Every finding on record at Saluda Nursing Center

Based on observation, interview, and facility guideline review, the facility failed to date, label, and/or cover food products stored in 1 of 1 kitchen. This failure had the potential to create an environment for food-borne illnesses which could affect 142 of 144 residents who consumed food prepared from the facility's kitchen.Findings include: Review of the facility's undated and untitled guidelines that the facility followed for food storage and provided by the Dietary Manager (DM), revealed a content list for storing staples, refrigerator, freezer items, mixes, and packaged foods. The document addressed storage and handling by food category. During an observation and tour on 06/16/26 from 9:25 AM to 10:15 AM, with the Dietary Coordinator (DC), revealed the following: The main walk-in refrigerator contained an open cardboard box with no date; inside were open plastic bags with 12 dozen peeled hard boiled eggs in a total of seven bags with no dates. There were three plastic bags containing 24 apples in each plastic bag with no dates. There were three plastic bags of oranges with 15 oranges in each bag and one plastic bag of lemons with 15 lemons: all with no dates. The main walk-in freezer contained two loaves of frozen bread in plastic bags with no dates. There was an open cardboard box with no date and inside was an open plastic bag with frozen cookie dough (35 pieces) with no dates. There was another open cardboard box with an open plastic bag containing a frozen mixture of broccoli and cauliflower with no dates. There was another open cardboard box with an open plastic bag containing 50 cooked fried eggs with no dates. There was a plastic bag of frozen shrimp with 71/90 pieces with no date. There was an open plastic bag containing four plastic bags of beef/pork ragu sauce with no dates. There was another open cardboard box containing two plastic bags of hot dog rolls with no dates and with ice accumulating on top of the hot dog rolls. There was another open cardboard box with an open plastic bag with five plastic bags (32oz each) of whipped topping with no dates. During an interview on 06/16/26 at 10:20 AM, the DC confirmed the above observations and stated that staff should date all refrigerated products once the food items were opened. The DC also stated that there was no schedule for checking all food for date labels or expired food. During an interview on 06/17/26 at 10:30 AM, the DM stated that the guidelines were what the kitchen followed when it came to food handling and storage. The DM stated there was no section regarding dating items when they were received or dating items once they were opened.

Based on record review, interview, and policy review, the facility failed to ensure that cardiopulmonary resuscitation (CPR) was initiated after one of 11 residents (Resident (R) 361) was found unresponsive on [DATE]. The facility's Administrator, Director of Nursing (DON), and the Assistant Director of Nursing (ADON) were informed on [DATE] at 6:18 PM that Immediate Jeopardy (IJ) existed related to the failure to ensure that one of 11 residents received CPR as required. The facility provided an IJ Removal Plan that was accepted on [DATE] at 4:37 PM. The survey team validated implementation of the removal plan through interviews, and review of training records. IJ was verfied as removed on [DATE] at 5:21 PM, with a compliance date of [DATE]. After the removal of the IJ, the deficiency remained at a D scope and severity for isolated potential for more than minimal harm. Findings include: Review of the facility's policy titled, Emergency Procedure-Cardiopulmonary Resuscitation, revised [DATE], revealed if an individual was found unresponsive and not breathing normally, a licensed staff member who was certified in CPR/BLS [Basic Life Support] shall initiate CPR unless there was a known DNR [Do not Resuscitate] order or there are obvious signs of irreversible death (rigor mortis). Review of R361's Face Sheet located in resident's closed record file, dated [DATE], revealed advanced directive full code. Review of R361's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located in the resident's electronic medical record (EMR) under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated the resident had moderate cognitive impairment. Review of R361's Physician Orders, dated [DATE] and located in the resident's EMR under the Orders tab, revealed Full code for code status. Review of the closed hard chart revealed an insert that read Full Code for R361. Review of R361 Progress Note located under the Notes tab of the EMR and dated [DATE] at 2:24 PM by Social Worker (SW) 2, revealed She was a full code. Review of R361 Daily Nursing Assessment, dated [DATE] at 2:45 AM written by Licensed Practical Nurse (LPN) 7, revealed resting in bed, eyes closed, respirations easy and unlabored with oxygen via nasal cannula maintaining oxygen saturations within normal limits. Increased confusion will continue to monitor. Review of R361 Death Assessment, located under the Assessments tab of the EMR, dated [DATE] at 6:00 AM written by LPN7, revealed time of death on [DATE] at 5:05 AM. Registered Nurse (RN) 6 assessed for death and MD [Medical Doctor]/NP [Nurse Practitioner] was notified at 5:10 AM. Further review revealed there was no documentation for an assessment of R361 when she was found unresponsive. The start and stop time for CPR was blank. Review of Progress Notes located under the Notes tab of the EMR, dated [DATE], revealed no documentation about when or what time R361 was found or an assessment of the condition of R361's body at the time she was found. There was no documentation that 911 was called or if CPR was initiated and/or stopped. Review of Progress Notes located under the Notes tab of the EMR on [DATE] by SW2, revealed Resident passed away unexpectedly on [DATE] around 5:10 a.m. She was [AGE] years old. Resident had a dx [diagnosis] of Chronic Systolic Congestive Heart Failure. Resident financial POA [Power of Attorney] and Healthcare POA were notified of resident passing by nurse. NP/MD was also notified of resident passing. Resident body was released to [Name] Funeral Home. During an interview on [DATE] at 8:47 AM, LPN7 stated he went into R361's room to pass medications and had a cup of water. He said she would normally be asleep past that time but was easily aroused. He stated she did not respond so he touched her on the shoulder and observed there was no rise and fall in her chest. He said he called for help but was unable to remember who and started CPR. He said another nurse assisted him with CPR but he nor any other staff called 911. He stated it was the facility's protocol to call 911 when a resident coded but he could not remember why they did not, but he should have. He said while they were doing CPR, they realized R361 had already been deceased for a while and the other nurse called the NP who told them to stop. He said he did CPR for a good ,d+[DATE] minutes. He stated he did not know why there was no documentation about the resident and her condition when she was found that morning. During an interview on [DATE] at 10:22 AM, RN6 stated when a resident was found unresponsive staff should call for help, call 911, and initiate CPR. She said 911 was right below them and could get there quickly. She said on [DATE], LPN6 came to the other side of the unit to tell her that R361 was unresponsive so she went down to R361's room to access R361 who was cold to the touch and her limbs appeared blue. She stated she never observed LPN7 doing CPR and she never assisted LPN7 with CPR. She stated she went down to call the NP who told them they could stop doing CPR. She stated she could not say with any certainty that CPR was ever initiated. She stated she never asked him if he had started CPR. She stated she was unsure why there was no documentation for the assessment of R361 but there should have been. During an interview on [DATE] at 11:09 AM, NP stated she never assessed the resident herself but based on the nurse's assessment the resident was cold, and her limbs were blue. She stated she instructed them to stop CPR. During an interview on [DATE] at 5:04 PM, the DON stated to her knowledge staff did not initiate CPR at any time that night and that they had an order not to start CPR and she told them to document that. The DON stated the LPN should have yelled for someone to call 911 and to get a RN and he should have gotten the crash cart and started CPR until he was instructed to stop. The facility's removal plan included: Residents Who Could be Involved or Affected: All residents had the potential to be affected by this non-compliance; however, this was an isolated event related to R361 and no other residents were affected by this non-compliance. Removal Plan Actions Taken: 1. On [DATE] after review of the event of non-compliance related to R361, there was no specific corrective action that could take place related to the nature of the event (resident was expired); however, future corrective actions are outlined below. 2. To prevent future non-compliance, the following steps have been implemented: a. Nursing staff education completed by 11:59 pm on [DATE] for 100% of nurses employed by the facility to include how to determine a resident's current code status and the process for initiating CPR for residents will a full code status b. Nursing staff education completed by 11:59 pm on [DATE] for 100% of nurses employed by the facility on the understanding of the importance of immediate initiation of CPR when applicable 3. Ongoing audits will be performed by nursing supervisors monthly for adequate nursing documentation and presented to the QA committee for the next six months (May, June, July, August, September, October). A total often residents' charts will be randomly selected for this audit. 4. This action plan will be monitored as mentioned above and outliers will be addressed on an individual basis should they occur. Date Actions Taken: [DATE] Staff Education Plan: 1. By 11:59pm on [DATE], 100% of nurses employed by the facility were re-educated on the importance of complete and thorough documentation. Nurses who were present at the facility on this date were educated via face-to-face communication by nursing supervisors and administrative personnel. Nurses not present at the facility on this date were educated via telephone by nursing supervisors and administrative personnel. 2. By 11:59pm on [DATE], 100% of nurses employed by the facility were re-educated on the policy and procedures for Cardiopulmonary Resuscitation. Nurses who were present at the facility on this date were educated via face-to-face communication by nursing supervisors and administrative personnel. Nurses not present at the facility on this date were educated via telephone by nursing supervisors and administrative personnel.

Based on record review, interview, and policy review, the facility failed to ensure that code status was reflected accurately in the medical record for one of 11 residents (Resident (R) 360) reviewed for advanced directives of 36 sample residents. R360 requested to be a Do Not Resuscitate (DNR) but was listed as a Full code in the electronic medical records and hard chart. The facility's Administrator was informed on 04/16/25 at 3:20 PM that Immediate Jeopardy existed related to the failure to ensure that one of 11 residents identified as requesting to be a DNR, was documented as DNR. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 04/17/25 at 4:14 PM. The survey team validated implementation of the removal plan through interviews, and review of training records. Immediate Jeopardy was verified as removed on 04/17/25 at 5:21 PM, with a compliance date of 04/16/25. After the removal of the Immediate Jeopardy, the deficiency remained at a D scope and severity for isolated potential for more than minimal harm. Findings include: Review of the facility's policy titled, Do Not Resuscitate Order, dated 2001, revealed our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there was a Do Not Resuscitate Order in effect. Review of R360's Face Sheet located in resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] and was listed as Full code. Review of R360's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/11/25 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Review of R360's Physician Orders, dated 04/03/25 and located in the resident's EMR under the Orders tab, revealed Full code for code status. Review of the hard chart located at the Wise unit wing nurses station revealed Full code for R360. During an interview on 04/15/25 at 1:31 PM, R360 along with Family Member (FM) 1 were in his room talking. R360 was observed sitting in his wheelchair in front of the TV and FM1 was sitting next to him. R360 and FM1 stated he was a DNR and that all the paperwork had already been provided to the facility during the admission process. Review of R360's Nursing Progress Note, located under the Notes tab of the EMR written by Registered Nurse (RN) 5, dated 04/04/25 at 7:02 PM, revealed [AGE] year admitted to [room number] from Hospital. He is alert and oriented x 3 but [Name] reported sundowners at night. He was able to answer questions appropriately. Takes meds whole and on a regular diet. No known medication or food allergies but dislikes sweet potatoes. He was dependent on turning and repositioning. He was ambulatory at home but has been unable to walk since fall. Prior to hospital stay he lived alone. Transfers with full body lift bed to wheelchair. Feeds himself. He wishes to be a DNR. Review of the Emergency Medical Services Do Not Resuscitate (DNR) order notice to emergency medical services (EMS) personnel signed and dated 04/04/25 and located in the hard chart, revealed R360 requested no resuscitative efforts including artificial stimulation in the event of cardiopulmonary arrest. Review of the Do Not Resuscitate Request/Order, signed and dated 04/04/25 by R360 and located in the hard chart, revealed it witnessed by RN5 and Unit Manager (UM) 2 and signed by physician. Review of Code Status Nursing report, located at each nursing station and provided by the facility, dated 04/15/25 at 4:11 PM, revealed R360 code status was DNR. During an interview on 04/16/25 at 12:10 PM, UM2 stated they had the signed DNR on 04/04/25 but she was the one responsible for converting the code status in the electronic chart and hard chart after the DNR was signed by the physician. She said she simply overlooked R360's signed DNR and did not update the chart to reflect DNR until last night. She said it was lying in a stack of papers on her desk. During an interview on 04/17/25 at 2:14 PM, the Director of Nursing (DON) stated she expected all residents to have the correct code status listed in their chart and in their EMR. The facility's removal plan included: Residents Who Could be Involved or Affected: All residents had the potential to be affected by this non-compliance; however, this was an isolated event related to R360 and no other residents were affected by this non-compliance. Removal Plan Actions Taken: 1. On 4/16/2025 after review of R360's medical record, the non-compliance mentioned was already corrected. The order for Do Not Resuscitate was already initiated and active on R360's list of active physician orders. 2. To prevent future non-compliance, the following steps have been implemented: a. Upon admission or at any time, if a resident or a resident's representative sign Do Not Resuscitate documents, the resident's practitioner will be notified by the witnessing nurse on the same day. b. When the practitioner signs the Do Not Resuscitate documents, the signed documents will be hand delivered to the nurse on duty. c. The nurse receiving the Do Not Resuscitate documents that have been signed by the resident or resident's representative and the practitioner will update the resident's code status order by entering the new Do Not Resuscitate order into the resident's medical record on that date. 3. On 4/16/2025, an immediate audit was completed on 100% of all current resident charts by nursing supervisors for accuracy of code status orders and corresponding documentation. This audit was completed by 9:00pm on 4/16/2025 and all charts were in compliance. 4. Ongoing audits will be performed by nursing supervisors monthly for compliance and presented to the QA committee for the next six months (May, June, July, August, September, October). 5. This action plan will be monitored as mentioned above and outliers will be addressed on an individual basis should they occur. Allegation of Compliance Date; April 16, 2025 Staff Education Plan: 1. On 4/16/2025 at 4:45pm, nursing supervisors were educated via face-to-face communication by the Director of Nursing on the process of auditing all residents' code status orders and ensuring proper corresponding documentation in the medical record as determined by the residents' wishes. 2. By 11:59 pm on 4/16/2025, 100% of nurses employed by the facility were re-educated on the facility policy for advance directives. Nurses who were present at the facility on this date were educated via face-to-face communication by nursing supervisors and administrative personnel. Nurses not present at the facility on this date were educated via telephone by nursing supervisors and administrative personnel. 3. By 11:59 pm on 4/16/2025, 100% of nurses were re-educated on the importance of complete and thorough documentation of resident wishes to include any conversation of advance directives. Nurses who were present at the facility on this date were educated via face-to-face communication by nursing supervisors and administrative personnel. Nurses not present at the facility on this date were educated via telephone by nursing supervisors and administrative personnel.

