Every finding on record at The Oaks Post Acute

Based on observation, interview, and review of facility policy, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in 1 of 1 Kitchen, 1 of 3 Unit Nourishment Rooms, and 1 of 1 Medication Rooms.Review of the facility policy titled Food Receiving and Storage last revised in July 2014 revealed, Foods shall be received and stored in a manner that complies with safe food handling practices. Food Services, or other designated staff, will maintain clean food storage areas at all times. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. Refrigerated foods must be stored below 41F unless otherwise specified by law. Refrigerated foods will be stored in such a way that promoted adequate air circulation around food storage containers. Functioning of the refrigeration and food temperatures will be monitored at designated intervals thought the day by the Food Service Manager or designee and documented according to the state-specific requirements. Food items and snacks kept on the nursing units must be maintained, all food items to be kept below 41F must be placed in the refrigerator located at the nurses' station and labeled with a use by' date. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Other opened containers must be dated and sealed or covered during storage.Review of the facility policy titled Food Preparation and Service last revised in November 2022 revealed, Food and nutrition service employee prepare, distribute and serve food in a manner that complies with safe food handling practices. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.Review of the facility policy titled Foods Brought by Family/Visitors last revised in March 2022 revealed, Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs or residents brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility prepared food. Perishable foods are stored in re-sealable container with tightly fitted lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. During an observation and interview on 01/11/26 at 10:29 AM, revealed Kitchen Staff (KS)1 in the kitchen without a hairnet, KS1 stated that they recently returned to the kitchen after a break. KS1 further stated that they came through the back door of the facility and the hairnets are on the front door near the hallway entrance of the facility. Observation of the back door of the kitchen revealed no area for hairnets. KS1 finally stated that staff are required to have a hairnet on at all times in the kitchen. During an observation on 01/11/26 at 10:32 AM, in the Dry Storage Room of the Main Kitchen revealed the following food items not labeled/stored appropriately:A plastic grocery bag with 2 packs of Hazelnut Coffee with an expiration date of December 2025; during interview with KS1 they stated that they were unsure why this item was still in the grocery bag and why this item was not discarded prior to it's expiration date. 1 box of thickened liquids not dated when received.1 opened bag of Bread Crumbs in a plastic storage container with a use-by date on the lid dated for 10/19/25.During an observation and interview on 01/11/26 of the Riverside Unit Medication Room revealed two Pimento Cheese Sandwiches wrapped in plastic wrap on a snack tray at room temperature. Licensed Practical Nurse (LPN)1 revealed that this food item should have been refrigerated. During an observation on 01/12/26 of the Nourishment Room for Riverside and [NAME] Units revealed a personal food item (unable to determine due to frost) in the freezer area of the refrigerator in a tupperware container with the resident's last name (R33) written on the lid with no item description or use-by date. Further observation of the refrigerator revealed the door not adequately sealing, at time of observation there was no thermometer to determine temperature of refrigerator. Multiple food items were observed in the refrigerator.Review of the Electronic Medical Record (EMR) revealed R33 was discharged from the facility to the hospital on [DATE]. During an interview with Dietary Director (DD)2 on 01/13/26 at 11:50 AM, the DD2 stated Kitchen staff are required to wear hairnets when they enter the kitchen, if a hairnet is not available by the back-door then I would expect my staff to come around to the main door and get a hairnet and then enter the kitchen. All food items should labeled and dated when received and when to use by. During an observation and interview on 01/13/26 at 4:15 PM, LPN5 stated, regarding the Nourishment Room for Riverside and [NAME] Units of the facility, the refrigerator did not have a thermometer because it is out of order due to the refrigerator not adequately sealing, during time observation there were approximately 8 nutritional supplement drinks in the refrigerator, LPN5 discarded items at time of observation and stated that no food items should have been in the refrigerator. During an interview with DD1 on 01/13/26 at 5:08 PM, revealed Nursing staff are responsible for ensuring the nourishment room refrigerators are maintained and food items are being labeled/dated and discarded in a timely manner. DD1 further stated that the facility will be replacing the refrigerator in the Nourishment Room because it is not adequately sealing to ensure food items are being maintained at the correct temperature and food items should have not been in the refrigerator due to this reason.

Based on review of facility policy, observation, record review, and interview, the facility failed to maintain a clean, homelike environment for Residents (R)57, R71, and R95 for 2 of 3 units observed.Findings include: Review of the facility policy titled Resident's Rights revealed, Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to: a. A dignified existence . Review of the facility policy titled Cleaning and Disinfecting Residents' Rooms with a revision date of August 2013 revealed, General Guidelines: 1. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. During multiple observations on 01/11/26 and 01/12/26, a cart made of white PVC pipes was noted at the entrance leading behind the nursing station on the 400 Riverside Unit. This cart had dried brown liquid, crumbs, and dust on the bottom shelf. Further observation revealed a Hoyer lift in the alcove of the hallway where rooms 420-438 were located had dried debris and dust on the base and in the crevices. During an interview with the Lead Housekeeper on 01/13/26 at 9:15 AM, she revealed, The PVC pipe cart you are talking about on the Riverside Unit is an old snack cart. It shouldn't even be there, but yes, it should be cleaned by someone. I know maintenance does power wash equipment regularly, but I'm not sure how often. I want to say monthly, but it could be quarterly. During an interview with the Maintenance Director on 01/13/26 at 9:39 AM, he revealed, We don't have a set schedule for cleaning the equipment, such as Hoyer lifts. We try to do it quarterly. We try to do the residents' wheelchairs at the same time. During an interview with DON on 01/13/26 at 4:45 PM, she revealed, My expectation is that all staff, nursing and housekeeping, work together to keep the resident's rooms clean. If they see something, they should pick it up. It's everyone's responsibility. During an observation of room [ROOM NUMBER] on 01/11/26 at 12:25 PM, revealed a strong odor of urine and feces in room. The resident asked that I look in her closet. There were four used briefs noted on the floor of resident's closet. There was also a dirty hospital gown, and an empty ginger ale can on the floor of resident's closet. The Resident also stated that the wheel on her wheelchair was tied on with string. Further observation revealed that the left wheel on resident's wheelchair is held in place with zip ties, string and cloth. During an observation of room [ROOM NUMBER] on 01/11/26 at 2:30 PM revealed the closet in the same condition as earlier in the day. The left wheel on the resident's wheelchair continued to be held in place with zip ties, string and cloth. During an observation of room [ROOM NUMBER] on 01/12/26 at 9:54 AM revealed the closet in the same conditions as the previous day. The left wheel on resident's wheelchair continued to be held in place with zip ties, string and cloth. During an interview on 01/12/26 at 12:04 PM Resident (R)71 revealed the closet had soiled briefs on the floor, as well as a soiled gown and an empty ginger ale can for four days. R71 revealed that the left wheel on her wheelchair had been held in place with zip ties, string and cloth for months. During an interview on 01/13/26 at 9:15 AM, the Lead Housekeeper stated, We don't have housekeepers during night shift, so when the day shift comes in, they are playing catch up from the night before. The barrier thing you are talking about on the Riverside unit is an old snack cart. It shouldn't even be there, but yes, it should be cleaned by someone. I know maintenance does power wash equipment regularly, but I'm not sure how often. I want to say monthly, but it could be quarterly. During an interview with the Maintenance Director (MD) on 01/13/26 at approximately 12:04 PM revealed that he was not aware of any maintenance issues in room [ROOM NUMBER]. The MD revealed that R71 is a difficult resident. The MD confirmed that he was not aware that there was a problem with a loose left wheel on the resident's wheelchair in room [ROOM NUMBER] and he would get it fixed today. During an observation and interview of room [ROOM NUMBER] on 01/11/26 at 2:45 PM, revealed that the cover for the overhead light was off and the cover was noted leaning up against the wall in the resident's room. R57 revealed that a couple of weeks ago the cover on the overhead light came off. R57 revealed that she is glad it was not the light directly above her bed or it would have hit her and possibly injured her. During an observation of room [ROOM NUMBER] on 01/12/26 at 10:30 AM revealed the overhead light cover continued to be leaning against the wall. During an observation of room [ROOM NUMBER] on 01/13/26 at 9:00 AM revealed the overhead light cover continued to be leaning against the wall. During an interview with the MD on 01/13/26 at 8:51 AM revealed that he was not aware of any maintenance issues in room [ROOM NUMBER]. He confirmed that the facility has a QR code system to submit work orders. He further verified that there is no work order in the system right now for that room. The MD revealed that every nurse's station has a QR code posted and every manager has a QR code. They can scan the code and put in a work request. He further revealed that eventually, every resident room will have its own QR code. He confirmed that he was not aware that the cover fell from the overhead light in room [ROOM NUMBER] and he will get it fixed today. He just hired an assistant, and she will have a checklist for things like that. He revealed the assistant will be checking every week. The MD concluded, I am trying to take a proactive approach and not wait for something to break.            During an interview with the Director of Nursing (DON) on 01/13/26 at 5:00 PM revealed, My expectation is that all staff, nursing and housekeeping, work together to keep the resident's rooms clean. If they see something, they should pick it up. It's everyone's responsibility. During an interview with the Administrator on 01/13/26 at 5:00 PM revealed, Anyone with a phone should be able to put in the work orders. It doesn't have to be a nurse. I think the CNAs are mistaken. The QR codes are needed to put the work orders in are at the nursing station, but anyone can use them. I think people misunderstood and thought only the nurses could do it. It sounds like we need to do a PIP to add closets to the things people need to check and ensure cleanliness. During an observation on 01/11/26 during the initial tour, on 01/12/26 at approximately 9:06 AM and 2:00 PM, and on 01/13/26 at approximately 4:30 PM, R95's bathroom (room [ROOM NUMBER]) had an offensive odor with a plastic wash basin filled with dirty towels and water sitting on the shower stall floor. On each of these days unidentified members of the housekeeping staff, certified nursing assistants and nurses were seen entering room [ROOM NUMBER]. During an interview on 01/11/26 at approximately 4:36 PM, Licensed Practical Nurse (LPN)3 confirmed the finding and stated sometimes R95 just throws stuff there and that she would notify housekeeping.

Based on review of facility policy, observation, record review, manufacturer labeling and interview, the facility failed to ensure proper storage of medications in 2 of 3 medications rooms and 1 of 6 medications carts.Findings include: Review of the facility policy titled Medication Labeling and Storage with a revised date of February 2023 documents, if the facility has discontinued, outdated or deteriorated medications, the dispensing pharmacy is contacted for instructions regarding or destroying these items and multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated . Review of the Aplisol Manufacturer (Endo) Labelling documented, Once entered, vial should be discarded after 30-days and the manufacturer package insert documented, Failure to store and handle Aplisol as recommended may result in a loss of potency and inaccurate test results. During an observation on 01/11/26 at approximately 11:31 AM, of the [NAME] (A Wing) Medication Room refrigerator revealed one opened and not dated as to opened date vial of Aplisol (Tuberculin Purified Protein Derivative) 1ml (milliliter) 10 tests. During an interview on 01/11/26 at approximately 11:42 AM, Registered Nurse (RN)1 confirmed this finding. During an observation on 01/11/26 at approximately 1:46 PM, of the Riverside (D Wing) inspection of the medication room revealed one [NAME] RCI Prefilled Humidifier Aqua Pak 340 ml Sterile Water lot 21B392, expired on 8/20/25 During an interview on 01/11/26 at approximately 1:56 PM, Licensed Practical Nurse (LPN)1 confirmed this finding. During an observation on 01/11/26 at approximately 2:31 PM, of the Riverside (D Wing) medication cart 2 revealed one Breztri Aerosphere inhaler by AstraZeneca dated by the facility as opened on 08/10/25. Review of the manufacturer labelling documented, Discard . within 3 months of opening . During an interview on 01/11/26 at approximately 2:38 PM, LPN2 read the manufacturer labeling and confirmed this finding. During an observation on 01/11/26 at approximately 12:10 PM, of the Palmetto-[NAME] (C Wing) medication room revealed one opened bottle of Stool Softener (Dioctyl Sodium) by Equate expired on 01/2025 and one opened bottle of Levocetirizine 5 mg (milligram) Allergy Relief by Equate expired on 04/2024. During an interview on 01/11/26 these findings were confirmed by an unidentified RN. During an interview on 01/11/26 at approximately 3:00 PM, the Director of Nursing stated that expired medications should be removed from active storage.

Based on review of facility policy, record review and interview, the facility failed to provide quarterly account statements for Resident (R)7's personal fund for 1 out of 1 resident reviewed for Personal Funds. Findings include:Review of the facility policy titled Accounting and Records of Personal Funds with a revision date of April 2021 revealed, Policy Statement: Our facility maintains accounting records of resident funds on deposit with the facility. Policy Interpretation and Implementation: . 5. Individual accounting records are made available to the resident through quarterly statements and upon request.Review of R7's Face Sheet revealed R7 was admitted to the facility on [DATE], with diagnoses including but not limited to type 2 diabetes, dementia, major depressive disorder, epilepsy, and high blood pressure. Review of R7's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/25 revealed R7 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating she had severe cognitive impairment. During an interview with R7's Responsible Party (RP) on 01/12/26 at 10:20 AM, the RP revealed, She gets $30 a month. You know, now that you mention it, I haven't gotten a statement since the new management took over. I used to get one for her account every quarter.During an interview with the Business Manager (BM) on 01/13/26 at 9:41 AM, the BM revealed, I haven't sent a statement out to her RP because we don't put any money into her account. When I send the quarterly statements out, I make a note at the bottom of the list indicating the statements were sent out. It's a general statement. No, I don't make notations on individual accounts or save records (such as copies of envelopes) to show they were sent out.During an interview with the Administrator on 01/13/26 at 2:26 PM, the Administrator revealed, Everybody's account is different. I think it would depend on if we are keeping their funds. I believe it just went up at the start of this year to $60 a month; the resident can keep each month. The statements, I'm pretty sure, go out quarterly. I would have to ask my Business Manager to be absolutely sure.

