Every finding on record at Oak Harbor Healthcare

Based on review of the facility policy, observations, and interviews, the facility failed to ensure that medications were properly stored in 3 of 3 medication rooms. Findings include: Review of the facility policy entitled Medication Access and Storage . revised 7/2022 states It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls Medications requiring refrigeration or temperatures between 2 degrees (C) Centigrade 36 degrees (F) Fahrenheit and 8 degrees C and (26 degrees F) are kept in a refrigerator with a thermometer to allowing temperature monitoring. Temperatures will be monitored each shift. If temperature is found out of range, adjust temperatures and recheck in 30 minutes. If temperature is still out of range, remove medications and contact maintenance. and Outdated, medications .are immediately removed from stock, disposed of according to procedures for medication destruction . On 5/15/25 at approximately 11:40 AM, inspection of the Hall 200 Medication Room refrigerator revealed, in active storage, 18 syringes of Influenza Vaccine, Adjuvanted FLUAD by Seqirus Lot 388492, expiration date 5/2/25. On 5/15/25 at approximately 11:48 AM, this finding was confirmed by Licensed Practical Nurse (LPN)1. On 5/15/25 at approximately 11:59 AM, the Consultant Pharmacist acknowledged the vaccine was in active refrigerator storage, but was intended to be returned to the manufacturer. On 5/15/25 at approximately 11:56 AM, inspection of the Hall 100 medication room refrigerator thermometer revealed a temperature reading of 32 degrees Fahrenheit (F). On 5/15/25 at approximately 11:57 AM, the thermometer reading of 32 degrees F was confirmed by LPN2. The Refrigerator Temperature Log for May 2025 has been filled out with multiple reading of 36 degrees F and the Log stated temperatures should be between 36 - 46 degrees F. On 5/15/25 at approximately 11:58 AM, the Surveyor placed his calibrated thermometer in the refrigerator, closed the refrigerator door and asked LPN2 to call the Maintenance Director (MD) to check the refrigerator temperature using the facility's thermometer. On 5/15/25 at approximately 11:59 AM, the Administrator and MD were made aware of the concern and on 5/15/25 at approximately 12:09 PM, the MD arrived on Hall 100, but did not check the refrigerator temperature with the two thermometers he had brought from the kitchen. On 5/15/25 at approximately 12:10 PM, the Surveyor's thermometer read 46 degrees F after being in the closed refrigerator approximately 12 minutes. On 5/15/25 at approximately 12:15 PM, inspection of the Hall 300 medication room refrigerator thermometer revealed a temperature reading of 17 degrees F. The Refrigerator Temperature Log did not have a temperature entry for 5/15/25, 7 AM-7 PM. On 5/15/25 at approximately 12:17 PM, the thermometer temperature reading of 17 degrees F was confirmed by LPN3 and the Surveyor placed his calibrated thermometer inside the refrigerator and closed the refrigerator door. On 5/15/25 at approximately 12:37 PM, the surveyor's thermometer read 46 degrees F after being in the closed refrigerator approximately 20 minutes. On 5/15/25 at approximately 12:39 PM, LPN4 (Unit Manager) was informed of the 17 degree F reading of the refrigerator thermometer and after reviewing the Refrigerator Temperature Log for May 2025 stated no temperature had been taken for 5/15/25 on the day shift 7 AM -7 PM, that they should have been taken and that she expected the temperature to be between 36-46 degrees F. On 5/15/25 at approximately 12:43 PM, the Administrator was informed of the Hall 300 medication room thermometer reading of 17 degrees. The Administrator confirmed the reading was not acceptable and that the MD would be directed to place new thermometers in Halls 100 and 300 medication room refrigerators, for correct temperature readings to be verified and refrigerator functioning to be checked out. On 5/15/25 at approximately 3:20 PM, the Surveyor rechecked the Hall 100 medication refrigerator which now contained two new thermometers each reading 38 degrees F. On 5/15/25 at approximately 3:30 PM, the Surveyor rechecked the Hall 300 medication refrigerator which now contained two new thermometers each reading 40 degrees F. On 5/15/25 at approximately 3:41 PM, the Administrator stated that new refrigerators had been ordered for all medication rooms and that these would not contain a freezer compartment.

Based on record review and interviews, the facility failed to ensure residents were informed of their right to have access to names, addresses and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups and information on filing a complaint and or reporting alleged abuse violations. The facility further failed to ensure residents knew where the above information was located within the facility as revealed by 10 of 10 residents during 1 of 1 resident council meeting. The findings included: Review on 05/13/25 at approximately 4:00 PM of the Resident Council Minutes for December 2024, January 2025, February 2025 and March 2025 made no mention of informing residents of the resident's right to have access to a list of names, addresses and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups and information on filing a complaint and or reporting alleged abuse violations. The Resident Council Minutes did not mention the whereabouts of such information within the facility. Interviews on 05/14/25 at approximately 11:30 AM, during a resident council meeting, 10 of 10 residents in attendance confirmed they were not aware of their right to have access to a list of names, addresses and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups and information on filing a complaint and or reporting alleged abuse violations and the whereabouts of this information in the facility. An interview on 05/14/25 at 02:06 PM with the Activity Director revealed, Yes, I go over resident rights with the residents in resident council. There is a list of 10 questions that I go over with them. Examples of the questions reviewed include, Do you get your mail unopened? Do you know your resident rights? The AD stated, I have not reviewed the location of the contact information for the Omsbudsman. I have not met the new Omsbudsman. She was here 2 or 3 weeks ago, but she did not introduce herself to me. I am not aware that there is a complaint line that residents can call to lodge a complaint with the state. I do not know where the Omsbudsman's contact information is posted. The AD was unsure where the information is to lodge a complaint with the state. On 05/14/25 at 02:52 PM, an interview with the Administrator revealed, I need to work more with her. The Ombudsman has not worked much with our activities department. We have involved the Ombudsman in resident issues in the past. My expectation would be to add to resident council that contact information for the Ombudsman and how to lodge a complaint with the state. This will be especially important to review this information with new residents.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure the kitchen was properly cleaned, food was properly handled, and the dish machine was working in accordance with professional standards for food service safety as required for 121 census residents who received meals from the facility kitchen. These failures had the potential to lead to food-borne illness among all facility residents. Findings include: The facility's policy titled, Dishwashing: Machine Operation, dated 2020, documented The Dining Services staff shall maintain the operation and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food .All dishwashing machines should be operated according to manufacturer recommendations .Check the dishwashing machine before first use. If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function. The facility's policy titled, Proper Hand Washing and Glove Use, dated 2020, documented All employees will use proper hand washing procedures and glove usage in accordance with State and Federal sanitation guidelines .Employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual resident .Gloves are to be used whenever direct food contact is required .Hands are washed before donning gloves and after removing gloves .Gloves are changed any time hand washing would be required .if the gloves become contaminated by touching the face, hair, uniform, or other non-food contact surface, such as door handles and equipment. The facility's policy titled, Sanitizing Equipment and Food Contact Surfaces, dated 2020, documented Employees shall sanitize equipment and food contact surfaces utilizing the proper sanitizing solution. 1. During observations alongside the Dietary Manager (DM) on 03/27/24 at 7:00 AM revealed: -The walk-in refrigerator had a visibly soiled door and dark debris on the handle. -The walk-in freezer had multiple broken curtain slats with ice buildup on the curtain and around the door. 2. During observations alongside the DM on 03/28/24 at 10:15 AM revealed: -There was a knife storage box, with numerous knives stored into the slots. There were three knives that rested sideways on the top of the storage box. The lid was observed with dried dirt and debris on the exposed sides of the box, including the top where the knives rested. -The floor was observed with broken tile approximately 3/4 inch thick at the entrance to the pantry, with extensive dark debris built-up along the length of the door. -The dishwasher temperatures were monitored with multiple cycles run, which revealed: First run: Wash temperature of 90 F (Fahrenheit), a rinse temperature of 103 F, and 200 PPM (parts per million) of the sanitizer. Second run: Wash temperature of 100 F, and a rinse of 119 F, and 200 PPM of the sanitizer. Third run: Wash temperature of 112 F, and a rinse of 122 F, and 200 PPM of the sanitizer. Review of the March 2024 Temperature Log for the Dish Machine revealed the expected parameters of Wash: 120 F, Rinse 120 F, and Test Strip 50 PPM (parts per million). The log was documented for Breakfast, Lunch, and Dinner each day. The log was documented with temperatures of 100 F for all the Wash and Rinse cycles during Lunch on 03/02/24 through 03/10/24. A concurrent interview on 03/28/24 at 10:42 AM with the DM, Corporate Dining Consultant (CDC), and Registered Dietician (RD) confirmed that the facility had a new booster to improve hot water levels due to a history of low temperature concerns. They all confirmed the dishwasher required temperatures of 120 F and should have always been logged accurately, after ensuring the correct temperatures had been reached. During a meal service observation on 03/28/24 at 12:23 PM, Cook1 was observed plating food for lunch. Cook1 pulled on gloves, pulled up their pants, then continued to pick up a serving utensil and began to plate the food. Cook1 was observed touching the inside edge of the resident plates with the same gloved hands. On multiple occasions, Cook1 was observed using the same gloved fingers to touch the mixed vegetables that were on the scoop, to ensure the food did not fall out of the scoop while plating. Cook1 dropped a pair of tongs onto the stuffing, with the handle touching the food, then picked them back up with the same gloved hands. During an interview on 03/29/24 at 12:40 PM, DM confirmed that many of the dietary staff were new, and she had spoken many times to them, including Cook1, about wearing gloves and touching items they should not touch, including clothes. The DM stated she was still educating new dietary staff on cleaning processes.

Based on observation, interview, and facility policy review, the facility failed to ensure effective hand hygiene during wound care and there was a way to restrict air flow between the dirty laundry and clean laundry area. This had the potential to cause wound infection and exposure to viruses and bacteria to any of the 121 residents in the facility. Findings include: Review of the facility's policy titled, Hand Hygiene, reviewed 12/23, showed: .3. Washing Hands a. Vigorous lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature .b. Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of sink. c. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel . Review of the facility's policy titled, Departmental (Environmental Services) - Laundry and Linen, revised January 2014, showed: General Guidelines . 3. Consider all soiled linen to be potentially infectious and handle with standard precautions .Washing Linen and other Soiled Items .6. Keep soiled and clean linen, and their respective hampers and laundry carts, separate at all times. 7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts . Review of the facility policy titled, Infection Control Prevention and Control Program, reviewed 09/17, showed: .C. Prevention of Infection Staff and resident education is done to identify risk of infection and promote practices to decrease risk. Policies, procedures and aseptic practices are followed by personnel in performing procedures, linen handling and disinfection of equipment. The hand hygiene procedures will be followed by staff involved in direct resident contact . 1. During an observation of R113's ischial pressure ulcer on 03/29/24 at 10:15 AM, the Wound Care Nurse (WCN) entered the bathroom and performed a handwash of six seconds from soap push to turning the water off, then pulled a paper towel to dry hands. After pulling the privacy curtain and closing the blinds, WCN performed a hand wash at 10:16 AM that was five seconds from soap push to towel pull, then turned the water off. After adjusting the bed and removing the old dressing with gloved hands, WCN performed a hand wash at 10:19 AM that was nine seconds from soap push to towel pull (WCN dropped the normal saline and went to the door for another staff to retrieve one from the treatment cart). At 10:21 AM, WCN performed a handwash that was five seconds from soap push to water off, turned the water back on and washed nine seconds to pulling a paper towel, then turning the water off. WCN applied gloves and cleaned the wound, removed gloves, and performed a handwash at 10:23 AM that was ten seconds from soap push to water off, then pulled a paper towel. After treating and dressing the wound, WCN removed gloves and was waiting for staff to assist to provide other care to R113. During an interview on 03/29/24 at 10:28 AM about effective handwashing, WCN stated that you should sing Happy Birthday while washing. When asked to sing the song how many times, WCN responded, Once, then thought about it and stated, yes, once; no wait, twice. When asked the sequence of effective handwashing, clarifying, when was the water to be turned off, WCN stated, Towel then water off. When advised of the observations, WCN stated One time I turned the water back on. During an interview on 03/29/24 at 1:25 PM, the Director of Nursing (DON) stated a handwash expectation of 20 seconds at a minimum. Clarified, the DON stated that was the scrub portion (vigorously rubbing hands together). When asked the sequence of handwashing, the DON stated, Turn on the faucet, soap, lather at least 20 seconds getting in between fingers and nails, rinse hands pointed down, grab a paper towel and dry hands, discard and get a new paper towel to turn off the water source. 2. During an observation of the laundry area and interview on 03/29/24 at 12:10 PM, the laundry room had no physical barrier to separate dirty laundry from the clean laundry area. Laundry Staff (LS) 1 was present during the observation and stated the blue line is the divider - nothing dirty past here & nothing clean over there . She confirmed there was no curtain, or any type of barrier used to separate the dirty laundry while it was sorted into the washing machines. During a second laundry area observation and interview on 03/29/24 at 12:30 PM, LS1 showed three gray large barrels that LS1 confirmed was dirty laundry for sorting and was not in any type of contained area (i.e. the laundry room was one large room). The washing machines were directly across the walkway from the barrels. Looking from the washing machines, there was a wash sink area between the washers and dryers and a blue line across a table with clean linen folded and stored approximately twelve inches from the tape, and tape on the floor that LS1 confirmed was the divider between clean and dirty. When asked if the blue line was the only thing to keep any bacteria/viruses that might be agitated during the sorting of the dirty laundry or the placement of the dirty laundry into the washing machines, LS1 stated That's what divides the clean and dirty. Above the 'blue line' divider was a large air vent that LS1 stated was output, not intake. The air would blow straight down and cause any settled bacteria/ viruses/ dust/ lint/ dirt on the dirty side of the table or floor to go airborne. During an interview on 03/29/24 at 12:20 PM, the Administrator stated the no barrier in the laundry was identified during their mock survey. During an interview on 03/29/24 at 1:33 PM the DON stated an expectation regarding laundry handling was There needs to be separation between clean and dirty; proper PPE [personal protective equipment worn] when sorting or putting in washer, and that the air does not flow from dirty to clean.

