 1 removed one tablet of [MEDICATION NAME] 30 mg. from the medication cart and discovered that three more tablets were needed. On 5/27/14 at approximately 4:10 PM he/she removed three tablets of [MEDICATION NAME] 30 mg from the Cubex (first dose supply automated dispensing machine) and at approximately 4:16 PM LPN # 1 administered four tablets of [MEDICATION NAME] 30 mg (total dose of 120 mg) to Resident A. During medication reconciliation, the physicians orders for 5/1/14 - 5/31/14 revealed an order for [REDACTED]. During an interview with LPN # 1 on 5/27/14 at approximately 4:30 PM, he/she verified that four tablets of [MEDICATION NAME] 30 mg instead of [MEDICATION NAME] 24 HR 120 mg had been administered to Resident A. During an interview with Pharmacist # 1 on 5/27/14 at approximately 5:00 PM he/she stated that there was no [MEDICATION NAME] 24 HR CD 120 mg stocked in the Cubex. Further medical record review of Resident A revealed the resident was admitted to the facility on [DATE] at 8:30 PM. The resident's [DIAGNOSES REDACTED]. Further review of the MAR (Medication Administration Record) revealed that 7 doses of [MEDICATION NAME] CD 120 mg Capsule ([MEDICATION NAME] HCL) had been documented as having been administered between 5/14/14 8:00 AM and 5/27/14 8:00 AM. Further review of a Cubex transaction record for Resident A, provided by Pharmacist # 1, revealed that a total of 12 tablets of [MEDICATION NAME] 30 mg (8 on 5/24/14 at 10:13 AM and 4 on 5/26/14 at 9:47 AM) had been removed from the machine between 5/14/14 8:00 AM and 5/27/14 8:00 AM thus revealing the incorrect medication had been removed for the resident and there was no removal on some days to justify the daily signatures. The DON (Director of Nursing) provided a report on 5/28/14 at 9:20 AM which showed that no [MEDICATION NAME] 24 HR CD 120 mg had been obtained for Resident A from any outside pharmacy.

On the days of the survey, based on observations and interviews, the facility failed to handle soiled linens in a manner to prevent the spread of infection. A Laundry Aide was observed contaminating his/her arms, shirt, pants, and glasses. There was an observation of another Laundry Aide going from handling soiled linen (sweater) to clean linen without handwashing. The findings included: An observation on 5/28/2014 at approximately 10:08am revealed Laundry Aide #1 was standing in front of the washer and leaning into the soiled clothes bin. S/he was pulling out soiled linen wearing a black gown and short disposable gloves that exposed his/her forearms. Parts of his/her shirt remained exposed. Laundry Aide #1 was taking soiled linen/clothes out of the bin and putting/pushing the soiled linen into the washer multiple times with forearms touching the soiled contaminated linen. S/he was observed leaning into the bin and his/her sleeve was touching the inside of the bin. After putting all the linen into the washer, s/he sprayed the gown with Steriphene II spray and proceeded to remove the gown allowing the straps to touch the floor. S/he removed his/her gloves. Without washing his/her hands, Laundry Aide # 1 was obsesrved to touch his/ her glasses, pants, and shirt. Laundry Aide #1 did not wash his/her hands until 10:15am. During an observation on 5/28/2014 at approximately 10:15 am, Laundry Aide #2 did not take his/her gloves off, touched a soiled sweater and without washing hands, went back to the clean washed linen. Interview on 5/28/2014 at approximately 10:20am with the Director of Environmental Services, who was present at the time of the observations, verified that no handwashing was done immediately after the 2 Laundry Aides removed their gloves. S/he verified that the 2 Laundry Aides were wearing short disposable gloves. The Director of Environmental Services verified that there were long gloves available on the laundry cart in front of the washers for use with soiled linen.