Based on review of facility policy, observation, record review, drug manufacturer recommendation and interview, the facility failed to notify a medical doctor or nurse practitioner of a clinical concern related to Resident (R)23. Furthermore, the facility failed to maintain stock of an ordered medication for R6. Findings include: Review of the facility policy titled Acute Condition Changes - Clinical Protocol with a revised date of January 2025 documented, The nursing staff will contact the physician based on the urgency of the situation. Review of the facility policy titled Medication Labeling and Storage with a revised date of February 2025 documented, The nursing staff is responsible for maintaining medication storage . in a . safe manner . and if the facility has . the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Review of R23's Face Sheet revealed R23 was admitted to the facility on [DATE] with diagnoses including but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. On 01/11/26 at approximately 10:40 AM, during an initial tour interview, R23 expressed a concern about her body by pointing to the area. On 01/13/26 at approximately 11:05 AM, a review of R23's medical record, revealed a progress note, dated 01/09/26 which stated, Res (resident) noted to have a yellowish vaginal discharge. No c/o (complaint of) itching/burning. On 01/13/26 at approximately 1:32 PM, Licensed Practical Nurse (LPN)3 was interviewed about the vaginal discharge progress note dated 01/09/26, for R23. After reviewing the progress note LPN3 stated this should have been reported to the physician or nurse practitioner via the QR (quick response) code On Site. On 01/13/26 at approximately 1:50 PM, Nurse Practitioner (NP)1 reviewed R23's progress note, dated, 01/09/2026, and stated the concern should have been reported to him via On Site and that it had not been reported. On 01/13/26 at approximately 3:20 PM, during an interview, the Director of Nursing (DON) stated nurses were expected to notify the physician/NP of any concern about a resident. Review of R6's Face Sheet revealed R6 was admitted to the facility on [DATE] with diagnoses including but not limited to cardiac heart failure and dementia. On 01/11/26 at approximately 2:31 PM, an inspection of the Riverside (D Wing) Medication Cart #2 revealed, 1 empty dispensing vial belonging to R6 and labelled to contain Nitroglycerin 1 sublingual every 5 minutes x 2 as needed for chest pain with no bottle of nitroglycerin in the vial or medication cart. On 01/11/26 at approximately 2:38 PM, this finding was verified by LPN2, who searched the medication cart and was unable to locate a vial of nitroglycerin belonging to R6. On 01/13/26 at approximately 3:00 PM, during an interview, the DON stated that medications are to be ordered, according to the pharmacy contract, in time to prevent residents from running out of a prescribed medication.

Based on review of facility policy, observation, interview, and record review, the facility failed to ensure proper usage or the hoyer lift, for 1 of 1 Resident R(49), reviewed for accident hazards/supervision/devices.Findings include:Review of the facility policy titled Lifting Machine, Using a Mechanical documents, Purpose: The purpose of this procedure is to establish the general principles for using a mechanical lifting device. It is not a substitute for manufacturer's training and instructions. General Guidelines: 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift . 4. Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility . Steps of Procedure: . 2. Measure the resident for proper sling size and purpose, according to manufacturer's instructions. 3. Select a sling bar that is appropriate for the resident's size and the task. 4. Prepare the environment: a. Clear an unobstructed path for the lift machine; b. Ensure there is enough room to pivot; c. Position the lift near the receiving surface; and d. Place the lift at the correct height . 8. Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition. 9. Double check the sling and machine's weight limits against the resident's weight. 10. Place the sling under the resident. Visually check the size to ensure it is not too large or too small . 12. Attach sling straps to the sling bar, according to manufacturer's instructions. a. Make sure the sling is securely attached to clips and that it is properly balanced. b. Check to make sure the resident's head, neck and back are supported. c. Before resident is lifted, double check the security of the sling attachment. d. Examine all hooks, clips or fasteners. e. Check the stability of the straps. f. Ensure that the sling bar is securely attached and sound. 13. Lift the resident 2 inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution . 15. Slowly lift the resident. Only lift as high as necessary to complete the transfer.Review of the Medline Manufacturer Instructions for Full Body Slings revealed, Do not exceed the maximum weight capacity of sling or patient lift. Always confirm the weight capacity of the sling against the patient's weight and ensure proper placement before performing a lift. Always confirm the compatibility between the connection style of the patient sling and the patient lift before use. Medline loop - style 6-point cradles are compatible with these slings. If other lift cradles are being used, the user should confirm compatibility between the hoist and the sling. Reach out to your Medline Representative with questions.Review of R49's Face Sheet revealed the facility admitted R49 on 05/10/24 with diagnoses including, but not limited to, Type 2 Diabetes Mellitus, pain, muscle spasm, hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side, and systemic lupus erythematosus.Review of R49's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/25, revealed R49 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates that R49 is cognitively intact.Review of R49's admission MDS with an ARD of 11/05/25, also revealed R49 is dependent with all transfers.Review of R49's Fall Care Plan initiated on 05/17/24, documented approaches that included, Ensure proper lift pad is used when transferring resident.Review of a facility incident report dated 01/09/26, revealed, resident fell during hoyer lift transfer. No injuries were observed at the time of incident. Intervention: Ensure proper size lift pad is used when transferring resident.Review of Resident Lifting or Assisting in Transfer Training revealed that the nursing assistants involved in the incident received mechanical lift training on 10/10/22 and 02/10/23. There is no further documented lift/transfer training noted for the two nursing assistants involved in the incident. During an interview on 01/11/26 at 12:37 PM, R49 revealed, I fell from the lift on Friday. They lifted me way up and I fell out on my left side. I went to the hospital on Friday. Nothing was broken but now I am scared to get out of bed. I do not want to fall again. The lift is the only way I get up.During a phone interview on 01/12/26 at 4:07 PM, Certified Nursing Assistant (CNA)2 revealed she was actually down the hall when CNA4 asked her to spot her while using the lift. CNA2 stated, I went in the room as she was getting the resident out of the bed with the lift. The lift gave way as we were transferring the resident to the chair, as the other CNA pulled the lift from out from under the bed, the resident's weight shifted and she fell. The type of lift pad we use depends on the resident. Usually, we use the lift pad that crosses over in the front with this resident but that one was not available. It happened so fast. We were just trying to catch her. I do not remember what lift pad was used but she slid completely out of that lift pad.On 01/12/26 at 4:07 PM attempted to contact Certified Nursing Assistant CNA4 for a phone interview. Phone message revealed, the wireless caller is unavailable. Message left. Awaiting return call.During a phone interview on 01/12/26 at 4:20 PM, Registered Nurse (RN)2 revealed CNA4 informed her that she and CNA2 were transferring R49 from the bed to the gerichair. The sling was not the pad that crossed over to prevent the resident from falling. The pad they used was straight with no criss crosses for the legs. We did not have the one that criss crossed at the time. R49 was adamant to get up and go outside to meet a friend that was coming to visit. The CNA's got R49 up with the wrong lift pad. The sling gave way and R49 fell. CNA4 has been here long enough that she should know what sling to use with R49.During an interview on 01/12/26 at 4:50 PM, the Director of Nursing (DON) revealed that the lift pad that the CNAs used on R49 is a new type of lift pad that does not cross over in the front. She stated this is new technology.During an interview on 01/12/26 at 1:45 PM, Licensed Practical Nurse (LPN)6 revealed that she does not know how the certified nursing assistants know what size lift pad to use with residents that require a lift for transfers. LPN6 verified that the size of the lift pad is not located on the care plan, physician orders or nursing assistant assignment sheets.During an interview on 01/13/26 at 1:35 PM, the Director of Therapy revealed R49 was evaluated today after a fall from the lift. Occupational Therapy will begin working with R49 regarding transfers. He revealed, the lift pads are chosen based on the resident's weight. There are two sizes of lift pads, a smaller lift pad and a larger lift pad. He further revealed that bigger never hurts anything. The sling we have in the therapy department crosses over the resident in the front. I do not know why. He further revealed, the nursing assistants know the type and size of sling that should be used on a resident through nursing communication.During a follow up interview on 01/13/26 at 4:45 PM, the Director of Nursing revealed, We have the morning meetings every morning with all of administration present. We discuss anything that has come up in the past 24 hours. We discuss everything under the sun at those meetings. We use the sling that comes with the Hoyer lift, for example that holds 400 pounds. I'll be honest. This is the first time I've learned about measuring the girth of the resident to determine the size of the sling needed. I never heard of that before.

Based on facility policy review, observation, record review and interview, the facility failed to provide respiratory care in accordance with professional standards. Specifically, the facility failed to ensure Resident (R)122's nebulizer machine, oxygen mask and medication chamber were clean and stored properly when not in use for 1 of 1 resident. Findings include:Review of the facility policy titled Oxygen Administration with a revised date of October 2010 documented, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure, if no order in place initiate nursing measure of oxygen administration when applicable. 2. Review the resident's care plan to assess for any special needs of the resident. Steps in the Procedure: . 7. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.On 01/13/26 at 9:00AM, a request was made to review the facility policy on maintenance and storage of equipment associated with respiratory therapy tasks particularly nebulizer machines. On 01/13/26 at 12:00 PM, the Regional Nurse Consultant stated there was no policy for the cleaning and storage of a nebulizer machine. She further stated, it should be included in the oxygen policy. Review of the Oxygen Administration policy did not reveal documentation regarding maintenance and storage of respiratory equipment.Review of R122's Face Sheet revealed R122 was admitted to the facility on [DATE] with diagnoses including but not limited to Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder and Dementia.Review of R122's Physician Orders with a start date 01/08/26 revealed an order for Albuterol Sulfate Solution 108 (90 base) MCG/ACT 2 puffs inhaled orally every 4 hours as needed for COPD, rinse mouth without swallowing after use and Oxygen at 2 liters per Minute (LPM) via nasal cannula continuous per concentrator/tank every shift. During an observation and interview on 01/11/26 at 12:45 PM, revealed R122's Oxygen (O2) concentrator was set to 3.5 LPM and oxygen tubing is not dated. The nebulizer was in the seat of a chair beside resident's bed, next to the resident's tennis shoes. The oxygen mask was propped up against the nebulizer machine. The mask was attached to the medication chamber and the tubing. The nebulizer tubing was not dated. The mask was not bagged. There was a clear liquid noted in medication chamber. The medication chamber was attached to the mask and the oxygen tubing. The medication chamber was not bagged. R122 stated she is on oxygen due to Chronic Obstructive Pulmonary Disease, but she is not certain how many liters of oxygen she receives. During an observation on 01/12/26 at 10:00 AM, revealed R122 resting in bed with eyes closed. O2 concentrator was set to 3.0 LPM and the oxygen tubing was not dated. R122's nebulizer was in a chair beside the resident's bed, next to the resident's tennis shoes. The nebulizer tubing was not dated. There was a clear liquid noted in medication chamber. The oxygen mask was propped up against the nebulizer machine. The mask was attached to the medication chamber and the tubing and the mask was not bagged. During an interview on 01/12/26 at 4:15 PM, Licensed Practical Nurse (LPN)6 revealed that she had not bagged R122's nebulizer mask or washed out the medication chamber. LPN6 stated, I did not even know she had a nebulizer. I did not see it when I gave her medication earlier. LPN6 also verified that the resident's oxygen was on 3.0 LPM and the doctor's order was for 2 LPM. LPN6 proceeded to adjust the oxygen to the correct rate. During an interview with the Director of Nursing (DON) on 01/13/26 at approximately 5:15 PM revealed, Nebulizers are kept in the rooms usually at the bedside. The tubing is changed weekly. The machine is covered when it's not being used. The mask is also changed weekly or as needed. The mask should also be covered when not in use. The DON also revealed that her expectation would be for the nurse to check the oxygen order for the rate and adjust it to the correct rate. They would need to look at the rate at eye level. If the resident is the one who is known to change the rate of their oxygen, we would care plan for it and re-educate the resident. My expectation is that the oxygen rate be checked every shift.

Based on observation, interview, and facility policy review, the facility failed to provide a safe and sanitary environment to help decrease the risk of infections. Specifically, the facility failed to offer residents hand hygiene prior to dining in the 400 Riverside Unit. Furthermore, the facility failed to prevent potential cross-contamination by housekeeping staff. Review of the facility policy titled Handwashing/Hand Hygiene with a revision date of October 2023, revealed, The Oaks Post Acute Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation: Administrative Practices to Promote Hand Hygiene: . 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies . 6. Residents, family members, and/or visitors are encouraged to practice hand hygiene.During an observation on 01/11/26 at 12:55 PM, the staff began bringing residents to the dining room on the 400 Riverside Unit. The staff did not offer residents any hand sanitizer prior to serving their meals. One resident was noted to eat his hamburger patty with his hands. During an interview with Certified Nursing Assistant (CNA)1 on 01/11/26 at 1:37 PM, CNA1 revealed, I know we are supposed to sanitize the residents' hands before they eat. I'm not going to lie to you. I haven't seen the sanitizer on the container with the meal trays lately. They used to put one on there, but lately, they haven't.During an interview with the Administrator on 01/13/26 at approximately 2:26 PM, he revealed, I don't think we have a policy on hand hygiene for residents. We can certainly make sure there is hand sanitizer on all the dining carts to make sure the supplies are available.During an observation on 01/11/26 at 12:20 PM, the Housekeeper left the 400 Riverside Unit with blue disposable gloves still on. She went into a utility room in the main hallway outside the unit's locked doors. She re-entered the hallway with a mobile mop/cleaning unit still wearing blue gloves. During an interview with the Housekeeper on 01/11/26 at 12:20 PM, she revealed, No, they didn't train me on infection control measures.During an interview with the Lead Housekeeper on 01/13/26 at 9:15 AM, she revealed, No, staff should not be wearing gloves when they leave the unit. They are told to remove them before leaving. When a new employee starts, I teach them about infection control standards, such as removing gloves when leaving the unit, changing the mop liquid, etc. No, there is no online or written training. I have a housekeeper who has been here for about four years. The new employee works with her at least two full weeks before being on their own.

