Every finding on record at Physical Rehabilitation And Wellness Center Of Spa

Based on review of facility policy, manufacturer manual, record review, and interview, the facility failed to properly secure Resident (R)4 for transfer via hoyer lift. Specifically, the facility used the incorrect size sling to transfer R4, resulting in R4 slipping out of the sling, falling to the floor, and suffering a hematoma to the back of the head.Findings include: Review of the facility policy titled Mechanical Lifts: General Guidelines with a revision date of 05/05/23, documented, Policy: The Facility may employee [sic] the use of mechanical lifts to assist with transfers to ensure the safety of patients, residents, and staff. Procedure: . 3. Prior to initiating use of mechanical list for a patient or resident: B. Validate patient/resident weight is within operating parameters for the mechanical lift and associated equipment. E. Evaluate for appropriate sling size, when used. 1) Slings too large may allow the person to slip out of the sling. F. Choose the correct sling based on manufacturer recommendations and the following criteria: . 3) Size and weight . Review of the Joerns Hoyer Service - Parts Manual under the section Hoyer Clip Style Sling Color/Size Chart - Standard Size section documented, Recommended weight range should only be used as a guideline as other factors can affect sizing. Further review of this section revealed the Comfort Standard Material: Polyester Sling was used in the transfer of R4, as indicated by the Director of Nursing (DON). The recommended weight range for the sling that was used in the transfer of R4 was documented as XL (xtra large), blue in color, and the Recommended Weight Range (lbs) was 275 - 500 lbs. Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE], with diagnoses including but not limited to; muscular dystrophy, low back pain, age-related physical debility, displaced fracture of second cervical vertebra, need for assistance with personal care, cognitive communication deficit, muscle weakness, severe protein-calorie malnutrition, and paraplegia. Review of R4's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/27/26, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R4 had intact cognition. Further review of the MDS revealed under the Functional Abilities Mobility section (roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, care transfer, walk 10 feet) that R4 was either Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, assistance of 2 or more helpers is required for the resident to complete the activity) or the activity was Not attempted due to medical condition or safety concerns. Additionally, the section Functional Abilities Self Care (eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene) was also coded as Dependent. Review of R4's Quarterly MDS with an ARD of 04/29/26, revealed R4 had a BIMS score of 15 out of 15, indicating R4 had intact cognition. Review of the section Functional Abilities Self Care was coded as either Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, assistance of 2 or more helpers is required for the resident to complete the activity) or the activity was Not attempted due to medical condition or safety concerns. Further review of the Functional Abilities Mobility section was coded as either Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, assistance of 2 or more helpers is required for the resident to complete the activity) or the activity was Not attempted due to medical condition or safety concerns except for Roll left and right, which was coded as 02-Substantial/maximal assistance - helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Review of R4's Care Plan with an edited date of 05/06/26, revealed a problem [R4] requires assist with ADL [Activity of Daily Living] Care . The approaches, with a start date of 01/29/26, directed staff to, Bathing: requires assist of 1-2, Bed Mobility: requires assist of 1-2, Toileting: requires assist of 1-2 . Another approach, with a start date of 04/27/26, directed staff to, Hoyer lift wiht [sic] 2 staff for all transfers. Further review of R4's Care Plan revealed another problem with a start date of 01/29/26, [R4] at risk for falling R/T [related to] decreased mobility, weakness, deconditioning, paraplegia. The goal was for R4 to remain free from injury through next review. Review of R4's Progress Note dated 05/27/26 at 3:59 PM, documented, At roughly 1430, CNAs alerted cart nurse and Unit Manager that resident was on the floor. Upon entering resident's room, resident was on the floor, lying on her back, underneath the hoyer lift. CNAs had placed a pillow under her head but had not moved her, her legs still laying over one of the legs of the hoyer lift. CNAs stated leg straps were properly crossed under residents legs, sling hooked up properly to hoyer lift hooks, but resident slid out of the hole at the bottom where her butt sits. She then fell from the sling onto the floor, hit her back and head. Unit Manager assessed resident - PERRLA present, hematoma (slightly larger than a golf ball) forming to the right occipital area of the head, and resident complaints of pain to her back and head. Unit Manager instructed not to move resident due to potential spine, neck, and head injury, asked cart nurse to call EMS for transport and notify provider. CNAs brought vital sign machine - V/S - B/P (111/73), HR (81), Resp (20), Temp (98.3), O2 (96 RA). EMS arrived, assessed resident. EMS attempted to place C-Collar and backboard for spinal injury precautions/safety - resident refused despite EMS encouragement. EMS transferred resident to gurney and departed with resident at 1450. Review of R4's Vitals dated 05/01/26 at 9:12 AM, revealed R4's weight was 120.9 lbs (pounds). According to the Joerns Hoyer Service - Parts Manual the recommended sling based on R4's weight was the Comfort Standard Material: Polyester sling which is red in color with a recommended weight range of 75 - 150 lbs. Further review of R4's vitals revealed the following weights: 04/03/26 - 116.4 lbs, 03/02/26 - 114.8 lbs. Review of R4's Computed Tomography (CT) Scan with a date of study on 05/27/26, revealed a small right posterior scalp hematoma. During an interview on 05/27/26 at 4:10 PM, Unit Manager (UM)1 stated, CNAs gave the resident a shower, utilizing the hoyer lift for transfer. The resident slipped through the crisscross sling. There were 2 CNAs present during the transfer. The crisscross sling was secured properly. The resident complained of back and head pain, we initialed spinal protocol. EMS arrived and the resident refused c collar and backboard. There were no visible signs of injuries except for a hematoma on the back of her head. During an observation and interview on 05/27/26 at an unspecified time, with the Director of Nursing (DON) and UM1, revealed the sling used during the transfer was still in R4's room. Upon entering the room, the sling was on R4's bed, which was confirmed by UM1. Observation of the sling did not reveal a serial number or identifiable marking. Interview with UM1 and DON revealed that slings are color coded based on recommended weight. Observation confirmed that the sling was blue in color. (Joerns Hoyer Service - Parts Manual indicated that a blue comfort standard sling was recommended for residents' weighing 275 - 500 lbs) During an interview on 05/27/26 at 4:29 PM, Certified Nursing Assistant (CNA)1 stated, We was putting her (R4) up in the sling and we had her up and the lady with me had her feet. When we went to move the sling to put her back in the chair, she slipped through the crisscross of the sling. [CNA2] was the other lady. She fit in the sling perfectly, I guess we used the correct sling. She hit the floor and I put some pillows under her while [CNA2] went and got the nurse. I didn't see any injuries, I didn't want to move her too much. At attempted interview with CNA2 on 05/27/26 at 4:33 PM, was unsuccessful. During an interview and observation on 05/27/26 at 5:05 PM, the DON stated, The resident prefers that sling. If I had knowledge about the sling sizes and her preference, I would have verified that she understood the risk of using that sling. In regards to the correct size sling, I will have to check. The DON further revealed that slings are kept in the laundry rooms when not in use. If a resident is using the sling it will stay with that resident until it needs to be washed. During an observation on the laundry rooms on Unit 100, did not reveal a red sling, which was the appropriate size for R4.

Based on record reviews and interviews, the facility failed to ensure a resident (R)1, who was on NPO (nothing by mouth) status, was adequately supervised to prevent the resident from receiving a cereal bar and a cup of water. Resulting in the resident experiencing symptoms of projectile vomiting and clamminess, which resulted in hospital transfer.On 02/19/26 at 03:45 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.On 02/20/26 at 09:35 AM, the Administrator was notified that failure to ensure a resident who was on NPO status was adequately supervised to prevent the resident from receiving a cereal bar and cup of water constituted Immediate Jeopardy (IJ) at F689.On 02/20/26 at 09:35 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility that IJ existed as of 02/07/26. The IJ was related to 42 CFR 483.25 - Free of Accident Hazards/Supervisions/Devices.On 02/20/26 at 11:02 AM, the facility provided an acceptable IJ Removal Plan. On 02/20/26 at 11:52 AM, the survey team validated the facility's corrective actions and removed the IJ, confirming the facility had put forth good faith attempts to correct the deficiency prior to survey, warranting the IJ at Past-noncompliance, effective 02/10/26.Findings include:A review of the facility policy titled, Food from Outside Sources, Safe Handling of, with a complete revision date of 08/01/20, states: 3. To the extent possible, nursing staff monitor the food provided for patients or residents by outside sources to verify safe handling, storage, and appropriateness for the recommended dietary needs of the individual patient/resident.R1 was admitted to the facility on [DATE] at 10:13 AM with diagnoses including but not limited to vomiting, convulsions, essential (primary) hypertension, and gastrostomy status.A review of R1's Physician's orders revealed an active order for Dietary Order-NPO with a start date of 01/07/2026. A review of R1's care plan with a start date of 02/07/23 revealed that [R1] is at high nutrition risks r/t [related to] Dysphagia with dependence on EN [enteral nutrition] for 100% nutrient/energy needs; Functional Quadriplegia/Hx [history] of SAH; Epilepsy.A review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/26 revealed R1 had not been assessed for a Brief Interview of Mental Status (BIMS). In addition, R1 had a memory problem and had modified independence. R1 has a nutritional approach, which was a feeding tube.A review of R1's Interact SBAR completed by Licensed Practical Nurse (LPN)1 dated 02/08/26 at 02:12 AM, which states that the event started on 02/07/26 with symptoms of vomiting, sweating, clamminess, and grg (gurgling). The resident ate a cereal bar from a church member. Resident is NPO, primary diagnosis dysphagia. Vital signs: BP 184/108.A review of Hospital records from Spartanburg Medical Center with a hospital admission date of 02/08/26 revealed 45 yo [Male] M [history]hx [Intracerebral hemorrhage] ICH w/ residual [left] L-sided deficits, [stroke]CVA, schizophrenia . who presents to SMC ED from SNF for vomiting. He was intubated for airway protection . 1. Suspected Aspiration Pneumonia. Care Level: Critical Care. On 02/13/2026 Tracheostomy was done.A phone interview with R1's brother on 02/19/26 at 11:45 AM revealed, My brother is not supposed to have anything by mouth. The facility called me on 02/07/26 and stated visitors from the local church came, and gave pts [patients] snacks and drinks, and his brother was one of them. My brother took the snacks. They called me that day, and told me he ate it, and the nurse stated they would keep an eye on him to see if anything happens during the day on 02/07/26, after midnight going into 02/08/26. He states he received another call stating he was vomiting, and he had to get sent out. He is still in the hospital, in a coma, for the moment.During an interview with Certified Nursing Assistant (CNA)1 on 02/19/26 at 12:11 PM revealed that On the day of 02/07/26, he (R1) was in his room, sitting back on his bed, he had a cereal bar in his mouth. She stated she removed it from his hand. She notified the nurse. She saw the visitors, not his usual visitors, but church members who do missionary work, which is common on weekends.During a phone interview with LPN2 on 02/19/26 at 1:00 PM, LPN2 states she was walking by and noticed a cereal bar (blue wrapper) and a Styrofoam cup. She states she took what he had; he had some in his mouth and some in his hand. Half of the bar was in his mouth, maybe 2 inches left, all smushed up. All of the water was gone. He could not tell her who gave it to him.A phone interview with the Medical Director (MD) on 02/19/26 at 1:15 PM revealed his understanding that the incident occurred on 02/07/26 when an unknown church member or group came in and gave the resident a cereal/granola bar along with some water.A phone interview on 02/19/26 at 1:51 PM with the Nurse Practitioner (NP) revealed she received a call from the nurse that night stating R1 was NPO and that earlier that day, he had received a cereal bar and some water from a church group that visited. The nurse reported symptoms of projectile vomiting and clamminess present; she gave the order for the resident to be sent out. The NP stated that eating and drinking while on NPO (nothing by mouth) can lead to vomiting. She also stated that his blood pressure at the time, 184/100, is considered critically high and an urgent situation.An interview with the Facility Administrator (FA) on 02/19/26 at 3:11 PM revealed that he first heard about the event with R1 on the following Monday, 02/09/26, during the morning meeting, which included a review of nurses' notes, clinical review, and all department heads. He explained that during the day on weekends, the facility has a receptionist present. If she is away from the desk, she informs the nurses so they can monitor visitors. Accushield, the screening tool for visitors, is hit or miss when a group of people enters at the same time. The last update on R1 is that he had a tracheostomy. The expectation is that when he returns, he will be on the rehab side. Immediate actions taken included speaking with staff, implementing bright pink signage to inform visitors not to offer food or drink without consulting nurses due to the resident's condition, and discussions with the clinical team. The facility's removal plan included:The identified resident was assessed by the provider following the incident on 02/07/26 with orders implemented. The resident was discharged to the hospital on [DATE]. Residents in-house who have orders for nothing by mouth were assessed for change in condition, including change in vital signs, respiratory distress, and gastrointestinal distress by the Director of Nursing/Designee on 02/09/26; no concerns identified. A sign was placed at the entrance of the facility for visitors and/or delivery drivers to consult with a nurse prior to delivering and/or providing food or drink to a resident. Residents who have orders for nothing by mouth had signs posted in their rooms identifying them as nothing by mouth and to contact the nurse prior to providing any food or drink to the resident on 2/10/26. Facility Staff were reeducated by the Administrator/Designee beginning 02/09/26 on the policy of food brought in from outside sources Including: Questioning visitors providing food/drink to a resident to check with the nurse first. Requesting visitors to notify the nurse prior to providing food/drink to a resident. The facility will complete audits of food distributed from outside sources, validating proper distribution 3x a week for 1 month, then randomly thereafter. Ad Hoc QAPI was held on 2/10/26. The Medical Director was notified on 02/08/26 and updated with interventions completed. Allegation of Compliance 2/10/26.

Based on facility policy review, record review, and interviews, the facility failed to protect the Resident (R)19's rights to be free from sexual abuse, from R79, for 1 of 7 residents reviewed for abuse. This failure had the likelihood of causing physical, mental, and psychosocial harm.On 01/14/26 at 3:45 PM, the Administrator and Director of Nursing (DON) were notified that the failure to protect a resident from sexual abuse constituted Immediate Jeopardy at F600.On 01/14/26 at 3:45 PM, the survey team provided the Administrator with a copy of the CMS IJ Template and informed the facility IJ existed as of 12/09/25. The IJ was related to 42 Code of Federal Regulations (CFR) 483.12 - Freedom from Abuse, Neglect, and Exploitation.On 01/16/26 at 3:04 PM, the facility provided an acceptable IJ Removal Plan. On 01/16/26 the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at a lower scope and severity of D. An extended survey was conducted in conjunction with the Recertification and Complaint Survey for non-compliance at F600, constituting substandard quality of care.Findings include:Review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment revised on 10/23/2019, indicated, . 1. The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient's/resident's property and/or funds . Definitions . 1. Abuse is the willful infliction . Instances of abuse of all residents, irrespective of any mental or physical condition . It includes verbal abuse, sexual abuse . Review of R79's Face Sheet revealed the facility admitted R79 on 07/30/24 with diagnoses including but not limited to: dementia, depression, anxiety disorder, personal history of transient ischemic attack (TIA) and cerebral infarction (a stroke) without residual deficits, and a cognitive communication deficit. Review of R79's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/06/25, indicated that R79 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident had moderate cognitive impairment. The MDS revealed that the resident exhibited other behavioral symptoms not directed toward others during the assessment period. The MDS indicated that such behaviors could include hitting, scratching self, pacing, public sexual acts, disrobing in public, or verbal/vocal symptoms such as screaming. Review of R79's 1 Psychiatric Follow-Up Evaluation (Addendum), dated 10/17/25, revealed that staff had reported that the resident was exhibiting hypersexual behaviors, frequently entering rooms of residents of the opposite sex. Per the record, there had been no witnessed incidents or assaults, and the resident had been easy to redirect. The record included an Addendum that indicated that the report was based on nursing staff reporting that the resident had engaged in sexually inappropriate behaviors. Review of R19's Face Sheet revealed the facility admitted R19 on 04/19/25 with diagnoses including but not limited to: vascular dementia, psychosis, anxiety, and cognitive communication deficit. Review of R19's Quarterly MDS, with an ARD of 10/23/25, revealed R19 had a BIMS score of 3 out of 15, which indicated the resident had severe cognitive impairment. Review of R19's Care Plan included a problem statement initiated on 04/27/25, that indicated the resident had impaired decision-making related to vascular dementia. Interventions directed staff to encourage the resident to verbalize feelings, concerns, and fears (initiated 04/27/2025). Review of R19's Resident Progress Notes dated 12/09/25 at 12:02 PM, revealed Unit Manager (UM)1 documented that a resident-to-resident incident occurred at approximately 10:55 AM on 12/09/2025 in the Unit 2 day room. Per the notes, a housekeeper was walking by and saw R19 was seated on a couch and R79 sitting directly in front of R19 in a wheelchair, fondling R19's breasts with their right hand. The notes revealed the housekeeper immediately called for nursing staff assistance. According to the notes, a certified nursing assistant (CNA) responded and saw R79 remove their hand from the front of R19's shirt. The notes revealed the CNA communicated to R79 that they could not touch another resident without consent, and R79 became verbally aggressive but left the dayroom via wheelchair on their own. Per R19's Resident Progress Notes, the CNA reported the incident to the medication cart nurses, who notified the UM and Administrator. The note revealed the UM obtained and documented statements from staff who were present during the incident. Review of a facility Initial Report dated 12/09/25, revealed at 10:55 AM, two staff members observed R79 with their right hand up under the shirt of [R19] touching [the resident's] breast. Review of a facility Five-Day Follow-Up Report, dated 12/12/25, revealed that after a thorough and complete investigation, including record review and review of staff and witness statements, the facility concluded that R79 inappropriately touched R19. Review of R79's Resident Progress Notes included a 1 Psychiatric Follow-Up Evaluation note, dated 12/12/25 at 12:00 AM, that indicated the resident had vascular dementia with hypersexual behaviors. The note indicated the condition was chronic, recurrent, and moderate in severity and was managed with medications and staff support. On 12/16/2025 at 10:30 AM, CNA5 stated that Housekeeper (HSK)4 came to her and told her that R79 was in the day room with their hand in R19's shirt, fondling the resident. Per CNA5, when she arrived at the day room, she told R79 that they were not supposed to do that and told the resident to remove themselves. During an interview on 01/12/26 at 8:20 AM, the Social Services Director (SSD) stated she had become aware that R79 had touched R19 about four to five weeks prior. She stated that she found out from a housekeeper. The SSD stated that the housekeeper saw R79 place their hands under R19's shirt, placed on the resident's stomach. The SSD stated that after the incident, the facility staff tried to keep R79 with residents of the same sex in order to protect residents of the opposite sex. During an interview on 01/12/26 at 9:56 AM, UM1 stated that within minutes of the incident between R19 and R79, R79 was removed and taken to their room. UM1 stated that R19 lacked capacity to be interviewed. He stated that initially, R79 denied the incident, but the Administrator told him that after he had questioned R79 more, R79 confirmed they had placed their hand under R19's shirt. The UM stated R79 had been moved to Unit 1 to remove the resident from being near R19. During an interview on 01/13/26 at 8:31 AM, HSK4 stated that she observed R79's right hand touching R19's breast. She stated that she yelled, and CNA5 responded and told R79 that what they were doing was not right. During a telephone interview on 01/13/26 at 2:33 PM, R19's Responsible Party (RP)7 stated that they were notified by the Administrator that a housekeeper had observed a resident with their hand up R19's shirt. RP7 stated that after the incident, they moved the other resident to a different area of the facility.During an interview on 01/13/26 at 10:30 AM, the Director of Nursing (DON) stated she had been unaware of any allegations of sexual abuse from residents in October 2025 or November 2025 and confirmed interventions to protect residents from R79 had not been initiated until December 2025, after the incident with R19. The DON stated that the intervention was to move R79 from Unit 2 to Unit 1.During an interview on 01/14/26 at 8:41 AM, the Administrator stated that the first intervention for R79, implemented in December 2025 when the incident with R19 occurred, was to transfer R79 from Unit 2 to Unit 1. He stated that was to place distance between R79 and R19 and to allow R19 to freely wander on Unit 2.On 01/16/26 at 3:04 PM. The facility presented an approved removal plan which included the following: 1. Residents #9, #19, #20, #34, #80, #106, #116 will have a head to toe assessment completed on 1/14/2026 by a licensed nurse. A psychosocial evaluation will be completed on identified residents by the licensed social worker on 01/14/2026. Identified residents #9, #19, #20, #34, #80, #106 and #116 will have referrals completed for psychological services and/or revisits completed by 01/15/2026. 2. Resident #79 was placed on 1:1 supervision on 01/10/2026 and will remain on 1:1 supervision while at the facility. Resident #79 will be seen by psychology and psychiatry on 01/15/2026. This will be completed by 01/15/2026 3. Administrator/Designee interviewed alert and orientated residents to identify possible allegations of abuse on 01/10/2026. The Director of Nursing/Designee will assess cognitively impaired residents for signs and symptoms of abuse by 01/15/2026. Residents identified will have psychosocial assessments completed and referrals made as appropriate by 01/15/2026. This will be completed by 01/15/2026. 4. A review of grievances and incident reports from 08/01/2025 through 01/15/2026 has been completed by 01/15/2026 by the Director of Nursing or Administrator to identify possible allegations of abuse or neglect. Any identified will be reported per policy and investigated by the Director of Nursing and Administrator. 5. The Facility Leadership Staff, which includes the Administrator, Director of Nursing, Unit Managers (2), Social Services Director, Social Services Assistant, Activity Director, Human Resources Director, Business Office Manager, Scheduler, Dietary Manager, Staff Development Coordinator, Maintenance Director, Therapy Director were re-educated by the Clinical Consultant on 01/14/2026 on the Abuse, Neglect and Misappropriation policy including: Identification of abuse or neglect, by observable and objective evidence, witness reports of unusual occurrence or patterns or trends of potential abuse or neglect Abuse is the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental and psychosocial wellbeing. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse Inappropriate sexual behavior displays by and/or toward an incapable resident Immediate identification and removal of the alleged perpetrator Identification and assessment of the alleged victim Implementation of protective measures to maintain physical and psychological safety for alleged victims The Facility will report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the State Survey agency and other in accordance with state law Conducting a prompt, thorough investigation of any allegation of abuse or neglect and grievances and appropriate actions taken to protect the resident Investigations should be prompt, comprehensive and responsive to the situation and contain founded conclusions Staff and/or residents may contact the Clinical Consultant, Regional [NAME] President and/or the anonymous compliance line at any time to report Abuse coordinator, Grievance Officer, Clinical Consultant, Regional [NAME] President and anonymous compliance line numbers are posted throughout facility 6. The facility staff will be re-educated by the Administrator/Designee by 01/15/2026 on the Abuse, Neglect and Misappropriation policy including: Identification of abuse or neglect, by observable and objective evidence, witness reports of unusual occurrence or patterns or trends of potential abuse or neglect Abuse is the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental and psychosocial wellbeing. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse Inappropriate sexual behavior displays by and/or toward an incapable resident Immediate identification and removal of the alleged perpetrator Identification and assessment of the alleged victim Implementation of protective measures to maintain physical and psychological safety for alleged victims Conducting a prompt, thorough investigation of any allegation of abuse or neglect and grievances and appropriate actions taken to protect the resident Staff and/or residents may contact the Clinical Consultant, Regional [NAME] President and/or the anonymous compliance line at any time to report Abuse coordinator, Grievance Officer, Clinical Consultant, Regional [NAME] President and anonymous compliance line numbers are posted throughout facility This reeducation began immediately and will be completed by 01/15/2026. Any, including as needed (PRN), staff not receiving this education prior to this date (01/15) will receive education prior to their next scheduled shift. This education will be presented to agency staff and new hires. 7. A Resident Council meeting will be held on 01/15/2026 by the Activity Director and the Administrator to review abuse, including the below. During the Resident Council, input will be requested, and questions will be answered. types of abuse reporting of abuse Abuse Coordinator in the facility as well as postings throughout the facility with this information and additional phone numbers of people that may be contacted for reporting. Clinical Consultant, Regional [NAME] President and anonymous compliance line facilities responsibility in reporting and investigating allegations of abuse. 8. The Administrator and Director of Nursing will review incident reports and grievance reports completed from the prior day in morning meeting daily beginning 01/16/2025 for seven days then Monday through Friday ongoing for identification of possible allegations of abuse. The weekend supervisor will review the incident reports and grievances on the weekends to identify possible allegations of abuse. The weekend supervisor will notify the Administrator and the Director of Nursing if any identified for further direction. 9. The Clinical Consultant will review incident reports and grievances for allegations of abuse beginning 01/15/2026 for 90 days validating immediate action has been taken to protect the victim and provide psychosocial support; interventions are put in place to prevent further abuse and a thorough investigation is completed and reported timely per policy. 10. The Administrator/Designee and the Director of Nursing/Designee will each interview 4 random residents daily beginning 01/16/2026 for one week validating residents feel safe, free from abuse and have no care concerns, then 4 residents randomly per week for 4 weeks. 11. The Director of Nursing/Designee will assess 4 cognitively impaired residents daily beginning 01/16/2026 for 1 week to identify any signs and symptoms of abuse, then 4 residents per week for 4 weeks. 12. Human Resources will interview 3 random employees daily beginning 01/16/2026 for one week to validate transfer of knowledge of education provided, then 3 employees weekly for 4 weeks. 13. Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held on 01/14/2026 with the Administrator, Director of Nursing, Unit Managers (2), Social Services Director, Social Services Assistant, Activity Director, Business Office Manager, Scheduler, Dietary Manager, Maintenance Director, Therapy Director, Staff Development Coordinator and Medical Director in which the Immediate Jeopardy Templates and the contents of this plan were discussed. The Medical Director was notified of the Immediate Jeopardy and the contents of this plan on 01/14/2026. Allegation of compliance 1/16/26