Based on observations, interviews, and facility policy review, the facility failed to ensure medical records containing personal health information (PHI) were not accessible for one of one resident (Resident (R) 132) of 36 sample residents. This failure had the potential to allow inappropriate access to residents' records. Findings include: Review of the facility's policy titled, Electronic Medical Records, dated 2001, revealed the facility will make reasonable efforts to limit the use or disclosure of protected health information to only the minimum necessary to accomplish the intended purpose of the use or disclosure. During an observation on 04/15/25 at 11:34 AM, the wise unit revealed one of the medication carts was in front of the nurse's station. The cart was locked but the computer screen was left unlocked and visible revealing medical information for R132. There were unidentified residents who walked by the cart. During an observation and interview on 04/15/25 at 11:35 AM, Registered Nurse (RN) 5 was observed sitting at the nurse's station before getting up and walking around to the med cart. RN5 said she did not realize she left the computer screen unlocked with resident medical information visible. She stated she knew she was supposed to lock the screen before walking away from the nurse's cart. During an interview on 04/17/25 at 2:14 PM the Director of Nursing (DON) said nursing staff were supposed to lock their computer screens when they walked away and to ensure they did not allow resident medical information to be accessed.

Based on record review, interviews, and facility policy review, the facility failed to provide a shower bed to accommodate activities of daily living (ADL) showers three times a week for one of two residents (Resident (R) 116) reviewed for accommodation of needs of 36 sample residents. This failure had the potential to affect R116's quality of life. Findings include: Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised March 2018, revealed .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) . Review of the Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed R116 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease without dyskinesia. Review of the Height, dated 12/18/24 and located in the EMR Vitals tab, revealed R116 was 73.0 (6 feet one inch) Inches standing. Review of the Clinical Orders, dated 12/24/24 and located in the EMR under the Orders tab, revealed .Showers every evening shift every Monday, Wednesday, Friday . Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/24/25 revealed R116 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R116 was cognitively intact. Further review revealed R116 was dependent on staff for assistance with showers. Review of the Care Plan, dated 03/24/25 and located in the EMR under the Care Plan Detail tab, revealed R116 .The resident has an ADL self-care performance deficit r/t [related to] Decreased mobility, and [sic] Impaired balance . with interventions to assist with bathing. Review of the Treatment Administration Records (TARs) dated January 2025, February 2025, March 2025, and April 2025 and located in the Orders tab of the EMR, revealed R116 was documented as receiving showers by staff. Review of the Point of Care Response History (POC) look back 30 days located in the EMR POC tab, revealed showers were marked as Not Applicable from 03/19/25 to 04/16/25. Review of the Weights, dated 04/16/25 and located in the EMR Vitals tab, revealed R116 was 290.8 Lbs. [pounds]. During an interview on 04/15/25 at 1:18 PM, R116 stated the facility did not have a shower bed to accommodate his size. R116 stated, Doesn't mind the bed bath, but it would be nice to have a shower once in a while. Further interview revealed R116 talked to the Unit Manager, and she told R116 they were trying to get something worked out. R116 revealed it had been a month or two since he had not had a shower and that it was not possible to get into the whirlpool because of issues with standing. During an interview on 04/16/25 at 3:30 PM, Certified Nursing Assistant (CNA)3 stated R116 was receiving bed baths but was not getting showers. CNA3 stated the shower bed creaked when trying to turn him. CNA3 stated they had limitations with him because of his size. CNA3 stated he was taking up the whole shower bed. CNA3 stated they had a bariatric shower bed, but it was too small. CNA3 stated it had been two months since R116 was given a shower. During an interview on 04/16/25 at 3:51 PM, CNA4 stated R116 was getting bed baths instead of showers due to his weight. During an interview on 04/16/25 at 4:00 PM, CNA6 stated we have a bariatric bed, and it is not a good fit for him. He could not turn in the bed, he holds on to the handicap bar and he turns on the other side and he does not have a handicap bar, just the shower bed bar, the bed can roll over with [R116]. [R116] had been getting bed baths for two months and the family is aware. We have a shower chair, but it is not wide enough. During an interview on 04/16/25 at 4:11 PM, CNA7 stated [R116] gets a bed bath. The bariatric bed is hard for him to maneuver in and for the CNAs to maneuver. He is used to getting showers weekly. He is a two to one person assist with bed baths. The Unit Manager said she was going to work on it, and I have not heard anything else about it. I'm sure he was upset about going from showers three days a week to just bed baths. During an interview on 04/17/25 at 10:47 AM, the Unit Manager (UM)3 stated we were putting him on the trolley bed for showers. There was tilt when [R116] was placed on trolley. We put the showers on hold. [R116] just started to learn a different method to transfer. There is a therapy consult to guide us for showers. [R116] had been without showers for four weeks and had been getting bed baths. A consultation was placed yesterday for therapy for safe transfer. UM3 was aware of the situation prior to therapy consultation. The Unit Manager stated, We definitely want to accommodate him. During an interview on 04/17/25 at 04:09 PM, the Director of Nursing (DON) stated, the expectation is that if it is appropriate and the resident wants a shower, they are to be put on the shower schedule to accommodate their needs.

Based on observation, interview, and facility policy review, the facility failed to ensure food stored in the kitchen was covered and/or dated, free of scoops, and did not have expired manufacturer's use by dates. This had the potential to affect 140 of 141 residents who consumed food prepared in the facility's kitchen. Findings include: Review of the facility's policy titled, Food Storage, dated 2020, indicated, Guideline: Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Procedure: 1. General storage guidelines to be followed: a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded . 2. Refrigerated storage guidelines to be followed . Wrap food properly. Never leave any food item uncovered and not labeled. Observation on [DATE] from 7:35 AM to 8:03 AM of the initial kitchen inspection revealed the following: a. In a kitchen dry storage area a large plastic container which contained fish mix and a large plastic container which contained sugar were stored opened to air with their tops not completely closed. Additionally, a scoop was observed stored inside the container of sugar. During an interview on [DATE] at 7:40 AM, the Dietary Manager (DM) confirmed the containers of fish mix and sugar were stored opened and a scoop was stored inside the container of sugar. The DM stated the containers of fish mix and sugar should be completely closed by staff when stored and the scoop should not have been stored in the container of sugar. b. Observation of bread products stored on bread racks in the kitchen revealed a package of sliced bread with an expired manufacturer's use by date of [DATE], six undated packages of thawed hamburger buns, one undated package of thawed hot dog buns, and 15 undated loaves of thawed sliced sour dough bread. During an interview on [DATE] at 7:45 AM, the DM confirmed the package of sliced bread which had an expired use by date of [DATE] and the undated bread products stored on the kitchen's bread racks. The DM stated staff were expected to discard any bread product that had an expired use by date and to date bread products when they were removed from the freezer to thaw. c. Observation of food stored in a kitchen reach in refrigerator revealed a package of sliced ham and a package of sliced turkey that were undated and stored opened to air. During an interview on [DATE] at 7:50 AM, the DM confirmed the packages of sliced ham and sliced turkey stored in the reach in refrigerator were not covered and were not dated. The DM stated staff were expected to date and cover food items prior to storing them for future use.

Based on interview, record review, and facility policy review, the facility failed to ensure residents' right to participate in the care planning process was honored for one of one residents reviewed for care plans out of 32 sampled residents (Resident (R) 48). This failure placed the resident at risk for the care plan not being a person-centered care plan. Findings include: Review of the facility's policy titled Resident Participation - Assessment/Care Plans, dated 12/2016, revealed The resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan.The Resident/Family Services Director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. Notices include: a. The date, time, and location of the conference; b. The name of each person contacted and the date he or she was contacted; c. The method of contact (e.g., mail, telephone, email, etc.); d. Input from the resident or representative if they are not able to attend; e. Refusal of participation, if applicable; and f. The date and signature of the individual making the contact. Review of R48's undated Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R48 was admitted to the facility on [DATE] with diagnoses that included hemiplegia with hemiparesis following a cerebral infarction affecting the right dominant side. Review of R48's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/22/24 and located under the MDS tab of the EMR, revealed R48 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R48 was cognitively intact. During an interview on 05/13/24 at 11:09 AM, R48 stated that he chose to stay in bed in his room and not leave his room. R48 said he only had use of his left arm and that he had to ask to have the television turned on to a station he liked due to cataracts and not being able to see very much. During the interview about his care, R48 stated, they don't invite me to care conference anymore like they used to, I'd like to be there. During an interview on 05/14/24 at 9:05 AM, R48 stated, I want to be invited to my care conference like I used to be, they would come in my room to have the meeting. During an interview on 05/15/24 at 9:59 AM, R48 stated, It's been a while since the last Team Conference (care conference) in my room, more than three or four months, I would like them to come in again. Review of R48's Team Conference, forms, located in the paper chart revealed interdisciplinary team conferences on 05/10/23, no documented evidence that R48 or a representative were invited or attended the care conference. The form documented, nurse spoke with resident who offered no concerns. Review of the Social Service Progress Notes, located in the EMR under the Clinical tab revealed Team Conferences were held: On 03/29/24, there was no documented evidence that R48 was invited or attended the care conference. On 01/02/24, there was no evidence that R48 was invited or attended the care conference. On 10/31/23, there was no evidence that R48 attended the care conference. On 07/25/23, there was no evidence that R48 was invited or attended the care conference. During an interview on 05/15/24 at 10:53 AM, the Social Service Director/Admissions (SSD/AD) stated, The Director of Nursing (DON) runs the team conferences and the resident's Social Worker would be the one who invited the resident. During an interview on 05/15/24 at 12:02 PM, R48's Social Worker (SW) stated, Sometimes he wants to go and other times not, it varies day to day. If it's not in my notes, I must not have documented if he participated or not. Sometimes the nurse will just have a conversation with him in his room. During an interview on 05/15/24 at 2:48 PM, the Director of Nursing (DON) stated, The resident has changed so much, he won't come out of his room, I didn't know he wanted to come.