Based on observation, record review, and interview, the facility failed to ensure that Resident (R)3 was free from misappropriation by Certified Nursing Assistant (CNA)1, for 1 of 3 residents reviewed for misappropriation or property. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating last revised on September 2022, revealed All reports of resident abuse (including injuries of unknown origin, neglect, exploitation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law. The Administrator or individual making the allegation immediately reports his or her suspicion to the following persons or agencies; the state licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsman, the resident's representative, law enforcement officials, the resident's attending Physician and the facility Medical Director. Review of the undated facility policy titled Resident Rights revealed, Employees shall treat all residents with kindness, respect, and dignity. Federal and state law guarantee certain basic rights to all residents of this facility, these rights include a dignified existence, be treated with respect, kindness, and dignity. To be free from abuse, neglect, misappropriation of resident property, and exploitation. Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE], with diagnoses including but not limited to: Type 2 Diabetes without complications, hypertension, protein calorie malnutrition, and muscle spasm. Review of R3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/29/25, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that R3 was cognitively intact. Review of a Grievance dated 06/02/25, revealed, [R3] had theft from her bank account after allowing [CNA1] to borrow her phone. Social Worker met with [R3] to interview, law enforcement notified. Review of an Incident/Investigation Report dated 06/02/25 at 11:31 AM, revealed, Crime Incident - Wire Fraud; value $21.05; On 06/02/25 this unit responded to the incident located in reference to wire fraud. The Administrator informed this unit that a Resident [R3] had made a complaint in reference to larceny of money by an employee [CNA1]. [R3] stated that [CNA1] borrowed her cellphone for approximately 30 minutes to find her personal cellphone. [R3] stated that [CNA1] returned her phone and told the resident that she located her cellphone in the grass, however [R3] stated she received notifications from Cash App informing her that someone accessed her account and attempted to transfer two separate transactions totaling $700 to [CNA1] account but they were decline by [R3's] bank. A single transaction for $10.00 did go through but the funds were returned to fraudulent activity. She also stated her Shien Account was accessed, and a $21.05 order was placed. Additionally, another order was placed for $96.26 but was declined. This unit provided [CNA1] with her [NAME] rights prior to interviewing her, [CNA1] stated that on 05/29/25 she borrowed R3's cellphone for approximately five minutes and utilized it to locate her cellphone. [CNA1] advised [R3] she located her cellphone in her vehicle and returned [R3's] cellphone to her. When questioned in reference to the three Cash App transactions made from [R3's] account to hers she denied the $600 and $100 attempt but stated that she must have used the wrong phone to send her son $10.00, [CNA1] denied knowledge of the two transactions made towards the Shien account. Ultimately [R3] declined prosecution, Administrator informed this unit the facility was required to report the incident to the state agency. She also stated that [CNA1] would be placed on suspension while the facility completed an investigation. During an interview on 06/23/25 at 10:05 AM, R3 revealed that on 05/29/25 they received a text message from their bank related to a $600 authorization from Cash App to send to CNA1. R3 further stated that she replied to the text message no and then called her bank and was informed by a Fraud Investigator about other potentially fraudulent activities which included requests through Cash App for $100 which was also denied by the residents financial institution. The fraud investigator informed R3 that two successful transactions were completed by CNA3, the first was $10 which were later credited back to the residents account and a $21.05 through an online shopping website ([NAME]). R3 stated that she would often let CNA1 and other staff members charge their phones because they often have the same type of phone (iPhone). R3 was able to recall CNA1 borrowed her phone because CNA1 told the resident that she had misplaced her personal phone and needed to call it so she can locate it. R3 stated that CNA1 borrowed her phone for about 30 minutes and then returned it to her, R3 then later received the fraudulent text messages from her bank. R3 stated that they spoke with law enforcement about the incident but declined to press charges on CNA1, she always so kind to me and I didn't want her to get into trouble with the law. R3 stated she was disappointed. During review on 06/23/25 at 10:05 AM, of R3's cellphone, revealed text messages from her financial institution alerting her of potential fraud on 05/29/25 at 3:58 PM. R3 also showed her bank statement from May 2025, which revealed CNA1's name making an attempt to send $10.00 to herself and a $21.05 order for [NAME] Clothing which the resident denies attempting herself. During a phone interview on 06/23/25 at 11:21 AM, R3's Resident Representative (RR) revealed that he was disappointed and frustrated that a staff member would take money from his mother. R3's RR further stated that he didn't know much about the incident and could not recall if the facility notified him about the incident. During a phone interview with CNA1 on 06/23/25 at 3:19 PM, revealed that they denied misappropriating any funds from R3 or any other residents. CNA1 stated, One time by accident [R3] sent her $10.00 through Cash App but they denied the transaction and sent the resident back the money. CNA1 further stated they were unsure of how R3 knew their personal Cash App identification. R3 stated that they are currently suspended from the facility due to the allegation of misappropriation of resident property and has been suspended for approximately 2 weeks and are unsure when they will be able to return to the facility. During an interview on 06/23/25 at 3:53 PM, the Social Services Director (SSD) revealed they were informed by the Activities Director (AD) that R3 wanted to speak with her because she had received notification from her finical institution that detected fraudulent activity with her account, after allowing a staff member (CNA1) to borrow her phone. The SSD and the AD went to go speak with R3 regarding her concern. The SSD stated that R3 said that she allowed CNA1 to use her phone because CNA1 told the resident that she misplaced her phone and she needed to call to it to locate it. R3 told staff that CNA1 took her phone outside of her room to call her own phone. The SSD further stated that during interview with the resident she was able to show text messages from her bank notifying R3 of the potentially fraudulent activity through Cash App and [NAME] (online clothing store). While interviewing R3 she stated that she did not approve these transactions and was notified as well. During an interview on 06/24/25 at 11:17 AM, the Director of Nursing (DON) and the Administrator revealed that they were notified of this incident by the SSD and Activities Director. CNA1 was at work when the resident reported the misappropriation, and she was immediately pulled from the unit and interviewed by facility staff and law enforcement. CNA1 denied misappropriating from the resident however, due to law enforcement having R3's text messages and bank statement they wanted to arrest her for theft. R3 did not want to press charges against CNA1 therefore law enforcement could not arrest CNA1. CNA1 was placed on suspension on 06/02/25 and was later terminated from the facility on 06/06/25 after the investigation was completed and the substantiation of the allegation of misappropriation of property.

Based on review of facility policy, record review and interview, the facility failed to accurately document Fall Risk Assessments, for 1 of 3 residents, Resident (R)1, reviewed for accidents/falls. This failure placed R1 at an increased risk for falls and injuries. Findings include: Review of the facility policy titled, Falls - Clinical Protocol last revised on 03/18, documents, 2. the nurse shall assess and document/report the following . i. All current medications and j. All active diagnoses . 3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record . a. Examples of risk factors for falling include . multiple medications and medical conditions affecting the central nervous system. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's Disease, Dementia, essential (primary) hypertension and major depressive disorder. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/31/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R1 had moderate cognitive impairment. Further review revealed R1 used a wheelchair for mobility and required substantial/maximal assistance with nearly all transfer activities and could walk 10 feet dependently. Review of R1's Quarterly MDS with an ARD of 10/30/24, revealed R1 had a BIMS score of 13 out of 15, indicating R1 was cognitively intact. Further review revealed R1 required substantial/maximal assistance with transfers and ambulation was not attempted. R1 was documented as having one fall with no injury and one fall with injury except major. R1 was noted as not taking any high risk medications. Review of R1's Physician Orders revealed the following: Aspirin (an antiplatelet- used to prevent blood clots) 81 Milligrams (mg) 1 tablet by mouth one time a day. Gabapentin (anticonvulsants- used to decrease pain and seizures) 300 mg 1 capsule by mouth three times a day. Melatonin 3 mg 1 tablet by mouth at bedtime. Amlodipine (an antihypertensive- used to treat high blood pressure) 5 mg 1 tablet by mouth daily. Review of R1's Nursing - Fall Risk Observation/assessment dated [DATE], revealed a score of 18 indicating R1 was a high risk for falls. Further review indicated R1 had three or more Health Conditions/Risk Factors present and was currently taking or has taken 1-2 medications (anesthetic, antianxiety, anticonvulsant, antidepressant, antihistamine, antihypertensive, muscle relaxant or narcotic analgesic) listed in the past seven days. Review of R1's Nursing - Fall Risk Observation/assessment dated [DATE], revealed a score of 14 indicating R1 was a moderate risk for falls. Further review indicated R1 had 1-2 falls in the last 90 days and there were no Health Conditions/Risk Factors present, and no listed medications taken. Review of R1's Nursing - Fall Risk Observation/assessment dated [DATE], revealed a score of 14 indicating R1 was a moderate risk for falls. Further review indicated R1 had no falls in the last 90 days and there were no Health Conditions/Risk Factors present, and no listed medications taken. Review of R1's Nursing - Fall Risk Observation/assessment dated [DATE], revealed a score of 16 indicating R1 was a high risk for falls. Further review indicated R1 had no falls in the last 90 days and no listed medications were noted as taken. Review of R1's undated Care Plan indicated, R1 was at risk for falls with a goal to minimize risk for falls to extent possible and not experience a fall related to risk factors. R1 was care planned for anticoagulant/antiplatelet medications. R1 was not available for interview. During an interview on 03/10/25 at 2:02 PM, the Director of Nursing (DON) stated floor nurses are responsible for completing fall risk assessments after any fall, readmission, or as needed. The DON stated she was unsure why R1's risk factors and medications were not included in the Fall Risk Assessments.

Based on review of facility policy, observation and interview, the facility failed to ensure biologicals and supplements were stored appropriately. Findings included: Review of the facility policy titled Storage of Medications last revised on November 2020, documented, The facility stores all drugs and biologicals in a safe, secure, and orderly manner . 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. During a facility tour of the Riverside Hall on 03/10/25 at 12:38 PM and 1:00 PM, the following was observed to be stored on the floor: Four packages of Maximum Strength Anti-Itch Cream 1% Hydrocortisone Cream. Eleven boxes of Welmate Maximum Strength 4% Lidocaine Numbing Patches. Three eight ounce bottles of Povidone Iodine Solutions. One three pack of Gauze Rolls. One open box of wild berry flavor BOOST Breeze nutritional drinks. Two open boxes of BOOST Glucose Control nutritional drinks. One open box of strawberry flavored Ensure Original Shakes. One open box of milk chocolate flavored Ensure Plus nutritional shakes. One open box of vanilla flavored Nepro Therapeutic nutritional shakes. One open box of mixed berry flavored Nepro Therapeutic nutritional shakes. During an interview on 03/10/25 at 2:02 PM, the Director of Nursing (DON) stated, the Central Supply Manager is responsible the storage of supplies and they do have a designated storage area for supplies, that is not on the floor. During an interview on 03/10/25 at 2:22 PM, the Central Supply Manager (CSM) stated, the facility stores supplies in her office or in a warehouse, the CSM also states that she is the only person who puts away supplies when they are delivered and the truck recently came in on Friday, however she doesn't work on weekends. The CSM confirmed the supplies were placed on the floor and knows that they are not supposed to be stored on the floor.

Based on interview, record review, and facility policy the facility failed to ensure that Resident (R)163, a resident with an Advanced Directive as Full Code received Cardiopulmonary Resuscitation (CPR) after being found unresponsive on [DATE]. 1 of 1 reviewed for CPR. On [DATE] at 7:15 PM the Administrator and Director of Nursing (DON) were notified that the failure to initiate CPR on R163 on [DATE] after being found unresponsive constituted an Immediate Jeopardy (IJ). The IJ was determined to first exist on [DATE] at approximately 4:10 PM (time of death according to County Coroner's Office/ Electronic Medical Record). The facility presented a removal plan on [DATE] at 5:52 PM, the deficient practice remained at F678 at a lower scope and severity of D, the facilities failure constituted substandard quality of care at F678. The facilities removal plan for F678 included Audit completed by the Social Services Director (SSD) on all residents to ensure that all advanced directive paperwork is present and correct Physician's Order is in the Electronic Medical Record (EMR) and Care Plan is correct. Education initiated immediately on [DATE] for all licensed by the DON and designees to include what to if you find someone unresponsive and initiated CPR immediately. All newly hired nurses, agency nurses, or facility staff not reached by phone will receive the education prior to their next scheduled shift at the facility. Mock Code Blue drills be conducted monthly by the DON/ designee and alternate shifts to ensure all shifts receive training. Audit/review of all deaths in the facility will be reviewed on the following business day by the Nursing Administration team to ensure that CPR initiated when needed for full code status and documentation complete. SSD will do random audit of five residents per week to ensure that code status paperwork is correct and order matches and correlating Care Plan in place as well. Audits will be weekly for four weeks then monthly for two months then random thereafter. Results will be reported to the Quality Assurance committee to determine need for further monitoring. Findings include: Record review of facility policy titled, Emergency Procedure - Cardiopulmonary Resuscitation revealed Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: A. Instruct a staff member to activate emergency response system (code) and call 911. C. Verify or instruct a staff member to verify the DNR or code status of the individual. D. Initiate the basic life support (BLS) sequence of events. Record review of a facility policy titled, Advanced Directive, with a last revised [DATE], revealed The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Additionally, the policy also reveals: Refusing or Requesting Treatment 1. The resident has the right to refuse medical or surgical treatment, whether or not he or she has an advance directive. a. A resident will not be treated against his or her own wishes. b. Residents who refuse treatment will not be transferred to another facility unless all other criteria for transfer are met. c. The residents refusal does not absolve facility staff from providing other care that allows him/her to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. R163 was admitted to the facility on [DATE] with diagnoses including but not limited to encounter for orthopedic aftercare, dementia with psychotic disturbance, muscle weakness, hypertension, major depressive disorder, and anemia. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed, R163 had the Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicates that R163 has severe cognitive impairment. Record review on [DATE] at 11:30 AM, of R163's Discontinued Physician Orders revealed R163 had an order for Full Code that was discontinued on [DATE]. Record review on [DATE] at 11:35 AM, of an Electronic Medication Administration Record (EMAR) Note dated [DATE] at 8:56 PM, revealed Resident was nonresponsive to verbal or touch, no pulse or blood pressure was not detected the Nurse Practitioner was in the room to check the resident and stated she had passed. Resident Representative notified. Record review of a Nurses Note dated [DATE] at 5:03 PM revealed Received a call back from Coroner's office, resident's information given to county coroner. The time of the resident's death was 4:10 pm. Family at the facility and aware. The funeral home of choice is [NAME] Funeral Home. Record review on [DATE] 11:37 AM, of R163 Care Plan last revised [DATE] revealed that R163 was not care-planned for Advanced Directives. Record review on [DATE] 11:44 AM, of R163 Advanced Directive dated [DATE], revealed I, the resident or authorized party understand the nature of illness involved, prognosis, and the treatment available, as explained in full and I understand the consequences of either providing or withholding this measure. I also understand this request may be revised upon consultation with said parties. I fully understand the consequences of refusing cardiopulmonary resuscitation. I do want Cardiopulmonary Resuscitation. Record review on [DATE] at 5:21PM, of R163 vital signs. No documented vital signs seen on resident electronic health records during the time of resident death. Record review on [DATE] at 5:59 PM of R163 EMR revealed no documentation of the resident's decisional making capacity. Record review on [DATE] at 6:54 PM of a Physican Progress Note dated [DATE] revealed R163 seen today at the facility for weakness, per nursing staff, resident has not eaten or drank much since this morning. Minimally interactive, she had an orthopedic appointment today at 9:30 AM, since being back, she has still declined food and drink. Per nursing staff there has been an overall decline since arriving at the facility. Assessment included will discuss transition to palliative care with family members, (unable to reach at the time of this writing). An attempted telephone interview on [DATE] at 11:54 AM, to R163's Resident Representative was unsuccessful, a voicemail message was left with contact/call back information. An attempted telephone interview on [DATE] at 11:57 AM, to Licensed Practical Nurse (LPN)1 was unsuccessful, a voicemail message was left with contact/call back information. A second attempted telephone interview on [DATE] at 1:26 PM with LPN1 was unsuccessful. A third attempted telephone interview on [DATE] at 2:43 PM with LPN1 was unsuccessful. A fourth attempted telephone interview on [DATE] at 3:14 PM with LPN1 was unsuccessful. An interview on [DATE] at 3:20 PM, with LPN2 revealed the expectation for nursing staff when a resident has an advanced directive of full code is to immediately begin CPR and notify the Unit Manager and Physician and call 911. After CPR initiated and the resident is stable/EMS has arrived nursing staff are expected to notify the Resident Representative of the incident and other appropriate parties. Nursing staff are to document every step that was taken from when the resident was found unresponsive, when CPR was initiated and for how long/who was involved or notified/ and if the resident passes during the notification to the coroner's office and resident representative. During interview with LPN2 they stated that they were also unable to find documentation in R163 Electronic Medical Record (EMR) if CPR was initiated when the resident was found unresponsive. An interview with the Nurse Practitioner (NP) on [DATE] at 4:07 PM, revealed that their expectation when a resident is full code and is found non responsive for staff is to immediately initiate CPR and at minimum of two cycles and to notify the Physician and contact EMS. Further interview revealed that the Nurse Practitioner was on site on [DATE] but was not on his case load. The NP reveals that the staff nurse only informed him that the resident had passed away because he was inside the facility during the time of the resident's transition. NP further stated that he was notified by nursing staff (unsure of whom) that the resident was a Do Not Resuscitate and that he did not witness nursing staff complete CPR on the resident. NP finally stated when he went to see, the resident appeared to be deceased for about 30 minutes or longer. An interview with the Director of Nursing (DON) on [DATE] at 4:42 pm, revealed that their expectation when a resident is full code and unresponsive is to call the code, someone would grab the crash-cart, and all CPR Certified staff will participate in the process. The DON further revealed she was told that the patient was a DNR. An interview with the Administrator on [DATE] at 4:42 pm, revealed the resident returned from an appointment in transition. A call was made to the family, and the decision was made to Do Not Resuscitated. A telephone attempt was made on [DATE] at 05:23 PM to reach the Resident Representative, no answer at this time. A follow up interview with the NP on [DATE] at 5:56 pm, revealed that the signature on the Physician's telephone order dated [DATE] for DNR for R163 is his signature. It was further revealed that two nurses took the verbal order form the family member to change the resident from full code to DNR on the day of the resident's death. NP stated, when I entered the room of the resident the nurse advised the resident was DNR. I was not notified of the code changing form Full Code to DNR, on that day, until I returned to my office after the resident was pronounced died and I was told the order needed to be signed. An interview on [DATE] at 06:12 PM with the Medical Doctor revealed My staff, RN, LPNs and, myself will discuss code status. It will be me who will write an order after the ok with the family. This lady's family did not want her to be an DNR. She was never a DNR. She was never switch over to a DNR. My expectation is for anyone who is a full code it is my expectation for staff to start CPR. R136 was found cold and obviously dead for quite a while. I was not aware of the DNR order. This family stated they wanted everything done for their mother even though she was declining. She has had conversations with staff about her being a full code. Because of the nature of our relationship with the OAKs they can order labs and etc. All of their orders come through me. At some times orders do get written by Oaks Practitioners and Physicians.