Based on observation, interview, facility document review and policy review, the facility failed to ensure dietary staff followed proper personal hygiene practices to prevent food contamination when serving food for residents and failed to ensure food items were labeled appropriately and that the refrigerator was maintained at a proper temperature in 1 (Unit 100) of 3 snack/nourishment room refrigerators. Findings include:1. Review of a facility policy titled, Nutrition Policies and Procedures, Subject: Sanitation and Safety in Food and Nutrition Services, revised 10/15/25 revealed, The Certified Dietary Manager (CDM) will assume responsibility for the food safety and sanitation of the Nutrition Culinary Department. Procedures: 1. Infection control and sanitation practices are followed to minimize the risk of contamination of food and prevent food borne illness. During the initial observation of the kitchen on 12/15/25 at 8:45 AM, Dietary Aide (DA) 14 and DA 15 were observed plating and arranging food on residents' breakfast trays. DA 14 and DA 15 were observed with facial hair and were not wearing beard nets. During the same observation, DA 15 was observed arranging food on residents' plates and was not wearing gloves. During an interview on 12/19/25 at 2:44 PM, DA 15 stated that the kitchen staff had to wear a beard net every time they came into the kitchen. He also stated gloves should be worn when staff touched food. DA 15 stated he had probably forgotten to wear a beard net on 12/15/25. During an interview on 12/19/25 at 2:56 PM, DA 14 stated that beard nets were supposed to be worn anytime staff were in the kitchen. DA 14 stated that he should have been wearing a beard net on 12/15/25, but he was running late and forgot to put it on. During an interview on 12/19/25 at 4:07 PM, the Administrator (ADM) stated that he completed weekly sanitization checks in the kitchen. The ADM stated he expected dietary staff to wear beard nets and gloves consistently and every single time they were necessary.2. Review of a facility policy titled, Nutrition Policies and Procedures Subject: Food Safety in Receiving and Storage revised 10/15/25, revealed, 3. Check and record refrigerator temperatures at least 2 times per day (Refer to Refrigerator/Freezer Temperature Log). Temperatures not in the appropriate range are reported to the Certified Dietary Manager or maintenance. 4. Maintain the ambient temperature of refrigerators at 34 to 40 [degrees Fahrenheit (F)]or per state regulations. Review of a facility policy titled, Nutrition Policies and Procedures Subject: Food From Outside Sources, Safe Handling of revised 04/14/21, indicated, 5. Foods are labeled to identify the patient/resident's name, container contents, and the date it was prepared. Food items are stored in disposable, tightly covered containers, or sealable plastic bags. Items will be stored for three (3) days. Expired and unlabeled items will be discarded. The policy also revealed, 8. No foods and/or beverages are returned to the pantry area or communal resident's refrigerator once taken into a resident's room. These food items should be discarded if unable to be stored safely in the resident's room. During an observation of Unit 100's snack/nourishment room refrigerator on 12/19/25 at 10:30 AM, revealed the thermometer in the refrigerator indicated the temperature was 50 degrees F. During the observation, a fast-food milkshake with a straw was observed unlabeled in the refrigerator door. Review of a temperature log in the Unit 100 snack/nourishment room revealed the AM fridge temperature on the 19th (no month or year documented) was 42. The PM fridge temperature for the 18th was incomplete. During an observation of Unit 100's snack/nourishment room on 12/19/25 at 2:48 PM, an Out of Order sign was observed on the refrigerator. During an interview on 12/19/25 at 2:05 PM, Licensed Practical Nurse (LPN) 17 stated it was the kitchen staff's responsibility to monitor the refrigerator temperature in the unit snack/nourishment room. She stated that it was the nurse's responsibility to label items like drinks used for multiple residents with the date as it expired in three days. LPN 17 stated no employee personal items were supposed to be stored in unit snack/nourishment room refrigerators.During an interview on 12/19/25 at 11:18 AM, the Certified Dietary Manager (CDM) stated the dietary department was responsible for completing temperature logs in the snack/nourishment rooms and for making sure that all food items that they delivered were labeled. She stated the dietary department was also responsible for making sure the food items the department placed in the unit refrigerators had not expired. The CDM stated that the nursing department was responsible for labeling any other resident food items they placed in the refrigerators. During an interview on 12/19/25 at 3:18 PM, the Director of Maintenance (DOM) stated staff were responsible for monitoring the temperatures of the snack/nourishment room refrigerators. He stated that if there was an issue with the refrigerator temperature, staff were supposed to notify the maintenance department. The DOM stated the CDM notified him that the snack/nourishment room refrigerator was not at the correct temperature on 12/19/25 (exact time unknown) and he turned up the refrigerator temperature. An observation of the Unit 100 snack/nourishment room refrigerator temperature during the interview revealed it was 42 degrees F. During an interview on 12/19/25 at 2:24 PM, the Director of Nursing (DON) stated it was the responsibility of nursing staff to date/label resident items placed in the refrigerator and discard them after three days. The DON stated that dietary and nursing staff should have monitored and completed the temperature logs, and if there was an issue with the temperature, they should notify her, maintenance staff, or a supervisor. During an interview on 12/19/25 at 4:07 PM, the Administrator (ADM) stated that dietary staff were responsible for checking refrigerator temperatures in the snack/nourishment rooms. The ADM stated that he expected staff to check them daily and to immediately notify a supervisor if there was an issue.

Based on facility policy review, observation, and interview, the facility failed to protect residents' personal information for 5 Residents (R)27, 70, 78, 107, and 121of 23 sampled residents. Specifically, staff left a computer monitor that was on a medication cart unsecure where resident protected health information (PHI) was displayed for anyone to see.Findings include:Review of a facility policy titled, Safeguarding Electronic Protected Health Information, last revised 04/29/22, revealed, All employees safeguard electronic protected health information in an effort to fulfill their duty to maintain the confidentiality and integrity of patient/resident health information as required by law, professional ethics and accreditation requirements. Access to and the use and disclosure of electronic protected health information is limited to the minimum necessary to fulfill the employee's obligations and duties. When accessing systems or applications that contain electronic protected health information including systems or applications administered by health plans or other providers; the following procedures must be followed. Whenever possible, the de-identified information will be used. The policy revealed the Procedures included, H. Employees log off the network or, at a minimum, lock their workstation when leaving the work area, and J. Computer monitors are positioned so that unauthorized persons cannot easily view information on the screen.Observation and interview on 12/16/25 at 8:31 AM revealed a medication cart unattended in the hallway, with the computer screen unlocked. The unlocked computer screen displayed personal and medical information for R 107, including allergies and medication use, and listed the names and code statuses of Residents 78, 121, 107, 70, and 27. Unit Manager (UM) 3 observed the deficient practice, entered Resident 107's room and verbally instructed RN 9 to step away and lock the computer screen. At 8:42 AM, the computer screen remained unlocked. UM 3 returned and instructed RN 9 to correct the issue. At 8:45 AM, RN 9 locked the computer screen, RN 9 stated the screen was not within her line of sight and acknowledged staff were required to lock the screen or log out of the computer when stepping away, to protect residents' PHI.During an interview on 12/16/25 at 8:52 AM, RN 2 stated the computer screen on the medication cart should be locked when unattended and stated that doing so prevented unauthorized viewing of residents' personal and medical information by visitors, staff, or other residents.During an interview on 12/16/25 at 9:01 AM, UM 3 stated nurses were required to lock medication cart computer screens to protect residents' personal information and prevent unauthorized access. UM 3 further stated that staff had been educated to lock the screen whenever stepping away from the workstation.During an interview on 12/18/25 at 4:31 PM, the Director of Nursing (DON) stated that computer screens must be secured by locking the screen, positioning the cart to prevent viewing, or closing the laptop. The DON stated nursing staff were expected to protect residents' PHI.During an interview on 12/18/25 at 5:12 PM, the Administrator (ADM) stated that all staff were expected to follow the Health Insurance Portability and Accountability Act (HIPAA) requirements and lock computer screens to protect residents' PHI. The ADM further stated that agency staff received the facility's privacy policies and completed a pre-test prior to working at the facility.

Based on record review, observation, and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 Resident (R)103 of 1 resident reviewed for bowel and bladder incontinence. Findings include:Review of R103's Resident Face Sheet revealed the facility admitted R103 on 03/17/23. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of vascular dementia, disorientation, and muscle weakness. Review of R103's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/06/25, revealed R103 had a Brief Interview of Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident required partial to moderate assistance with activities of daily living (ADLs). The MDS indicated the resident was frequently incontinent of urine. The MDS indicated that the resident required partial/moderate assistance with toileting hygiene. Review of R103's Care Plan included a problem area initiated 03/29/23, that indicated the resident was at risk of skin breakdown related to impaired cognition, communication, mobility, and bowel/bladder incontinence. Interventions directed staff to provide toileting/incontinence care as needed (initiated 03/29/23). Review of R103's Care Plan included a problem area initiated 03/29/23, that indicated the resident was at risk for complications related to the need for support with ADL care. Interventions directed staff to provide incontinence care as needed (initiated 03/29/23). During an observation on 12/15/25 at 9:56 AM, R103 was observed awake, lying in bed, dressed in a pajama top, and was wearing an incontinent brief. A visible urine stain under the resident's bed pad was observed, which was underneath the resident. R103 stated they were unsure of when their bed was last changed. During an observation on 12/15/25 at 10:45 AM, R103 was observed lying in bed sleeping and the urine stain was still visible on the resident's bed pad and bed sheet. During an observation on 12/15/25 at 1:00 PM, R103 was observed sitting on the side of their bed, eating from their lunch tray, which had been placed on the resident's bedside table. The resident's bed still had not been changed and was in the same condition as before. R103's bed pad was still on the bed, and the bed sheets still had the same large urine stain visible. During an interview on 12/15/25 at 10:04 AM, Certified Nursing Assistant (CNA) 19 stated he was not assigned to R103 but was assigned to the other resident in the room. CNA 19 stated he had not seen any issues with R103 that morning, but the resident had been sleeping, and he had not really looked at the resident. During an interview on 12/15/25 at 1:05 PM, Unit Manager (UM) 1 stated his expectation was CNAs checked on residents every two hours and more often as needed. During the interview, UM 1 was taken to R103's room and shown the condition of the resident's bed sheets and the stain on the bed. UM 1 agreed that the stain looked like urine and stated it was unacceptable. He stated the resident's bed should have been taken care of earlier. UM 1 stated he had been in the resident's room earlier in the day but had not noticed the state of the resident's bed. He stated that the CNA assigned to R103 was CNA 8, and she was currently in another resident room. UM 1 stated he would let the CNA know R103's bed needed to be changed.During an interview on 12/15/25 at 1:30 PM, CNA 8 stated that she worked through a contracted nursing staffing agency and had not provided care to R103 before. CNA 8 stated that she checked on R103 at 7:00 AM that morning and asked if they were okay. She stated that she had not noticed any urine stains on the resident's bed. She stated that she also checked on the resident before her break at 11:00 AM and had not noticed any urine stains on the bed. During an interview on 12/16/25 at 1:48 PM, The DON stated that the frequency of resident rounding was based on the resident's care plan. She stated there was no set time schedule for resident rounding and expected the CNAs to frequently round on the residents. The DON stated her expectation of the care for R103 was that the CNA assigned to the resident should have observed the resident and identified any care issues. During an interview on 12/18/25 at 8:34 AM, The ADM stated that the facility did not have an actual time frame for the staff to round on the residents, but the rounding should have been done as quickly as possible and as often as needed to meet the needs of the residents. He stated the facility staff did not lock themselves down to a particular time frame. The ADM stated he had been made aware of the situation with R103. The ADM stated his expectation was that once the situation with R103 was brought to the attention of the staff, the staff should have gone in and addressed the situation with the resident or any other resident who needed assistance.

Based on interview, record review, facility document review, and policy review, the facility failed to ensure that the safety locks on a shower chair were properly locked and secure for 1 of 5 residents (R)1 reviewed for accident hazards. This failure resulted in R1 experiencing a fall without injury.Findings include:Review of a facility policy titled Fall Management dated 05/05/23 revealed, 3. The facility provides assistive devices based on individual resident needs to facilitate mobility and prevent falls. Review of a facility document titled Staff Education/Orientation Policies and Procedures competency for a Shower, revised 01/12/24, revealed performance criteria included, 1. Evaluates the patient/resident's ability to assist with or participate in any part of the shower. Encourages participation where appropriate. 2. Explains procedure to patient/resident. 3. Provides for privacy. 4. Gather hygienic aides, toiletry items and linens. 5. Assist with removing robe, gown, or pajamas. 6. Perform hand hygiene and applies gloves and assist with washing. The policy/procedure did not address safety measures for assistive devices, including a shower chair.Review of R1's Face Sheet indicated the facility admitted R1 on 02/28/25. According to the admission Record, the resident had a medical history that included diagnoses of osteoarthritis and repeated falls. Review of R1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/05/25, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident required set up or clean-up assistance (helper sets up or cleans up and assists only prior to or following the activity) with showers/bathing. R1's Care Plan included a problem statement, started 03/08/25, that indicated the resident had a history of falling related to debility, osteoarthritis, and poor safety awareness. The Care Plan also revealed a problem statement, started 03/08/25, that indicated the resident had self-care deficits related to poor activity tolerance and weakness. An intervention started on 03/08/25, directed staff to bathe the resident per facility protocol. R1's Morse Fall Scale, dated 02/28/25, indicated the resident was a high fall risk. Review of a Patient/Resident Incident/Accident Investigation Worksheet, dated 06/13/25, revealed a Certified Nursing Assistant (CNA) reported that R1 was in the shower and tried to sit down on the shower chair and fell. Per the facility's investigation, the resident sustained no injury. The investigation worksheet revealed the CNA was educated related to ensuring the shower chair was locked prior to residents getting up or sitting down on the shower chair. During an interview on 12/15/25 at 11:12 AM, R1 stated that the staff member who gave them a shower did not lock the shower chair. R1 stated that as they were sitting down, the shower chair rolled backward. During an interview on 12/17/25 at 2:02 PM, CNA 20 stated that she did not lock the shower chair when she assisted R1 with a shower. She stated that when R1 attempted to sit down, the shower chair moved out from under them. She stated that the chair rolled backwards, and the resident fell on their back and buttocks. During an interview on 12/17/25 at 1:47 PM, Licensed Practical Nurse (LPN) 21 stated that CNA 20 notified her that R1 fell on the floor. She stated she asked CNA 20 if the shower chair was locked, and the CNA revealed that it was not locked. LPN 21 stated that the resident also confirmed that the shower chair was not locked. During an interview on 12/18/25 at 1:12 PM, the Director of Nursing (DON) stated that the root cause of R1's fall was the staff member's failure to lock the wheels on the shower chair. She stated her expectation was for staff to lock the wheels on the shower chair. During an interview on 12/18/25 at 2:50 PM, the Administrator stated he expected staff to lock the shower chair wheels. He stated that the CNA should have locked the wheels on the shower chair for R1.

Based on facility policy, record review, and interviews, the facility failed to provide the bed hold policy to Resident (R)1 and/or Resident Representative (RR) in a timely manner for 1 of 1 reviewed for hospitalization . Findings include: Review of the facility policy Leadership Policies and Procedures Section III: Organization Ethics, Subject: Bed Hold Policy, revision dated 10/23/19, revealed Policy: 1. Facility's staff will provide each patient/resident or their qualified legal representative with facility's written bed-hold policy at the time of admission and each time the patient/resident leaves the facility for hospitalization or therapeutic leave. Procedures: 2. Written notice of facility's bed hold is included in the Admission Handbook and is provided to each patient/resident or his/her legal representative at the time of admission. Written notice is also provided at the actual time of transfer for hospitalization or therapeutic leave, and specifies the duration of the bed-hold period. Review of R1's Electronic Medical Record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: Asymptomatic human immunodeficiency virus infection status, human immunodeficiency virus disease, cognitive communication deficit, difficulty in walking, other lack of coordination, muscle weakness (generalized), and mild cognitive impairment. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 12/13/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R1 has no cognitive impairment. Review of R1's electronic medical record (EMR) revealed R1 was discharged to the hospital on 12/26/24. There was no documentation of a bed hold notification given to the resident and/or responsible party prior to R1's transfer to the hospital. During an interview on 01/29/25 at 1:10 PM, the Social Services Director who stated the bed holds are usually completed by the Business Office Manager (BOM) and Admissions. During an interview on 01/29/25 at 1:19 PM, the BOM who reported that she obtains the midnight census when arriving at work and before morning meeting. If any residents are noted to have been sent out of the building their name will be added to the spreadsheet for follow up. BOM stated that she does not make contact and thought the admissions department made contact. It was reported that she was new and started about 3 weeks ago but works closely with admissions. During an interview on 01/29/25 at 1:37 PM, the Admissions Director stated that she had never been told to do bed holds and had worked at the facility for three months. She stated that what she does is put the resident out in Matrix Care. She verbalized seeing the bed hold forms and that there was a bed hold policy book at every nurse's station. She reported that R1 was discharged with an expected return and was not on a bed hold and had Humana. Bed holds are only provided when a resident has Medicaid, managed Medicaid, and complex Medicaid. During an interview on 01/29/25 at 6:11 PM, the Admissions Director reviewed the bed hold policy provided to the surveyor. It was confirmed that the policy was not provided on the day of the transfer to the resident or the responsible party. It was confirmed by reading the first paragraph out loud that it should have been given. It was confirmed that the ombudsman was not notified. During an interview on 01/29/25 at 6:20 PM, the Administrator reported that the bed hold policy is reviewed on admission and when residents are leaving for any reason regardless of payor source. The administrator agreed that if there is not a signed document available the task was not completed.

Based on review of facility policy, observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for a resident with aggressive behaviors for 1 of 2 residents reviewed, Resident (R)02. Findings include: Review of the facility's policy titled, Care Plan Process, Person Centered Care dated 05/2023 revealed, Policy: The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person - centered care of the resident that meet professional standards of quality care. Procedures: Following RAI Guidelines develop and implement a comprehensive person - centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Review of R02's Face Sheet revealed R02 was admitted to the facility on [DATE] with diagnoses including but not limited to; aphasia, hemiplegia and diabetes mellitus. Review of R02's Quarterly Minimum Data Set (MDS) with Assessment Review Date (ARD) date of 12/19/24 revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R11 was moderately cognitively impaired. Review of R02's Care Plan with a start date of 03/27/24 and target date 04/30/25 documented, focus Receives antidepressant medication to help with appetite dx of adult failure to thrive. Documented goal Will not exhibit signs of drug related sedation, hypotension or anticholinergic symptoms. Documented intervention revealed, Monitor resident's mood and response to medication including weight. Further review of the Care Plan revealed that there was no new psychosocial care plan or new interventions related to the incident that occurred on 11/29/24. Review of the 5-day investigation revealed that the social worker would monitor both residents for psychosocial needs as indicated to prevent any further incidences. Review of R02's Physician Order with a start date of 10/12/23 documented, Behavior Monitoring every shift: Antidepressant drug Remeron (mirtazapine) r/t depression monitor for withdrawn/social isolation/ refusal of food/beverage/poor PO intake Special Instructions: Interventions: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quite Time/Rest G: Increased Observation H: Other I: No Interventions Needed Outcomes: 1. Improved, 2. Unchanged, W, Worsened every shift, Day, Second, Third. During an interview on 01/29/25 at 04:04 PM, the Director of Social Services revealed that her assistant would have put the updated care plan in for this resident after the incident on 11/29/24. The Director of Social Services revealed that the full time MDS nurse quit two weeks ago. She stated that there is a part time MDS nurse, but she was not here today. During an interview on 01/29/25 at 04:10 PM, the Director of Nursing (DON) revealed the care plan should have been updated with behaviors and interventions to reflect the altercation. If social services did not do it, MDS should have done it. During an interview on 01/29/25 at 04:15 PM, the Director of Social Services revealed that she had spoken with her assistant, and her assistant thought that she had updated the care plans for both residents, but she guessed she had not.