Based on record review, interviews, and facility policy review, the facility failed to ensure dialysis related medications were provided for one of two residents (Resident (R) 71) reviewed for dialysis of 33 sampled residents. Findings include: Review of the facility's policy titled, Dialysis (Renal), Pre- and Post-Care, dated 01/22, revealed, It is the policy of this facility to: Assist resident in maintain homeostasis pre- and post-renal dialysis; assess and maintain patency of renal dialysis access; assess resident daily for function related to renal dialysis; participate in ongoing communication and collaboration with the dialysis facility regarding dialysis care and services .Hold any blood pressure medications and/or any other specified medications as ordered by physician. Review of R71's Admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses including diabetes mellitus II, end stage renal disease, and dependence on renal dialysis. Review of R71's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/27/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. The resident was documented to require dialysis while a resident. Review of R71's Care Plan, located in the Care Plan tab of the EMR, initiated 09/14/22 and last revised 12/02/22, documented that the resident had Hemodialysis r/t [related to] Renal failure. The interventions included for the resident to attend dialysis on Monday, Wednesday, and Friday. During an interview on 03/27/24 at 9:01 AM, R71 stated that he went to dialysis three times a week, approximately 4:50 AM. R71 stated that the facility sent him with food. He stated that he was not always given his Renvela on dialysis days, which was his only concern. R71 stated that when he asked the nursing staff about receiving the medication, he was told that other residents were receiving medication administration before him, and he would have to wait. Review of R71's Orders tab of the EMR revealed an order, dated 09/12/23, for Renvela Oral Tablet 800mg, give two tablet [sic] by mouth with meals for hyperphosphatemia related to end stage renal disease. Take with snack. To be administered 7:30 AM, 12:00 PM, and 5:00PM. Review of R71's Medication Administration Record (MAR) of the EMR under the Orders tab for January 2024, revealed Renvela Oral Tablet 800mg was not administered on 01/22/24 and 01/31/24 at 7:30 AM, coded by nursing staff as out of the facility on scheduled dialysis dates. Review of R71's MAR of the EMR under the Orders tab for February 2024, revealed Renvela Oral Tablet 800mg was not administered on 02/21/24 at 7:30 AM and coded by nursing staff as out of the facility on scheduled dialysis date. Review of R71's MAR of the EMR under the Orders tab for March 2024, revealed Renvela Oral Tablet 800mg was not administered on 03/01/24, 03/06/24, 03/07/24, 03/13/24, 3/18/24, 03/20/24, 03/27/24, and 03/28/24 at 7:30 AM, coded by nursing staff as out of the facility on scheduled dialysis dates. Review of R71's EMR under the Progress Notes tab revealed: -03/22/24 Renvela just got back from HD [hemodialysis] -03/29/24 Renvela at dialysis. During an interview on 03/29/24 at 11:01 AM, Unit Manager (UM) 2 stated that R71 went to dialysis very early in the mornings and did not always get his Renvela. UM2 stated that when the resident returned it was almost time for his lunch dose. During an interview on 03/29/24 at 11:05 AM, Nurse Practitioner (NP) stated that there should not be any outcome for R71 missing Renvela due to being at dialysis and was not sure if the resident needed to receive the medication on those mornings. NP stated that he was reviewing the resident's medication, and confirmed R71 was not currently receiving Renvela on numerous dialysis days per the physician order. During an interview on 03/29/24 at 11:44 AM, Director of Nursing (DON) stated he was not aware if there had been communication or review of the Renvela not being administered on numerous dialysis days for R71. DON stated that he would have to speak with the medical provider to determine if the medication should be reviewed.

Based on observations, interviews, and record review, the facility failed to provide a splint device for contracture per plan of care for one of three residents (Resident (R) 112) reviewed for positioning/mobility of 33 sampled residents. Findings include: The facility's policies and procedures related to Range of Motion (ROM) and splinting were requested on 03/29/34 at 10:00 AM. During an interview with the Director of Therapy on 03/29/24 at 11:01 AM, she stated the facility did not have a policy/procedure to address the use of splints or ROM. Review of R112's Admission Record, dated 03/29/24 and found in the electronic medical record (EMR) under the Admission tab, indicated R112 was admitted to the facility on [DATE] with diagnoses including history of seizures. Review of R112's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/23 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) assessment was not completed because the resident was non- responsive. The assessment indicated the resident was completely dependent upon staff to complete all her ADLs (Activities of Daily Living), including movement in bed and range of motion. Review of R112's undated Alteration in Musculoskeletal Status r/t (Related to) Right Hand Contracture Care Plan, found in the EMR under the Care Plan tab, indicated R112 had an actual contracture to her right hand. The care plan indicated the use of a right-hand [NAME] guard/splint to prevent further worsening of the resident's right hand contracture. Review of R112's physician's orders, dated 03/29/24 and found in the EMR under the Orders tab, revealed no current order for the resident's use of a right-hand splint. Review of R112's Treatment Administration Records (TARs), dated 03/01/24 through 03/29/24 and found in the EMR under the Orders tab, revealed nothing to indicate the resident's right hand splint had been applied per her plan of care. R112 was observed on 03/28/24 at 9:44 AM, 10:50 AM, and 12:06 PM. The resident's right hand was severely contracted, and a splint was not observed to be applied to her right hand during the observations. The resident's hand splint was observed to be hanging on a hook on the wall at the resident's bedside. During an observation of R112 with Licensed Practical Nurse (LPN) 2 on 03/28/24 at 12:10 PM, LPN2 confirmed R112 was not wearing her right-hand splint per her plan of care and stated the splint should have been on R112's right hand per her plan of care. LPN2 applied the resident's splint to her right hand. During an interview on 03/28/24 at 2:43 PM, the Director of Therapy confirmed R112 had a right-hand contracture and was dependent upon staff for all her daily care. She stated R112 was supposed to be wearing her right hand splint all day and that nursing staff had been provided with education related to the application of the splint. She stated orders had been in place for the resident's splint, and application of the resident's splint was expected to be documented in the TAR. The Director of Therapy stated the splint order had been omitted from the resident's physician order set and so had not been populating on the TAR to trigger nursing staff to apply the splint. She stated the order for the resident's splint had been put back into the EMR this day (03/28/24) and nursing had been made aware the splint was expected to be applied during the day every day. During an interview on 03/28/24 at 2:52 PM, the Director of Nursing (DON) stated R112's right-hand splint was expected to be applied according to her plan of care. The DON stated physician's orders were expected to be in place for the resident's splint, and stated his expectation was the application of the resident's splint to be documented in the TAR.

28154 30067 Based on record review, interviews, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessments captured: hemodialysis treatments for Resident (R)17; pain requiring interventions daily for R29; and anticoagulant therapy for R113 to appropriately meet the resident's specialized care needs in the facility. This failure affected three residents (R17, R29, and R113) of 33 sampled residents reviewed for MDS assessment accuracy. Findings include: Review of the facility policy titled, Accuracy of Assessment (MDS 3.0), reviewed 05/21, showed: Policy: It is the policy of this facility to ensure that the assessment accurately reflect the resident's status. Purpose: To assure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledgeable about the resident's status, needs, strengths, and areas of decline. Procedures .3. The assessment sections are completed with utilization of the RAI [Resident Assessment Instrument] manual guidance, [sic] . Review of the October 2023 RAI Manual, Page N-7 showed: N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). N0415E2. Anticoagulant: Check if there is an indication noted for all anticoagulant medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days) . 1. Review of R17's Admission Record, dated 03/29/24 and found in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD) and dependence on dialysis. Review of R17's Order Summary Report, dated 03/29/24 and found in the EMR under the Orders tab, indicated an order for the resident to receive dialysis services three times weekly on Mondays, Tuesdays, and Fridays related to his diagnosis of ESRD. Review of R17's Renal Condition and Risk for Complications Care Plan, dated 10/03/22 and found in the EMR under the Care Plan tab, indicated the resident was receiving dialysis services three times weekly on Mondays, Tuesday, and Fridays. Review of R17's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/15/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident had intact cognition. The assessment incorrectly indicated the resident was not receiving dialysis services. During an interview on 03/29/24 at 11:30 AM, the MDS Coordinator (MDSC) confirmed R17 had been receiving dialysis services since his admission to the facility. The MDSC stated the 03/15/24 MDS assessment was incorrect and stated, I will have to modify that (the assessment to correctly reflect the resident's dialysis services). 2. Review of R29's Face Sheet found in the EMR, under the Profile tab, revealed R29 was admitted to the facility on [DATE] with diagnoses including dementia with behaviors, osteoarthritis, anxiety disorder, and a history of falls. Review of R29's most recent quarterly MDS with an ARD of 03/07/24 revealed a BIMS score of 00 which indicated R29 was rarely to never understood and could not make decisions regarding her care. The MDS assessment addressed pain. The assessment failed to capture that R29 was frequently in pain expressed by facial wincing, and grimacing or crying out. The resident had an order for narcotic pain medications that were available for pain and were administered at least once daily (and twice daily in most cases) during the seven days look back period of the MDS assessment. Review of R29's Medication Administration Record (MAR) for the month of March 2024 revealed an order for Hydrocodone 5/325mgs (milligrams) by mouth every six hours as needed. The review revealed R29 received the pain medication twice each day. Her first dose was usually upon rising, and a second dose was needed in the afternoon or evening. The medications were documented as effective in relieving R29's intermittent pain. During an interview on 03/28/24 at 3:00 PM, the Licensed Practical Nurse (LPN)1 revealed she cared for R29 regularly and stated, She [R29] speaks in word salad but can definitely let you know if she's hurting . LPN1 stated R29 had a history of falls and occasionally resisted care, especially if she's already hurting. LPN1 stated the pain medications ordered appeared to work well for her and it definitely increased her compliance with cares. 3. Review of R113's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses that included sepsis, quadriplegia, stage four pressure ulcer, chronic embolism and thrombosis, and pulmonary embolism. During an interview on 03/28/24 at 10:01 AM, R113 stated he did not think he took a blood thinner medication. Review of R113's MAR from the EMR Orders tab showed R113 was administered apixaban [anticoagulant] five milligrams (mg) twice a day. Further review of the Orders tab for anticoagulant medication showed that apixaban was ordered and started on 12/13/23 and had received the medication daily unless refused. Review of R113's quarterly MDS with an ARD of 01/24/24 showed no coding for R113 taking an anticoagulant medication. Review of R113's admission MDS, dated [DATE] and five day MDS, dated [DATE], showed R113 was coded for taking an anticoagulant. During an interview on 03/28/24 at 10:29 AM, MDSC reviewed R113's 01/24/24 MDS and stated, No, I did not code him for an anticoagulant. MDSC then reviewed R113's January 2024 MAR and commented, He was on it for AFib [atrial fibrillation] all of January. So that was my error. I was a baby MDS coordinator in January.

Based on interview, record review, and review of facility policy, the facility failed to maintain resident safety from harm for 1 of 1 resident. Specifically, while bathing Resident (R)1 on 09/01/23, Certified Nursing Assistant (CNA)1 grabbed the bed linen/sheet and attempted to move/reposition R1 resulting in R1 falling to the floor and suffering injuries. On 11/09/23 the facility presented a Time Line of events. The survey team's investigation revealed the facility implemented interventions to address the noncompliance, indicating past noncompliance as of 09/02/23. Findings include: Review of the undated facility policy titled Fall Management System revealed, Standard: This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents. Policy: It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses to include but not limited to, dementia, convulsions, hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/25/23, revealed a Brief Interview for Mental Status (BIMS) was not conducted due to R1 being non-verbal. Further review of R1's MDS revealed R1 needs extensive assistance with two person physical assist with bed mobility and R1 is total dependence with two person physical assist with transfers. Review of R1's Care Plan (unspecified date) revealed, Falls: risk for injury/falls r/t impaired mobility/coordination, cognitive/judgement deficits, medications . Risk for injury/falls will be minimized . Interventions include, Anticipate and meet needs. Mechanical lift for transfers. Needs a safe environment: . the bed in low position at night; side rails as ordered . Further review of the Care Plan revealed, ADL Mobility: ADL Self Care Performance Deficit r/t Disease Process and Limited Mobility. ICH/CVA with Left Hemiparesis, dysphagia, aphasia, seizure disorder, hydrocephalus, MDD, GERD, HTN, gastrostomy. Interventions include, Transfer: Requires (2) staff participation: Mechanical Aid (Sling) for transfers. Bathing: Usually needs total assistance. Bed Mobility: Usually needs total assistance. Review of R1's Progress Note dated 09/01/23 at 5:08 AM, written by Advanced Practice Nurse (APN) revealed, [R1] is a pleasant [AGE] year-old female resident who presents this morning with a chief complaint of fall from bed during care with contusion of the head. A small laceration with active bleeding to the occipital area was found by nursing and they initiated emergent transfer to the ER due to head injury with active bleeding. Review of R1's Neurosurgery Consult Note dated 09/01/23 revealed, .presenting as transfer from living facility with trace right frontal traumatic subarachnoid hemorrhage. Patient was being bathed by the facility staff when she was dropped and struck her head. Unknown if loss of consciousness. Patient is not on any AC/AP meds. Per EMS and patient's facility, she is at her neurologic baseline. On my exam, patient's eyes are open spontaneously, pupils reactive, right gaze preference, moans, purposeful on the right, contracted on the left. Patient was a trauma transfer he [sic] also has some C-spine fractures per report. Review of R1's Discharge Summary dated 09/02/23 revealed, .presenting as transfer from living facility with trace right frontal traumatic subarachnoid hemorrhage. Transfer for higher level of care needs and transferred to [local hospital] after sustaining a reported slip w/ care needs. Hospital Course . Consultants were obtained 2/ 2 complex injury patterns . Chronic ossific fragment vs osteophyte fracture at C6. Review of a witness statement written by CNA1 on 09/01/23 revealed, I was bathing the resident in room [ROOM NUMBER]-B while I was bathing her, she was pulling on her brief and her feeding tube. I held her hand gently to stop her from pulling on anything else and proceeded to bathe her. I then used the sheet to pull her towards me and the chuck pad and turned her in the opposite direction. I rolled the resident over and she fell off the bed onto the floor. I then checked on the resident and laid a towel under her head. I went to the hallway and called for the nurse. Review of a witness statement written by Licensed Practical Nurse (LPN)1 on 09/01/23 revealed, This nurse was passing Meds on Hall one [CNA1] assigned to [R1] came to me to report that the resident had fallen out of her bed and was bleeding from the head. This nurse went immediately to check on the resident. Upon entering the resident room, she was noted laying on the floor on the right side of the bed nearest the air conditioner lying on her back and her head at the base of the nightstand. Bright red blood noted. [CNA1] had placed a towel under her head for support and to stop the bleeding. Third eye on call Advance Practice Nurse (APN) notified with message. I will be there shortly resident was assisted off of the floor to be cleaned as she noted having a BM and the floor soiled water or urine. After assisting resident to bed, she was turned over so this nurse could check to see where she was bleeding. A laceration was noted to the back of her head. EMT notified for transport to ER [local hospital] for further eval. On call NP and R/P are made aware. During an interview with the Director of Nursing (DON) on 11/09/23 at 1:37 PM revealed, My expectation is to follow the training they received when hired and [CNA1] did not. The DON stated staff should never reposition/move a patient in that manner. On 11/09/23, the facility presented a timeline of events which included interventions that were implemented to address the noncompliance. 11/9/2023 - Self Reportable investigation regarding [R1] [R1] had a change of elevation on 9/1/2023 during a bed bath. The patient required emergency medical services and was transported to [local hospital], the Registered Nursc at [local hospital] notified staff on 9/1/2023 at 11:26 am that the patient had sustained a neck fracture. 9/1/2023 - Immediate education was started with staff on the following: Providing Care to residents with restlessness, total assist; Post Fall instruction for possible Major/Serious Injury and Turning and Repositioning a Client as well as education on LMS/Relias for Dementia Care: Performing ADLs. 9/1/2023 - Teachable moment provided with CNA stating: When assisting a total care patient, 2 staff members are required for all care. Patients must be turned toward you and not away from you. 1:1 Education. 9/1/2023: Witness statements began to be obtained per investigation process and Interventions added to patient plan of care. (Fall Mats, Bolstered Mattress to aide with centering re ident in the bed and 2 person assist with ADLs). 9/2/2023: Patient returned to the facility from the Hospital with set interventions in place per IDT Team. At the hospital per discharge summary the patient did not require Acute Neurosurgical interventions, Repeat CTH upon arrival from [local hosital] to [local hospital] was stable, no additional imaging necessary. [R1] was kept overnight for observation and discharged back with the documentation from [local hospital] stating that patient was at Baseline. Orthopedic Spine consulted at [local hospital] and deemed no C Collar needs at time of discharge.