Based on review of the facility policy, observations and interviews, the facility failed to ensure biologicals were stored appropriately in 3 of 3 Medication Treatment Carts. Findings include: Review of the facility policy, copyright 2001 Med-Pass, Inc, titled, Medication Labeling and Storage documents, the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Medication Storage 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. During an observation on [DATE] at 12:23 PM, of the [NAME] Treatment Cart revealed the following: -Gentell rolled gauze bandage (4.5 x 4.1 YDS (11cm x 3.7m) Lot # 240217 exp 2027 02 16 Sterile and opened. -Silvercel Non-adherent antimicrobial Alginate Dressing with Easy Lift ,d+[DATE] ,d+[DATE] in x 4 ,d+[DATE] in (11cm x 11cm) Manufacturer Sustagenix Lot # 55760V001 Expired 2024 09 30 Manufacturer Sustagenix X6 was expired. During an interview on [DATE] at 12:51 PM, Licensed Practical Nurse (LPN)5 stated, The wound nurse and unit managers check the expiration dates. The wound nurse changes the dressings except on the weekends and nights. All the nurses are responsible for changing dressings. LPN5 discarded the items. During an observation on [DATE] at 1:07 PM, of the Riverside Treatment Cart revealed the following: -Medline Extra Absorbent Abd Pad single use Sterile Ref # PRM 21453 Lot # 6052406001 Sterile and opened. -Xeroform Gauze Dressing 5 in x 9in (13cm x 23 m) Manufactured for HealQu LLC exp 2026 08 24 Sterile and opened. -Wound Closure Strip ,d+[DATE] x 3 Manufacturer [NAME] Skin Closure Strips non reinforced sterile MRF # 3000 AirLife Ref Al4109k Lot T22N32 exp 2024 12 01 Sterile and opened. During an interview on [DATE] at 1:25 PM, LPN2 stated, We usually check the treatment carts. LPN2 discarded the open items into the trash. During an observation on [DATE] at 1:59 PM, of the Palmetto [NAME] Treatment Cart revealed, Nystatin Cream USP (1000, 000 USP) Nystatin units Manufacturer Padagis R 34321766 exp ,d+[DATE] and was opened. During an interview on [DATE] at 2:08 PM, LPN6 stated the wound nurse checks the treatment cart. During an interview on [DATE] at 3:25 PM, the Director of Nursing (DON) stated, Both wound nurse and floor nurse should check the treatment cart for expirations.

Based on observations and interviews the facility failed to ensure that the ice machine in 1 of 1 kitchen was kept clean and sanitized. Findings include: A facility policy regarding the ice machine was requested on 11/05/24 at 3:22 PM. At 5:15 PM, the Administer advised that a policy was not available. During the initial tour of the Kitchen on 11/03/24 at 9:55 AM, the ice machine was observed, in the presence of the Kitchen Manager (KM), to have a black moldlike substance around the ice dispenser. During an interview on 11/03/24 at 9:55 AM, the KM verified the the black moldlike substance in the ice machine and stated that it is her expectation that the ice machine is cleaned daily, at the end of the day. Attempted review of the kitchens cleaning logs, revealed there were no cleaning logs of the ice machine available. During an interview on 11/05/24 at 3:22 PM, the Administrator stated that it is expected that all equipment is maintained in a clean and sanitized manner.

Based on interview, record review, and review of facility policy, the facility failed to develop a Care Plan for Resident (R)163, related to Advance Directives, for 1 of 2 residents reviewed. Findings include: Review of the facility policy titled Care Plan, Comprehensive Person Centered last revised on March 2022, documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 1. The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 7. The comprehensice, person-centered care plan: a. includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident excersing his or her rights, including the righ to refuse treatment; Review of R163's Face Sheet revealed R163 was admitted to the facility on [DATE], with diagnoses including but not limited to: encounter for orthopedic aftercare, dementia with psychotic disturbance, muscle weakness, hypertension, major depressive disorder, and anemia. Review of R163's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/24, revealed R163 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated that R163 had severe cognitive impairment. Review of R163's Care Plan, last revised on 11/04/24, revealed that R163 was not care planned for Advanced Directives. An interview on 11/04/24 at 3:20 PM with Licesned Practical Nurse (LPN)2 revealed that they were unable to locate interventions in R163 Electronic Medical Record (EMR) related to Advanced Directives. An interview on 11/05/24 at 6:03 PM with the Administrator and Director of Nursing (DON) revealed that R163 was not care planned for Advanced Directives while a resident in the facility.

Based on review of facility policy, observation, interview, and record review, the facility failed to ensure Resident (R)52, who was dependent on staff for activities of daily living (ADLs), received the necessary services to maintain personal hygiene, for 1 of 6 residents reviewed. Findings include: Review of the facility policy titled, Activities of Daily Living (ADL), Supporting with a date of 2001, documented, Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: 2. 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 with assistance with: a. hygiene (bathing, dressing, grooming, and oral care) . Review of R52's Admission Record revealed R52 was admitted to the facility on [DATE], with diagnoses including but not limited to: Parkinson's Disease, chronic kidney disease, muscle weakness, acquired absence of right leg above knee, and acquired absence of left leg above knee. Review of R52's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/23/24, indicated R52 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R52 had intact cognition. Review of R52's Task Documentation revealed no showers were documented for the months of June through November 2024, indicating R52 did not receive showers during that time frame. During an observation on 11/03/24 at 12:46 PM, R52 was observed laying in bed, with no shirt and laying underneath a sheet. R52's face was unshaven, and a crusty discharge was in the corners of both eyes. During an observation on 11/04/24 at approximately 12:20 PM, R52 was observed laying in bed without a shirt, face still unshaven. During an interview on 11/03/24 at 12:46 PM, R52 stated he has not had a shower since his admission into the facility in June 2024. R52 further stated he does not know his shower days and he is dependent on staff to take him for his showers. R52 concluded that he does not refuse showers. During an interview on 11/04/24 at approximately 12:20 PM, R52 stated he had not received a shower or bed bath today. During a follow up interview on 11/05/24 at 10:52 AM, R52 stated staff provided him with a bed bath earlier, but he still was not offered a shower or received one. R52 verified that he does not refuse showers, and he has not had a shower since he has been in the facility. During an interview on 11/05/24 at 11:19 AM, Certified Nursing Aide (CNA)2 revealed she is familiar with R52. CNA2 stated, To be honest I had never put him in the shower. [R52] usually received a bed bath by staff on the previous shift. CNA2 further stated that most of the time he has already had a bed bath on the previous shift. CNA2 concluded that she has never offered R52 a shower. During an interview on 11/05/24 at 3:28 PM, Unit Manager Licensed Practical Nurse (LPN)4 revealed she is the unit manager for [NAME]-100 wing where R52 resides. LPN4 stated R52's shower days are Monday, Wednesday and Friday. Residents shower schedules are charted, and refusals are documented in the system. LPN4 further stated, it is the expectation that staff will offer residents showers on their scheduled days. The days that are not shower days; residents receive bed baths. If residents refuse showers, the CNA notifies the nurse, and the nurse will reapproach residents.

Based on review of the facility policy, record review, and interviews, the facility failed to notify Resident (R)1's responsible party (RP) of a change in skin condition when an unstageable wound was discovered for 1 of 3 records reviewed for quality of care. Findings include: Review of the facility policy, with a revision date of 2001, titled, Change in a Residents Condition or Status revealed under policy, Unless otherwise instructed by the resident, a nurse will notify the resident's representative when, there is a significant change in the residents physical status. Review of R1's Face Sheet revealed the facility admitted R1 on 12/25/2020 with diagnoses including, parkinsonism, chronic obstructive pulmonary disease and type 2 diabetes. Review of R1's treatment administration record (TAR) dated 05/17/2024, revealed a treatment order to, cleanse left trochanter with wound cleanser, and apply hydrogel, cover with bordered foam gauze daily for unstageable every shift. Review of the TAR revealed the signatures began on 05/17/2024, signed as treatment administered. Review of R1's physician orders dated 05/13/2024 revealed an order to refer to QSM for evaluation and treatment of left hip. Record review of R1's wound notes dictated by an outside provider dated 05/15/2024 revealed a note, left hip recorded as in house pressure ulcer as unstageable and new. An interview with R1's RP on 06/14/2024 at 10:27 AM revealed she was not notified timely of R1's wound to her left hip. She said she came from out of state to visit and then met with the Director of Nursing (DON), the Social Worker (SW) and the Wound Nurse on 05/20/2024. She said it was in this meeting when she learned about the wound. An interview with the Wound Nurse on 06/14/2024 at 11:30 AM revealed she notifies the residents responsible parties of all wounds. She said she remembered telling R1's RP in the meeting with the DON and SW present, when they were visiting. She confirmed she had notified R1's RP in the meeting, not before. An interview with the DON on 06/14/2024 at 12:39 PM revealed, The family member should have been notified before they came to visit, after the wound developed.

Based on review of the facility policy, record review, and interview, the facility failed to ensure a written grievance was filed for Resident (R)1 regarding care concerns for 1 of 3 residents reviewed for quality of care. Findings include; Review of the facility policy, revised April 2017, titled, Grievances/Complaints Filing revealed under policy, Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. Record review of the facility Resident Grievance Log dated May 2024, does not record any concerns for R1. An interview with R1's Personal Representative on 06/14/2024 at 10:27 AM revealed, I visited about a month ago and had care concerns. I asked to speak to the head of nursing and the social worker, but they were both off, it was on Friday the 17th. I returned Monday, the 20th of May and met with the head of nursing, the social worker and the wound nurse. I had a lot of concerns about the care, the odors, R1's fall, and her hip wound, which I was surprised about and the state of her room. They told me they would take care of it. An interview with the Social Worker (SW) on 06/14/2024 at 11:11 AM revealed, If I had received a concern, it would have been noted as a concern on the grievance. When I was coming into the conference room, I entered the conference room and I was brought into a conversation with R1's Personal Representative (PR) and the Director of Nurses (DON). I was asked about hospice services, and I explained to the PR about hospice and so we did initiate hospice services soon after. If it had been brought to my attention as a grievance, I would have written it. Anyone can write out a grievance. We have the forms posted on each bulletin board. I would present the grievance in the AM meeting, and I would then log it. I will also follow up on it as well. An interview with the DON on 06/14/2024 at 12:39 PM revealed she was not the DON at the time of the grievance, but any care issues or concerns should have been written and presented as a grievance for all her concerns. An interview with the Wound Nurse on 06/14/2024 at 12:55 PM revealed, The SW, the DON and I were in the meeting with R'1s PR and she had a lot concerns.

Based on policy review, record review, and interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed accurately for 3 of 3 residents (Resident (R)77, R17, and R60) reviewed for PASRR. Findings include: Review of the facility's policy titled, Resident Assessment-Coordination with PASARR [preadmission screening and resident review] Program, dated 2022, indicated All applicants will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with State Medicaid rules for screening. PASARR level I- initial screening that is completed under admission .The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority .Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. 1. Review of R77's Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 09/15/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R77 had intact cognition. The resident was admitted on [DATE] with a readmitted [DATE]. The resident was documented with [CONDITION(S)] disorder under psychiatric/ mood disorder. The resident received an antipsychotic seven times over the seven days look back period. Review of the Profile Face Sheet provided by the facility, undated, revealed R77 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R77's PASARR Level 1 screening form, dated 03/30/22 revealed: Section all Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Section II: diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The PASARR form did not include the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of R17's MDS with an ARD of 09/27/22 revealed a BIMS score of 7 out of 15, which indicated R17 had severely impaired cognition. The resident was admitted on [DATE] with a readmitted [DATE]. R17 was documented with [CONDITION(S)] disorder and anxiety under psychiatric/ mood disorder. R17 received an antipsychotic and antianxiety, antidepressant, and hypnotic six times over the seven days look back period. Review of the Profile Face Sheet provided by the facility, undated, revealed R17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R17's PASARR Level 1 screening form, dated 10/17/13 revealed: Section all Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Section II: diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No other psych medications documented. The PASARR form did not include the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Review of R60's MDS with an ARD of 08/30/22 revealed a BIMS of 15 out of 15, which indicated R60 had intact cognition. R60 was admitted on [DATE] with a readmitted [DATE]. The resident was documented with [CONDITION(S)] disorder, anxiety, and [CONDITION(S)] under psychiatric/ mood disorder. The resident received an antipsychotic and antianxiety seven times and an antidepressant four times over the seven days look back period. Review of the Profile Face Sheet provided by the facility, undated, revealed R60 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R60's PASARR Level 1 screening form, dated 08/22 revealed: Section all Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Section II: Blank and not filled out. Section III: Blank and not filled out. The PASARR form did not include the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/05/22 at 2:58 PM, the Social Worker (SW) stated the residents came in with PASARR on admission. The SW stated The SW stated the admission staff received the PASARR, the physician was the one who made change requests for the PASARR, and no one was monitoring the accuracy of the PASARR. During an interview on 10/06/22 at 10:54 AM, the admissions staff member stated she received the PASARR from the hospital and scanned them into the computer system. She stated she checked to ensure the PASARR was signed and dated, but did not monitor for accuracy. She stated she was taught that PASARR was under the SW department.