Based on observation, record review, and interviews, the facility failed to 1.) complete wound care in a manner to prevent cross-contamination for one of four residents (Resident (R) 25) reviewed for pressure ulcers, 2.) and failed to administer medications in a manner to prevent cross-contamination for three of three residents (R50, R53, and R31) observed for medication administration out of a total sample of 25, and 3.) failed to complete yearly reviews of the facility's infection control policies and procedures. These failures had the potential for spreading infections to the vulnerable population in the facility. Findings include: 1. Review of R25's undated Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses which included diabetes mellitus, asthma, and atrial fibrillation. Review of R25's admission Minimum Data Set (MDS) located under the MDS tab in the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 11/11/24 coded the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of R25's Physician Orders located under the Orders tab in the EMR revealed an order, dated 11/15/24, which revealed Daily wound Treatment: Location stage 4 [sic] wound on sacrum, cleanse with wound cleanser/NS [Normal Saline], apply Medi Honey with alginate calcium w [with] silver, cover w [sic] boarder gauze dressing. During a dressing change observation to R25's sacrum and interview on 11/25/24 at 2:45 PM, the Wound Care Nurse (WCN) was asked if R25 should have been in Enhanced Barrier Precautions (EBP). WCN stated, Yes, she should, but I don't see a sign on the door. When asked if WCN had been wearing her gown and gloves during the previous dressing changes and WCN stated, I have to be honest and tell you I have not been wearing a gown. I look to see if a sign is on the door for the Enhanced precautions and if I don't see one, then I don't wear a gown. During the observation, the overbed table was wiped down with a Sani Cloth and a barrier was applied directly after cleaning. The WCN did not wait for the dry time of the Sani Cloth to have occurred. R25 had bowel movement on the buttocks prior to the dressing change. The WCN, using a wipe, wiped the resident's bottom cleaning the bowel movement in an upward fashion toward the wound. When cleaning the wound with the wound cleanser, the WCN patted the wound dry several times using the same 4x4. The WCN opened the container of Medi Honey and applied this to alginate calcium with silver. The WCN proceeded to apply this to the wound with the same gloves as she had used to open the Medi Honey container that had been stored in the wound care cart with the other supplies used for other residents. During an interview on 11/25/24 at 3:10 PM, the WCN stated, I should have waited for the dry time before I placed the barrier down on the overbed table. WCN was asked the dry time of the Sani Cloth that was used and WCN replied, It is two minutes. WCN continued to state, I forgot, and I should have used a new 4x4 to dry the wound instead of patting it dry with the same one. I should have changed my gloves after I had opened the Medi Honey container before I dressed the wound. During an interview on 11/26/24 at 10:21 AM, the Director of Nursing (DON) stated, I expect the wound care nurse to follow physician orders and standard of nursing which includes infection control for a dressing change. During an interview on 11/25/24 at 5:55 PM, the Infection Preventionist (IP) nurse stated, The nurse should wait for the total dry time after wiping down the overbed table prior to placing a barrier on the table. You should never clean a resident toward the wound, you should always go away from the wound. The nurse should have changed her gloves after she opened the container of Medi Honey up and did not use the same gloves that she opened to apply the clean bandage to the wound. 30260 2. During medication administration observation on 11/24/24 at 5:00 PM, Licensed Practical Nurse (LPN)6 prepared to administer a tube feeding for R50. R50 had an enhanced barrier precautions sign on her door, an infection control tool indicating a requirement for gowns and gloves during high-contact resident care activities to reduce the spread of multidrug-resistant organisms. LPN6 entered R50's room to set up tubing, syringe, and tube feeding using a pump. LPN6 performed hand hygiene, donned a pair of gloves, and checked R50's PEG (percutaneous endoscopic gastrostomy) tube was inserted through the abdomen wall and into the stomach to provide nutrition for residual and placement. LPN6 then administered the tube feeding to R50. LPN6 did not wear a gown during the high contact procedure with R50. At 5:37 PM, LPN6 finished administering R50's tube feeding and with the same pair of gloves used during the administration, she gathered the used supplies and trash and touched the room door with the gloved hand to take out the trash. LPN6 discarded the trash in the bin attached to her medication cart and returned to R50's room with the same gloves. LPN6 returned to R50's room at 5:38 PM and ungloved without performing hand hygiene. LPN6 collected the rest of her supplies from R50's room and returned to her medication cart. During an interview on 11/24/24 at 5:44 PM, LPN6 stated she was not sure what the enhanced barrier sign on R50's door was for. LPN6 stated the sign must be for the staff to use gowns when performing personal care for the resident but did not believe it applied to her because she used a clean technique, wore gloves, and controlled any splash with a towel. LPN6 stated during report she was not told R50 had any active infection. LPN6 stated she had received infection control training in the facility. When told she was observed donning gloves without hand hygiene and failing to perform hand hygiene after taking off her gloves, she acknowledged the hand hygiene breaches. 3. During observation of medication administration with LPN2 on 11/25/24 at 8:18 AM, while standing at the medication cart, LPN2 placed a pair of gloves in her pocket and performed hand hygiene. LPN2 entered R53's room. LPN2 left the room to retrieve a vital sign machine. LPN2 returned to the room with the vital sign machine in a pouch and placed the pouch on R53's bed. Without performing any further hand hygiene, LPN2 donned the gloves in her pocket. LPN2 performed vital signs. LPN2 administered eye drops for R53 with the same gloved hands. LPN2 touched drawers in R53's room looking for the lidocaine cream. Without taking off the gloves LPN2 opened the lidocaine cream and applied the cream on R53's right upper arm. LPN2 replaced the cap on the lidocaine cream and retrieved cling film from the drawers to wrap the lidocaine cream on R53's right upper arm. Finding it difficult to lift the film with a gloved hand, LPN2 took off just one glove from her right hand, placed the glove on the bedside table, removed the cling film, wrapped it on R53 right upper arm, and then put the same glove on. LPN2 returned to her medication cart, retrieved cleansing wipes and used it to clean the blood pressure machine before finally taking off the gloves and performing hand hygiene. During an interview on 11/25/24 at 8:35 AM when informed of the foregoing breaches in hand hygiene and infection prevention and the fact that she used only one pair of gloves the entire time she was in R53's room LPN2 acknowledged the hand hygiene breaches. 4. During medication observation and interview on 11/25/24 at 4:22 PM, LPN1 donned a pair of gloves without first performing hand hygiene to enter R50's room to perform a fingerstick glucose test. After the fingerstick, LPN1 left R50's room with gloves still on, carrying glucometer, retractable lancet, and used alcohol wipes. LPN1 discarded trash in her cart appropriately, ungloved, and returned to the bathroom of R50 to wash her hands. LPN1 withdrew an insulin pen (insulin lispro) from the medication cart that had no open and discard date on it and applied a needle to the pen without first cleaning the rubber septum of the pen. LPN1 applied a pair of gloves. LPN1 gave the medication to R50. LPN1 ungloved without performing hand hygiene. LPN1 returned to the medication cart in the hallway, touched the computer, mouse, cart, and keys in pocket, before moving on to the next resident. At 4:35 PM, LPN1 donned a pair of gloves without performing hand hygiene and went to perform a fingerstick blood test on R13. On 11/25/24 at 4:40 PM, LPN1 returned with a glucometer, and used supplies from R13's room, ungloved at the medication cart, failed to perform hand hygiene after ungloving, touching the cart, computer, and mouse. LPN1 stated at that point she needed to go back into R13's bathroom to wash her hands. When asked why she did not use the hand sanitizer on her medication cart instead of making the journey back into R13's bathroom, LPN1 stated I thought we had to wash our hands before using sanitizer. During an interview on 11/25/2 at 4:42 PM, LPN1 acknowledged the hand hygiene breaches. During an interview on 11/25/24 at 5:54 PM the IP stated enhanced barrier precautions meant that when a resident had a urinary catheter, central line, PEG tube or wounds, staff were to wear enhanced personal protective equipment (PPE), no exceptions. 5. During medication administration observation and interview on 11/26/24 at 8:13 AM, LPN4 entered R31's room without first performing hand hygiene and without donning gloves. LPN4 placed the medication on the bedside table of R31 with no barrier. LPN4 delivered the medication to R31 without gloves. On 11/26/24 at 8:47 AM, LPN4 exited R31's room without performing hand hygiene and returned the albuterol to the medication cart. During an interview, LPN4 acknowledged the foregoing infection control breaches. During an interview with the DON and the Administrator on 11/26/24 at 5:37 PM the DON stated it was her expectation that staff must perform hand hygiene before donning gloves, and after taking them off, should not touch anything in between to prevent cross contamination. The DON also stated that it was her expectation that staff performed hand hygiene before entering a patient's room, and after ungloving. The DON stated LPN6 should have adhered to the EBP sign and worn a gown when administering tube feeding to a resident with a PEG tube. She stated LPN2 should have performed appropriate hand hygiene and should not have reused gloves. The DON stated LPN1 should have performed appropriate hand hygiene and cleaned the rubber septum of the insulin pen before use andLPN4 should have performed hand hygiene and used gloves when administering the albuterol. 6. Review of the facility's infection control policies and procedures, provided by the facility, revealed the revision or review of the policies that occurred on 07/20/23. During an interview on 11/25/24 at 10:30 AM, the DON stated, We had several revisions of the infection control policies last year. After reviewing the dates provided to me, the DON stated, These should have been reviewed in July of this year and it wasn't. During an interview on 11/26/24 at 3:15 PM, the Administrator stated, Then these (policies) weren't reviewed annually.

Based on observation, interview, record review, and facility policy review, the facility failed to obtain a physician's order prior to the administration of oxygen for one of two residents (Resident (R) 25) out of 25 sampled residents. This failure had the potential for R25 to have adverse reactions from the administration of oxygen. Findings include: Review of the facility's policy titled, Oxygen Therapy, dated 02/12/24, revealed Verify the provider's order for the oxygen therapy . Review of R25's undated Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses which included diabetes mellitus, asthma, and atrial fibrillation. Review of R25's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/11/24 coded the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R25 was cognitively intact. During an observation on 11/24/24 at 2:10 PM and on 11/25/24 at 2:45 PM, R25 had oxygen on at two L/min (liters/minute) by nasal cannula. During an observation and interview on 11/25/23 at 9:10 AM, the Assistant Director of Nursing (ADON) accompanied the surveyor to R25's room. When the ADON was asked how much oxygen R25 was receiving by nasal canal, the ADON stated, It is on two and one-half liters/minutes. The ADON went to review the EMR and confirmed that R25 did not have an order for the administration of oxygen. ADON stated, You have to have an order for oxygen. During an interview on 11/26/24 at 10:19 AM, the Director of Nursing (DON) stated, There should be an order to administer oxygen.

Based on interviews, record review, and review of facility documents, the facility failed to ensure showers were conducted according to resident preferences for one (Resident (R) 24) of 25 sampled residents. This failure denied the resident the right to self-determination for showers. Findings Include: Review of the facility's policy titled, Social Service Policies and Procedures, revision date of 10/01/20, revealed The Facility employs measures to ensure patient and resident personal dignity, well-being, and self-determination are maintained and will educate patients and residents regarding their rights and responsibilities. The Facility has established the Patient/Resident [NAME] of Rights and Responsibilities in accordance with state and federal regulations. The Facility will communicate the Patient/Resident [NAME] of Rights and Responsibilities to the patient and residents in a language or means of communication that ensures patient and resident understanding. The [NAME] of Rights is recognized and supported by all facility staff. Staff document the communication and provision of this information when provided to the patient, resident, and legal representative. The Facility will ensure residents can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. Review of R24's Face Sheet, located under the Face Sheet tab of the electronic medical record (EMR), revealed the resident was admitted on [DATE] with a diagnosis of spinal stenosis, site unspecified, hypertensive heart disease with heart failure, diabetes mellitus due to an underlying condition without and morbid (severe) obesity with alveolar hypoventilation. Review of R24's Physician Orders, located under the Orders tab of the EMR and dated 02/19/24, revealed that R24's shower days were Sunday and Thursday. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/24 and located under the MDS tab of the EMR revealed R24 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. It was recorded that R24 required partially to moderate assist with bathing. Review of R24's Care Plan, located under the Care Plan tab of the EMR, and revised 09/03/24, revealed ADL CARE ---- [R24] is at risk for complications related to the need for support with ADL CARE. She has chronic pain and impaired mobility, debility. Assist with bed mobility and transfers as needed. During an interview on 11/24/24 at 1:43 PM, R24 revealed she was not getting showers. R24 stated she should be getting way more showers than she was receiving. R24 stated she was supposed to get two showers a week. R24 stated they would provide her with a bed bath, but not a shower. She stated she would like a shower. During an interview on 11/26/24 at 2:42 PM, the Social Service Director (SSD) revealed that R24 had come to her office yesterday and had discussed going home. She stated R24 came by often, and she never mentioned not getting her showers. The SSD looked in the shower book for October and November, and R24 had only two shower days for those months, one on 10/23/24 and one on 11/21/24. The SSD stated she was getting with nursing about the issue. During an interview on 11/26/24 at 4:52 PM, the Administrator and Director of Nursing (DON) revealed resident showers were set up during their care plan meeting and noted in the physician orders. They stated they would look into why the resident only received two showers in the last two months.

Based on interview and record review, the facility failed to issue accurate Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) to one of two residents (Resident (R) 74) and a Notice of Medicare Non-Coverage (NOMNC) forms and a SNFABN to one of two residents (R75) reviewed for liability and beneficiary notices out of total sample of 25. This failure had the potential for residents or their responsible parties not to have all the information to make an educated decision about the ending of skilled services. Findings include: 1. Review of R74's electronic medical record (EMR) Census tab, revealed the resident was admitted on [DATE] for Medicare A services. Review of a document, completed by the facility and listing the residents who had been discharged from skilled services revealed R74 was issued a NOMNC on 09/19/24. It was documented that the facility did not issue the SNFABN to R74 because R74 did not appeal. 2. Review of R75's EMR Census tab revealed the resident was admitted on [DATE] for Medicare A skilled services. Review of a document, completed by the facility and listing the residents who had been discharged from skilled services, revealed R75's spouse was notified by phone that R75's Last Covered Day for skilled services was 07/19/24. It was recorded R75 received her skilled services through a managed care plan instead of Medicare, and that the resident could call United Healthcare for any assistance with her services. It was documented that R75 was not issued a SNFABN because no appeal was filed. During an interview on 11/26/24 at 1:07 PM the SSD stated she only issued the SNFABN for Medicare Part B residents in the building. When asked how she received the NOMNC to issue to residents, she stated she received them from a case manager. The SSD was not aware that she was supposed to create the NOMNCs for Medicare A residents in the facility and was under the impression that SNFABNs were only issued if a resident appealed the NOMNC they were issued. She was not aware the SNFABN was to be issued to any resident with remaining Medicare A days and remaining in the facility.

Based on record review, interview, and facility policy review, the facility failed to ensure a written copy of the baseline care plan was provided to the resident and/or responsible party (RP) within 48 hours for one of one resident (Resident (R) 25) reviewed for baseline care plans of 25 sample residents. This failure had the potential for residents and/or RP not to be informed of the plan of care. Findings include: Review of the facility's policy titled, Care Plan Process, Person-Centered Care, dated 05/03/23, revealed . Provide the resident and their legal representative (if applicable) a copy of the baseline person-centered care plan summary . Review of R25's undated Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses which included diabetes mellitus, asthma, and atrial fibrillation. Review of R25's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/11/24 coded the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R25 was cognitively intact. Review of R25's Baseline Care Plan located under Care Plan tab in the EMR, revealed this care plan was dated on 11/05/24 and had signatures of staff members but no documentation that the written baseline care plan was given to R25. During an interview on 11/26/24 at 8:35 AM, the Social Services Director (SSD) stated, I will attempt to go and give it to the residents but if they are hard to find in their rooms, I will sometimes forget to go back to give this information. During an interview on 11/26/24 at 10:00 AM, R25 stated, I don't remember getting anything from the staff about this. During an interview on 11/26/24 at 2:30 PM, the Director of Nursing (DON) stated, The Social Worker should make sure she gets a written form of the baseline care plan to the residents. If she is having trouble in getting this done, then she needs to ask someone to help her.

Based on record review, interviews, and facility policy review, the facility failed to 1.) ensure the comprehensive care plan included the resident's religious preference for one of one resident (Resident (R) 42) reviewed for activities based on a resident's mental and psychosocial needs out of 25 sample residents. This failure had the potential to cause R42's psychosocial needs not to be met, and 2.) failed to develop a comprehensive care plan (CP) for a pressure ulcer for one of four residents (Resident (R) 25) out of 25 sampled residents. This failure had the potential for R25 to have an inaccurate plan of care for a stage four pressure ulcer. Findings include: Review of the facility's policy titled, Care Plan Process, Person-Centered Care, last revised 05/05/23, revealed: . The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes trying to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and understanding the resident's life before coming to reside in the nursing home. 1. Review of R42's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (Primary), urinary tract infection, site not specified, pain in throat, sacrococcygeal disorders, not elsewhere classified, muscle wasting and atrophy, acute atopic conjunctivitis, and chronic pain syndrome. Review of R42's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/01/24 and located under the MDS tab of the EMR, revealed R42 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R42's Care Plan, located under the Care Plan tab of the EMR revealed under the Activities category, dated 10/03/19, Problem: [R42] prefers to do his activities in his room, such as listening to R&B [Rhythm and Blues] music/TV and visiting with friends and family .Goal . [R42] will engage in independent activities such as listening to music/TV talking on the phone to friends and family .Approach .Approach Start Date: 07/29/2022 Staff will play R&B, gospel, rap, jazz music of his interest during weekly visits. 07/29/2022 staff Will play religious services of his interest on his TV or our radio during weekly visits. During an interview on 11/24/24 at 1:45 PM, R42 stated the facility did not provide accommodation for his religious preferences and that all activities were Christian. R42 also stated that sometimes the facility gave him a ham sandwich and he did not eat ham because he is a Muslim. During an interview on 11/25/24 at 2:39 PM, the Activity Director (AD) stated R42 was invited to activities and participated occasionally in group activities when he was not in dialysis. The AD stated if he could not be there, activities would still provide him the snacks shared during activities. When asked what R42's religion was, she stated R42 was a Christian. When asked if R42's profile revealed his religion, the AD stated she was unaware. The AD stated she was aware R42 did not like pork products but did not know it was a religious preference. When informed activities listed in R42's care plan included gospel music, which the resident did not subscribe to it, the AD reiterated that she was unaware of R42's religious preferences and that the care plan entry was entered by her predecessor. During an interview on 11/25/24 at 2:57, the MDS Coordinator (MDSC) stated she was aware R42 was a Muslim but did not believe he actively practiced his religion. When asked if she had asked R42 whether he practiced his religion or if she assessed R42 for his religious preferences, she stated she had not. During an interview on 11/26/24 at 9:26 AM, the Registered Dietician (RD) stated she was not aware R42 was a Muslim with religion-related dietary preferences. The RD stated R42 had requested bacon and other pork products before. The RD stated she was not aware it was in R42's profile that he was a Muslim. During an interview on 11/26/24 at 10:14 AM, the Social Services Director (SSD) stated she had been the SSD for about one year. The SSD stated she was unaware R42 was a Muslim. The SSD stated she did not know if R42 was attending mosque or if he was an active Muslim. When informed that R42's religion was on his profile in his face sheet, the SSD stated she was new to the facility and did not know and that she would work with activities to honor R42's religious preferences. During an interview on 11/26/24 at 12:51 PM, the Dietary Manager (DM) stated she was aware he did not like pork, and this was reflected in his tray card. The DM stated she did not know why he did not like pork products and believed it was just his preference. During an interview on 11/26/24 at 6:07 PM, the Administrator stated he did not know R42 was a Muslim or what his religious preferences were. The Administrator stated that to his knowledge, R42 was very vocal, and his food preferences varied over a period of time, and that he had delivered pizza with pork products to R42's room on occasion. The Administrator acknowledged that it was on R42's profile that he was a Muslim, and the facility had failed to ensure that this information was reflected in R42's care plan. 28306 2. Review of R25's undated Face Sheet located under the Face Sheet tab of the EMR revealed the resident was admitted on [DATE] with diagnoses which included diabetes mellitus, asthma, and atrial fibrillation. Review of R25's admission MDS located under the MDS tab in the EMR with an ARD of 11/11/24 coded the resident as having a BIMS score of 15 out of 15 which indicated R25 was cognitively intact. R25 was also coded as having a skin tear with MASD [Moisture Associated Skin Damage] and was at risk for developing a pressure ulcer. Review of R25's Physician Orders located under the Orders tab in the EMR revealed an order dated 11/15/24, which revealed Daily wound Treatment: Location stage 4 [sic] wound on sacrum, cleanse with wound cleanser/NS [Normal Saline], apply Medi Honey with alginate calcium w [with] silver, cover w [sic] boarder gauze dressing. Review of R25's Wound Evaluation & [and] Management Summary, dated 11/20/24 and located under the Wound Management tab of the EMR, revealed the resident had a stage four pressure wound to the sacrum and the treatment plan was Alginate calcium w [with]/silver apply once daily for 23 days; Leptospermum of [medical grade of honey] honey apply once daily for 23 days. Review of R25's Care Plan located under the Care Planning tab in the EMR and dated 11/12/24, revealed a Problem as .has a current wound/disruption of skin surface: MASD with skin tear. The Approach was CNA [Certified Nurse Assistant] to inspect skin, especially over bony prominences, during bathing and personal care. Encourage fluids to maintain hydration. Licensed nurse to complete wound observation .Minimize skin exposure to moisture from incontinence, perspiration, or wound drainage by mild cleansing agents and using skin barrier cream for skin protection .Use aseptic techniques when performing dressing changes. Dress and cover wo Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictates the need such as but not limited to falls and pressure ulcer development would [sic] before dressing other wounds, washing hands and observing aseptic technique. Use draw sheets or similar for positioning and turning to maintain skin integrity . A care plan for the stage four pressure area was not documented. During an interview on 11/26/24 at 11:00 AM, the Director of Nursing (DON) stated, I see the one [CP] for the MASD but do not see where they started one for the pressure ulcer. The nurses should have started one for that.

Based on observation, record review, interviews, and facility policy review, the facility failed to promote dignity during a dressing change for one of one resident (Resident (R) 25) of 25 sample residents. This failure caused R25 to have increased anxiety during a dressing change. Findings include: Review of the facility's policy titled, Social Services Policies and Procedures, dated 06/09/23, revealed . Well-being/Quality of Life: The Department addresses the physical, mental, social, and emotional well-being of each patient and resident served in the facility. in doing so, the Department assists every patient and resident to achieve maximum quality of life . Quality of life begins with the preservation of a sense of dignity and individuality . Review of R25's undated Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses which included diabetes mellitus, asthma, and atrial fibrillation. Review of R25's admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/11/24 coded the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R25 was cognitively intact. R25 was also coded as having a skin tear with MASD [Moisture Associated Skin Damage] and was at risk for developing a pressure ulcer. During a dressing change observation on 11/25/24 at 2:45 PM to R25's sacrum area, Licensed Practical Nurse (LPN)5 entered R25's room and was explaining that her roommate was having to be transported to the hospital for a blood transfusion. Approximately ten minutes later, LPN5 came back into the room and held the privacy curtain together while two male attendants from the transport ambulance came into the room. LPN5 was asked if this could wait for a few minutes and she stated, No, this is an emergency. R25 became very anxious by trying to pull her gown down and trying to move her hips so that her sacral area could not be seen by the male ambulance attendants that had entered the room. R25 was in the first bed in the room and the roommate that was being transported to the hospital was in the second bed by the window. LPN5 proceeded to give report to the ambulance attendants, then they transferred the roommate to the stretcher and left the room. After the Wound Care Nurse (WCN) finished the dressing to R25, she apologized to the resident because there were male attendants that came into the room. During an interview with R25 after the dressing change the resident stated, I really didn't like them coming into my room at that time. If they could just have waited, it would have taken the nurse about five more minutes, and she would have been done. During an interview on 11/25/24 at 3:26 PM, LPN5 was asked if the practice was to allow male attendants with a transport team to come in a resident's room while R25 was having a dressing change to the sacral area. LPN5 stated, That was why I held the curtain together, so they would not see her. I deal with emergencies first. During an interview on 11/25/24 at 3:35 PM, the Director of Nursing (DON) stated, They could have waited five minutes for the nurse to finish the dressing change. The transport was urgent not emergent.