Based on record review, facility policy review, and interviews, the facility failed to report an allegation of abuse to the Administrator and the State Survey Agency within the two-hour timeframe for 1 (Resident (R)2) of 3 residents reviewed for abuse. Findings include: The facility policy, titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, revised in October 2022, indicated, Procedure: 1. In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but: not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. 2. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: a. The Administrator of the Facility b. The State Survey Agency. A review of R2's Admission Record revealed the facility admitted the resident on 02/17/2022 with diagnoses that included chronic pain, anxiety disorder, and the presence of other specified devices. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 02/03/23, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. R2 had no behaviors, was able to feed themself after set-up, and received anti-anxiety medications, diuretics, and opioid medications seven out of seven days of the look-back period. Review of a nursing Progress Note, dated 01/22/23 at 3:55 PM, revealed R2's family member called the facility requesting to speak to the head nurse. The writer informed the family member that she was a nurse and asked how she could help. The family member began to question if the nurse knew how to care for the elderly, stating that what they were doing to R2 was elder abuse and neglect. The family member stated that R2 was in the hospital, and the family member received a call stating that R2's labs showed they were not receiving their medications. The family member said that meant someone at the facility was taking the medications. The family member wanted to know who was working the night shift with R2 because they were told that R2 did not receive any of their medications. The nurse informed the family member that R2 had received all their scheduled medications on the 7:00 AM - 7:00 PM shift the day before as well as thus far that day and could only speak for the shifts the writer worked. The nurse informed the family member that they needed to speak to the unit manager regarding their concern as the writer was an agency nurse on staff. A review of the Initial 2/24-Hour Report, dated 01/23/23, indicated the State Survey Agency was notified of the abuse allegation on 01/23/23 at 3:02 PM, which was approximately 24 hours after the abuse allegation was made. During an interview on 05/04/23 at 10:30 AM with the Administrator, he stated he would expect any allegation of abuse to be sent to the State Survey Agency within the required two-hour time frame. He stated that in this circumstance, the facility was not notified of the abuse allegation on the day it was made, as the nurse was with an external agency. The next day, when the 24-hour chart audits were done, they saw the allegation. The allegation was reported at that time.

Based on interviews and record review, the facility failed to provide quarterly financial statements in writing to the resident's representative for one resident (Resident (R) 71) of 32 residents in the initial pool sample, within 30 days after the end of the quarter, and upon request. This failure had the potential for the resident's representative not to be aware of charges to the resident's account. Findings include: Review of R71's undated Admission Record located in R71's electronic medical record (EMR) under the Profile tab, indicated R71 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R71's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/22, revealed the facility assessed R71 to have a Brief Interview of Mental Status (BIMS) score of four out of 15, indicating R71's cognition was severely impaired. During an interview conducted on 03/14/22 at 1:14 PM, R71's representative stated they did not receive R71's quarterly financial statements from the facility. During an interview conducted on 03/16/22 at 1:45 PM, the Business Office Manager (BOM) stated she gives R71 the quarterly statements in person in the resident's room. The BOM confirmed she did not send the statement or hand the R71's Power of Attorney (POA), a copy of the quarterly statements. Review of the facility's policy titled Management of Resident Funds revised 08/11/17, indicates the facility will provide written notification to .the resident's responsible party in cases where the resident is not competent .it is the policy of this facility to provide a written statement to the resident or legal representative every quarter for review.

Based on interview, record review, and facility policy review, the facility failed to ensure the Preadmission Screening and Resident Review (PASSAR) Level I) was updated for one resident (Resident (R) 108) of five residents reviewed for PASSAR. Due to this failure, R108 did not receive a PASSAR Level II evaluation to ensure R108 was receiving the appropriate care and services. Findings include: Review of R108's undated Admission Record located in R108's electronic medical record (EMR) under the Profile tab, indicated R108 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R108's quarterly Minimum Data Set (MDS) with an Assessment Reference Data (ARD) of 03/03/22, located in R108's EMR under the MDS tab, revealed a Brief Interview of Mental Status (BIMS) score was not attempted due to resident was rarely/never understood. The staff assessment for mental status indicated R108's ability to make decisions regarding tasks of daily life was severely impaired and never or rarely made decisions. R108 was assessed as not exhibiting any behaviors during the look back period. Review of R108's PASARR Level-I Screening Form dated 07/31/19, provided by the facility, indicated R108 did not have any diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Indicating R108 would not meet the requirements for a PASARR Level II evaluation. During an interview conducted on 03/15/22 at 3:14 PM, the Social Services Director (SSD), indicated the SSD would be the person to review all PASARR's upon admission. The current SSD started at the facility in September 2021 and was unaware R108's PASARR I was inaccurate. The SSD stated upon review of R108's PASARR I, a new PASARR should have been resubmitted. Review of the facility's policy titled Admission Criteria revised March 2019, indicated all new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment, interest, and the physical, mental, and psychosocial well-being for two of seven sampled residents (Resident (R) 33 and R105) reviewed for activities This failure caused the residents' activity preferences not to be honored. Findings include: 1. Review of R33's undated Face Sheet located in the electronic medical record (EMR) under the Profile tab indicated R33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R33's Activities Initial Review dated 10/07/21 located in the EMR under the Assessments tab documented prior to admission R33 participated in listening to TV (news, spiritual programs), listening to music (all kinds), would like to social visit in the dayroom, and due to vision impairment, staff need to set TV to preferred stations and need to assist with transport. Review of R33's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/08/21, located in the resident's EMR under the MDS tab revealed the resident's preferences identified music was very important to her. Review of the quarterly MDS with an ARD of 01/04/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated the resident was severely cognitively impaired. Review of the activity Care Plan revised on 01/13/22, located in the resident's EMR under the Care Plan tab documented the resident had little or no interest in group activities. Previous interests included listening to television, news, Sunday services, and all types of music. R33 was accepting of dayroom visits and visits with staff for socialization. Interventions included to provide one to one visits frequently as tolerated, and ensuring needs are known and met. Observations on 03/14/22 at 10:00 AM, 11:00 AM, 12:00 PM, 1:15 PM, and 2:00 PM identified R33 sitting in a wheelchair, at a table in the unit dining/dayroom. R33 was sitting alone at the table. The television was on an oldies station and was approximately twenty-five feet from the resident. Sound from the television was not audible where R33 was sitting. During the observations, music was not playing in the room and staff did not engage the resident in any other forms of socialization. Observation on 03/15/22 at 9:08 AM, 9:45 AM, 11:00 AM, 12:00 PM, and 1:30 PM identified R33 sitting in a wheelchair at a table in the unit dining/dayroom. The television had on a game show and sound was not audible, where R33 was sitting. During the observations, there was no music playing in the room. Review of the March 2022 calendar of activities, located in the resident's room, did not identify any music programs on the calendar. Review of R33's March 2022 Activity Attendance Record provided by the Activity Director, revealed television was provided daily; however, music was not provided on any day. In an interview on 03/16/22 at 09:53 AM, the Activity Director stated R33 did not go to the main activity room for programs because she preferred to stay in the unit dining/dayroom. The Activity Director stated R33 loved to eat ice cream and listen to music, and she was not aware staff were not putting music on for R33 when she was in the unit dining/dayroom. The Activity Director stated she thought staff were aware to put music on per R33's preference. In an interview on 03/16/22 at 10:45 AM, Licensed Practical Nurse (LPN) 2, who was the unit manager, stated R33 spent almost all day in the dining/dayroom per her preference. LPN2 was not aware staff should ensure music was on when R33 is in the dining/dayroom. 2. Review of R105's undated Face Sheet located in the EMR under the Profile Tab indicated R105 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident Preferences Evaluation dated 12/03/21, located in the resident's EMR under the Assessments tab documented, .How important is it to you to do your favorite things: Very important favorite activities include: music, tv watching westerns, fishing shows, news. Review of R105's quarterly MDS with an ARD of 03/01/22, located in the resident's EMR under the MDS tab revealed the resident had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact. Continued review of the MDS revealed R105 required extensive assist of one for bed mobility, total assistance of two for transfer with mechanical lift, and total assistance of one for locomotion. Review of the activity Care Plan dated 02/22/22, revised on 03/03/22, located in the resident's EMR under the MDS tab documented R105 was dependent on staff for meeting emotional, intellectual, physical, and social needs and demonstrates passive participation in activity events. Interventions included to provide the resident with the activities calendar and staff will provide daily contact to ensure that his needs are being known and met. Observation on 03/14/22 at 10:20 AM, 11:30 AM, and 1:20 PM identified R105 was sitting in a wheelchair in his room. The television was on and was on a channel airing a game show and then soap opera. The television was not on to a channel showing westerns, news, or fishing program. R105 did not have a radio or device to play music in the room. R105 had his head down and appeared to be sleeping during the observations. Observation on 03/15/22 at 9:30 AM, 10:00 AM, 11:50 AM, 1:00 PM and 1:20 PM identified R105 sitting in a wheelchair in the unit dining/dayroom. R105 was at a table not positioned in a manner to be able to view the television that was on in the room. The television was on a channel airing a western program; however, R105 could not see or hear the program. Music was not playing in the dining/dayroom during the observations. Observation on 03/16/22 at 8:35 AM identified R105 lying in bed awake. The television was on and dialed to the Nickelodeon channel. There was not music on in the room. Review of R105's March 2022 Activity Attendance Record provided by the Activity Director revealed television was provided daily and music was not provided on any day. Review of the March 2022 calendar of activities located in the resident's room did not identify any music programs on the calendar. In an interview on 03/16/22 at 09:53 AM, the Activity Director stated R105 used to come to the main activity room; however, that stopped with COVID. She stated programs had resumed, but R105 had not attended. The Activity Director stated music was played during coffee chat, coloring crazy programs, and Wednesday socials. She said there was no reason he could not go; it was on the care plan and the staff should have assisted R105 to activities because R105 was dependent on staff for activities. The Activity Director stated now that she knew his preferred programs were not on the television and music was not available in his room, she would make sure R105 got to programs and the television is on the right channel. In an interview on 03/16/22 at 10:45 AM, LPN2 stated she did not know what activity programs R105 liked to attend, and recreation staff never asked nursing staff to transport R105 to a program. LPN2 was not aware staff should put R105's television on specific channels.

Based on observation, interview, and record review, the facility failed to ensure that one resident (Resident (R) 48) of two residents reviewed for limited range of motion was provided appropriate treatment and services to increase and/or prevent a further decrease in range of motion to R48's severely contracted left hand. This deficient practice had the potential for R48 to experience additional pain/discomfort and poor hygiene. Findings include: Review of R48's undated Admission Record located under the Profile tab in the electronic medical record (EMR) revealed R48 was admitted to the facility on [DATE] for long term care. Review of R48's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/13/22 revealed R48 had a Brief Interview for Mental Status Score (BIMS) of 04 out of 15, which indicated the resident was severely cognitively impaired. The MDS also documented the resident had arthritis and functional impairment in range of motion (ROM) of the upper extremity on one side. Review of R48's Care Plan under the Care Plan tab in the EMR revealed on 10/12/21 identified a problem ADL/MOBILITY: ADL deficits with risk for fluctuation/decline with an intervention on 11/27/21 DON [put on] RIGHT PALM GUARD DAILY, UP TO 4 HOURS AS TOLERATED, OFF FOR MEALS AND BATHING. There was no documentation in R48's active Care Plan that R48 had severe left hand and finger contractures or any interventions to prevent further decline of the left hand. Review of R48's Interdisciplinary Form: GG0130 Self Care Rehabilitation Review-PT [Physical Therapy] GG0170 Mobility dated 01/19/21, 04/15/21, and 07/27/21 provided by the Rehabilitation Director (RD) and identified as quarterly therapy screens for R48, indicated that the documented information was for the Assessment period is days 1 through 3 of the SNF [skilled nursing facility] PPS[Prospective Payment System] Stay /Skilled Care Discharge End of SNF PPS stay is the last 3 days of the skilled stay, ending on LCD. The forms did not contain a range of motion assessment/measurement of R48's upper extremities, including her hands. Review of R48's Initial Contracture Assessment form dated 11/08/21 provided by the RD documented that R48 had Severe contractures in the right and left finger joints; identified as 25% of range by the form. Review of the R48's Occupational Therapy Discharge Summary provided by the RD dated for services from 11/12/21 to 12/10/21 revealed Reason for Referral: [R48] is a LTC resident who was referred to skilled occupational therapy for decline in hand contractures, positioning, and functional decline in bed immobility. Patients [sic] left hand has severe finger immobility with MP [middle phalange] moderate flexion Patient will benefit from skilled occupational therapy to address caregiver training in wc [wheelchair] sitting tolerance, splint management, PROM[passive range of motion] HEP [home exercise program], and safe w/c positioning, use of AE [adaptive equipment] in self feeding to prevent further decline and contractures with recommendations for R48 for Splint/Orthotic Recommendations: It is recommended the patient wear finger separators, a palmar guard and to further assess and order/fabricate on left wrist, on left hand and on left fingers for 4 hrs [hours] on / 4 hrs off in order to maintain joint integrity manage tone develop/establish wearing schedule and adapt/modify splint device. A comment for the use of left fingers separators and palmer guard documented that Splint was assessed and needed for right dominant hand, in between meals and off tor hygiene and documented on 11/12/21 and 11/24/21 that the intervention was N/A [not applicable]. No other documentation addresses the reason a left palm guard or other interventions were not utilized to address R48's severe left-hand contracture. Continued review of the discharge summary revealed the short-term goal was for R48 to achieve normal anatomical alignment of the left hand, left fingers and left wrist for 4 hours using finger separators and a palmar guard in order to reduce tone/promote mobility, in order to facilitate joint mobility, in order to prevent contractures and in order to maintain joint integrity. PROM was initiated with left hand on 11/23/21 focused on right hand splint to prevent disuse/contracture shoulder Caregiver training has not been initiated in PROM. on y [sic] with self feeding [sic] AE and splint management .PROM was provided to patients left hand during right splint tolerance time Patient reported she still uses her L [left] hand for eating intermittently Patient has MIP [Metacarpal interphalangeal (joint- finger bones)] flexion with PROM provided to open up finger hand and thumb webspace. Patient had good PROM tolerance. The discharge summary also revealed an entry dated 12/10/21 documented that Training caregivers was not completed d/t [due to] change in caregivers as well appropriate as patients [sic]inconsistent tolerance in shoulder ROM. Patient will safely wear a palmar guard on right hand for up to 4 hours w/minimal s/s of redness, swelling, discomfort or pain and progressed with a right splint tolerance of one hour on 11/24/21 to four hours upon discharge from occupational therapy on 12/10/21. There were no therapy recommendations for the severe left hand and finger contractures nor assessment of any improvement and/comment regarding the goals of therapy. During observations on 03/14/22 at 10:18 AM, 03/14/22 at 1:40 PM, 03/14/22 at 2:47 PM, 03/14/22 at 4:21 PM, 03/15/22 at 9:04 AM, 03/15/22 at 12:29 PM, and 03/16/22 at 7:16 AM, R48's left hand was tightly fisted with all fingers touching the palm; no splint device was on R48's severely left contracted hand. During an interview on 03/16/22 at 11:35 AM, the RD acknowledged that R48 was provided OT from 11/12-12/10/21 for therapy for hand contractures and although R48 was referred for contractures of the left hand, the palm guard worked better on the right. In addition, the RD acknowledged there were no therapy recommendations for the left hand and the contractures can place the resident at risk for discomfort and poor hygiene. During a concurrent interview and observation on 03/16/22 at 1:05 PM with the RD, R48 was in bed sitting in high fowlers with a tray table and a drink in front of her with a fisted left hand. The RD director asked the R48 to open her left hand and when the resident opened her left hand, the RD acknowledged that the resident's fingers were still severely contracted. During the observation, the RD asked the resident if she would wear a palm guard and the resident stated she wanted to be able to use one of her hands. During this interview, the RD did not explore further options for hand joint mobility with the resident nor formulate a resident centered plan for preventing further joint contractures of the left hand and fingers. During an interview on 03/16/22 at 02:03 PM, Licensed Practical Nurse (LPN) 1 who was the Unit Manager, acknowledged that the facility had not had restorative nursing program since the COVID-19 pandemic. In addition, LPN1 acknowledged that R48 has had hand and fingers contractures for quite a while that worsened, and nursing staff made the occupational therapy referral last year. LPN1 stated she knew the resident only had a palm guard for the right hand. During an interview on 03/16/22 at 5:20 PM, the RD acknowledged that the facility did not have a policy for contractures and stated that therapy staff follow scope of practice and Centers for Medicare and Medicaid Services (CMS) guidelines for the provision of therapy services.