Based on record review and interviews, the facility failed to prevent neglect to Resident (R)8, who was diagnosed with Vascular Dementia and history of wandering. Specifically, on 05/16/23 at 6:34 PM, R8 successfully eloped from the facility. R8 eloped through the front sliding doors of the facility by following closely behind an unidentified individual. R8 was observed by two other cognitively intact residents (R10 and R11) wandering outside of the building and going towards a local doctors office. R10 notified nursing staff that R8 was outside wandering without supervision and was brought back to the facility by staff. On 5/30/23 at 1:45 PM the Administrator and the Director of Nursing (DON) were notified that R8's successful elopement from the facility constituted Immediate Jeopardy (IJ) at F600. An IJ template was provided to the Administrator and DON notifying them that IJ existed at F600 with an effective date of 5/16/23. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 5/30/23 at 5:53 PM, the facility provided an acceptable IJ Removal Plan. The facility indicated they identified their own deficient practice and implemented a plan prior to the start of the survey. The survey team validated the removal plan and was able to confirm the facility put forth good faith attempts and implemented a plan to remove the immediacy of the IJ, effective 5/17/23. Therefore, the IJ at F600 is at Past-noncompliance. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Finding include: Review of the facility policy titled Abuse and Neglect revealed Neglect: 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. The facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect. Review of R8's undated Face Sheet revealed R8 was admitted to the facility on [DATE] with the diagnosis including but not limited to; vascular dementia without behaviors, hypertension, type 2 diabetes, and dysphasia. Review of R8's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/22 revealed R8 had a Brief Interview of Mental Status (BIMS) score of 99 which indicates R8 was not cognitively intact. Further review of the MDS indicated that R8 had wandering behaviors frequently during the assessment period. Review of R8's Care Plan last revised on 05/19/23 revealed, R8 is an elopement risk related to dementia, wandering through units, exits seeking behaviors, disorganized thinking, ambulatory status, and has a wander score of 15 out of 15. Interventions include: alert other units that resident may wander to another unit and try redirect resident; monitor placement of secure anklet closely; complete behavior assessment every shift; 15 minutes checks. Review of a Nurses Note dated 05/16/23 revealed at 6:25 PM, Registered Nurse (RN)1 brought R8 to the nurses desk. Per RN1 she was alerted by residents that R8 was outside walking near the patio and heading towards the local Dr. Office next to the facility unsupervised. I assessed R8 and her skin was dry and intact, mental status was at her baseline, and she showed no sign of distress. I checked R8's electronic monitoring device and it was in place and working properly on the door of R8 unit and front entrance door. I spoke with the Director of Nursing (DON) and notified appropriate individuals. During an interview on 05/30/23 at 9:45 AM with the Administrator and Director of Nursing revealed, the resident was observed by two other residents walking outside in the grass area around 6:34 PM right after dinner. The Administrator and DON reported that it was a busy week at the facility for Nursing Home week and the staff was constantly in and out of the building for activities. The front door at the facility has an automatic sliding door with an electronic monitoring system code for residents that wear electronic monitoring systems however, if the sliding door is not fully closed a resident with an electronic monitoring system is still able to exit the facility because the door will not fully close. R8 was observed on video footage following behind an unknown individual closely and was able to elope successfully from the facility. RN1 was alerted by other cognitive residents that R8 was outside of the building unsupervised. RN1 brought the resident back to the facility and completed a body audit and appropriate parties were notified related to the elopement. During an interview on 05/30/23 at 10:55 AM with R10 revealed, I'm not sure what day it was but I was sitting outside at the patio area near my room when I saw [R8] walking by the patio area without staff and heading towards the doctor's office next door. I recognized [R8] was a resident at the facility and went back inside and got [RN1]. [RN1] went running down the hill and brought [R8] back inside, it took about 5 minutes for [RN1] to bring [R8] back to the facility, but I'm not sure how long she was outside before I saw her and told staff. During an interview on 05/30/23 at 11:15 AM with the Maintenance Director (MD) revealed, the sliding doors in the front lobby has a keypad with a code and will alarm when someone with an electronic monitoring system device gets too close to the door however, if the door is open and someone with an electronic monitoring system device is following too closely behind someone else the door will not close and a resident is able to get outside the facility. I was not working on the night of the incident but when I arrived to work the next morning I checked all the doors including the front lobby door, R8 was able to elope from, and found that it was in working order. During an observation and interview with RN1 and DON on 05/30/23 at 11:24 AM revealed, R8 had walked .10 of a mile (the distance from the front lobby door to the doctor's office) on 5/16/23. RN1 stated that she was alerted by two cognitive residents that were sitting outside near a patio on their unit when they observed R8 walking outside unsupervised. RN1 stated, When I caught up to R8 she was pulling on the door of the doctor's office, I was able to re-direct her and bring her back to the facility and completed a body audit and found no signs of harm/distress. I notified the appropriate individuals related to the elopement. During an interview on 05/30/23 at 12:35 PM with R11 revealed, the weather on that day (5/16/23) was very nice and she and another resident were sitting out on the patio near their room and saw R8 walking through the grass and heading to the building next door. R10 went inside and told RN1. RN1 went running down the hill after R8 and brought her back to the facility. Review of the video surveillance from the 05/16/23 elopement revealed, at 6:33 PM R8 followed behind an unknown individual through the sliding doors at the front entrance of the facility. At 6:35 PM R10 and R11 were observed notifying facility staff that R8 was outside without supervision. At 6:40 PM R8 was observed walking back inside with RN1. Implementation of the removal plan at F600 included the following: Wandering and elopement training with all staff started on 5/17/23. R8 was on 30-minute location check per physician order prior to this elopement, after she exited the building, she was placed on 15-minute location checks per physician order. R8 had an electronic monitoring device on prior to exiting the building. The electronic monitoring system was checked for proper functioning after she was redirected into the facility, the electronic monitoring system alarmed at the doorways. R8 enjoys putting together puzzles, staff set up puzzles for resident for an activity. Resident also enjoys toting her 2 baby dolls around the facility. Abuse training is done with staff at least yearly. An audit will be completed monthly for six months to assess wandering resident risk score to ensure all high risk for eloping have been assessed for the need of an electronic monitoring system. Monthly audit will be completed on allegations of abuse, and this will be reported to the Quality Assurance (QA) committee. Random door audits will be completed at least monthly for six months to monitor for compliance for employees to look behind every time. This audit will be present to the QA committee.

Based on record review, interviews, and video surveillance, the facility failed to ensure proper supervision of Resident (R)8, who was diagnosed with Vascular Dementia and history of wandering. Specifically, on 5/16/23 at 6:34 PM R8 successfully eloped from the facility. R8 was observed by two other cognitively intact residents (R10 and R11) wandering outside of the building and going towards a local doctor's office. R10 notified nursing staff that R8 was outside wandering without supervision and was brought back to the facility by staff. On 5/30/23 at 1:45 PM the Administrator and the Director of Nursing (DON) were notified that R8's successful elopement from the facility constituted Immediate Jeopardy (IJ) at F689. An IJ template was provided to the Administrator and DON notifying them that IJ existed at F689 with an effective date of 5/16/23. The IJ was related to 42 CFR 483.25 - Quality of Care. On 5/30/23 at 5:53 PM, the facility provided an acceptable IJ Removal Plan. The facility indicated they identified their own deficient practice and implemented a plan prior to the start of the survey. The survey team validated the removal plan and was able to confirm the facility put forth good faith attempts and implemented a plan to remove the immediacy of the IJ, effective 5/17/23. Therefore, the IJ at F689 is at Past-noncompliance. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of facility's undated policy titled Wandering and Elopements revealed, The facility will identify residents who are at risk of wandering, unsafe wandering, and elopement. The facility will strive to prevent harm while maintaining the least restrictive environment for our residents. Elopement risk reduction interventions include frequent monitoring of resident's whereabout to assure he or she remains in the facility for example: 15- or 30-minute location checks; functional door alarm system with checks weekly by maintenance staff; staff training on orientation and at least annually on wandering residents/risk of elopement with prevention interventions; signage at all doors for staff and visitors to ensure that the door locks when they exit the door and look to make sure a resident has not followed them out of facility. Review of R8's undated Face Sheet revealed R8 was admitted to the facility on [DATE] with the diagnosis including but not limited to; vascular dementia without behaviors, hypertension, type 2 diabetes, and dysphasia. Review of R8's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/22 revealed R8 had a Brief Interview of Mental Status (BIMS) score of 99 which indicates R8 was not cognitively intact. Further review of the MDS indicated that R8 had wandering behaviors frequently during the assessment period. Review of R8's Care Plan last revised on 05/19/23 revealed, R8 is an elopement risk related to dementia, wandering through units, exits seeking behaviors, disorganized thinking, ambulatory status, and has a wander score of 15 out of 15. Interventions include: alert other units that resident may wander to another unit and try redirect resident; monitor placement of secure anklet closely; complete behavior assessment every shift; 15 minutes checks. Review of a Nurses Note dated 05/16/23 revealed at 6:25 PM, Registered Nurse (RN)1 brought R8 to the nurses desk. Per RN1 she was alerted by residents that R8 was outside walking near the patio and heading towards the local Dr. Office next to the facility unsupervised. I assessed R8 and her skin was dry and intact, mental status was at her baseline, and she showed no sign of distress. I checked R8's electronic monitoring device and it was in place and working properly on the door of R8 unit and front entrance door. I spoke with the Director of Nursing (DON) and notified appropriate individuals. During an interview on 05/30/23 at 9:45 AM with the Administrator and Director of Nursing revealed, the resident was observed by two other residents walking outside in the grass area around 6:34 PM right after dinner. The Administrator and DON reported that it was a busy week at the facility for Nursing Home week and the staff was constantly in and out of the building for activities. The front door at the facility has an automatic sliding door with an electronic monitoring system code for residents that wear electronic monitoring systems however, if the sliding door is not fully closed a resident with an electronic monitoring system is still able to exit the facility because the door will not fully close. R8 was observed on video footage following behind an unknown individual closely and was able to elope successfully from the facility. RN1 was alerted by other cognitive residents that R8 was outside of the building unsupervised. RN1 brought the resident back to the facility and completed a body audit and appropriate parties were notified related to the elopement. During an interview on 05/30/23 at 10:55 AM with R10 revealed, I'm not sure what day it was but I was sitting outside at the patio area near my room when I saw [R8] walking by the patio area without staff and heading towards the doctor's office next door. I recognized [R8] was a resident at the facility and went back inside and got [RN1]. [RN1] went running down the hill and brought [R8] back inside, it took about 5 minutes for [RN1] to bring [R8] back to the facility, but I'm not sure how long she was outside before I saw her and told staff. During an interview on 05/30/23 at 11:15 AM with the Maintenance Director (MD) revealed, the sliding doors in the front lobby has a keypad with a code and will alarm when someone with an electronic monitoring system device gets too close to the door however, if the door is open and someone with an electronic monitoring system device is following too closely behind someone else the door will not close and a resident is able to get outside the facility. I was not working on the night of the incident but when I arrived to work the next morning I checked all the doors including the front lobby door, R8 was able to elope from, and found that it was in working order. During an observation and interview with RN1 and DON on 05/30/23 at 11:24 AM revealed, R8 had walked .10 of a mile (the distance from the front lobby door to the doctor's office) on 5/16/23. RN1 stated that she was alerted by two cognitive residents that were sitting outside near a patio on their unit when they observed R8 walking outside unsupervised. RN1 stated, When I caught up to R8 she was pulling on the door of the doctor's office, I was able to re-direct her and bring her back to the facility and completed a body audit and found no signs of harm/distress. I notified the appropriate individuals related to the elopement. During an interview on 05/30/23 at 12:35 PM with R11 revealed, the weather on that day (5/16/23) was very nice and she and another resident were sitting out on the patio near their room and saw R8 walking through the grass and heading to the building next door. R10 went inside and told RN1. RN1 went running down the hill after R8 and brought her back to the facility. Review of the video surveillance from the 05/16/23 elopement revealed, at 6:33 PM R8 followed behind an unknown individual through the sliding doors at the front entrance of the facility. At 6:35 PM R10 and R11 were observed notifying facility staff that R8 was outside without supervision. At 6:40 PM R8 was observed walking back inside with RN1. Implementation of the removal plan for F689 included the following: Signage placed on all exit doors for staff and visitors to ensure that doors close behind them and that a resident has not followed them out of the door. A fluorescent rope was purchased to place across the lobby foyer when staff is not present in the lobby or reception desk. Quality Assurance Performance Improvement (QAPI) audits will be completed for six months and reported to the Quality Assurance (QA) committee. Audits will include observations of staff and visitors leaving the facility to ensure they check door and for residents who wander. Photos of high-risk wandering residents are placed at all nursing stations to alert staff of wandering residents. Door checks will be completed weekly by maintenance staff, this will be audited monthly and is reported to the QA committee. The facility has been approved for flashing lights to be placed on road in front of the facility to slow traffic while passing through area. Training with staff was started on 05/17/23 on wandering and elopement procedures and importance of checking behind every time staff leave the facility to ensure that doors lock, and residents do not follow them out of the facility.