Based on record review and interview, the facility failed to have collaboration of care with the dialysis center for one of two resident (Resident (R) 21) reviewed for dialysis out of 25 sampled residents. This failure had the potential to put R21 at risk for lack of communication between the facility and the dialysis center, Findings include: Review of R21's undated Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) indicated R21 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus and end stage renal disease. Review of R21's admission Minimum Data Set (MDS) located in the EMR under the MDS Assessment tab with an Assessment Reference Date (ARD) of 10/31/24 revealed the resident was coded as receiving dialysis services while a resident in the facility. Review of R21's Physician Order located in the hard chart of the medical record, under the Orders tab, revealed orders, dated 10/24/24, which revealed R21 had dialysis on Mondays, Wednesdays, and Fridays. Review of R21's Hemodialysis Communication Record provided by the facility, revealed the records, dated 11/06/24, 11/15/24, and 11/18/24, had documentation missing from the dialysis center for shunt site (which described the location, dressings, pain and change in condition), lab values which described the events during the course of treatment, medications given at dialysis, recommendations, and food/fluid intake along with missing signatures and dates. The communication sheets for 11/06/24, 11/09/24, and 11/15/24 had documentation missing from the shunt observation of the dressing, assessment of the auscultation of the bruit, palpation of thrill, and if the resident reported pain. During an interview on 11/26/24 at 10:02 AM, the Director of Nursing (DON) stated, The nurses are to call dialysis center and get a verbal report if the communication sheet is not completely filled out. The nurses are also to do an assessment of the resident when they return to the facility.

Based on observation, record review, interview, and review of facility policy, the facility failed to maintain a medication error rate below five percent. Three errors/omissions out of 26 opportunities resulted in a medication error rate of 11.54% for three of three residents (Resident (R)13, R31, and R30) of 25 sample residents. This failure had the potential to cause residents to not receive the proper dosages of their medications. Findings include: Review of facility's policy titled, Physician Orders, last revised 05/05/23, revealed Medication/Treatment 1. The facility should not administer medications or biologicals except upon the order of a physician/prescriber lawfully authorized to prescribe them. 2. Elements of the medication order include: A. Full name, date of birth, and room number of the resident B. Name of medication C. Strength of medication, where appropriate D. Dosage E. Form of drug (tab, liquid, solution, etc.) F. Time or frequency of administration G. Route of administration H. Quantity or duration of therapy, if limited I. Diagnosis or indication of use J. Parameters for holding medication if indicated. K. Prescribers full name Review of the facility's policy titled, Medication Management Program, last revised on 05/05/24, revealed .4.Authorized staff must understand: A. Indications or reason for therapy. B. Effectiveness for achieving the therapeutic goal. C. Drug actions. D. The 8 Rights for administering medication: 1) The Right Patient/Resident 2) The Right Drug 3) The Right Dose 4) The Right Time 5) The Right Route 6) The Right Charting 7) The Right Results 8) The Right Reason .5. The same person authorized medical or licensed person prepares, administers, and records the medications . 15. Outdated medication is destroyed or returned to the pharmacy according to applicable state rules and regulations. A new supply of medication is obtained, when necessary. 16.Medications are dispensed at the time of administration. Pre-pouring or dispensing for a later administration time is not permitted .5.The authorized staff member validates the following information is documented on the MAR (Medication Administration Record): A. Correct physician's order and diagnosis for each medication. 8. Medication and label are correct .6.The authorized staff member reads the label on the medication three (3) times. A. Before removing the medication from the drawer. B. Before dispensing the medication. C. After dispensing the medication .11. Immediately after administering the medication to the resident, the authorized staff or licensed nurse will return to the medication cart and document medication administration with initials on the MAR. If a medication is not administered, the authorized staff or licensed nurse must explain why it was not given .16. Once removed from the package or container, unused doses should be destroyed following facility policy and documenting the destruction according to facility policy. 1. Review of R13's physician orders located under the Orders tab of the electronic medical record (EMR), revealed the order for insulin lispro (an anti-diabetic injection) 100 unit/mL with a sliding scale as follows: Per Sliding Scale If Blood Sugar is less than 60, call MD. If Blood Sugar is 200 to 249, give 2 Units. If Blood Sugar is 250 to 300, give 4 Units. If Blood Sugar is 301 to 349, give 6 Units. If Blood Sugar is 350 to 399, give 8 Units. If Blood Sugar is 400 to 449, give 10 Units. If Blood Sugar is 450 to 499, give 12 Units. If Blood Sugar is greater than 499, call MD. During a medication observation on 11/25/24 at 4:22 PM, Licensed Practical Nurse (LPN)2 checked R13's fingerstick blood sugar. The result was 293, indicating four units of insulin lispro per physician's order were required. LPN2 tuned the dial on the insulin pen containing the medication and approached R13 to give the medication. The surveyor requested to see the number of insulin units about to be given. LPN2 showed it to the surveyor and the dial was turned on five units. At the time of the observation, LPN2 stated the dial must have slipped, turned down the dial to the correct dosage of four units, and administered the medication to the resident. 2. During a medication observation on 11/26/24 at 8:45 AM in the 300 unit, LPN4 put multiple tablets, including one chewable aspirin 81 mg (milligram) for R31 into a cup. R31 was given all the pills in the cup to swallow including the chewable aspirin. During an interview on 11/26/24 at 8:52 AM, LPN4 admitted the aspirin was a chewable tablet and should have been given to the resident to chew. 3. During medication observation in the 300 unit on 11/26/24 at 3:47 PM, LPN7 opened the medication cart and in the cart was an unlabeled and unsecured medication cup containing two tablets. When asked what they were, LPN7 stated they were Lyrica and Carafate meant for R30 that should have been given by LPN4 at 2:00 PM. LPN4 stated the medications were not given because R30 was away from the unit at therapy. When asked what she was going to do with the open medications, LPN7 stated she was going to R30's room to see if he was back on the unit so she could give him the medications. LPN7 picked up the cup from the medication cart and proceeded to R30's room followed by surveyor. In R30's room, LPN7 approached R30 and explained to him that she had brought him the 2:00 PM medications Carafate and Lyrica that he had missed and tried to hand the cup containing the two mediations to R30. LPN7 stated she knew what the medications were because LPN4 had informed LPN7 that she left them in the cart before LPN7 left for the day. During an interview with the Director of Nursing (DON) and the Administrator on 11/26/24 at 5:37 PM the foregoing medication errors were discussed with them and the DON stated it was her expectation that LPN4 should have followed the correct route of chewing a chewable aspirin and that LPN7 should not have tried to give medications that she did not withdraw herself.

Based on observation, interview, and review of facility policy, the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for one of one resident (Resident (R) 13) and failed to ensure that all drugs and biologicals were stored in locked compartments for one of one resident (R30) out of 25 sample residents. This failure had the potential to cause residents to receive the wrong or contaminated medications. Findings include: Review of the facility's policy titled, Medication Management Program, last revised on 05/05/24, revealed . 5. The same person authorized medical or licensed person prepares, administers, and records the medications . 15. Outdated medication is destroyed or returned to the pharmacy according to applicable state rules and regulations. A new supply of medication is obtained, when necessary. 16. Medications are dispensed at the time of administration. Pre-pouring or dispensing for a later administration time is not permitted .5.The authorized staff member validates the following information is documented on the MAR (Medication Administration Record): A. Correct physician's order and diagnosis for each medication.8. Medication and label are correct .6. The authorized staff member reads the label on the medication three (3) times. A. Before removing the medication from the drawer. B. Before dispensing the medication. C. After dispensing the medication . 11. Immediately after administering the medication to the resident, the authorized staff or licensed nurse will return to the medication cart and document medication administration with initials on the MAR. If a medication is not administered, the authorized staff or licensed nurse must explain why it was not given . 16. Once removed from the package or container, unused doses should be destroyed following facility policy and documenting the destruction according to facility policy. 1. During medication observation in the 100 unit on 11/25/24 at 4:22 PM, Licensed Practical Nurse (LPN)2 took a pen containing the medication insulin lispro out of a transparent plastic bag that contained another identical looking pen with a different medication, with no open and discard date marked on the pen. The plastic bag containing the pen was marked with the name of the other medication, Lantus Solostar 100 U/ML (Units/ Milliliter) (a long-acting insulin). It was observed that the Lispro insulin pen was labeled with R13's name, room number and medication name. However, the date the medication was first opened and the discard date were not written on the pen. When asked when the pen was first opened, LPN2 stated she did not know as she was not the one who opened it. LPN2 stated the pen was good for 28 days after it was first opened. When asked if the medication was appropriate to give since it did not have an opened date and discard date written on it, LPN2 stated she was going to administer it to the patient because the way his sugars run, there is no way the pen could last 28 days. During an interview on 11/25/24 at 5:54 PM, the Infection Preventionist (IP) stated the insulin pen should have been marked with an open date and discard date and that LPN2 should not have given the undated insulin, and it should have been discarded immediately. 2. During medication observation in the 300 unit on 11/26/24 at 3:47 PM, LPN7 opened the medication cart and in the cart was an unlabeled and unsecured medication cup containing two tablets. When asked what they were, LPN7 stated they were Lyrica and Carafate meant for R30 that should have been given by LPN3 at 2:00 PM. During an interview with the Director of Nursing (DON) and the Administrator on 11/26/24 at 5:37 PM the forgoing medication storage and labelling concerns were discussed with them. The DON stated it was her expectation that LPN2 should have discarded the insulin pen that was unlabeled with open and discard dates and followed physician's order for the correct dosage, and LPN7 should not have tried to give medications that she did not withdraw herself and the medications were inappropriately stored.

Based on observation, interview, and record review, the facility failed to ensure food palatability for one of one resident (Resident (R) 73) reviewed for dialysis out of a total sample of 25. This failure had the potential to affect the resident's nutritional intake and cause food-borne illnesses. Findings include: Review of R73's Face Sheet located in the electronic medical record (EMR) under the Admission tab, revealed the resident was admitted to the facility on [DATE] with a diagnosis that included end-stage renal disease; the resident was on dialysis. Review of the quarterly Minimum Data Set (MDS), located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/13/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that R73 was cognitively intact for daily decision-making. During an interview on 11/24/24 at 1:49 PM, R73 revealed she attended dialysis on Tuesday, Thursday, and Saturday. R73 stated she left the facility around 5:00 AM and did not return until between 10:00 AM to 10:30 AM. R73 stated that upon return, her breakfast tray was in her room and that the food was cold. She stated that sometimes, staff would come and warm the food, but it was still not good. R73 stated she wanted to have a hot breakfast because all she had before going to dialysis was crackers. During an interview on 11/25/24 at 2:39 PM, Certified Nurse Assistant (CNA)1 revealed that when passing breakfast, R73's tray was placed in her room so that she could have breakfast upon her return from dialysis. CNA1 stated the tray was usually warmed up for R73. During an observation on 11/26/24 at 8:53 AM, R73's breakfast tray was taken to her room and left. The resident was out of the facility at dialysis. During an interview on 11/26/24 at 8:59 AM, the Registered Dietician (RD) stated she was not aware R73's breakfast tray was left in her room for two or more hours. She stated that it was not only a palatable issue but possibly foodborne illness issues as well. She stated eggs were not safe to be left out like that, and I can't imagine they would taste good warmed up. The RD stated that a tray should not be left in the room. During an interview on 11/26/24 at 11:50 AM, the Dietary Manager (DM) stated she was aware that R73's breakfast tray was left in the room so that she could have breakfast upon dialysis. The DM stated she did not see a problem with the tray being left, indicating that the CNAs reheated the food. The DM asked, What else are we supposed to do? DM stated R73 needed her breakfast upon return and that R73 did not take a snack bag with her. When asked about the food sitting out for at least two hours, the DM stated that they were not thinking about it that way. During an interview on 11/26/24 at 2:42 PM, the Social Service Director (SSD) stated she did not know R73's breakfast was being left in her room. The SSD stated that she had spoken with R73 several times, and R73 had never voiced a concern. During an interview on 11/26/24 at 4:52 PM with the Administrator and Director of Nursing (DON), they both stated that R73's tray should not be left in the room and the resident should be offered a fresh hot tray upon return from dialysis.

Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to protect a resident's right to be free from sexual abuse by a resident for 1 Resident (R1) of 10 residents reviewed for abuse. The failure resulted in R2, a cognitively intact resident, engaging in an inappropriate sexual act with R1, a severely cognitively impaired resident. It was determined that a reasonable person in R1's position would have experienced psychosocial harm as a result of sexual abuse. Findings include: Review of a facility Social Services policy, with the subject titled, Abuse, Neglect, Exploitation, or Mistreatment, with a revision date of 10/01/20, indicated, The facility's leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient's/resident's property and/or funds. The facility ensures that alleged violations involving abuse are reported immediately. The policy defined sexual abuse as non-consensual sexual contact of any type with a resident. The policy indicated, Conduct a prompt investigation of any allegation of suspected abuse, neglect or exploitation or mistreatment and implement immediate action to safeguard resident. In the Component IV: Identification, section of the policy, the following types of abuse were referenced, Rape, molestation, or other inappropriate sexual behavior against a resident, such as: sexual coercion, and inappropriate sexual behaviors displayed by and/or toward an incapable resident. Guidelines for Investigation also indicated, Social Service will provide support services to the resident/patient and implement an interdisciplinary care plan. The Component VII: Protection, section of the policy indicated, During the investigation, the facility protects the patient/resident, as appropriate, including but not limited to the following: Removal of the alleged abuser from the patient/resident care setting. Review of a Resident Face Sheet, indicated the facility admitted R2 with diagnoses that included vascular dementia with mood disturbance, male erectile dysfunction, and mood disorder due to known physiological condition. Review of the discharge Minimum Data Set (MDS), dated [DATE], revealed R2 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated the resident was independent or required supervision with activities of daily living (ADLs); however, walking and locomotion only occurred once or twice. According to the MDS, R2 had verbal and other behavioral symptoms not directed toward others one to three days during the review period. The MDS indicated the resident was not receiving psychotropic medication. A review of R2's Care Plan, with a problem start date of 03/05/23, revealed the resident was at risk for negative outcomes of their psychosocial wellbeing related to allegations of sexual abuse. Interventions in the Care Plan directed staff to provide psychosocial visits for three days and interdisciplinary team (IDT) monitoring of the resident for any changes in identified areas or potential triggers. The Care Plan also included the problem area of behavioral symptoms. A statement in this section, dated 06/14/22, indicated the resident was known to engage in consensual sexual activities and was decisional and able to make sexual decisions. An intervention in the Care Plan dated 12/20/22, indicated staff were to Provide the resident with privacy during sexual activities. Review of R1's Resident Face Sheet indicated the resident was admitted to the facility with Alzheimer's disease, dementia without behavioral disturbance, cerebral infarction, and major depressive disorder. The quarterly MDS, dated [DATE], revealed R1 had a BIMS score of 0, which indicated the resident was severely cognitively impaired. The MDS indicated the resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. According to the MDS, walking did not occur, the resident used a wheelchair for mobility, and supervision was required for locomotion on the unit. The MDS indicated R1 received antianxiety and antidepressant medications seven of seven-days during the review period. A review of R1's Care Plan, with a problem start date of 03/05/23, revealed the resident was at risk for negative outcomes of their psychosocial well-being related to allegations of sexual abuse by another resident. Interventions directed staff to: periodically monitor for psychosocial distress; provide psychosocial visits for three days; monitor the resident for any changes in the identified areas or potential triggers; provide reassuring touch, verbally assure the resident of their safety, as needed; and refer the resident to psychiatric services for evaluation and treatment, as needed. R1's Care Plan, with a start date of 05/31/19, indicated the resident had mood and behavior needs related to the diagnosis of unspecified dementia, anxiety disorder, and major depressive disorder as evidenced by a history of refusing care, agitation, episodes of crying, sexually inappropriate, and yelling out. Interventions included a psychiatric referral related to inappropriate sexual behaviors, dated 12/16/21. A review of the facility's Initial 2/24-Hour Report, dated 03/05/23, revealed an allegation of sexual abuse involving two residents (R1 and R2) was witnessed on 03/05/23 at 2:50 PM. The report indicated an investigation was initiated by the Administrator, and the resident's representatives, the Medical Doctor (MD), and the police were notified. According to a fax transmission report, the notification of alleged sexual abuse was faxed to the state survey agency on 03/05/23 at 7:26 PM. A review of the facility Five-Day Follow-Up Report, dated 03/10/23, indicated R2 was observed by staff at the bedside of R1. R2 was observed to have their hand beneath R1's clothing rubbing the resident's breast while simultaneously holding R1's hand and moving it in an up and down motion over R2's covered genitalia. The report indicated the residents were immediately separated and interviewed with no new information provided. According to the report, the staff reported no injuries to R1. The County Sheriff's Office was contacted and responded to the facility on [DATE]. The report indicated R2 was placed on one-to-one observation beginning on 03/05/23. Review of a Deputy Report for Incident document revealed an alleged sexual assault/rape was reported to the local sheriff's department on 03/05/23 at 6:24 PM and was assigned to an officer on 03/06/23. The report did not include documented disposition of the case. The Administrator indicated the facility had not received a final report. On 03/21/23 at 11:05 AM, a voicemail message was left for the assigned detective to discuss the case and provide a final report. This writer did not receive a response prior to the end of the survey. Review of a One on One log for R2 revealed the resident had a one-on-one sitter beginning on 03/05/23 at 11:00 PM through 03/10/23 at 3:00 PM. Review of the facility's investigative file revealed resident interviews were conducted with 90 residents who lived in the facility. There were no concerns related to sexual misconduct reported during the interviews. Body audits were completed for 16 residents who were unable to answer the questions related to sexual misconduct. There were no findings identified during the body audits that might be indicative of sexual misconduct. A review of R2's Resident Progress Notes, dated 03/06/23, revealed the resident was in the courtyard accompanied by a staff member and R2 had no behavioral symptoms noted during the day shift. Further review of Resident Progress Notes revealed a psychosocial visit was conducted by the Social Services Director (SSD) on 03/06/23 at 4:39 PM related to the allegations of sexual abuse towards R1. R2 denied the allegation and stated they had no desire to engage in sexual activities with anyone at the facility. Review of a letter that was reportedly hand delivered to R2, and dated 03/10/23, advised the resident of Notice of Transfer or Discharge. The letter indicated the resident was being discharged from the facility because the patient's clinical or behavioral status endangers the safety of individuals in the facility. The date of transfer from the facility was documented as 03/10/23 to the county detention center. The letter indicated that a copy of the letter was provided to the resident's representative and the state long-term care ombudsman. Review of R1's Resident Progress Notes, dated 03/05/23, revealed a full body audit was completed and no concerns were identified. Further review of Resident Progress Notes revealed the MD was notified of the incident on 03/05/23 at 4:53 PM and no new orders were provided. A review of R1's Observation Report, dated 03/05/23 at 3:05 PM, indicated the body/skin audit was normal and without issues or concerns. Review of R1's Resident Progress Notes, dated 03/06/23, revealed the resident was participating in their normal routine with no evidence of distress. The Resident Progress Notes indicated the resident was pleasantly interacting with other residents, smiling, and had no behavioral symptoms. According to the Resident Progress Notes, the SSD interviewed the resident on 03/06/23 at 11:46 AM and documented the resident stated they were feeling good. Review of R1's Nurse Practitioner (NP) Progress Note, dated 03/06/23, indicated an assessment of the resident was conducted following the sexual assault. The NP documented the resident had no recollection of the event and was calm, without any acute concerns by this provider. Observations were made of R1 on 03/21/23 at 11:30 AM, on 03/21/23 at 12:15 PM, and on 03/22/23 at 9:15 AM. During each observation, the resident was observed lying in bed, smiling, and no behavioral symptoms, or mood indicators such as crying or anxiety were observed; the resident was unable to respond to questions due to cognitive impairment. During an interview on 03/21/23 at 12:15 PM, R11, a cognitively intact resident and R1's roommate at the time of the incident, stated there had not been any incidences when someone came into their room and bothered them or their roommate or touched them in an inappropriate manner. During an interview on 03/21/2023 at 3:40 PM, Certified Nursing Assistant (CNA)1 stated she reported any allegations of abuse immediately to her supervisor or to the Administrator. CNA1 described sexual abuse as inappropriate touching all the way to a full sexual act. CNA1 stated R2 had girlfriends in the past who were cognitively intact, and they were observed kissing, but it was consensual. CNA1 stated she entered R1's room on 03/05/23 and saw R2 beside the resident's bed inappropriately touching the resident on the breast. CNA1 said R2 was holding R1's hand and moving the resident's hand up and down over R2's private area. CNA1 stated neither resident was exposed. CNA1 further stated R1's roommate was present and watching. During an interview on 03/22/23 at 10:05 AM, CNA2 stated she had never witnessed R2 being inappropriate with any of the other residents. CNA2 said R2 lived on a different hallway than R1 and was often seen walking around and visiting other residents. CNA2 stated she was surprised by the allegation and never thought the resident would do something like that. During an interview on 03/22/23 at 10:14 AM, Registered Nurse (RN)4 stated she had not witnessed the incident on 03/05/23 but was made aware by a CNA who had reported to her that she had witnessed R2 inappropriately touching R1. RN4 said she immediately made R2 leave R1's room, checked on R1, then contacted the Assistant Director of Nursing (ADON) and the Administrator to let them know what had occurred. RN4 indicated the ADON and Administrator came to the facility quickly and started the investigation. RN4 stated she and a nursing supervisor located R2 seated in the courtyard and interviewed R2 who denied any wrongdoing. R2 was escorted back to their room, which was private, and the resident was asked to stay in their room at that time. RN4 stated R2 had not been observed entering R1's room, but it was not unusual for R2 to go in and out of resident rooms to visit with residents who were the resident's friends. During an interview on 03/22/23 at 10:27 AM, Licensed Practical Nurse (LPN)3 stated she routinely took care of R2 but was not working the day of the incident. LPN3 stated R2 never exhibited behavioral symptoms when she worked with the resident in the past. LPN3 said the resident walked around the building a lot but had not demonstrated sexually inappropriate behaviors towards others. LPN3 stated she was shocked when she heard about the incident. During an interview on 03/22/23 at 10:35 AM, Nurse Supervisor (NS)5 stated he was working at the facility when the incident occurred on 03/05/23 and immediately following the incident, R2 was escorted to their room. NS5 stated he was very surprised by the incident as he had not observed this type of behavior from the resident. NS5 stated the staff were made aware R2 was to remain in the resident's room at that time and the staff were instructed to keep watch. During an interview on 03/22/23 at 11:10 AM, the SSD stated R2 had previously expressed interest in being sexually active with their ex-partner and was not interested in having any type of sexual relations with any residents in the facility. The SSD stated she was very surprised when the incident occurred with R1 and said it was out of character for R2. The SSD stated the facility immediately initiated one-on-one sitters for R2 to ensure all other residents, including R1, were safe. The SSD stated she had multiple psychosocial visits with R1 following the incident and indicated there had been no changes in the resident's behavior or mood. During an interview on 03/22/23 at 2:35 PM, the Director of Nursing (DON) stated she had been employed at the facility for about a month and had just arrived at the building when the incident between R1 and R2 occurred. The DON further stated she had attended at least three training programs on abuse since being employed at the facility and her role was to immediately notify the Administrator of any allegations of abuse. The DON indicated there was a two-hour window to report to the state survey agency. The DON also stated it was most important to keep the residents safe. The DON stated it was her expectation that staff would immediately report an allegation of abuse to a supervisor, the DON or the Administrator. During an interview on 03/22/23 at 3:15 PM, the Administrator stated if abuse was witnessed or there was an allegation of abuse, then the residents involved in the incident must be separated, or the staff member indicated in the allegation must be removed from duty, and the resident victim be placed in a safe area. The Administrator stated the staff know to immediately call me, and I report to the state agency within the time frames provided. The Administrator further stated she would begin an investigation of abuse immediately and the SSD would interview facility residents, including the residents involved in the allegation. The Administrator stated she reviewed the interviews and might go back to ask more questions. The Administrator stated she interviews all staff working on the unit at the time of an incident/alleged occurrence and once an investigation is completed, the Administrator submits the five-day report to the state survey agency. The Administrator stated it was her expectation that staff immediately report any suspicions of abuse, whether alleged or witnessed. During the interview on 03/22/23 at 3:15 PM, the Administrator stated that in addition to conducting the investigative process for the incident involving R1 and R2, she had an ad hoc quality assurance (QA) meeting with the MD and members of the interdisciplinary team and discussed what happened and corrective actions, and identified residents who might be similar to R2. The Administrator stated that during the meeting, they identified four residents who had expressed interest in having sexual relations, two were a married couple and two were male residents who denied wanting to have sex with anyone in the facility. The Administrator said the identified residents were interviewed and the MD assessed each resident and completed a decision-making capacity form. According to the Administrator, the residents were determined to be able to make decisions. Regarding monitoring of resident behavior, the Administrator stated each morning the administrative team reviews the behavior monitoring forms, the facility activity reports, and the incident reports from the previous day; on Monday mornings the documents from Friday through Sunday were reviewed. The Administrator stated that since the incident on 03/05/23, she had initiated walking rounds and planned to focus on the cognitively impaired residents to ensure they did not have unwanted visitors in their rooms. PAST NON-COMPLIANCE VERIFICATION On 03/23/23, the Administrator provided a Mitigation Plan, dated 03/05/23, that identified corrective action related to the sexual abuse incident. On 03/05/23 one-on-one supervision of R2, the perpetrator, was initiated and a body audit of R1 was completed. Notification of the MD, responsible parties, the local sheriff's department, and the state survey agency was completed on 03/05/23 and a psychosocial care plan was initiated for R1. Per the Mitigation Plan, all other residents had the potential to be affected by the alleged deficient practice. Ninety residents were interviewed to determine if there had been other incidents of sexual misconduct that may have occurred. A review of the interviews revealed no concerns of sexual misconduct. Body checks and skin assessments were completed for residents who could not be interviewed. The facility identified four residents who expressed a desire to participate in sexual activities. The four residents were assessed by the medical provider and social services to determine their ability to consent, and the medical records were updated. On 03/06/23 staff education was provided for 73 staff members that included the abuse policy, abuse reporting, maintaining a safe environment, and resident sexual relations. The Mitigation Plan addressed ongoing staff education related to abuse prevention and reporting, care plan updates and interventions to prevent sexually inappropriate behaviors and maintaining a safe environment. The DON planned to review progress notes, behavior monitoring forms, and incident reports daily for four weeks, then weekly for eight weeks, for any resident attempting to engage in sexual relations. Results of the monitoring would be presented to the QA committee meeting monthly for three months. Evidence of behavior monitoring audits from 03/06/23 through 03/22/23 was provided and no concerns were identified. The Mitigation Plan also included that the social worker would conduct random resident interviews with five residents weekly for four weeks, and monthly for two months, to identify any residents with like behaviors. Evidence was provided indicating the interviews were conducted as planned and no concerns were identified. The Administrator would also conduct random walking facility rounds five days a week to validate that cognitively impaired residents did not have uninvited visitors. Evidence indicating the walking rounds were conducted for 03/06/23 through 03/23/23 were reviewed and no issues were noted.