Based on record review and interviews, the facility failed to ensure that a resident's clinical record was accurately documented related to pacemaker checks being done as ordered for 1 of 1 sampled residents reviewed with a pacemaker. Resident #100 was ordered to have pacemakers checks every 6 months. The last documented pacemaker check in the medical record was noted on 12/20/19. The findings included: The facility admitted Resident #100 on 1/19/15 with [DIAGNOSES REDACTED]. A review of the medical record on 8/25/20 at approximately 11:35 AM revealed physician's orders [REDACTED]. Further review of the medical record revealed Resident #100 last pacemaker check was documented as being done on 12/20/19 with the next scheduled appointment noted for 6/19/20. There was no documentation in the medical record that the resident was seen by the cardiologist on 6/19/20. An interview on 8/25/20 at 11:45 AM with Licensed Practical Nurse (LPN) #1 confirmed there was no documentation in the medical record to indicate resident had seen the cardiologist on 6/19/20. LPN #1 then referred the concerns to the Director of Nursing for review. An interview on 8/25/20 at 2:30 PM with Registered Nurse (RN) #1 revealed he/she called the cardiologist office today (8/25/20) and the cardiologist office indicated the resident had a cardiac remote done on 5/13/20 and an 8/13/20 follow up. There was no documentation in the resident's paper charting or electronic chart of the 5/13/20 and 8/13/20 cardiac remote monitoring being done. RN #1 confirmed the findings. An interview on 8/25/20 at 3:31 PM with the DON revealed Resident #100 cardiac pacemaker monitoring documentation was not placed in the resident's medical record until 8/25/20.

Based on interviews and record reviews, it was determined the facility failed to ensure one (Resident #5) of five sampled residents was free from abuse, when a Certified Nursing Assistant (CNA) physically assaulted the resident, resulting in an injury that required surgical intervention. The findings included: Resident #5 had [DIAGNOSES REDACTED]. A Baseline Care Plan, dated 03/08/19, indicated he had behavior problems of cursing and racially inappropriate name calling. Interventions for his behaviors included approaching his care with two employees and re-approaching him as needed. A Discharge Minimum Data Set (MDS), dated [DATE], indicated he was being discharged to an acute hospital. A staff assessment for mental status documented had some difficulty in new situations only. He had verbal behaviors directed at others one to three days of the last seven days. He had other behavioral symptoms not directed toward others one to three days of the last seven days. He required supervision from staff with transfers between surfaces and personal hygiene. He required limited assistance from staff with dressing. He required extensive assistance from staff with toilet use. He did not walk during the last seven days prior to the assessment. He was independent with eating and locomotion on and off the unit. He had received an antidepressant each day of the last seven days. He had received an antipsychotic six days of the last seven days. A Weekly Nursing Summary Body Audit, dated 03/14/19, indicated Resident #5 had no injuries to his face or eyes. A Resident Incident Report, dated 03/15/19 at 7:15 PM, indicated a reportable event involving Resident #5 had been reported by CNA #1 and CNA #2. The report indicated upon learning of the incident Licensed Practical Nurse (LPN) #1 entered the resident's room and found the resident sitting on his bed, his hand over his left eye, and blood coming from his eye and nose. The report indicated the resident had a 1.5 cm. (centimeter) laceration under his left eye. The report indicated the resident refused vital signs and neurological checks but did accept an ice pack. The report indicated the physician was notified at 7:18 PM, the Administrator (ADM) and Director of Nurses (DON) were notified at 7:20 PM, and the resident was taken to the hospital at 8:00 PM. A Mount Pleasant Police Department Report, dated 03/15/19, documented an officer was dispatched to the facility at 8:40 PM. On 03/18/20 at 10:08 AM, Nurse #1 was asked if she could recall this incident. She stated she did not usually work that floor, but that night she happened to be assigned there. She stated she had been traumatized by the event, and in her [AGE] years of working as a nurse had never seen anything like that. She stated she had been sitting at the desk that evening and CNA #2, the little one came to her and stated she did not want to work with Resident #5 because, He hits. Nurse #1 stated she instructed CNA #2 not to go into the resident's room alone, but to take CNA #1 with her when she went into the room. She stated a few minutes later both CNA #1 and CNA #2 returned reporting the resident had fallen. She stated she rushed to the room and found the resident sitting on the side of the bed. His left eye was really swollen, and there was blood everywhere. She stated she thought it had happened many minutes ago because his eye was blue and because of the amount of blood. On entering the room, Resident #5 said, That [***] hit me, referring to CNA #1. Nurse #1 stated she immediately told the two CNAs to go sit in the dayroom, and she called 911, the DON, ADON (Assistant Director of Nursing) and the ADM. On 03/18/20 at 11:10 AM, Detective #1 was interviewed by phone and asked the status of the case. He stated both CNAs had been charged with felonies. He stated after CNA #1 failed a polygraph test, she admitted to hitting the Resident #5. He stated the resident had surgery on his eye on 03/29/19. He stated the Resident had a fracture of his orbit which had resulted in [DIAGNOSES REDACTED] (an increase of pressure in a compartment of the body with increased pain, decreased blood flow and potential nerve damage). He stated, according to the surgeon, that injury was, almost never caused by falling, but is caused by direct force to the eye. On 03/18/20 at 2:15 PM, the ADM was asked when he first received knowledge the courts were going to take action against CNA #1 and CNA #2. He stated, on 03/27/19 at 4:15 PM, the Detective working the case informed him CNA #1 had confessed to hitting the resident in the face. He stated at that time he filed an Addendum to the 5-Day Follow Up Report that had been submitted on 03/22/19 with this update. He stated the Detective had told him that maybe the next day the CNAs were meeting the Detective in Bond Court instead of being arrested publicly. He stated his understanding of the reporting process is that DHEC (Department of Health and Environmental Control) would report the CNAs to the Nurse Aide Registry. He stated in the addendum he requested to be informed if he needed to take further action regarding contacting the Nurse Aide Registry. On 03/18/20 at 2:16 PM, it was confirmed with DHEC that the ADM followed the correct reporting process, and, as DHEC had licensing authority and a contract with the Nurse Aide Registry, DHEC did the reporting to the Nurse Aide Registry. The DON provided documentation that both CNA #1 and CNA #2 had cleared all reference, background, and certification checks prior to being hired at the facility. She provided documentation that both CNA #1 and CNA #2 had completed abuse training and signed a facility code of conduct and compliance policy. On 03/18/20 at 1:38 PM, the DON stated an investigation had been immediately started including interviewing staff members. Those documents were provided, and there were no concerns. The DON was asked what facility-wide measures had been implemented after the allegation of abuse was known. She stated body audits of residents were immediately started and were completed on 100% of the residents. She stated body audits were first completed on the unit Resident #5 lived on, the Green Wing. She stated, once the facility learned the allegation had been substantiated, body audits were completed on all the remaining residents in the facility. She provided this documentation. She stated residents in the entire building were interviewed. Interviewable residents were interviewed by the social worker or nursing. She stated families of non-interviewable residents were interviewed, sometimes by phone, by the social worker. She provided this documentation. Staff in-services were immediately started. She stated 100% of staff were re-trained on abuse, and no one could work until they had been trained. She provided documentation of this staff training, including dated and timed in-service attendance, along with in-service content and the instructor. There were no concerns identified with the documentation. She stated the Performance Improvement Project (PIP) was started on 03/16/19, and by 04/11/19, they were in compliance. Monitoring and auditing of the PIPs continued for one month. Documentation of the monitoring was provided, and there were no concerns. The DON provided documentation ongoing monitoring had occurred on 03/21/19, 03/27/19, 04/04/19 and 04/11/19 and had been completed. On 03/18/20 at 10:30 AM, interviews were conducted with one Registered Nurse (RN), two LPNs, three CNAs, and the Activities Director. All staff members interviewed were familiar with the abuse protocol. All staff members confirmed ongoing abuse education. There were no concerns. A facility policy titled, Abuse Prohibition/Investigative Policy, documented: .The facility will prohibit abuse .Abuse, is the willful infliction of injury .Anyone who witnesses an incident of suspected abuse .is to tell the abuser to stop immediately and to report it to the nursing supervisor immediately . Upon learning of the incident, the facility immediately put measures in place to keep residents safe, and conducted a thorough investigation of the incident. The facility was in compliance at the time of the complaint survey. Therefore, this deficiency was cited as Past Non-Compliance. The non-compliance began 03/15/19, and the facility alleged compliance on 04/11/19. WRITTEN PLAN OF ACTION: The facility provided documentation of an appropriate plan of correction. A facility Performance Improvement Plan, dated 03/16/19, documented: Topic/Opportunity: Potential staff to resident abuse has been reported. Current Target: All residents will be free from abuse. Action Plan: - Staff will be educated on abuse prevention and reporting including recognizing when signs and symptoms of stress builds and how to respond to potential aggression. Person Responsible: ADM, DON. Start 03/16/19. - All residents will have a body audit conducted to ensure no new areas of concerns are present. Person Responsible: DON, ADON, Licensed Nurses. Complete 03/24/19. - All residents will be interviewed to determine if mistreatment has ever occurred or if they feel scared or afraid. Person responsible: DON, ADON, Director of Social Services. Green Wing complete 03/18/19. Blue Wing complete 04/1/19. Gold Wing complete 04/1/19. - Five residents per week will be interviewed to determine if they feel safe, if mistreatment has occurred, and if they feel safe. Audit will continue for four weeks to ensure continued compliance. Person responsible: DON, ADON, Director of Social Services. Complete 04/11/19. - Information will be submitted to QAPI (Quality Assurance and Performance Improvement) Committee to determine compliance. Person responsible: DON, ADON. QAPI determines compliance 04/11/19. . (handwritten at the bottom of the document) substantiated on 03/27/19.

Based on observation, interview, and food safety preparation standards, the facility failed to follow proper sanitization practices to prevent the outbreak of food borne illness in 1 of 1 kitchen. The dishwasher, 3 compartment sink, and red buckets had no sanitizer. The temperature log and measurement of sanitizer was incomplete. The findings included: During the initial tour of the kitchen on 02/25/19 at approximately 11:15 AM, the following observations were made and verified by the Certified Dietary Manager (CDM): (1) The red buckets were foamy. No sanitizer was used; only soap and water. (2) The 3-compartment sink registered no sanitizer when tested . (3) The dishwasher had no sanitizer when tested . Air was observed in the sanitizer line. The CDM immediately instructed staff to stop all meal preparation for lunch and instructed the staff to use disposable dishes and utensils. The Maintenance Director was contacted to look at the dishwasher. On 02/25/19 at 11:51 AM, the Maintenance Director cycled the dishwasher to remove the air in the line after adjusting the hose in the sanitation bucket. On 02/25/19 at 01:33 PM during an interview, the Maintenance Director stated, It took about 20 cycles to get the air out of the line. On 02/25/19 at 01:10 PM, review of the dishwasher log revealed testing for temperature and sanitizer was completed every morning for the month of February; however, the afternoon and evening documentation was missing from (MONTH) 16th-24th. During an interview on 02/25/19 at approximately 01:15 PM, the CDM stated, They should have been checking the sanitizer levels for breakfast, lunch, and dinner. The buckets and 3-compartment sink should have contained sanitizer. We are scheduling an inservice for all dietary staff. No log for testing the sanitizer level of 3-compartment sink was provided. The temperature log for the water was provided. On 02/25/19 04:02 PM, observation of the dishwasher and 3-compartment sink showed the sanitizer within acceptable limits tested by the CDM.