Based on review of the CMS RAI Version 3.0 Manual, interview and record review, the facility failed to transmit Minimum Data Set (MDS) assessments per the required timeframes, for 1 of thirty-one residents, Resident (R) 252. Findings include: Review of the CMS RAI Version 3.0 Manual, revised October 2019, revealed MDS assessments are required to be transmitted to CMS within 14 days of the ARD. Review of the MDS screen of R252's electronic medical record (EMR) revealed MDS assessments were completed, but not transmitted, for a quarterly MDS with an Assessment Reference Date (ARD) of 11/18/20; a quarterly MDS with an ARD of 02/09/21; a quarterly MDS with an ARD of 05/03/21; an annual MDS with an ARD of 07/20/21; and a Death in Facility MDS with an ARD of 08/12/21. An interview with the Director of Nursing (DON) on 07/21/22 at 1:26 PM revealed that she had received notifications from the Centers for Medicare and Medicaid (CMS) for years that R252's MDS Assessments had not been transmitted, and the facility tried to transmit them with each notification but for some reason the assessments were not accepted. The DON stated that the facility had not reached out to CMS to resolve the issue as she felt it was something wrong with the facility's computer system.

Based on review of the Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, observation, interview, and record review, the facility failed to complete a Significant Change of Condition (SCOC) Minimum Data Set (MDS) assessment for 1 of thirty-one sampled residents Resident (R) 148, creating the potential that her care plan would not be revised to meet her needs. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, revised October 2019, revealed, If a significant change in status is identified in the process of completing any OBRA assessment except Admission and SCSAs [significant change in status assessments], code and complete the assessment as a comprehensive SCSA instead . Decline in two or more of the following . Any decline in an ADL physical functioning area (at least 1) where a resident is newly coded as Extensive assistance, Total dependence, or Activity did not occur since last assessment . Resident's incontinence pattern changes . Emergence of a new pressure ulcer at Stage 2 or higher . Review of R148's Census tab in her electronic medical record (EMR) revealed she was admitted to the facility on [DATE], discharged to the hospital on 06/21/22, and readmitted to the facility on [DATE]. Review of R148's quarterly MDS assessment with an Assessment Reference Date (ARD) of 04/14/22 revealed R148 required limited assistance from one staff member for locomotion on the unit, limited assistance with eating, was occasionally incontinent of bladder, and had no pressure ulcers. Review of R148's annual MDS assessment with an ARD of 07/06/22 revealed she required extensive assistance from one staff person for locomotion on the unit and eating, was frequently incontinent of bladder, and had an unhealed stage 2 pressure ulcer. An interview with the MDS Coordinator (MDSC) on 07/21/22 at 11:21 AM revealed that the 07/06/22 MDS assessment should have been coded as a SCOC assessment rather than an Annual assessment, because the resident had declined in two of her Activities of Daily Living (ADLs), was more incontinent of bladder, and had developed a pressure ulcer. The MDSC stated that the facility did not have a policy on completing MDS assessments, but used the Resident Assessment Instrument (RAI) manual.

Based on policy review, resident interview, staff interviews and record review, the facility failed to thoroughly investigate an allegation of verbal abuse by 1 of 3 residents, Resident (R) 33 reviewed for abuse. This failure created the potential for further abuse by the alleged perpetrator. Findings include: Review of the facility's July 2017 Abuse Investigation and Reporting policy revealed, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; j. Review all events leading up to the alleged incident; [and] k. Obtain statements from staff members as indicated. The investigator will consult daily with the Administrator concerning the progress/findings of the investigation. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator. Review of the Profile tab of the electronic medical record (EMR) revealed R33 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R33's quarterly Minimum Data Set (MDS) assessment, located in the EMR in the MDS tab, with an assessment reference date (ARD) of 05/13/22 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The resident exhibited signs of depression such as feeling down, feeling tired or sleeping too much, feeling bad about herself, and trouble concentrating. Review of R33's Care Plan dated 06/24/22, located in the Care Plan tab of the EMR, revealed, The resident has a potential for behavior: The resident has potential to be physically aggressive (hitting/kicking) r/t [related to] dementia, mood disorder, [CONDITION(S)], delusional disorder, [CONDITION(S)], depression, [CONDITION(S)], [and] [CONDITION(S)] med[ication] use. The approaches included: Administer medications as ordered. Monitor/document for side effects and effectiveness . Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Behavior Management: When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later . Complete Behavior Assessment every shift . [and] explain tasks to resident prior to implementing. R33's care plan did not include a history of false allegations. In an interview with R33 on 07/19/22 at 1:09 PM, the resident stated she had not been abused in the facility. Review of a 06/21/22 Health Status Note, found in the Progress Notes tab of the EMR, revealed, When therapist entered room for therapy, resident stated she had been abused by staff. Told RN [Registered Nurse] she had been verbally abused but unable/unwilling to say account for what was said. Told nurse this had happened all day. (Nurse worked 7a-7p resident only awoke long enough to take meds [and] sips of liquids.) Had slept through AM care performed by CNA [certified nursing assistant]. On 07/20/22 at approximately 10:00 AM, an investigation into the above allegation of verbal abuse was requested. On 07/20/22 at 11:27 AM, the Unit Manager (UM) provided an undated typed statement on blank white paper, written by the UM, documented, 6/21/22 Nurse stated that resident told the therapist she had been verbally abused by staff today. She was not able/willing to provide any details about the alleged abuse. Resident slept most of the day today and was only awake for short periods like to take meds and eat. She even slept through her bath this morning. She has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence to substantiate the abuse. In an interview on 07/20/22 at 11:27 AM, the UM stated R33 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The UM stated R33 even slept through her morning care, since she was recently readmitted from the hospital and was not feeling herself at the time. The UM added R33 also likely had a urinary tract infection which could cause delusions. The UM stated she had conducted interviews with the three CNAs on duty that day to investigate the allegation, and she had attempted to interview the resident who did not respond. On 07/20/22 01:02 PM, the UM stated she had not interviewed the therapist, whom R33 reported the allegation to, and she was unsure which therapist it was. The UM also stated no additional resident interviews were completed as part of the investigation, stating, we did not go that far because she slept all day, and we already knew she probably had a [CONDITION(S)]. She has a history of making accusations when she has a [CONDITION(S)]. The UM provided three statements from the CNAs that were undated and written on blank white paper: Review of a statement written by RN1 revealed, On 6-21-22, I was the assigned nurse for resident in [room number]. I observed resident sleeping all shift. She awoke long enough to take crushed meds in applesauce with a few sips of liquids then immediately went back to sleep. CNA also reported she had slept during AM care [and] would not awaken for meals. I never saw or heard anything indicating abuse throughout my shift. Review of a written statement by CNA3 revealed, On 6/21/22 I, [CNA3], did not hear or see any type of abuse or neglect. [R33] was asleep every time I went by her room. Review of a written statement by CNA2 revealed, To whom [it] may concern I [CNA2] had [R33]. I tried feed her breakfast [but] couldn't get her awake. I let the nurse [RN1] no [sic] she even tried [to] wake her up and couldn't. [R33] said leave her alone she slept all day. Review of a written statement by CNA1 revealed, On 6/21/22 I worked and did not see or hear any kind of abuse on [R33] in [room number]; she was asleep all day. In an interview on 07/20/22 at 1:17 PM, the Occupational Therapist (OT) stated she was not working with R33 but would stop in her room to check on her or chat with her. The OT stated, She may have made a comment to me about being abused but stated she did not really remember. The OT stated she passed on what R33 said to [RN1]. The OT stated, I never saw anything or had any indication from the CNAs that something was wrong. On 07/21/22 at 9:00 AM, the Director of Nursing (DON) stated R33 had made similar allegations of verbal abuse back in 2020 and these allegations had been reported and thoroughly investigated but were not substantiated. The DON stated the resident's allegation on 06/21/22 was automatically considered unfounded because of all the circumstances, starting with R33's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated this allegation would have been unsubstantiated had the investigation been completed, as the resident could not have been abused because she was sleeping all day. The DON stated she would report/investigate only those allegations of abuse where abuse was actually suspected, and R33's allegation was not considered credible in this case. On 07/21/22 at 11:25 AM, RN1 stated she recalled some of the details of R33's allegation on 06/21/22, but not all. RN1 stated a therapist, she did not recall who, reported to her that R33 said she had been verbally abused by staff. RN1 recalled she told the therapist R33 had been asleep all day and only woke her for medications. Also, R33's CNA reported she was sleeping during morning care, so she [RN1] was keeping an eye on her. RN1 stated, I don't see where she had been verbally abused because she hadn't been awake long enough. RN1 added the resident had frequent delusions and has made false accusations in the past. RN1 stated she attempted to interview R33, but the resident did not say anything during the interview. RN1 stated she used her nursing judgement since R33 had been asleep all day and she didn't see where she could have been abused. RN1 stated she reported the allegation to the UM. In an interview on 07/21/22 at 11:55 AM, the Administrator stated she was unaware of the resident's allegation, as it was investigated by nursing staff and not reported to her. The Administrator stated she did not feel the allegation was considered credible, so the nursing staff had taken the appropriate action. The Administrator stated her understanding was that only allegations of abuse where abuse was actually suspected were to be reported and investigated. The Administrator stated the allegation was not investigated further as it was not considered a credible allegation.

Based on review of the facility policy, resident interviews, staff interviews and record review, the facility failed to report an allegation of verbal abuse by 1 of 3 residents Resident (R)33 reviewed for abuse to the State Survey Agency. This failure created the potential for further abuse by the alleged perpetrator. Findings include: Review of the facility's July 2017 Abuse Investigation and Reporting policy revealed, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee. to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials: f. The resident's Attending Physician; and g. The facility Medical Director. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. Review of the Profile tab of the electronic medical record (EMR) revealed R33 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R33's quarterly Minimum Data Set (MDS) assessment, located in the EMR in the MDS tab, with an assessment reference date (ARD) of 05/13/22 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The resident exhibited signs of depression such as feeling down, feeling tired or sleeping too much, feeling bad about herself, and trouble concentrating. Review of R33's Care Plan dated 06/24/22, located in the Care Plan tab of the EMR, revealed, The resident has a potential for behavior: The resident has potential to be physically aggressive (hitting/kicking) r/t [related to] dementia, mood disorder, [CONDITION(S)], delusional disorder, [CONDITION(S)], depression, [CONDITION(S)], [and] [CONDITION(S)] med[ication] use. The approaches included: Administer medications as ordered. Monitor/document for side effects and effectiveness . Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Behavior Management: When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later . Complete Behavior Assessment every shift . [and] explain tasks to resident prior to implementing. In an interview with R33 on 07/19/22 at 1:09 PM, the resident stated she had not been abused in the facility. Review of a 06/21/22 Health Status Note, found in the Progress Notes tab of R33's EMR, revealed, When therapist entered room for therapy, resident stated she had been abused by staff. Told RN [Registered Nurse] she had been verbally abused but unable/unwilling to say account for what was said. Told nurse this had happened all day. (Nurse worked 7a-7p resident only awoke long enough to take meds [and] sips of liquids.) Had slept through AM care performed by CNA [certified nursing assistant]. On 07/20/22 at 11:27 AM, the Unit Manager (UM) provided an undated typed statement on blank white paper, written by the UM, documented, 6/21/22 Nurse stated that resident told the therapist she had been verbally abused by staff today. She was not able/willing to provide any details about the alleged abuse. Resident slept most of the day today and was only awake for short periods like to take meds and eat. She even slept through her bath this morning. She has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence to substantiate the abuse. In an interview on 07/20/22 at 11:27 AM, the UM stated R33 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The UM stated R33 even slept through her morning care, since she was recently readmitted from the hospital and was not feeling herself at the time. The UM added R33 also likely had a urinary tract infection which could cause delusions. The UM stated she did not feel the allegation should be reported to the State Survey Agency because it was a credible allegation. On 07/21/22 at 9:00 AM, the Director of Nursing (DON) stated R33's allegation on 06/21/22 was automatically considered unfounded because of all the circumstances, starting with R33's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated this allegation was not reported to the State Survey Agency because they would report only those allegations of abuse where abuse was actually suspected, and R33's allegation was not considered credible in this case. The DON stated she was cautious about reporting abuse allegations because, in the past, they had reported a witnessed incident of staff to resident abuse and received a citation due to the abuse actually occurring. On 07/21/22 at 11:25 AM, RN1 stated she recalled some of the details of R33's allegation on 06/21/22, but not all. RN1 stated a therapist, she did not recall who, reported to her that R33 said she had been verbally abused by staff. RN1 stated she reported the allegation to the UM. In an interview on 07/21/22 at 11:55 AM, the Administrator stated she was unaware of the resident's allegation, as it was investigated by nursing staff and not reported to her. The Administrator stated she did not feel the allegation was considered credible, so it did not need to be reported to the State Survey Agency. The Administrator stated her understanding was that only allegations of abuse where abuse was actually suspected to have occurred were to be reported and investigated. The Administrator stated the allegation was not reported as it was not considered a credible allegation.