Based on review of the facility's policy, record reviews, and interviews, the facility failed to protect 18 of 25 residents from significant medication error. Facility failed to administer evening medication passes to Residents (R)1-R18 on 11/26/2022. Review of facility investigation and interview with Licensed Practical Nurse (LPN)1 confirmed that LPN1 failed to administer medication to an entire medication cart assignment. On 01/19/2023 at approximately 10 AM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. The administrator was notified the facility's failure to provide medication to R1-R18 constituted immediate jeopardy (IJ) at past noncompliance at F760 beginning on 11/26/2022. On 01/19/2023, the facility provided an acceptable IJ removal plan indicating the facility placed corrective actions in place, identifying their own deficiency, as of 11/29/2022. On 01/19/2023 at approximately 12 PM, the survey team validated the facility's corrective actions and removed the IJ retroactively on 11/29/2022. Findings include: Review of the facility's undated Nursing Policies and Procedures revealed Medications are administered no more than one hour before to one hour after the designated medication pass time. Furthermore, the authorized staff member must seek assistance from the nursing supervisor/designee and consulting pharmacist when any aspect of medication administration is in question. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, chronic rhinitis and unspecified convulsions. R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, atrial fibrillation, adult failure to thrive, insomnia, and hypertensive chronic kidney disease (CKD). R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to, hyperlipidemia (HLD), hypertension (HTN), and schizophrenia. R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to, HLD. R5 was admitted to the on 07/31/2020 with diagnoses including, but not limited to, pain in right ankle and joints of right foot and weight loss. R6 was admitted to the facility on [DATE] with diagnoses including, but not limited to, hyperglyceridemia, type 2 diabetes mellitus (DM2), and diabetic neuropathy. R7 was admitted to the facility on [DATE] with diagnoses including, but not limited to, sleep apnea, acute embolism (blocked artery) and thrombosis (blood clot causing obstruction of blood flow) of unspecified vein, unspecified convulsions, hypomagnesemia, DM2, and benign prostatic hyperplasia. R8 was admitted to the facility on [DATE] with diagnoses including, but not limited to, surgical amputation, hypomagnesemia, insomnia, delusional disorders, and DM2 with diabetic CKD. R9 was admitted to the facility on [DATE] with diagnoses including, but not limited to, pain in joints of right hand, HTN, mood disorder due to known physiological condition, chronic pain, and insomnia. R10 was admitted to the facility on [DATE] with diagnoses including, but not limited to, age-related cognitive decline, DM2, generalized anxiety disorder, acute embolism with thrombosis of unspecified deep veins of lower right extremity, major depressive disorder (MDD), and constipation. R11 was admitted to the facility on [DATE] with diagnoses including, but not limited to, unspecified edema. R12 was admitted to the facility on [DATE] with diagnoses including, but not limited to, constipation, insomnia, and dry eye. R13 was admitted to the facility on [DATE] with diagnoses including, but not limited to, DM2 with diabetic neuropathy and Gastroesophageal Reflux Disease. R14 was admitted to the facility on [DATE] with diagnoses including, but not limited to, moderate persistent asthma with acute exacerbation, HLD, unspecified urinary retention, polyneuropathy, DM2, tachycardia, schizoaffective disorder, constipation, and insomnia. R15 was admitted to the facility on [DATE] with diagnoses including, but not limited to, HLD, unspecified bipolar disorder, HTN, DM2, and insomnia. R16 was admitted to the facility on [DATE] with diagnoses including, but not limited to, pruritis, HLD, seizures, and anorexia. R17 was admitted to the facility on [DATE] with diagnoses including, but not limited to, HLD and MDD. R18 was admitted to the facility on [DATE] with diagnoses including, but not limited to, anorexia, epilepsy, and constipation. Review of LPN1's 12/05/2022 witness statement provided to the facility revealed that though her shift ended at 7 PM on 11/26/2022, she was asked to stay until 11 PM, to which she agreed. She was not aware when she agreed that she would be the only nurse on the unit and expected to pass evening medications to two carts worth of assignments (approximately 40 residents). She was unable to start the second cart before her shift ended, and she informed the nurse on-call as well as the oncoming nurse. Interview with LPN1 on 01/17/2023 at approximately 09:30 AM confirmed her statement provided to the facility. She was unable to start the second cart's medication pass (an assignment of 18 residents) and messaged the nursing supervisor. Review of facility investigation and medication error sheets revealed the following residents missed their medications on the evening of 11/26/2022: R1 did not receive Fluticasone proprionate (a steroid used for rhinitis) 50 micrograms (mcg) or Levetiracetam (an anticonvulsant) 750 milligrams (mg). R2 did not receive Apixaban (a blood thinner) 5 mg, water 240 milliliters (mL), Melatonin (sleep hormone) two tablets of 3 mg, O2 saturation check and ensuring oxygen was in place, and Sodium Bicarbonate (baking soda -- used to correct acid-base disturbances in patients with kidney disease) 650 mg. R3 did not receive Atorvastatin (used to lower low-density lipoprotein or LDL i.e., bad cholesterol and raise high-density lipoproteins or HDL i.e., good cholesterol) 100 mg and Olanzapine (an antipsychotic) 5 mg. R4 did not receive Atorvastatin 40 mg. R5 did not receive Acetaminophen (an analgesic i.e., pain reliever) two tablets of 325 mg and Mirtazapine (an antidepressant commonly used to treat anorexia and weight loss) 7.5 mg. R6 did not receive Atorvastatin 80 mg, finger-stick blood sugar (FSBS), Gabapentin (an anticonvulsant commonly used to treat neuropathic pain i.e., pain caused by damaged nerves), and Insulin detemir 10 units. R7 did not receive their continuous positive airway pressure (CPAP - a device used to push air down the airway of a patient), Apixaban (blood thinner) 2.5 mg, Lamotrigine (anticonvulsant) 100 mg, Levetiracetam 750 mg, Magnesium hydroxide (magnesium supplement) 400 mg, Insulin aspart sliding scale, Phenytoin (anticonvulsant) 200 mg, and Tamsulosin (alpha-blocker commonly used to relax muscles in prostate and bladder neck) 0.4 mg. R8 did not receive Acetaminophen 500 mg, Atorvastatin 80 mg, Magnesium oxide 400 mg, Melatonin 10 mg, Risperidone (antipsychotic) 0.75 mg, and Insulin deglu[DATE] units. R9 did not receive Acetaminophen 650 mg, Carvedilol (used to treat high blood pressure) 25 mg, Divalproex (an anticonvulsant commonly used as a mood stabilizer), Labetalol (used to treat blood pressure) 200 mg, Pregabalin (used to treat neuropathic pain) 25 mg, Tramadol (narcotic analgesic), and trazodone (antidepressant commonly used for insomnia) 75 mg. R10 did not receive Donepezil (cognition-enhancing medication used to treat dementia) 10 mg, Insulin glargine 8 units, Buspirone (anxiolytic used to treat anxiety) 7.5 mg, Apixaban 5 mg, Ranolazine (used to treat chest pain), Mirtazapine 30 mg, and Senna (laxative). R11 did not receive a basic metabolic panel (BMP, a blood test used to assess fluid and electrolyte balance as well as kidney function). R12 did not receive Docusate sodium (stool softener) 100 mg, Melatonin two tablets of 3 mg, and Olopatadine (antihistamine) 0.1% drop. R13 did not receive Gabapentin 100 mg and Lansoprazole (stomach-acid reducing medication) 30 mg. R14 did not receive Fluticasone propionate / salmeterol 250 - 50 mcg (bronchodilator), Albuterol (bronchodilator) sulfate 2.5 mg / 3 mL vial, Aspercreme (analgesic cream) 4%, Atorvastatin 80 mg, Tamsulosin 0.4 mg, Gabapentin 600 mg, Insulin lispro sliding scale, Metoprolol (used to treat high blood pressure and high heart rate), Montelukast (anti-anflammatory) 10 mg, Nortriptyline (antidepressant) 10 mg, Olanzapine 7.5 mg, Quetiapine (antipsychotic) 100 mg, Cyclosporine (immunosuppressive) 0.5% , Sennosides - docusate sodium 8.6 - 50 mg, and Trazodone 100 mg. R15 did not receive Atorvastatin 40 mg, Bupropion (antidepressant) 100 mg, Carvedilol 3.125 mg, Insulin lispro sliding scale, and Trazodone 50 mg. R16 did not receive Cetirizine (antihistamine) 10 mg, Atorvastatin 40 mg, Divalproex 125 mg, Levetiracetam 250 mg, and Mirtazapine 15 mg. R17 did not receive Atorvastatin 20 mg and Mirtazapine 30 mg. R18 did not receive Mirtazapine 7.5 mg, Phenytoin 200 mg, and Senna 8.6 mg. An interview with the facility's Nurse Practitioner (NP)1 on 01/18/2023 at approximately 3:50 PM revealed multiple residents had a likelihood for serious adverse outcomes as a result of missing their medication. R1 was placed at an increased risk for convulsions. R2 was put at an increased risk for embolism. R5 was put at an increased risk for exacerbation of pain and increased risk for hyperglycemic (high blood sugar) episode. R6 was put at an increased risk for a hyperglycemic episode. R7 was placed at an increased risk for a hyperglycemic episode and a convulsive episode. The last convulsive episode of R7 lasted approximately a week. Furthermore, there was a known correlation between a drop in the resident's magnesium and increased risk for seizures. R9 was placed at an increased risk of hyperglycemic episodes and exacerbation of CKD. R9 was put at an increased risk for exacerbation of pain. R10 was put at an increased risk of embolism and increased risk of hyperglycemic episode. R11's missing BMP was drawn the following Monday, leading to a possible delay in treatment. However, R11's BMP returned with no irregularities and no changes in treatment. R14 was put at increased risk for acute exacerbation of persistent asthma. Furthermore, the resident has sarcoidosis and respiratory crises often require hospitalization . R15 was put at an increased risk for a hyperglycemic episode. R16 was put at an increased risk for a convulsive episode. R18 was put at an increased risk for a convulsive episode. The remaining residents (R3, R4, R11, R12, R13, and R17) were not likely to have severe adverse outcomes as a result of missing their medications, however NP1 confirmed they failed to receive the doses scheduled for evening of 11/26/2022. The facility IJ removal plan included the following: The responsible parties and medical providers were notified of the allegation. All appropriate state agencies were notified on 11/28/2022. The Spartanburg County Police were notified of the allegation on 11/28/2022. The Medical Director was notified by Administrator on 11/28/2022. All affected residents were evaluated by the NP on 11/28/2022. Body audits were completed 11/28/2022. Medical error sheets were completed 11/28/2022. Psychosocial care plans were initiated, and social services visited residents three times for psychosocial concerns. Residents followed up with in-house psychiatric services as needed. The nurse assigned to the residents at the time of the allegation was suspended pending investigation. An audit was completed on all residents on the involved unit (Unit 2) including NP assessments, body audits, medication error sheets, psychosocial care plans, and social services assessments. CSD re-educated Director of Nursing and Administrator on Medication Administration Policy on 11/28/2022 Re-education included evaluation of medication administration times and the complexity of the medication pass. The Director of Nursing or Designee will re-educate licensed nurses on Medication Administration Policy and what to do and who to call if there are any questions or concerns during medication pass. This re-education was initiated on 11/28/2022. Any licensed nurses not receiving this re-education on 11/28/2022 will receive it before their next scheduled shift. The education will be provided at new hire orientation. An Ad-Hoc Quality Assurance Performance Improvement Meeting was held on 11/28/2022. Unit Mangers will review medication compliance reports to validate compliance five days weekly for 4 weeks, then three days weekly for 8 weeks. The Administrator will report all findings from audits to the Quality Assurance committee for 3 months for further recommendation. Any concerns will be addressed at the time of discovery.

Based on review of the facility policy, record review and interviews, the facility failed to ensure 3 of 3 Residents (R) were free from sexual abuse. R1 and R2 were involved in a sexual relationship without being properly assessed by the facility, proper documentation and notification. R2 and R8 was also involved in a sexual relationship without proper assessments, documentation, and notifications in place to prevent sexual abuse. On 11/22/22 at 3:45 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. The Administrator was notified that the failure to ensure residents were free from sexual abuse constituted Immediate Jeopardy (IJ) at F600 beginning on 09/29/22. On 11/23/2022 at 2:17 PM, the facility provided an acceptable IJ Removal Plan. On 11/23/22 at 4:00 PM, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F600 at a lower scope and severity of D. The immediate jeopardy was due to the facility's failure to properly evaluate and assess if the relationship was consensual; investigate and report the decisional capacity and report any adverse effects from the relationship or indicators of harm/hurt. The facility failed to follow their policy for Guidelines for Patient/Resident Rights to Sexual Relations. Findings Include: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Mistreatment dated 10/01/20 revealed: Definitions by CMS Section 483.5 #7 Sexual abuse is non-consensual sexual contact of any type with a resident. Facility Leadership General Procedures stated that report no later than 2 hours after the allegation is made. If the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not result in serious bodily injury. Conduct a prompt investigation of any allegation of suspected abuse, neglect or exploitation or mistreatment and implement immediate action to safeguard resident. Review of the facility's policy titled, Social Services Guidelines for Patient/Resident Rights to Sexual Relations dated 10/01/20 revealed, Procedure 2. Patients engaging in sexual activities and relations will be evaluated by a licensed social worker or other licensed and qualified professional for a psychiatric evaluation to determine whether the patient/resident is able to adequately assess the risks, dangers and benefits of the activity or relations. Staff are not required to obtain intimate details of the activity or relationship but should conduct an interview regarding consent, mutuality and the safety and well-being of the patients/resident. Procedure 3. Each partner will be educated by the (Social Worker or Director of Nursing) about the following: sexually transmitted diseases; pregnancy; risks and dangers for physical injury resulting from the activity and the need for patients/residents to respect roommates(s), if any, as well as other patients/residents, staff and visitors while engaging in sexual activity and relations. Procedure 9. For patients/residents with impaired cognition, staff should examine the behaviors carefully and determine if there is a valid need to be met. If there is the need should be met in a dignified way. R1 was admitted to the facility on [DATE] with diagnoses including but not limited to, vascular dementia, agitation, dysuria, and mood disorder. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/22 revealed a Brief Interview of Mental Status (BIMS) score 5 out of 15, indicating severe cognitive impairment. Review of R1's Care Plan dated 8/05/22 revealed Problem: R1 is having mood and behavior needs as evidence by periods of engaging in sexual activities with other residents per her choice related to diagnosis of vascular dementia, unspecified severity, with other behavioral disturbance, mood disorder, hallucinations, and anxiety disorder. The goal is R1 will safely engage in sexual activities per her choice. Staff to provide privacy when needed for an increased quality of life. Approaches are labs as ordered, provide privacy as needed, communicate resident status via 24-hour report as needed and notify family of changes in resident status or of new or escalated behaviors to get their input as to suggestions or recommendations of interventions/approaches. Review of R1's Decisional Capacity dated 06/22/21 and 06/25/21 indicated R1 DOES NOT meet all criteria for decisional capacity. Review of R1's Hospital discharge date d 10/20/22 revealed bacterial vaginitis was clinical impressions, prescribed Metronidazole (an antibiotic to treat bacterial vaginitis) 500 mg oral 2 times daily. Review of R1's Labs dated 10/20/22 revealed Hepatitis A-AB pending, Hep A-AB, IGM nonreactive; Hepatitis C-AB nonreactive. Review of R1's Labs dated 10/26/22 revealed Hepatitis A-AB reactive. Review of R1's Physician note dated 08/10/22 revealed, Patient family made aware of this and state that they are ok with these sexual relations, and they state that it is their choice to engaged in sexual relations. Patient does not take any medications for dementia and patient sees in house psych provider. Review of R1's Progress Notes dated: 10/13/2022 08:50 PM Resident in bed this shift states she just don't feel good. VS 98.2 84 18 143/72 95%. Resident c/o itching real bad. CNA reports foul odor during skin care. Noted white discharge vaginal slightly red on assessment. No abdominal pain on palpation. No tender or distended bladder. Voiding adequate amount urine. Color dark in brief. Will place in Dr book for A.M. treatment. 10/13/2022 09:02 PM Notified resident daughter and informed placed in Dr book for assessment. She asks if possible resident has STD. Told her resident has to be examined. She requested STD test. Will continue to monitor and report to oncoming. 10/17/2022 12:24 PM Urine culture obtained resident tolerated procedure well. 09/30/2022 02:17 PM Social Services spoke with resident. She states that she is understands what she is doing when participating in sexual activities. She understands that she can say yes or no to sexual activities. Social services will continue to monitor. 09/29/2022 05:05 PM [Recorded as Late Entry on 09/30/2022 10:12 AM] Social Services spoke with resident regarding keeping sexual activities with another male resident private. Resident's roommate is uncomfortable with sexual activities taking place in their room. Resident states that she will go to his room since he is alone from now on. She doesn't want to make anyone uncomfortable. Social services will continue to monitor and follow up as needed. R2 was admitted to the facility on [DATE] with diagnoses including but not limited to; dementia with other behavioral disturbance, dysphagia, other sexual dysfunction not due to a substance or known physiological condition, benign prostatic hyperplasia without lower urinary tract symptoms; difficulty in walking and lack of coordination. Review of R2's MDS with an ARD of 9/22/22 revealed a BIMS score of 3 out of 15, indicating R2 was severely cognitively impaired. Review of R2's care plan with a start date of 06/28/21 and revision date of 10/25/22 revealed problem: R2 has mood and behavior needs related to the diagnosis of unspecified dementia without behavioral disturbance, vascular dementia without behavioral disturbance, and chronic pain syndrome as evidence by refusing care, refusing to wear his mask, refusing medications, uses cursing as everyday language, being verbally aggressive with staff. R1 was witnessed masturbating in his doorway on 2/08/22, making false accusations of theft on 3/08/22, makes frequent comments about leaving this place; and R2 has been known to engage in sexual activities. The care plan was last updated to include Resident is known to give his money to other residents and buy other residents snacks, added 10/12/22. Review of R2's Decisional Capacity dated 08/05/21 indicated R2 DOES NOT meet all the criteria for decisional capacity. Review of R2's Physician Progress Note dated 08/10/22 revealed, Patient's family made aware of these behavior and state that they are ok with these sexual relations. Family also states that the patient has a right to engage in these relations and it is his choice to engage in sexual relations. Nursing denies any concerns. Review of R2's Progress Notes dated: 10/27/2022 12:07 PM Resident ask if he could go see R1. This nurse asked and went through proper protocol with instruction to get verbal consent from resident. This nurse along with witness asked resident (R1) if R2 could come to her door and just say Hey; resident agreed. This nurse accompanied resident to the door and stayed with him for the 5 min; we did not enter the room we were at the door opening. Both resident's spoke to each other and were both smiling. This nurse accompanied resident back to Rehab where he is currently sitting at this nurse's station with this nurse. 09/30/2022 09:52 PM Amendment to 29 SEP note: Resident redirected to room and encourage to perform activities in private. Female resident woke during the night to find said resident in room touching her roommate. 09/29/2022 05:44 PM Resident sitting inside doorway of room with pants pulled down below scrotum and stroking penis masturbating indecent exposure. Visitors present. Told resident that he must be in privacy of room. Reported indecent exposure to social worker. Unable to redirect behavior. Neighboring resident reports him sneaking into room middle of night fondling roommate while she sleeps. Will continue to monitor and report to oncoming. 09/29/2022 05:00 PM [Recorded as Late Entry on 09/30/2022 10:09 AM] SSD was notified by nurse that resident is masturbating in doorway and that roommate of another resident has concerns regarding him coming into their room in the morning for sexual activities with another female resident. Resident was observed to be in his room at this time. SSD spoke with resident in regard to keeping sexual activities private. SSD advised to have activities take place in his room since his room is private. He voiced understanding and said, I'll keep it private. Social services will continue to monitor and follow up as needed. R8 was admitted to the facility on [DATE] with diagnoses including but not limited to; Alzheimer's, Parkinson's disease, urinary tract infection, Altered mental status, cognitive communication deficit, major depressive disorder and anxiety. Review of R8's MDS with an ARD of 9/21/22 revealed a BIMS score of 15 out of 15, indicating she is cognitively intact. Review of R8's Care Plan dated 8/19/22 revealed a problem: R8 is at risk for adverse effects related to diagnosis of anxiety and receives an anticonvulsant, has a diagnosis of major depressive disorder and use of an antidepressants. Approaches are to; have psych screen, provide soothing type activities PRN (as needed), encourage appropriate behavior and praise efforts, monitor and record mood or behavior problems, monitor for opportunity to decrease Psychotropic medications quarterly, remove from stressful situations as needed. No documentation regarding Decisional Capacity was provided for R8. Review of a document presented by the facility titled Timeline of Events revealed on 9/29/22, R2 was observed masturbating in the doorway of his room and noted to go to R1's room for sexual activity. Further review of this document revealed, Licensed Practical Nurse (LPN)1 documented that resident was sneaking into neighboring resident's room in the middle of the night to fondle roommate while she sleeps. Roommate does not feel comfortable. Review of a nursing note dated 10/03/22 revealed on 9/30/22 at 7:45 PM a note by LPN1 stating R2 is a predator and has access to vulnerable females, R2 was only removed and R1 protected due to this detailed nursing note. Note further stated, I did in fact, changed and revised the details at the Administrator's request. Review of Police Report dated 10/20/2022 case number [PHONE NUMBER], revealed, investigation of alleged Special Victim's crime occurring within the jurisdiction of Spartanburg County, SC. Further investigation needed. During an interview with R1's Daughter on 11/21/22 at approximately 11:46 AM, she revealed, when asked was she aware of her mother having sexual relations. She stated she was informed by someone and was asked what she wanted to do about it, and she stated what can I do about it. But then she went on further to say, that she was going to tell the real deal, she was told from a Nurse. She stated it was a Nurse who she spoke with. She stated the Nurse worked there but she was fired. She stated Nurse stated she found them in the room naked and that another person had pushed her mother in the room and closed the door. She stated she told her brother, and she made a phone call to DHEC and the Ombudsman. She stated her brother called the police and they took her to the ER and now she has Hepatitis A, which she never knew that she had it and she had some vaginal irritation. She stated which she didn't have before. She stated she looked it up (Hepatitis A) and you could get it through contaminated food, water and through sexual contact with another person. No changes were noted in her behavior by the daughter. She stated her mother has dementia and delusions therefore she was the same. During an interview with R1 on 11/21/22 at approximately 12:22 PM, she stated she does not have any sex with anyone. She stated when she was younger, what happened when someone asks you for sex, you did it anyway's. She stated she has not had sex while here at the facility. She stated she has no one to visit her. She does like living here. She asked if this place was for crazy people? During an interview with the Director of Social Services (SS) on 11/21/22 at approximately 12:44 PM, she revealed the family was notified that R1 was sexually involved with another resident. The Director stated Social Services assessed the residents psychosocially and they appeared fine. When Social Services spoke with R1, she had no recollection as to what the SS Director was talking about regarding having sexual relations with another resident. During an interview with the Administrator on 11/21/22 at approximately 1:04 PM, she stated, The two residents, R1 and R2, were in a relationship. The Administrator stated the family was made aware that they were not able to make their own decisions to engage in sexual activity, therefore they gave their consent. She then stated SS spoke with families on 08/05/22 and physician progress notes dated 08/10/22 noted the family's consent, if they kept it private, but R1's roommate began to complain. She stated on 10/20/22 the police, fire truck and EMS showed up at the facility because R1's son called and reported his mother was raped. She stated this was all kickstarted when a Nurse saw R2 in the hallway masturbating and she wanted something to be done about it. She stated she informed the nurse, it is their right, but it must be done in private. So, she (the nurse) called the family to inform them about the sexual activity between R1 and R2. Administrator stated R1 had a Urinary Tract Infection (UTI) and in turn was on antibiotics, which resulted in a yeast infection. The Administrator was also aware of the BV-Bacterial Vaginosis and Hep A. The Administrator further stated R1 did not have any sexual diseases, no semen and no trauma present. R1 and R2 have visited once since this incident but it was supervised. She informed the person that arranged the visit that R1 could not remain with R2 without supervision. During an interview with R2 on 11/21/22 at approximately 2:06 PM revealed he does have a girlfriend that he can only see for a second, they talk to each other, and he trusts her. R2 further stated he lets his girlfriend have her way. R2 denies any inappropriate touching. R2 requested the surveyor to go get his girlfriend and bring her back to his room for a hug. During a telephone interview with LPN1 on 11/21/22 at approximately 3:54 PM, she revealed she called the Department of Health and Environmental Control (DHEC) about a month ago on October 26th, when she was terminated. LPN1 revealed she was suspended a week before on October 19, 2022, because the Administrator said she refused to participate in the investigation. LPN1 revealed she notified the Administrator back in June 2022 that R2 was targeting R1. LPN1 was told their relationship was consensual, and they [the facility] couldn't do anything about it but close the door and give them their privacy. She stated she and another Certified Nursing Assistant (CNA) witnessed the interaction between the two of them [R1 and R2] in June 2022. LPN1 further revealed in August or September of 2022, R2 was masturbating in the hallway, and she informed the Administrator. She stated she was informed by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) that she couldn't put this observation in his medical record charting. LPN1 stated she was suspended because of what she noted in the chart. She stated the Administrator wanted her to correct her charting, the Administrator told LPN1 an amendment needed to be made. LPN1 revealed R2 was always waking in the middle of the night and R1's roommate complained about all the sexual activity in the room. She stated her and CNA1 witnessed R1 lying down in bed, R2 was standing over her; another incident where he pulled R1 in his room, her clothes were off, and her diaper was off. LPN1 reported this to the Administrator and was informed it was against R1 rights to stop her and she does not have to be in her right mind. LPN1 thought this was disrespectful. LPN1 viewed R2 as a predator. She stated she has a mother and could not allow this to happen. She stated they were on the floor daily with these residents and she has an obligation to report what she believes isn't right. She stated she was fired unfairly because of what she reported and recorded. She was suspended and placed on leave for allegedly threatening three (3) CNA's but was paid for that suspension. She was fired later for failure to cooperate in the investigation. She stated that CNA1 resigned because they were targeting her. It became too much for her. LPN1 revealed she has reported many incidents to the Social Worker and Administrator. During an interview on 11/22/22 with the Director of Social Services (DSS) at approximately 11:15 am revealed residents were consenting to sexual relationships and family consented. DSS identified R8 as being involved in a sexual relationship with R2 in the past. DSS stated that R2 and R8 gave verbal consent, and their relationship was before August. The DSS further revealed her expectation with both residents having a low BIMS score, if the facility was notified and if they have no concerns, the patients still have desires, it's a fine line. The DSS concluded that R1's responses to consent, changed from day to day. During an interview on 11/22/22 at approximately 11:33 AM revealed R1 might remember the man [R2], but she can't remember. R1 asked What is his name again? R1 revealed I must not have wanted him if I don't remember. R1 asked for a picture and said maybe she would remember then. R1 further revealed not too long ago, someone tried to get in her pants, but she stopped them. R2 stated she would be ok with having sex if if they take me somewhere, but not here. They would have to pay me because sex is not free. R1 concluded she does feel safe here and proceeded to ask What room she is in, was this her room? During an interview on 11/22/22 at approximately 11:43 AM revealed R9 (previous roommate to R1) remembered R1. R9 stated, Nothing is wrong with my mind, I'm in here because I can't walk. She revealed R2 lived across the hallway and they were having sex in here. R9 revealed they (R1 and R2) were laying on each other, R2 would come in, R1 would pull out her breast and R2 would play with it. During an interview on 11/22/22 at approximately 11:48 AM with LPN2 at approximately 11:48 AM revealed LPN2 believed R1 was able to consent. LPN2 further revealed she has seen R2 go from her room to his room and would see R1 go looking for R2. LPN2 felt like this was okay. During an interview on 11/22/22 at approximately 11:53 AM R2 was observed to have confusion and a scared expression when asked about his relationship with R1. R2's eyebrows raised, and he placed both hands mid-way off his arm rest and stated she was just my friend. R2 was informed he wasn't in any trouble, and he could speak freely. R2 hesitated, raised his hands and stated, she was just my friend. An attempted telephone interview with R1's Son on 11/22/22 at 12:31 PM was unsuccessful. During an interview on 11/22/22 at approximately 1:10 PM the DSS revealed R2 and R8 were having sex four to six months ago, she stated It was sex, not a relationship. The place designated for the two residents to have sex was in R2's room. The DSS revealed she was not educated on the procedures and policies of resident-to-resident sexually relationships. The new administration informed her that both parties have to be cognitive, there needs to be consent between both parties, and their families before sexual relationships can occur and it is up to the medical staff to refer residents to have Sexually Transmitted Infection (STI) check-ups. The DSS stated none of this information regarding residents receiving STI check-ups is in writing. The DSS further revealed R8 wanted the sexual relationship to end because of her religious beliefs and R2 was okay with the decision. There was no decline in health or mental health to R2 and R8 appears happier since she has stopped having sex with R2. During an interview on 11/22/22 at approximately 1:24 PM CNA2 revealed she heard R8 say that she likes R2 although she had never seen the two residents engaged in sexual activities. When R2 would come to R8's room, CNA2 would ask R3 to please don't come into the room because R8's family was prejudice, she would tell R2 you know you can't be in ladies' rooms. Sometimes her request would be met with resistance from R2, and he would curse, but eventually he would continue down the hall. CNA2 further revealed R1 would beg for R2's snacks and to keep down on confusion, CNA2 would redirect R1. CNA2 stated the procedure and policy regarding intimate/sexually relationship is that the residents must be cognitive, and the families must be notified, and their consent must be in writing. During an interview on 11/22/22 at approximately 1:30 PM with R2's Resident Representative (RR) revealed no one informed them that their brother was engaging in any sexual activity or relationship with anyone at the facility. R2's RR further revealed they visited last week and the brother tells them all the time that he wants to leave, but has never been notified or given consent for R2 to be in a sexual relationship. R2's RR concluded when R2 was in [NAME], SC, a long time ago, somebody accused him of messing around with a girl. During an interview on 11/22/22 at approximately 1:32 PM with Registered Nurse (RN)1 revealed if residents want to have an intimate/sexual relationship, the resident must be cognitive and must have written consent and families must be notified. During an interview on 11/22/22 at approximately 2:14 PM the Medical Director (MD) revealed he was onsite the day the police arrived at the facility. He remembers R1 being asked is she was touched, and she replied no. R2 was very adamant that nothing happened. The MD further revealed he was aware of the STI which resulted from this incident and explained you have patients who try to visit each other, but they keep them separate. They have separated R1 and R2 and they are both on different sides of the building. The MD called this surveyor at approximately 2:33 PM to provide more information. The MD revealed he reviewed his and R1's diagnosis of Bacterial Vaginosis (BV) is not contagious. You can get this from female to female, douching, poor hygiene and anything that interrupts the flora. There is no way that she got this from inappropriate touching. The MD went on to state, R1's diagnosis of Hep A could have been caused by drug use, swapping needles, in the gay community. The MD has no idea how R1 contacted it but it could have come from sharing food and drinks. It would be a real stretch to say it's connected to sexual activity. The facility's removal plan included: Facility re-addressed resident's decisional capacity on 11/23/2022. Responsible parties of R1, R2, R8 were notified and care plans were updated. Facility Staff including agency/contract will be re-educated by the Director of Nursing/designee starting 11/22/2022 regarding decisional capacity and residents rights to consent toe Sexual Activity. Director of Nursing will monitor progress notes, behavior monitoring, incident reports Monday through Friday x4, then weekly x8 weeks for any residents attempting to engage in sexual relations; random interveiws with 5 residents weekly x4 weeks, then monthly x2 to identify any other residents with like behaviors.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure residents were free from abuse for 5 (Residents #248, #398, #75, #63, and #54) of 6 sampled residents reviewed for abuse. Specifically, the facility failed to prevent staff-to-resident verbal abuse for Resident #248 and failed to prevent resident-to-resident physical abuse for Resident #398, Resident #75, Resident #63, and Resident #54. Findings included: Review of a facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment, revised 11/01/2017, revealed, The facility's leadership prohibits neglect, mental, physical, and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. The policy also indicated prevention of abuse would include, Ongoing assessment, care planning, and monitoring of those patients/residents with special needs that may lead to neglect, for example: A. History of aggressive behavior; B. History of entering other patient/resident rooms; C. History of self-injury; D. Communication disorder; and/or, E. Patients/residents requiring excessive nursing care or staff attention. F. Residents with history of resident-to-resident altercations. The policy further indicated, Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: A. The use of derogatory/harassing language; B. Rough handling; and C. Ignoring the patient's/residents needs request, etc. [et cetera]. 1. Review of a Face Sheet revealed Resident #248 had diagnoses which included chronic obstructive pulmonary disease (COPD), major depressive disorder, anxiety, chronic respiratory failure, muscle atrophy (degeneration/shrinkage of muscle tissue), and heart failure. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #248 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident was totally dependent for bathing and personal hygiene; required extensive assistance with bed mobility, transfers, dressing, and toileting; required supervision and set-up help with eating; and used a wheelchair for mobility. According to the MDS, Resident #248 exhibited no behaviors and had mood symptoms of feeling down, depressed, or hopeless several days over the previous two weeks. Review of a care plan, dated as initiated 02/12/2016, revealed Resident #248 was at risk for complications related to the need for support with activities of daily living (ADL) care. The care plan indicated the resident had occasional urinary incontinence and frequent bowel incontinence. The facility developed interventions that included providing incontinent care/toileting as needed. Review of a care plan, dated as initiated on 05/23/2022, revealed Resident #248 had mood and behavior needs related to diagnoses of panic disorder, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, hard of hearing, COPD, and major depressive disorder. The facility developed interventions that included ruling out environmental causes for mood/behavior and ensuring physical needs were met such as toileting. Review of a South Carolina Department of Health and Environmental Control (DHEC) Initial 2/24-Hour Report, dated 05/23/2022 at 10:15 AM, revealed there was an allegation of verbal abuse involving Resident #248 and Certified Nursing Assistant (CNA) #12. The report indicated the employee was suspended pending an investigation. Review of a South Carolina DHEC Accident/Incident Reporting Form, dated 05/27/2022, revealed Resident #248 stated he/she felt verbally abused by CNA #12. Resident #248 stated CNA #12 came into the resident's room and was verbally aggressive. The report indicated the employee and resident were immediately separated after the incident and the resident was safe. According to the report, after a review of all records and statements, the facility substantiated the allegation of verbal abuse and CNA #12 was terminated. Review of an Occupational Therapy Treatment Encounter Note, dated 05/23/2022, revealed the Certified Occupational Therapy Assistant (COTA) found the resident with a soiled brief, and the resident reported having been soiled for approximately two hours. The COTA assisted the resident with changing the brief. The note indicated that during the therapy session, CNA #12 entered Resident #248's room and a verbal altercation between the CNA and the resident began. The note indicated that the CNA placed her face approximately three inches from Resident #248's face and was disrespecting patient with words and actions. The note indicated the resident appeared scared. A nurse from the hallway heard the commotion and came and removed CNA #12 after three verbal prompts to leave the room. The note indicated the COTA reported the incident immediately to administration and filed a formal report. Review of Resident #248's Social Service Note, dated 05/23/2022 at 4:15 PM, revealed the Social Services Director (SSD) visited with the resident on 05/23/2022 to assess psychosocial needs related to the allegations of verbal abuse. The resident reported feeling good about reporting the incident because, no one should be talked to that way. The resident reported feeling safe in the facility and had no other concerns. There was no distress noted. Review of a typed document dated 05/23/2022 at 3:30 PM revealed the interview the facility conducted with Resident #248 during the investigation. The resident stated in the interview that CNA #12 entered the resident's room and the resident told CNA #12 that he/she was tired of laying in poop. CNA #12 replied that she was not [Resident #248's] CNA anyway. The resident stated he/she would report CNA #12 to the Administrator, DHEC, or the senator secretary about the abuse you are doing. Resident #248 indicated that CNA #12 then got down in the resident's face and stated she did not care who the resident told, and she would do as she pleased. Resident #248 pushed CNA #12 away, then another staff in red floral print entered and physically pulled CNA #12 away from the resident. Resident #248 stated what happened was verbal abuse. Review of a typed facility interview dated 05/23/2022 with the COTA revealed she witnessed CNA #12 enter Resident #248's room. CNA #12 approached the resident and began verbally arguing with Resident #248 that she was not assigned to care for the resident. The resident told CNA #12 he/she was not getting into this with you [CNA #12]. The COTA indicated CNA #12 was inches from the resident's face and speaking in a raised voice. The COTA reported a nurse entered the room and asked CNA #12 three times to leave the room. Review of a typed facility interview dated 05/23/2022 at 3:40 PM with Licensed Practical Nurse (LPN) #13 revealed she was in her office with the door closed and heard the raised voices of Resident #248 and CNA #12. When the raised voices persisted, she went to the resident's room. LPN #13 witnessed CNA #12 speaking to the resident in a raised voice, stating she was not the resident's CNA that day. Resident #248 then asked the CNA, Then what are you doing in here? Review of a typed facility interview dated 05/26/2022 with CNA #12 indicated the CNA asserted that she told Resident #248 she was going to talk to the Administrator about the incident. CNA #12 stated she went into the room because the call light was on, and she did not know if Resident #248's roommate needed assistance. During an interview with the Assistant Director of Nursing (ADON) and LPN #13 on 09/22/2022 at 2:56 PM, the ADON revealed she heard CNA #12 was speaking to Resident #248 inappropriately. LPN #13 stated she heard the argument through her closed office door and went to investigate. She stated upon entering the resident's room, CNA #12 was yelling at Resident #248. She told the CNA to stop, but she kept on. She stated she had to grab CNA #12's arm to remove her from the room and separate her from the resident. She stated CNA #12 was suspended, escorted out of the facility, and fired after the investigation was completed. She stated after Resident #248 had calmed down from the altercation, the resident just wanted to know why the CNA had engaged with him/her if the CNA was supposed to be caring for his/her roommate. On 09/21/2022 at 2:48 PM, a telephone interview was attempted with Administrator #2, who was the Administrator at the time of the incident between Resident #248 and CNA #12. A voicemail was left, but no return call was received. 2. Review of a Face Sheet revealed Resident #398 had diagnoses which included mild cognitive impairment, epilepsy, myocardial infarction (heart attack), depressive disorder, insomnia, and adult failure to thrive. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #398 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The MDS indicated the resident exhibited physical and verbal behaviors directed toward others on one to three days during the seven-day assessment period and wandered daily. The MDS revealed the resident was independent with bed mobility, transfers, and ambulation. Review of a Care Plan, dated as initiated on 04/07/2021, revealed Resident #398 was at risk for psychosocial wellbeing issues related to allegations of assault toward other residents. The care plan indicated the resident was involved in an allegation of sexual abuse on 07/19/2021 and a resident-to-resident altercation on 12/27/2021. 2.a) Review of a Face Sheet revealed Resident #75 had diagnoses including stage 4 chronic kidney disease, dementia with behavioral disturbance, lack of coordination, cognitive communication deficit, and insomnia. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #75 had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The MDS indicated the resident had no mood or behavioral symptoms during the assessment period. According to the MDS, the resident required extensive assistance with bed mobility, supervision with transfers, and required supervision with set-up help for locomotion. The MDS indicated the resident used a wheelchair for mobility. Review of a Care Plan, dated as initiated on 09/09/2021, revealed Resident #75 had mood and behavioral needs related to an anxiety disorder and cognitive communication deficit, as evidenced by being sexually, physically, and verbally aggressive and refusing care. Review of an Accident/Incident Reporting Form, dated 04/26/2022, revealed Licensed Practical Nurse (LPN) #4 witnessed an altercation between Resident #398 and Resident #75 on 04/26/2022. According to the LPN's statement, Resident #398 was walking with another resident on Unit Two between rooms [ROOM NUMBERS] and was passing Resident #75. Resident #75 propelled out of his/her room and began a verbal altercation with Resident #398. Resident #398 swung at Resident #75 and missed. Resident #75 swung back, grazing Resident #398 on the right leg. Resident #398 swung again and hit Resident #75 on the right arm. The residents were separated, and Resident #398 continued to be verbally aggressive while leaving the area. Review of an undated, typed Five Day Follow Up summary revealed no injuries were found to either resident. Resident #398 was transferred to the hospital for a psychiatric consultation with no identified concerns. The Staff Development Coordinator (SDC) provided in-service training to staff regarding abuse. Both residents were to follow up with the facility's psychiatric service. According to the summary, Resident #75 received medication changes. The summary indicated that after a review of medical records, body audits, psychosocial notes, and statements, the facility could not substantiate resident-to-resident contact. Review of a Social Service Note, dated 04/26/2022, revealed the Social Services Director (SSD) visited with Resident #75 related to the resident-to-resident altercation. The resident stated he/she was fine and, it was nothing. The resident stated he/she was getting ready to rest and reported feeling safe and had no concerns. Review of Nursing Notes, dated 04/26/2022 at 12:10 PM, revealed Resident #398 had an altercation with another resident on Unit Two at 10:10 AM. The resident refused to let the nurse do a complete body audit. No injuries were noted to the hands, arms, or face and no complaints were voiced. The note revealed Resident #398 was transferred to the hospital for a psychological evaluation. Review of Resident #398's care plan revealed a revision to include the resident to resident altercation 4/26/2022 as a problem; however, there was no documentation of any interventions put in place at that time to prevent further resident altercations/abuse. During an interview with Resident #75 on 09/19/2022 at 2:03 PM, the resident stated he/she felt safe at the facility and stated the staff were, good people. The resident stated no one at the facility had hurt or yelled at the resident. The resident did not recall an altercation with Resident #398. Observation of Resident #398 on 09/20/2022 at 10:54 AM revealed the resident was exiting an office and walking calmly to his/her room. Observation of Resident #398 on 09/21/2022 at 1:38 AM revealed the resident was in his/her room, sitting on the bed. During an interview with Resident #398 on 09/21/2022 at 1:50 AM, the resident stated he/she had a good night. The resident was dressing a doll. The resident knew his/her name and where he/she was. During an interview on 09/20/2022 at 9:53 AM, LPN #4 revealed she witnessed the altercation between Resident #398 and Resident #75 on 04/26/2022. She stated Resident #75 was very protective of women, and Resident #398 was walking with a female resident. Resident #75 stated he/she would protect the female resident because no one else was. She stated the residents swung at each other making contact, but neither hit the other hard and no injuries were found upon assessment. She stated she reported the incident to Registered Nurse (RN) #3, who was the Director of Nursing (DON) at that time. During an interview on 09/20/2022 at 11:03 AM, LPN #11 stated Resident #398 was kind of a bully, could be aggressive, and had a foul mouth. She stated she had witnessed the altercation between Resident #398 and Resident #75 and no contact was made. She stated she reported the incident to the former DON. During a telephone interview on 09/21/2022 at 2:57 PM, RN #3, who was the DON when the incident occurred, revealed she did not recall the altercation between Resident #75 and Resident #398. During an interview on 09/20/2022 at 11:30 AM, the Assistant Director of Nursing (ADON) revealed Resident #398 was involved in most of the facility's reportable incidents. She stated the resident was noncompliant and would yell and lash out when agitated. She stated the resident was ambulatory, refused psychiatric services and medications, and that the facility could not transfer the resident because the resident did not have a guardian or responsible party. The ADON stated if staff redirected the resident calmly and gently, the resident was more compliant. In addition, if the resident felt helpful and useful, the resident did better. She stated Resident #75 would make racial comments, which Resident #398 did not like. The ADON further stated Resident #75 was demented but pleasant most of the time and had no altercations before or after the 04/26/2022 incident. During an interview on 09/21/2022 at 10:46 AM, the SSD stated Resident #398 did better when engaged and when he/she felt helpful, which kept the resident calm. She stated the facility attempted one-to-one supervision upon admission, but the resident knew he/she was being followed and it irritated the resident. According to the SSD, Resident #75 was admitted to the facility for rehabilitation and transitioned to long-term care. She stated the resident was pleasant overall and was not quick to become aggressive but had the potential to do so when upset. She stated Resident #398 and Resident #75 exchanged words, and Resident #75 became upset and struck Resident #398. On 09/21/2022 at 2:48 PM, a telephone interview was attempted with Administrator #2, who was the Administrator at the time of the 04/26/2022 incident. A voicemail was left, but no return call was received. 2.b) Review of a Face Sheet revealed Resident #63 had diagnoses which included stage 3 chronic kidney disease, visual hallucinations, vascular dementia with behavioral disturbance, cerebral infarction (stroke), anxiety disorder, and violent behavior. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #63 was severely impaired in cognitive skills for daily decision making per a staff assessment of mental status. The MDS indicated the resident exhibited physical behaviors directed toward others on one to three days during the seven-day assessment period, verbal behaviors directed toward others on four to six days during the assessment period and wandered daily. The MDS indicated the resident required extensive assistance with bed mobility, required limited assistance with transfers and locomotion, and used a wheelchair for mobility. Review of a Care Plan, dated as initiated 08/10/2020, revealed Resident #63 had visual hallucinations related to a diagnosis of dementia with behavioral disturbance, as evidenced by refusing care, being physically and verbally aggressive with others, having increased exit seeking behaviors, and packing belongings frequently. Review of a Care Plan, dated as initiated 08/09/2021, revealed the resident was at risk for psychosocial wellbeing issues related to an allegation of physical abuse toward another resident. Review of a Care Plan, dated as initiated 11/13/2020, revealed the resident needed encouragement and redirection to attend and participate in activities. The care plan indicated the resident was disruptive during activities by running his/her wheelchair into other residents and trying to hit them. Review of a South Carolina DHEC Initial 2/24-Hour Report, dated 06/02/2022 at 12:30 PM, revealed an incident of resident-to-resident contact occurred with Resident #63 and Resident #398, and both residents were separated and immediately taken to safe areas of the facility. Review of an Accident/Incident Reporting Form, dated 06/09/2022, revealed an interview statement from Ward Clerk #1, who witnessed the incident between Resident #398 and Resident #63 on 06/02/2022 at 12:10 PM. According to the Ward Clerk's interview, Resident #398 was sitting next to a female resident, holding the resident's hand, when Resident #63 rolled his/her wheelchair up next to Resident #398. Ward Clerk #1 heard Resident #398 state, You better not hit me, and Resident #63 hit Resident #398 on the top of the right leg. In response, Resident #398 hit Resident #63 on the left cheek. The residents were immediately separated. Review of an undated typed document titled, Five Day Follow Up revealed a summary which indicated no injuries were found to either resident. Resident #63 was transferred to the hospital for a psychiatric consultation, with no identified concerns. The facility's nurse practitioner and psychiatric services followed up with the residents, and Resident #63 was to be monitored when off his/her home unit. According to the summary, after a review of medical records, body audits, psychosocial notes, and statements, the facility substantiated resident-to-resident contact. Review of Nursing Notes, dated 06/02/2022 at 12:10 PM, revealed Resident #398 was at the nurse's station when another resident from Unit Two (Resident #63) came to the nurse's station. Resident #398 told the resident from Unit Two they better not hit the resident. The resident from Unit Two hit Resident #398 on the leg, and in turn Resident #398 hit the other resident on the left side of the face. Staff separated the residents. Resident #398 went to his/her room and slammed the door. The residents' responsible parties (RP) and NP were notified, with orders to send the other resident to the hospital for evaluation. The note indicated monitoring would continue. During an interview on 09/21/2022 at 1:37 PM, Ward Clerk #1 revealed she witnessed the altercation between Resident #398 and Resident #63 on 06/02/2022. She stated Resident #398 was sitting next to a female resident and tried to kiss the resident. She stated Resident #63 rolled up to the nurse's station in his/her wheelchair and looked as if he/she was going to slap the female resident. At that point, Resident #398 slapped Resident #63. She stated Resident #398 was redirected and stormed off to his/her room and slammed the door. She stated Resident #398 was not receptive to education, so if staff saw the resident with female residents, they were to move the female resident to a different area of the facility. She stated she reported what she witnessed to the former DON. She stated Resident #63 was a strong-willed resident who would roll about the facility in his/her wheelchair. Resident #63 entered other resident rooms and was difficult to redirect, becoming combative with staff. She stated Resident #63 was sent to the hospital for evaluation after Resident #398 slapped the resident, with no injuries found. According to Ward Clerk #1, in the past, she had heard Resident #398 yelling in his/her room and in the hallways at both staff and residents, especially at new nurses. She stated the resident would curse out new nurses. She stated the behaviors of Resident #398 had improved greatly since the most recent hospitalization . During an interview on 09/20/2022 at 9:53 AM, LPN #4 revealed Resident #63 was aggressive but that she had a good rapport with the resident and could usually redirect the resident easily. LPN #4 stated Resident #398 was aggressive and mean. She stated she was present for the altercation between the two residents, witnessed Resident #398 hit Resident #63 on the face, and moved Resident #63 to safety. She stated she was not sure if Resident #63 hit Resident #398 first. According to LPN #4, Resident #398's behaviors had improved the past few months. During a telephone interview with Registered Nurse (RN) #3 on 09/21/2022 at 2:57 PM, she stated she was the DON at the time of the altercation between Resident #398 and Resident #63. She stated when Resident #63 saw Resident #398 sitting with a female resident, Resident #63 became upset and started yelling. Resident #398 then hit Resident #63 on the face. She stated Resident #63 had a red mark on his/her cheek. She stated Resident #398 had behaviors that included verbal altercations with other residents and staff, cussing them out. During an interview on 09/21/2022 at 1:23 AM, LPN #9 stated Resident #398 could be nice one minute and the next would be defensive and confrontational. LPN #9 stated she was notified of the incident between Resident #398 and Resident #63. She stated Resident #398 was moved to a different unit afterwards. She stated Resident #63 would sometimes approach other residents and take things the wrong way, but usually the resident kept to him/herself. During an interview on 09/20/2022 at 11:03 AM, LPN #11 stated Resident #63 used to be aggressive until the physician adjusted the resident's medications. She stated Resident #398 was kind of a bully, could be aggressive, and had a foul mouth. She stated she had never witnessed Resident #398 hit another resident but was aware of the incident involving Resident #63. She stated Resident #63 and Resident #398 were required to be kept apart. During an interview with the Social Service Assistant (SSA) on 09/20/2022 at 12:41 PM, she stated if staff asked Resident #398 to do something in the wrong way or told the resident to do something, his/her behavior escalated quickly. She stated she was able to redirect the resident with activities, coloring, and assisting the SSA with small tasks. She stated she could anticipate the resident's mood fluctuations, stating the resident's voice would get louder when he/she was becoming upset. She stated that after the most recent hospital stay, Resident #398 had calmed tremendously. She stated she had witnessed the resident walk away from a situation that would have escalated him/her in the past. She stated the resident was placed in a private room upon returning from the most recent hospital stay and usually hung out there. During an interview with the Social Service Director (SSD) on 09/20/2022 at 12:59 PM, she revealed Resident #398 returned from the last hospitalization in August 2022 and had been more compliant with medications and redirection and was in a private room. She stated if Resident #398 felt useful, he/she was more redirectable. She stated staff should be watching the resident when the resident was out of his/her room and walking around the facility. During a follow-up interview with the SSD on 09/21/2022 at 10:46 AM, she stated Resident #398 would remain in a private room for the duration of his/her stay until community placement could be acquired. She stated Resident #63 rolled up to Resident #398, hit the resident's leg, and Resident #398 hit the resident back. She stated Resident #63 enjoyed roaming the facility and socializing with others. She stated staff knew they were required to keep the two residents apart and separate them if seen together. During an interview with the Activities Director (AD) on 09/20/2022 at 1:17 PM revealed Resident #398 would volunteer during group activities frequently and did well. He stated the resident would assist other residents with the activity and did well when he/she felt they were helping. He stated Resident #398 responded to redirection from him well, and he tried to keep the resident busy. He stated he was made aware of the physical altercations involving Resident #398 but had not witnessed an incident. During a telephone interview with the psychiatric nurse practitioner (PNP) on 09/21/2022 at 10:30 AM, she stated she evaluated Resident #398 on 08/08/2022. She stated the resident had vascular dementia without behaviors and a mood disorder related to the dementia. She stated when she evaluated the resident, the resident was stable. She stated staff reported the resident was having anger symptoms and could be verbally aggressive. She stated she ordered psychiatric therapy for the resident because the resident could verbalize thoughts, make eye contact with her while speaking, and was cooperative. She stated the resident was in the hospital for behavior issues when she was last scheduled to meet with the resident. During an interview on 09/20/2022 at 11:30 AM, the ADON revealed staff were to watch Resident #398 when he/she was out of the room and that this was included on the resident's care plan. The ADON stated Resident #63 used to be aggressive until the physician prescribed Marinol, which had curbed much of the aggression. She stated Resident #63 wandered the facility mumbling, which irritated Resident #398. She stated Resident #398 would like Resident #63 one minute, then dislike the resident the next. On 09/21/2022 at 2:48 PM, a telephone interview was attempted with Administrator #2, who was the facility Administrator during this altercation. A voicemail was left, and no return call was received. During an interview with the current Administrator on 09/21/2022 at 5:07 PM, she stated Resident #398 had a hospital stay in August 2022, and they completed an evaluation and made some medication changes. She stated the facility would be seeking alternative placement for the resident when guardianship was determined by the courts by the end of the month. She stated gentle redirection worked best with Resident #398, and the resident had done better having a private room. She stated the resident would be in a private room for the remainder of his/her stay at the facility. She stated floor staff watched the resident when he/she walked through the facility and would check in with the resident. During an interview with the Medical Director (MD) on 09/22/2022 at 10:09 AM, he revealed Resident #398 had psychiatric and behavioral issues and required a lot of redirection. He stated the resident would be level-headed one minute then go off the next. The MD stated Resident #75 did not have decision-making capacity but interacted and socialized well with the other residents. He stated Resident #75 enjoyed sitting in the doorway of his/her room, chatting with passers-by. He stated he had never seen Resident #75 be physically or verbally aggressive or have any behaviors. According to the MD, Resident #63 used to be very aggressive but since the Marinol was started, the resident's aggressive behaviors had improved vastly. 3. Review of a Face Sheet revealed Resident #13 had diagnoses which included dementia with behavioral disturbance, lack of coordination, cognitive communication deficit, anorexia, and diabetes mellitus. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident was severely cognitively impaired. The MDS indicated Resident #13 had mood symptoms with a total severity score of seven, indicating mild depression. The MDS revealed the resident rejected care on four to six days during the seven-day assessment period but had no physical, verbal, or other behavioral symptoms. The MDS indicated the resident required supervision and set-up help with bed mobility, transfers, ambulation, and locomotion and used a wheelchair for mobility. Review of Resident #13's Care Plan, initiated on 07/11/2021, indicated the resident had mood and behavioral needs due to behaviors that included being verbally and/or physically aggressive with staff and having violent behavior, threatening to kill others on 05/22/2022. The facility developed interventions that included having the psychiatrist see the resident on the next visit (created 06/02/2022); non-pharmacological interventions (including activity programs, quiet time/rest, redirection/reassurance, increased observation); administering medications as ordered and monitoring for effectiveness and side effects. Review of a South Carolina DHEC Initial 2/24-Hour Report, dated 06/16/2022 at 10:15 AM, revealed a resident-to-resident altercation occurred between Resident #13 and Resident #54, and both residents were separated immediately. Further review of facility reports revealed no Accident/Incident Reporting Form investigation was included for the altercation on 06/16/2022 between Resident #13 and Resident #54. A review of Nursing Notes, dated 06/16/2022 at 11:12 AM, revealed Resident #13 was yelling at his/her roommate (Resident #54) and threw the lid from his/her meal tray at the roommate. The resident refused to come out of the room, and redirection from staff was unsuccessful. The note revealed 911 was called, and the resident was sent to the hospital for psychiatric evaluation. Observation of Resident #13 on 09/19/2022 at 12:14 PM revealed the resident was in bed with the covers over his/her head. The resident had no roommate, and a wheelchair was at the foot of the bed. Review of Resident #54's Face Sheet revealed the facility admitted the resident with diagnoses which included diabetes mellitus, depression, anemia, osteoarthritis, muscle atrophy, stroke, and abnormal posture. A review of an annual Minimum Data Set (MDS), dated [DATE], revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS indicated the resident had no behavioral [NAME][TRUNCATED]

Based on observations, interviews, record reviews, and facility policy reviews, it was determined that the facility neglected to provide proper observation for 1 of 1 resident reviewed for elopement. The findings include: Resident #1 (R #1) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/2021 revealed R #1 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicating severe cognitive impairment. Further MDS review of R #1's functional status revealed h/she requires one-person limited assistance for bed mobility, transfer, dressing, and walk in room. R #1 requires set up only and supervision for walk in corridor, locomotion on unit and eating, and extensive one-person assist for toileting. A Record Review of a progress note for R #1 dated 05/15/2021 10:38AM revealed was notified by staff that Resident could not be located. Assisted Cerified Nursing Assistant (CNA) to locate resident. Unable to locate resident. Called code white. As census was being printed resident was found by CNAs on rehab in an empty room in the bathroom. A Record Review of a progress note for R #1 dated 05/20/2021 6:14AM revealed Resident awake sitting in common area watching tv, then up walking around, staff assisted h/her to room and then into bed, when this nurse was making rounds, noted resident was not in bed, noted to be in 408 bathroom, staff assisted him/her back to common area to watch tv, noted moving from chair to chair and finally falling asleep, will continue to monitor. A Record Review of a progress note for R #1 dated 05/26/2021 7:15AM revealed Resident up and ambulating down back hall at approximately 5:30am. Resident directed to have a seat in the Unit 1 lobby. At approximately 6:15am resident was noted not sitting in the lobby. Immediate search for resident began. Resident not located on Unit 1 or rehab. Code white called. DON notified Search continued thru facility and facility grounds. Resident located off facility premises laying in a ditch where h/she had fallen. Resident returned to facility. Resident complained of left forearm pain. Nurse Practitioner (NP) called and notified; order for xray obtained. Complete body audit performed; skin intact. When asked by this nurse where h/she was going resident stated going to get a drink of water. Resident noted to ambulate at will but, had not had exit seeking behavior until this incident. Attempted to call RP but no answer. A Record Review of a progress note for R #1 dated 05/26/2021 9:00AM revealed Resident is resting in bed. Alert with some confusion; oriented to person. Resident is unaware of place time nor current situation. Requires assistance with ADLs (activities of Daily Living). Ambulates ad lib (at will). Voiced c/o pain to left arm. Medicated with Tylenol per prn order; will note effectiveness. No further evidence of injuries noted related to previous unsupervised exit from facility. Resident unable to recall/relay events pertaining to exiting the building. States that he hurt his arm on the inside not outside of the building. Wander guard anklet in place and functioning. A Record Review of a progress note for R #1 dated 05/26/2021 2:33PM revealed This DON was notified at 6:45am that the above resident was last seen around 5:45am sitting and resting in a chair in the lobby day room. I was informed that staff looked for the resident and could not locate him. A Code White was called at that time and a complete head count for each resident was completed on each unit. It was communicated to me around 7:05am that the resident had been located about quarter mile away from the facility on the left side of the road. Body audit completed, resident assessed, wander guard placed, x-ray to the left arm completed related to complaints of pain. NP, Responsible Party (RP) and all required officials notified. Resident cont. to be monitored by staff. An Observation of R #1 on 5/27/2021 at approximately 10:54AM revealed, R#1 in bed with eyes closed, appears sleeping. An Observation of R #1 on 5/27/2021 at approximately 3:51PM revealed, R# 1 in bed with eyes closed, appears sleeping. On 5/27/2021, a review of a witness statement by the Maintenance Director revealed On 5/26/21 all facility doors were checked to make sure hey were in proper working order. No issues were found. All doors and alarms are functioning properly. On 5/27/2021, a review of a witness statement by CNA #4 revealed R #1 wonder from room to bathroom to room I stop h/her throughout the [MEDICATION(S)] 5:30am. During the early morning I was doing my rounds in the middle of my rounds I ask for h/her to set in front I told the nurse h/she is a wonder and I can't care for the other residents because of R #1 refuse to sit. So she had him sit before within a hour is gone. I was told by other CNA's that work with h/her on Rehab h/she is known to wonder. I didn't know any of this information. On 5/27/2021, a review of a witness statement by CNA #5 revealed I was just getting through cleaning a resident when I heard the code over the intercam. I asked who the Resident was and started walking the parking lot. I went up the side me and another CAN and across the street. Once we got over there we saw him crotched down in a ditch. I called the staffing phone and walked him until staffing pulled up with a car. We all got in the car and came back to the building. An interview with CNA #2 on 5/27/2021 at 11:43 AM revealed It was doing med rounds, 645am, one of the nurses state R #1 was missing. I was on Rehab unit, starting looking and walking towards Asheville Highway, a school bus passed then stopped. That's when I saw R #1's baseball cap in the ditch, I started running towards h/her. R #1 was down in the ditch on their side trying to get up, it was about 6:50am. We started to walk back, staff called on phone, R #1 was holding left arm complaining of pain; a car with staff came and we were taken back to facility. We got out vehicle, escorted R #1 in and the nurses started their assessments, it was about 7am. Don't know how long h/she was gone or if taken to the hospital after, I was told to go after I gave my statement. R #1 was a new resident to me, unfamiliar and a wanderer. An Interview with the DON on 5/27/2021 AT 11:09AM revealed No one saw R #1 exit, they were last seen in the lobby. R #1 never exit seeks, just walks to tire h/her self out. R #1 was last seen around 5:45am, nurse was passing medicines, between 6:30-6:45AM went to check on R #1 and didn't see them. R #1 was found one quarter mile from the building down the street. R #1 has wander guard now, elopement assessment completed. H/she didn't have exit seeking behavior, the facility is in the process of changing doors. Wander guard was placed yesterday. The main exit/entrance door had no alarms, looking at changing that. A Record Review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment defines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A Record Review of the facility policy titled Elopement revealed, it is the facility's policy to safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing.

Based on interviews and record reviews, the facility failed to ensure adequate supervision and assistance to prevent accidents for 1 of 3 residents reviewed for wandering. Resident (R) #1 complained of pain to left arm after a successful unattended elopement off facility premises and being found in a ditch. The findings include: R#1 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, [CONDITION(S)], Chronic Kidney Disease, Dysphagia, and [CONDITION(S)] Syndrome. A review of R#1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/2021 revealed R#1 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicating severe cognitive impairment. Further MDS review of R#1's functional status revealed h/she requires one-person limited assistance for bed mobility, transfer, dressing, and walk in room. Resident #1 requires set up only and supervision for walk in corridor, locomotion on unit and eating, and extensive one-person assist for toileting. A Record Review of a progress note for R#1 dated 05/15/2021 10:38AM revealed was notified by staff that resident could not be located. Assisted CNA's to locate resident. Unable to locate resident. Called code white. As census was being printed resident was found by CNAs on rehab in an empty room in the bathroom. A Record Review of a progress note for R#1 dated 05/20/2021 6:14AM revealed Resident awake sitting in common area watching tv, then up walking around, staff assisted h/her to room and then into bed, when this nurse was making rounds, noted resident was not in bed, noted to be in 408 bathroom, staff assisted h/her back to common area to watch tv, noted moving from chair to chair and finally falling asleep, will continue to monitor. A Record Review of a progress note for R#1 dated 05/26/2021 7:15AM revealed Resident up and ambulating down back hall at approximately 5:30am. Resident directed to have a seat in the Unit 1 lobby. At approximately 6:15am resident was noted not sitting in the lobby. Immediate search for resident began. Resident not located on Unit 1 or rehab. Code white called. Director Of Nursing (DON) notified Search continued thru facility and facility grounds. Resident located off facility premises laying in a ditch where h/she had fallen. Resident returned to facility. Resident complained of left forearm pain. Nurse Practitioner (NP) called and notified; order for xray obtained. Complete body audit performed; skin intact. When asked by this nurse where h/she was going resident stated going to get a drink of water. Resident noted to ambulate at will but, had not had exit seeking behavior until this incident. Attempted to call RP but no answer. A Record Review of a progress note for R#1 dated 05/26/2021 9:00AM revealed Resident is resting in bed. Alert with some confusion; oriented to person. Resident is unaware of place time nor current situation. Requires assistance with ADLs. Ambulates ad lib. Voiced c/o pain to left arm. Medicated with Tylenol per prn order; will note effectiveness. No further evidence of injuries noted related to previous unsupervised exit from facility. Resident unable to recall/relay events pertaining to exiting the building. States that he hurt his arm on the inside not outside of the building. Wander guard anklet in place and functioning. A Record Review of the radiology order dated 5/26/2021 revealed an xray order Lt Shoulder; Lt wrist 3 views; Lt forearm: Lt elbow. Xray results revealed [CONDITION(S)] joint disease of the left shoulder; otherwise, no fracture or dislocation seen; normal left humerus; normal left elbow, A Record Review of a progress note for R#1 dated 05/26/2021 2:33PM revealed This DON was notified at 6:45am that the above resident was last seen around 5:45am sitting and resting in a chair in the lobby day room. I was informed that staff looked for the resident and could not locate him. A Code White was called at that time and a complete head count for each resident was completed on each unit. It was communicated to me around 7:05am that the resident had been located about quarter mile away from the facility on the left side of the road. Body audit completed, resident assessed, wander guard placed, x-ray to the left arm completed related to complaints of pain. NP, Responsible Party (RP) and all required officials notified. Resident cont. to be monitored by staff. On 5/27/2021, a review of a witness statement by the Maintenance Director revealed On 5/26/21 all facility doors were checked to make sure hey were in proper working order. No issues were found. All doors and alarms are functioning properly. On 5/27/2021, a review of a witness statement by Certified Nursing Assistant (CNA) #4 revealed Resident #1 wonder from room to bathroom to room I stop h/her throughout the morning after 5:30am. During the early morning I was doing my rounds in the middle of my rounds I ask for h/her to set in front I told the nurse h/she is a wonder and I can't care for the other residents because of R#1 refuse to sit. So she had him sit before within a hour is gone. I was told by other CNA's that work with h/her on Rehab h/she is known to wonder. I didn't know any of this information. On 5/27/2021, a review of a witness statement by CNA #5 revealed I was just getting through cleaning a resident when I heard the code over the intercam. I asked who the resident was and started walking the parking lot. I went up the side me and another CNA and across the street. Once we got over there we saw him crotched down in a ditch. I called the staffing phone and walked him until staffing pulled up with a car. We all got in the car and came back to the building. An interview with CNA #2 on 5/27/2021 at 11:43 AM revealed It was doing med rounds, 645am, one of the nurses state R#1 was missing. I was on Rehab unit, starting looking and walking towards Asheville Highway, a school bus passed then stopped. That's when I saw R#1's baseball cap in the ditch, I started running towards h/her. R #1 was down in the ditch on their side trying to get up, it was about 6:50am. We started to walk back, staff called on phone, R#1 was holding left arm complaining of pain; a car with staff came and we were taken back to facility. We got out vehicle, escorted R#1 in and the nurses started their assessments, it was about 7am. Don't know how long h/she was gone or if taken to the hospital after, I was told to go after I gave my statement. R #1 was a new resident to me, unfamiliar and a wanderer. An Interview with the DON on 5/27/2021 at approximately 11:09AM revealed No one saw R #1 exit, they were last seen in the lobby. R #1 never exit seeks, just walks to tire h/her self out. R #1 was last seen around 5:45am, nurse was passing medicines, between 630-645am went to check on R#1 and didn't see them. R #1 was found one quarter mile from the building down the street. R #1 has wander guard now, elopement assessment completed. H/she didn't have exit seeking behavior, the facility is in the process of changing doors. Wander guard was placed yesterday. The main exit/entrance door had no alarms, looking at changing that. An interview with the Administrator on 5/27/2021 at approximately 1:58PM revealed that the front lobby door is now locked and requires a code to go in and out. Alarm now sounds when trying to get out. A Record Review of the facility policy titled Elopement revealed, it is the facility's policy to safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing.

Based on record review, interview and review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, Resident #1's critical PT ([MEDICATION NAME])/INR (international normalizing ratio) was called by the lab to Registered Nurse #1 on 01/25/2016. RN #1 failed to address the critical PT/INR, Resident #1 received her/his previously ordered dose of [MEDICATION NAME] on 1/25 and 1/26/2016. On 1/27/2016 Resident #1 had a nosebleed and was admitted to the hospital with [REDACTED]. 1 of 5 residents reviewed with orders for [MEDICATION NAME]. The failure of the facility staff to address the critical PT/INR and the resident continued to receive the anticoagulant subsequently leading to a hospitalization resulted in the findings of Immediate Jeopardy at Past Noncompliance existing in the facility on 1/26/16. The facility implemented a plan of correction and the Immediate Jeopardy was removed on 2/2/16. The findings included: Cross refer to F-333 as it relates to a significant medication error. A critical PT/INR for Resident #1 was not addressed by the facility licensed staff on 1/25/2016. Resident #1 continued to received her/his previously ordered [MEDICATION NAME] on 1/25 and 1/26/2016. S/he was admitted to the hospital following a nosebleed on 1/27/2016 with an INR of 10.6. Review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, revealed: Dosing of [MEDICATION NAME] ([MEDICATION NAME]) must be individualized according to patient response to the drug as indicated by the INR . Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) coded her/him as having a BIMS (brief interview of mental status) of 15. Review of the most recent Quarterly MDS dated [DATE] coded her/him as having a BIMS of 09. Her current [DIAGNOSES REDACTED]. She required extensive assistance of two with bed mobility, transfer, toilet use and personal hygiene; one person assist with locomotion on and off the unit; extensive assistance of one person was required for dressing and eating. She used a wheelchair for ambulation. Review of the Resident Progress Notes dated 1/27/2016 stated, Resident sent to hospital at 7 PM. Resident had INR level of 7.76. Sneezing out bloodclots from nose. Review of the Hospital Admission history and physical dated 1/28/2016 stated, . Apparently, the patient has had PT/INR checked on the 25 of this month and INR was 7.4 some reason has not been checked the other levels until today, and the patient has been getting her/his regular dose of [MEDICATION NAME] . The patient has rechecked here with INR 10.6 with combined epistaxis and high risk of bleed. The patient was offered admission. S/he has received 2 units of FFP (fresh frozen plasma) here in the ER . Review of the facility investigation revealed a Five-Day Follow-Up Report faxed to the State Agency dated 2/4/2016 that included the following summary of the investigation: Resident #1 had a PT/INR drawn, as ordered, on the morning of 1/25/2016 with critical results. These results were called to Registered Nurse (RN) #1 at approximately 11 AM on the same morning. RN #1 notified Nurse Practitioner (who was in the facility at the time), but did not give details regarding the patient, type of lab, or lab value when reporting. NP was completing patient dictation at the time that the nurse states s/he notified her/him. RN #1 failed to follow up with ensuring that the provider addressed the critical result as well as the order for [MEDICATION NAME] and any need for administration of Vitamin K. Standard procedure for critical lab results with the contracted lab includes both verbal (via phone call) and faxed hard copy results are sent to the facility. The lab company did notify the nurse (RN #1) of the critical value. Subsequently, the nurse did notify the provider on duty that critical results were to be faxed. However, the nurse failed to relay pertinent details that were necessary to treat the patient. The hard copy (faxed copy) of the critical results were never received from the lab for the provider to review. The patient continued to receive [MEDICATION NAME] on the nights of January 25 and January 26, 2016. The nurse receiving the critical result failed to document the result and failed to communicate it to oncoming shifts during change of shift report. On January 27, 2016 the patient sustained a minimal nose bleed [MEDICATION NAME] approximately 1-2 minutes. At this time, the nurse on duty requested the most recent INR result from the lab to be refaxed to the facility. Upon receipt of these results, the critical PT/INR was again noted. The nurse notified the on-call physician of the medication error and critical value and the patient was transferred to the hospital. The nurse involved with this allegation was placed on suspension on the morning of January 26, 2016 . In a facility obtained interview dated 1/28/16 at 8:35 AM Registered Nurse (RN) #1 stated, Employee confirms that s/he was assigned as the staff nurse to care for Resident #1 . Employee was asked if s/he recalls notification from the contracted lab service of any significant lab values, s/he states that s/he does recall the lab contacting her/him via phone call to notify critical INR results for Resident #1. S/he states that immediately upon receipt of the phone call, s/he walked behind the nurse's station to notify the Nurse Practitioner of the call. Employee was asked if s/he recalls exactly what s/he relayed to the Nurse Practitioner and states that s/he informed her/him, 'The lab just called a critical value and they're faxing over the copy to that fax machine.' Employee states that s/he did not indicate the patient's name, lab type, or lab value to the Nurse Practitioner when stating this information. S/he explains that NP was sitting directly beside the fax machine that the lab utilizes to fax results and that s/he expected the provider to pick up the copy off of the fax machine moments later. Employee states that s/he did not return to the NP concerning the lab value or check the fax machine during the remainder of her/his shift. S/he states that s/he was not notified of any new orders following her/his conversation with the provider. Employee admits that s/he is aware that s/he should have followed up with the lab results as well as the medication order for [MEDICATION NAME]. In a telephone interview with the surveyor on 4/21/2016 at approximately 9:00 AM Registered Nurse #1 confirmed the statement s/he gave the facility. S/he stated, I did tell the Nurse Practitioner the resident's name and the lab value. S/he stated s/he should have followed up with the lab results and any new orders. In a facility obtained interview dated 1/28/16 at 10:00 AM Nurse Practitioner #1 stated, that s/he does not recall receipt of any critical lab values - neither paper copy nor reported verbal results - from the facility or facility staff . S/he states that s/he evaluated Resident #1 the morning of the prior day (1/27/16) and did not observe or receive report of any signs or symptoms that would indicate [MEDICATION NAME] toxicity or bleeding. S/he states that the patient did have slight ecchymosis to her/his upper bilateral extremities but indicates that these were present upon previous evaluation. NP states that s/he does recall being in the dictation area behind the nurse's station of the Rehabilitation Unit . but does not recall RN #1 reporting any abnormal lab values to her/him or any other conversation with the nurse. S/he states that s/he does not typically check the fax machine on any of the units within the facility as this is the responsibility of the facility staff. NP states that the normal process for addressing critical labs within the facility is for the nurse to receive the value from the lab company and report it to her/him verbally or via paper/faxed copy from the lab. At this point, s/he notifies the nurse of the need for orders . S/he states that s/he addresses any critical INR results immediately with holding or discontinuing [MEDICATION NAME] orders and evaluating the need for Vitamin K administration, bleeding risk, and necessary transfer to the hospital. In an interview with the surveyor on 4/6/2016 at 10:45 AM the Nurse Practitioner stated it was not her/his job to sit by the fax machine. The nurses call with changes and orders are written per lab values. I would have expected the nurse to have given me the resident's name with the lab value and I would have given her/him orders. In a facility obtained interview dated 1/28/16 at 1:00 PM the Lab Supervisor states that verbal critical results were called to the facility at approximately 11 AM on 1/25/16 to the nurse on duty, RN #1 per standard procedures. In regards to the hard faxed copy that the facility was unable to locate, s/he states that labs are faxed via automated system and errors may occur at times. S/he states that the lab ensures that all critical results are reported immediately via phone call to the facility nursing staff. An acceptable Plan of Correction was submitted by the facility with the date of correction 2/2/2016, which included: 1. Identified employee was suspended 1/28/16 pending investigation of identified issue. Employee's last day at the facility was 1/28/16 and employment was terminated 2/5/16 related to identified incident. Resident #1 had an elevated PT/INR on 1/25/16, physician was not notified. On 1/25/16 and 1/26/16, Resident #1 was given previously ordered dose of [MEDICATION NAME]. On 1/27/16, Resident #1 developed a nosebleed and was admitted to the hospital for treatment. Resident #1 was readmitted to facility on 2/10/16. 2. Residents in the facility receiving [MEDICATION NAME] therapy have the potential to be affected by this alleged deficient practice. An audit of all current facility residents receiving [MEDICATION NAME] was completed on 1/28/16 by the Director of Nursing to validate most recently obtained PT/INR's had physician notification of results and implementation of any corresponding orders. No other concerns were identified, therefore, no employee required further action. 3. The facility Staff Development Coordinator re-educated facility Information Specialists on validating ordered PT/INR's obtained by contracted phlebotomy services, monitoring fax machines throughout the shift for faxed PT/INR results and obtaining PT/INR results through laboratory portal. This occurs Monday-Friday and the weekend supervisor completes duties on Saturday and Sunday. Licensed Nurses were re-educated on physician notification of obtained PT/INR's, implementation of corresponding orders and documenting actual PT/INR results in the electronic Medication Administration Record [REDACTED]. Any licensed nurses/Information Specialist not receiving this re-education on this date was re-educated prior to next scheduled shift. This information will be presented in new hire orientation. 4. The facility Director of Nursing/Weekend Nurse Supervisor began monitoring ordered PT/INR results 1/29/16 for physician's orders [REDACTED]. The facility Administrator is randomly reviewing monitored information weekly for 3 months. 5. Results of the monitoring was presented to the Quality Assurance Performance Improvement (QAPI) Committee initially on 2/25/16 again on 3/24/16 and will continue for period of 3 months or until substantial compliance is achieved and maintained. Any areas of concern identified were addressed at time of discovery. All required auditing and re-education was completed 2/2/16. Date of Correction 2/2/16 Review of the Plan of Correction documentation, audit tools completed, inservice content and staff inservice completion sign off sheets, staff interviews, and record review of residents with physician ordered [MEDICATION NAME] was completed onsite during the survey. The findings confirmed the facility was in substantial compliance at F-281 as of 2/2/16, the date all interventions developed in the facility Plan of Correction had been completed.

Based on record review and interview Resident #1's critical PT ([MEDICATION NAME])/INR (international normalizing ratio) was called by the lab to Registered Nurse #1 on 01/25/2016. RN #1 failed to address the critical PT/INR, Resident #1 received her/his previously ordered dose of [MEDICATION NAME] on 1/25 and 1/26/2016. On 1/27/2016 Resident #1 had a nosebleed and was admitted to the hospital with [REDACTED]. 1 of 5 residents reviewed with orders for [MEDICATION NAME]. The failure of the facility assure staff acted upon a critical lab value and to assure a resident is free from significant medication errors, Resident #1 continued to receive an anticoagulant with a critically high PT/INR lab value, resulted in the findings of Immediate Jeopardy at Past Noncompliance existing in the facility on 1/26/16. The facility implemented a plan of correction and the Immediate Jeopardy was removed on 2/2/16. The findings included: Review of the facility investigation revealed a Five-Day Follow-Up Report faxed to the State Agency dated 2/4/2016 that included the following summary of the investigation: Resident #1 had a PT/INR drawn, as ordered, on the morning of 1/25/2016 with critical results. These results were called to Registered Nurse (RN) #1 at approximately 11 AM on the same morning. RN #1 notified Nurse Practitioner (who was in the facility at the time), but did not give details regarding the patient, type of lab, or lab value when reporting. NP was completing patient dictation at the time that the nurse states s/he notified her/him. RN #1 failed to follow up with ensuring that the provider addressed the critical result as well as the order for [MEDICATION NAME] and any need for administration of Vitamin K. Standard procedure for critical lab results with the contracted lab includes both verbal (via phone call) and faxed hard copy results are sent to the facility. The lab company did notify the nurse (RN #1) of the critical value. Subsequently, the nurse did notify the provider on duty that critical results were to be faxed. However, the nurse failed to relay pertinent details that were necessary to treat the patient. The hard copy (faxed copy) of the critical results were never received from the lab for the provider to review. The patient continued to receive [MEDICATION NAME] on the nights of January 25 and January 26. The nurse receiving the critical result failed to document the result and failed to communicate it to oncoming shifts during change of shift report. On January 27, 206 the patient sustained a minimal nose bleed [MEDICATION NAME] approximately 1-2 minutes. At this time, the nurse on duty requested the most recent INR result from the lab to be refaxed to the facility. Upon receipt of these results, the critical PT/INR was again noted. The nurse notified the on-call physician of the medication error and critical value and the patient was transferred to the hospital. The nurse involved with this allegation was placed on suspension on the morning of January 26, 2016 . Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) coded her/him as having a BIMS (brief interview of mental status) of 15. Review of the most recent Quarterly MDS dated [DATE] coded her/him as having a BIMS of 09. Her current [DIAGNOSES REDACTED]. She required extensive assistance of two with bed mobility, transfer, toilet use and personal hygiene; one person assist with locomotion on and off the unit; extensive assistance of one person was required for dressing and eating. Review of the Resident Progress Notes dated 1/27/2016 stated, Resident sent to hospital at 7 PM. Resident had INR level of 7.76. Sneezing out bloodclots from nose. Review of the Hospital Admission history and physical dated 1/28/2016 stated, . Apparently, the patient has had PT/INR checked on the 25 of this month and INR was 7.4 some reason has not been checked the other levels until today, and the patient has been getting her/his regular dose of [MEDICATION NAME] . The patient has rechecked here with INR 10.6 with combined epistaxis and high risk of bleed. The patient was offered admission. S/he has received 2 units of FFP (fresh frozen plasma) here in the ER . In a facility obtained interview dated 1/28/16 at 8:35 AM Registered Nurse (RN) #1 stated, Employee confirms that s/he was assigned as the staff nurse to care for Resident #1 . Employee was asked if s/he recalls notification from the contracted lab service of any significant lab values, s/he states that s/he does recall the lab contacting her/him via phone call to notify critical INR results for Resident #1. S/he states that immediately upon receipt of the phone call, s/he walked behind the nurse's station to notify the Nurse Practitioner of the call. Employee was asked if s/he recalls exactly what s/he relayed to the Nurse Practitioner and states that s/he informed her/him, 'The lab just called a critical value and they're faxing over the copy to that fax machine.' Employee states that s/he did not indicate the patient's name, lab type, or lab value to the Nurse Practitioner when stating this information. S/he explains that NP was sitting directly beside the fax machine that the lab utilizes to fax results and that s/he expected the provider to pick up the copy off of the fax machine moments later. Employee states that s/he did not return to the NP concerning the lab value or check the fax machine during the remainder of her/his shift. S/he states that s/he was not notified of any new orders following her/his conversation with the provider. Employee admits that s/he is aware that s/he should have followed up with the lab results as well as the medication order for [MEDICATION NAME]. In a telephone interview with the surveyor on 4/21/2016 at approximately 9:00 AM Registered Nurse #1 confirmed the statement s/he gave the facility. S/he stated, I did tell the Nurse Practitioner the resident's name and the lab value. S/he stated s/he should have followed up with the lab results and any new orders. In a facility obtained interview dated 1/28/16 at 10:00 AM Nurse Practitioner #1 stated, that s/he does not recall receipt of any critical lab values - neither paper copy nor reported verbal results - from the facility or facility staff . S/he states that s/he evaluated Resident #1 the morning of the prior day (1/27/16) and did not observe or receive report of any signs or symptoms that would indicate [MEDICATION NAME] toxicity or bleeding. S/he states that the patient did have slight ecchymosis to her/his upper bilateral extremities but indicates that these were present upon previous evaluation. NP states that s/he does recall being in the dictation area behind the nurse's station of the Rehabilitation Unit . but does not recall RN #1 reporting any abnormal lab values to her/him or any other conversation with the nurse. S/he states that s/he does not typically check the fax machine on any of the units within the facility as this is the responsibility of the facility staff. NP states that the normal process for addressing critical labs within the facility is for the nurse to receive the value from the lab company and report it to her/him verbally or via paper/faxed copy from the lab. At this point, s/he notifies the nurse of the need for orders . S/he states that s/he addresses any critical INR results immediately with holding or discontinuing [MEDICATION NAME] orders and evaluating the need for Vitamin K administration, bleeding risk, and necessary transfer to the hospital. In an interview with the surveyor on 4/6/2016 at 10:45 AM the Nurse Practitioner stated it was not her/his job to sit by the fax machine. The nurses call with changes and orders are written per lab values. I would have expected the nurse to have given me the resident's name with the lab value and I would have given her/him orders. In a facility obtained interview dated 1/28/16 at 1:00 PM the Lab Supervisor states that verbal critical results were called to the facility at approximately 11 AM on 1/25/16 to the nurse on duty, RN #1 per standard procedures. In regards to the hard faxed copy that the facility was unable to locate, s/he states that labs are faxed via automated system and errors my occur at times. S/he states that the lab ensures that all critical results are reported immediately via phone call to the facility nursing staff. An acceptable Plan of Correction was submitted by the facility with the date of correction 2/2/2016, which included: 1. Resident #1 had an elevated PT/INR on 1/25/16, physician was not notified. On 1/25/16 and 1/26/16, Resident #1 was given previously ordered dose of [MEDICATION NAME]. On 1/27/16, Resident #1 developed a nosebleed and was admitted to the hospital for treatment. Resident #1 was readmitted to facility on 2/10/16. 2. Residents in the facility receiving [MEDICATION NAME] therapy have the potential to be affected by this alleged deficient practice. An audit of all current facility residents receiving [MEDICATION NAME] was completed on 1/28/16 by the Director of Nursing to validate most recently obtained PT/INR's had physician notification of results and implementation of any corresponding orders. No other concerns were identified, therefore, no employee required further action. 3. The facility Staff Development Coordinator re-educated facility Information Specialists on validating ordered PT/INR's obtained by contracted phlebotomy services, monitoring fax machines throughout the shift for faxed PT/INR results and obtaining PT/INR results through laboratory portal. This occurs Monday-Friday and the weekend supervisor completes duties on Saturday and Sunday. Licensed Nurses were re-educated on physician notification of obtained PT/INR's, implementation of corresponding orders and documenting actual PT/INR results in the electronic Medication Administration Record [REDACTED]. Any licensed nurses/Information Specialist not receiving this re-education on this date was re-educated prior to next scheduled shift. This information will be presented in new hire orientation. 4. The facility Director of Nursing/Weekend Nurse Supervisor began monitoring ordered PT/INR results 1/29/16 for physician's orders [REDACTED]. The facility Administrator is randomly reviewing monitored information weekly for 3 months. 5. Results of the monitoring was presented to the Quality Assurance Performance Improvement (QAPI) Committee initially on 2/25/16 again on 3/24/16 and will continue for period of 3 months or until substantial compliance is achieved and maintained. Any areas of concern identified were addressed at time of discovery. All required auditing and re-education was completed 2/2/16. Date of Correction 2/2/16 Review of the Plan of Correction documentation, audit tools completed, inservice content and staff inservice completion sign off sheets, staff interviews, and record review of residents with physician ordered [MEDICATION NAME] was completed onsite during the survey. The findings confirmed the facility was in substantial compliance at F-333 as of 2/2/16, the date all interventions developed in the facility Plan of Correction had been completed.