Based on review of the facility policy, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were submitted within the 14-day period for 1 of 1 Resident (R)1, reviewed for resident assessments. Findings include: Review of the facility's policy titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/19, indicated Entry: Transmission date no later than entry date +14 calendar days; Comprehensive assessment: Transmission date no later than care plan completion date +14 calendar days; Discharge assessment: Transmission date no later than MDS completion date +14 calendar days. Review of the MDS with an Assessment Reference Date (ARD) of 04/27/22 revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated R1 had severely impaired cognition. This MDS revealed R1 was admitted on [DATE]. Review of the MDS transmission logs provided by the MDS coordinator revealed: Entry MDS date 04/20/22; Submitted and accepted 05/27/22. Comprehensive MDS date 04/27/22; Submitted and accepted 05/27/22. 5-Day MDS assessment date 04/27/22; Submitted and accepted 05/27/22. Discharge MDS assessment date 05/06/22; Submitted and accepted 05/27/22. During an interview on 10/08/22 at 10:55 AM, the MDS Coordinator verified the Entry MDS assessment was due 05/03/22 but was not completed until 05/27/22, the comprehensive assessment was due 05/03/22 but was not completed until 05/27/22, the 5-day assessment was due on 05/03/22 but was not completed until 05/27/22, and the discharge assessment was due on 05/19/22 but was not completed until 05/27/22. The MDS coordinator stated she started at the facility in May and completed the assessments at that time. She stated the facility was in-between MDS coordinators when she started the MDS position.

Based on observation, interview, and record review, the facility failed to review and revise Resident #1's care plan related to elopement for 1 of 5 residents reviewed for elopement. Findings include: Resident #1 was first admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility readmission on 2/15/2021 added an additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R #1's medical record on 5/4/2021 at 12:30 PM, revealed R #1 had a Brief Interview of Mental Status (BIMS) score of 10, indicating the Resident had moderately impaired cognition on his/her most recent Minimum Data Set (MDS) dated [DATE]. During observation and attempted interview of R #1 on 5/4/2021 at 1:15 pm, s/he repeated each question asked by this surveyor with no apparent understanding/comprehension. Observation of R #1 showed s/he had a wanderguard in place to his/her left ankle. Review of the Care Plan on 5/5/2021 at 10:06 am with an effective date of 10/14/2020, showed R #1 was assessed on 10/17/2020 to be at risk for exit behavior due to previously opening and stepping outside of the facility door to courtyard. The Care Plan goal was for R #1 to not leave property unattended. Interventions were to a) check functioning of secure alarm per order, b) personal secure alarm as ordered, c) 1:1 and to be checked every 15 minutes. Additional review of the medical record and progress notes showed additional elopement attempts on 10/17/2020, 12/1/2020, 12/6/2020, 12/13/2020, 12/15/2020, 12/21/2020, 4/6/2021 and 4/12/2021. However, there were no updated interventions on the care plan. During an interview with the MDS Nurse on 5/5/2021 at 10:30 am, s/he indicated Care Plans should be updated with each incident and/or attempt of elopement. When asked why the other attempts were not updated, the MDS Nurse stated s/he did not know. During an interview with the Director of Nursing (DON) on 5/5/2021 at 11:40 am, s/he stated that Care Plans are only updated quarterly. The DON also stated the facility did not have a policy for updating care plans.

Based on observations, record reviews, interviews, and review of the facility's policy titled Elopement, the facility failed to provide adequate supervision for 1 of 5 residents reviewed for accidents. R #1 had a successful elopement from the facility and was without supervision for an extended period of time and found sleeping outside in a wooded area. On May 4, 2021 at 12:54 PM, the survey team provided an Immediate Jeopardy (IJ) template to the facility's Administrator, Chief Executive Officer, and Director of Nursing notifying them that IJ existed at F689, with an effective date of 4/12/2021. On May 5, 2021 at approximately 10:00 AM, the facility provided an acceptable IJ Removal Plan. The immediacy of the IJ was removed as of May 5, 2021. The IJ was lowered to a scope and severity of E for pattern of elopement with attempts. An extended survey was conducted May 4-5, 2021. The facility's removal plan implemented required facility wide training and inservices to be conducted beginning May 4, 2021 related to elopement. All staff are required to complete/attend the training prior to working their next shift. Installation of the EGRESS Maglocks and wanderguard system was completed on 5/4/2021. Elopement risk assessments and system function tests were successfully completed on 5/4/2021 for the 5 residents currently residing in the facility with wanderguards. Implementation of the removal plan was verified through observations, staff interviews, and record review. Observations verified that all doors were successfully functioning properly with the wanderguards being used in the facility. Interviews and record reviews were conducted and verified staff were trained on the proper use of the wanderguard system and the proper protocol to follow if an alarm was triggered. The Administrator and Director of Nursing were notified that the immediate jeopardy was removed on 5/5/2021 at 11:45 am. The deficient practice was lowered to an E (pattern scope and severity with a potential for more than minimum harm) following the removal of the immediate jeopardy. The findings included: R #1 was admitted to the facility on [DATE] with diagnoses: [CONDITION(S)], Seizures, [CONDITION(S)], Major Depressive Disorder, Epigastric Pain, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] (GERD), Non-compliance with Medical Treatment and Regimen, and [CONDITION(S)]. R #1 was transferred to a hospital on 2/8/2021 and readmitted to the facility on [DATE] with new diagnoses [CONDITION(S)] with Dementia, Paranoia, Agitation, and [CONDITION(S)]. Resident #1 has a brief interview of mental status (BIMS) of 10 (moderate cognitive impairment). A record review of the progress note dated 12/1/2020 06:35 AM (EST) revealed, At approximately 6:00 a.m. resident was noted to be missing from common area on [NAME] where he had been sitting for several hours. Prior to the elopement the resident stated s/he needed to go back to work. A record review of the progress note dated 12/6/2020 07:37 AM (EST) revealed, At approx 5:30 a.m. A CNA reported resident not in his room. Search began room by room and RN Supervisor in the facility notified. After room by room search maintenance notified to begin grounds search. At approximately 6:40 a.m R #1 was returned to the facility. The Resident had two wanderguards on his/her person of which neither initiated the alarm. A record review of the progress note dated 12/13/2020 12:02 AM (EST) revealed, At 10:40 PM Resident trying to elope facility. A record review of the progress note dated 12/15/2020 03:41 AM (EST) revealed, Since 2:04 AM resident continues attempts to elope. A record review of the progress note dated 12/21/2020 11:12 AM (EST) revealed, Resident is back to fighting staff and attempting to get out of facility. A record review of the interdisciplinary notes dated 4/6/2021 8:28 PM revealed, Resident alert with confusion. Resident exited facility. R #1 made her/his way to front of the building. The facility submitted a 2 hour notice by telephone to the Bureau of Certification on 4/12/2021 at 9:37 PM, indicating R #1 was missing from the facility. Per the incident investigation report, R #1 was last seen on 4/12/2021 around 6:50 PM and noted out of his/her room around 7:45 PM. A facility search was initiated and when Resident #1 could not be located. Additional staff were called in to assist with the search. A record review of the progress notes dated 4/6/2021, R #1 present but the progress note does not provide documentation of the elopement that occurred on 4/12/2021. Per the 5 day Report submitted to the State Agency on 4/16/2021, the Resident went outside between 7:00 PM and 7: 45 PM on 4/12/2021. The facility's elopement protocol was initiated, rooms were searched including closets and common areas. The staff moved the search outdoors and the Resident was located. Prior to the incident, the Resident was being monitored on 15 minute checks. The Police, Physician and Responsible Party were notified of the incident. Review of the timeline of the incident indicated on 4/12/2021: -6:50 PM- Resident was seen at the nurses station by the CNA -7:45 PM- Resident was noted out of his/her room and off of the unit by the primary Nurse. The elopement procedure was initiated according to policy. The entire facility was searched. Staff looked in all rooms and every accessible space. -8:20 PM- After the initial search of the interior of the building, the on-call nurse, DON and Administrator were notified. Staff were then instructed to call the police to assist with the search. The maintenance staff were also notified. The DON and Administrator reported to the building and started the investigation. -9:37 PM- DHEC Certification was notified via phone by the Administrator of the situation. -9:45 PM- The Resident was found by the Maintenance Director. EMS was onsite and assessed the patient for possible injuries. The resident did not have any injuries but was transported to the Emergency Department for precautionary evaluation. An attempt was made to interview R #1 on 5/4/2021 at 11:15 am. R #1 was pleasant but confused while answering questions. S/he could not recall the events but remembered going outside. An interview with the DON on 5/4/21 at 11:30 am revealed R #1 exited through the door in the dayroom across from the Nurses' station. S/he stated that not all the doors would alarm if opened or if someone with a wanderguard went near it. During a tour with the DON and Assistant DON, they showed the surveyors where R #1 had exited and how far s/he had eloped from the main building. It was not a common area, and it was gated, which should have been locked, however the gates are not locked at the time of the elopement. The Resident had a wander guard prior to incident. However, a new Wanderguard was placed after the R #1 was returned to the facility. R #1 had to be convinced to allow the DON to place it on his/her leg. When asked about monitoring for residents with elopement risks, the DON responded most residents do not try to elope, but staff know who they are. The facility was unable to provide contact information for the Nurse who originally noted the Resident missing. S/he no longer works for the facility. During an interview with the Maintenance Director on 5/4/2021 at 12:00 PM, s/he stated, A little after 8 PM, I received a call from the Unit Manager, and said someone was missing. I then begin reaching out to everyone who lives close to come in and help search since it takes me roughly an hour to get back to the campus from home. When I arrived, I began combing the area looking for the resident. Once I couldn't locate her/him, the Grounds Supervisor picked me up in a golf cart and with the aid of a spotlight the resident was found in the woods sleeping. When we questioned why s/he was outside, R #1 stated just wanted to take a nap and I just wanted to be outside. When asked by the surveyor if the resident was found in a common area, the Maintenance Director responded, Where the Resident was found is not a commonly used area and not a place you would typically look to find someone. When asked if the gates to side courtyard are secured, the Maintenance Director responded, the gates should be latched. The facility has 24/7 maintenance security and security is responsible for checking secured areas. However, the facility is in the process of updating wanderguard system because the enunciators did not alarm as loud as they should. So you may not know when someone with a wanderguard got near or exited the door. S/he continued to say the system is not fully updated and the installation Quote came in prior to incident but the work was scheduled to began the week after the incident and that no additional testing of the system was completed. The Maintenance Director also added the wanderguard just was not working properly this day. An interview with the Unit Manager (UM) on 5/4/21 at 12:19 PM revealed, the unit Nurse was performing medication pass and noted the Resident was not in his/her room. S/he looked around and then called the UM. The UM said s/he instructed staff to shut everything down and called the Maintenance Director to return to search the building. However, the UM did not return to assist with the search. The UM stated R #1's speech is usually understandable and s/he does not usually go farther than the Nurses' station. S/he will however make comments like I have to go to work, or remarks to wanting a job The Resident's family is not active in visiting. A review of the facility policy titled Elopement revealed an elopement assessment will be done upon admission, annually, and if any significant changes occur with a resident. The policy also indicates a list of all potential elopers will be kept at each nurse's station and receptionist office. This list should be maintained and updated as needed by maintenance employee. Staff at the nursing station were interviewed on 5/4/2021 at 2:00 PM with no knowledge of the potential elopers list. Further review of R #1 ' s Progress Notes and assessments revealed R #1 did not have an elopement assessment upon admission, after each incident nor after any significant changes. An elopement assessment was provided dated 5/4/2020 after a request was made from the surveyors for copies of Resident #1's assessments.

Based on review of facility files and interview, the facility failed to ensure each resident was free from abuse and neglect. Resident #41 reported an allegation of physical and verbal abuse that the facility substantiated. CNAs forced Resident #41 to have a brief change and verbally abused the resident. The CNAs were not suspended until 5 days after administration was made aware of the allegation of abuse. CNA #4 held Resident #90's hands down. When the resident pulled his/her hands away, s/he struck him/herself in the nose, fracturing his/her nasal bones. Two of five resident's reviewed for abuse. The findings included: The facility reported an allegation of physical and verbal abuse to the State Agency for Resident # 41 on 1/6/16. The facility noted the incident happened 12/31/15 but was not reported to the facility until 1/5/16. The facility reported that Resident #41 stated that s/he did not want to go to bed because it was New Year's Eve and s/he wanted to see the ball drop. The resident stated that s/he did put him/herself to bed and was asleep. CNA #7 came in to change him/her and pulled the covers back fast, and started changing his/her brief. Resident #41 stated that the CNA hit him/her while changing the brief and cursed him/her. Resident #41 stated that s/he cursed the CNA and exchanged blows. Resident #41 also stated that the other CNA #8 stood at the doorway making fun of the situation. The facility reported that Resident #41 was alert and oriented and had not wavered from the above statement. The facility reported upon conversation with CNA #7 s/he was asked if the resident did not want to be changed did you go to the nurse or RN supervisor to ask for assistance and the CNA answered no. CNA #7 was asked so basically you manhandled the resident to give him/her care and the CNA answered yes. The facility's report indicated the MSW (Masters in Social Work) and BSW (Bachelors in Social Work) both interviewed the resident. There was no documentation in the investigative file or Resident #41's Clinical Notes of the content of those interviews. Review of Resident #41's medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 11. The Quarterly MDS coded Resident #41 as requiring extensive assistance for transfers, dressing, hygiene, and bed mobility with no behaviors coded as occurring during the assessment period. Reviewed Resident #41's Clinical Notes Report from 12/3/15-1/1/16 with no documentation of resident having behaviors toward staff. Note resident did not want to get out of bed on 12/17/15. LPN #9's facility-obtained statement indicated Resident #41 stated that s/he was upset and wasn't being treated right. Resident #41 described CNA#7 and stated s/he physically punched him/her for opening his/her brief and they exchanged blows. Resident #41 stated the other CNA,#8, mocked and made fun of him/her while standing at the door ( by saying No wonder your family doesn't come visit and you didn't deserve to get anything for Christmas). RN #2's facility-obtained statement dated 1/4/16 indicated s/he spoke with Resident #41 and s/he stated that the big, fat black girl punched him/her in the right arm and right hip. Resident #41 stated CNA #8 jumped in and told him/her that no one visits him/her and s/he didn't get anything for Christmas. CNA #11's facility-obtained statement dated 1/8/16 indicated when s/he entered the room, Resident #41 began telling him/her how bad s/he was treated by the night CNA. Resident #41 stated the the CNA came in to change him/her when s/he was asleep. The blanket was pulled off him/her and with no warning, s/he was pushed over so hard that his/her head hit the bed rail. Resident #41 also stated that s/he tried to fight back. At that point, s/he began to curse the CNA. CNA #8's facility-obtained statement dated 4/12/16 indicated s/he went to Resident #41's room at 7:00 PM and the resident started to curse at CNA #7. CNA#8 told CNA#7 to come out of the room. CNA#7 went back in the room after they returned from the chapel New Year's Day at 1:00 AM. Resident #41 was cursing at CNA #7 and CNA#7 returned to the room at 5:00 AM and the resident started cursing and swinging at CNA #7. CNA #7 changed the resident's brief and then s/he started cursing again. CNA #7's facility-obtained statement dated 1/12/16 indicated s/he went into Resident #41's room and the resident started calling her/him dirty dog, mother [***] , son of a [***] and everything so s/he pulled the resident's covers back and put the pads and chucks on the the bed. The other CNA came and got him/her and told him/her to leave the resident up. CNA #7 came back to Resident #41's room around 11 and s/he was still cursing the CNA out so CNA #7 left out the room again. Around 1:00 CNA #7 went back into the resident's room and s/he had already put him/herself in bed so CNA #7 removed the resident's pants and put on a brief. While CNA #7 was doing that the resident was still calling him/her out and cursing him/her. During CNA #7's last round, s/he turned Resident #41 and pulled the brief off and the resident started swinging at him/her. CNA #7 leaned back and put the brief on the best way s/he could to prevent the resident from trying to hit him/her. CNA #7 did not go get the nurse about the resident's behavior. In an interview with the surveyor on 2/9/17 at approximately 12:45 PM, the facility administrator stated s/he was informed about the allegation by a nurse on 1/5/16. The nurse stated Resident #41 had just reported the incident. They went to Resident #41 and talked with him/her, s/he described the employees and they checked the schedule. The facility administrator stated Resident #41 does not have any behaviors, and is alert and oriented. The administrator asked the CNA questions about the resident's care, as documented in typed statement. The facility administrator stated they substantiated the allegation of rough handling, but not the allegation that staff hit the resident. The administrator stated the CNAs were suspended to keep the resident safe. After the investigation and they get everything together, then the staff was terminated. In an interview with the surveyor on 2/9/17 at approximately 1:17 PM, human resources staff stated CNA #7 and CNA #8 worked 1/8-1/10/16. The CNAs were suspended on 1/11/17. They would have been off Monday and Tuesday 1/11 and 1/12, so they were suspended Wednesday 1/13, Thursday 1/14, off Fri/Sat/Sun, and suspended on Monday 1/18. That would have been third day of suspension. S/he is not sure why they were not suspended until the 11th. In an interview with the surveyor on 2/9/17 at approximately 2:40 PM, the facility administrator stated they would normally suspend the staff if they felt it was a true allegation. They did not suspend the CNAs until after the investigation was completed. She thought they suspended them at the time of the allegation. They substantiated verbal abuse and rough handling. Their policy is to suspend during investigation and then if substantiated they terminate the employee. The administrator stated Resident #41 did not want to be bothered the night of the incident. The administrator would have expected the CNAs to let the resident know what they were going to do, if the resident said no s/he didn't want to be bothered, they should talk to the resident about coming back in a short time to check on him/her. The administrator stated the CNAs should have let the resident watch the ball drop since s/he wanted to watch it. Review of the Timecard Report for CNA #7 and CNA #8 showed the CNAs worked 1/8, 1/9 and 1/10/16. Review of the Employee Communication Report revealed CNA #7 and CNA #8 were suspended on 1/12/16. Review of the facility's Policies and Procedures for Abuse, Neglect and Exploitation revealed definitions of abuse as the willful infliction of intimidation or punishment with resulting physical harm or pain or mental anguish. Verbal abuse was defined as use of oral language that includes disparaging or derogatory terms to residents. When reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. An investigation should be conducted, interview the involved resident and document all responses. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and visitors in the area. All statements should be signed and dated by the person making the statement. When abuse, neglect or exploitation is suspected, suspend the accused employee pending completion of the investigation. Remove the employee from resident care areas immediately. The facility reported an allegation of physical abuse for Resident # 90 to the State Agency for an incident that occurred on 8/3/16. The facility reported that at approximately 2:00 AM, Resident #90's CNA went into the room to check on him/her. The resident hit CNA #4 and the CNA held the resident's hand down to prevent him/her from hitting again while the CNA tried to reposition the resident in bed. CNA #4 reported that when s/he let go of Resident #90's hand it came back in his/her face and hit his/her nose. The CNA reported the incident to the nurse and orders were received to send to the resident to the ER for evaluation. Resident #90 was diagnosed with [REDACTED]. Further review of the medical record revealed the Significant Change Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] coded Resident #90 as having a Brief Interview for Mental Status score of 0. The Significant Change MDS coded Resident #90 as totally dependent for transfers, dressing, hygiene, and bed mobility with no behaviors coded as occurring during the assessment period. Review of the care plan revealed resident exhibiting numerous behavior problems (attempted to slap at staff providing care, shaking bedrails, cursing staff, attempting to hit staff) was identified as a problem area on 8/11/16. Interventions and approaches to this problem area were documented on the care plan and included during episodes of physical aggression, postpone care and reapproach later when resident is calmer. Review of the Nurses' Notes dated 8/3/16 at 6:07 AM indicated per CNA, during 2 AM round, the CNA was trying to pull the resident up in the bed. When the CNA pulled the resident up in the bed, the resident hit the CNA in the face. The CNA grabbed the resident's hand to stop the resident from hitting him/her again and when the CNA did that, the resident pulled back and hit him/herself in the face. The resident's nose started to bleed and the nurse was called to the room. There was a small amount of swelling noted to the nasal cavity. Review of the Nurses' Notes dated 8/3/16 at 11:15 AM indicated resident noted to have increased facial swelling and discoloration due to incident on PM shift. Resident given PRN pain medication and denies any pain when area palpated. Order received per MD to send resident to ER for evaluation and x-rays. Clinical Notes were reviewed from 7/1/16-8/3/16 with no documentation of resident having behaviors of striking out at staff. Resident noted to have behavior of yelling out. Review of the ED Note dated 8/3/16 revealed the resident accidentally hit self in the face last night during altercation at SNF and has swelling to eyes and nose, MD requested facial x-rays. Resident denies any pain but is tearful with questioning. Resident was noted to have an ecchymosis of the right superior orbital rim, generalized left periorbital ecchymosis with [MEDICAL CONDITION]. There were several ecchymosis of the right side of the forehead. The Final Report of the CT head, Maxillofacial and cervical spine revealed the impression was bilateral nasal bone fractures and left frontal scalp soft tissue swelling. LPN #10's facility-obtained statement dated 8/3/16 indicated at 2:00 AM the CNA came out of the resident's room and stated his/her nose is bleeding. The nurse asked what happened and the CNA stated the resident slapped him/her in the face (CNA had visible mark on the left side of his/her face with a faint scratch) while s/he was trying to pull the resident up in the bed. The CNA then blocked/grabbed the resident's arm to prevent the resident from hitting him/her again. The resident yanked his/her arm back hard, hitting him/herself in the face, causing his/her nose to bleed. The CNA was visibly upset. LPN #10 examined the resident, palpating the nose. Resident #90 denied pain upon palpation. The nurse asked the resident if s/he knew what happened and the resident stated no. Resident #90 was asked if s/he hit him/herself in the face and s/he said no. Resident #90 was asked if anyone had hit him/her in the face and the resident said no. At 4:15 AM LPN #10 entered the resident's room and the resident's face was noted to be swollen. Resident #90's left eye was swollen and bruised, his/her nose was [MEDICAL CONDITION] and there was some swelling and discoloration noted to the right eye. LPN #10 palpated the resident's nose and s/he denied pain or discomfort. At 6:18 AM PACE was notified of the incident with no new orders. LPN #10 informed the dayshift nurse of the incident and notified the DON via text. CNA #4's facility-obtained statement dated 8/4/16 indicated that at 2:00 AM on 8/3/16 s/he went to Resident #90's room to do his/her normal round. S/he was going to change the resident and pull him/her up in the bed. CNA #4 told the resident what s/he was going to be doing. Resident #90 hit CNA #4 in the face, so the CNA grabbed the resident's hand so s/he couldn't do it again. When CNA #4 grabbed the resident's hand s/he snatched it away and hit him/herself in the face. The resident's nose started pouring blood so s/he cleaned it up and stopped the bleeding. CNA #4 then went to find the nurse, LPN #10. CNA #4 told the nurse what happened and showed a CNA that his/her face was red from where Resident #90 hit him/her. Review of the facility's Tips to Deal Effectively with Difficult Residents indicated if a resident is combative/resistive to care then leave the room, inform the nurse and re-approach later. In an interview with the surveyor on 2/9/17 at approximately 2:55 PM , the facility administrator stated the nurse reported the incident to the PACE oncall nurse. The PACE doctor ordered for the resident to go to the emergency room . Resident #90's nose was bleeding and swollen. The administrator stated the CNA was called in and questioned. CNA #4 was trying to give care, the resident hit him/her, s/he held the resident's arm, when s/he let go the resident's arm hit him/her in the face. The administrator stated there was no bruising on the resident's arm or on the CNA. The surveyor asked the Administrator if s/he felt CNA #4's behavior was appropriate. The administrator stated staff is trained to back up and come back later, go get a nurse when a resident is refusing care. The Administrator stated s/he would not expect the CNA to hold the resident down. CNA #4 was suspended, but not terminated. The CNA was suspended from 8/3/16-9/20/16 when s/he resigned from his/her position. The administrator stated that because the sheriff's department was still investigating, human resources said to wait until they heard from the Sheriff's department. The CNA called and said s/he was getting another job. They probably would have terminated him/her for not following procedure. The administrator was shown a letter from the Human Resources Manager at The Oaks addressed to CNA #4. The letter was located in CNA #4's file. The letter indicated CNA #4 was informed that s/he could return to a like job in the company's Senior Solutions Department. The letter indicated the investigation results were unfounded and the employee was paid for time they would have been scheduled during the investigation. The administrator stated that Senior Solutions is their home care services.

Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect. Resident #41 reported an allegation of physical and verbal abuse that the facility substantiated. CNAs forced Resident #41 to have a brief change and verbally abused the resident. The CNAs were not suspended until 5 days after administration was made aware of the allegation of abuse. CNA #4 held Resident #90's hands down. When the resident pulled his/her hands away, s/he struck him/herself in the nose, fracturing his/her nasal bones. The facility stated Resident #90's nasal bone fractures were an injury of unknown origin. Resident #141 reported an allegation of abuse and neglect. The facility failed to thoroughly investigate the incident. Three of five resident's reviewed for abuse. The findings included: The facility reported an allegation of physical and verbal abuse to the State Agency for Resident # 41 on 1/6/16. The facility noted the incident happened 12/31/15 but was not reported to the facility until 1/5/16. The facility reported that Resident #41 stated that s/he did not want to go to bed because it was New Year's Eve and s/he wanted to see the ball drop. The resident stated that s/he did put him/herself to bed and was asleep. CNA #7 came in to change him/her and pulled the covers back fast, and started changing his/her brief. Resident #41 stated that the CNA hit him/her while changing the brief and cursed him/her. Resident #41 stated that s/he cursed the CNA and exchanged blows. Resident #41 also stated that the other CNA #8 stood at the doorway making fun of the situation. The facility reported that Resident #41 was alert and oriented and had not wavered from the above statement. The facility reported upon conversation with CNA #7 s/he was asked if the resident did not want to be changed did you go to the nurse or RN supervisor to ask for assistance and the CNA answered no. CNA #7 was asked so basically you manhandled the resident to give him/her care and the CNA answered yes. The facility's report indicated the MSW (Masters in Social Work) and BSW (Bachelors in Social Work) both interviewed the resident. There was no documentation in the investigative file or Resident #41's Clinical Notes of the content of those interviews. Review of Resident #41's medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 11. The Quarterly MDS coded Resident #41 as requiring extensive assistance for transfers, dressing, hygiene, and bed mobility with no behaviors coded as occurring during the assessment period. Reviewed Resident #41's Clinical Notes Report from 12/3/15-1/1/16 with no documentation of resident having behaviors toward staff. Note resident did not want to get out of bed on 12/17/15. LPN #9's facility-obtained statement indicated Resident #41 stated that s/he was upset and wasn't being treated right. Resident #41 described CNA#7 and stated s/he physically punched him/her for opening his/her brief and they exchanged blows. Resident #41 stated the other CNA,#8, mocked and made fun of him/her while standing at the door ( by saying No wonder your family doesn't come visit and you didn't deserve to get anything for Christmas). RN #2's facility-obtained statement dated 1/4/16 indicated s/he spoke with Resident #41 and s/he stated that the big, fat black girl punched him/her in the right arm and right hip. Resident #41 stated CNA #8 jumped in and told him/her that no one visits him/her and s/he didn't get anything for Christmas. CNA #11's facility-obtained statement dated 1/8/16 indicated when s/he entered the room, Resident #41 began telling him/her how bad s/he was treated by the night CNA. Resident #41 stated the the CNA came in to change him/her when s/he was asleep. The blanket was pulled off him/her and with no warning, s/he was pushed over so hard that his/her head hit the bed rail. Resident #41 also stated that s/he tried to fight back. At that point, s/he began to curse the CNA. CNA #8's facility-obtained statement dated 4/12/16 indicated s/he went to Resident #41's room at 7:00 PM and the resident started to curse at CNA #7. CNA#8 told CNA#7 to come out of the room. CNA#7 went back in the room after they returned from the chapel New Year's Day at 1:00 AM. Resident #41 was cursing at CNA #7 and CNA#7 returned to the room at 5:00 AM and the resident started cursing and swinging at CNA #7. CNA #7 changed the resident's brief and then s/he started cursing again. CNA #7's facility-obtained statement dated 1/12/16 indicated s/he went into Resident #41's room and the resident started calling her/him dirty dog, mother [***] , son of a [***] and everything so s/he pulled the resident's covers back and put the pads and chucks on the the bed. The other CNA came and got him/her and told him/her to leave the resident up. CNA #7 came back to Resident #41's room around 11 and s/he was still cursing the CNA out so CNA #7 left out the room again. Around 1:00 CNA #7 went back into the resident's room and s/he had already put him/herself in bed so CNA #7 removed the resident's pants and put on a brief. While CNA #7 was doing that the resident was still calling him/her out and cursing him/her. During CNA #7's last round, s/he turned Resident #41 and pulled the brief off and the resident started swinging at him/her. CNA #7 leaned back and put the brief on the best way s/he could to prevent the resident from trying to hit him/her. CNA #7 did not go get the nurse about the resident's behavior. In an interview with the surveyor on 2/9/17 at approximately 12:45 PM, the facility administrator stated s/he was informed about the allegation by a nurse on 1/5/16. The nurse stated Resident #41 had just reported the incident. They went to Resident #41 and talked with him/her, s/he described the employees and they checked the schedule. The facility administrator stated Resident #41 does not have any behaviors, and is alert and oriented. The administrator asked the CNA questions about the resident's care, as documented in typed statement. The facility administrator stated they substantiated the allegation of rough handling, but not the allegation that staff hit the resident. The administrator stated the CNAs were suspended to keep the resident safe. After the investigation and they get everything together, then the staff was terminated. In an interview with the surveyor on 2/9/17 at approximately 1:17 PM, human resources staff stated CNA #7 and CNA #8 worked 1/8-1/10/16. The CNAs were suspended on 1/11/17. They would have been off Monday and Tuesday 1/11 and 1/12, so they were suspended Wednesday 1/13, Thursday 1/14, off Fri/Sat/Sun, and suspended on Monday 1/18. That would have been third day of suspension. S/he is not sure why they were not suspended until the 11th. In an interview with the surveyor on 2/9/17 at approximately 2:40 PM, the facility administrator stated they would normally suspend the staff if they felt it was a true allegation. They did not suspend the CNAs until after the investigation was completed. She thought they suspended them at the time of the allegation. They substantiated verbal abuse and rough handling. Their policy is to suspend during investigation and then if substantiated they terminate the employee. The administrator stated Resident #41 did not want to be bothered the night of the incident. The administrator would have expected the CNAs to let the resident know what they were going to do, if the resident said no s/he didn't want to be bothered, they should talk to the resident about coming back in a short time to check on him/her. The administrator stated the CNAs should have let the resident watch the ball drop since s/he wanted to watch it. Review of the Timecard Report for CNA #7 and CNA #8 showed the CNAs worked 1/8, 1/9 and 1/10/16. Review of the Employee Communication Report revealed CNA #7 and CNA #8 were suspended on 1/12/16. Review of the facility's Policies and Procedures for Abuse, Neglect and Exploitation revealed definitions of abuse as the willful infliction of intimidation or punishment with resulting physical harm or pain or mental anguish. Verbal abuse was defined as use of oral language that includes disparaging or derogatory terms to residents. When reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. An investigation should be conducted, interview the involved resident and document all responses. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and visitors in the area. All statements should be signed and dated by the person making the statement. When abuse, neglect or exploitation is suspected, suspend the accused employee pending completion of the investigation. Remove the employee from resident care areas immediately. The facility reported an allegation of neglect and verbal abuse for Resident #141 to the State Agency on 4/6/16. The results of the facility's investigation revealed staff were found to provide substandard care, neglect and verbal abuse. Resident #141 stated his/her call light was taken away and s/he did not get changed properly. Review of the facility's investigation file into the incident revealed only one witness statement, the speech therapist's. The only information in the investigative file provided to the surveyor was a copy of the Initial 24 hour report to DHEC, the Five-Day Follow-Up Report, an email to certification, Resident #141's face sheet , the SW note dated 4/7/16 and the speech therapist's statement. Further review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded Resident #141 as having a Brief Interview for Mental Status score of 15. The Initial MDS coded Resident #141 as requiring extensive assistance for transfers, dressing, hygiene, and bed mobility with no behaviors coded as occurring during the assessment period. Review of the Social Work note dated 4/7/16 indicated s/he went to the resident's room on 4/6/16, the resident was awake and alert. Resident #141 was able to explain his/her concerns and issues to the social worker clearly. Resident #141 was aware of the time early in the morning and the three individuals that were on that shift to assist her. The resident reported to the social worker some concerns and issues s/he had experienced with the night shift staff two day prior, particularly with 3 individuals. The social worker took the resident's information down and took the information to the administrator. There was no documentation of what Resident #41's concerns and issues were with the staff. The speech therapist's facility-obtained statement dated 4/6/16 indicated that during a therapy session, the resident stated they will hide the call button so you can't use it. This was in response to a skilled intervention to assess safety. When questioned further, Resident #141 stated a description of 3 heavyset black women working overnight. When questioned about the current time to assess credibility of orientation, resident responded 2:30. It was 2:35 PM. The therapist told the resident that s/he intended to tell someone about this and the resident further reported they let me sit in my[***]for 3 hours. The therapist asked if they came to change him/her and the resident stated no, they just didn't come. In an interview with the surveyor on 2/8/17 at approximately 1:55 PM, the speech therapist confirmed the accuracy of his/her statement as written. The speech therapist stated that the resident was cooperative with care and nice. The speech therapist told a nurse whose office was on the unit. The nurse told him/her to write a statement because the social worker needed to take over. CNA #12's facility-obtained statement dated 4/6/16 indicated s/he came into work at 6:45 AM. When CNA #12 said to CNA#6 OK, let's do walk arounds, CNA #6 stated I ain't washed anyone so there isn't any need to do walk arounds. CNA #6 's voice was very snappy and rude. The resident in 122 asked when s/he would be washed. Upon beginning to bathe resident, it was noted s/he was soaked. When asked about the situation, the resident stated the little, short, fat black, lady didn't want to give me the urinal and stated that she doesn't do that. CNA #13's facility-obtained statement dated 4/6/16 indicated s/he reported to work at 6:45 AM. S/he asked CNA #6 to do walk arounds and to give a report on the residents. CNA #6 stated that there was no need to do walk arounds because s/he didn't do or wash any of the residents. The resident in room [ROOM NUMBER] stated that the short, fat, black nurse was very rude and mean to him/her. The resident sated that the night CNA told him/her that s/he does not hold urinals when s/he asked for help. The resident in room [ROOM NUMBER] kept turning up the volume on his/her television to the highest volume. CNA #13 entered the room and asked what was wrong, the resident stated the reason s/he was turning up the volume was because s/he didn't have a call light. CNA #13 noticed the call light was away from the resident. The resident told CNA #13 that a nurse on the night shift took the call light away and threw it so that the resident couldn't reach it. CNA #12 and CNA #13's facility-obtained statements were not located in the investigation file, but found in human resource files during the complaint survey. In an interview with the surveyor on 2/8/17 at approximately 2:05 PM, the facility Administrator stated s/he completed the investigation. The speech therapist told him/her about the incident. The administrator stated s/he went and talked with the resident and asked him/her what happened. The resident told the administrator the call light was taken away and s/he wasn't changed. The resident could not give names but gave descriptions. They pulled the schedule and talked with the staff members. LPN #2 was a witness. LPN #2 was terminated because s/he witnessed the incident and did not do anything about it or report it. At approximately 2:35 PM the facility administrator stated they had completed an investigation and s/he was not sure what had happened to some of the paperwork. The administrator stated the two CNAs involved in the incident were suspended, left the building and did not write a statement. The administrator stated LPN #2 provided a written statement, but they could not locate the statement. (Review of the investigation information sent to certification when the incident was reported revealed only one statement was included in the paperwork, the speech therapist's statement) In an interview with the surveyor on 2/9/17 at approximately 2:48 PM, the facility stated s/he did not have an investigation for the other resident noted in the statements. The administrator stated s/he went and talked with the resident but did not have anything to document that conversation. The facility administrator stated s/he does not have documentation that they interviewed other residents on the hall. Review of the facility's Policies and Procedures for Alleged Violations Involving Mistreatment, Neglect, or Abuse, Including Injuries of Unknown Source and Misappropriation of Resident Property revealed a section on conducting a thorough investigation. The following guidance represents the components of an investigation that would constitute a thorough investigation. The facility should document all aspects of their investigation in order to provide evidence that all allegations were thoroughly investigated. The guidance included to interview the person reporting the incident, develop a list of known and possible witnesses to the reportable incident. Interview staff, resident, and/or visitors or anyone who has or might have knowledge of the incident under investigation. Interview the resident in the same room, or residents in the immediate vicinity where the reportable incident occurred. Obtain written, signed, double witnessed statements from the reporter and all other identified witnesses. If possible, obtain written statements from the resident who was the subject of the reportable incident and from any other residents you have identified as possible witnesses. If the allegation involves neglect, maintain physical evidence related to the care of the resident in use on the day of the incident (i.e. personal care records, CNA assignment sheets, and facility communication sheets). The Facility Investigative File section indicated at the onset of the investigation, begin compiling the investigative file, to be maintained as a record. A complete investigative file may contain/but is not limited to the following: witness statements for all witness alleged abusers, and resident if applicable. Include written statements not only from everyone involved in the incident but also everyone who participated in any way in the investigation. Documents that serve as instruction to CNAs related to the care of the resident. Assignment sheets for staff caring for the resident at the time of the incident. The facility reported an allegation of physical abuse for Resident # 90 to the State Agency for an incident that occurred on 8/3/16. The facility reported that at approximately 2:00 AM, Resident #90's CNA went into the room to check on him/her. The resident hit CNA #4 and the CNA held the resident's hand down to prevent him/her from hitting again while the CNA tried to reposition the resident in bed. CNA #4 reported that when s/he let go of Resident #90's hand it came back in his/her face and hit his/her nose. The CNA reported the incident to the nurse and orders were received to send to the resident to the ER for evaluation. Resident #90 was diagnosed with [REDACTED]. Further review of the medical record revealed the Significant Change Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] coded Resident #90 as having a Brief Interview for Mental Status score of 0. The Significant Change MDS coded Resident #90 as totally dependent for transfers, dressing, hygiene, and bed mobility with no behaviors coded as occurring during the assessment period. Review of the care plan revealed resident exhibiting numerous behavior problems (attempted to slap at staff providing care, shaking bedrails, cursing staff, attempting to hit staff) was identified as a problem area on 8/11/16. Interventions and approaches to this problem area were documented on the care plan and included during episodes of physical aggression, postpone care and reapproach later when resident is calmer. Review of the Nurses' Notes dated 8/3/16 at 6:07 AM indicated per CNA, during 2 AM round, the CNA was trying to pull the resident up in the bed. When the CNA pulled the resident up in the bed, the resident hit the CNA in the face. The CNA grabbed the resident's hand to stop the resident from hitting him/her again and when the CNA did that, the resident pulled back and hit him/herself in the face. The resident's nose started to bleed and the nurse was called to the room. There was a small amount of swelling noted to the nasal cavity. Review of the Nurses' Notes dated 8/3/16 at 11:15 AM indicated resident noted to have increased facial swelling and discoloration due to incident on PM shift. Resident given PRN pain medication and denies any pain when area palpated. Order received per MD to send resident to ER for evaluation and x-rays. Clinical Notes were reviewed from 7/1/16-8/3/16 with no documentation of resident having behaviors of striking out at staff. Resident noted to have behavior of yelling out. Review of the ED Note dated 8/3/16 revealed the resident accidentally hit self in the face last night during altercation at SNF and has swelling to eyes and nose, MD requested facial x-rays. Resident denies any pain but is tearful with questioning. Resident was noted to have an ecchymosis of the right superior orbital rim, generalized left periorbital ecchymosis with [MEDICAL CONDITION]. There were several ecchymosis of the right side of the forehead. The Final Report of the CT head, Maxillofacial and cervical spine revealed the impression was bilateral nasal bone fractures and left frontal scalp soft tissue swelling. LPN #10's facility-obtained statement dated 8/3/16 indicated at 2:00 AM the CNA came out of the resident's room and stated his/her nose is bleeding. The nurse asked what happened and the CNA stated the resident slapped him/her in the face (CNA had visible mark on the left side of his/her face with a faint scratch) while s/he was trying to pull the resident up in the bed. The CNA then blocked/grabbed the resident's arm to prevent the resident from hitting him/her again. The resident yanked his/her arm back hard, hitting him/herself in the face, causing his/her nose to bleed. The CNA was visibly upset. LPN #10 examined the resident, palpating the nose. Resident #90 denied pain upon palpation. The nurse asked the resident if s/he knew what happened and the resident stated no. Resident #90 was asked if s/he hit him/herself in the face and s/he said no. Resident #90 was asked if anyone had hit him/her in the face and the resident said no. At 4:15 AM LPN #10 entered the resident's room and the resident's face was noted to be swollen. Resident #90's left eye was swollen and bruised, his/her nose was [MEDICAL CONDITION] and there was some swelling and discoloration noted to the right eye. LPN #10 palpated the resident's nose and s/he denied pain or discomfort. At 6:18 AM PACE was notified of the incident with no new orders. LPN #10 informed the dayshift nurse of the incident and notified the DON via text. CNA #4's facility-obtained statement dated 8/4/16 indicated that at 2:00 AM on 8/3/16 s/he went to Resident #90's room to do his/her normal round. S/he was going to change the resident and pull him/her up in the bed. CNA #4 told the resident what s/he was going to be doing. Resident #90 hit CNA #4 in the face, so the CNA grabbed the resident's hand so s/he couldn't do it again. When CNA #4 grabbed the resident's hand s/he snatched it away and hit him/herself in the face. The resident's nose started pouring blood so s/he cleaned it up and stopped the bleeding. CNA #4 then went to find the nurse, LPN #10. CNA #4 told the nurse what happened and showed a CNA that his/her face was red from where Resident #90 hit him/her. Review of the facility's Tips to Deal Effectively with Difficult Residents indicated if a resident is combative/resistive to care then leave the room, inform the nurse and re-approach later. In an interview with the surveyor on 2/9/17 at approximately 2:55 PM , the facility administrator stated the nurse reported the incident to the PACE oncall nurse. The PACE doctor ordered for the resident to go to the emergency room . Resident #90's nose was bleeding and swollen. The administrator stated the CNA was called in and questioned. CNA #4 was trying to give care, the resident hit him/her, s/he held the resident's arm, when s/he let go the resident's arm hit him/her in the face. The administrator stated there was no bruising on the resident's arm or on the CNA. The surveyor asked the Administrator if s/he felt CNA #4's behavior was appropriate. The administrator stated staff is trained to back up and come back later, go get a nurse when a resident is refusing care. The Administrator stated s/he would not expect the CNA to hold the resident down. CNA #4 was suspended, but not terminated. The CNA was suspended from 8/3/16-9/20/16 when s/he resigned from his/her position. The administrator stated that because the sheriff's department was still investigating, human resources said to wait until they heard from the Sheriff's department. The CNA called and said s/he was getting another job. They probably would have terminated him/her for not following procedure. The administrator was shown a letter from the Human Resources Manager at The Oaks addressed to CNA #4. The letter was located in CNA #4's file. The letter indicated CNA #4 was informed that s/he could return to a like job in the company's Senior Solutions Department. The letter indicated the investigation results were unfounded and the employee was paid for time they would have been scheduled during the investigation. The administrator stated that Senior Solutions is their home care services.

On the days of the survey based on observations, full and/or limited record reviews, interviews and review of the facility provided policies for "Performing a Blood Glucose Test with the Assure Platinum Meter", "Infection Control" related to cleaning and disinfecting of the Assure Platinum Blood Glucose Monitoring System and "Eye Drops Administration Procedure", the facility failed to ensure the disinfecting of multi-resident use glucometers between each resident use by two of two nurses (Licensed Practical Nurses, (LPN) #1 and #7) who were observed performing a Blood Glucose Monitoring (BGM) via finger sticks. This affected one sampled Resident (Resident #67) and had potential to effect 32 additional residents residing in the facility with physician orders [REDACTED]. The facility also, based on observation and interview failed to ensure that proper handwashing was completed prior to the administration of eye drops for one of one Resident's onserved recieving eye drops. (Resident #103) The findings included: During a medication pass on 4/10/13 at approximately 11:30 AM, Licensed Practical Nurse (LPN) #7 administered insulin after performing a Blood Glucose Test via a finger stick to Resident # 67. The surveyor did not observe the LPN #7 clean or disinfect the glucometer. During an interview with LPN #7 regarding the cleaning of the glucometer, s/he revealed s/he cleans the glucometer with alcohol wipes. On 4/12/13 at approximately 9:00 AM, during an interview with LPN #1 regarding training on glucometer cleaning, s/he stated there had been an inservice within the last 6 months and revealed s/he had been inserviced at that time to clean the glucometer with alcohol. On 4/12/13 at 9:45 AM, during an interview with LPN #4, s/he revealed alcohol wipes were used during cleaning of the glucometer. S/he stated Sani-wipes were located in the medication room but there were none located on her/his medication cart. On 4/12/13 at 9:50 AM, during an interview with LPN #5, s/he revealed that during the cleaning of the glucometer Sani-wipes were used. Observation of the medication cart revealed there were no Sani-wipes located in the cart. LPN #5 stated "Sani- wipes are located in the medication room and were not replaced after the last wipe was used." On 4/12/13 at 9:42 AM, LPN #9 and LPN #10 each stated, "To clean the glucometer you would use disinfectant wipes." On 4/12/13 at 10:50 AM, LPN #9 and LPN #10 each stated, "The cleansing of the glucometer procedure is located in the Infection Control Policy." On 4/12/13 at 11:07 AM, LPN #5 stated, "The cleansing of the glucometer is located in the policy. I have been using Sani-wipes but now I am told it needs to be alcohol wipes." On 4/12/13 at 11:15 AM, during an interview with the Director of Nursing (DON), s/he stated the Education Inservice person had given an inservice related to the cleaning of the glucometers. On 4/12/13 at 11:07 AM, Clinical Care Coordinator #1 stated that to clean the glucometer Sani-wipes or alcohol wipes were used. On 4/12/13 at approximately 11:30 AM, LPN #1 was preparing to complete a finger stick blood sugar. LPN #1 was observed cleaning the glucometer with an alcohol wipe. The surveyor stopped LPN #1 prior to completing the finger stick blood sugar and instructed LPN #1 to clean meter with a Sani-wipe. LPN #1 stated "I use a Sani-wipe if there is visible blood". During an interview with the Director of Nursing (DON) on 4/12/13 at approximately 10:30 AM regarding a policy and procedure on cleaning of glucometers, the DON stated, "I need to check the policy, I do not want to tell you the wrong thing." The facility's policy and procedure titled "Performing a Blood Glucose Test with the Assure Platinum Meter" and "Infection Control" related to cleaning and disinfecting of the Assure Platinum Blood Glucose Monitoring System states the following respectively: 1) Alcohol wipe; clean and disinfect Assure Platinum Blood Glucose Meter between patient test (refer to policy: cleaning the assure platinum meter with). 2) To clean the outside of your blood glucose meter, use a lint free cloth dampened with soapy water or [MEDICATION NAME] alcohol (70-85%). To disinfect the meter, dilute 1 milliliter of household bleach and (5-6% sodium hypochlorite solution) in 9 milliliters of water to achieve a 1-10 dilution and (final concentration of 0.5%-0.6% sodium hypochlorite). In the event you do not have bleach or your policies prohibit bleach being kept in the facility, you can recommend one of the following products as an alternative. Steris Coverage Spray HB, or Super Sani-Cloth and Sani-cloth HB germicidal disposable wipe. On 4/12/13 at approximately 12:35 PM, the Administrator and Chief Executive Officer were informed of the Immediate Jeopardy (IJ). Information was shared regarding not disinfecting the glucometer between each resident during blood glucose monitor observations and conflicting knowledge of staff during interviews. The facility presented a credible Allegation Of Compliance (AOC) on 4/12/13 at 3:19 PM. The AOC was accepted at 3:40 PM and included the following: a) The nurse observed by the survey team to improperly follow or respond to questions regarding cleaning procedures for a glucometer while caring for a resident was immediately removed from the floor to be inserviced on the proper procedure of the cleaning of the glucometer. b) Licensed staff will be re-inserviced regarding proper glucometer cleaning by the Assistant Director of Nursing and the Director of Nursing or trained Registered Nurse designee prior to returning to work on the floor. As part of the orientation process, the nurse being trained will sign that the process of cleaning a glucometer is clearly understood. The procedure for proper cleaning of a glucometer has been approved for accuracy and it has been verified that only the approved version of the procedure is available. The Oaks does not employ agency nurses and does employ PRN (as needed) nurses who will be inserviced prior to returning to work on the floor. c) The facility will verify that the proper method of cleaning the glucometer continues to be followed by providing one weekly interview per shift of the nurses providing glucometer testing. The interview will be provided and documented by the DON, ADON, Clinical Coordinator (CC) or RN designee. Once per week, nurses on each shift will be observed by the DON, ADON, CC, or RN designee for proper glucometer cleaning procedures. The observation will be documented. The results of the interviews and the observations will be reported once a week to the Interdisciplinary Team. Cumulative results for the month will be reported in the monthly Quality Assurance (QA) meeting by the DON or ADON. Achievement of 100% of the understanding and 100% compliance for 4 weeks and the approval of the QA Team will result in reduction to monthly random testing of all shifts for proper cleaning of the glucometer and expressed understanding of the procedure. Additional actions as deemed necessary by the Administrator, DON and QA Team may also take place. The reporting of results of observation and interviews will become a part of the QA meeting. Training was provided on 4/12/13 to all nurses on duty related to cleaning and disinfection of the blood glucose meters. All seven nurses on duty could state the proper procedure for cleaning and disinfection of the glucometer. On 4/12/13 at 3:51 PM, after the aforementioned observations and interviews were completed, and the new policies and procedures were evaluated, the immediacy of IJ was removed and the facility had implemented corrective actions as alleged in the AOC based on interviews and inservice training. At this time the scope and severity of the citation was lowered from a "K" level to an "E". Review of the training documentation regarding glucometers on 4/12/13 revealed 11 nurses had been trained on the proper procedure for cleaning and disinfection of glucometers. The facility admitted resident #167 with [DIAGNOSES REDACTED]. During an observation on 4/10/13 at 8:57 AM, LPN #2 administered [MEDICATION NAME] eye drops to resident #167 without washing her hands prior to the administration of eye drops. During an interview with LPN #2 on 4/11/13 at 1:24 PM regarding the procedure for administering eye drops, s/he stated, "I hold the lower eye lid with a tissue and give one drop and then do the other eye. I wash my hands prior to giving eye drops and after eye drops are given". S/he verified that s/he forgot to wash her/his hands prior to administration of the eye drops. The resident in the adjorning room was noted to have been placed on contact precautions for an eye infection. Review of the"Eye Drops Administration Procedure" on 4/12/13 at 10:00 AM, revealed the first step under procedure is #1 was to "wash hands".

On the days of the survey based on observations, full and/or limited record reviews, interviews, and review of the policy provided by the facility entitled "Performing a Blood Glucose Test with the Assure Platinum Meter and the Infection Control Policy related to ensuring correct cleaning and disinfecting of the Assure Platinum Blood Glucose Monitoring System", facility administration failed to assure appropriate policies and procedures were implemented and monitored regarding the cleaning of glucometers when used between multiple residents placed the residents at risk for serious harm. There were 32 Residents residing in the facility who were receiving finger stick blood sugar monitoring. Cross refer to F 441as it relates to the failure of the facility to follow acceptable standards of practice for cleaning multi-resident use glucometers. The findings included: Based on interviews, observations, full and/or limited record reviews, and review of facility policies entitled "Performing a Blood Glucose Test with the Assure Platinum Meter and the Infection Control Policy", the facility failed to ensure a safe environment to prevent the development and transmission of disease and infection by failing to ensure cleaning and/or disinfection of multi-resident use glucometers between each resident use by 2 of 2 nurses (LPN #1 and #7), who were observed during finger stick blood surgar monitoring. The action affected one sampled resident (Resident #67) and had potential to affect 32 residents identified with physician orders [REDACTED]. During an interview on 4/12/13 at 11:15 AM, the Director of Nursing (DON) stated the Education Inservice staff member had given an inservice related to cleaning of glucometers. On 4/12/13 the Education Inservice person stated an inservice had been presented related to the cleaning and disinfecting of the glucometers, but the content of the infection control inservice could not be produced. The facility had policies and procedures regarding the cleaning and disinfecting of the glucometers but failed to assure all staff were knowledgeable in the policy and failed to monitor staff adherence to the policy. The systemic failure of the administration to educate and monitor staff placed rsidents with orders for finger stick blood sugar levels at risk for serious injury/harm. On 4/12/13 at approximately 12:35 PM, the Administrator and Chief Executive Officer were informed of the Immediate Jeopardy (IJ). Information was shared regarding the observation of facility staff not disinfecting the glucometer between each resident during blood glucose monitor observations. The facility presented a credible Allegation Of Compliance (AOC) on 4/12/13 at 3:19 PM. The AOC was accepted at 3:40 PM and included the following: a) The nurse observed by the survey team to improperly follow or respond to questions regarding cleaning procedures for a glucometer while caring for a resident was immediately removed from the floor to be inserviced on the proper procedure of the cleaning of the glucometer. b) Licensed staff will be re-inserviced regarding proper glucometer cleaning by the Assistant Director of Nursing and the Director of Nursing or trained Registered Nurse designee prior to returning to work on the floor. As part of the orientation process, the nurse being trained will sign that the process of cleaning a glucometer is clearly understood. The procedure for proper cleaning of a glucometer has been approved for accuracy and it has been verified that only the approved version of the procedure is available. The Oaks does not employ agency nurses and does employ PRN (as needed) nurses who will be inserviced prior to returning to work on the floor. c) The facility will verify that the proper method of cleaning the glucometer continues to be followed by providing one weekly interview per shift of the nurses providing glucometer testing. The interview will be provided and documented by the DON, ADON, Clinical Coordinator (CC) or RN designee. Once per week, nurses on each shift will be observed by the DON, ADON, CC, or RN designee for proper glucometer cleaning procedures. The observation will be documented. The results of the interviews and the observations will be reported once a week to the Interdisciplinary Team. Cumulative results for the month will be reported in the monthly Quality Assurance (QA) meeting by the DON or ADON. Achievement of 100% of the understanding and 100% compliance for 4 weeks and the approval of the QA Team will result in reduction to monthly random testing of all shifts for proper cleaning of the glucometer and expressed understanding of the procedure. Additional actions as deemed necessary by the Administrator, DON and QA Team may also take place. The reporting of results of observation and interviews will become a part of the QA meeting. Review of the training documentation regarding glucometers on 4/12/13 revealed 11 nurses had been trained on the proper procedure for cleaning and disinfection of glucometers. On 4/12/13 at 3:51 PM, after observations and interviews were completed ,the immediacy of IJ was removed after determining the facility had implemented corrective actions as alleged in the AOC. At this time the scope and severity of the citation was lowered from a "K" level to an "E".

On the day of the complaint inspection, based on limited record review, interviews, and review of the facility files, the facility failed to provide adequate supervision to ensure the prevention of accidents. The facility failed to assess and/or treat timely an injury to Resident #1. The findings included: Resident #1 was reviewed as a result of a facility reported incident. The Five-Day Follow-Up Report contained information documenting on 12/29/12 Certified Nursing Assistant (CNA) #1 reported to Licensed Practical Nurse (LPN) #1 that when s/he rolled Resident #1's wheelchair forward that the resident's left leg bent backwards, caught behind the wheelchair. On 1/2/13 the same CNA (#1) reported to LPN #1 that the Resident now had a bruise by her knee (left). At no time did the nurse follow-up on or document the CNA's concerns (12/29/12 and 1/2/13). Resident's #1's leg was x-rayed on 1/4/13 and diagnosed as a fractured femur. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. On 2/25/13 at 2:06 PM review of the Nurse's Notes revealed a note dated 1/4/13 at 9:00 AM that stated the Hospice CNA notified Licensed Practical Nurse (LPN) #2 that Resident #1 had swelling in the left ankle. Further review revealed a note timed at 10:00 AM the same day that the CNA on duty reported the resident had swelling to the left ankle and left knee with purple discoloration to the left ankle. Additional review revealed a note timed at 11:00 AM on 1/4/13 that LPN #2 informed the Clinical Coordinator (CC), a Registered Nurse, of the findings. On 1/5/13 at 12:45 PM, the Clinical Coordinator documented that the resident's son was informed of the incident and that the "DON (Director of Nursing) was investigating (and) would speak (with) him/her on Mon(day)." Review of the Personal Care Record (PCR) completed be the Certified Nursing Assistants for January, 2013, revealed a note dated 1/2/13 by CNA #1 that stated "LE (lower extremity) - On 12/29/12 report that resident left leg was bended (sic) backward when I (CNA) push (sic) the chair forward. I notify nurse. I also continue (sic) ROM (Range of Motion) observe during the day." Additional documentation dated 1/2/13 stated "Resident has a bruise by her/his knee (area). I (CNA #1) report to the nurse also still doing ROM." On 1/3/12, CNA #1 documented "Resident has a bruise area on top of foot (left) I notify nurse." On 1/4/13, the CNA (#2) assigned to the resident on that date, documented "Resident left knee is swollen (big) - Left foot is bruise (blue and black). S/he make loud noise when you move or touch her/his left leg. Nurse was notify (sic)." In an interview with the surveyor on 2/25/13 at 11:53 AM CNA #1 confirmed that on 12/29/12 after morning care s/he reported to the nurse about bending the resident's leg back under the chair. S/he stated that the nurse said s/he would check on the resident. CNA #1 stated at the end of the shift s/he reported to the nurse that the resident had pain when turning and changing brief. The CNA stated that on 1/2/13 when undressing the resident during morning care s/he saw a bruise on the resident's left knee, which s/she reported to the nurse. In an interview with the surveyor on 2/15/12 at 1:35 PM LPN #1 stated that s/he did not recall being told about the incident on 12/29/12. S/he stated that s/he learned of the incident on 12/30/12 when report was received from the prior shift; that after report s/he assessed the resident's leg and found no swelling/redness. "The resident always moaned". LPN #1 confirmed that s/he did not fill out an incident report or inform anyone of the incident. S/he stated that s/he was busy on 1/2/13 and the bruise reported by CNA #1 slipped her/his mind. On 2/25/13, during an interview at 4:08 PM, the Clinical Coordinator stated s/he was not working on 12/29/12 or 1/2/13 but was working on 1/4/13 when the resident was sent to the hospital for x-rays. The CC stated that the Licensed Practical Nurse (LPN) working on 1/4/13 asked the CC and the DON to come to the unit and look at the resident's leg. Per the CC, the DON, at that time, thought the bruise was associated with a prior incident and told the LPN that they were aware of the bruise. The CC stated that sometime between 2:00 and 4:00 PM, the LPN asked the MDS (Minimal Data Set) Nurse to look at the bruise. The MDS Nurse said the current bruise was not the one from the previous incident and informed the DON at that time and called the physician. When asked how the facility discovered what had happened, the CC stated that during the investigation, documentation from the CNA's was found. The CC stated that the LPN completed the Incident/Accident form and the CC completed another facility form. S/he confirmed that neither report was available for review during the complaint inspection.