Based on observations, interviews, records reviews, facility policy and procedures, and review of video surveillance, the facility failed to provide one of three sampled residents (Resident #1) adequate supervision and assistance devices, including a secured, alarmed door to prevent Resident #1 from wandering out of the facility. As a result, Resident #1, assessed to be at risk for wandering, exited the facility on 05/04/2020 at 7:00 AM, through the exit door in the isolation area. The exit door leads directly to the facility parking lot and the main road (two-way street). This failure placed the resident at risk for serious injury, serious harm, serious impairment, and or death. The Director of Nursing (DON), also the facility's provisionary Administrator, was informed on 05/12/2019 at 5:15 PM that Immediate Jeopardy and/or Substandard Quality of Care existed on 05/01/2020. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 05/12/2019 at 10:15 PM, and the Immediate Jeopardy at F689 was removed with an effective completion date of 05/05/2020 and cited at Past Noncompliance. Findings include: Review of Resident #1's Face Sheet dated 05/01/2020, indicated the resident admitted to the facility on [DATE] from another post-acute rehabilitation center. Resident #1's admission Minimum Data Set (MDS) assessment was not available for review. Resident #1 was in the facility less than 14-days. The staff was in the process of completing the MDS assessment. Review of Resident #1's Temporary or Working Care Plan (baseline care plan), indicated the facility updated the care plan on 05/04/2020 to include elopement. The care planned interventions directed staff to keep the physician informed; apply a secure care anklet for the secure care system; check the secure care anklet weekly; monitor the resident closely for their whereabouts; redirect the resident when trying to leave unit; complete risk for elopement format least (sic) quarterly; patience and understanding; encourage visits from family and provide privacy during visits; calendar of events in the room; invite and assist to and from small and large activities after the pandemic. On 05/05/2020 a keypad system applied to back door of isolation room that will lock with the secure care system. Secure care anklet to the left ankle, which expires on 03/2021; monitor left ankle due to secure care anklet and monitor skin. Review of Resident #1's Wandering Risk Scale - V1 assessment dated [DATE], indicated the resident followed instructions, was ambulatory, was able to communicate, had no history of wandering, has a medical [DIAGNOSES REDACTED]. Resident #1 scored a nine (9) on the wandering risk assessment (score 0 - 8 = low risk to wander, 9 - 10 high risk to wander, 11 and above = above high risk to wander). Review of the Clinical Admission Evaluation dated 05/01/2020, Resident #1 admitted to the facility from a prior stay at a nursing facility. Resident #1 had weakness (baseline), obeyed commands, was confused and experienced signs of short-term memory loss. The resident's current state of confusion was considered his/her baseline. The resident had moderate cognitive impairment (memory loss), was able to communicate, had clear speech, was capable of understanding verbal communication, was usually able to make self-understood, and was able to see with adequate lighting. The residents' mood was pleasant, he/she did not demonstrate unwanted behaviors, slept through the night, had an unsteady gait, poor balance, and used a walker. Review of the Progress Note dated 05/01/2020 indicated Resident #1, a new admission, was coming in today from another post-acute care facility. He/she will go to the isolation room for a 14-day quarantine period. Currently, there are no plans for him/her to return home. The family felt Resident #1 was incompetent but first needed an evaluation to determine whether or not to pursue assessing his/her competence. Review of the Progress Notes dated 05/01/2020 - 05/03/2020, Resident #1 did not display any wandering or exit seeking behaviors. Review of the Daily assessment dated [DATE] indicated Resident #1 was alert and oriented times four (person, place, time, and situation). Resident #1 had some confusion noted at times (example: resident came out of her/his isolation area tonight and said he needed a mask so S/he could go to his/her truck and get something. Staff reminded Resident #1 that his/her vehicle was not at the facility, and he/she was not able to come out of the isolation area at this time. The resident returned to bed.) Resident #1 was pleasant and cooperative with staff and was able to make his/her needs known. Review of the Progress Note dated 05/04/2020 indicated RN#1 came out of another resident's isolation room, glanced into the resident's isolation area, and noticed Resident #1 was not there. RN#1 started calling out the resident's name, and he/she did not answer. Resident #1 was in his/her area at 6:55 AM, messing in a bag. At 7:03 AM, RN#1 went out of the exit door and started calling the resident's name. The resident did not answer so, RN#1 came back in and told Certified Nurse Aide (CNA) #2 that Resident #1 was missing. CNA#2 started looking for the resident. The Nurse called the DON, advised the maintenance staff, and started looking for the resident outside. At 7:10 AM, the A/B unit called and asked if one of our residents were missing, RN#1 said yes. Resident #1 showed up at the front door and told the staff to call the sheriff. The staff brought Resident #1 back to the isolation area. RN#1 notified Resident #1's physician and placed a secure care anklet on Resident #1's left ankle. RN#1 attempted to call Resident #1's responsible party and left a message to call the facility. At approximately 9:30 AM, RN#1 spoke with Resident #1's responsible party and daughter-in-law regarding the resident leaving the facility. Review of the Incident Report dated 05/04/2020 indicated that at 7:00 AM, RN#1 came out of another resident's isolation room, glanced into the isolation area, and noticed Resident #1 was not there. RN#1 started calling out the resident's name, but he/she did not answer. Resident #1 was in his/her area at 6:55 AM, messing in a bag before RN#1 went into another resident's isolation room. Immediate Action Taken, at 7:03 AM, RN#1 first went looking for the resident out the back door, calling his/her name. RN#1 returned to the isolation area and told CNA#2 Resident #1 was gone. CNA#2 started looking for the resident while RN#1 called the DON, ADON, and maintenance staff to help look for the resident outside. At 7:10 AM, the A/B unit called and asked if we were missing a resident, RN#1 said yes. Licensed Practice Nurse (LPN) #3 said Resident #1 told them to call the sheriff. The staff brought Resident #1 back to the isolation room. Staff placed a secure care anklet on Resident #1, notified the physician, attempted to contact Resident #1's responsible party, and left a message for a return call. Further review revealed Resident #1 was oriented to person, place, and time, and sustained no injuries - predisposing factors: confused, active exit seeker, and wanderer. Review of the Progress Note dated 05/04/2020 indicated Resident #1 got out of the isolation area this morning - see incident report. Resident #1 kept coming out of the isolation area, and when redirected, he/she laid down in bed with no more behaviors noted. Staff moved Resident #1 into a room (located in the isolation area) where he/she could close the door. Resident #1 appeared to be more complaint. Review of the Daily assessment dated [DATE] indicated Resident #1's bed was in a low position, call bell placed on the bedside table, and a bell placed on the outer door handle of the room. Staff within view of resident #1's room at all times. Review of the Physicians Order dated 05/04/2020 (no time) indicated staff obtained an order to place a secure care anklet on Resident #1, check the placement of secure care anklet on the left ankle every shift, and check the alarm on the secure care anklet every Wednesday. Review of the Treatment Administration Record (TAR) dated 05/2020 indicated that on 05/04/2020, staff applied a secure care anklet on Resident #1's left ankle. The staff signed off the secure care anklet was checked every shift and tested on Wednesday. Review of the Statement of Work (SOW) invoice dated and signed by the DON on 05/04/2020, indicated the facility requested and approved (Signal Technologies) to install a wandering capable, secure care panel, external antenna, and keypad outside the therapy door (isolation area). On 05/05/2020 (time not noted), (Signal Technologies) installed the door secure care alarm system on the therapy door. The 24-hour Follow-Up assessment dated [DATE] indicated Resident #1 was alert with some confusion noted. No complaints voiced, very pleasant, and cooperative. The resident has not voiced to staff that he/she was going to leave the facility. The resident has a secure care anklet on his/her left lower leg that staff monitors each shift. The care plan was reviewed and updated. Review of the Daily Assessments and Progress Notes dated 05/05/2020 - 05/11/2020 did not indicate Resident #1 displayed any further wandering or exit seeking behaviors. Observation on 05/11/2020 at 9:30 AM, during a facility tour, revealed 19 entry/exit doors throughout the facility. At no time did any resident exhibit wandering or exit seeking behaviors. The staff placed a folding table in front of the isolation area door leading from the hallway into the isolation area. Signs posted on the entrance to the isolation area that notified staff/visitors staff designated the room as an isolation area and to ring the bell for assistance. Observation on 05/11/2020 at 10:45 AM - 11:16 AM, conducted with the maintenance director (MD), revealed 19 facility entrance/exit doors, including the isolation area. All entrance/exit doors were equipped with either a secure care alarm/autolocking system and/or required a code to gain access. All doors, door alarms, automatic locking systems functioned properly. During the observation, the MD indicated (Signal Technologies) installed the alarm on 05/05/2020; as a result of Resident #1 leaving the facility unattended. Observations on 05/11/2020 at 11:16 AM revealed Resident #1 in a private room located within the isolation area. Resident #1 had a secure care anklet in place and did not display any wandering or exit seeking behaviors. The isolation area (therapy room) had three small offices used as an isolation room. In the center of the room, there were four beds sectioned off, surrounded by privacy screens, and tape outlines on the floor that identified each isolation area. On 05/11/2020, at 12:35 PM, the facility's surveillance video for 05/04/2020 was reviewed in the presence of the DON. The outside temperature on 05/04/2020 at 6:56 AM was 67 degrees Fahrenheit (https://www.timeanddate.com/weather/usa/wilmington-nc/historic). A review of the surveillance video revealed Resident #1 exited the backdoor of the isolation area at 7:00 AM. The exit door leads out into the staff parking lot, which backed-up to Medical Park Road (a two-way street). The weather outside was clear (no rain, wind, or snow), the ground was dry, and it was light outside (sunrise 6:34 AM). Resident #1 had on long pants, a short-sleeve shirt, and shoes. At 7:03 AM, Resident #1 walked around the building, directly to the outside A/B Unit entrance doors (approximately 400-500 feet from where he/she exited the facility.) At 7:03 AM, Ward Clerk (WC) #4 was seated at the A/B unit door was checking staff temperatures and COVID-19 checks as staff reported to work. WC#4 immediately went to the A/B unit door, approached the resident, walked a few feet to the A/B nurses station to notify the staff (Resident #1 remained in view). LPN#3 approached Resident #1 to assist, and another staff member picked up the phone and made a phone call (later determined to be the police). At 7:06 AM, LPN#3 made a phone call (later determined to be to the isolation area). At 7:07 AM CNA #2, and housekeeping/maintenance staff arrived at the outside front entrance to the A/B Unit. Staff escorted Resident #1 back to the isolation area. During the incident, Resident #1 was not in distress. Observation on 05/12/2020 at 10:08 AM revealed Resident #1 was asleep in his/her room in the isolation area with the door closed. Two staff members were present in the isolation area. Resident #1 did not exhibit any wandering or exit seeking behaviors. At 12:25 PM, Resident #1 was in his/her room in the isolation area watching TV. Resident #1 had a secure care anklet in place. Two staff members were present in the isolation area. Resident #1 was calm and did not display any wandering or exit seeking behaviors. During an interview with Ward Clerk (WC) #4 on 05/11/2020 at 11:47 AM, WC#4 stated, she sits at the front (A/B Unit entrance) to check staff temperatures as they report to work. On 05/04/2020, sometime around 6:30 AM, a person (Resident #1) came up to the outside of the A/B unit doors. He/she looked like a homeless person (was wearing pajamas). She stated she cracked the door and asked Resident #1, how can I help you? Resident #1 told her he needed to speak to the police because someone had been murdered. At which time, she went to the A/B nursing station (few feet away from the door) to notify LPN#3 and RN #5 about the person outside. Within three to five minutes, CNA#2 arrived and escorted Resident #1 back to the isolation room. Resident #1 was not outside for more than five minutes. She reported that the weather was clear, not raining, cool, and dark. Resident #1 did not appear to have any apparent injuries at the time. WC#4 described the facility's process for missing residents, which followed the facility's elopement policy. WC#4 said that each nurses' station has a list of residents at risk for wandering, and also noted on the TAR. Resident #1 was a new admission, and she was not sure if the staff in the isolation area assessed Resident #1 to be at risk for wandering/elopement. During an interview with LPN#3 on 5/11/2020 at 1:43 PM, LPN#3 stated she arrived at the facility on 05/04/2020 around 6:30 AM. WC#4 came to the nurses' station and said there is a person outside who stated that there was a murder and was not leaving until we (staff) called the police. LPN#3, went to the door and asked Resident #1, can I help you? Resident #1 said, I need to speak to the sheriff, and I'm not leaving until I do. At which time, RN#5 called 911. Around that time, LPN#3 stated we got a phone call staff in the isolation area, making us aware that there was a missing resident. At that time, CNA#2 came up to the A/B unit from outside and approached Resident #1 and brought him back to the isolation area. RN#5 called 911 to cancel the call. LPN#3 said that nurses assess residents upon admission; if the resident were at risk for wandering, the staff would place a secure care anklet on the resident. When residents have a secure care anklet on, they cannot go out the door without alarms going off and/or locking. LPN#3 described the facility's process for missing residents, which followed the facility's elopement policy. LPN#3 said that each nurses' station has a list of residents at risk for wandering, and also noted on the TAR. Resident #1 was a new admission, and she was not sure if the staff in the isolation area assessed Resident #1 to be at risk for wandering/elopement. An attempt to interview CNA#2 on 05/11/2020 at 6:59 PM was unsuccessful. A message was left for CNA#2 to return the call; however, CNA#2 did not return the call during or after the survey. During an interview with RN#1 on 5/12/2020 at 11:08 AM, RN#1 said she arrived at the facility on 05/04/2020 at 6:30 AM. She said she had to keep telling Resident #1 to stay in his/her little area (of the isolation room). CNA#2 was bathing another resident who generally yells out. S/he went to take another resident BP, peeked through the curtain, and saw Resident #1 was no longer in the isolation area. RN#1 immediately went out of the door to find Resident #1, but he/she was not there. S/he notified the maintenance staff, who started looking for the resident. RN#1 called the DON to inform her that Resident #1 was missing. At that time, the A/B Unit called to let her/him know that Resident #1 was on the AB unit. Staff assisted the resident back to the isolation area. S/he notified the physician and put a secure care anklet on the resident, even though the back door did not have an alarm. S/he added that s/he placed bells on the resident's door handle as well. From that point on, she stated staff provided the resident with 1:1 care and moved him/her to a room within the isolation area. Resident #1 allowed RN#1 to place a secure care alarm on his ankle. The staff moved Resident #1 to a room of his own in the isolation area. RN#1 stated the resident did not have a history of wandering, as stated in the incident report - just would not stay in the taped isolation area, but when reminded, the resident would say ok. RN#1 assessed the resident who did not sustain any injuries. RN#1 said Resident #1 told her exactly what he/she did, he/she said he/she walked around the building to the sidewalk and came to the first door. RN#1 described the facility's process for missing residents, which followed the facility's elopement policy. RN#1 said that each nurses' station has a list of residents at risk for wandering, and also noted on the TAR. An attempt to interview Resident #1's responsible part on 05/12/2020 at 10:42 AM was unsuccessful. A message was left for the responsible party to return the call; however, the responsible party did not return the call during or after the survey. During an interview with a frequent visitor of Resident #1 on 05/12/2020 at 11:08 AM, he/she did not voice any concerns related to resident elopements. He/she stated the facility reported the incident regarding resident #1 and provided a copy of the facility incident report. He/she spoke to Resident #1's family member, who was very complimentary of the staff's care. The facility notified the family that resident #1 left the facility unattended. The family did not have any concerns and thought Resident #1 was getting better, was probably getting tired of being cooped up, and decided to leave the isolation area. During an interview with Resident #1 on 05/12/2020 at 12:25 PM, Resident #1 was pleasantly confused. Resident #1 was not aware of where he/she was or how he/she got to the facility. Resident #1 denied any knowledge of leaving the facility through the isolation area door on 05/04/2020 at 7:00 AM. Resident #1 denied any knowledge of stating that someone was being murdered, screaming, or yelling out in the isolation area on 05/04/2020. Resident #1 said the facility was moving him to a new room today, although he/she would like to be at home, he/she needed to stay at the facility to get stronger. Resident #1 denied any plans to leave the facility. During an interview with RN#6 on 05/12/2020 at 12:40 PM, RN#6 stated that he/she assessed Resident #1 upon admission and was at risk for wandering. A secure care alarm was not initiated because the resident was not exit-seeking; therefore, a secure care anklet was not warranted. The facility does not like to put alarms on residents unless they are absolutely necessary. Since Resident #1 was not actively exit seeking, we did not apply a secure care anklet on the resident. RN#6 described the facility's process for missing residents, which followed the facility's elopement policy. RN#6 said that each nurses' station has a list of residents at risk for wandering, and this information is also noted on the TAR. During an interview with the DON on 05/12/2020 at 2:23 PM, he/she stated that he/she received a call from RN#1 that resident #1 was missing and called maintenance staff who were looking for resident #1. The DON said he/she advised RN#1 that if he/she could not find Resident #1 to call the police. RN#1 called back within a few minutes to report that Resident #1 was located at the front entrance doors on the A/B Unit. The DON said that he/she arrived at the facility within five minutes and talked with the staff. After speaking with staff, he/she stated that CNA#2 was bathing another resident, who was yelling out at the time (normal for him/her) and determined that is what resident #1 was talking about at the time. RN#1 assessed Resident #1, who did not have any injuries noted. RN#1 placed a secure care anklet on Resident #1. The DON advised RN#1 that since the door to the isolation area did not have a secure care alarm, two staff needed to remain on the unit at all times, and the staff needed to stagger resident care. During the morning meeting, she asked the MD to call the alarm company to get an alarm installed on the door to the isolation area, which the alarm company installed on 05/05/2020. The DON reported that when the CDC (Center for Disease Control) recommendations came out, the ADON noted that another facility moved residents into an isolation unit. Since the facility only had two empty beds and would not be a sufficient amount of space to house residents being admitted or readmitted to the facility for the 14-day guarantee, they decided to turn the therapy room into an isolation area. The DON stated that he/she was aware that the exit door to the therapy room did not have an alarm. She thought that because the isolation area was a confined space, staff to resident ratio would be one to one, and residents closely monitored. At that time, there were not any residents at risk for wandering or elopement in the isolation room. The DON stated that residents admitted to the facility are monitored during the first week to learn their behaviors. The DON said it was easy to figure out which residents kept going to the door, saying they wanted to go home or leave, observed packing up their belongings, trying to open the door or leave the facility. Some residents just want to go out and sit on the porch. Even though a resident scores high on the elopement risk assessment, they are not always at risk for elopement; some just like to sit outside. Also, family members notified staff if residents had a history of [REDACTED]. The admission staff also identify residents wandering or exit seeking behaviors during the pre-admission process. The DON acknowledged that staff would not know an unobserved wanderer exited the facility if they did not have a secure care anklet in place. The DON stated since the incident, nothing else has occurred. She reported that he/she advised the nurses that if a nurse were in an isolation room tending to a resident, the CNA would not need to provide a bath/shower. The DON acknowledged that he/she did not document this education and provided a written statement on 05/12/2020 at 3:45 PM. During an interview with the Assistant Director of Nursing on 05/12/2020 at 5:30 PM, the ADON verified department heads and unit managers were notified of the incident and planned to install a secure care alarm on the door in the isolation area. During a follow-up interview with RN#1 on 05/12/2020 at 7:25 PM, RN#1 verified that on 05/04/2020, the DON provided verbal education to the isolation staff regarding keeping the residents in full view at all times. The facility's policy titled, Wandering and Elopements, last revised 12/2007, indicated (T)he facility will identify resident (sic) who are at risk of unsafe wandering and strive to prevent harm while maintain (sic) the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. If a resident is missing, initiate the elopement/missing resident emergency procedure. Determine if the resident is out on an authorized leave or pass; if the resident was not authorized to leave, initiate a search of the building(s) and premises; if the resident is not located, notify the Administrator and the DON, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.). When the resident returns to the facility, the DON or Charge Nurse shall examine the resident for injuries; contact the Attending Physician and report findings and condition of the resident; notify the resident's legal representative (sponsor); notify search teams that the resident has been located; complete and file an incident report; and document relevant information in the resident's medical record. The Immediate Jeopardy Removal Plan included the following: This removal plan is due to Elopement of Resident #1 that happened on 05/04/2020 from the isolation room. The facility designed the therapy room as a separate area within the facility with an outside door to attempt to separate suspected/positive COVID-19 residents and those with unknown COVID-19 status (admission and readmissions). Also, if possible, dedicate a unit/wing exclusively for any residents coming or returning from the hospital. This can serve as a step-down unit where they remain for 14 days with no symptoms (instead of integrating as usual on short-term rehab floor or returning to long-stay original room) https://www.cms.Eov/files/document/qso-20 14 nh-revised.pdf. Immediate Action On 05/01/2020 at 6:55 AM, RN#1 observed resident #1 rummaging in a bag. RN#1 went into another resident's room to render care. RN#1 came out at 7:00 AM and noticed that Resident #1 was no longer in the isolation room at this time. She immediately looked outside, and when she did not see Resident #1, she immediately called the other staff to look for the missing resident. CNA#2 was continuing to search for the missing resident while RN#1 contacted other staff. RN#1 called the DON at approximately 7:07 AM and reported that resident # l was missing from the isolation room and that staff was currently searching for the resident. The DON informed RN#1 that if resident could not be located to call the police immediately. The DON stated that she would be at the facility within a few minutes. At 7:03 AM, Resident # 1 came to the A&B entrance and tried to enter the facility. WC#4 (staff member that was a doorway to screen staff as they arrived for work) opened the door, and the resident stated, call the police, someone is being murdered. While LPN#3 went to the A&B entrance to check on the situation, RN#5 on A&B unit placed a call to the police to notify them of the situation. Resident #1 was escorted back inside the facility at 7:06 AM, as verified by the video camera. At 7:10 AM. RN#1 called the DON back to notify her that Resident #1 had been safely located at the facility. At approximately 7:15 AM, RN#1 examined Resident #1 and noted no signs or symptoms of distress or injury. On 05/04/2020, at approximately 7:25 AM, the DON arrived at the facility. At approximately 7:25 AM, after verifying the resident's safety, the DON questioned staff about the event. The DON talked to RN#1 and CNA#2 at approximately 7:35 AM about the situation. CNA #2 stated she was bathing another resident at the time Resident #1 exited the building. CNA #2 was bating a resident that tends to yell out with AM care. CNA#2 stated that the resident yelled out while being bated. After further investigation, the DON concluded that Resdident#1's exit seeking behavior was prompted by concern for the resident that yelled out while being bathed. Resident #1 had never voiced a desire to leave the facility no had he/she exhibited any exit seeking behaviors prior to this event. There was no exit seeking behaviors noted during Resident #1's pre-admission screening process or verbal report from the receiving facility. Identification of others: Between 05/01/2020 to 05/ 0, no other residents were affected by the deficient practice. Action taken: On 05/04/2020, a secure care anklet applied RN#1 at approximately 7:20 AM. At approximately 7:45 AM, The DON verbally educated staff in Isolation unit that staff needed to stagger care to ensure that all residents would be visually monitored at all times to ensure that any unknown exit seeking behavior will be observed and intervened immediately. Debra verbally educated staff that care should be staggered to ensure residents' safety until alarms could be installed on the door. A written statement was provided to the surveyor on 05/12/2020 by the DON/ verifying this information. This information was also verified by RN#1 at 7:25 PM on 5/12/2020 by the surveyor interview. On 05/04/2020, the DON notified the MD, at 8:00 AM (at their 8:00 AM meeting) to contact (Signal Technologies) immediately to install an alarm on the isolation room door. At 2:46 PM, Signal Technologies faxed a statement of work with an estimate of $4207.00. The DON signed the statement of work and faxed the document back at approximately 3:00 PM. On 05/05/2020 ( Signal Technologies) arrived at approximately 9:00 AM to install a magnetic keypad and door alarm to the isolation room door. They completed the installation at approximately 2:00 PM and verified it was properly functioning. On 05/04/2020, Nurses assessed and documented the presence of the alarm on resident #1 each shift. Staff continued to stagger care to ensure resident safety until the installation of the alarm was completed and verified for proper functioning. Nurses are checking resident #1's secure care sensor weekly for proper functioning since 05/04/2020. On 05/05/2020, the isolation door was added to the maintenance department's list of routine weekly alarm checks, which was verified during the survey on 5-11-20 by the surveyor at 11:16 AM. Copies of logs with alarm checks provided to the surveyor by MD supervisor on 5/11/2020. On 05/04/2020 at 11:00 AM, All department heads and unit managers were verbally notified at the standup meeting of the event. The staff was notified of the alarm being installed on the isolation room door as soon as possible. During the first quarter of 2020, all staff was educated via Healthcare Academy for Dementia Behaviors, which included Elopement. On 05/04/2020, Resident #1's care plan updated related to elopement. The next QAPI (Quality Assessment and Performance Improvement) meeting is scheduled for 05/27/2020. The elopement event will be discussed at the next QAPI meeting. Completion Date: 05/05/2020.