Based on observations, record reviews, interviews and USP (United States Pharmacopoeia) standards, the facility failed to remove expired medications from active storage in 1 of 6 medication carts and 1 of 3 treatment carts. The findings included: On 2/25/19 at approximately 1:18 PM, inspection of the Hall 100 Medication Cart 1 (Rooms 107-114) revealed an opened vial of [MEDICATION NAME] Injection 50 mg (milligram)/ml (milliliter), with an expiration date of 1/19 (1/31/19) belonging to Resident #40. On 2/25/19 at approximately 1:20 PM, this finding was verified by LPN (Licensed Practical Nurse) # 1. On 2/26/19 at approximately 10:32 AM, inspection of the Hall 200 Treatment Cart revealed one opened 250 ml container of USP Normal Saline, 0.9 % (percent) Sodium Chloride (1/3 full) by Nurse Assist, Lot 37, labeled by the manufacturer No antimicrobial or other substance added and Contents Sterile unless container is opened or damaged. One opened 250 ml container of Sterile Sodium Chloride 0.9% for Irrigation USP (1/4 full) by Aqua Care Lot 8, labeled by the manufacturer No antimicrobial or other substance has been added. On 2/26/19 at approximately 10:37 AM these findings were confirmed by LPN # 2. The USP standard for 0.9% Sodium Chloride for Irrigation is to Discard unused portion.

Based on observation, interview, and review of the facility's policies and procedures the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. The food trays, plates, bowls, cups, pitchers, and other food preparation containers were not clean and/or set to drain properly. Food items were not labeled and dated appropriately. Expired foods were not discarded. The dishwasher sanitation level did not register and there was no record of levels measured for 2 meals prior to the level check. The findings included: During the initial tour of the kitchen beginning at approximately 11:00 AM on [DATE], the following were observed with and verified by the Certified Dietary Manager (CDM): (1) At least 5 trays of wet cups were not inverted so they could drain. (2) Trays were stacked wet. (3) Clean dishes, including bowls, 4 plates, and 11 divided plates, were observed stacked with water and food particles on them. (4) Eight (8) wet pitchers were stored upside down on wire drying racks that had Lexan liners on them causing water to build up underneath. (5) The walk-in refrigerator contained several outdated and/or unlabeled food items and items that were improperly stored. These items included: sliced meat dated [DATE], an open bag of cheese slices dated [DATE], Swiss cheese dated [DATE], chopped bell peppers dated [DATE], an unidentified type of shredded cheese with no label or date, an unidentified type of cookie dough with no label or date, and a bag of Pimentos which had been removed from their original container dated [DATE]. (6) The reach-in refrigerator had a bag of tuna salad (as identified by the CDM) labeled as apples and a bag of mixed fruit labeled as apples with the date [DATE]. Also during the initial tour of the kitchen, while food was being prepared and placed on the steam table, a dietary staff member was observed in the kitchen without appropriate hair covering. A staff member also walked through the kitchen without her/his hair covered. During observation of the dish machine with the RD on [DATE] at 03:34 PM, 2 staff members were again observed in the kitchen without hair covered. Most of the dishes used for the noon meal had already been processed through the dish machine when the sanitation level of the low temp dish machine was checked with the RD. It did not register. Dietary Aide #1 stated the chemicals had been changed out a couple of days ago. Review of the work order noted this had been done the previous day. The log was requested for review to determine how long the machine had not been sanitizing dishes appropriately. The RD verified there was no record of sanitation levels having been measured for the breakfast and noon meals that day.

Based on record review, interview, and review of the facility policy entitled Transfer or Discharge, Emergency (2016), the facility failed to record the events surrounding a resident fall and transfer to the hospital for treatment of [REDACTED]. According to hospital records, Resident #530 was admitted following a fall which was not recorded in the facility's medical records. The findings included: The facility admitted Resident #530 with [DIAGNOSES REDACTED]. Record review on 2-15-18 at 2:43 PM revealed 9-18-17 Physician's Orders to transport the resident to the hospital. Review of Nurse's Notes at 2:25 PM on 2-15-18 revealed no entry regarding the reason for transport to the emergency room for evaluation. No transfer form was located in the record. Further review revealed a hospital History and Physical that stated Resident #530 had been found on the floor next to her (his) bed. A hematoma was noted on her (his) forehead. The patient appeared to be agitated and was groaning. During an interview at 4:45 PM on 2-15-18, the Director of Nursing (DON) reviewed the record and verified the Physician's Telephone Order to transfer the resident. S/he stated that the order should have included the reason for transfer. The DON could find no record of the fall in the Nurses Notes. S/he stated no incident/accident report or transfer record had been completed and there was no entry on the 24 Hour (shift) Report. The facility policy provided by the DON on 2-16-18 at 10:27 AM and titled Transfer or Discharge, Emergency states: 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: .b. Notify the receiving facility that the transfer is being made; .d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member; f. Assist in obtaining transportation .

Based on record review and interview, the facility failed to notify the physician of significant weight loss for 1 of 9 residents reviewed for nutrition. The findings included: Resident #26 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 2/15/18 revealed that Resident #26 had an unidentified significant weight loss of 6.9% from August 2017 to October and 10.34% from August 2017 to January 2018. Resident #26's weight on 8/7/17 was 174.8lbs, on 9/4/17 was 163.8lbs and on 1/1/18 was 153lbs. Further review of Resident's record revealed that the physician and responsible party were not notified until 12/8/17 of Resident's continued weight loss but an intervention was not in place until 12/12/17. Further review also indicated that Resident #26 was care planned for mechanically altered food texture and a therapeutic diet, but not for weight loss or potential for weight loss. On 2/15/18 at 3PM, the Director of Nursing (DON) stated the care plan is not updated, but I will happily update it now for you. A revised care plan was submitted the following day. In an interview with LPN #1 on 2/15/18 at 330PM, LPN stated that the weight of 174.8lbs that was entered in the computer for 8/7/17 was incorrect, which made the written weight listed in the hard chart also incorrect. A note on the Vital Signs and Weight Record for 8/7/17 read weight in [MEDICAL CONDITION] in error. Additionally, a dietary note written by the Certified Dietary Manager (CDM) on 8/18/17 stated, Nurses re-weighed resident and still in WBW range. CBW 174.8 on 8/7-previous weight of 164.8 was an error. No weight loss indicated. Continue P(NAME). The Registered Dietitian (RD) confirmed that the dietary department did not identify significant weight loss from 8/7/17-9/4/17.

Based on record review, interviews and review of a form titled, Risk of Elopement/Wandering Review, the facility failed to ensure residents with the potential for elopement/wandering were completely and accurately assessed and identified before applying an Accu-Tech bracelet for monitoring. Residents #125, #153, #133, #110, #140, #108 were 6 of 6 residents sampled for accuracy of elopement assessments. The findings included: The facility admitted Resident #153 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 2:21 PM of Resident #153's medical record revealed a form titled, Risk of Elopement/Wandering Review, dated [DATE], [DATE] and ,[DATE]. All revealed Resident #153 is not at risk for elopement/wandering at this time. The assessment was not complete and accurate. Resident #153 exited the facility unsupervised on [DATE] even though he/she had an Accu-Tech bracelet applied. The facility admitted Resident #140 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 4:44 PM of Resident #140's medical record revealed a form titled, Risk of Elopement/Wandering Review, dated [DATE] and states, Resident is not at risk for elopement/wandering at this time. Resident #140 had an Accu-Tech bracelet on his/her lower extremity. The facility admitted Resident #133 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 12:11 PM of Resident #133's medical record revealed a form titled, Risk of Elopement/Wandering Review, dated [DATE]. The form stated Resident #133 is not at risk for elopement/wandering at this time. The assessment was not completed and accurate. Resident #133 had an Accu-Tech bracelet on his/her lower extremity. The facility admitted Resident #125 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 2:49 PM of Resident #125's medical record revealed a form titled, Risk of Elopement/Wandering Review. dated [DATE], [DATE], [DATE] and [DATE]. The summary of review revealed Resident # 125 is not at risk for elopement/wandering at this time. The summary also read, uses walker with ambulation, resident is confused and looking for deceased spouse and her car, etc. He/she is easily redirected. Will ask about going home at times. The assessment was not complete and accurate. Resident #125 was observed to have an Accu-Tech bracelet on his/her lower extremity. The facility admitted Resident #110 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 3:32 PM of Resident #110's medical record revealed a form titled, Risk of Elopement/Wandering Review, dated [DATE], [DATE] and [DATE] and each states, Resident is not at risk for elopement/wandering at this time. The assessment was not completed and accurate. Resident #110 had an Accu-Tech bracelet on his/her lower extremity. The facility admitted Resident #108 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 6:52 PM of Resident #108's medical record revealed a form titled, Risk of Elopement/Wandering Review, dated [DATE] and [DATE] and states, Resident is not at risk for elopement/wandering at this time. Resident #108 had an Accu-Tech bracelet on his/her lower extremity. During an interview on [DATE] at approximately 8:45 AM the Director of Nursing confirmed the Elopement/Wandering assessments were not complete and accurate for Residents #153, #125, #133, #110, #140, and #108. The facility provided an Allegation of Compliance to the survey team on [DATE]. The action plan included the following: I. Corrective Action taken to remove the Immediate Jeopardy; On [DATE] at approximately 2:45pm, the survey team notified the facility that an Immediate Jeopardy situation was present in regards to prior Elopement of resident on [DATE]. 1) Corrective Action was accomplished for the resident to have been affected by the deficient practice. Resident was returned to facility and was immediately placed on every 15 minute checks for safety and location. The wander guard was checked for placement and function on [DATE]. A body audit and assessment was completed with no signs of injury noted. Vital signs were stable on [DATE]. An Elopement Risk Assessment was completed on the resident on [DATE]. Code Silver walking rounds were initiated; all residents accounted for on each unit. The physician and legal representative were notified of the incident. An order was received from the Medical Director to send the resident to (the hospital) for psychiatric evaluation and treatment on [DATE]. The resident was discharged on [DATE]. 2. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur: Established time line and analysis of root cause. A 100% audit of all wander guards for placement and function was completed on [DATE]. Door code was changed. All staff were in-serviced by the Director of Nursing and Assistant Director of Nursing on the new code with instructions not to divulge that code to family, visitors or vendors; completed [DATE]. Code Silver Drills will be completed. Door signs posted on Main Entrance and Side Entrance doors warning visitors not to allow any person out of the facility without notification to facility staff on [DATE]. All nursing staff were in-serviced by the Assistant Director of Nursing beginning on [DATE] on policy for rounding and location of their residents, all nursing staff were educated by [DATE]. Maintenance continues to check all doors for wander guard function once per week. Resident wander guards will continue to be checked daily for placement and function. All findings were presented to the QA Committee for review and recommendation for continued intervention or amendment of plan on [DATE]. All ambulatory residents and any resident in a wheelchair who can self-propel, excluding those residents residing in our Secured Unit will have an elopement risk assessment completed by [DATE]. Any resident identified as at risk for elopement or wandering will have their care plan updated as appropriate by [DATE]. All new employees, including prn staff will be in-serviced/educated by Director of Nursing /Assistant Director of Nursing during orientation and prior to resident assignment on policy regarding rounding and location of their residents and door lock codes will not be divulged to visitors/family or vendors. Licensed nursing staff will complete an Elopement risk assessment for each residents upon admission, quarterly and at significant change. The Assistant Director of Nursing and/or Director of Nursing will in-service all Licensed Nurses on accurate completion of Elopement Risk Assessments, all new licensed nurses will be in-serviced during orientation and prior to resident assignment. Allegation of compliance date- [DATE]. Observations, record reviews, and interviews revealed the AOC submitted by the facility on [DATE] had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. The Administrator was informed of this on [DATE]. The Immediate Jeopardy at F272 was removed with the Scope and Severity of the citation lowered to a D.

Based on record review and interview the facility failed to ensure services were provided in accordance with the written Comprehensive Plan of Care for 1 of 6 residents reviewed for elopement and wandering. Resident #153 exited the facility unsupervised after demonstrating agitation and restlessness. The findings included: The facility admitted Resident #153 with [DIAGNOSES REDACTED]. Review on 9/1/2015 at approximately 2:21 PM of Resident #153's medical record revealed a Comprehensive Plan of Care with a problem date of 7/6/2015. The problem stated Resident #153 wanders at times. The goal read, Risk for elopement will be minimized daily through next review. An intervention included an Accu-Tech Bracelet. Further review of the Comprehensive Plan of Care for Resident #153 revealed another intervention which included, Provide .cues, re-direction and or supervision as needed. Resident #153 was noted to be restless and agitated on 7/11/2015 and exited from the nursing facility on 7/11/2015 unsupervised. Resident #153 was last observed in the facility at 6:15 PM and was out of the facility for approximately 45 minutes, when the police called the facility to inform them the resident had been picked up by them and they were taking the resident to the emergency room to be assessed. When notified by the police the facility staff was unaware the resident had eloped. An interview on 9/3/2015 at approximately 9:00 AM with the Director of Nursing confirmed that due to lack of supervision for Resident #153 no one noticed that Resident #153 had eloped. The facility provided an Allegation of Compliance to the survey team on 9/3/2015. The action plan included the following: I. Corrective Action taken to remove the Immediate Jeopardy; On 9/2/2015 at approximately 2:45pm, the survey team notified the facility that an Immediate Jeopardy situation was present in regards to prior Elopement of resident on 7/11/2015. 1) Corrective Action was accomplished for the resident to have been affected by the deficient practice. Resident was returned to facility and was immediately placed on every 15 minute checks for safety and location. The wander guard was checked for placement and function on 7/11/2015. A body audit and assessment was completed with no signs of injury noted. Vital signs were stable on 7/11/2015. An Elopement Risk Assessment was completed on the resident on 7/11/2015. Code Silver walking rounds were initiated; all residents accounted for on each unit. The physician and legal representative were notified of the incident. An order was received from the Medical Director to send the resident to (the hospital) for psychiatric evaluation and treatment on 7/11/2015. The resident was discharged on [DATE]. 2. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur: Established time line and analysis of root cause. A 100% audit of all wander guards for placement and function was completed on 7/11/2014. Door code was changed. All staff were in-serviced by the Director of Nursing and Assistant Director of Nursing on the new code with instructions not to divulge that code to family, visitors or vendors; completed 7/14/2015. Code Silver Drills will be completed. Door signs posted on Main Entrance and Side Entrance doors warning visitors not to allow any person out of the facility without notification to facility staff on 7/11/2014. All nursing staff were in-serviced by the Assistant Director of Nursing beginning on 7/14/2015 on policy for rounding and location of their residents, all nursing staff were educated by 7/24/2015. Maintenance continues to check all doors for wander guard function once per week. Resident wander guards will continue to be checked daily for placement and function. All findings were presented to the QA Committee for review and recommendation for continued intervention or amendment of plan on 7/17/2015. All ambulatory residents and any resident in a wheelchair who can self-propel, excluding those residents residing in our Secured Unit will have an elopement risk assessment completed by 9/3/2015. Any resident identified as at risk for elopement or wandering will have their care plan updated as appropriate by 9/3/2015. All new employees, including prn staff will be in-serviced/educated by Director of Nursing /Assistant Director of Nursing during orientation and prior to resident assignment on policy regarding rounding and location of their residents and door lock codes will not be divulged to visitors/family or vendors. Licensed nursing staff will complete an Elopement risk assessment for each residents upon admission, quarterly and at significant change. The Assistant Director of Nursing and/or Director of Nursing will in-service all Licensed Nurses on accurate completion of Elopement Risk Assessments, all new licensed nurses will be in-serviced during orientation and prior to resident assignment. Allegation of compliance date- 9/3/2015. Observations, record reviews, and interviews revealed the AOC submitted by the facility on 9?3/2015 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. The Administrator was informed of this on 9/3/15. The Immediate Jeopardy at F282 was removed with the Scope and Severity of the citation lowered to a D.