Based on record review and interview the facility failed to ensure residents were free from involuntary seclusion. Certified Nursing Aide (CNA) #1 barricaded the doorway of Resident #75 and Resident #128 with two mechanical lifts and one recliner. 2 of 2 residents reviewed for involuntary seclusion. The findings included: Record review of Resident #75's medical record revealed that Resident #75 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #75's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 9. Record review of Resident #128's medical record revealed that Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #128's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 8. Review of Resident #128's MDS dated [DATE] revealed a BIMS of 9. Review of the facility's five-day report dated 5/29/19 revealed that on 5/24/19 (Resident #75) was noted to up and out of (his/her) room at 4:30 AM (and) was returned to near (his/her) room by nurse, within a few minutes (s/he) was headed off unit again (and) nurse returned (him/her) to unit and nurse told (CNA #1) (s/he) had returned res (resident #75), then around 5:20 AM nurse paged for (CNA #1) (and) told (her/him) resident was in (his/her) w/c (wheelchair) going off the unit and (CNA #1) needed to redirect (him/her) back to (his/her) room because at this time the unit nurse was working with another resident who required medial assistance. At approximately 6:00 AM, (Licensed Practical Nurse (LPN) #2) asked (CNA #1) if (s/he) knew where the resident (Resident #75) was and (CNA #1) replied that (s/he) had given (him/her) a bath and returned (him/her) to bed. At approximately 6:50 AM (LPN #2) went to check on residents on North Side of unit and noticed that the door to resident's room was open and both residents (Resident #75 and Resident #128) in room were asleep. (LPN #2) also noticed that there were lifts and a recliner chair in the doorway of the residents' (Resident #75 and Resident #128) room. (LPN #2) requested that another nurse, (LPN #1) witness the lifts and recliner chair. (LPN #2) then proceeded to remove the lifts and the chair obstructing the doorway, and (s/he) informed (CNA #1) that the action was unacceptable. (CNA #1) statement indicated that (s/he) placed the objects in the doorway so that the resident (Resident #75) would not wander out of the room again while (s/he) was providing care to other residents . Further review of the facility's five-day report dated 5/29/19 revealed that when (Director of Nursing (DON)) met with (CNA #1), (CNA #1) confirmed that (s/he) placed the chair and the lifts in the doorway. (DON) explained to (CNA #1), that the facility, from (MONTH) 22, 2019-April 30, 2019, had just completed abuse in-service training and that all forms of abuse were discussed, including involuntary seclusion . Review of CNA #1's facility obtained statement dated 5/24/19 revealed I (CNA #1) attended care for (Resident #75), around 4:20 AM. Called from care of (another resident) to (Resident #75) going up the wall undressed. Nurse went and got (him/her) came back, I asked (her/him) to tell (her/him) please wait and I will get (her/him) dressed. Got (her/him) back got away again and then I asked (her/him) to wait (s/he) began cursing I asked (her/him) please do not curse me, began to start back out again I asked (her/him) to come back that (s/he) could not go alone in this hallway without assistance (s/he) again tried to get out so I placed a lift in from of door plus recliner to finish work with other patients. Nurse came down the hall said I had to move that recliner and lift I said I would (s/he) stated this was a fire hazard I said ok and did so at 5:20 AM. During an interview with LPN #1 on 07/18/2019 at approximately 3:25 PM, LPN #1 stated that at 6:50 AM I went down to room [ROOM NUMBER] where there were two lifts placed in front of the patient's room to barricade them in. The part that is used to clip the lift to the patient sling was clipped together. A chair was placed in between the two lifts. Resident #75 got up at 4:30 AM trying to come out of (his/her) room before the lift was ever placed. CNA #1 was told to remove the lifts and remove the chair. During an interview with the Administrator on 07/18/2019 at approximately 4:45 PM, the Administrator stated that Resident #75 could get out of bed and yell for staff even though the door was being blocked. The Administrator stated that he/she did not understand why CNA #1 did it, since they were both asleep. Review of the Sheriff's Office Report dated 5/24/19 revealed .Upon arrival R/O (reporting officer) went to (name of unit) and spoke with the floor nurse (name of nurse) who states at approximately 04:30 hours the patient in room (room number) left (his/her) room. The CNA (name of CNA) was able to get (him/her) back to (his/her) room and place the patient back in (his/her) bed (CNA#1) then placed a Geri chair in front of the open door of room (room number) and placed 2 mechanical lifts around it and locked the wheels. The floor nurse made (her/his) rounds at 07:00 hours and noticed room (room number) door open but barricaded. The nurse removed the aforementioned barricade from the patients door allowing ingress and egress from the room. (CNA #1) was subsequently terminated from Saluda Nursing Center .

Based on record review and interview, the facility failed to implement new interventions to prevent further weight loss for 2 of 7 residents reviewed for nutrition. Resident #89 and #141 did not have further/additional nutritional interventions implemented related to continued weight loss. The findings included: The facility admitted Resident #141 with [DIAGNOSES REDACTED]. Record review of Resident #141's medical record on 3/29/19 at 4:57 PM revealed physician orders [REDACTED]. Further review of the physician orders [REDACTED]. Review of Resident #141's nutritional assessment dated [DATE] revealed Resident #141's weight was 193.6 pounds and his/her meal intake were 50-75%. Further review of the nutritional assessment revealed Resident #141 had a greater than 7.5% weight loss in past 90 days and at the time recommended Magic Cup twice a day and would follow as needed. Further review of Resident #141's weight revealed his/her weight was noted as: 9/11/18: 204 10/4/18: 209 11/1/18: 204 12/5/18: 205 1/3/19: 193.6 1/17/19: 191.2 1/24/19: 186.8 2/7/19: 185.4 3/6/19: 177.8 3/15/19: 171 3/22/19: 172.2 3/29/19: 172.2 No further recommendations were noted from the Registered Dietician. Further record review revealed Resident #141 was on the Occupational Therapy (OT) case load for pocketing food and difficulty feeding, from 9/2/18 and was discharged on [DATE]. A referral was made to OT on 1/31/19 for adaptive cup due to spillage, 3/27/19 referral for difficulty eating, not drinking or eating as before hospitalization . During an interview with the Unit Manager on 3/30/19 at 12:10 PM, s/he stated Resident #141's weight loss possibly could be attributed to broken dentures. The resident's dentures have been broken since 11/23/18. The Unit Manager stated that it takes approximately three months to get dentures. S/he stated when the resident did not feed himself/herself, another intervention was to feed Resident #141. S/he also stated the resident's replacement dentures had arrived on 3/27/19. During an interview with the Registered Dietician (RD) on 3/30/19 9:45 AM, s/he stated I can only recommend and evaluate when it is communicated to me of a weight loss. He/she continued by stating if Resident #141 had missing dentures and trouble chewing the resident would be followed by speech therapy. Review of Resident #141's medical record revealed no current orders for speech therapy and no notes were provided to the surveyor related to speech therapy. During an interview with the Dietary Manager on 3/30/19 at 10:06 AM, s/he stated the Registered Dietician receives information from me and he/she goes around to the units and gets information from the nurses related to any concerns for weights and makes his/her recommendations. S/he stated the loss of Resident #141's bottom dentures could have contributed to weight loss, but s/he was put on a mechanical, soft, ground meat diet. The Dietary Manager confirmed the resident had not been seen or had any recommendations from the RD since 1/9/19 and could not find any other information. S/he confirmed it was a concern Resident #141 continued to trend down with no further RD intervention. During meal observations on 3/28/19 at 12:41 PM Resident #141 was observed sitting up in bed with family at bedside feeding the resident. During meal observations on 3/29/19 at 12:30 PM Resident #141 was observed up in the dining room assisted by a CNA. The resident had a two handled cup with lid. Resident #141 was being assisted and was eating without resistance or difficulty with prompting. The facility admitted Resident #89 with [DIAGNOSES REDACTED]. Record review on 03/29/19 at approximately 2:08 PM revealed recorded weights for Resident #89 as follows: 03/06/19: 163, 03/05/19: 160, No (MONTH) weights recorded, 01/04/18: 170.5 01/02/18: 176.2 12/31/18: 161.2 12/31/18: 161 12/30/18: 158.7 12/29/18: 155.5 12/27/18: 168.5 12/26/18: 165.2 12/20/18: 169.5 12/19/18: 172 12/12/18: 188.4 Admission. Subsequent review revealed a Physicians Order for weekly weights dated 01/11/19 but none were found in the electronic health record. Review of the Care Plan revealed the intervention for weekly weights was not included in the plan. During an interview on 03/29/19 at approximately 6:47 PM the Unit Manager stated that the order for weekly weights was entered incorrectly as no action required which caused it to not be added to the Medical Administration Record for tracking nor to the Care Plan for implementation as an intervention. During a telephone interview on 03/30/19 at approximately 9:40 AM the Registered Dietician (RD) stated the facility is to place residents needing review on a weight loss list to be given priority beyond scheduled reviews but that this was not done for Resident #89. During an interview with the Director of Nursing (DON) on 3/29/19 at 4:41 PM The DON stated that the scales were being recalibrated as part of a facility QA plan but that is did not affect the failure of the staff to implement the order for weekly weights to accurately track the resident's progress. During an interview on 03/30/19 at approximately 9:53 AM the Dietary Manager reviewed the Quarterly Dietary Review form s/he completed on 03/13/19 documenting significant weight change but was unable to provide a reason why the section marked Refer to RD was not completed and a referral was not made for Resident #89. During a meal observation on 3/29/19 at 9:00 AM Resident #89 was observed in room, sitting in wheel chair, LPN #1 entered with tray and fed the resident pureed bacon, eggs, toast, cranberry juice. During a meal observation on 3/29/19 at 12:35 PM Resident #89 was observed in room his/her roommate was eating the curtain was pulled. Resident #89's lunch tray was sitting in the residents room on an over bed table uncovered. Resident #89 was in a high back wheel chair beside bed. At 12:50 PM this surveyor asked the medical records clerk, in the hall at the time, who had put the tray in Resident #89's room. The medical records clerk came back with the CNA responsible for Resident #89 who stated s/he had not put the tray in the room but that s/he was told earlier that Resident #89 was no longer a feeder but a slow eater also stated s/he was willing to feed him/her and set up the tray and began to assist Resident #89. Since the plate had been left uncovered while sitting on the table, the pureed foods had cooled and become stiff. LPN #1 confirmed assisting the resident with breakfast earlier in the day.