Based on record review and interviews and review of a form titled, Resident Incident Report, the facility failed to provide interventions and supervision to promote safety for residents identified as having the potential for elopement/wandering. Resident #153, 1 of 6 residents sampled for behaviors with elopement/wandering tendencies, exited the facility unsupervised after demonstrating agitation and restlessness. The facility was unaware of the resident's absence until notified by local authorities. The facility further failed to ensure Lancet's were disposed of properly and safely during medication pass for 1 of 1 finger stick blood sugar observed during med pass. The findings included: The facility admitted Resident #153 with [DIAGNOSES REDACTED]. A brief interview of mental status (BIMS) on 7/3/2015 indicated a score of 3 out of 15. Review of Resident #153's medical record on 9/1/2015 at approximately 2:21 PM revealed a Nurses Note dated 7/10/2015 at 7:00 PM noting, Out of bed, propelling self throughout the unit, very agitated this shift, refused all bedtime medications stated, I don't want them. Responsible party notified, left message, no call back. Review of the nurses notes dated 7/11/2015 at 2:30 PM states, Activities of daily living completed by resident with set up and minimal assistance. Feeds himself/herself after set up. Propels himself/herself throughout the facility in wheel chair He/she is incontinent at times and wears a brief for protection. He/she has been very agitated with staff in regards to taking medications. Has refused to take meds and to drink Medpass. Denies pain and no signs or symptoms of distress noted. Will continue to encourage him/her to take meds. Further review on 9/1/2015 at approximately 2:21 PM revealed yet another nurses note dated 7/11/2015 (no time of note written) and states, Resident has been very restless and angry today. He/she has refused to take meds at 1:00 PM. Police called and stated he/she was found out on a heavily traveled commercial intersection. He/she was taken to (hospital) Medical Director and the Director of Nurses (DON) notified. The next nurses note dated 7/11/2015 at 8:00 PM states, Returned to facility. Resident is sleeping at present. Head to toe skin assessment done, reveals no current skin issues. Resident is easily aroused. Follows verbal commands. Resident drifts back off to sleep. Instructed by DON to transfer resident to the (hospital) emergency room for evaluation. Spoke with (hospital) nurse re: as to why this resident was being transported to (hospital ER), due to his wandering off the unit tonight and refusal of medications last night and today. The ambulance service was notified for pick up. A note at 12:30 AM on 7/12/15 states, ambulance here, resident transferred via stretcher to hospital emergency room . Responsible party notified. DON made aware of transfer. Review of a form titled, Resident Incident Report, on 9/1/2015 at approximately 2:30 PM reveals, Resident #153 eloped from the nursing home on 7/11/2015. He/she had no injuries. The report indicated that the medical director and the attorney for the facility were notified. No mention was made that the family or responsible party was notified by the facility that the resident had eloped. The narrative of the incident states, At 6:55 PM the police called, resident was picked up at Anna Knapp and Highway 17 - took resident to ECMC to be checked out. Patient last seen at the facility at 6:15 PM. He/she had finished his/her dinner. Review of Resident #153's Medication Administration Record (MAR) on 9/1/2015 at approximately 2:45 PM revealed he/she was on a medication regimen of Depakote Extended Release 500 mg (milligrams) 2 tablets at bedtime for a [DIAGNOSES REDACTED]. Cogentin 0.5mg 2 times daily for muscle stiffness. He/she was also on Niacin 250 mg at bedtime for a [DIAGNOSES REDACTED]. Other medications included Zantac 300 mg at bedtime for reflux, Terazosin 1 mg at bedtime for Benign Prostatic Hypertrophy , and Vitamin B-1 and Vitamin E each AM. Based on review of the MAR for Resident #153 the missed doses of medications were as follows: 7/10/2015 - Aspirin 81 mg at 8:00 PM, Cogentin 0.5 mg at 5:00 PM, Depakote 1000 mg at 8:00 PM, Niacin 250 mg at bedtime, Seroquel 400 mg at 8:00 PM, Zantac 300 mg at bedtime, Terazosin 1 mg at bedtime and 4:00 PM and the 8:00 PM dose of Medpass. The 7/11/2015 medications missed were as follows: Norvasc 5 mg the 9:00 AM dose, Aspirin 81 mg the 8:00 PM dose, Cogentin 0.5 mg the 9:00 AM dose, a MultiVitamin at 9:00 AM, Niacin 250 mg at 9:00 PM, Nicotine 14 mg/24 hour patch topical at 9:00 AM, Seroquel 200 mg the 8:00 AM dose and the 12:00 Noon dose. Seroquel 400 mg the 8:00 PM dose. Terazosin 1 mg the 8:00 PM dose and Vitamin B-1 and Vitamin E the 8:00 AM doses. The 8:00 PM and the 9:00 PM doses were not given on 7/11/2015 due to the resident just returning from the hospital after the elopement. An interview on 9/1/2015 at approximately 4:00 PM the DON revealed, the police picked him/her up due to the unsteady gait. The DON stated this resident was sent to the VA emergency room due to refusal of medications and the elopement episode. During an interview on 9/2/2015 at approximately 9:15 AM with Certified Nursing Assistant (CNA) #1, he/she stated, this resident could walk. He/she was flippy. CNA #1 stated this meant that sometimes he/she would be ok one minute and the next minute he/she would flip out, but went on to say that he/she did not work with Resident #153. In an interview with CNA #2 on 9/2/2015 at approximately 9:25 AM, he/she stated, He/she was very nice. Never had any aggressive or combative behavior toward me. CNA #2 stated, Never heard this resident mention going anywhere. He/she was not an exit seeker. He/she would go outside sometimes but would knock on the door and we would let him/her back in. I was not here when he/she walked out but I was very surprised to hear that he/she did that. He/she did love to eat. Very pleasant and nice person. An interview with CNA #3 on 9/2/2015 at approximately 9:30 AM he/she stated, I never saw him/her walking. I did not know he/she could walk. He/she was not aggressive or combative, very pleasant. He/she never attempted to leave the building, not an exit seeker. During an interview on 9/2/2015 with CNA #3, he/she stated, This resident was a very nice person. I did not have any trouble out of him/her. It is my understanding he/she walked out behind a family member and another resident. During an interview on 9/2/2015 at approximately 9:40 AM with Registered Nurse (RN) #2, this surveyor asked, What is the process you follow if a resident refuses medications? RN #2 stated, We should go back and try again to see if the resident will take the medications. We document the behaviors, and the reason why the medications were not given in the medical record and on the nurses notes. We would call the physician if the behaviors are not alleviated and report if the resident has refused any medications. During an interview on 9/2/2015 at approximately 9:45 AM with Licensed Practical Nurse (LPN) #2 he/she stated, I think he/she eloped in the 7p to 7a shift. He/she would refuse care sometimes. He/she never refused to take medications from me. It was probably due to his diagnoses. He/she did not adhere to instructions well. He/she would try to get up unassisted, but I never knew he/she could walk. He/she never mentioned leaving or wanting to go anywhere. An interview on 9/2/2015 at approximately 3:20 PM with the Social Services Director revealed, I guess he/she was sent out for an evaluation due to his/her diagnoses. No documentation could be found in the social service section of the medical record in regards to the elopement and the discharge. No mention of a bed hold or that that the resident would be returning could be found in the medical record for Resident #153. On 9/1/15 at 5:03 pm, during an observation of med pass on the Green Wing, RN #1 checked Resident #101 ' s blood sugar by drawing blood with a lancet. Following the FSBS procedure, RN #1 placed the lancet into Resident #101 ' s trash can. RN#1 was asked if the lancet needed to be put in a sharps container instead of the trash can. RN #1 stated, Yes, I forgot. On 9/1/15 at 8: 00 PM, during an interview with the Director of Nursing (DON), s/he was asked what her/his expectation for disposal of a lancet after a FSBS. The DON stated, It should be placed in the sharps container on the cart. On 9/2/15 at 1:00 PM, a review of the facility policy entitled 5.5 SYRINGE AND NEEDLE DISPOSAL revealed under procedure 2.) Immediately after use, syringes and needles are placed into puncture resistant, one-way containers specifically designed for that purpose. Syringes and needles are never deliberately bent or broken. The facility provided an Allegation of Compliance to the survey team on 9/3/2015. The action plan included the following: I. Corrective Action taken to remove the Immediate Jeopardy; On 9/2/2015 at approximately 2:45pm, the survey team notified the facility that an Immediate Jeopardy situation was present in regards to prior Elopement of resident on 7/11/2015. 1) Corrective Action was accomplished for the resident to have been affected by the deficient practice. Resident was returned to facility and was immediately placed on every 15 minute checks for safety and location. The wander guard was checked for placement and function on 7/11/2015. A body audit and assessment was completed with no signs of injury noted. Vital signs were stable on 7/11/2015. An Elopement Risk Assessment was completed on the resident on 7/11/2015. Code Silver walking rounds were initiated; all residents accounted for on each unit. The physician and legal representative were notified of the incident. An order was received from the Medical Director to send the resident to (the hospital) for psychiatric evaluation and treatment on 7/11/2015. The resident was discharged on [DATE]. 2. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur: Established time line and analysis of root cause. A 100% audit of all wander guards for placement and function was completed on 7/11/2014. Door code was changed. All staff were in-serviced by the Director of Nursing and Assistant Director of Nursing on the new code with instructions not to divulge that code to family, visitors or vendors; completed 7/14/2015. Code Silver Drills will be completed. Door signs posted on Main Entrance and Side Entrance doors warning visitors not to allow any person out of the facility without notification to facility staff on 7/11/2014. All nursing staff were in-serviced by the Assistant Director of Nursing beginning on 7/14/2015 on policy for rounding and location of their residents, all nursing staff were educated by 7/24/2015. Maintenance continues to check all doors for wander guard function once per week. Resident wander guards will continue to be checked daily for placement and function. All findings were presented to the QA Committee for review and recommendation for continued intervention or amendment of plan on 7/17/2015. All ambulatory residents and any resident in a wheelchair who can self-propel, excluding those residents residing in our Secured Unit will have an elopement risk assessment completed by 9/3/2015. Any resident identified as at risk for elopement or wandering will have their care plan updated as appropriate by 9/3/2015. All new employees, including prn staff will be in-serviced/educated by Director of Nursing /Assistant Director of Nursing during orientation and prior to resident assignment on policy regarding rounding and location of their residents and door lock codes will not be divulged to visitors/family or vendors. Licensed nursing staff will complete an Elopement risk assessment for each residents upon admission, quarterly and at significant change. The Assistant Director of Nursing and/or Director of Nursing will in-service all Licensed Nurses on accurate completion of Elopement Risk Assessments, all new licensed nurses will be in-serviced during orientation and prior to resident assignment. Allegation of compliance date- 9/3/2015. Observations, record reviews, and interviews revealed the AOC submitted by the facility on 9?3/2015 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. The Administrator was informed of this on 9/3/15. The Immediate Jeopardy at F323 was removed with the Scope and Severity of the citation lowered to a D.

Based on record reviews, review of facility files, and interviews, the facility failed to show that is was administered in a manner to ensure the safety of each and every resident by providing the appropriate supervision for 1 of 6 residents reviewed for behaviors. Resident # 153 eloped from the facility on 7/11/2015. He/she was not missed until the police called to say that they had picked up the resident who was found wandering down the street and had been out of the facility for approximately 45 minutes. Cross refers to F-201 - Transfer and Discharge. The facility failed to ensure Resident #153 was discharged in an appropriate manner. Resident #153 was discharged on [DATE] due to elopement and refusing few medications. Resident #153 was sent out to Veterans Hospital for evaluation and not allowed to return. Cross refers to F-272 Comprehensive Assessments - The facility failed to ensure residents residing in the facility had complete and accurate assessments related to elopement and wandering. Cross refers to F-323 Accidents, Hazards/Supervision. The facility failed to ensure Resident #153 was sufficiently monitored and supervised. The facility failed to completely and accurately assess other residents residing in the facility with the potential for elopement and wandering. Any system in place at the facility failed to ensure cognitively impaired residents did not exit the facility unsupervised without the facility having immediate awareness of the resident's absence. The facility provided an Allegation of Compliance to the survey team on 9/3/2015. The action plan included the following: I. Corrective Action taken to remove the Immediate Jeopardy; On 9/2/2015 at approximately 2:45pm, the survey team notified the facility that an Immediate Jeopardy situation was present in regards to prior Elopement of resident on 7/11/2015. 1) Corrective Action was accomplished for the resident to have been affected by the deficient practice. Resident was returned to facility and was immediately placed on every 15 minute checks for safety and location. The wander guard was checked for placement and function on 7/11/2015. A body audit and assessment was completed with no signs of injury noted. Vital signs were stable on 7/11/2015. An Elopement Risk Assessment was completed on the resident on 7/11/2015. Code Silver walking rounds were initiated; all residents accounted for on each unit. The physician and legal representative were notified of the incident. An order was received from the Medical Director to send the resident to (the hospital) for psychiatric evaluation and treatment on 7/11/2015. The resident was discharged on [DATE]. 2. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur: Established time line and analysis of root cause. A 100% audit of all wander guards for placement and function was completed on 7/11/2014. Door code was changed. All staff were in-serviced by the Director of Nursing and Assistant Director of Nursing on the new code with instructions not to divulge that code to family, visitors or vendors; completed 7/14/2015. Code Silver Drills will be completed. Door signs posted on Main Entrance and Side Entrance doors warning visitors not to allow any person out of the facility without notification to facility staff on 7/11/2014. All nursing staff were in-serviced by the Assistant Director of Nursing beginning on 7/14/2015 on policy for rounding and location of their residents, all nursing staff were educated by 7/24/2015. Maintenance continues to check all doors for wander guard function once per week. Resident wander guards will continue to be checked daily for placement and function. All findings were presented to the QA Committee for review and recommendation for continued intervention or amendment of plan on 7/17/2015. All ambulatory residents and any resident in a wheelchair who can self-propel, excluding those residents residing in our Secured Unit will have an elopement risk assessment completed by 9/3/2015. Any resident identified as at risk for elopement or wandering will have their care plan updated as appropriate by 9/3/2015. All new employees, including prn staff will be in-serviced/educated by Director of Nursing /Assistant Director of Nursing during orientation and prior to resident assignment on policy regarding rounding and location of their residents and door lock codes will not be divulged to visitors/family or vendors. Licensed nursing staff will complete an Elopement risk assessment for each residents upon admission, quarterly and at significant change. The Assistant Director of Nursing and/or Director of Nursing will in-service all Licensed Nurses on accurate completion of Elopement Risk Assessments, all new licensed nurses will be in-serviced during orientation and prior to resident assignment. Allegation of compliance date- 9/3/2015. Observations, record reviews, and interviews revealed the AOC submitted by the facility on 9?3/2015 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. The Administrator was informed of this on 9/3/15. The Immediate Jeopardy at F490 was removed with the Scope and Severity of the citation lowered to a D.