Based on record review, interview and facility policy, the facility failed to update the care plan related to interventions to prevent further weight loss for Residents #89, 1 of 7 sampled residents reviewed for Nutrition. The findings include: The facility admitted Resident #89 with [DIAGNOSES REDACTED]. Record review on 03/29/19 at approximately 2:08 PM revealed recorded weights for Resident #89 as follows: 03/06: 163, 03/05: 160, No (MONTH) weights recorded 01/04: 170.5 01/02: 176.2 12/31: 161.2 12/31: 161 12/30: 158.7 12/29: 155.5 12/27: 168.5 12/26: 165.2 12/20: 169.5 12/19: 172 12/12: 188.4 Admission. Subsequent review revealed a Physicians Order for weekly weights dated 01/11/19 but none were found in the electronic health record. Review of the Care Plan revealed the intervention for weekly weights was not included in the plan. During an interview on 03/29/19 at approximately 6:47 PM the Unit Manager stated that the order for weekly weights was entered incorrectly as no action required which caused it to not be added to the Medical Administration Record for tracking nor to the Care Plan for implementation as an intervention. During a meal observation on 3/29/19 at 9:00 AM Resident #89 was observed in room, sitting in wheel chair, LPN #1 entered with tray and fed the resident pureed bacon, eggs, toast, cranberry juice. During a meal observation on 3/29/19 at 12:35 PM Resident #89 was observed in room his/her roommate was eating the curtain was pulled. Resident #89's lunch tray was sitting in the residents room on an over bed table uncovered. Resident #89 was in a high back wheel chair beside bed. At 12:50 PM this surveyor asked the medical records clerk, in the hall at the time, who had put the tray in Resident #89's room. The medical records clerk came back with the CNA responsible for Resident #89 who stated s/he had not put the tray in the room but that s/he was told earlier that Resident #89 was no longer a feeder but a slow eater also stated s/he was willing to feed him/her and set up the tray and began to assist Resident #89. Since the plate had been left uncovered while sitting on the table, the pureed foods had cooled and become stiff. LPN #1 confirmed assisting the resident with breakfast earlier in the day. Review of facility policy titled Weight Assessment and Intervention revealed: 2. Individualized care plans shall address, to the extent possible .c. Time frames and parameters for monitoring and reassessment.

Based on record review, interview, and review of the facility policy titled Abuse Investigation and Reporting, the facility failed to implement the facility's abuse policy for 1 of 16 residents reviewed for abuse. The facility failed to implement the components of its abuse policy that prohibit and prevent abuse for Resident #37. Certified Nursing Assistant (CNA) #1 hit Resident #37 on his/her left cheek while assisting the resident to bed and in the presence of CNA #2. The findings included: Review of the facility 5-day investigation report dated 9/5/18-States that on 8/31/18 CNA #1 and CNA #2 worked together while providing care to Resident #37. After putting the resident to bed, CNA #1 rolled the resident toward (him/her) to change (him/her)-The resident was agitated hit CNA #1 in the arm and called (her/him) the N word and CNA #1 slap/hit the resident on left cheek. The facility investigation also uncovered that Resident #37 shared concerns of mistreatment by the same nursing assistant (CNA #1) with (her/him) friend/visitor on 8/30/18. Review of Resident #37's nurse's notes on 3/27/19 revealed a nurses note dated 8/31/18 stated 7:50 pm Resident was yelling out went in room to check on (her/him) and resident stated (s/he) was struck on the left cheek by CN[NAME] Resident stated I was hit on (left) cheek and she said this two times. Another CNA was in the room (at) the time. CNA #1 (alleged perpetrator) facility-obtained statement dated 8/31/19 and timed 7:45 PM- indicated that CNA #1 admitted hitting Resident #37 on (his/her) face but did not mean to do it. CNA #2 (alleged witness) facility-obtained statement dated 9/1/18 indicated that CNA #2 witnessed CNA #1 slap Resident #37 after the resident hit CNA #1 on the arm and called (him/her) N word. During a phone interview with CNA #2 0n 3/28/19 at 3:55 PM (s/he) stated that when CNA #1 and (him/her) took Resident #37 to bed, the resident was combative and hit CNA #1 in the arm and called (him/her) the N word and then CNA #1 hit the resident on (his/her) left cheek (left side of her face). CNA #2 added that (s/he) could not remember what hand the CNA used to hit the resident but (s/he) remembers that the resident's face got red for about 5 seconds. Registered Nurse (RN) #3 facility-obtained statement dated 8/31/18 and timed 7:50 PM indicated that Resident #37 told RN #3, two times, that CNA #1 hit (her/him) on the left check and CNA #2, who was in the room at the time, told RN #3 that it was true, CNA #1 hit the resident on the left cheek of face. Interview with RN #1 on 03/28/19 at 03:29 PM-Stated that Resident #37 kept repeating (CNA #1) slap me in my face. So I asked the other CNA #2, who was present at the time of the incident and (s/he) confirmed that CNA #1 slap the resident like (s/he) said. CNA #1's employee file review on 3/29/19 revealed that the CNA was suspended on 8/31/18 pending investigation. The CNA was terminated on 9/1/18. His/her last day worked was 8/31/18. During an interview with the Director of Nursing (DON) on 3/29/19 at approximately 4:00 PM (s/he) stated that the CNA #1 was terminated due to facility's investigation concluded substantiated abuse. During a phone interview with the resident's friend/visitor on 3/29/19 at 1:07 PM (s/he) stated that resident #37 told (him/her) that CNA #1 was very rough with (him/her) on 8/30/18. The resident's friend stated that (s/he) shared resident $37's concerns with the nurse in charge. During an interview with the DON on 3/29/19 at approximately 2:00 PM (s/he) stated the facility was not aware the Resident #37 had complained to (his/her) regarding CNA #1 being rough (him/her) the day before. This issue was brought up during the facility investigation the nurse that was allegedly told about concerns no longer works for the facility. Review of the facility policy titled Abuse and Neglect-Clinical Protocol revealed under Treatment/Management The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Review of the facility policy titled Abuse Prevention Program states Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Under the Policy Interpretation and Implementation section 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. Implement measures to address factors that may lead to abusive situations, for example: b. Instruct staff regarding appropriate ways to address interpersonal conflicts; and c. Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts.

Based on record review and interview, the facility failed to ensure one of 16 sampled residents reviewed was free from abuse by staff. Certified Nursing Assistant (CNA) #1 hit Resident #37 on (his/her) left cheek while assisting the resident to bed and in the presence of CNA #2. The findings included: Review of the facility 5-day investigation report dated 9/5/18 revealed that on 8/31/18 CNA #1 and CNA #2 worked together while providing care to Resident #37. After putting the resident to bed, CNA #1 rolled the resident toward (him/her) to change (him/her)-The resident was agitated hit CNA #1 in the arm and called (her/him) the N word and CNA #1 slap/hit the resident on left cheek. The facility investigation also uncovered that Resident #37 shared concerns of mistreatment by the same nursing assistant (CNA #1) with (her/his) friend/visitor on 8/30/18. Review of Resident #37's medical record on 3/27/19 revealed that (s/he) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #37's care plan on 3/27/19 at approximately 9:37 AM revealed a 3/12/18 care plan titled Alteration in thought process-problems including mood, obsessive and pervasive disorders, severe agitation associated with [NAME]D, disorganized thinking, verbal and physical behavioral symptoms daily- The resident is very impulsive, very demanding and impatient at times. -Resident apologize at time when acting out. The interventions include attempting to redirect the resident when (s/he) becomes agitated.-If the resident is agitated (all staff) leave the resident alone and try to approach the resident at a later time.-Approach the resident (all staff) in a calm and gentle manner.-Remind resident in a gentle but firm manner that (his/her) behavior is unacceptable when acting out. On 5/1/18 resident's care plan was updated with x2 staff member (all staff) to render care to at all times. Review of Resident #37's nurse's notes on 3/27/19 revealed a nurses note dated 8/31/18 stated 7:50 pm Resident was yelling out went in room to check on (her/him) and resident stated (s/he) was struck on the left cheek by CNA. Resident stated I was hit on (left) cheek and she said this two times. Another CNA was in the room (at) the time. Review of the facility incident report revealed Resident #37's level of consciousness at the time of the incident was alert and oriented to self. Another certified Nursing Assistant (CNA) #2 was in the room at the time of the incident and confirmed the resident's claim. DHEC licensing notified at 8:10 PM and the Saluda County Sheriff's Department notified at 8:17 PM. Notification to the administrator, DON and unit manager on 8/31/18 at 8:10 AM. Resident up to broad chair-left cheek clear and no residual effects. CNA #1 (alleged perpetrator) facility-obtained statement dated 8/31/19 and timed 7:45 PM- indicated that CNA #1 admitted hitting Resident #37 on (his/her) face but did not mean to do it. CNA #2 (alleged witness) facility-obtained statement dated 9/1/18 indicated that CNA #2 witnessed CNA #1 slap Resident #37 after the resident hit CNA #1 on the arm and called (him/her) N word. During a phone interview with CNA #2 on 3/28/19 at 3:55 PM (s/he) stated that when CNA #1 and (him/her) took Resident #37 to bed, the resident was combative and hit CNA #1 in the arm and called (him/her) the N word and then CNA #1 hit the resident on (his/her) left cheek (left side of her face). CNA #2 added that (s/he) could not remember what hand the CNA used to hit the resident but (s/he) remembers that the resident's face got red for about 5 seconds. Registered Nurse (RN) #3 facility-obtained statement dated 8/31/18 and timed 7:50 PM indicated that Resident #37 told RN #3, two times, that CNA #1 hit (her/him) on the left check and CNA #2, who was in the room at the time, told RN #3 that it was true, CNA #1 hit the resident on the left cheek of face. During an interview with RN #1 on 03/28/19 at 03:29 PM RN #1 stated that Resident #37 kept repeating (CNA #1) slap me in my face. So, I asked the other CNA #2, who was present at the time of the incident and (s/he) confirmed that CNA #1 slap the resident like (s/he) said. CNA #1's employee file review on 3/29/19 revealed that the CNA was suspended on 8/31/18 pending investigation. The CNA was terminated on 9/1/18. His/her last day worked was 8/31/18. During an interview with the Director of Nursing (DON) on 3/29/19 at approximately 4:00 PM (s/he) stated that the CNA #1 was terminated due to facility's investigation concluded substantiated abuse. During a phone interview with the resident's friend/visitor on 3/29/19 at 1:07 PM (s/he) stated that resident #37 told (him/her) that CNA #1 was very rough with (him/her) on 8/30/18. The resident's friend stated that (s/he) shared resident #37's concerns with the nurse in charge. During an interview with the DON on 3/29/19 at approximately 2:00 PM (s/he) stated The facility was not aware that Resident #37 had complained to friend/visitor regarding CNA #1 being rough (him/her) the day before. This issue was brought up during the facility investigation the nurse allegedly was told about concerns no longer works for the facility.

Based on observation, interview, and review of the facility policy, the facility failed to serve food under sanitary conditions for 1 of 4 steam tables reviewed and has the potential to affect 22 of 169 residents with ordered diets as evidenced by failing to plate food sanitarily. The findings included: On 3/26/19 at approximately 12:45 PM, an observation of the dining room steam table revealed: Cook #1 with gloved hands touched the steam table, plates, handles on the table, clothes multiple times then pulled buns out of a bag and put the buns on the resident's plates without sanitizing or changing gloves. On 3/27/19 at approximately 8:35 AM, an observation with the Certified Dietary Manager (CDM) of the dining room steam table revealed: Cook #2, with gloved hands touched the table, shirt pocket, plates and utensils then pulled bread out of a bag and put bread on residents' plates without changing gloves or sanitizing hands. On 3/27/19 at approximately 8:40 AM, the CDM verified Cook #2 was touching bread with his/her hands and putting the bread on the resident's plates. The CDM then stated, They should be using tongs. Review of the facility policy, Food Service / Distribution, states under (6.) Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. Disposable gloves are single-use items and shall be discarded after each use.