On the days of the survey based on observations, record review and interview, Substandard Quality of Care and/or Immediate Jeopardy was identified on [DATE] at 11:45 AM, related to the failure of the facility to protect Resident #1 from alleged humiliation and harassment. Resident #1 had a hidden camera placed in his/her room on [DATE]. The camera captured Certified Nursing Assistant (CNA) #1 allegedly harassing Resident #1 between ,[DATE] PM on [DATE]. The facility failed to attempt an interview with Resident #2, the roommate of Resident #1 who witnessed the harassment per the video footage. Resident #3 had escalating behaviors; the facility medicated the resident without investigating the cause of the escalating behaviors. The facility failed to investigate and report allegation of abuse/neglect reported by Resident #4. The findings included: On [DATE] Resident #1's family member had a hidden video camera placed at his/her bedside. On [DATE] the surveyor viewed a video at the police department that revealed on [DATE] between 6:00 PM and 7:00 PM Certified Nursing Assistant (CNA) #1 flicked the resident's nostril while the resident appeared to be asleep, then hid behind the curtain so the resident could not see what happened. CNA #1 then pulled the curtain between the two beds and grabbed the resident's arm through the curtain. Resident #1 attempted to grab his/her own hand in an attempt to release the CNA's grasp. The resident poured a glass of water on the CNA, grabbed an electric razor and struck the CNA to release his/her grasp. CNA #1 was observed to roughly clean the resident's arm with a wipe. CNA #1 then walked around the resident's bedside and leaned close to the resident and was observed to "yell" at the resident (no sound was available on the video at the time of the survey). CNA #1 was observed leaning close to the resident's cheek in what appeared to be an attempt to kiss the resident. On [DATE] the police alerted the facility of CNA #1's alleged behavior and the CNA #1 was escorted from the facility at approximately 6:30 PM. CNA #1 was arrested and charged with abuse of a vulnerable adult on [DATE]. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident scored a "0" on the Brief Interview for Mental Status. The resident was coded with a behavior of rejection of care ,[DATE] days during the assessment period. The resident was also coded as having "other behaviors directed towards others" ,[DATE] days during the assessment period. Review of the physician's orders [REDACTED]. The [MEDICATION NAME] was discontinued on [DATE]. No other psychoactive medications were ordered. Review of the Nurse's Notes revealed the following: [DATE] the resident was noted to have increased anxiety and an order for [REDACTED]. [DATE] at 3:35 AM, the resident was agitated and was attempting to pull out his/her Foley catheter. Further review revealed the resident would frequently refuse meals and requested staff to leave him alone. [DATE] at 6:30 PM, "Body Audit done on res noted scratch to R upper thigh and scratch to L hip area where brief is fastened, no other areas noted. Res (resident) refused supper." Review of additional incidents related to Resident #1 revealed the following incidents. On [DATE], the resident was noted to have a small amount of blood under his/her right eye from a "micro skin abrasion... unknown origin..." The incident was not investigated or reported to the state agency. On [DATE] the resident was transferred "roughly" by a CNA that resulted in bruising to the resident's left arm and elbow area. The incident was not reported to the state agency. During an interview on [DATE] at 2:15 PM, the ADON confirmed the three injuries of unknown origin for Resident #1. She/he confirmed that the injuries were not investigated or reported. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident scored a "0" on the Brief Interview for Mental Status. The resident was coded with a behavior of rejection of care ,[DATE] days during the assessment period. The resident was also coded as having "other behaviors directed towards others" ,[DATE] days during the assessment period. During an interview with the surveyor on [DATE] at 3:15 PM, with the Unit Manager, Resident #2 was interviewed related to the witnessed alleged abuse. Resident #2 was noted to be able to answer yes and no questions. Resident #2 answered yes appropriately three times when questioned by the surveyor if someone hit, yelled and kissed his roommate. Resident #2 was not able to give a name or answer appropriately when given a CNAs name. Resident #2 also answered yes appropriately twice when asked by the surveyor if someone kissed him and was rough with him. Resident #2 was not able to provide a name or answer appropriately when given a CNA's name. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored an "11" on the Brief Interview for Mental Status. No behaviors were coded as occurring during the assessment period. Review of the Care Plan (CP) revealed a problem area related to behaviors and/or [MEDICAL CONDITION] was identified on [DATE] with approaches including "labs as ordered c abnormalities reported per protocol, assist up to w/c as needed when restless in bed, Psych consult PRN, Administer meds per MD orders, observe and report any changes to MD, SSD and Nursing staff PRN, remain calm when approaching resident, continue to monitor medications, attempt to contact family and friend if unable to redirect." On ,[DATE] the care plan was updated to include "will continue to observe, psych consult will be recommended to MD." On ,[DATE] the CP was updated to include "(change) [MEDICATION NAME] 0.5 mg PRN to [MEDICATION NAME] 0.5 mg PO or IM BID PRN severe agitation." On ,[DATE] the CP was updated to include "reviewed and updated at this time." Review of the Nurse's Notes from [DATE] through [DATE]/2012 revealed the following documentation: [DATE] at 11 PM, "Res agitated earlier during shift attempting to get out of front door brought back to unit by activities. Rec'd order for [MEDICATION NAME] 0.5 mg po x 1 now. Res remains agitated at this time, refusing to go to bed. 2 CNAs placed resident on bed and (changed) brief res very upset stating they were trying to get in bed c her and look at her "tootsie." Res placed back in chair p brief (changed)... " [DATE] the nurse documented "was delusional and paranoid at beginning of shift thinking someone was trying to get her during the night..." ,[DATE] at 7:30 AM, "In bed anxious, yelling wanting (local police), requesting to go home..." On [DATE] at 5:30 AM, "resident very resistive and combative during brief change..." [DATE] at 9:30 PM, "Res also agitated, talking to people not present, saying she has to go to (?) and church. [MEDICATION NAME] 0.5 mg given at 5 P ineff(ective). Cont'd yelling and screaming that "your tying to kill me" when CNA was providing incont care..." [DATE] at 10:30 PM, "Res noted yelling and screaming during dinner, given IM [MEDICATION NAME] 0.1 cc for severe agitation rolling throughout hallway from door to door exit seeking. Multiple attempts to calm res unsuccessful. Taken to room approx ,[DATE]:30 P to put to bed and provide incontinent care. Res became combative CNA (2) and myself in room attempting to complete care, res scratching at CNA, 2nd CNA assisting 1st CNA while I observed. Incont care completed and res placed back in w/chair. Cont to exit seek and screaming and yelling in halls and dayroom. DON cam and sat c res for an hour helping to calm resident..." [DATE] at 10:45 PM, "res cont to become very agitated, [MEDICATION NAME] 0.5 mg given at 5 P..." No other behaviors were documented in the nurse's notes. During an observation/interview of the resident on [DATE] at 9 AM revealed the resident was sitting in her/his wheelchair. The resident was lethargic and had a difficult time staying awake during the interview. The resident stated "yeah" when asked by the surveyor if staff members were rough with her/him. S/he also stated "yeah" when asked if staff yelled at her/him or teased her/him." During an interview on [DATE] at 2:15 PM, the Assistant Director of Nurses (ADON), Nurse Consultant and Administrator confirmed the resident's behaviors. The Administrator confirmed that no investigation was initiated related to the resident's statements of alleged abuse. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident scored a ,[DATE] on the Brief Interview for Mental Status. The resident was coded to have verbally abusive behaviors ,[DATE] days during the assessment period. During an interview with the surveyor on [DATE] at 3:40 PM, the resident reported CNA #2 and CNA #3 would purposefully ignore him/her, not provide him/her the appropriate care and would say they were too busy to come to his/her room to assist him/her. Resident #4 also stated that CNA #1 would tease him/her. S/he stated that his/her roommate died several months prior and CNA #1 would pretend that s/he was "raising from the dead trying to scare" the resident. The resident at first stated that s/he did not inform any staff members, but in a later interview, stated that s/he had mentioned the teasing to the Unit Manager. Review of the Social Service Progress notes revealed on [DATE] "continues to make allegations that staff are ignoring him, yet retracts statements later. Resident has threatened staff with telling DHEC some lies if staff do not do what (the resident) wants. (Resident #4) continues to make allegations that staff are not taking care of (another resident). When confronted resident admits that s/he doesn't really know. (Resident #4) has a history of attempting to threaten and or intimidate staff with false allegations and accusations. LMSW and Social Service Assistant have discussed this with (Resident #4) today..." On [DATE] "Resident continues to be alert and oriented to self and surroundings. S/he continues to display verbal aggression towards staff, using threatening language of calling DHEC. This behavior is not new but is manageable." During an interview with the surveyor on [DATE] at 4:30 PM, the LMSW stated that Resident #4 did not have any documented grievances or reportable incidents. S/he stated that Resident #4 had a history of [REDACTED]. The LMSW stated that because of the resident's history, the allegations were false. S/he confirmed her/his note regarding the allegation of abuse/neglect, s/he also confirmed the allegations were not investigated or reported. During an interview on [DATE] at 5 PM, the Administrator was informed of the resident's allegation regarding CNA #2 and #3. S/he also confirmed that Resident #4 did not have his/her allegations investigated or reported based upon the resident's history of false allegations. On [DATE] at 11:45 AM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-223, F-226 and F-490 at a scope and severity of "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on [DATE] related to Resident #1's alleged abuse. Observations, interviews, and review of policy education and signature sheets on [DATE] revealed the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and were in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the abuse policy requiring staff to identify inappropriate behavior, report any allegation of potential abuse and thoroughly investigate allegations of abuse. Psychosocial assessments were completed on all residents residing on Unit One with the appropriate actions taken. The Administrator was informed of this on [DATE] at 4:45 PM. The citation at F-223 remained at a lower scope and severity of "E". The facility will be in compliance when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction.

On the days of the survey based on observations, record review and interview, Substandard Quality of Care and/or Immediate Jeopardy was identified on [DATE] at 11:45 AM, related to the failure of the facility to implement their Abuse Prohibition policy as evidenced by the absence of a thorough investigation of allegations of abuse, the failure to assess all resident's psychosocial needs, and report all incidents of potential abuse to the appropriate state agency. The facility staff failed to identify a Certified Nursing Assistant's (CNA's) behavior as inappropriate and potentially abusive towards residents. Resident #1 had a hidden camera placed in his/her room on [DATE]. The camera captured CNA #1 allegedly abusing Resident #1 between ,[DATE] PM on [DATE]. The facility investigation was not thorough related to the incident. The facility failed to assess the resident's room mate who was a witness to the abuse per the video footage. The facility failed to assess each resident's psychosocial needs. Resident #3 had escalating behaviors, the facility medicated the resident without investigating her/her allegations of staff abuse. The facility failed to investigate and report allegations of abuse/neglect reported by Resident #4. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident scored a "0" on the Brief Interview for Mental Status. The resident was coded as having rejection of care behaviors ,[DATE] days during the assessment period. The resident was also coded as having "other behaviors directed towards others" ,[DATE] days during the assessment period. The resident was noted to be under the care of Hospice. Review of the physician's orders [REDACTED]. The [MEDICATION NAME] was discontinued on [DATE]. No other psychoactive medications were ordered. Review of the Nurses Notes revealed on [DATE] the resident was noted to have increased anxiety and an order for [REDACTED]. Further review revealed the resident would frequently refuse meals and requested staff to leave him alone. On [DATE] at 6:30 PM, "Body Audit done on res noted scratch to R upper thigh and scratch to L hip area where brief is fastened, no other areas noted. Res refused supper." Review of additional incidents related to Resident #1 revealed the following incidents. On [DATE], the resident was noted to have a small amount of blood under his/her right eye from a "micro skin abrasion... unknown origin..." The incident was not investigated or reported to the state agency. On [DATE] the resident was transferred "roughly" by a CNA that resulted in bruising to the resident's left arm and elbow area. The incident was not reported to the state agency. During an interview with the surveyor on [DATE] at 2:15 PM, the Assistant Director of Nurses (ADON) confirmed the three injuries of unknown origin for Resident #1. S/he confirmed that the injuries were not investigated or reported. On [DATE] the resident's family member had a hidden video camera placed at Resident #1's bedside. Review of the video at the police department by the surveyor revealed that on [DATE] between 6:00 PM and 7:00 PM Certified Nursing Assistant (CNA) #1 was observed flicking Resident #1's nostril while the resident appeared to be asleep. CNA #1 then hide behind the curtain so the resident could not see what happened. The CNA was observed in the video pulling the curtain between the beds of Resident #1 and his/her roommate and grabbed Resident #1's arm through the curtain. Resident #1 attempted to grab his/her own hand in an attempt to release the CNA's grasp. The resident poured a glass of water on the CNA, grabbed an electric razor and struck the CNA to release his/her grasp. CNA #1 was observed roughly cleaning the resident's arm with a wipe. CNA #1 then walked around the resident's bedside, leaned close to the resident and was observed to "yell" at the resident (no sound was available on the video). CNA #1 was also observed leaning down close to the resident's cheek in what appeared to be an attempt to kiss the resident. The police informed the facility of the video and the allegation against CNA #1, s/he was escorted from the property on [DATE] at approximately 6:30 PM. CNA #1 was arrested and charged with abuse of a vulnerable adult on [DATE]. The facility reported the incident to the State Agency in accordance with regulation and started an investigation. The facility did not obtain witness statements from staff or residents in regards to CNA #1's behavior or interactions with residents. Review of the Corrective Action revealed "Alert and oriented residents who are typically assigned to the accused CNA were interviewed on [DATE]... No residents responded that they had any concerns or problems with the accused CNA. During the survey the surveyor interviewed three residents who voiced concerns related to staff mistreatment. Per the facility investigation no family member had any concerns related to abuse. The facility investigation did not include psychosocial assessments of any resident. Resident #1's roommate was a direct witness to the abuse per the video, however, the facility's failed to assess the resident or attempt to interview the resident. In addition staff members interviewed by the surveyor on [DATE] stated that CNA #1 teased, joked and kidded with the residents. Staff members did not see CNA #1's behavior with the residents as inappropriate or potentially harmful to any resident. Review of the facility's 5 Day Report revealed the facility's obtained statements from the Assistant Director of Nurses (ADON), CNA #1, CNA #2, CNA #3, the Unit Manager and Licensed Practical Nurse #1 and #2. The staff members interviewed were not questioned related to the alleged abuse of Resident #1 by CNA #1. A statement was provided by the Administrator dated [DATE] that indicated s/he interviewed staff members working the evening shift of [DATE] (the date of the alleged abuse). Per the statement, "each person was asked if they had ever seen any abusive behavior by (CNA #1), they indicated they had not." The staff members did not sign the statement and no other statement regarding abuse or mistreatment was obtained. The Director of Nurses (DON) provided a statement dated [DATE] that indicated s/he interviewed two other staff members (CNA #4 and #5) who were working the evening of [DATE], s/he "inquired if they had witnessed any abuse of any resident in the facility... both indicated to the (DON) that they had not witnessed any abuse." Again, the interviewed staff did not sign the statement and there were no other statement obtained related to abuse/mistreatment of [REDACTED]. Review of the video at the police department by the surveyor showed CNA #2 entering Resident #1's room during the time the alleged abuse occurred. Review of the facility obtained statement from CNA #2 documented by the ADON and dated [DATE] revealed "CNA (#2) agrees s/he worked Magnolia Wing ,[DATE] shift ,[DATE] and ,[DATE]. S/he reports s/he has no knowledge of hearing or seeing anything unusual Thursday ([DATE]). S/he has no concerns to report at this time. The statement was only signed by the ADON. CNA #2 did not provide any other witness statement. Also, the statement was not provided to the state agency in the 5 day report but was provided to the surveyor on [DATE]. During an interview with the surveyor on [DATE] at 3:30 PM, CNA #2, stated that s/he was working the evening shift on [DATE]. S/he also stated that s/he was working the same hallway as CNA #1. CNA #2 stated that s/he heard some "bumfumbling around" in Resident #1's room. S/he entered the room and saw CNA #1 in the room with both residents. CNA #2 stated that s/he didn't see anything unusual and left the room. During an interview on [DATE] at 3:45 PM, the Unit Manager stated that s/he performed a body audit on Resident #1 on [DATE]. S/he stated that the resident had two what appeared to be "fingernail" scratches on his/her legs. On the right thigh extending from the mid inner thigh outward towards the hip and on the left thigh in the groin area across the brief line. The Unit Manager stated that the two injuries could not be explained by the resident and the source of the injuries was not investigated. The injuries of unknown origin were not reported to the State Agency and were not investigated. The Unit Manager also stated that CNA #1 always joked and teased with the resident. S/he stated that CNA #1 could always be seen dancing and joking and hugging the residents. During a follow up interview, the Unit Manager stated that s/he had interviewed the "interviewable" residents related to the abuse allegation. S/he stated that s/he did not believe CNA #1 could have abused the resident and did not think s/he was capable of harming anyone as s/he was one of the best CNAs. The Unit Manager stated that one week after the allegation, s/he watched the video clip and read the news articles related to the allegation. S/he stated that it was not until that moment that s/he allowed her/himself to be open to the possibility that CNA #1 allegedly abused Resident #1. During an interview with the surveyor on [DATE] at 3:50 PM, CNA #3 stated that CNA #1 was "the life of the party." S/he stated that CNA #1 liked to kid and tease the residents. During an interview with the surveyor on [DATE] at 3:15 PM, with the Unit Manager, Resident #2 was interviewed related to the alleged abuse. Resident #2, the roommate of Resident #1 was in the room at the time of the alleged abuse. Resident #2 admitted to the facility with [MEDICAL CONDITION] and was heard of hearing s/he most recent Quarterly Minimum Data Set coded him/her as having short and long term memory problems with severely impaired cognitive skills for daily decision making. S/he was noted to be able to answer yes and no questions. Resident #2 answered yes appropriately three times when asked by the surveyor if someone hit, yelled and kissed his/her roommate. Resident #2 was not able to name the perpetrator. Resident #2 answered yes appropriately twice when asked if someone kissed him/her and was rough with him/her; s/he was not able to provide the name of the perpetrator. During an interview on [DATE] at 11:45 AM, the Administrator confirmed staff statements were not obtained related to the alleged abuse. S/he stated that s/he met with the staff members working [DATE] but admitted that their statements were not individually obtained nor were statements obtained related to CNA #1's behavior and practice. S/he also confirmed that no other staff member had viewed the CNA's behavior as inappropriate towards residents. The Administrator confirmed that no residents' psychosocial needs were assessed after the alleged abuse. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored an "11" on the Brief Interview for Mental Status. No behaviors were coded as occurring during the assessment period. Review of the Care Plan (CP) revealed a problem area related to behaviors and/or [MEDICAL CONDITION] identified on [DATE] with approaches including "labs as ordered c (with) abnormalities reported per protocol, assist up to w/c (wheelchair) as needed when restless in bed, Psych consult PRN (as needed), Administer meds per MD (medical doctor) orders, observe and report any changes to MD, SSD (social service director) and Nursing staff PRN, remain calm when approaching resident, continue to monitor medications, attempt to contact family and friend if unable to redirect." On ,[DATE] the care plan was updated to include "will continue to observe, psych consult will be recommended to MD." On ,[DATE] the CP was updated to include "(change) [MEDICATION NAME] 0.5 mg (milligrams) PRN to [MEDICATION NAME] 0.5 mg PO (by mouth) or IM (intramuscular) BID (twice a day) PRN severe agitation." On ,[DATE] the CP was updated to include "reviewed and updated at this time." Review of the Nurse's Notes from [DATE] through [DATE] revealed the following documentation: [DATE] at 11 PM, "Res (resident) agitated earlier during shift attempting to get out of front door brought back to unit by activities. Rec'd order for [MEDICATION NAME] 0.5 mg po x 1 now. Res remains agitated at this time, refusing to go to bed. 2 CNAs placed resident on bed and (changed) brief res very upset stating they were trying to get in bed c (with) her and look at her "tootsie." Res placed back in chair p (after) brief (changed)..." [DATE] the nurse documented "was delusional and paranoid at beginning of shift thinking someone was trying to get her during the night..." ,[DATE] at 7:30 AM, "In bed anxious, yelling wanting (local police), requesting to go home..." [DATE] at 5:30 AM, "resident very resistive and combative during brief change..." [DATE] at 9:30 PM, "Res also agitated, talking to people not present, saying she has to go to (?) and church. [MEDICATION NAME] 0.5 mg given at 5 P ineff(ective). Cont'd yelling and screaming that 'your tying to kill me' when CNA was providing incont (incontinent) care..." [DATE] at 10:30 PM, "Res noted yelling and screaming during dinner, given IM [MEDICATION NAME] 0.1 for severe agitation rolling throughout hallway from door to door exit seeking. Multiple attempts to calm res unsuccessful. Taken to room approx(imately) ,[DATE]:30 P to put to bed and provide incontinent care. Res became combative CNA (2) and myself in room attempting to complete care, res scratching at CNA, 2nd CNA assisting 1st CNA while I observed. Incont care completed and res placed back in w/chair. Cont to exit seek and screaming and yelling in halls and dayroom. DON came and sat c res for an hour helping to calm resident..." [DATE] at 10:45 PM, "res cont to become very agitated, [MEDICATION NAME] 0.5 mg given at 5 P..." During an observation/interview with the resident on [DATE] at 9 AM revealed the resident was sitting in her/his wheelchair. The resident was lethargic and had a difficult time staying awake during the interview. The resident stated "yeah" when asked by the surveyor if staff members were rough with her/him. S/he also stated "yeah" when asked if staff yelled at her/him or teased her/him." No other information could be obtained by the surveyor during the interview. During an interview on [DATE] at 2:15 PM, the Assistant Director of Nurses (ADON), Nurse Consultant and Administrator confirmed the resident's behaviors. The Nurse Consultant confirmed that the resident did not have any other documented interventions besides medication. All confirmed that the residents behaviors decreased drastically on [DATE]. The Administrator confirmed that no investigation was initiated related to the resident's statements of alleged abuse. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident scored a ,[DATE] on the Brief Interview for Mental Status. The resident was coded to have verbally abusive behaviors ,[DATE] days during the assessment period. During an interview on [DATE] at 3:40 PM, the resident reported CNA #2 and CNA #3 would purposefully ignore him/her, not provide him/her the appropriate care and would say they were too busy to come to his/her room to assist him/her. Resident #4 also stated that CNA #1 would tease him/her. S/he stated that his/her roommate died several months prior and CNA #1 would pretend that s/he was "raising from the dead trying to scare" the resident. The resident at first stated that s/he did not inform any staff members, but in a later interview, stated that s/he had mentioned the teasing to the Unit Manager. Review of the Social Service Progress notes revealed on [DATE] "continues to make allegations that staff are ignoring him, yet retracts statements later. Resident has threatened staff with telling DHEC some lies if staff do not do what (the resident) wants. (Resident #4) continues to make allegations that staff are not taking care of (another resident). When confronted resident admits that (s/he) doesn't really know. (Resident #4) has a history of attempting to threaten and or intimidate staff with false allegations and accusations. LMSW (Licensed Masters of Social Worker) and Social Service Assistant have discussed this with (Resident #4) today..." On [DATE] "Resident continues to be alert and oriented to self and surroundings. (S/he) continues to display verbal aggression towards staff, using threatening language of calling DHEC. This behavior is not new but is manageable." During an interview with the surveyor on [DATE] at 4:30 PM, the LMSW stated that Resident #4 did not have any documented grievances or reportable incidents. S/he stated that Resident #4 had a history of [REDACTED]. The LMSW stated that because of the resident's history, the allegations were false. S/he confirmed her/his note regarding the allegation of abuse/neglect, s/he confirmed the allegations were not investigated or reported. During an interview on [DATE] at 5 PM, the Administrator was informed of the resident's allegation regarding CNA #2 and #3. S/he also confirmed that Resident #4 did not have his/her allegations investigated or reported based upon the resident's history of false allegations. Review of the facility's policy on Abuse Prohibition revealed: "The Administrator has overall responsibility and accountability for designation of an Abuse Coordinator for the facility and implementing the Resident Abuse Prohibition program..." Identification: "All employees will be trained to identify potential and/or actual occurrences of abuse, neglect...Training includes: Physical Abuse-hitting, slapping, pinching, kicking and controlling behavior through corporal punishment and non-accidental use of physical force that results in bodily injury, pain or impairment are physically abusive behaviors. Unreasonable confinement or restraint, physical coercion, pushing and shoving are also physically abusive behaviors." Verbal Abuse-"The use of oral, written or gestured language that deliberately includes disparaging and derogatory terms within hearing distance of residents and family members...Threats of physical or emotional pain are also examples." Mental Abuse-"includes but is not limited to humiliation, harassment, and threats of punishment or deprivation or speaking in a language foreign to a resident in his/her presence." Investigation: "The facility will immediately investigate any alleged resident neglect, mistreatment, misappropriation of funds and/or physical, verbal, sexual, emotional/psychological abuse using the resident protection investigation procedure." Investigation Procedures: "Regardless of the specific nature of the allegation, the investigation shall consist of interview with: the person reporting the incident, the resident, any witnesses to the incident, staff members having contact with the involved parties during the period of alleged incident, the resident's roommate, family members, visitors or others who were near the incident...This information should be compiled as a complete, written report." The Interview Process: "Adhere to the following important guidelines during interviews: The summary statement is signed and dated as accurate by the interviewee and the statement attached to the Investigation Report Form." On [DATE] at 11:45 AM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-223, F-226 and F-490 at a scope and severity of "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on [DATE]. Observations, interviews, and review of policy education and signature sheets on [DATE] revealed the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and were in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the abuse policy requiring staff to identify inappropriate behavior, report any allegation of potential abuse and thoroughly investigate allegations of abuse. Psychosocial assessments were completed on all residents residing on Unit One with the appropriate actions taken. The Administrator was informed of this on [DATE] at 4:45 PM. The citation at F-226 remained at a lower scope and severity of "E". The facility will be in compliance when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction.

On the days of the survey based on observations, record review and interview, Immediate Jeopardy was identified related to the failure of the facility administration to administer the facility in a manner to use its resources effectively and efficiently to maintain the physical, mental and psychosocial well-being of each resident. The Abuse Prohibition Policy was not implemented related to the identification, investigation and reporting of alleged abuse. The findings included: Cross Refer to F-223 as it relates to the failure of the facility to respond appropriately to allegations made by residents of potential abuse. Cross Refer to F-226 as it relates to the failure of the facility to implement the Abuse Prohibition Policy related to investigation, identification and reporting alleged abuse. On 12/6/12 Resident #1's family member had a hidden video camera placed at his/her bedside. On 12/17/12 the surveyor viewed a video at the police department that revealed on 12/6/12 between 6:00 PM and 7:00 PM Certified Nursing Assistant (CNA) #1 flicked the resident's nostril while the resident appeared to be asleep, then hide behind the curtain so the resident could not see what happened. CNA #1 then pulled the curtain between the two beds and grabbed the resident's arm through the curtain. Resident #1 attempted to grab his/her own hand in an attempt to release the CNA's grasp. The resident poured a glass of water on the CNA, grabbed an electric razor and struck the CNA to release his/her grasp. CNA #1 was observed to roughly clean the resident's arm with a wipe. CNA #1 then walked around the resident's bedside and leaned close to the resident and was observed to "yell" at the resident (no sound was available on the video at the time of the survey). CNA #1 was observed leaning close to the resident's cheek in what appeared to be an attempt to kiss the resident. On 12/7/12 the police alerted the facility of CNA #1's alleged behavior and the CNA #1 was escorted from the facility on 12/7/12 at approximately 6:30 PM. CNA #1 was arrested and charged with abuse of a vulnerable adult on 12/10/12. Review of the facility's policy on Abuse Prohibition revealed: "The Administrator has overall responsibility and accountability for designation of an Abuse Coordinator for the facility and implementing the Resident Abuse Prohibition program..." During an interview on 12/18/12 at 11:45 AM, the Administrator confirmed staff statements were not obtained related to the alleged abuse. S/he stated that s/he had met with the staff members working 12/6/12 but admitted that their statements were not individually obtained or related to CNA #1's behavior and practice. The Administrator confirmed that CNA #1's behavior with the resident's was inappropriate. S/he also confirmed that no other staff member had viewed the CNA's behavior as inappropriate towards residents. The Administrator also confirmed that no residents' psychosocial needs were assessed after the alleged abuse. On 012/18/2012 at 11:45 AM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-223, F-226 and F-490 at a scope and severity of "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 12/06/2012. Observations, interviews, and review of policy education and signature sheets on 12/18/12 revealed the Allegation of Compliance submitted by the facility on 12/18/12 had been implemented by the facility and were in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the abuse policy requiring staff to identify inappropriate behavior, report any allegation of potential abuse and thoroughly investigate allegations of abuse. Psychosocial assessments were completed on all residents residing on Unit One with the appropriate actions taken. The Administrator was informed of this on 12/18/12 at 4:45 PM. The citation at F-490 remained at a lower scope and severity of "E". The facility will be in compliance when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction.