Every finding on record at West Village Post Acute

Based on observation and interview, the facility failed to ensure beverages were served in a safe and sanitary manner to residents who ate in their rooms. This deficient practice had the potential to affect all residents who received beverages from the facility. Findings include: During an observation on 01/12/26 at 11:41 AM, staff on Unit 3 dispensed tea from a container on top of the food delivery cart, then carried the food tray with the uncovered cup of tea from the food delivery cart outside room [ROOM NUMBER] past the nurses' station to room [ROOM NUMBER]. During an observation on 01/12/26 at 5:30 PM, staff on Unit 1 poured tea from a container on top of the food delivery cart near the nurses' station, then walked the tray with the uncovered tea to room [ROOM NUMBER]. Staff then poured tea into another cup, placed it on a tray, and carried the uncovered tea to room [ROOM NUMBER]. During an observation on 01/15/26 at 11:32 AM, Certified Nursing Assistant (CNA)1 poured tea and coffee from the container on top of the food delivery cart, then carried the uncovered tea and coffee down the hall past the medication cart to room [ROOM NUMBER]. During an observation on 01/15/26 at 11:34 AM, CNA2 carried an uncovered cup of tea from the food delivery cart near room [ROOM NUMBER] approximately 36 feet, past a medication cart and past five opened resident room doors to room [ROOM NUMBER]. During an interview on 01/15/26 at 11:35 PM, CNA1 stated she had training on how to deliver meal trays. CNA1 stated the cover over the food protected it from germs. CNA1 stated if the tea was not covered it could get germs in it, but the kitchen had not provided them with lids for the tea. During a concurrent interview and observation on 01/15/26 at 11:38 AM, CNA2 poured tea from the container on top of the food delivery cart on the 500 Hall, then carried the tea past the nurses' station and the medication cart and delivered the tea to room [ROOM NUMBER]. CNA2 stated if the tea was uncovered it could get germs in it, but the kitchen had not sent any lids for the tea. During an interview on 01/15/26 at 11:46 AM, Licensed Practical Nurse (LPN)3 stated if staff poured tea and carried it down the hallway uncovered, it would be an infection control issue. During an interview on 01/16/26 at 10:21 AM, the Director of Nursing (DON) stated all food and beverages should be covered when being transported down the hall for infection control purposes. During an interview on 01/16/26 at 11:37 AM, the Administrator stated there should be lids on the tea when it was being passed on the halls.

Based on observation, interview, record review, and facility policy review, the facility failed to follow the planned menu. Specifically, the facility served the incorrect portion size for the pureed diets for the lunch meal on 01/13/26. This failure had the potential to affect 13 residents who received pureed diets. Findings include: Review of a facility policy titled Menus, revised 10/2017, indicated, Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. Review of the facility menu for the lunch meal served on 01/13/26, indicated the pureed baked salmon should be a 4-ounce (oz) portion, pureed chicken should be a 4 oz portion, and the pureed collard green should be a 1/2 cup portion. During observations of the lunch meal on 01/13/26 beginning at 11:22 AM revealed, [NAME] 4 plated the lunch meal. [NAME] 4 used a green #12 (2.67 oz) scoop to serve the pureed salmon and the pureed collard greens, and a 2-oz serving spoon to serve the pureed chicken. During an interview on 01/13/26 at 12:06 PM, [NAME] 4 stated she knew what portions to serve from looking at the production sheet. [NAME] 4 reviewed the scoops that were used for the meal service. [NAME] 4 confirmed she used a 2 oz serving spoon to serve the pureed chicken. [NAME] 4 stated she could not find the size on the green scoops in the pureed salmon and pureed collard greens but based on the color of the scoop, they were #12 scoops. [NAME] 4 then reviewed the production sheet and confirmed that she should have served 4 oz of pureed chicken, 4 oz of pureed salmon, and 1/2 cup of pureed collard greens. [NAME] 4 stated the scoops that she used were not the correct portion sizes. The Dietary Director (DD), who was present during the interview, confirmed the #12 scoop was slightly over a 2 oz portion. During a follow-up interview on 01/15/26 at 1:46 PM, the DD stated they should follow the menu and the portion sizes to make sure that residents received the correct nutrition daily. During an interview on 01/14/26 at 3:27 PM, the Dietitian stated she expected the kitchen staff to follow the menu and serve the correct portions so that residents received nutritionally sound meals that met their nutritional needs. During an interview on 01/16/26 at 10:21 AM, the Director of Nursing (DON) stated the staff should follow the portion sizes on the menu. The DON stated it was important to serve the correct portion sizes for nutrition and weight management. During an interview on 01/16/26 at 11:37 AM, the Administrator stated the staff should follow the menu and serve the correct portion sizes so that residents received the right number of calories to maintain their health.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff used the proper personal protective equipment (PPE) during the care of a resident on Enhanced Barrier Precautions (EBPs) for 1 (Resident (R)81) of 2 residents reviewed for infection control. Findings include: Review of the facility policy titled Enhanced Barrier Precautions, revised in December 2024, indicated, 1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. 2. Enhanced barrier precautions apply when: and indicated, b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; and c. Contact precautions do not otherwise apply. The policy continued, 5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies. The policy continued, 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied prior to performing high contact resident care activity (as opposed to before entering the room). The policy continued, 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: and indicated, i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc. [et cetera, and so on]; and j) wound care (any skin opening requiring a dressing). Review of R81's admission Record indicated the facility admitted R81 on 11/16/23 . According to the admission Record, the resident had a medical history that included diagnoses of, but not limited to: osteomyelitis, mild protein-calorie malnutrition, and personal history of other infections and parasitic diseases. Review of R81's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/09/25, revealed R81 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident had intact cognition. The MDS indicated R81 had an indwelling catheter. Review of R81's Care Plan Report, included a focus area initiated on 11/05/24, that indicated the resident required EBP during high-contact resident care activities due to the presence of wounds and suprapubic catheter. Interventions directed staff to utilize PPE (gown and glove; face-shield as indicated) during high-contact resident care activities (initiated 11/05/2024). Review of R81's Order Recap [Recapitulation] Report, dated for the timeframe 01/01/23 through 01/31/26, contained an order for EBP related to wounds with start date of 11/18/25 with no end date. During an observation and interview on 01/12/26 at 10:15 AM, R81 was observed with a peripherally inserted central catheter (PICC) line in their right upper arm and a suprapubic catheter. R81 stated they also had a wound on their left foot. R81 said that when the staff came in to provide care, they only wore gloves and did not wear a gown. During an observation on 01/12/26 at 11:36 AM, Certified Nursing Assistant (CNA)2 entered R81's room wearing only one glove, and emptied R81's catheter bag. CNA2 did not don a gown during the observation. During an interview on 01/15/26 at 2:36 PM, CNA2 stated when emptying a resident's catheter, she should have worn gloves and a gown and confirmed she did not wear a gown. She stated the PPE bins were empty, and she did not know where to obtain the supplies. During an observation on 01/12/26 at 11:45 AM, Licensed Practical Nurse (LPN)21 entered R81's room, LPN21 handled and inspected R81's PICC access line with gloved hands. LPN21 did not don a gown during the observation. During an interview on 01/14/26 at 12:31 PM, Registered Nurse (RN)23 stated EBP was used for residents with Percutaneous Endoscopic Gastrostomy (PEG) (a tube used to deliver food or medicine directly into the stomach), catheters, open wounds, and ostomies. RN23 stated that the purpose of EBP was to prevent the spread of infection. RN23 stated that when emptying catheter bags or handling central lines, the CNAs and nurses should have worn gowns and gloves. During an interview on 01/14/26 at 3:53 PM, Licensed Practical Nurse Manager (LPNM)22 stated residents with hemodialysis catheters, suprapubic catheters, PICC lines, and feeding tubes were placed on EBP. The purpose of EBP was to reduce the spread of infections from residents to staff or staff to residents. LPNM22 stated that anytime CNAs or nurses entered a resident room that was on EBPs, the staff must wear gloves and gowns. LPNM22 said this included emptying R81's suprapubic catheter and touching the resident's PICC line. During an interview on 01/16/26 at 9:13 AM, the Director of Nursing (DON) stated residents with catheters, wounds, ostomies, and any type of IV required EBPs. The DON stated staff should have worn gowns and gloves when performing direct patient care such as emptying catheters or handling central lines. The DON stated CNA2 and LPN21 should have worn gowns when providing care for R81. The DON stated wearing gowns and gloves served to prevent infections from spreading from one individual to another. During a joint interview on 01/16/26 at 10:32 AM, the Administrator (ADM) and the Regional Director of Clinical Services (RDCS), the ADM stated EPBs protected staff and residents from spreading respiratory or contacting illnesses from one another. The ADM stated they expected staff to follow EBP guidelines. The ADM stated CNA2 and LPN21 should have worn a gown when providing patient care to R81. The RDCS stated CNA2 and LPN21 should have worn a gown when providing patient care to R81.

Based on interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the status of 1 (Resident (R)81) of 2 residents reviewed for pressure ulcers. Specifically, R81's Quarterly MDS, with an Assessment Reference Date (ARD) of 12/09/25, did not reflect that the resident had intravenous (IV) access, specifically a peripherally inserted central catheter (PICC). Findings include: Review of the facility policy titled Resident Assessments revised on 10/2023, indicated, . 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. Review of the CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.19.1, dated 10/2024, revealed, Chapter 3: MDS Items, O0110: Special Treatments, Procedures, and Programs specified, O0110O1, IV Access Code IV access, which refers to a catheter inserted into a vein for a variety of clinical reasons, including long-term medication administration, large volumes of blood or fluid, frequent access for blood samples, intravenous fluid administration, total parenteral nutrition (TPN), or, in some instances, the measure of central venous pressure. The manual instructed, O0110O4, Central (e.g. [exempli gratia, for example], PICC, tunneled, port) Check when IV access was centrally located. Review of R81's admission Record indicated the facility admitted R81 on 11/16/23. According to the admission Record, the resident had a medical history that included diagnoses of, but was not limited to: paraplegia, osteomyelitis, mild protein-calorie malnutrition, and personal history of other infections and parasitic diseases. Review of R81's Order Recap [Recapitulation] Report contained an active order dated 08/22/25 to place a PICC line for antibiotic therapy. Review of R81's Care Plan Report included a RESOLVED focus area, initiated on 08/25/25 and resolved on 12/04/25, that indicated the resident was at risk for complications due to the presence of a PICC line for the long-term treatment with IV antibiotic therapy. Review of R81's Progress Notes revealed an Infection Note, dated 11/30/25, that indicated the resident's PICC line in the right upper arm remained patent (open, unobstructed, and functioning properly). Review of R81's Quarterly MDS, with an ARD of 12/09/25, revealed the assessment did not reflect the presence of IV access within the 14-day look-back period. Section O was not checked to reflect the presence of IV access, including central access. During a concurrent interview and record review on 01/15/26 at 9:22 AM, the Registered Nurse (RN) MDS Coordinator stated that Section O of R81's MDS did not reflect that the resident had a PICC line but should have. During an interview on 01/16/26 at 9:13 AM, the Director of Nursing (DON) stated she expected MDS assessments to be accurate. The DON stated it was important for MDS assessments to accurately reflect each resident's current condition (at the time of the assessment). The Administrator and the Regional Director of Clinical Services (RDCS) were interviewed on 01/16/26 at 10:32 AM. The Administrator stated he expected MDS assessments to be accurate. The RDCS confirmed R81 utilized a PICC line and stated she expected Section O of the resident's MDS to be accurate.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a care plan was in place to address the care needs associated with the use of a peripherally inserted central catheter (PICC) line for 1 (Resident (R)81) of 2 sampled residents reviewed for pressure ulcers. Specifically, the facility resolved a care plan addressing R81's PICC line on 12/04/25 and one was never re-initiated, despite ongoing PICC line use and access. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised in 03/2022, indicated, 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. The policy further indicated, . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy revealed, . 11. Assessments of the residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of R81's admission Record indicated the facility admitted R81 on 11/16/2023. According to the admission Record, the resident had a medical history that included diagnoses of, but not limited to: paraplegia, osteomyelitis, mild protein-calorie malnutrition, and personal history of other infections and parasitic diseases. Review of R81's Order Recap [Recapitulation] Report contained an active order dated 08/22/25 to place a PICC line for antibiotic therapy. Review of R81's Care Plan Report included a RESOLVED focus area, initiated on 08/25/25 and resolved on 12/04/25, that indicated the resident was at risk for complications due to the presence of a PICC line for the long-term treatment with IV antibiotic therapy. The Care Plan Report revealed no active focus areas addressing the resident's ongoing use of the PICC line or interventions that directed staff on the needed care and services related to the resident's PICC line. During an observation on 01/12/26 at 10:15 AM, R81 was in their room, and a PICC line was observed in the resident's right upper arm. R81's PICC line dressing was visibly soiled; the transparent dressing, dated 01/02/26, was almost detached from the resident's skin; dried blood was observed on the Biopath (a small, sterile antimicrobial foam disk placed around the PICC insertion site to reduce the risk of infections); and the central line itself was exposed and not covered. During an interview on 01/14/26 at 9:57 AM, the Admissions Nurse (AN) stated R81 had a central line for antibiotic therapy to treat osteomyelitis (infection of the bone). During a concurrent interview and record review on 01/15/26 at 9:22 AM, the Registered Nurse (RN) Minimum Data Set (MDS) Coordinator stated care plans were updated daily. The RN MDS Coordinator stated that the Licensed Practical Nurse (LPN) MDS Nurse was responsible for updating the care plans for long-term residents. The RN MDS Coordinator stated that if R81 still had a PICC line, the care plan should have indicated the PICC line was in use. During an interview on 01/15/26 at 11:47 AM, the LPN MDS Nurse stated the RN MDS Coordinator participated in daily clinical meetings where she received and gathered information regarding each resident from staff reports, assessments, and orders and then relayed new information to the LPN MDS Nurse so that she could update residents' care plans. The LPN MDS Nurse confirmed she was responsible for updating long-term care residents' care plans. During an interview on 01/16/26 at 9:13 AM, the Director of Nursing (DON) stated care plans must be updated in a timely manner. The DON stated she expected if a resident had a PICC line inserted, their care plan should reflect it. The DON stated R81's PICC line care plan should not have been resolved if the resident still had a PICC line in place. The Administrator and the Regional Director of Clinical Services (RDCS) were interviewed on 01/16/26 at 10:32 AM. The Administrator and RDCS both stated they expected care plans to be accurate and reflect each resident's needs.

Based on observation, interview, record review, and facility policy review, the facility failed to provide Resident (R)45 with an ordered oral nutritional supplement and failed to serve the correct portion size to the resident during the lunch meal on 01/13/26. This deficient practice affected 1 of 5 sampled residents reviewed for nutrition. Findings include: Review of a facility policy titled Food and Nutrition Services, revised 10/2017, indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The policy specified, . 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. Reivew of R45's admission Record indicated the facility admitted R45 on 05/17/16. According to the admission Record, the resident had a medical history to include diagnoses of, but not limited to: dysphagia, speech and language deficits following cerebral infarction, and dementia. Review of R45's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/19/25, revealed R45 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had severely impaired cognitive skills for daily decision. The MDS indicated R45 had no significant weight loss and received a mechanically altered diet. Review of R45's Care Plan included a focus area initiated 09/14/22, that indicated the R45 required a mechanically altered diet texture related to swallowing concerns. Interventions directed the staff to provide supplement as ordered (initiated 03/20/2023). Review of R45's Order Summary Report with active orders as of 01/12/26, revealed an order dated 06/07/24, for a regular diet with pureed texture and thin liquids; an order dated 10/06/23, for ice cream daily with dinner for weight stability; an order dated 10/08/25, for an eight-ounce high protein oral nutritional supplement with lunch for weight stability; and an order dated 10/08/25, for an oral nutritional supplement two times daily with breakfast and dinner for weight stability. During an observation of the lunch meal on 01/12/26 beginning at 12:48 PM, R45 was served a pureed meal with an oral nutritional supplement. The resident was not served an eight-ounce high protein oral nutritional supplement for weight stability as ordered. During an observation of the dinner meal on 01/12/26 at 5:37 PM, R45 received a pureed diet with ice cream; however, there was no oral nutritional supplement on the resident's meal tray. During an observation of the lunch meal on 01/13/26 at 11:22 AM, [NAME] 4 plated the lunch meal and used a green #12 (2.67 oz) scoop to serve the pureed salmon and the pureed collard greens and a 2-oz serving spoon to serve the pureed chicken. During an interview on 01/13/26 at 12:06 PM, [NAME] 4 stated she knew what portions to serve from looking at the production sheet. [NAME] 4 reviewed the scoops that were used for the meal service. [NAME] 4 confirmed she used a 2 oz serving spoon to serve the pureed chicken. [NAME] 4 stated she could not find the size on the green scoops in the pureed salmon and pureed collard greens but based on the color of the scoop, they were #12 scoops. [NAME] 4 then reviewed the production sheet and confirmed that she should have served 4 oz of pureed chicken, 4 oz of pureed salmon, and 1/2 cup of pureed collard greens. [NAME] 4 stated the scoops that she used were not the correct portion sizes. The Dietary Director (DD), who was present during the interview, confirmed the #12 scoop was slightly over a 2 oz portion. During an interview on 01/14/26 at 3:04 PM, Registered Nurse 6 stated dietary was supposed to place the supplement on the resident's tray. During an interview on 01/14/26 at 3:27 PM, the Dietitian stated she expected the kitchen staff to follow the menu and serve the correct portions so that residents received nutritionally sound meals that met their nutritional needs. The Dietitian further stated if eight-ounce high protein oral nutritional supplement was ordered, dietary should purchase it and place it on the resident's tray. During an interview on 01/15/26 at 1:46 PM, the DD stated they should follow the menu and the portion sizes to make sure that residents received the correct nutrition daily. The DD stated that when a resident had an oral nutritional supplement ordered, they needed to receive it so they got the extra protein and nutrition they needed if their appetite was poor. During an interview on 01/16/26 at 10:21 AM, the Director of Nursing (DON) stated staff should follow the portion sizes on the menu. The DON stated it was important to serve the correct portion sizes for nutrition and weight management. The DON stated if the Dietitian recommended an oral nutritional supplement it should be given as ordered for the health and well-being of the resident, whether that was wound healing or weight management. During an interview on 01/16/26 at 11:37 AM, the Administrator stated the staff should follow the menu and serve the correct portion sizes so that residents received the right amount of calories to maintain their health. The Administrator stated he expected any ordered nutrition supplement to be given to the resident so the resident received the right amount of calories to maintain their health.

Based on observation, interview, record review, and facility policy review, the facility failed to provide care and treatment according to professional standards for peripherally inserted central catheter (PICC) lines (long thin flexible tube inserted through a peripheral vein in the upper arm and advanced to the large vein near the heart) for 1 (Resident (R)81) of 2 residents reviewed for PICC lines. Specifically, the facility failed to ensure R81's PICC line dressing was secure and changed per physician order and facility policy. Findings include: Review of a facility policy titled Central Venous Catheter Care and Dressing Changes, revised June 2025, indicated, . 5. Change the dressing if it becomes damp, loosened, or visibly soiled and: a. at least every 7 [seven] days for TSM [transparent semi-permeable membrane] dressing; b. at least every 2 [two] days for sterile gauze dressing (including gauze under a TSM unless the site is not obscured); or c. immediately if the dressing or site appears compromised. The policy also specified under a section titled Documentation that, The following information should be recorded in the resident's medical record: 1) Date and time dressing was changed; 2) Location and objective description of the insertion site; 3) Any complications, interventions that were done; 4) Condition of sutures (if present); 5) Any questions, education given to the resident, resident's statement regarding IV [intravenous] therapy, and response to the procedure; and 6) Signature and title of the person recording the data. Review of R81's admission Record indicated the facility admitted R81 on 11/16/23. According to the admission Record, the resident had a medical history that included diagnoses of, but not limited to: osteomyelitis, mild protein-calorie malnutrition, and personal history of other infections and parasitic diseases. Review of R81's Order Recap [Recapitulation] Report contained an active order dated 08/22/25 to place a PICC line for antibiotic therapy. During an observation on 01/12/26 at 10:15 AM, R81 was observed with a PICC line in their right upper arm. R81's PICC line dressing was visibly soiled, the transparent dressing was dated 01/02/26, was almost detached from the skin, dried blood was on the Biopath (a small, sterile antimicrobial foam disk placed around the PICC insertion site to reduce the risk of infections), and the central line itself was exposed and not covered. During a concurrent observation and interview on 01/12/26 at 11:45 AM, in R81's room, Licensed Practical Nurse (LPN)21 inspected R81's PICC access line with gloved hands. LPN21 stated the PICC line dressing looks terrible and was barely hanging on. LPN21 stated the date on the PICC line dressing was 01/02/26. LPN21 stated that the insertion site was exposed and not covered by a transparent dressing. LPN21 stated that the PICC line was at risk of coming out. During an interview on 01/14/26 at 3:53 PM, Licensed Practical Nurse Manager (LPNM)22 stated she observed R81's PICC line dressing. LPNM22 stated R81's PICC line dressing was coming off, and the PICC line was coming out. LPNM22 stated PICC line dressings should be changed every seven days or whenever soiled. LPNM22 stated R81's soiled dressing had potential to cause infection. During an interview on 01/14/26 at 12:44 PM, Registered Nurse (RN)23 stated soiled PICC dressings were not acceptable. She stated she saw R81's PICC line dressing on 01/12/26 and had the PICC line removed the same day. She stated that the dressing was dated 01/02/26 and should have been changed on 01/09/26. RN23 stated that PICC line dressings should be intact and should be changed every seven days to help prevent infections to the resident, as the PICC line went directly into the patient's heart. During an interview on 01/16/26 at 9:13 AM, the Director of Nursing (DON) stated PICC line dressings should be changed per physician's order. The DON stated nurses should be looking for redness, discharge, and ensuring the dressing's integrity. The DON stated RNs and IV certified LPNs were responsible for maintaining and managing PICC lines.

Based on interview, record review, facility document review, and facility policy review, the facility failed to report an allegation of abuse to the state survey agency timely for 1 (Resident #1) of 3 residents reviewed for abuse/neglect. Findings included: A facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 08/2022, indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation 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. The policy further indicated, If resident abuse (staff to resident and/or resident to resident), neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator. a. All allegations of staff to resident abuse must be reported immediately but no later than 2 hours. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. the state licensing/certification agency responsible for survey/licensing the facility. The policy also specified the term, immediately was defined as, a. within two hours of an allegation involving abuse or result [sic] in serious bodily injury. b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. An Initial Report, dated 01/25/2025, indicated Resident #1 stated a certified nursing assistant (CNA) on third shift was rough during care. The report indicated Resident #1 named CNA #11 as the staff member who had been rough, and the CNA was suspended pending the investigation. The police, physician, and responsible party were notified. The report indicated the operations manager was notified of the allegation on 01/25/2025 at 9:00 AM. An e-mail dated 01/25/2025 revealed the facility sent the initial report to the state survey agency on 01/25/2025 at 1:48 PM, a period of four hours and 48 minutes after being informed of the allegation, which was not in compliance with the required two-hour reporting timeframe. During an interview on 03/13/2025 at 5:21 PM, the Operations Manager stated he currently was the only one who could complete allegation submissions to the state agency. He indicated most of the facility's weekend staff were agency, and they did not have the same access as facility staff did. He stated he understood that the reports needed to be submitted within two hours and that when he got to the facility on [DATE], he immediately started gathering all of the information before sending the report to the state. During a follow-up interview on 03/14/2025 at 12:35 PM, the Operations Manager stated he tried to send the initial report in via fax, but it did not go through. He stated he did not have fax confirmation sheets to show those attempts. The Operations Manager stated when the report was faxed, it showed up in the queue, but by the time he got home, he remembered staff saying that the fax had failed. The Operations Manager stated he had staff continue to try to fax the report but they ultimately had to submit it via eFax, which was the e-mail documentation dated 01/25/2025 that he had previously provided. During an interview on 03/14/2025 at 3:55 PM, the Operations Manager stated that moving forward, he would have a manager on duty who would be able to send in an initial allegation report and he would communicate with staff to make sure they reported abuse immediately.

Based on review of facility policy, record reviews and interviews, the facility failed to ensure resident rights were upheld related to voting in the Presidential Election, for 8 of 8 residents reviewed for Resident Rights. Finding include: Review of the undated facility policy titled, Resident Rights documented, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: g. Exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. Be supported by the facility in exercising his or her rights. i. Exercise his or her rights without interference, coercion, discrimination or reprisal from the facility, j. Be informed about his or her rights and responsibilities. During interviews with residents at a Resident Council Meeting at an unspecified date and time, three residents verbalized that they did not get the opportunity to vote in the Presidential Election on 11/05/24. The residents also stated that they filled out the voter registration form, but never got to vote. Review of the South Carolina Voter Registration Forms dated 10/21/24, revealed eight resident completed the South Carolina Voter Registration Forms and the forms were emailed to the Greenville County Voter Registration office 7 days after the deadline of 10/14/24. During an interview on 11/14/24 at 9:35 AM, the Social Service Director (SSD) stated that residents have been coming to her upset because they did not get to vote. The SSD further stated that the forms for registration to vote were completed on the last day and they should have been completed sooner. During an interview on 11/14/24 at 10:30 AM, the Administrator stated he was upset that the residents that wanted to vote did not get to. The Administrator stated that he spoke with the Activity Director (AD) months before the voter registration form was to be completed, if the residents were going to vote. They were completed after the cut off date. During an interview on 11/14/24 at 11:00 AM, the AD provided signed voter registration forms for eight residents. The eight residents are still residing in the facility and signed the South Carolina Voter Registration form on 10/16/24, 2 days after the deadline to complete registration to vote.

Based on record review, observation and interviews, the facility failed to ensure Resident (R)79's Protected Health Information (PHI) was maintained in a private manner, for 1 of 9 residents observed during medication administration. Findings included: Review of the facility policy titled Confidentiality of Information and Personal Privacy with a revision date of February 2021, documented, Our facility will protect and safeguard resident confidentiality and personal privacy . 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records . 4. Access to resident personal and medical records will be limited to authorized staff and business associates. Review of R79's Face Sheet revealed R79 was admitted to the facility on [DATE], with diagnoses including but not limited to: paraplegia, diabetes mellitus type two, morbid obesity, post traumatic stress disorder, schizoaffective disorder, and major depressive disorder. During an observation on 11/14/24 at 10:18 AM, revealed the Unit Two Medication Cart (A) was unattended, while R79's Electronic Medication Administration Record (EMAR) was visible on the computer screen. Additionally, there were two cups of a white topical cream on the medication cart. The Unit Two Medication Cart (A) was located at the far end of the hall, away from the nurses station. The nurse assigned to the Unit Two Medication Cart (A) was not in sight. R79's EMAR was visible to other residents, staff, visitors and anyone else who walked by the medication cart. During a second observation on 11/14/24 at 10:27 AM, revealed R79's EMAR still open to view and the cart unattended. Registered Nurse (RN)2 was observed going to the treatment cart located next to nurse's station while the medication cart was still located at the end of the hall. During an interview on 11/14/24 at 10:36 AM, RN2 revealed that it is expected that the nurse hit the lock button to hide the screen. RN2 further stated, It is done for HIPPA purposes, so no-one can see residents' information. RN2 stated that she was in a rush due to patient care. RN2 concluded that treatment medications should not be left on the medication cart unattended for no length of time. During an interview on 11/15/24 at 8:57 AM, the Director of Nursing (DON) stated, this is an issue, and, in the past, I have grabbed their cart, make them come and explain to me why the screen was not hidden. The DON stated, My expectation is if you pull a medication give the medication, and in an emergency lock up the medication. Pull one, give and then pull the other, not two treatments for different patients at one time. During an interview on 11/15/24 at 2:02 PM, RN1 revealed the expectation to use the system, to lock your screen, or use control, alt, delete so no one can have access to the resident's medical records. RN1 further stated, I have seen this being an issue currently and I have been reminding staff to not have private information exposed.

Based on review of facility policy, observation, and interviews, the facility failed to remove expired medication cards in 1 of 6 medication carts reviewed. Findings include: Review of the facility policy titled, Storage of Medications revised on November 2020, documents, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to dispensing pharmacy or destroyed. During an observation on 11/14/24, of the Medication Cart B on Unit 3, revealed three cards of expired Tramadol 50 mg (milligram) half tablets. Card one had an expiration date of 8/2024 and had 13 half tablets remaining, card two (full card) had an expiration date of 10/2024 and card three (full card) had an expiration date of 10/2024. During an interview on 11/14/24 at 11:07 AM, Licensed Practical Nurse (LPN)1 revealed that the nurse is responsible for ensuring the medications are in date. LPN1 stated, As I am doing the medication administration, I review the dates on the medications. I check mostly the scheduled and as needed medications. When I encounter expired narcotics or expired medications, I take it out the cart and take them to the Director of Nursing (DON) or the Unit Manager. I then get a new script from the physician. I check medication's dates every shift I work, but I did not do it today. I did not see these expired narcotics and I did not give them my shift. The last time I worked on this cart was around three weeks ago because I am as needed (PRN) staff. During an interview on 11/14/24 at 11:12 AM, LPN2 revealed the unit does monthly audits on medications and the pharmacy also perform monthly audits. Pharmacy came about two weeks ago and went through the narcotic book for expired medications and issues with medications. Medication reconciliation is also done at that time by the pharmacy. We also update the medication as it is changed. Thursdays are the medication reconcile date for Unit 3, to ensure that changes promptly noted, and medications are ordered. This ensures medications are accessible throughout. LPN2 stated, The three cards of Tramadol 50 mg half tablets are expired, they will be taken off the cart and given to the DON to return safely. I will contact the Nurse Practitioner to get an order so the patient can have them when needed. During an intervention on 11/15/24 at 8:49 AM, the DON revealed going forward the facility will continue to do medication cart audits on Thursdays. The DON stated since there is an identified issue, we will now be color coding medication cards to ensure there is no further issue with expired narcotic medications. We do not want any expired medications given.

Based on record review, interview, and review of facility policy, the facility failed to ensure that a care plan with interventions related to smoking and wandering/elopement was developed for 1 (Resident (R)1) of 2 residents. This failure had the potential for staff to not provide appropriate care and supervision to R1's needs. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of March 2023, read in part: A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Review of the facility's policy titled, Smoking Policy - Residents, with a revised date of August 2022, read in part: Policy Interpretation and Implementation 8. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Review of the facility's policy titled, Wandering and Elopements, with a revised date of March 2019, read in part: Policy Interpretation and Implementation 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of R1's Face Sheet located in the Electronic Medical Record (EMR) revealed, R1 was admitted to the facility on [DATE] and discharged on [DATE]. R1 was admitted to the facility with diagnosis that included but were not limited to; major depressive disorder, epilepsy, suicide attempt, unspecified symptoms and signs involving cognitive functions and awareness. Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/15/23 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R1 had moderately impaired cognition. Review of R1's Smoking Observation/assessment dated [DATE] revealed, Resident is a smoker or user of tobacco products, resident smokes 2-5 times per day, and the resident smokes throughout the day. Review of R1's Wandering Risk Observation/assessment dated [DATE] revealed, R1 was at risk to wander. During an interview on 07/10/23 at 4:03 PM the MDS Coordinator stated, This is something I would have to speak with my lead about. When questioned about R1 not having a care plan related to smoking and wandering/elopement. During an interview on 07/11/23 at 10:52 AM the Registered Nurse MDS (RNMDS) stated, We care plan on the orders. I didn't care plan him [R1] for elopement/wandering because he never showed any signs or the need for interventions. It's not until he actually tries to elope then I would create a care plan, even though he [R1] had an assessment that indicated he was at risk for elopement. Anyone can put in a care plan. Normally, our social services department does the smoking care plans. During an interview on 07/11/23 at 11:30 AM the Social Services Director (SSD) and Social Services Assistant (SSA) revealed, the smoking care plan was an oversight. It was missed because we are trying to reinforce the safety of smoking and in all our audits and we just missed him. The Director of Nursing (DON) was not available for interview. During an interview on 07/11/23 at 12:15 PM the Administrator stated, Not going to get any excuses about his [R1] care plans. We are fixing it as we speak.

Based on review of facility policy, record review, and interviews, the facility failed to ensure 1 Resident (R)59 of 8 residents reviewed for abuse was free from abuse. This deficient practice resulted in physical harm to R59 when R274 entered R59's room, while the resident was in bed, and punched her in the face. R59 sustained fractures of the zygomatic arch (cheekbone) and orbital area (eye socket). Findings include: Review of the facility policy titled Abuse a Neglect - Clinical Protocol, dated 03/18 indicated .Residents have the right to be free from abuse, neglect. misappropriation of resident property and exploitation. This includes but is not limited to freedom from.physical abuse.Protect residents from abuse. neglect. exploitation or misappropriation of property by anyone including, but not necessarily limited to .other residents. 1. Review of R59's electronic medical record (EMR) titled Admission Record, located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R59's quarterly Minimum Data Set (MDS) in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 07/26/22 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which revealed the resident was severely cognitively impaired. This assessment revealed the resident was ambulatory and had no behaviors, such as physical aggression towards others during this assessment period. Review of R59's EMR Care Plan located under the Care Plan tab indicated the resident had cognitive impairment due to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Review of R274's EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R274's admission MDS with an ARD of 07/19/22 indicated the resident had a BIMS score of 1 out of 15, which revealed the resident was severely cognitively impaired. Review of R274's EMR Care Plan, located under the Care Plan tab dated 07/25/22 indicated the resident had cognitive impairment related to Alzheimer's disease. The care plan revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal was to not permit the resident from wandering and no more than one altercation of a resident-to-resident by the next care plan review. Review of documents provided by the facility, referred to as the facility's investigation, revealed on 08/18/22, a Certified Nursing Assistant (CNA) heard yelling and went to R59's room and found R274 next to R59's bed. CNA overheard R59 saying don't hit me. The CNA was able to redirect R274 back to his room. The police were notified. The residents' representatives were notified. The medical provider was notified and ordered R274 to be sent to the emergency room for evaluation and treatment. R274 did not return to the facility. R59 was sent to the hospital for evaluation and treatment. The facility investigation revealed R59 was returned back to the facility after being identified with facial injuries. Review of documents provided by the facility titled CT [computed tomography] Head without Contrast dated 08/18/22 indicated the resident was punched in the face and as a result the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident also sustained a left medial blowout fracture of the orbital wall. During an interview on 10/12/22 at 1:06 PM, the Director of Social Services (DSS) stated she defined abuse as anything that was perceived as unwanted. The DSS stated there were no prior issues with R274 while he was living at the facility. During an interview on 10/13/22 at 10:30 AM, the Administrator confirmed the resident-to-resident with R274 and R59 was abuse. The Administrator stated R274 was not brought back to the facility since he was a danger to himself and to others. This deficiency was cited based on complaint intake #SC 806 and SC 80.

Based on observation, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner and hygiene and food handling standards were followed to prevent the potential spread of foodborne illness to 115 of 123 total residents (eight residents received nutrition via feeding tubes). Specifically, concerns were noted with the dishwasher water temperatures, hand hygiene when touching ready to eat foods, cleanliness of kitchen surfaces, labeling and dating of foods, wearing hair coverings, cross contamination when handwashing, and food storage. Findings include: Review of the dietary policy titled, Environment dated September 2017 revealed, All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition . The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including . walls . The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces . All trash will be contained in covered, leak-proof containers that prevent cross contamination. Review of the dietary policy titled, Authorized Kitchen Personnel dated September 2017 revealed, All authorized personnel must wear appropriate head covering while in the kitchen or production area. Review of the dietary policy titled, Staff Attire dated September 2017 revealed, All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained . All staff will exhibit appropriate personal hygiene. Review of the dietary policy titled, Equipment dated September 2017 revealed, All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials . All non-foods contact equipment will be clean and free of debris. Review of the dietary policy titled, Food Preparation dated October 2017 revealed, All staff will practice proper hand washing techniques and glove use . All staff will use serving utensils appropriately to prevent cross contamination. Review of the dietary policy titled, Warewashing dated September 2017 revealed, All dishwaher, serviceware, and utensils will be cleaned and sanitized after each use . All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature or low temperature machines . Temperature and/or sanitizer concentration logs will be completed . 1. During the initial kitchen inspection with the Dietary Account Manager on 10/11/22 from 10:02 AM - 10:44 AM, the following concerns were noted: a. The garbage can in the handwashing area had a lid covering the can. The garbage can did not have a hands-free mechanism to open the can for disposal of paper towels after handwashing. The surveyors had to touch the potentially contaminated garbage can lid with clean hands to dispose of the used paper towels after handwashing. There was a pitcher in the handwashing sink that the Dietary Account Manager removed so the surveyors could wash their hands. The wall on which the hand washing sink was mounted, was soiled with several beige drips running down the wall approximately four feet from top to bottom. b. The reach in refrigerator was observed and there were unlabeled/undated contents as follows: -There was a container of a brown food (identified by the Dietary Account Manager as gravy) that was not labeled to identify the contents. -There was a Styrofoam food container that was not labeled with the item or date. The container was opened, and it contained a green salad. The Dietary Account Manager stated (during the inspection 10/11/22 from 10:02 AM - 10:44 AM) that the label should document the name of the food and when it was placed in the refrigerator. -There was a transparent plastic gallon bag with a bagged sandwich within that was not labeled with the name of the food; a date of 10/12 was documented on the bag. The Dietary Account Manager said (during the inspection on 10/11/22 from 10:02 AM - 10:44 AM) the sandwich was egg salad and verified the date of 10/12/22 was incorrect as the date of 10/12/22 had not occurred yet. c. The walk-in refrigerator contained a large bin of approximately 15 individual cartons of Mighty Shakes. There was also a partially full box of Mighty Shakes on the shelf. Neither the bin, the individual cartons, nor the box identified when the shakes were placed into the walk-in refrigerator. The label on the shakes revealed the shakes should be used within 14 days once refrigerated. The Dietary Account Manager verified (during the kitchen inspection on 10/11/22 from 10:02 AM - 10:44 AM) there was no date documented when the shakes were pulled from the freezer and placed into the walk-in refrigerator. The Dietary Account Manager stated the shakes should be used within 14 days from when they were placed into the walk-in and there should be a date to indicate when they were placed into the walk-in. d. The dry storage area contained bulk bins of flour and sugar. The scoops were located within the bins. The Dietary Account Manager stated (during the inspection on 10/11/22 from 10:02 AM - 10:44 AM) the scoops should not be stored in the bins. e. In the food preparation area near the stove, there was a windowsill located directly below a window air conditioning unit that was noted with accumulated black residue. f. The sides of the fryer and stove (located next to each other with a gap of approximately eight inches in between) had accumulated grease/black build up covering a substantial portion of the surfaces. g. There was a beverage in a cup with an opened lid that was on the bottom shelf of a cart located next to the stove. The Dietary Account Manager moved the cart and the beverage spilled onto the floor. The Dietary Account Manager stated (during the inspection on 10/11/22 from 10:02 AM - 10:44 AM) the drink should not be in a food preparation area. h. Staff members were washing dishes in the commercial dishwasher. The manufacturer's name plate revealed it was a low temperature machine with a minimum temperature of 120 degrees Fahrenheit (F) required for both wash and rinse and 50 parts per million (ppm) of chlorine to sanitize dishes. A cycle of dishwashing was observed, and the wash temperature was 96 degrees F, and the rinse temperature was 100 degrees F; the chlorine level was 100 ppm. The Dietary Account Manager verified (during the inspection 10/11/22 from 10:02 AM - 10:44 AM) staff were near the end of washing the breakfast dishes and that the temperatures were inadequate to sanitize the dishware. The Dietary Account Manager stated he was not aware the wash and rinse temperatures had not been hot enough. The Dish Machine Log from 10/01/22 - lunch 10/11/22 was reviewed during the initial inspection and there were significant discrepancies in the temperatures of the wash and rinse cycles between breakfast/lunch and dinner. For the dinner meal the wash and rinse temperatures were inadequate every day of the month. Findings from the log were: Temperatures were noted between 160 - 161 degrees F for the wash cycle on the breakfast and lunch shifts. The rinse temperature for the breakfast and lunch shift was documented between 140 - 145 degrees. Both the wash and rinse temperatures for the dinner shifts were documented at 110 degrees F consistently (below the minimum required temperature of 120 degrees F) each day of the month, indicating the temperatures had been out of range for at least 10 days. The recorded dish machine temperatures for both breakfast and lunch on 10/11/22 were already recorded and were 161 for wash and 140 for rinse for breakfast and 160 for wash and 141 for rinse for lunch (which had not yet been served when the log was reviewed). The Dietary Assistant Manager stated (during the initial kitchen inspection 10/11/22 from 10:02 AM - 10:44 AM) the lunch temperature should not be logged yet since staff were washing breakfast dishes and lunch had not been served. The Dietary Account Manager stated (during the initial kitchen inspection on 10/11/22 from 10:02 AM - 10:44 AM) he was not aware of the abnormal temperatures on the dish machine log for October. The Regional Certified Dietary Manager (CDM) stated (during the initial kitchen inspection 10/11/22 from 10:02 AM - 10:44 AM) the dishes would be washed using the three-sink method and they would serve meals on disposable dishware until the dish machine was serviced and water temperatures were at acceptable levels. 2. During a second kitchen inspection conducted on 10/12/22 at 9:24 AM with the Regional CDM, the following concerns were noted: a. There was a Styrofoam container without a label identifying the contents or date located in the reach-in refrigerator. Inside the container was a chef salad. There was also a large clear storage container of beans in the reach in refrigerator without a label identifying the contents and date. The Regional CDM verified the lack of labels and stated the containers should be labeled and dated with the item name and date. b. On the windowsill, under the air conditioning unit, the black residue continued to be present and there was also a spider web noted with small bugs entrapped. There were rolls of foil and plastic wrap located below the windowsill. c. There was a personal beverage in a cup with a straw on the cart located by the stove. The Regional CDM stated on 10/12/22 at 9:28 AM the drink should not be stored there. d. The sides of the fryer and stove (located next to each other with a gap of approximately eight inches in between) continued to have accumulated grease/black build up covering a substantial portion of the surfaces. The Regional CDM stated on 10/12/22 at 9:30 AM the area needed to be cleaned. 3. During an observation of tray line meal service for breakfast on 10/12/22 starting at 7:45 AM, two dietary aides (DA) were observed without their hair completely covered while assisting with breakfast meal service. DA 115 was wearing a hairnet but her bangs were not contained within the hair net. DA 118 had multiple small braids down her back were not covered by a hairnet. During an interview on 10/12/22 at 9:24 AM, the Dietary Account Manager stated the water heater was broken and although the dish machine temperatures reached 120 degrees, the water temperature fluctuated and dropped lower than 120 degrees F periodically. The Dietary Account Manager stated the hot water heater would be repaired on 10/13/22 and until that time, disposable dishware would be used, and all dishware, pots, and pans would be washed manually using the three-sink method. During an interview on 10/12/22 at 6:36 PM, the Maintenance Director stated the water heater went out on Friday (10/07/22) and the CDM notified him at that time of low water temperatures. . During an interview on 10/13/22 at 11:15 AM, the Regional CDM verified there should be, but was not, a garbage can that was foot operated so the person washing their hands did not contaminate their hands when discarding the used paper towels. The Regional CDM verified the garbage can for disposing of paper towels had a lid on it and the lid had to be touched to dispose of the used paper towels. . The cleaning schedule (10/03/22 - 10/10/22) September and October 2022 were reviewed. Review of the Cleaning Assignment Sign-off assignments from 09/01/22 - 10/10/22 revealed: Clean wall behind and around the dish room sink and handwashing sink was assigned to be completed once each month: on 09/08/22, and on 10/11/22. There was no documentation to show this monthly cleaning assignment was completed for September 2022 or October 2022. Wipe down, organize, and date all items in reach in refrigerator was assigned to be completed once each month: on 09/05/22 (not done), and on 10/15/22. This assignment was not completed on 09/05/22. It was not due in October 2022 until 10/15/22 (after completion of the survey). -For the 32 assigned cleaning tasks from 10/03/22 - 10/10/22, 12 assignments were not documented as having been completed. 10. During an interview on 10/13/22 at 2:27 PM with the Regional CDM and the Dietary Account Manager, . verified the dishwasher temperature logs documented unrealistic temperatures such as wash temperatures of 160 degrees F. They stated the logs should be monitored by the Dietary Account Manager at least once a week and staff should notify the manager of potential problems right away. The Regional CDM and Dietary Account Manager stated scoops should not be in the bulk food bins. The Regional CDM stated the sides of the oven and fryer had way too much grease. The Regional CDM verified the presence of drips down the wall where the handwashing sink was mounted on the wall. Both the Regional CDM and Dietary Account Manager verified the presence of a lot of holes in the cleaning schedule sign off. They stated designated positions were responsible for specific cleaning assignments. The Regional CDM and Dietary Account Manger stated an area, away from food preparation, was needed for staff's beverages. The Regional CDM and Dietary Account Manager stated staff's hair should be totally covered when working in the kitchen.

Based on observation, interview, record review, and policy review, the facility failed to ensure palatable food was served to 5 of 64 sampled residents (Resident (R)1, R81, R102, R66, and R76). Residents complained foods were not flavorful and were not hot when they received their meals. Findings include: Review of the facility's policy titled, Food: Quality and Palatability dated September 2017 revealed, Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature . Food palatability refers to the taste and/or flavor of the food. During an interview on 10/12/22 at 8:56 AM, R1 stated the breakfast was cold and she would not eat it. She had been served grits, scrambled eggs, and beverages. R1 stated she was not provided butter for the grits, and she did not like grits without it. Observation revealed she did not have butter or margarine on her tray. Review of R1's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/05/22, located in the electronic medical record (EMR) under the MDS tab revealed R1 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (score of 13 - 15 indicates intact cognition). During an interview on 10/11/22 at 10:12 AM, R81 stated the food was of poor quality, was typically cold, and not very good. Review of R81's quarterly MDS with an ARD of 09/08/22 in the EMR under the MDS tab, revealed R81 was intact in cognition with a BIMS score of 15 out of 15. During an interview on 10/11/22 at 10:32 AM, R102 stated the food was lousy and nasty. Review of R102's quarterly MDS located in the EMR under the MDS tab with an ARD of 08/04/22 revealed, R102 had a BIMS score of 15 out of 15, indicating R102 was cognitively intact. During an interview on 10/11/22 at 5:05 PM, R66 stated the food was[OBSCENITY]and reported she had previously worked as a chef. R66 stated the food was lukewarm. Review of R66's annual MDS located in the EMR under the MDS tab with an ARD of 08/29/22 revealed, R66 had a BIMS score of 15 out of 15, indicating R66 was cognitively intact. During an interview on 10/11/22 at 1:56 PM, R76 stated that sometimes the food was cold. Review of R76's quarterly MDS located in the EMR under the MDS tab with an ARD of 09/01/22 revealed, R76 had a BIMS score of 15 out of 15, indicating R76 was cognitively intact. Review of the undated Mealtimes document revealed meals were served from 7:15 AM - 8:15 AM and there were two carts sent to each station (1, 2, and 3) for a total of six meal carts. According to the Mealtimes document, the last two carts were scheduled for delivery to Station 1 at 8:05 AM and 8:15 AM. Observations of the tray line meal service and distribution of meals to residents in their rooms was made on 10/12/22 from 07:40 AM - 9:02 AM. Observation of the tray line revealed foods included scrambled eggs, grits, toast, and pureed bread and pureed eggs. There were also small pans with a few servings of bacon, sausage, and fried eggs. The majority of residents were served grits or cold cereal, scrambled eggs, and beverages. The following concerns were noted: The residents' beverages, individual serving sized cartons or cups (milk, Mighty Shakes, and juices), had been placed in bins on a cart. There was no ice or refrigeration in place to keep the beverages cold during meal service. Beverages were at room temperature in the kitchen from at least 7:40 AM when the surveyors entered the kitchen (meal service had started prior to this time) until 8:22 AM when the last meal cart was delivered from the kitchen to the Unit 1. There was no visible cheese in the scrambled eggs. The eggs were spongy in appearance. The last two carts for Station 1 were not enclosed carts. They were sheet pan racks that were open to air and had no mechanism in place to keep the hot foods hot. The first cart for Station 1 was wheeled out of the kitchen at approximately 8:07 AM. The second cart for Station 1 was wheeled out of the kitchen at 8:22 AM. A test tray of a regular diet with an assortment of beverages was the last tray dished up and placed onto the second cart for Station 1. When the second cart arrived near the nursing station on Station 1 at 8:22 AM, the first cart for Station 1 was also located at the nursing station, without the meals having been served. There were 18 meals on the first cart and 17 on the second cart for Station 1. There was a total of 24 residents' rooms on Station 1, with one to four residents residing in each room. At 8:26 AM a Certified Nursing Assistant (CNA) 18 removed the first tray from the second cart to deliver to the first resident. None of the trays on the first cart had been served. At 8:29 AM CNAs were serving trays from both carts and 13 trays remained on the second cart. At 8:38 AM there were nine trays remaining on the first cart. At 8:41 AM, five trays remained on the second cart. At 8:49 AM, there were nine trays remaining on the first cart. At 8:53 AM, there were four trays on the first cart and two trays on the second cart. At 8:56 AM there were three trays on the first cart and two trays on the second cart. At this time CNA 18 served R1 her breakfast tray consisting of grits, scrambled eggs, and beverages. R1's tray was taken from the first cart for Station 1 that had been taken to the nursing station at approximately 8:07 AM. R1 told the surveyors the meal was cold, and she was not going to eat it. R1 invited the surveyors to take the temperature of the hot foods. The temperature of the grits was 96.6 degrees Fahrenheit (F), and the scrambled eggs were 97.1 degrees F. At 9:02 AM the last tray from the Station 1 carts was served. It took approximately 55 minutes to serve all the trays on the first cart to Station 1 and 40 minutes to serve the second cart to Station 1. At this time, the temperature of the test tray was measured, and the temperatures were verified by CNA 12. The eggs were 102.6 degrees F, grits were 112.2 degrees F, orange juice was 62.6 degrees F, thickened cranberry juice was 64.5 degrees F, thickened milk was 62.8 degrees F, and two percent milk was 57.3 degrees F. The surveyors tasted the scrambled eggs, and they were spongy in texture and cool to the palate. The grits were congealed and when placing the tines of the fork into the grits the entire congealed piece stuck together on the fork. The grits were lukewarm. The thickened milk was lukewarm, and the two percent milk was cool but not cold. During an interview on 10/13/22 at 2:27 PM with Regional Certified Dietary Manager (CDM) and the Dietary Account Manager, they stated they had three insulated carts for distributing residents' meal trays to the units. They verified two of the carts, for Station 1, were sheet pan racks and were not enclosed and had no mechanism in place to keep the meals warm. They stated the temperature of the foods served to residents for hot foods should be between 120 - 130 degrees Fahrenheit (F) when the residents received their trays. They verified the beverages should be kept cold during meal service, on ice for example, and should not be at room temperature while trays were being dished up and served. The Dietary Account Manager verified he had received some complaints about food temperatures.

Based on review of facility policy, record review, obsevations, and interview, the facility failed to ensure residents received care and services in a dignified manner for 1 of 2 residents reviewed for dignity (Resident (R) 119). Staff entered R119's room on two occasions and turned off his call light without addressing R119 or attempting to determine what he needed. Findings include: Review of the undated facility policy titled Dignity read, 1. Residents are treated with dignity and respect at all times .8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice .13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity . R119's Order Summary Report located in the electronic medical record (EMR) under the orders tab, indicated R119 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R119's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/28/22 located in the EMR under the MDS tab, indicated R119 had short- and long-term memory problems and was rarely or never understood. The MDS indicated R119 required total care with all his activities of daily living. During an observation on 10/11/22 at 11:48 AM, R119 was laying on his left side in bed. R119 did not respond verbally, however, he made eye contact when spoken too and he tracked movement in the room with his eyes. R119's call light was a flat round pad which was activated by light pressure. The call light was located close to the back of R119's right shoulder. R119 activated his call light and Certified Nurse Aide (CNA)18 entered R119's room and turned off his call light then left the room. She did not speak to R119 at all while she was in the room. During an observation and interview on 10/11/22 at 11:50 AM, R119 again activated his call light. CNA18 entered R119's room and walked to his call light reset box located on the wall beside R119's bed. R119 tracked CNA 18's movement with his eyes. After turning R119's call light off, CNA 18 turned to leave the room without addressing R119. CNA 18 stated that R119's call light was placed behind resident at his shoulder so he could roll back on it if he needed something. She stated that R119 was not able to talk so she did not know what he wanted. Review of R119's care plan last revised 9/20/22, located in the EMR under the care plan tab, indicated R119 had impaired communication related to his cognitive deficits. The care plan indicated he was sometimes able to communicate yes/no but at most other times he was unable to answer adequately. The care plan goal was for R119 to have his needs met. Care plan interventions included, ask me simple, direct questions. Try to use questions that require only a yes or no answer when possible. Ask me to repeat important information to ensure understanding. Minimize/eliminate distractions as much as possible when communicating with me. Face me when speaking. Speak clearly and slowly. During an observation on 10/12/22 at 12:02 PM, R119 was laying in bed. He made eye contact and attempted to answer questions when spoken too. He followed movement in the room with his eyes. During an interview on 10/12/22 at 12:46 PM, the Social Services Director stated that staff should always address residents when entering their room. She stated that if a resident could not verbalize their needs, but their call light was on, staff should investigate why the call light was on. During and interview on 10/12/22 at 1:44 PM, CNA18 stated that R119 scooted around a lot so his call light came on frequently. She stated that she did not think he ever intentionally turned it on. She stated that she should verify if a resident did need anything prior to leaving the room. She stated that she did not do that with R119 because she had already been in the room several times. During an interview 10/12/22 at 3:58 PM, the Director of Nursing (DON) stated that she expected staff to always. attempt to find out what a resident wanted when they turned on their call light. She stated that if a resident was unable to express what they wanted, she expected staff to investigate every time. The DON stated that she expected staff to talk to every resident when they entered their room regardless of if the resident could answer. She stated that it was not appropriate to enter a resident's room and turn the call light off without addressing the resident.

Based on review of facility policy, observations, record review, and interview, the facility failed to ensure 1 of 1 resident (Resident (R) 82) had their call light within reach. Findings include: Review of undated facility policy titled, Signal System Policy revealed, Call light shall be placed within the reach of the resident. During an observation on 10/11/22 at 1:03 PM; 10/11/22 at 4:45 PM; 10/12/22 at 7:35 AM; 10/12/22 at 8:25 AM; 10/12/22 at 12:37 PM and 10/13/22 at 7:35 AM, R82's call light was on the floor on the right side, at the head of the bed. Review of R82's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R82's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 09/09/22 revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident was moderately impaired. During an interview on 10/12/22 at 12:45 PM, CNA22 stated when she assists a resident into bed, the call light should always be in place. During an interview on 10/13/22 at 5:35 PM, the Director of Nursing (DON) and the Administrator stated, all staff are trained to put call lights within reach. The DON stated, I would think they would pick it up and put it within reach. The DON and the Administrator both agreed R82 needed to have her call light within reach.

Based on review of the facility policy, record review, and interviews, the facility failed to ensure residents were allowed to have visitors of their choosing for 1 of 1 Resident (R)121 reviewed for visitation. R121 was not allowed visits from his responsible party. Findings include: Review of the facility's undated policy titled Visitation read, .Policy interpretation and implementation: 1. Residents are permitted to have visitors of their choosing at the time of their choosing .Reasonable Clinical and Safety Restrictions: 1. Some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security and/or rights of the facility's residents such as: .b. denying access or providing limited and supervised access to an individual if that individual is suspected of abusing, exploiting, or coercing a resident until an investigation into the allegation has been completed or has been found to be abusing, exploiting, or coercing a resident . Review of R121's face sheet, located in the electronic medical record (EMR) under the profile tab, indicated R121 was admitted to the facility 05/07/15 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R121's quarterly Minimum Data Set (MDS) located in the EMR under the MDS: tab, with an Assessment Reference Date (ARD) of 09/29/22 indicated R121's Brief Interview of Mental Status (BIMS) score indicated that he was rarely or never understood. During a telephone interview on 10/11/22 at 3:51 PM, R121's stepfather stated that he was R121's responsible party. He stated that he was the only person who came to visit R121. He stated that a facility representative told him several years ago that he wasn't allowed to visit R121 anymore. He stated that he had not been allowed to visit R121 since that time. During an interview on 10/12/22 at 1:30 PM Certified Nurse Aide (CNA)18 stated that she had worked with R121 for over a year and had never seen anyone visit R121. During an interview on 10/12/22 at 1:53 PM, the Social Services Director (SSD) stated that R121 never had visitors. She verified R121's responsible party was not allowed to visit. She stated that she heard from other staff that R121's responsible party had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that all the history occurred prior to her employment. During an interview on 10/12/22 at 4:17 PM, the Social Services Assistant (SSA) stated that R121 was placed in the facility by Department of Social Services (DSS). She stated that R121's stepfather became his responsible party when DSS closed his case. She stated it was reported that R121's responsible party would come to visit at 11:00 PM at night. She stated that it was reported that R121's stepfather was standing at the foot of R121's bed and did inappropriate things. The SSA stated that this occurred several years ago and R121's stepfather had not been allowed to visit since that time. She stated she thought it was the Administrator at the time of the incident who told R121's responsible party he could not come back to the facility. The SS assistant stated that she was not sure if the incident was reported to police, DSS, or the State agency. She confirmed R121's stepfather was R121's responsible party and no steps had been taken to legally prevent him from visiting R121. She stated there had not been any action taken to revisit the issue. During an interview on 10/13/22 at 9:41 AM, the SSD stated that the incident involving R121's stepfather occurred several years ago and that there was no documentation regarding the incident that caused R121's visitation with his stepfather to be removed. Review of R121's care plan dated 07/15/22 indicated R121 was at risk for alterations in mood and behaviors r/t [related to] complicated family relationships and previous experiences with family members. The care plan goal was for visits with family/friends to take place in open, safe, supervised public areas and for R121 to remain free from any adverse situations during visits from family/friends. Care plan intervention was to establish an alert and intervention system with staff to observe family/friend visits. During an interview on 10/13/22 at 1:22 PM, the Administrator stated that he did not know there was an issue with R121's responsible party visiting and that the issue should be revisited, and possible supervised visitation could be arranged.

Based on review of facility policy, record review, and interviews, the facility failed to act upon a grievance for 1 of 2 Residents (R)6 reviewed for personal property. Findings include: Review of facility policy titled, Resident Council, dated 12/31/15 revealed, Follow up to resident concerns shall be documented in the Resident Council Meeting minutes the following month .The Administrator/designee shall review and respond to all resident issues. Review of facility policy titled, Grievances/Complaints, Filing, dated 04/01/17 revealed, Any resident may file a grievance or complaint . regarding his or her stay at the facility. Review of R6's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R6's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 10/03/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of Resident Council Minutes dated 09/29/22, included R6 was in attendance in the meeting and stated her headphones are missing. During an interview on 10/11/22 at 3:36 PM, R6 stated when she moved to another room her earphones were missing. She stated that she had informed both the Social Service Director (SSD) and the Administrator. She stated that no one in the facility had done anything about her missing earphones and she had purchased another pair. During an interview on 10/13/22 at 9:32 AM, the SSD stated that she did not know the earphones were missing and could not confirm R6 had earphones upon admission because they were not on her inventory list. During an interview on 10/13/22 at 1:33 PM, the Activities Director (AD) stated that she would handle grievances and complete grievance paperwork and if a resident had something missing, she would notify the SSD and the Administrator but usually did not put anything in writing about a missing item. She stated that she had notified the Administrator and the SSD about R6's missing earphones. During an interview on 10/13/22 at 1:43 PM, the Administrator stated that he would normally review the resident council minutes but did not review the 09/29/22 minutes. He stated that if a resident had something missing, he would notify the SSD so she could work on replacing it. He stated that R6 had come to him about the missing earphones, but a few days later saw R6 wearing earphones so I assumed they had been found. He stated he had not talked to the SSD or the resident to confirm they had been found.

Based on review of the facility policy, record review, observation, and interviews, the facility failed to ensure the right to be free from restraints was exercised for 1 of 1 Resident (R)175 reviewed for restraints. Specifically, staff physically restrained (restrict freedom of movement) of R175 when she was placed in a geri-chair. The facility's deficient practice had potential to inflict mental anguish and/or physical harm to R175. Findings include: Review of the facility policy titled Use of Restraints, dated 04/17 indicated, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Review of R175's electronic medical record (EMR) titled Admission Record, located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R175's admission Minimum Data Set in the EMR under the MDS tab with an Assessment Reference Date of 10/10/22 revealed the staff could not determine a Brief Interview of Mental Status (BIMS) score and indicated the resident had short-and-long-term memory problems. The assessment indicated the resident would wander. The assessment revealed the resident required extensive assistance of one staff member for bed mobility and limited assistance of one staff member for transfers. The assessment indicated the resident was unstable without staff assistance for walking and that the resident did not utilize a restraint. Review of R175's EMR Care Plan, located under Care Plan, tab dated 10/12/22 that the resident was at risk for falls related to attempts to stand, transfer or to walk alone. The care plan revealed the contributing factors were related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 10/12/22 at 5:43 AM, R175 was observed sleeping in a geri-chair. The resident was in the 500/600 hallway main dining room. The geri-chair was reclined all the way down. During this observation and interview was conducted at 5:45 AM, Licensed Practical Nurse (LPN)45 stated the resident was wandering on the night shift and was place in the geri-chair so she could rest. On 10/12/22 at 5:50 AM, Certified Nursing Assistant (CNA)4 was interviewed and she stated she took the resident to the bathroom prior to placing her in the geri-chair. During an interview on 10/12/22 at 1:40 PM, CNA1 stated she has never seen R175 placed or use a geri-chair. CNA1 stated the resident did not like to use a wheelchair since she liked to get up and move. CNA1 stated a restraint would prevent a resident from doing what they wanted. During an interview on 10/13/22 at 9:42 AM, MDS Coordinator58 stated a restraint prevents a resident from free movement. During an interview on 10/13/22 at 10:38 AM, the Nurse Clinical Consultant stated she heard about the use of a geri-chair with R175. The Nurse Clinical Consultant stated she would have expected an attempt to place the resident in bed first and could not locate a restraint assessment for R175 prior to the survey team exiting the facility.

Based on record review, including the facility's abuse policy titled Abuse Investigation and Reporting, and interview the facility failed to implement the components of its abuse policy that prohibit and prevent abuse for one of three residents reviewed for abuse. Resident #87's family member informed the facility of an allegation of abuse on 4/20/18. The facility failed to interview the resident and the resident's roommate, both were noted to be interviewable. The facility failed to follow their policy related to protection of residents after an allegation of abuse. The findings included: The facility reported an allegation of mental abuse for Resident #87 to the State Agency on 4/20/19 and noted the incident was reported to the administrator on 4/20/19 at 6:00 PM. The report was faxed on 4/20/19 at 6:54 PM. Review of the assignment sheet dated 4/18/19 revealed CNA #6 worked 3:00 PM- 11:00 PM and was assigned to Resident #87. Review of the facility's 5-day report summary revealed Resident #87 alleged CNA #6 came into his/her room and threw his/her doll onto the ground and said you pee every five minutes and would not give the doll back when asked to. Review of Resident #87's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score 15. Review of the facility's investigation revealed a statement from the administrator dated 4/20/19 that indicated she received a phone call from staff stating that Resident #87's family member was at the facility with concerns. The administrator called the facility and spoke with the family member. The family member explained that Resident #87 called him/her and told him/her that a CNA refused to pick up his/her family member's baby doll from the floor. Review of the facility's investigation revealed a statement by Resident #87 dated 4/22/19 taken by the administrator and the Risk Manager. The statement indicated last Thursday on 2nd shift CNA #6 came in and threw my doll down and said you pee every 5 minutes. Resident #87 asked CNA #6 to give it back and s/he walked out. Resident #87 asked another CNA to give it to him/her and s/he said give him/her a minute and left. CNA #7 gave it back to the resident. There was no statement that indicated Resident #87 was interviewed at the time of the allegation on 4/20/19. In an interview with the surveyor on 5/9/19 at approximately 2:45 PM, the administrator stated the incident was reported to him/her on 4/20/19. The weekend nurse called and stated Resident #87's family was at the facility and very irate, they were upset about an incident that happened. The administrator talked with the resident's responsible party on the phone and s/he stated Resident #87 called him/her and told him/her someone threw his/her doll down and would not pick it up. It was a doll baby that the resident has on his/her bed. The administrator told the responsible party s/he would find out what was going on. The responsible party said the incident happened last Thursday during 1st shift. The responsible party said it was somebody named (CNA #6). When the administrator looked at the schedule CNA #6 did not work that day on 1st shift. The administrator talked to the resident on 4/22/19 and s/he said it was CNA #6, s/he stated it was not on 1st shift but on 2nd shift. The resident said it happened between 8:00 and 9:00 PM on Thursday. They identified it was CNA #6 and they suspended him/her. The administrator called CNA #6 on Monday 4/22/19 and told him/her s/he was suspended. CNA #6 was not on the schedule to work on Sunday. The administrator stated the Risk Manager came to the facility on Saturday and sent the reportable in. The administrator stated the Risk Manager did not talk with Resident #87. The administrator stated s/he talked with Resident #87 on Monday 4/22/19. The administrator stated s/he would expect the staff member who came up to the facility to interview the resident and try to identify the alleged staff member. When the administrator talked with Resident #87 on Monday 4/22/19 s/he identified the staff as CNA #6. Resident #87 said CNA #6 came in and threw his/her doll down, said you pee every 5 minutes, and left. The administrator and the Risk Manager interviewed CNA #6 together and s/he stated s/he told the resident not to be on the call light too much in a joking manner. At times, the resident will clip his/her call light to the doll. They talked with Resident #53, the roommate, and s/he stated that a CNA was changing another resident (there are 4 in the room). Resident #53 is blind and cannot see. They asked Resident #53 if s/he heard anything about CNA #6. Resident #53 said s/he didn't hear anything about peeing. S/he did hear Resident #87 ask CNA #6 to pick up the doll. Resident #53 did not hear anything else after that. The administrator could not locate a statement for Resident #53, the administrator stated s/he thought they typed the statement up. The administrator stated CNA #6 should have been suspended at the time the resident identified him/her on Saturday 4/20/19. The administrator stated they did not have any documentation of the interview with Resident #53. In an interview with the surveyor, the Risk Manager stated s/he talked with Resident #87 on Saturday 4/20/19. The Risk Manager asked Resident #87 how his/her weekend was. Resident #87 said not so good. Stated a CNA had put his/her doll on the floor. The Risk Manager asked who the CNA was, and the resident stated CNA #6 on 2nd shift. The Risk Manager stated s/he did not document the interview with Resident #87 on Saturday. The Risk Manager stated they suspended CNA #6 on Monday. The Risk Manager confirmed CNA #6 worked until 11:04 PM on Saturday. The Risk Manager stated s/he was not sure why CNA #6 was not suspended on Saturday. Review of the facility's Abuse Prevention Program revealed a section for protection of the resident. Guidance included .the charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation. Review of the facility policy titled Abuse Investigation and Reporting Revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management . Under Role of the Investigator revealed Interview any witnesses to the incident Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident

Based on review of facility files and interview the facility failed to thoroughly investigate and protect residents related to an allegation of abuse for one of three residents reviewed for abuse. Resident #87's family member informed the facility of an allegation of abuse on 4/20/18. The facility failed to interview the resident and the resident's roommate at the time of the allegation, both were noted to be interviewable. The facility failed to immediately suspend the alleged employee. The findings included: The facility reported an allegation of mental abuse for Resident #87 to the State Agency on 4/20/19 and noted the incident was reported to the administrator on 4/20/19 at 6:00 PM. The report was faxed on 4/20/19 at 6:54 PM. Review of the assignment sheet dated 4/18/19 revealed CNA #6 worked 3:00 PM- 11:00 PM and was assigned to Resident #87. Review of the facility's 5-day report summary revealed Resident #87 alleged CNA #6 came into his/her room and threw his/her doll onto the ground and said you pee every five minutes and would not give the doll back when asked to. Investigation was initiated. Staff member suspended pending investigation. After completing investigation of incident concluded the allegation of abuse did not occur. Educated staff member on call bell placement and all staff on abuse. Staff member will not care for this resident per resident request. Review of Resident #87 's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score 15. Review of the Social Services Progress Note dated 4/22/19 indicated the social services staff received a verbal report from the Risk Manager related to the concern expressed by Resident #87. Social services staff visited with Resident #87 for the purpose of offering/providing psychosocial support. Social services asked the resident if s/he wanted to discuss his/her concerns. Resident #87 described the event to social services staff confirming what s/he had related to the Risk Manager. Resident #87 stated s/he was still very upset and did not want that person back in his/her room. Review of CNA #6's time card revealed s/he worked on Saturday 4/20/19 from 7:20 AM- 11:04 PM. CNA #6 was not immediately suspended after the allegation was reported on 4/20/19 at 6:00 PM per the facility's abuse policy. Review of the facility's investigation revealed a statement from the administrator dated 4/20/19 that indicated she received a phone call from staff stating that Resident #87's family member was at the facility with concerns. The administrator called the facility and spoke with the family member. The family member explained that Resident #87 called him/her and told him/her that a CNA refused to pick up his/her family member's baby doll from the floor. Review of the facility's investigation revealed a statement by Resident #87 dated 4/22/19 taken by the administrator and the Risk Manager. The statement indicated last Thursday on 2nd shift CNA #6 came in and threw my doll down and said you pee every 5 minutes. Resident #87 asked CNA #6 to give it back and s/he walked out. Resident #87 asked another CNA to give it to him/her and s/he said give him/her a minute and left. CNA #7 gave it back to the resident. CNA #6 was interviewed by phone by the administrator and the Risk Manager. CNA #6 indicated on Thursday s/he went into Resident #87's room to change him/her and told him/her don't be on the call light to much in a joking manner. When CNA #6 finished changing the resident s/he put the call light, pillow and doll back beside the resident. Nothing else happened, s/he did not throw the resident's call light on the floor. CNA #6 stated s/he knew better than to do that. CNA #7's facility-obtained statement dated 4/25/19 indicated s/he came to work at 11:00 PM on Thursday 4/18/19 and went into Resident #87's room and s/he picked his/her call light off the floor. Resident #87 had his/her roommate ring the light for him/her because it was on the floor. CNA #7 was noted to work 11:00 PM - 7:00 PM. LPN #3's facility-obtained statement dated 4/23/19 indicated Resident #87 stated the bed wasn't working correctly, the bed was fixed. No other knowledge of any issues. LPN #3 was noted as the 3:00 PM-11:30 PM nurse. In an interview with the surveyor on 5/9/19 at approximately 2:45 PM, the administrator stated the incident was reported to him/her on 4/20/19. The weekend nurse called and stated Resident #87's family was at the facility and very irate, they were upset about an incident that happened. The administrator talked with the resident's responsible party on the phone and s/he stated Resident #87 called him/her and told him/her someone threw his/her doll down and would not pick it up. It was a doll baby that the resident has on his/her bed. The administrator told the responsible party s/he would find out what was going on. The responsible party said the incident happened last Thursday during 1st shift. The responsible party said it was somebody named (CNA #6). When the administrator looked at the schedule CNA #6 did not work that day on 1st shift. The administrator talked to the resident on 4/22/19 and s/he said it was CNA #6, s/he stated it was not on 1st shift but on 2nd shift. The resident said it happened between 8:00 and 9:00 PM on Thursday. They identified it was CNA #6 and they suspended him/her. The administrator called CNA #6 on Monday 4/22/19 and told him/her s/he was suspended. CNA #6 was not on the schedule to work on Sunday. The administrator stated the Risk Manager came to the facility on Saturday and sent the reportable in. The administrator stated the Risk Manager did not talk with Resident #87. The administrator stated s/he talked with Resident #87 on Monday 4/22/19. The administrator stated s/he would expect the staff member who came up to the facility to interview the resident and try to identify the alleged staff member. When the administrator talked with Resident #87 on Monday 4/22/19 s/he identified the staff as CNA #6. Resident #87 said CNA #6 came in and threw his/her doll down, said you pee every 5 minutes, and left. The administrator and the Risk Manager interviewed CNA #6 together and s/he stated s/he told the resident not to be on the call light too much in a joking manner. At times, the resident will clip his/her call light to the doll. They talked with Resident #53, the roommate, and s/he stated that a CNA was changing another resident (there are 4 in the room). Resident #53 is blind and cannot see. They asked Resident #53 if s/he heard anything about CNA #6. Resident #53 said s/he didn't hear anything about peeing. S/he did hear Resident #87 ask CNA #6 to pick up the doll. Resident #53 did not hear anything else after that. The administrator could not locate a statement for Resident #53, the administrator stated s/he thought they typed the statement up. The administrator stated CNA #6 should have been suspended at the time the resident identified him/her on Saturday 4/20/19. The administrator stated they did not have any documentation of the interview with Resident #53. In an interview with the surveyor, the Risk Manager stated s/he talked with Resident #87 on Saturday 4/20/19. The Risk Manager asked Resident #87 how his/her weekend was. Resident #87 said not so good. Stated a CNA had put his/her doll on the floor. The Risk Manager asked who the CNA was, and the resident stated CNA #6 on 2nd shift. The Risk Manager stated s/he did not document the interview with Resident #87 on Saturday. The Risk Manager stated they suspended CNA #6 on Monday. The Risk Manager confirmed CNA #6 worked until 11:04 PM on Saturday. The Risk Manager stated s/he was not sure why CNA #6 was not suspended on Saturday. The surveyor talked with Resident #87 and s/he stated s/he had a problem with a staff member throwing his/her call light on the floor. The facility took care of it and suspended the CN[NAME] The CNA no longer works with him/her.

Based on observation, record review, including the facility's abuse policy, and interview the facility failed to implement the components of its abuse policy that prohibit and prevent abuse for two of 6 residents reviewed for abuse and for conducting a thorough investigation for one of 6 residents reviewed for abuse. Resident #73, who required 1:1 supervision due to aggressive/agitated behaviors, grabbed Resident #2 by the wrists causing a skin tear and bruises to both of his/her wrists. CNA #1 was not interviewed as a witness for the incident involving Resident #73 and Resident #2. Resident #3 who was on 1:1 supervision due to wondering/elopement grabbed Resident #38's cane and struck Resident #38 on the head. The findings included: Review of the facility 5-day investigation report dated 12/17/18 revealed that on 12/12/18 Resident #2 was having an aggressive outburst towards staff when Resident #73 stood up to intervene. Resident #73 made contact with Resident #2 arms. Care plan followed. Observed with skin tear to right write and Skin tear to left wrist. The facility admitted Resident #73 on 4/3/18 with [DIAGNOSES REDACTED]. Review of Resident #73's nurse's notes on 2/12/19 at 2:29 PM revealed a nurse's note dated 10/1/18 (Resident #73) was belligerent in the hallway; screaming, yelling, and cursing up and down the hall. Aggressive to other residents and staff. Nurse's note dated 12/6/18, during the second shift, (Resident #73) has been aggressive towards others, when awake, called the sheriff department and had to be redirected from other female residents. Nurse's note dated 12/12/18 at 6:12 AM (Resident #73) continued on 1:1 supervision and was up in (his/her) wheelchair rolling around the unit. Nurse's note dated 12/12/18 at 2:07 PM (Resident #73) was noted yelling at another resident, jumped up out of his/her wheelchair shouting aloud. Review of Resident #73's care plan revealed that Resident #73 was care planned for 1:1 supervision r/t (related to) risk for adverse/unprovoked behavior towards other residents date initiated 6/7/18. During an interview with the LPN #1 (witness) on 2/12/19 at 2:54 PM LPN #1 that the incident happened on12/12/18 at around lunchtime (11:30 AM to 12:00 PM). LPN #1 stated that s/he was sitting at the first table facing the door and window in the dining room. S/he heard noises and saw the commotion as Resident #73 approached Resident #2, who was walking down the hall, cursing at him/her and making motions as if s/he was going to fight Resident #2. LPN #1 stated that Resident #73 tried to get up from his/her wheelchair but was not able to sustain his/her body and leaned to the side of the wall and held on to the handrail. The nursing assistant put Resident # 73 back to his/her wheelchair. LPN #1 stated that Resident #2 also made motions as if s/he was going to fight back Resident #73. LPN #1 stated that s/he believed that there was no physical contact between the residents and cannot remember if anyone (staff) grabbed Resident #2. During an interview with Certified Nursing Assistant (CNA) #1(not interviewed by the facility) on 2/13/19 at approximately 9:00 AM CNA #1 stated that s/he was in Resident #3's room (resident not involved) when s/he heard/saw Resident #2 eliminating (urinating) on the floor of Resident #3's room. CNA #1 stated that s/he told Resident #2 not to do that, then the resident fixed him/herself up and started walking down the hallway. CNA #1 stated that s/he looked down the hall to see if the resident was going to enter another resident's room, but saw was Resident #2 coming back charging at him/her. CNA #1 stated that s/he screamed for help and walked backward, trying to get out of Resident #2's way, and walked into the back door making a loud sound. At that time, Resident #2 turned around and started walking down the hall as if nothing has happened. CNA #1 stated that Resident #2 walked back and for the hallway a couple of times, and at one point, when Resident #73 was coming out of the dining room, they met. Resident #73 stood up from his/her wheelchair and grabbed Resident #2 by both wrists. Resident #2 pulled his/her arm back and continued walking his/her usual way. Resident #73 than, lost his/her balance but held on to the handrail, the staff assisted him/her back to his/her wheelchair. Resident #2 ended up with skin tear and bruises on his wrists. During an interview with CNA # 2 on 2/13/19 at 9:14 AM CNA #2 stated s/he did not see the whole incident, however, s/he saw Resident #73 trying to stand up and acting as if s/he was going to fight Resident #2. S/he said that Resident #73 was mad. S/he added that Resident #73 gets upset from time to time and can be physically and verbally aggressive. During an interview with CNA #3 on 2/13/19 at 9:26 AM CNA #3 stated that s/he saw Resident #73 propelling his/her wheelchair, with his/her feet, out of the dining room very fast. S/he did not expect Resident #73 to confront Resident #2 but as Resident #2 walked down the hallway and as Resident #73 was coming out to the dining room s/he stood up but could not tell if Resident #73 grabbed Resident #2, but saw Resident #2 pulled his/her arms back and Resident #73 lost his/her balance. During an interview with the Administrator and the Director of Nursing (DON) on 2/13/19 at 4:56 PM it was confirmed that CNA #1 who witness the resident to resident altercation was not interviewed. Review of the facility policy titled Abuse Investigation and Reporting Revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management . Under Role of the Investigator revealed Interview any witnesses to the incident Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident Review of the facility 5-day investigation report dated 11/2/18 revealed that on 10/28/18 Resident #38 was eating dinner in the dining hall when staff saw Resident #3 grab Resident #38's cane and make contact with Resident #38. The facility admitted Resident #3 on 4/3/18 with [DIAGNOSES REDACTED]. Review of Resident #3's care plan revealed that Resident #3 was care planned to be on 1:1 related to wandering/elopement, intervention dated 7/4/18. Review of Resident #38's Progress notes review on 2/12/19 at approximately 4:00 PM revealed that on 10/28/18 the certified nursing assistant report to a registered nurse that another resident (Resident #3) hit (Resident #38) in the top of (his/her) forehead and back of (his/her) head with resident's cane causing (him/her) a hematoma to the front of (his/her) forehead. During an interview on 2/14/19 at 2:49 PM CNA #5 stated that Resident #38 has always threatened Resident #3 with his/her cane but s/he never acted on and that Resident #3 has never before responded to Resident #38's threats. CNA #5 stated that s/he was the 1:1 sitter for Resident #3 on the date of the incident but since no one was bringing out Resident #3's meal tray CNA #5 asked CNA #6 to keep an eye on Resident #3 while s/he went to go get Resident #3's meal tray. CNA #5 sated that when s/he turned around s/he saw Resident #3 holding Resident #38's cane and when Resident #38 tried to get his/her cane back s/he saw Resident #3 strike Resident #38 on his/her forehead. During an interview with Registered Nurse #3 on 2/14/19 at 3:58 PM, RN #3 stated that s/he only knows what the nursing assistant told her/him. Resident #3 hit Resident #38 on the forehead with a cane. RN #3 stated that during his/her assessment of Resident #38 s/he saw some swelling on his/her forehead but no severe trauma. Review of the facility policy titled Abuse and Neglect - Clinical Protocol revealed under Treatment/Management The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect.

Based on observation, record review, and interview the facility failed to thoroughly investigate an allegation of resident to resident abuse for one of six resident review for abuse. Resident #73 who required supervision due to aggressive/agitated behaviors, grabbed Resident #2 by the wrists causing a skin tear and bruises to both of his/her wrists. The facility did not interview the certified nursing assistant that witnessed the altercation. The findings included: The facility admitted Resident #73 on 4/3/18 with [DIAGNOSES REDACTED]. Review of the facility 5-day investigation report dated 12/17/18 revealed that on 12/12/18 Resident #2 was having an aggressive outburst towards staff when Resident #73 stood up to intervene. Resident #73 made contact with Resident #2 arms. Care plan followed. Observed with skin tear to right write and Skin tear to left wrist. During an observation on 2/11/19 at 11:32 AM Resident #73 was observed in his/her wheelchair in his/her room accompanied by a sitter and wearing a wonder guard on his/her right foot. Review of the facility 5-day investigation revealed that the social worker and Licensed Practical Nurse (LPN) #1 witness the altercation. However, during an interview with the Social Worker (witness) on 2/12/19 at 2:34 PM s/he stated that s/he was at the nurse's station faxing some documents and did not see what had happened between the residents. The Social Worker stated that s/he heard the commotion and heard the staff (CNA) screaming. During an interview with the LPN #1 (witness) on 2/12/19 at 2:54 PM LPN #1 that the incident happened on12/12/18 at around lunchtime (11:30 AM to 12:00 PM). LPN #1 stated that s/he was sitting at the first table facing the door and window in the dining room. S/he heard noises and saw the commotion as Resident #73 approached Resident #2, who was walking down the hall, cursing at him/her and making motions as if s/he was going to fight Resident #2. LPN #1 stated that Resident #73 tried to get up from his/her wheelchair but was not able to sustain his/her body and leaned to the side of the wall and held on to the handrail. The nursing assistant put Resident # 73 back to his/her wheelchair. LPN #1 stated that Resident #2 also made motions as if s/he was going to fight back Resident #73. LPN #1 stated that s/he believed that there was no physical contact between the residents and cannot remember if anyone (staff) grabbed Resident #2. During an interview with Certified Nursing Assistant (CNA) #1(not interviewed by the facility) on 2/13/19 at approximately 9:00 AM CNA #1 stated that s/he was in Resident #3's room (resident not involved) when s/he heard/saw Resident #2 eliminating (urinating) on the floor of Resident #3's room. CNA #1 stated that s/he told Resident #2 not to do that, then the resident fixed him/herself up and started walking down the hallway. CNA #1 stated that s/he looked down the hall to see if the resident was going to enter another resident's room, but saw was Resident #2 coming back charging at him/her. CNA #1 stated that s/he screamed for help and walked backward, trying to get out of Resident #2's way, and walked into the back door making a loud sound. At that time, Resident #2 turned around and started walking down the hall as if nothing has happened. CNA #1 stated that Resident #2 walked back and for the hallway a couple of times, and at one point, when Resident #73 was coming out of the dining room, they met. Resident #73 stood up from his/her wheelchair and grabbed Resident #2 by both wrists. Resident #2 pulled his/her arm back and continued walking his/her usual way. Resident #73 than, lost his/her balance but held on to the handrail, the staff assisted him/her back to his/her wheelchair. Resident #2 ended up with skin tear and bruises on his wrists. During an interview with CNA # 2 on 2/13/19 at 9:14 AM CNA #2 stated s/he did not see the whole incident, however, s/he saw Resident #73 trying to stand up and acting as if s/he was going to fight Resident #2. S/he said that Resident #73 was mad. S/he added that Resident #73 gets upset from time to time and can be physically and verbally aggressive. During an interview with CNA #3 on 2/13/19 at 9:26 AM CNA #3 stated that s/he saw Resident #73 propelling his/her wheelchair, with his/her feet, out of the dining room very fast. S/he did not expect Resident #73 to confront Resident #2 but as Resident #2 walked down the hallway and as Resident #73 was coming out to the dining room s/he stood up but could not tell if Resident #73 grabbed Resident #2, but saw Resident #2 pulled his/her arms back and Resident #73 lost his/her balance. During an interview with the Administrator and the Director of Nursing (DON) on 2/13/19 at 4:56 PM it was confirmed that CNA #1 who witness the resident to resident altercation was not interviewed.

Based on observation, record review, and interview the facility failed to ensure residents remained free from abuse. Resident #73, who required 1:1 supervision due to aggressive/agitated behaviors, grabbed Resident #2 by the wrists causing a skin tear and bruises to both of his/her wrists. Resident #3 who was on 1:1 supervision due to wondering/elopement grabbed Resident #38's cane and struck Resident #38 on the head. Two of 6 residents reviewed for abuse. The findings included: Review of the facility 5-day investigation report dated 12/17/18 revealed that on 12/12/18 Resident #2 was having an aggressive outburst towards staff when Resident #73 stood up to intervene. Resident #73 made contact with Resident #2 arms. Care plan followed. Observed with skin tear to right write and Skin tear to left wrist. The facility admitted Resident #73 on 4/3/18 with [DIAGNOSES REDACTED]. During an observation on 2/11/19 at approximately 11:32 AM Resident #73 was observed in his/her wheelchair in his/her room accompanied by a sitter and wearing a wonder guard on his/her right foot. During an interview on 2/11/19 at approximately 11:32 AM Resident #73 was asked by the surveyor if s/he has had an issue with another resident s/he stated no. Resident #73 was asked by the surveyor if s/he has had any issue with Resident #2 s/he stated no. During an observation on 2/11/19 at approximately 10:55 AM Resident #2 was observed walking throughout the facility's hallways by him/herself. Resident #2 had a small skin tear (healing) on his/her left wrist and small bruises to his/her forearms. Review of Resident #73's nurse's notes on 2/12/19 at 2:29 PM revealed a nurse's note dated 10/1/18 (Resident #73) was belligerent in the hallway; screaming, yelling, and cursing up and down the hall. Aggressive to other residents and staff. Nurse's note dated 12/6/18, during the second shift, (Resident #73) has been aggressive towards others, when awake, called the sheriff department and had to be redirected from other female residents. Nurse's note dated 12/12/18 at 6:12 AM (Resident #73) continued on 1:1 supervision and was up in (his/her) wheelchair rolling around the unit. Nurse's note dated 12/12/18 at 2:07 PM (Resident #73) was noted yelling at another resident, jumped up out of his/her wheelchair shouting aloud. Review of Resident #73's Social Service notes revealed a Social Service note dated 12/12/18 at 1:07 PM (Resident #73) was seen by psychosocial support following concerns related to a resident to a resident altercation and that the resident was unable to recall the event and showed no signs of distress or injury. Review of Resident #73's care plan revealed that Resident #73 was care planned for 1:1 supervision r/t (related to) risk for adverse/unprovoked behavior towards other residents date initiated 6/7/18. During an interview with the LPN #1 (witness) on 2/12/19 at 2:54 PM LPN #1 that the incident happened on12/12/18 at around lunchtime (11:30 AM to 12:00 PM). LPN #1 stated that s/he was sitting at the first table facing the door and window in the dining room. S/he heard noises and saw the commotion as Resident #73 approached Resident #2, who was walking down the hall, cursing at him/her and making motions as if s/he was going to fight Resident #2. LPN #1 stated that Resident #73 tried to get up from his/her wheelchair but was not able to sustain his/her body and leaned to the side of the wall and held on to the handrail. The nursing assistant put Resident # 73 back to his/her wheelchair. LPN #1 stated that Resident #2 also made motions as if s/he was going to fight back Resident #73. LPN #1 stated that s/he believed that there was no physical contact between the residents and cannot remember if anyone (staff) grabbed Resident #2. During an interview with Certified Nursing Assistant (CNA) #1(not interviewed by the facility) on 2/13/19 at approximately 9:00 AM CNA #1 stated that s/he was in Resident #3's room (resident not involved) when s/he heard/saw Resident #2 eliminating (urinating) on the floor of Resident #3's room. CNA #1 stated that s/he told Resident #2 not to do that, then the resident fixed him/herself up and started walking down the hallway. CNA #1 stated that s/he looked down the hall to see if the resident was going to enter another resident's room, but saw was Resident #2 coming back charging at him/her. CNA #1 stated that s/he screamed for help and walked backward, trying to get out of Resident #2's way, and walked into the back door making a loud sound. At that time, Resident #2 turned around and started walking down the hall as if nothing has happened. CNA #1 stated that Resident #2 walked back and for the hallway a couple of times, and at one point, when Resident #73 was coming out of the dining room, they met. Resident #73 stood up from his/her wheelchair and grabbed Resident #2 by both wrists. Resident #2 pulled his/her arm back and continued walking his/her usual way. Resident #73 than, lost his/her balance but held on to the handrail, the staff assisted him/her back to his/her wheelchair. Resident #2 ended up with skin tear and bruises on his wrists. During an interview with CNA # 2 on 2/13/19 at 9:14 AM CNA #2 stated s/he did not see the whole incident, however, s/he saw Resident #73 trying to stand up and acting as if s/he was going to fight Resident #2. S/he said that Resident #73 was mad. S/he added that Resident #73 gets upset from time to time and can be physically and verbally aggressive. During an interview with CNA #3 on 2/13/19 at 9:26 AM CNA #3 stated that s/he saw Resident #73 propelling his/her wheelchair, with his/her feet, out of the dining room very fast. S/he did not expect Resident #73 to confront Resident #2 but as Resident #2 walked down the hallway and as Resident #73 was coming out to the dining room s/he stood up but could not tell if Resident #73 grabbed Resident #2, but saw Resident #2 pulled his/her arms back and Resident #73 lost his/her balance. During an interview with the Administrator and the Director of Nursing (DON) on 2/13/19 at 4:56 PM it was confirmed that CNA #1 who witness the resident to resident altercation was not interviewed. Review of the facility 5-day investigation report dated 11/2/18 revealed that on 10/28/18 Resident #38 was eating dinner in the dining hall when staff saw Resident #3 grab Resident #38's cane and make contact with Resident #38. The facility admitted Resident #3 on 4/3/18 with [DIAGNOSES REDACTED]. Review of Resident #3's care plan revealed that Resident #3 was care planned to be on 1:1 related to wandering/elopement, intervention dated 7/4/18. Review of Resident #38's Progress notes review on 2/12/19 at approximately 4:00 PM revealed that on 10/28/18 the certified nursing assistant report to a registered nurse that another resident (Resident #3) hit (Resident #38) in the top of (his/her) forehead and back of (his/her) head with resident's cane causing (him/her) a hematoma to the front of (his/her) forehead. During an interview on 2/14/19 at 2:49 PM CNA #5 stated that Resident #38 has always threatened Resident #3 with his/her cane but s/he never acted on and that Resident #3 has never before responded to Resident #38's threats. CNA #5 stated that s/he was the 1:1 sitter for Resident #3 on the date of the incident but since no one was bringing out Resident #3's meal tray CNA #5 asked CNA #6 to keep an eye on Resident #3 while s/he went to go get Resident #3's meal tray. CNA #5 sated that when s/he turned around s/he saw Resident #3 holding Resident #38's cane and when Resident #38 tried to get his/her cane back s/he saw Resident #3 strike Resident #38 on his/her forehead. During an interview with Registered Nurse #3 on 2/14/19 at 3:58 PM, RN #3 stated that s/he only knows what the nursing assistant told her/him. Resident #3 hit Resident #38 on the forehead with a cane. RN #3 stated that during his/her assessment of Resident #38 s/he saw some swelling on his/her forehead but no severe trauma.

Based on observation, record review and interviews, the facility failed to ensure that each resident remained free from neglect for 1 of 4 sampled residents reviewed. Resident #3 was found to have an Anterior Shoulder dislocation on 9/23/17. The facility's investigation revealed that one Certified Nursing Aide (CNA) transferred the resident using a stand lift. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. An observation and interview on 11/19/17 at approximately 4:40 PM revealed Resident #3 seated in wheel chair in room. Resident #3 could not recall the date, time or CNA involved in the incident that occurred on 9/23/17. Record review on 11/20/17 revealed a Quarterly Minimum Data Set ((MDS) dated [DATE] and a Significant change MDS dated [DATE] that indicated the resident had a Brief Interview of Mental Status (BI[CONDITION]) score of 6 (6 indicated resident not interview-able). Further record review revealed a nurse's note dated 9/20/17 that indicated a CNA lowered the resident to the floor because the resident was needing repositioned in w/c (wheel chair) and the CNA attempted to pull up resident with sling pad and the resident tried to sit on the floor. There was no documentation to indicate that two (2) CNA tried to position the resident in wheel chair while using a sling pad. The nurse's note also indicated an agency CNA was involved in the care of the resident. A nurse's note dated 9/23/17 indicated Resident #3 fell from a stand lift reportedly because an agency CNA did not realized the resident was unable to stand until the resident was off the bed. The nurse's note further indicated the facility nurse explained to the agency CNA after the incident that two (2) staff members are required for transfer with stand or sling lift. Per the nurse's note the resident was sent out to the hospital and returned with Rt (right) arm in sling, for support, support to be kept in place, in order to prevent dislocation of shoulder until assessment. A review of a radiology report dated 9/23/17 indicated Resident #3 had an Anterior Shoulder Dislocation. A review of an undated Nurse Aide's Information Sheet revealed the Resident #3 required two (2) staff assist with activities of daily living. A review of the care plan initiated on 9/14/16 revealed assist with transfers time 2 staff members using hoyer lift and assist with mobility. A review of the facility's witness statement written by the agency Certified Nursing Aide (CNA) involved in the incident that cause the dislocation of Resident #3 shoulder, revealed he/she was aware that the resident required another staff member when using a mechanical lift. The written statement by the CNA further indicated he/she used the wrong lift and did not get another staff member to assist. An interview on 11/20/17 at approximately 10:05 AM with the Director of Nursing (DON) confirmed that Resident #3 required two staff assist with transfer. The DON stated the agency CNA was dismissed and will no longer be allowed back to the facility. The incident report for 9/20/17 was requested by the surveyor but not received at time of exit from the facility. An interview on 11/20/17 at approximately 10:25 AM with the Medical Director revealed he/she examined Resident #3 on 9/25/17 and that the resident had a dislocation of the right shoulder which was not broken or fractured. The Medical Director further stated he/she was told the resident had a fall but not the circumstances of the fall. The Medical Director stated staff should have followed instructions of the care plan and personal care record. The Medical Director stated there was protocol in place and there should be policy to avoid incidents like this in the future. A telephone call was made of 11/20/17 at approximately 2:10 PM with the agency CNA involved in incident. There was no answer.

Based on observation, record review and interviews, the facility failed to ensure that each resident received supervision and/or have interventions in place to prevent accidents for 2 of 8 sampled residents reviewed for falls. Resident #4 was found to have an Acute Right Hip Intertrochanteric Fracture due to fall on 9/14/17 while receiving care. Resident #1 was assessed as a falls risk with no timely interventions put in place to prevent further falls. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. An observation and interview on 11/19/17 at approximately 3:50 PM revealed Resident #4 in fetal position while in bed. The resident was observed to be petite and frail. Resident did not respond to greeting, he/she just looked at surveyor. Record review on 11/19/17 at approximately 4:53 PM revealed a Quarterly Minimum Data Set ((MDS) dated [DATE] that indicated the resident had a Brief Interview of Mental Status (BI[CONDITION]) score of 7 and a Significant change MDS dated [DATE] that indicated the resident had a Brief Interview of Mental Status (BI[CONDITION]) score of 6 (6-7 indicated resident not interview-able). Further record review revealed there was no nurse's note dated at the time of the 9/14/17 fall. There was an incident report that indicated the resident fell from bed to the floor. The facility's Five-Day Follow-Up Report dated 9/18/17 and staff turned to get supplies and resident was observed sitting on floor. The Five Day Report further indicated the resident's radiology report showed the resident had an Acute Right intertrochanteric Fracture. A review of the radiology report dated 9/14/17 revealed no dislocation or destructive bony process and there was no soft tissue abnormality. The radiology report indicated there was an Acute right hip intertrochanteric fracture. Osseous structures are osteopenic. An interview on 11/20/17 at approximately 8:30 AM with Licensed Practical Nurse (LPN) #3 revealed that he/she was the nurse on duty at time of the fall. LPN #3 stated he/she did not witness the fall but stated CNA #1 had the resident sitting on the side of the bed like he/she usually does when the resident fell to the floor. A review of the facility's witness statement written by Certified Nursing Aide (CNA) #1 revealed he/she had Resident #4 sitting on the side of the bed like he/she always does; he/she turned to get some things and the resident was on the floor. An interview on 11/20/17 at approximately 10:40 AM with the Medical Director revealed he/she was informed that Resident #4 fell out of bed. The Medical Director stated he/she was no aware staff had resident sitting on side of bed at the time of the fall. The Medical Director stated he/she did not think the resident was capable of sitting on side of bed due to postural condition. An interview on 11/20/17 at approximately 10:47 AM with CNA #1 confirmed his/her written statement and stated he/she usually sit up the resident on side of bed like he/she always do. CNA #1 stated he/she turned his/her back to the resident to get the resident shirt from bedside table and the resident fell to floor. The CNA stated the bed side table was no more than 4 feet away and the resident fell so fast. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review of a Fall Risk assessment, dated 6/9/2017, on 11/20/2017 at 10:41 AM revealed that Resident #1 had a Fall Risk score of 10 indicating the resident was a high fall risk. Record review of the Nurse's Notes on 11/20/2017 at 11:03 AM revealed a note from 6/21/2017 indicating the resident had fallen out of bed. Staff heard a thump and observed resident on floor laying on right side with no apparent injuries noted. Review of the Incident Report (dated 6/21/2017 at 2:45 AM) for the fall on 11/20/2017 at 10:41 AM revealed the facility implemented a fall mat to the floor and pillows to the bed to prevent the resident from sliding off the air mattress and falling out of bed. The Incident Report indicated the resident did not suffer any injuries. Review of additional Nurse's Notes also revealed the resident did not suffer any injuries from the fall. Review of the Interim Care Plan on 11/20/2017 at 9:17 AM revealed a problem area for falls with interventions. However, Falls was not selected as a risk area on the Interim Care Plan and none of the interventions were checked to indicate they had been implemented. Record review of the resident's Comprehensive Care Plan on 11/20/2017 at 10:51 AM revealed that the resident's Risk for Falls had been care planned for on 6/21/2017. All interventions to prevent falls were also initiated on 6/21/2017, including but not limited to, use of a bed alarm and keep bed in lowest position. Review of the Nurse Aide's Information Sheet revealed interventions including bed alarm, bed in lowest position and floor mats on both sides of bed. There was not a date to indicate when these interventions were implemented. There was no other documentation to indicate fall prevention interventions had been implemented prior to 6/21/2017. During an interview with the Director of Nursing (DON) on 11/20/2017 at 11:35 AM the DON confirmed that the resident was assessed as a high fall risk on admission. The DON also confirmed that Fall Risk and associated interventions were not initiated on the Interim Care Plan on admission. During an interview with the DON on 11/20/2017 at 12:12 PM the DON stated she/he completed the Interim Care Plan on admission. The DON stated the Fall Risk area of the Interim Care Plan was left blank because the resident's electronic (computer) Fall Risk assessment indicated the resident was a high fall risk. The DON stated the Fall Risk assessment should have triggered Fall Risk and interventions on the electronic (computer) Comprehensive Plan of Care. The DON explained the facility was transitioning to an electronic medical record at the time and away from the paper Interim Care Plans. The DON stated that whenever a resident is assessed as a high fall risk the computer Fall Risk assessment triggers Fall Risk on the computer Care Plan. The DON did not know why Fall Risk and interventions did not trigger to the computer care plan. The DON stated that side rails were implemented on admission for safety and did have documentation of this. The DON confirmed that the resident's Fall Risk and interventions were not initiated until 6/21/2017, after the resident fell from bed to the floor. During an interview with the resident's family member on 11/20/2017 at 8:50 AM, the family member stated the facility did not implement appropriate fall prevention interventions until after the resident fell from bed.

Based on record review and interviews, the facility failed to ensure that each resident's care plan was followed 1 of 8 sampled residents reviewed for falls. Resident #3 care plan was not followed which resulted in an Anterior Shoulder dislocation on 9/23/17. The facility's investigation revealed that one Certified Nursing Aide (CNA) transferred the resident using a stand lift while the care plan indicated the resident was to be transfer with 2 staff members when a lift was used. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Record review on 11/20/17 revealed a Quarterly Minimum Data Set ((MDS) dated [DATE] and a Significant change MDS dated [DATE] that indicated the resident had a Brief Interview of Mental Status (BI[CONDITION]) score of 6 (6 indicated resident not interview-able). Further record review revealed a nurse's note dated 9/20/17 that indicated a CNA lowered the resident to the floor because the resident was needing repositioned in w/c (wheel chair) and the CNA attempted to pull up resident with sling pad and the resident tried to sit on the floor. There was no documentation to indicate that two (2) CNA tried to position the resident in wheel chair while using a sling pad. The nurse's note also indicated an agency CNA was involved in the care of the resident. A nurse's note dated 9/23/17 indicated Resident #3 fell from a stand lift reportedly because an agency CNA did not realized the resident was unable to stand until the resident was off the bed. The nurse's note further indicated the facility nurse explained to the agency CNA after the incident that two (2) staff members are required for transfer with stand or sling lift. Per the nurse's note the resident was sent out to the hospital and returned with Rt (right) arm in sling, for support, support to be kept in place, in order to prevent dislocation of shoulder until assessment. A review of a radiology report dated 9/23/17 indicated Resident #3 had an Anterior Shoulder Dislocation. A review of an undated Nurse Aide's Information Sheet revealed the Resident #3 required two (2) staff assist with activities of daily living. A review of the care plan initiated on 9/14/16 revealed assist with transfers time 2 staff members using hoyer lift and assist with mobility. A review of the facility's witness statement written by the agency Certified Nursing Aide (CNA) involved in the incident that cause the dislocation of Resident #3 shoulder, revealed he/she was aware that the resident required another staff member when using a mechanical lift. The written statement by the CNA further indicated he/she used the wrong lift and did not get another staff member to assist. An interview on 11/20/17 at approximately 9:55 AM with Licensed Practical Nurse (LPN) #1 who coordinates the care plan confirmed Resident #3 required two (2) staff members assist with transfer when using a lift. LPN #1 further stated the care plan for two (2) staff members assist with transfer was developed on 9/14/16. LPN further stated that the facility had contacted the contract agency on 9/20/17 abuse an agency CNA due to the incident that occurred on 9/20/17 with Resident #3. An interview on 11/20/17 at approximately 10:05 AM with the Director of Nursing (DON) confirmed that Resident #3 required two staff assist with transfer. The DON stated the agency CNA was dismissed and will no longer be allowed back to the facility. An interview on 11/20/17 at approximately 10:25 AM with the Medical Director revealed he/she saw Resident #3 on 9/25/17 and that the resident had a dislocation of the right shoulder which was not broken or fractured. The Medical Director further stated he/she was told the resident had a fall but not the circumstances of the fall. The Medical Director stated staff should have followed instructions of the care plan and personal care record. The Medical Director stated there was protocol in place and there should be policy to avoid incidents like this in the future.

Based on record review, interviews and review of the facility's abuse policy and procedures, the facility failed to ensure that policy and procedures were being implemented for 2 of 5 sampled residents reviewed. Resident #3 was found to have an Anterior Shoulder dislocation on 9/23/17 in which the facility's investigation revealed that one Certified Nursing Aide (CNA) transferred the resident using a stand lift. Resident #2 was involuntarily secluded in his/her room by Certified Nursing Assistant (CNA) #2 on 6/24/17. There was nothing in the abuse policy and procedures that addressed agency staff. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Record review on 11/20/17 revealed a nurse's note dated 9/20/17 that indicated a CNA lowered the resident to the floor because the resident was needing repositioned in w/c (wheel chair) and the CNA attempted to pull up resident with sling pad and the resident tried to sit on the floor. There was no documentation to indicate that two (2) CNA tried to position the resident in wheel chair while using a sling pad. The nurse's note also indicated an agency CNA was involved in the care of the resident. A nurse's note dated 9/23/17 indicated Resident #3 fell from a stand lift reportedly because an agency CNA did not realized the resident was unable to stand until the resident was off the bed. The nurse's note further indicated the facility nurse explained to the agency CNA after the incident that two (2) staff members are required for transfer with stand or sling lift. Per the nurse's note the resident was sent out to the hospital and returned with Rt (right) arm in sling, for support, support to be kept in place, in order to prevent dislocation of shoulder until assessment. A review of a radiology report dated 9/23/17 indicated Resident #3 had an Anterior Shoulder Dislocation. A review of an undated Nurse Aide's Information Sheet revealed the Resident #3 required two (2) staff assist with activities of daily living. A review of the facility's witness statement written by the agency Certified Nursing Aide (CNA) involved in the incident that cause the dislocation of Resident #3 shoulder, revealed he/she was aware that the resident required another staff member when using a mechanical lift. The written statement by the CNA further indicated he/she used the wrong lift and did not get another staff member to assist. An interview on 11/20/17 at approximately 10:05 AM with the Director of Nursing (DON) confirmed that Resident #3 required two staff assist with transfer. The DON stated the agency CNA was dismissed and will no longer be allowed back to the facility. An interview on 11/20/17 at approximately 10:25 AM with the Medical Director revealed he/she saw Resident #3 on 9/25/17 and that the resident had a dislocation of the right shoulder which was not broken or fractured. The Medical Director further stated he/she was told the resident had a fall but not the circumstances of the fall. The Medical Director stated staff should have followed instructions of the care plan and personal care record. The Medical Director stated there was protocol in place and there should be policy to avoid incidents like this in the future. A review of the facility's abuse policy and procedures under ABUSE PREVENTION PROGRAM revealed Verbal, sexual, physical, and mental abuse, corporal punishment, neglect and involuntary seclusion of the resident, resident exploitation as well as misappropriation of resident property, are prohibited. In order to provide a safe environment for the residents. The policy further indicated that staff will receive training at orientation and on-going on how to recognize signs of burnout, frustration and stress that may lead to abuse. The policy had a revised date of September 2016. There was no in the facility's abuse policy and procedures that addressed the use of agency CNA and the training agency staff would receive to ensure the facility policy/guidelines would be followed while working in the facility. An interview on 11/20/17 at 12:20 PM with Staff Development Coordinator revealed the facility did not have a training record for agency staff to show documentation of training. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 4:40 PM revealed the Risk Manager messaged the Greenville County Sheriff explaining that Resident #2 was involuntarily secluded by CNA #2 who was suspended. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 4:50 PM revealed that CNA #4 went to Resident #2's room several times because the call light was on and found each time that CNA #2 had blocked the door with the chair. S/he walked by the door once more and heard the doorknob turning. Believing that Resident #2 was trying to leave his/her room, CNA #4 informed the nurse. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 4:55 PM revealed that CNA #3 did not see anything, but heard knocking on the door of Resident #2's room. S/he believed it sounded like someone trying to leave the room. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 5 PM revealed that CNA #4 reported to Licensed [MEDICATION NAME] Nurse (LPN) #2 that Resident #2 was being confined to his/her room by CNA #2. LPN #2 forced open the door to find CNA #2 sitting in chair in front of door. LPN #2 explained that the door cannot be blocked. Resident #2 was found to be agitated and immediately left the room. Review of facility investigation of involuntary seclusion on 11/20/17 at approximately 8:40 PM revealed CNA #2 was with Resident #2 in his/her room was encouraging him/her to finish his/her supper but the resident kept getting up and down. The tray was taken from the resident's room by another CNA. A nurse told CNA #2 that we cannot keep him/her in the room and CNA #2 explained she wanted him/her to finish his/her supper. CNA #2 took the resident out and Resident #2 looked tired and confused and almost fell three times. They made it to Station 1 and went in room [ROOM NUMBER] and the nurse from the agency told CNA #2 to walk him/her out. CNA #2 said s/he would let out the resident slowly because s/he is one on one. Soon after a nurse told CNA #2 to leave and stated that CNA #2 was keeping Resident #2 from leaving the room. Interview with CNA #2 on 11/20/17 at approximately 10 AM revealed that CNA #2 left the door cracked. The door, CNA #2 stated, was not closed or blocked. CNA #2 stated s/he was encouraging Resident #2 to finish his supper. Interview with CNA #3 on 11/20/17 at approximately 10:10 AM revealed that CNA #3 was passing trays. S/he heard Resident #2 knocking on the door and trying to get out. CNA #3 tried to locate the resident's CNA. CNA #4, the resident's CNA, tried to open the door but found it blocked by the sitter. CNA #3 admitted s/he did not witness CNA #4 trying to force open the blocked door, and only heard about it after. Interview with CNA #4 on 11/20/17 at approximately 11:05 AM revealed that around lunch CNA #4 knocked on the door and tried to open it. S/he found the sitter's chair was in the way but assumed it was an accident at that time. A few hours later CNA #4 heard the doorknob turning and realized Resident #2 was trying to leave. S/he did not hear CNA #2's explanation but went to find the nurse. Interview with the Director of Nursing (DON) on 11/20/17 at approximately 3 PM revealed that LPN #2 called the DON at home to explain that Resident #2's door had been blocked. LPN #2 stated that CNA #4 informed her of this, and when LPN #2 went to open the door, it had to be forced open because the sitter--CNA #2-- had been blocking it with his/her chair. The DON told CNA #2 to leave the building. Interview with the DON on 11/20/17 at approximately 3:35 PM revealed that CNA #2 told the DON that the reason Resident #2's door was blocked was because s/he kept getting up and down and the CNA wanted to keep him/her in his/her bed so the resident would take a nap.

Based on record review, observation and interviews the facility failed to provide supervision to 1 of 11 residents reviewed for injury. Resident #2 spilled hot coffee, which resulted in a burn to his/her left chest and left back area. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the resident's Weekly Body Audit revealed on 1/13/15 the resident had a pink area on his/her left back and left chest area. On 1/20/15 the body audit stated, "chest wound healing well. No drainage, area pink"; 1/27/15, "Tx (treatment) cont (continues) to left chest wound..." Review of the Nurse's Notes revealed on 1/14/15 at 2:00 PM the resident was noted with a red area on his/her chest. At 10:45 PM there was a dressing on his/her chest. The Nurse's Notes continued to address the chest wound through 2/7/15 at 1:00 AM. "Wound to left side chest healing well". There was no further mention of the chest wound. Review of the Physician's Progress Notes revealed the resident was seen on 1/14/15. "Staff reported a rash to pts (patients) chest wall, pt states s/he accidentally spilled some coffee on his/her chest 2 days ago and burned his/her chest, s/he did not want to bother anyone". Under the area of Assessment/Plan it stated, "1. Burn of skin - Established stable - will start daily silvadene dressings, covered with nonadherent dressing. to change daily". The Physician's progress note of 3/17/15 stated "Pt is unable to get his/her spoon to his/her mouth and has not wanted to get oob (out of bed) today." Review of the Social Services Notes revealed on 1/16/15 the Social Worker visited with the resident. "SW (Social Worker) visited with resident related to providing Social Support. Resident stated that s/he spilled hot coffee on him/herself but did not report because s/he had palsy thought he would not be able to have his/her coffee any longer". Review of the resident's care plan revealed a problem of "Impaired skin Blisters to left chest" S/he was identified as requiring extensive assistance with ADL's (Activities of Daily Living) related to debility and advanced Multiple Sclerosis. Fluctuations and/or decline in ADL status expected due to progressive nature of the disease. The surveyor interviewed the resident on 3/30/15 at approximately 12:45 PM. The resident stated, "I sloshed the coffee on myself. I don't remember exactly what happened. I went to the kitchen and handed them my coffee cup (Pointed at travel mug with large flat bottom). They put coffee in it, I didn't have my lid. I sloshed it on myself." Observation of the resident's chest during the interview revealed, left of midline a large reddish-blue discolored area. The resident stated s/he had sloshed coffee on same area s/he had an infection in the past. Review of the coffee temperatures revealed the coffee was tempted at 130 degrees on 1/14/15. The resident spilled hot coffee on him/herself and caused a burn to his/her chest. S/he did not have a lid for his/her cup and was given hot coffee from the kitchen. The resident required extensive assistance with ADL's. There was no supervision provided to the resident to prevent the resident from burning him/herself. The facility was unaware the resident had burned himself.

On the days of the Complaint and Extended Survey, based on record reviews, interviews, and review of the policy provided by the facility entitled Smoking Policy/Procedure, the facility failed to administered in a manner that ensured staff were trained in the prevention of accidents and hazards related to smoking. Concerns identified with 8 of 17 sampled residents reviewed for smoking included the following: Residents #1, #2, #3, #15, and #17 did not receive supervision and services to prevent accidents and hazards related to smoking. Residents #9, and #16 did not receive a smoking assessment as care planned. Residents #3,and #4, identified, as currently smoking and/or smoking with family, had not signed the facility's smoking policy acknowledging agreement. The findings included: 1. Cross refer to F-323 based on record reviews, interviews, and review of the policy provided by the facility entitled Smoking Policy/Procedure, the facility failed to ensure a safe environment to prevent accidents and hazards related to smoking. 2. The facility Administration failed to adequately monitor staff that was responsible for providing supervision to residents who smoke and ensuring smoking supplies remained secured. The facility staff failed to implement all components of the smoking policy to include: 1) No smoking would be allowed in the facility. 2) No unsupervised smoking would be allowed to occur. 3) Care plans would reflect support for the non-safe smoker decisions. 4) Screening of smokers would be done upon admission and quarterly. 5) No smoking materials would be allowed on any resident's person. 6) Smoking materials would be kept in a locked area. (and) 7) Any violation of the above policy would result in a 30 day notice of discharge. During an interview with the surveyor on 5/7/13 at 11:03 AM, with the Director of Nursing (DON) and the Administrator, the Administrator confirmed that Resident's #3 and #4, identified as current smokers, had not signed the facility's smoking policy on admission. When asked what was done if a resident refused to sign the policy, the Administrator did not know. The Administrator stated that there had been several attempts to get Resident #4 to sign the policy and that the policy had been verbally reviewed with the resident. The Administrator stated that Resident #4 agreed to abide by the policy on 5/2/13 (after the fire incident with Resident #1) and that his/her care plan had been updated. During an interview on 5/7/13 at 2:12 PM, Resident #1's Attending Physician stated that s/he had no knowledge that the resident had smoking materials on his/her person or of any instances of smoking unsupervised outside of designated areas. According to the Physician, a resident with Oxygen is at a higher risk for catching on fire if s/he attempts to smoke. An Allegation of Compliance dated 5/7/13 was developed by the facility and included the following: Criteria #1- Resident #1 on 5/2/13 at 12:30 AM was observed sitting on the side of bed with the Oxygen concentrator on, shirt on fire, and there was a pack of cigarettes noted in the resident's bed. The fire was extinguished immediately by the nursing staff. The resident was transferred to the hospital via Emergency Medical Services with 3rd [MEDICAL CONDITION]. Criteria #2- An audit was completed by (1) licensed nurse on May 2, 2013 of all resident rooms to ensure there were not any smoking materials in resident care areas or on the resident's person. A smoking screen questionnaire was completed on (7) residents who currently smoke by (2) licensed nurses and (1) social worker on May 7, 2013. There are (6) residents with a history of smoking but are not currently smoking, a smoking screen questionnaire will be completed if and when the resident decides to smoke. The Smoking Policy/Procedure was reviewed with (11) residents on May 2, 2013 by the Administrator and the policy was signed by the residents. Of the 11 residents 2 were cognitively impaired. Resident #8's responsible party reviewed the smoking policy with the Social Services Director on May 7, 2013 and signed the policy. Resident #13's responsible party was notified via telephone on May 7, 2013 by the Social Services Director and reviewed the smoking policy, the responsible party agreed to come in and sign the policy on May 10, 2013. The Smoking Policy/Procedure was reviewed with (1) resident on May 3, 2013 by the Administrator and the policy was signed by the resident (1) alert and oriented resident refused to sign the smoking policy. The Administrator informed the resident s/he would not be allowed to smoke until s/he agreed to review and sign the smoking policy. Criteria #3 All staff including part time and PRN (As Needed) of Glorified Health & Rehab were re-educated on or before May 3, 2013 in regards to the smoking policy and procedure including the requirements of ensuring residents adhere to the policy and procedure. Employees will receive this re-education prior to starting their shift. This training will be added to the orientation process. Date of Compliance: May 7, 2013 Observations, interviews, record review, and review of policies/screens on 5/7/13 revealed the Allegation of Compliance (AOC) submitted by the facility on 5/7/13 had been implemented by the facility and was in practice. Interviews on 5/7/13 of 6 licensed nurses, 8 certified nursing assistants, and 5 interviewable residents listed as currently smoking revealed facility nursing staff and resident smokers were knowledgeable of the smoking policy. The Administrator was informed of this on 5/7/2013. The Immediate Jeopardy was removed at F-490 but the citations remained at a lower scope and severity of "D".

On the days of the Complaint and Extended Survey, based on limited record reviews and interviews, the facility failed to implement care plan interventions to ensure that residents received the necessary supervision and services to prevent accident related to smoking for 7 of 17 sampled residents. The Care Plan was not followed for Residents #1, #2, #3, #15, and #17 relative to supervision while smoking and/or with keeping smoking materials at the nurse's station and out of residents' possession. Residents #9 and #16 were not assessed related to smoking per the Care Plan. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Resident #1 received full and partial [MEDICAL CONDITION] 15% of his/her body after s/he attempted to light/smoke a cigarette in his/her room. S/he was in the hospital at the time of the survey and had not been discharged from the facility as of 5/7/13. County fire officials determined the cause of the fire was smoking materials. During an interview on 5/6/13 at 1:42 PM, Certified Nursing Assistant (CNA) #1 stated that Resident #1 required supervision for smoking. According to CNA #1, s/he was supervising the smoking residents, including Resident #1 during the smoke break on 5/1/13 at 1:45 PM. CNA #1 stated that Resident #1 pulled a lighter from his/her inside coat pocket and gave the lighter to the CNA to light the cigarette. CNA #1 stated that s/he regularly took Resident #1 out to smoke, and the resident never had a lighter before. S/he stated that Resident #1 told her/him that the resident's family member had given the lighter to the resident. CNA #1 stated that s/he wasn't going to give the lighter back to Resident #1, but Resident #1 fussed and cussed. When asked by the surveyor if s/he had told anyone the resident had the lighter, CNA #1 stated s/he went to the Nurse's Station and "blurted it out" to CNA #2 and Licensed Practical Nurse (LPN) #1. According to CNA #1, no one remembered her/him telling her/him this information. Review of the Care Plan for Resident #1 revealed an entry dated 3/29/13 which stated, "Smoking: Potential for safety hazard, injury related to smoking". Approaches included the following: Staff Note: Resident Smokes... Nursing to keep all smoking materials at nurse's station." Nursing staff failed to remove the lighter from Resident #1's possession and keep all smoking materials at the nurse's station as care planned. The facility admitted Resident #17 with [DIAGNOSES REDACTED]. The Admission MDS Assessment with an ARD of 3/12/13 documented Resident #17 with a BIMS score of 6 that indicated severely impaired cognition at the time of the assessment. Resident #17 had been discharged from the facility and was sampled as a closed record. During an interview on 5/6/13 at 3:00 PM, CNA #13 stated that s/he knew of an incident where there were 2 residents in room --, and one resident had been smoking in the room. CNA #13 stated, "You could see the smoke". According to CNA #13, this happened about 2 months ago. CNA #13 stated s/he told a nurse about the smoking incident, but was unsure what happened as a result. Review of Nurses Notes revealed the following entries: -3/24/13 3:30 AM- "...outside smoking, unsupervised. Counseled re: same. Compliant and co-operative." -3/26/13 2:00 PM- "Received report from other nurse that (Resident #17) is outside picking up cigarette butts from the ashtray & smoking them. Notified sister, --- of this behavior. She sts (states) that she will have her son bring some cigarettes here. No distress noted." -3/27/13 10:30 - "Late entry for 3/25/13- Staff noted smoke smell in room. Room checked for cigarettes. None found. Will monitor closely (after) comes in from smoking R/T (related to) Dementia & picking up cig(arette) butts from smoking area. Smoke detector placed in room." Review of the Care Plan for Resident #17 revealed an entry dated 3/7/13 which stated, "Resident requires supervision with smoking". The goal was that the resident would cause no harm to self or others during smoking thru the next review date 6/7/13. Approaches listed included, "Residents are permitted to smoke only in designated areas. Staff will stay with the supervised resident until cigarette is finished. Resident will not be allowed to take cigarette and lighter to their room. Cigarettes and lighters must be kept at the nurse's station. Smoking assessment routinely and prn (as needed). Encourage resident to wear smoking apron". Handwritten entries had been added 3/8/13 (tapering the [MEDICATION NAME] along with resident refusing patch) and 3/18/13 (D/C (Discontinue) Nicotine patches, (pt's refuses)". The Care Plan had not been updated to include information that Resident #17 was found smoking outside unsupervised 3/24/13, that the resident had been smoking inside the facility (in his/her room) on 3/25/13 (and that a smoke detector had been placed in the resident's room), or that the resident had been picking up cigarette butts and smoking them on 3/26/13. The resident's Care Plan had not been followed in that facility staff failed to ensure the resident had sufficient supervision to ensure smoking materials were not kept on his/her person/room or to ensure that smoking occurred only in designated areas. During an interview on 5/7/13 at 1:25 PM, the DON reviewed the Nurses Notes and the Care Plan and verified that the Care Plan had not been updated, and that no new interventions had been added to the Care Plan related to the incidents on 3/24/13, 3/25/13, or 3/26/13. When asked, the DON stated that a written/formal investigation had not been conducted related to the incidents since it was believed the resident obtained cigarettes by picking up the butts. The DON stated that staff was told to "watch" and an alarm was placed in the resident's room. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. During an interview on 5/6/13 at 1:43 PM, CNA #12 stated that Resident #3 smoked (in the smoking area) without supervision (staff present). During an interview on 5/7/13 at 9:50 AM, Social Worker #2 stated that s/he was aware of conversations that staff have had with Resident #3 related to understanding the smoking policy related to not keeping smoking materials in his/her room. According to Social Worker #2, Resident #3 is adamant about smoking unsupervised. During an interview on 5/7/13 at 10:00 AM, Social Services Worker #1 stated that when Resident #3 first came in, s/he wanted to smoke and felt that s/he was an adult and didn't like "our rules". According to SSW #1, the previous Social Worker had talked to Resident #3 extensively. SSW #1 stated that Resident #3 was allowed to have cigarettes and a lighter that s/he believed the resident kept in his/her room in a drawer. SSW #1 did not believe this drawer had a lock and stated Resident #3 had never had a room mate. SSW #1 stated that all the other smoking residents kept their smoking supplies in a drawer at the nurse's desk. Review of Nurses Notes on 5/6/13 at 3:00 PM revealed the following: -3/18/13 8:15 AM- "Ask(ed) resident to give cigarettes + lighter to writer (with) witness X 2. (RN #4) and (MDS nurse). Resident stated (s/he) threw lighter away last night and (s/he) did not have any cigarettes left. Writer stated Thank you and also told him it was a fire safety issue. -3/18/13 8:30 AM- "Resident gave this nurse a pack of cigarettes (with) 3 cigarettes in it from under the cushion of (his/her) w/c. This nurse gave cigarettes to ADON --". During an interview on 5/7/13 at 10:42 AM, the Assistant Director of Nurses (ADON) verified s/he had written the Nurses Note dated 3/18/13 at 8:15 AM. After reviewing the above Nurses Notes, the ADON stated that RN #4 thought Resident #3 had something hidden under his wheelchair cushion, and thought it could be cigarettes. The ADON, MDS nurse, and RN #4 went to the resident's room and asked the resident if s/he had any cigarettes or a lighter. Resident #3 responded that s/he did not have any cigarettes and that s/he had thrown the lighter away last night. Resident #3 then asked the nurses to leave the room. Later, RN #4 came back and told the ADON that the resident had just given her/him the cigarettes from under the wheelchair cushion. During an interview on 5/7/13 at 11:03 AM, the DON stated that Resident #3 would sit (outside) on the patio and staff would light the cigarette and watch him while feeding resident's (inside). According to the DON, Resident #3 would get upset if staff sat beside him/her and would comment that s/he "wasn't a child". The DON stated that as far as they knew, Resident #3 was there (in the smoking area) and someone was in the vicinity to watch him. When asked if the facility had investigated how Resident #3 had obtained the cigarettes and lighter on 3/18/13, the DON stated Resident #3 had his/her own money and that the resident would have visitors buy cigarettes for him/her. According to the DON, s/he more or less talked to staff about this, and there was no formal or written investigation into how Resident #3 obtained the smoking supplies. The DON stated that s/he talked to the resident, but Resident #3 did not say how s/he obtained the smoking supplies other than to say it was his/her business and that s/he could do what s/he wanted. Review of Nurses Notes on 5/7/13 at 10:30 AM revealed the following entry dated 2/28/13 at 12:30 PM that stated, "Resident yelling in hallway, cursing at staff. Sts (States) "I am having a claustrophobic attack." Repeatedly asks to be taken out to smoke. Resident has been out twice already this shift. Resident is not understanding of this. Request [MEDICATION NAME] which I admin(istered) at this time. After a few minutes resident seen outside in smoking area unsupervised. DON notified of this situation. No further issues (with) this resident this shift...". During an interview on 5/7/13 at 11:03 AM, the DON said that in response to the incident on 2/28/13, s/he had talked with Resident #3 and asked him/her to please have staff in the area when s/he smoked. When asked what Resident #3's response was, the DON said that Resident #3 "always says yes, but does what s/he wants afterward". Review of Resident #3's Care Plan revealed an entry dated 2/14/13 which stated that Resident #3 required supervision with smoking. According to the Care Plan, staff would stay with Resident #3 and supervise until the cigarette was finished. Resident #3 would not be allowed to take a cigarette or lighter to his/her room. Cigarettes and lighters would be kept at the nurse's station. Further review revealed handwritten entries that had been added to Resident #3's Care Plan for smoking that included, 2/18/13 "Resident non-compliant with facility smoking policy". The resident's Care Plan had not been followed in that nursing staff failed to stay with the resident and supervise the resident until the cigarette was finished. Nursing staff also failed to keep smoking materials at the nurses station as care planned. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Initial Nursing Assessment for Resident #2 revealed a BIMS score of 15 that indicated the resident had been cognitively intact on admission. An MDS Assessment with an ARD of 4/21/13 revealed a BIMS score of 6 that indicated severely impaired cognition at the time of the assessment. During an interview on 5/6/13 at 1:25 PM, Resident #2 stated that sometimes residents ask for a lighter and/or cigarettes from family members but this is against the rules; and families tell them "no". According to Resident #2, lighters and cigarettes are kept at the nurses desk and s/he has not heard of anyone smoking in their room or visitors giving anyone lighters or cigarettes. S/he stated that if s/he knew this, then s/he would tell authorities. Resident #2 stated that s/he had not smoked in 8 days. During an interview on 5/6/13 at 2:12 PM, LPN #5 stated that a CNA told her/him that Resident #2 had a cigarette, so s/he took the cigarette from the resident, confiscated it immediately, and put it in the drawer. This occurred "a couple of weeks ago". According to LPN #5, Resident #2 told her/him that s/he had found the cigarette. LPN #5 stated that all smoking materials were kept locked in the med room. During an interview on 5/6/13 at approximately 2:40 PM, RN #1 was asked about her/his facility obtained statement dated 5/2/13, provided as part of the investigation into the fire incident for Resident #1. The statement included the following, "...Have to tell CNAs not to hand both cigarettes to residents as they don't smoke them and hide them". According to RN #1, this information had been included in the statement because s/he had found cigarettes on Resident #2 and had taken them away. RN #1 was unsure if s/he had told anyone about this at the time of the incident. According to RN #1, s/he had found cigarettes on Resident #2 twice before. When RN #1 asked the resident where s/he had gotten the cigarettes, Resident #2 stated that s/he didn't always smoke both cigarettes. RN #1 stated that s/he then spoke with the CNAs on duty at the time and reminded them to make sure Resident #2 gave the cigarettes back that the resident didn't smoke. A Care Plan Entry dated 4/11/13 revealed, "Smoking: Potential for safety hazard, injury related to smoking. Potential for health improvement related to smoking cessation". Approaches listed included, "Staff Note: Resident Smokes. Smoking allowed only in designated smoking areas. No smoking is allowed inside facility at any time. Evaluate for need of smoking apron. While smoking, will have direct supervision by staff or family member. Patient education-Encourage to stop smoking and offer smoking-cessation assistance as desired. Consult MD for nicotine patch/gum or other medications as needed. Nursing to keep all smoking materials at nurse's station." The Care Plan had not been updated to reflect information that Resident #2 was found with cigarettes on his person or that staff were to give the allotted cigarettes one at a time. The Care Plan for Resident #2 had not been followed in that nursing staff failed to keep all smoking materials at the nurse's station and out of the resident's possession. The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Resident #15 had been discharged from the facility and was reviewed as a closed record. During an interview on 5/6/13 at 3:00 PM, CNA #13 stated that Resident #15's cigarettes had not been locked and had been kept behind the nurse's station in a drawer. According to CNA #13, Resident #15 would go out and smoke unsupervised, since s/he knew the code (to get out the door to the smoking area). A Care Plan entry dated 2/27/13 revealed "Smoking: Potential for safety hazard, injury related to smoking...Staff Note: Resident Smokes...While smoking, will have direct supervision by staff or family member". The Care Plan had not been followed as evidenced by staff interview of Resident #15 smoking unsupervised. The facility admitted Resident #16 with [DIAGNOSES REDACTED]. According to the Admission MDS assessment dated [DATE], Resident #16 had a BIMS score of 15. Resident #16 had been discharged from the facility and was reviewed as a closed record. Record review on 5/7/13 at 12:45 PM revealed a Care Plan entry dated 1/23//13 that stated, "I require supervision with smoking". Approaches listed included to provide the resident with a smoking assessment routinely and PRN. Further chart review revealed there was no smoking screen or signed smoking policy. The Administrator was notified of this and on 5/7/13 at 1:10 PM, provided the surveyor with a copy of the facility policy signed by Resident #16's Responsible Party on 1/23/13. A smoking assessment for Resident #16 was not provided to the surveyor. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 that indicated moderate cognitive impairment at the time of the assessment. Record review on 5/6/13 at 4:12 PM revealed a Care Plan with an entry dated 9/14/12 that stated, "I require supervision with smoking". The Approaches listed included to "Do smoking assessments per protocol". Review of the Smoking Policy (signed by the resident's RP on 9/14/12 and signed by the resident on 5/2/13) revealed that "...Screening of smokers will be done upon admission, quarterly, and annually to assure safety of each resident...". Further review revealed a "Smoking Screen Questionnaire" had been completed on 10/26/12 and 5/2/13. The quarterly screen (due the end of January 2013/beginning of February 2013) had not been completed. During an interview on 5/7/13 at 11:30 AM, the Administrator and DON were notified of the missing quarterly screen. An Allegation of Compliance dated 5/7/13 was developed by the facility and included the following: Criteria #1- Resident #1 on 5/2/13 at 12:30 AM was observed sitting on the side of bed with the Oxygen concentrator on, shirt on fire, and there was a pack of cigarettes noted in the resident's bed. The fire was extinguished immediately by the nursing staff. The resident was transferred to the hospital via Emergency Medical Services with 3rd [MEDICAL CONDITION]. Criteria #2- An audit was completed by (1) licensed nurse on May 2, 2013 of all resident rooms to ensure there were not any smoking materials in resident care areas or on the resident's person. A smoking screen questionnaire was completed on (7) residents who currently smoke by (2) licensed nurses and (1) social worker on May 7, 2013. There are (6) residents with a history of smoking but are not currently smoking, a smoking screen questionnaire will be completed if and when the resident decides to smoke. The Smoking Policy/Procedure was reviewed with (11) residents on May 2, 2013 by the Administrator and the policy was signed by the residents. Of the 11 residents 2 were cognitively impaired. Resident #8's responsible party reviewed the smoking policy with the Social Services Director on May 7, 2013 and signed the policy. Resident #13's responsible party was notified via telephone on May 7, 2013 by the Social Services Director and reviewed the smoking policy, the responsible party agreed to come in and sign the policy on May 10, 2013. The Smoking Policy/Procedure was reviewed with (1) resident on May 3, 2013 by the Administrator and the policy was signed by the resident (1) alert and oriented resident refused to sign the smoking policy. The Administrator informed the resident s/he would not be allowed to smoke until s/he agreed to review and sign the smoking policy. Criteria #3 All staff including part time and PRN (As Needed) of Glorified Health & Rehab were re-educated on or before May 3, 2013 in regards to the smoking policy and procedure including the requirements of ensuring residents adhere to the policy and procedure. Employees will receive this re-education prior to starting their shift. This training will be added to the orientation process. Date of Compliance: May 7, 2013 Observations, interviews, record review, and review of policies/screens on 5/7/13 revealed the Allegation of Compliance (AOC) submitted by the facility on 5/7/13 had been implemented by the facility and was in practice. Interviews on 5/7/13 of 6 licensed nurses, 8 certified nursing assistants, and 5 interviewable residents listed as currently smoking revealed facility nursing staff and resident smokers were knowledgeable of the smoking policy. The Administrator was informed of this on 5/7/2013. The Immediate Jeopardy was removed at F-282 but the citations remained at a lower scope and severity of "D".

On the days of the Complaint and Extended Survey, based on review of the facility's policy entitled Smoking Policy/Procedure, record reviews, and interviews, the facility failed to ensure that 6 of 17 sampled residents reviewed for smoking received the necessary supervision and services to prevent accidents and ensure safety while smoking. Facility staff failed to follow facility policy and ensure that no smoking materials (cigarettes or lighters) were kept on residents, or kept in their room ensuring that residents did not smoke unsupervised. Resident #1 received full and partial thickness burns over 15% of his body on 5/2/13 at 12:30 AM after s/he attempted to light and/or smoke a cigarette in his/her room. County fire officials determined the cause of the fire was smoking materials. Allegedly, a family member on 5/1/13 gave cigarettes and a lighter to Resident #1. A facility staff member, Certified Nursing Assistant (CNA) #1, was aware on 5/1/13 at 1:45 PM that Resident #1 had a cigarette lighter in his/her possession. Residents #2, #3, #15, and #17 were not supervised while smoking and/or had smoking materials on their person or in their rooms. Resident #2 did not have a documented Smoking Assessment prior to 5/2/13. Resident #3 had not signed the facility's smoking policy prior to 5/2/13 acknowledging agreement with the policy. Resident #4, who was currently smoking with family supervision, refused to sign the facility's smoking policy. Resident #4 did not have a quarterly smoking screen documented for February 2013 (per facility policy). The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Resident #1 was in the hospital at the time of the survey. Review of the Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 3/28/13 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14. A BIMS done on 5/1/13 documented a score of 15. Both scores indicated the resident was cognitively intact. According to the MDS assessment, the resident had impairment on one side of his/her upper extremities and impairment on both sides of his/her lower extremities with range of motion; a walker or wheelchair was used for mobility. Resident #1 required setup help with supervision for eating and required limited assistance with one person physical assist for Personal Hygiene. Review of the Admission Physician order [REDACTED]. Record review on 5/6/13 at 9:48 AM revealed Nurse ' s Notes dated 5/2/13 at 7:00 AM that stated, "Resident requested pain med at 12:00 am, (2) Norco given as ordered. 12:30 AM, CNA (Certified Nursing Assistant) came out of room stating, 'S/he's on fire'. When I entered room, found resident sitting on side of bed engulfed in flames, fire extinguished on resident by smothering it with (his/her) coat that was the quickest accessible item to use. Once fire was out on resident, the fire extinguisher was used to put out the flames in the bed and w/c (wheelchair). Resident was then removed from room via another w/c, wrapped in a clean bath blanket and handed over to EMS (Emergency Medical Services) who just arrived at the facility to treat/transport (him/her). Resident transported to (hospital) at 12:50 AM". On 5/6/13 at 10:30 AM, the facility provided an Incident Report along with statements of the facility staff related to the incident. The incident report dated 5/1/13 (the incident occurred 5/2/13) indicated the incident occurred at 12:40 AM in the resident's room. According to the report, Resident #1's spouse was notified on 5/1/13 at 2:30 AM and the Medical Director was notified on 5/1/13 at 9:00 AM. During an interview on 5/6/13 at 12:40 PM, the resident's spouse stated s/he was notified at approximately 1:20 AM on her/his cell phone after the facility attempted to reach him/her at 1:16 AM by calling the home phone. During an interview on 5/7/13 at 2:12 PM, Resident #1's Attending Physician, (who is not the Medical Director), stated s/he was notified of the incident after arriving at the facility at approximately 9:00 AM on 5/2/13. The Incident Report indicated there was a fire in the room that involved a wheelchair. It stated that CNA #3 was the first to respond and that Resident #1 was "sitting on side of bed" was "Alert, oriented" and sustained burns to his/her upper torso. During an interview on 5/6/13 at 10:45 AM, the Life Safety Surveyor displayed an opened pack of cigarettes that contained 1 cigarette, 2 cigarettes that had been partially smoked, and the butt of one cigarette along with a lighter. The Life Safety Surveyor indicated that these smoking materials had been found in Resident #1's bed after the incident. Review on 5/6/13 at approximately 10:55 AM of the facility investigation of the fire involving Resident #1 revealed staff statements obtained from CNAs #3, #4, #5, #6, #7, #8 and #9; RN (Registered Nurse) #1, #2, #3 and #4; LPN (Licensed Practical Nurse) #2, and #3. The statements from CNA #3 and RN #2 (dated 5/2/13) are detailed below: Review of the facility investigation file revealed a handwritten statement dated 5/2/13 by CNA #3 that stated, "Resident had call light on to ask pain medication, which nurse gave. Approximately 10-15 minutes later, Resident put call light on again + wanted more pain medication. Resident got self up in wheelchair. I was vital signs and round on 600 hall when (s/he) laid (himself/herself) down. I was in 601 to assist resident with his cares. Then I heard the O2 (Oxygen) concentrator come on and heard a "woof" sound. I went into 605 and saw fire on resident and bottom of blanket on bed. Then yelled, "(RN #2's name), (woman/man) on fire. Come on down here". Charge nurse came down immediately-the other CNA was pulling fire alarm and getting fire extinguisher. I then went to the other stations to get more help". In a facility obtained handwritten statement dated 5/2/13 Registered Nurse (RN) #2 stated, "I was in room around 12 midnight and resident was in wheelchair. Pain medication given per (his/her) request and resident stated s/he was going to straight cath(eterize) (himself/herself) and wheeling towards bathroom. I came to nurse's station and call light (605) came on and CNA #3 went to answer call light. About 12:30, CNA #3 came out of 605 and stated "(S/he's) on fire." I went immediately to room 605. I saw resident, bed, and wheelchair was aflame. I grabbed a jacket and smothered flames on resident. Then (CNA #4) came into room with fire extinguisher and I put out fire on w/c and bed. Flames were out on resident after smothering with a jacket. Then you and CNA assisted into wheelchair to remove resident from room. O2 concentrator was turned off immediately. Resident was taken to nurse's station and covered with blanket. Fire department here at this time and EMS was called immediately by fire department... I observed burns (with) this resident on the shoulders, chest, torso areas as well as (lower) extremities. Also observed some facial burns and back of hair was singed". During an interview on 5/6/13 at 12:40 PM, the resident's spouse stated that Resident #1 told her/him on 5/3/13 after the incident occurred and after having been admitted to the Burn Center, that a family member gave him/her the cigarettes. Resident #1 did not say how s/he had obtained the lighter. According to the resident's spouse, s/he had asked this family member to meet Resident #1 at the doctor's office on 5/1/13 since s/he was unable to go with the resident to the appointment. According to the resident's spouse, this family member also returned back to the facility with Resident #1 after the appointment. Further interview with Resident #1's spouse on 5/6/13 revealed information that s/he always lit cigarettes for Resident #1 because s/he was afraid her/his spouse would take the lighter. The resident's spouse also stated that Resident #1 would have cigarettes in his/her mouth and would be dozing, and that Resident #1 had asked the spouse several times to leave him/her the lighter. Review of Nurse's Notes dated 5/1/13 at 12:40 PM revealed "Res(ident) went out to urologist this am. Came back with... and a appt. (appointment) date. Family present and aware..." Observation on 5/6/13 at 12:58 PM with RN #3 revealed packs of residents' cigarettes locked in a drawer in Station 3 ' s medication room. According to RN #3, there were no other cigarettes/lighters located elsewhere for the residents that smoked on that unit. S/he was not aware of any incidents where residents had smoking materials when they shouldn't or of any incidents of smoking in resident rooms. During an interview on 5/6/13 at 1:42 PM, CNA #1 stated that Resident #1 required supervision for smoking, and that a smoking apron was required. S/he stated that the resident was allowed 2 cigarettes per smoke break and would be given one at a time, with staff lighting the cigarettes for the resident. According to CNA #1, s/he was supervising the smoking residents, including Resident #1 during the smoke break on 5/1/13 at 1:45 PM. CNA #1 recalled that this was the day that Resident #1's family member took him/her to a doctor's appointment. CNA #1 stated that Resident #1 pulled a lighter from his/her inside coat pocket and gave the lighter to the CNA to light the cigarette. CNA #1 stated that s/he regularly took Resident #1 out to smoke, and the resident never had a lighter before. S/he stated that Resident #1 told her/him that the resident's family member had given her/him the lighter. CNA #1 stated that s/he wasn't going to give the lighter back to Resident #1, but Resident #1 fussed and cussed. When asked by the surveyor if s/he had told anyone the resident had the lighter, CNA #1 stated s/he went to the Nurse's Station and "blurted it out" that Resident #1 had a lighter. CNA #1 stated that Licensed Practical Nurse (LPN) #1 and CNA #2 were present at the Nurse's Station at the time. During the interview, CNA #1 also stated that Resident #1 would fall asleep while smoking, and that s/he would wake him up. CNA #1 stated that no ashes fell or burned his clothes. When asked if s/he told anyone about the resident's dozing while smoking, CNA #1 stated when this happened, s/he would go back and tell CNA #2. During interviews on 5/6/13 at 1:08 PM and again at 1:58 PM, CNA #2 denied any knowledge of Resident #1 or any other resident having a lighter or cigarettes in their possession. When asked about Resident #1 dozing while smoking, CNA #2 stated Resident #1 would hold his/her head down when smoking, but would not be sleeping. During a phone interview on 5/6/13 at 7:24 PM, LPN #1 denied any knowledge of Resident #1 having possession of a lighter or cigarettes. According to LPN #1, there was one resident the facility allowed to have cigarettes only, but no lighter. But now they are locking them up due to the fire incident with Resident #1. On 5/6/13 (afternoon), the Administrator provided a facility obtained statement from CNA #13 related to the fire incident for Resident #1. According to the statement, "...When family visits, they take (him/her) out to smoke. They give (Resident #1) cigarettes, including their own". During an interview on 5/7/13 at 11:30 AM, the surveyor asked the Administrator if s/he was aware that one of their staff had witnessed Resident #1 with a lighter the afternoon prior to the resident igniting himself/herself on fire. The Administrator stated that on 5/2/13, during the facility's investigation of the incident, an interview was conducted with CNA #1. When asked what CNA #1 told her/him, the Administrator said that the CNA told her/him what the surveyor had just told her/him, that CNA #1 had witnessed the resident with the lighter prior to the incident. When asked why this statement was not included with the other statements provided to the surveyor on 5/6/13 upon entrance to the facility, the Administrator stated s/he had the written statement and thought it had been provided to the surveyor with the others. The Administrator stated that CNA #1 had been suspended on 5/2/13 (Thursday) and didn't work on Friday, Saturday, or Sunday. On 5/7/13 at 11:58 AM, the Administrator provided the surveyor with written statements from CNAs #1, #2 and LPN #1. Review of the statement dated 5/2/13 by CNA #1 revealed, "(CNA #1), worked 5/1/13 and took care of residents on the 400 Hall. S/he was assigned to take res(idents) out to smoke. At 9:30 smoking time (on 5/1/13), (Resident #1) was out to (his/her) doctor appointment. One day last week I had taken the smokers out and saw that (Resident #1) had cigarettes in his jacket. The pack was empty because s/he smoked the last one. I reported this to (Registered Nurse (RN) #1) and (LPN #1), about (him/her) having cigarettes. At 1:45 PM (on 5/1/13) I took (Resident #1) out to smoke. (Resident #1) had a lighter on (him/her) and stated that (his/her) (family member) had left it with (him/her). I did not take the lighter away from (Resident #1). (Resident #1) returned his other cigarette and went to the front of facility. I did not see (Resident #1) again after taking (him/her) out to smoke. I did tell (CNA #2) that (Resident #1) had a lighter. CNA #2 was (Resident #1's) CNA yesterday (5/1/13). Review of the statement dated 5/2/13 by CNA #2 revealed that Resident #1 and his/her family were observed by CNA #2 smoking in the smoking area prior to the resident's doctor's appointment on 5/1/13, and after the appointment. According to CNA #2's statement, Resident #1's family left at approximately 1:30 PM and "At no time did I see (him/her) with any cigarettes or lighter on (him/her). I, (CNA #2) was not aware that (Resident #1) had a cigarette lighter". Review of the statement dated 5/2/13 by LPN #1 revealed "...I do not recall being told that (Resident #1) had any cigarettes or lighter on him...Yesterday I answered the alarm, (Resident #13) was coming back inside from the smoking patio where (Resident #3) was. I did not see (Resident #13) smoking. (CNA #2) stated to (Resident #13) that he/she was not supposed to be outside. I do not know of any resident who has smoking materials on them". Review of the Care Plan for Resident #1 revealed an entry dated 3/29/13 that stated, "Smoking: Potential for safety hazard, injury related to smoking". The goal was that the resident would not cause injury to himself or others, or cause damage to property related to smoking. Approaches included the following: Staff Note: Resident Smokes, Provide with a copy of facility smoking policy. Smoking allowed only in designated smoking areas. No smoking is allowed inside facility at any time. Provide smoking apron. While smoking, will have direct supervision by staff or family member. Nursing to keep all smoking materials at nurse's station." There were nothing in the care plan to show the facility had identified concerns for Resident #1 dozing during smoking and/or that Resident #1 had smoking materials on his/her person that were not kept at the nurse 's desk. Record review revealed a "Smoking Screen Questionnaire" for Resident #1 dated 3/29/13. For question #8, "NO" was marked in answer to the question, "Is the resident able to safeguard smoking materials and not endanger other residents when smoking?" "Yes" was marked for questions 1-7 and 9 which indicated Resident #1- smoked at home prior to coming to the center, understood the smoking policy related to safety measures, knew the exact location of designated smoking areas, demonstrated the dexterity skills needed to smoke safely, had stable coordination skills to smoke safely, understood the smoking rules and was able to abide by them, had the ability to use an ashtray properly and extinguish smoking material in a safe manner when finished, and -demonstrated cognitive skills related to safe smoking. Review of the facility's "Smoking Policy/Procedure" revealed documentation that Resident #1's spouse had signed the policy on 3/21/13, with the resident having signed 3/29/13. A Social Services Progress Note dated 3/29/13 stated, "(Resident #1) has decided to smoke. I discussed smoking policy with him/her. S/he voiced understanding and signed policy. Obtained cigarettes and placed at desk until family can bring some-Nursing staff and CNA made aware..." The facility's smoking policy stated the following: -"It shall be the policy of this facility to provide a smoke free environment. No smoking will be allowed in the facility by our residents, staff or guests. This includes electric cigarettes. -Our facility is a non-smoking facility. Due to inherent safety risks, no unsupervised smoking is allowed to occur. Designated smoking areas for residents and staff will be provided outside the facility. -Each resident who is admitted to this facility that chooses to smoke will be assessed by the assessment coordinator using BIMS or the cognitive performance scale to determine if they are a safe smoker or a non-safe smoker. -Family members will be made aware of the facility smoking policy during the admission process. -Employees will be inserviced on our non-smoking policy and the location of the approved designated areas outside the building during their orientation process. -Care plans will reflect support for the non-safe smoker decisions. Screening of smokers will be done upon admission, quarterly, and annually to assure safety for each resident. Residents may be placed on a smoking schedule supervised by staff is the assessment determines it necessary. -No smoking materials are allowed on any residents' person. Smoking materials will be kept in a locked area. -The policy is posted for review. -The Quality Assurance sub committee, Environment of Care, reviews adherence to the smoking policy. -Failure to comply with the facility's smoking policy includes but is not limited to: Smoking paraphernalia kept in resident's room (cigarettes, cigars, lighters, etc.); Smoking unsupervised. -Any violation of the above policy will result in a 30 day notice of discharge." During an interview on 5/7/13 at 10:05 AM, Social Services Worker #1 was asked where the smoking policy was posted in the facility since the policy stated it would be "posted". S/he did not know where it was posted and asked the Director of Nursing (DON), who was not aware where it was posted. The DON stated s/he would have to ask the Administrator, and returned stating the Administrator was going to check to see where it was posted. At 10:15 AM, the Administrator stated the smoking policy was posted in the Station 3 break room. Observation of the Station 3 break room with Social Services Worker #1 at 10:16 AM revealed a copy of the smoking policy taped to the bare wall next to the rest room door. When asked how residents and visitors were able to see/read the notice since it was posted in the Station 3 break room and not clearly visible for everyone, Social Services Worker #1 did not know. Observations throughout the facility and the Station 1 break room revealed no other smoking policy posted. The Administrator later approached the surveyor and stated that family members were provided with the smoking policy on admission. On 5/6/13, the facility provided a list of "Smokers", updated 5/3/13. According to the facility list, there were 7 residents who currently smoked (Residents #2, #3, #5, #6, #9, #12, and #13); 3 residents who "did not always smoke or were not smoking a lot at this time" (Residents #4, #7, #8) and 3 residents who were "not smoking at this time" (Residents #10, #11, and #14). Review on 5/6/13 of the facility obtained statements provided as part of the investigation into the fire incident for Resident #1 revealed a statement dated 5/2/13 from CNA #14 that stated, "...(Resident #3) only resident who had own cigarettes and lighter...(Residents #1, #2, #13) keep cigarettes at desk. Lighter is put back in drawer at Nurses station after smoke break (by CNA). A facility obtained statement from CNA #13 related to the fire investigation for Resident #1 revealed, "...(Resident #3) has (his/her) own lighter and (s/he) keeps (his/her) cigarettes as well. (S/he) has let others borrow (his/her) lighter but it has always been returned..." During an interview on 5/6/13 at 3:00 PM, CNA #13 stated that Resident #3's cigarettes and lighter had not been locked up in the med room until after the fire incident with Resident #1 on 5/2/13. CNA #13 stated that prior to that incident, Resident #3's cigarettes along with a lighter had been kept in a drawer behind the nurse's station. During an interview on 5/6/13 at 1:43 PM, CNA #12 stated that Resident #3 smoked in the smoking area without supervision. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment with an ARD of 2/21/13 revealed a BIMS score of 15. During an interview on 5/6/13 at 1:18 PM, Resident #3 stated that the facility did not allow residents to keep cigarettes or lighters on their person or in their room, and that residents had to be supervised while smoking. S/he stated that there are times at night when s/he "has to get out" and that s/he can smoke, even though it was not a designated smoking time. S/he was not aware of any visitors or others giving cigarettes or lighters to residents. Resident #3 stated, "I'm sure it happens though". Review of Resident #3 ' s Nurse ' s Notes on 5/6/13 at 3:00 PM revealed the following: -3/18/13 8:15 AM- "Ask(ed) resident to give cigarettes + lighter to writer (with) witness X 2. (RN #4) and (MDS nurse). Resident stated (s/he) threw lighter away last night and (s/he) did not have any cigarettes left. Writer stated Thank you and also told him/her it was a fire safety issue. -3/18/13 8:30 AM- "Resident gave this nurse a pack of cigarettes (with) 3 cigarettes in it from under the cushion of (his/her) w/c. This nurse gave cigarettes to ADON --". During an interview on 5/7/13 at 10:42 AM, the Assistant Director of Nurses (ADON) verified s/he had written the Nurse ' s Note dated 3/18/13 at 8:15 AM. The ADON stated that RN #4 was the nurse taking care of the resident. The ADON stated that RN #4 was no longer employed at the facility and that the MDS nurse was currently on leave. After reviewing the above Nurse's Notes, the ADON stated that RN #4 thought Resident #3 had something hidden under his/her wheelchair cushion, and thought it could be cigarettes. The ADON, MDS nurse, and RN #4 went to the resident's room and asked the resident if s/he had any cigarettes or a lighter. Resident #3 responded that s/he did not have any cigarettes and that s/he had thrown the lighter away last night. Resident #3 then asked the nurses to leave the room. Later, RN #4 came back and told the ADON that the resident had just given her/him the cigarettes from under the wheelchair cushion. Review of Resident #3 ' s Nurse ' s Notes on 5/7/13 at 10:30 AM revealed the following entry dated 2/28/13 at 12:30 PM that stated, "Resident yelling in hallway, cursing at staff. Sts (States) "I am having a claustrophobic attack." Repeatedly asks to be taken out to smoke. Resident has been out twice already this shift. Resident is not understanding of this. Request Ativan which I admin(istered) at this time. After a few minutes resident seen outside in smoking area unsupervised. DON notified of this situation. No further issues (with) this resident this shift..." RN #4 signed the note. Review of Resident #3's Care Plan revealed an entry dated 2/14/13 which stated that Resident #3 required supervision with smoking and that s/he refused to wear a smoking apron. According to the Care Plan, Resident #3 was only permitted to smoke in designated areas. Staff would stay with him/her and supervise until the cigarette was finished. Resident #3 would not be allowed to take a cigarette or lighter to his/her room. Cigarettes and lighters would be kept at the nurse's station. Resident #3 would be provided with a smoking assessment routinely and PRN (As Needed). Resident #3 would also be encouraged to wear a smoking apron. Further review revealed the following handwritten entries that had been added to Resident #3's Care Plan for smoking: -2/19/13 Refuses to completely wear smoking cape. Will only wear smoking cape in lap. -2/18/13 Resident non-compliant with facility smoking policy. -5/2/13 Resident met with Administrator and smoking policy reviewed and Resident acknowledges his/her understanding and signed policy. -5/7/13 Reviewed smoking assessment and BIMS score of 13. Resident is an independent smoker and does not require supervision. Smoking materials continue to be stored at nurse's station. The Care Plan had not been updated relative to the Nurse's Note dated 3/18/13 to show that Resident #3 had violated the smoking policy and had cigarettes and a lighter on his/her person. The Care Plan had also not been updated specifically related to Resident #3 going out to the smoking area without supervision on 2/28/13. During an interview on 5/7/13 at 10:50 AM, the ADON reviewed the above Nurse's Notes along with Resident #3's Care Plan. According to the ADON, all residents are supervised with smoking until deemed able to smoke independently. The ADON agreed that from the Care Plan documentation above, Resident #3 was to be supervised with smoking until 5/7/13. The ADON agreed that the Nurse's Note did not document any action taken by RN #4 after Resident #3 was seen smoking unsupervised on 2/28/13 other than notifying the DON. The ADON stated that if s/he had found the resident smoking unsupervised, s/he would have remained with the resident until s/he could get someone's attention so they could remain with the resident while s/he called the DON. Review of two "Smoking Screen Questionnaires" for Resident #3 dated 2/14/13 and 5/2/13 revealed the response to question #8, "Is the resident able to safeguard smoking materials and not endanger other residents when smoking?" was marked "No". Further review revealed Resident #3 signed the facility "Smoking Policy/Procedure" on 5/2/13. There was no documentation in the record to indicate that Resident #3 signed a smoking policy prior to 5/2/13. During an interview on 5/7/13 at 9:50 AM, Social Worker #2 stated s/he was aware that staff had conversations with Resident #3 with regards to understanding the smoking policy related to not keeping smoking materials in his/her room. According to Social Worker #2, Resident #3 was adamant about smoking unsupervised. Social Worker #2 stated s/he was not aware that the staff found smoking materials on the resident and had no knowledge of the resident having "unlocked" smoking materials. During an interview on 5/7/13 at 10:00 AM, Social Services Worker #1 stated that when Resident #3 first came in, s/he wanted to smoke and felt that s/he was an adult and didn't like "our rules". According to SSW #1, the previous Social Worker talked to Resident #3 extensively. SSW #1 stated that Resident #3 was allowed to have cigarettes and a lighter that s/he believed the resident kept smoking materials in his/her room in a drawer. SSW #1 did not believe this drawer had a lock and stated Resident #3 had never had a room mate. SSW #1 stated that all the other smoking residents kept their smoking supplies in a drawer at the nurse's desk. According to SSW #1, prior to the fire on 5/2/13, CNAs asked the ward secretary or the nurse to remove cigarettes and lighters from the unlocked drawer at the nurse's station. SSW #1 was not aware if this location for the smoking supplies and/or the procedure had changed since the fire incident on 5/2/13. During an interview on 5/7/13 at 11:03 AM, the Administrator and DON were present. The Administrator stated that Resident #3 had refused to sign the smoking policy on admission. According to the Administrator, the resident's Care Plan was updated on 5/2/13 when Resident #3 agreed to abide by and signed the smoking policy. During the interview, the DON was asked about the Nurse's Note dated 2/28/13 and what had occurred. After reviewing the 2/28/13 Nurse's Note, the DON stated that s/he had talked with Resident #3 and asked him/her to please have staff in the area when s/he smoked. When asked what Resident #3's response was, the DON said that Resident #3 "always says yes, but does what s/he wants afterward". The DON stated that this conversation had not been documented anywhere and that s/he was not sure the conversation occurred on the same day as the incident. The DON verified the handwritten care plan entry dated 2/28/13 that documented the resident had been noncompliant with the smoking policy. The Care Plan entries did not include any actions taken as a result of Resident #3's noncompliance with the smoking policy or specifically document that Resident #3 had been smoking unsupervised so that staff could monitor this behavior. The DON was also asked about the Nurse's Note dated 3/18/13 and stated s/he had been made aware of the incident. According to the DON, facility staff did not know that Resident #3 had been putting cigarettes under his/her cushion. The DON stated that Resident #3 would sit on the patio; in the outside smoke area and staff would light the cigarette and watch him/her while feeding residents inside the building in view of the patio. According to the DON, Resident #3 would get upset if staff sat beside him/her and would comment that s/he "wasn't a child". The DON stated that as far as s/he knew, Resident #3 was there (in the smoking area) and someone was in the vicinity to watch him/her. When asked if the facility had investigated how Resident #3 obtained the cigarettes and lighter on 3/18/13, the DON stated Resident #3 had his/her own money and that the resident would have visitors buy cigarettes for him/her. According to the DON, s/he more or less talked to staff about this, and there was no formal or written investigation into how Resident #3 obtained the smoking supplies. The DON stated that s/he talked to the resident, but Resident #3 did not say how s/he obtained the smoking supplies other than saying it was his/her business and that s/he could do what s/he wanted. When asked if they had discussed discharging Resident #3 (since the smoking policy stated that any violations to include unsupervised smoking and smoking paraphernalia in residents rooms would result in a 30 day notice of discharge), the Administrator and DON stated they had discussed discharging Resident #3 due to noncompliance with the Medicaid application and payment for services but that they couldn't find placement for him/her. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Initial Nursing Assessment for Resident #2 revealed a BIMS score of 15 that indicated the resident had been cognitively intact on admission. An MDS Assessment with an ARD of 4/21/13 revealed a BIMS score of 6 indicating severely impaired cognition at the time of the assessment. During an interview on 5/6/13 at 1:25 PM, Resident #2 stated that sometimes residents ask for a lighter and/or cigarettes from family members but that this was against the rules; and families would tell them "no". According to Resident #2, lighters and cigarettes are kept at the nurse's desk. S/he had not heard of anyone smoking in their room or visitors giving anyone lighters or cigarettes. S/he stated that if s/he knew this, then s/he would tell authorities. Resident #2 stated that s/he had not smoked in 8 days. During an interview on 5/6/13 at 2:12 PM, LPN #5 stated that a CNA told her/him that Resident #2 had a cigarette, so s/he took the cigarette from the resident, confiscated it immediately, and put it in the drawer. This occurred "a couple of weeks ago". According to LPN #5, Resident #2 told her/him that s/he had

On the days of the survey, based on record review, review of the facility standing orders, and interviews, the facility failed to document notification of the physician related to low finger stick blood sugar (FSBS) levels for Residents #11, #17, #19, #21, and #34 (5 sampled residents reviewed for physician notification related to low FSBS's) The findings included: The facility readmitted Resident #11 on 11/20/12 with [DIAGNOSES REDACTED]. Record review on 12/11/12 revealed a discharge summary from the hospital dated 11/20/12 related to a hypoglycemic episode occurring on 11/17/12. Facility Nurses Notes dated 11/17/12 at 9 PM documented the residents blood sugar was 361 (high). Eight units of Humalog insulin and 7 units of [MEDICATION NAME] were administered per routine physician's orders. At 11:05 PM, the resident felt "weak". The resident's Blood sugar was 40 (low) and glucoburst was administered. At 11:20 PM, the resident's blood sugar was 58 and another glucoburst given. At 11:50 PM the resident's blood sugar was 47 and [MEDICATION NAME] was administered. At 12:35 A, the blood sugar reading was 42. At that time ( approximately 1.5 hours after the initial onset of [DIAGNOSES REDACTED]) the physician was notified and orders were received "to send to ER"(emergency room .) At 1:00 AM, 911 was called; 1:20 AM EMS responded and at 1:30 AM the resident was transported to the ER. There was no documentation of treatment provided to the resident between 12:35 AM and 1:30 AM. Resident # 19 was admitted to the facility with [DIAGNOSES REDACTED]. Record review revealed the resident had a fasting blood sugar of 54 on 12/8/12. There was no documentation the physician was notified as verified by Licensed Practical Nurse # 4. The facility "Standing Orders" for a Hypoglycemic/Insulin Reaction included: "... If patient is responsive, administer 8 oz. (Ounces) fruit juice of patient choice or give instaglucose 31 gm (gram) or similar product. If pt (patient) unable to swallow and or unresponsive, admin. (administer) [MEDICATION NAME] 1 amp/1 mg (milligram) IM (Intramuscularly) Stat (immediately). Special instructions: determine blood sugar by fingerstick. If glucose <(less than) 60, administer treatment and contact MD (Medical Doctor) for further orders. An interview on 12/11/12 at 3:00 PM with LPN's (Licensed Practical Nurses) #2 and #3 revealed that the nurses would give the juice or [MEDICATION NAME] for a blood sugar below 60 and follow standing orders to notify the physician for further orders. During a telephone interview with Physician #1 on 12/12/12 at 12:30 PM, the physician stated he/she would expect the staff to give the treatment for [REDACTED]. The facility admitted Resident #34 on 1-25-12 with a [DIAGNOSES REDACTED]. On 12-10-12 at approximately 12:00 PM, during a closed record review nurses progress notes dated 1-27-12 at 1:10 PM stated the resident's blood sugar (BS) was 29, and an intramuscular (IM) [MEDICATION NAME] injection was administered. At 1:20 PM, the resident's blood sugar was rechecked and was recorded as 36. IM [MEDICATION NAME] was re-administered and the resident was transferred to the hospital. During this hypoglycemic episode the physician was not documented as being notified. On 12-10-12 at 3:00 PM, a review of the facility policy titled, "Blood Glucose Monitoring," revealed under general documentation guidelines: 5.) If the blood glucose level is above or below normal range, document the time the physician was notified. Furthermore, review of the facility "Policy and Procedure, Symptomatic Protocol," under symptom and treatment #22 [DIAGNOSES REDACTED], subsection b.) if glucose is less than 60, administer treatment and contact medical doctor (MD) for further instructions. On 12-12-12 at approximately 9:00 AM an interview with Registered Nurse (RN) #4 confirmed that on 1-27-12 no documentation was found that the physician was notified of the resident's low blood sugars. On 12-11-12 at 3:30 PM record review of Resident #21 revealed a physician order for [REDACTED]. units and call Nurse Practitioner or Medical Doctor. Additionally, the facility policy was reviewed and stated the nurse was to contact physician if the FSBS result was less than 60. On 12-11-12 at 3:45 PM a review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 10-17-12 FSBS at 7AM was 54 11- 05-12 FSBS at 9AM was 53 11-18-12 FSBS at 6AM was 59 11-23-12 FSBS at 11:30AM was 55 On 12-11-12 at 4 PM, review of Nursing notes revealed no documentation that the Nurse Practitioner or Medical Doctor was contacted to advise them of the FSBS results. Review of Resident #17's medical record on 12/11/12 at approximately 3:50 PM revealed a Physician's order for a Fingerstick Blood Sugar and regular insulin sliding scale to be performed (BID) twice daily before meals. Further review of the resident's medical record revealed [REDACTED]. On 11/25/12 the resident's FSBS was 51 and orange juice and sugar was provided. On 12/2/12 the resident's FSBS was 54, and on 12/5/12 the FSBS was 59. Per facility policy, the nurse was to contact the physician if the FSBS result was less than 60. There was no documentation of physician notification noted or provided.

On the days of the Recertification and Complaint Survey based on observations, record review, interview and review of the facility's policy on "Maintaining Good Skin Integrity and Preventing Skin Breakdown" the facility failed to ensure 3 of 4 sampled residents received appropriate pressure ulcer care to prevent new sores from developing and/or necessary treatments to promote healing. There was no evidence treatments were provided as ordered for Resident # 32 and the resident also received an incorrect treatment for 3 days. Resident # 36 was not re-positioned and did not receive incontinence care, resulting in the development of Stage I pressure areas. Additionally. the resident was observed without a pressure ulcer dressing in place per the physician's orders [REDACTED]. The findings included: The facility admitted Resident #32 with [DIAGNOSES REDACTED]. The resident expired at the facility on [DATE]. A closed record review on [DATE] revealed Resident #32 was severely anemic and required blood [MEDICAL CONDITION]. The resident also was noted to have a poor appetite and was prescribed multiple nutritional supplements. Resident #32 was admitted with a sacral pressure ulcer. The wound was noted to deteriorate on [DATE]. Further record review revealed the Nurse Practitioner assessed the wound frequently and changed the treatment regimen 3 times in a 5 week period due to wound deterioration. Review of the physician's orders [REDACTED]. Further review revealed the resident developed a persistent Urinary Tract Infection and Pneumonia. The sacral wound on [DATE] was noted to be "odorous" and the wound was deeper and was gray/black in color. Review of the Treatment Record for [DATE] revealed the resident no evidence that the resident received treatment to the left buttock from [DATE] through [DATE] (date the resident expired). There was no evidence the resident received the prescribed order to the sacral wound on ,[DATE], ,[DATE], ,[DATE] or [DATE]. The resident also received the wrong treatment on ,[DATE], ,[DATE] and [DATE]. The resident was to receive ,[DATE]% Dakin's solution for three days then changed to a wet to dry Santyl dressing. The staff treated the resident with both Dakin's and Santyl simultaneously. During an interview on [DATE] at 11 AM, Registered Nurse #2 stated that s/he was the wound care nurse for Resident #32. She/he stated that s/he would always initial the Treatment Record after s/he completed the treatment. S/he stated "if it wasn't documented, it wasn't done." During an interview on [DATE] at 11:10 AM, the Administrator and Director of Nurses confirmed the missing treatments for the resident's wound and confirmed that the wound deteriorated. The resident's multiple co-morbidity conditions were also confirmed. The facility admitted Resident #36 with [DIAGNOSES REDACTED]. During continuous observation of the resident on [DATE] from 9:30 AM through 12:20 PM, Resident #36 was observed to be in her/his gerichair on her/his right side slumped down with her/his head resting on the arm rest of the gerichair. The resident was noted to be in the corner of the common area in front of the kitchen. Resident #36 was not observed to have been provided incontinent care or repositioned during that time frame. At 12:20 PM, Certified Nursing Assistant (CNA) #1 transferred the resident to her/his room and into the bed to provide care. The resident's hips were noted to be red as well as her/his coccyx. The resident was noted to not have a pillow between her/his legs to prevent pressure areas between her/his knees and ankles. The resident's knees were also noted to have reddened areas as well as her/his lateral bony prominence of her/his ankle. No dressing was noted on the resident's coccyx. The resident was noted to be severely contracted, with her/his legs folded and arms held close to her/his chest. CNA #1 attempted to reposition the resident in the bed by hooking one arm under the resident's arm pit and an arm under the resident's knee and dragged the resident across the bed. The resident's brief was noted to be soiled as well as wet. Cross Refer to F 315 related to inappropriate incontinent care. Record review revealed, on [DATE] the resident developed a Stage II pressure ulcer to her/his coccyx and Exuderm Monday, Wednesday and Friday was ordered. An Exuderm was initialed as placed on [DATE] per the Treatment Record. During an additional observation on [DATE] at 8:30 AM, Licensed Practical Nurse (LPN) #2 and Registered Nurse (RN) #1 confirmed the still existing red areas to the resident's bony prominence's of her/his hips, knees and ankle. RN #1 stated that s/he would notify the provider and initiate treatment for [REDACTED]. RN #1 also confirmed the resident should have had a dressing per the physician's orders [REDACTED]. The facility admitted Resident #35 with [DIAGNOSES REDACTED]. During continuous observation of Resident # 35 on [DATE] from 9:30 AM through 12:45 PM, Resident #35 was noted to be in a reclined gerichair lying on his/her back. Resident #35 was not observed to receive incontinent care nor was the resident repositioned during that time frame. At 12:45 PM, CNA #1 was observed to transfer the resident to his/her room and provided incontinent care to the resident. The residents sacral area was noted to be red with deep red indented marks from the pad and brief. A darker red area was noted on the resident's left inner buttock. The resident's brief was both wet and soiled. After care was provided, CNA #1 left the resident positioned flat on his/her back. Record review on [DATE] revealed the resident did not have any noted skin impairments and was ordered to have moisture barrier applied three times a day. No other skin treatments were ordered. Cross Refer to F 315 related to inappropriate incontinent care. During an additional observation on [DATE] at 8:45 AM, Resident #35's sacral area was still red and the left inner buttock remained a darker red area. RN #1 confirmed the area and stated that a treatment would be ordered for the newly acquired pressure area. RN #1 also stated that the resident should be repositioned at least every two hours. During a telephone interview on [DATE] at 12:35 PM, the Attending Physician stated that any resident that was not able to move themselves should be turned and repositioned at least every two hours. The Physician stated that if the residents' pressure loading areas were not offloaded then the blood supply could be altered and pressure wounds could develop. The Physician was informed of the observations and resultant new pressure areas to Resident #35 and Resident #36. Review of the facility's policy on "Maintaining Good Skin Integrity and Preventing Skin Breakdown" revealed: "The facility will follow steps to minimize the risk of skin breakdown from occurring and maintain good skin integrity...2. Monitor for signs of pressure ulcer formation. These commonly occur over bony prominence's and affect residents who do not move or cannot change position for a long time. When prolonged redness or a break in the skin occurs, the charge nurse should be notified so treatment orders can be obtained and the cause of the skin breakdown can be assessed. 3. Keeping the skin clean, dry and moisturized is one of the keys to preventing pressure ulcers. Special consideration should be paid to those who suffer from incontinence...6. For incontinent residents...keep in mind that diapers and pads do not replace the need for diligent good skin hygiene...7. Friction and sheer can occur together when transferring or changing a resident's position. CNA's should keep in mind the following suggestions: Use lifting devices such as trapeze or lift to move residents rather than dragging them...10. Residents at risk for developing a pressure sore should avoid uninterrupted sitting in any chair. Reposition frequently..."

On the days of the survey, based on record reviews, observations, and interviews, the facility failed to provide appropriate care and services for a resident with a Picc line, resident's experiencing [DIAGNOSES REDACTED] and a resident with a surgical wound. Resident # 11 experienced a low blood sugar without prompt physician notification and no evidence of intervention while waiting one hour to be be transferred to the hospital. Resident # 21 had no documented interventions for low blood sugars. Resident #6 received inappropriate surgical wound care. Resident # 5 had no documentation of a PICC (peripherally inserted central catheter line) having been flushed after receiving an antibiotic. ( 2 sampled residents with low blood sugars, 1 sampled resident with PICC line, and 1 of 2 sampled residents with surgical wounds reviewed for appropriate care and services) Cross refer to F 157 as it relates to the failure of the facility to appropriately notify the physician when resident's were experiencing [DIAGNOSES REDACTED]. Cross refer to F 281 as it relates to the failure of the facility to follow professional standards for resident with a PICC line. The findings included: The facility readmitted Resident # 11 on 11/20/12 with [DIAGNOSES REDACTED]. Record review on 12/11/12 revealed a discharge summary from the hospital dated 11/20/12 related to a hypoglycemic episode occurring on 11/17/12. Facility Nurses Notes dated 11/17/12 at 9 PM documented the residents blood sugar was 361 (high). Eight units of Humalog insulin and 7 units of [MEDICATION NAME] were administered per routine physician's orders [REDACTED]. The resident's Blood sugar was 40 (low) and glucoburst was administered. At 11:20 PM, the resident's blood sugar was 58 and another glucoburst given. At 11:50 PM the resident's blood sugar was 47 and [MEDICATION NAME] was administered. At 12:35 AM, the blood sugar reading was 42. At that time ( approximately 1.5 hours after the initial onset of [DIAGNOSES REDACTED]) the physician was notified and orders were received "to send to ER"(emergency room .) At 1:00 AM, 911 was called; 1:20 AM EMS responded and at 1:30 AM the resident was transported to the ER. There was no documentation of treatment provided to the resident between 12:35 AM and 1:30 AM. The facility "Standing Orders" for a Hypoglycemic/Insulin Reaction included: "... If patient is responsive, administer 8 oz. (Ounces) fruit juice of patient choice or give instaglucose 31 gm (gram) or similar product. If pt (patient) unable to swallow and or unresponsive, admin. (administer) [MEDICATION NAME] 1 amp/1 mg (milligram) IM (Intramuscularly) Stat (immediately). Special instructions: determine blood sugar by fingerstick. If glucose <(less than) 60, administer treatment and contact MD (Medical Doctor) for further orders. An interview on 12/11/12 at 3:00 PM with LPN's (Licensed Practical Nurses) #2 and #3 revealed that the nurses would give the juice or [MEDICATION NAME] for a blood sugar below 60 and follow standing orders to notify the physician for further orders. During a telephone interview with Physician #1 on 12/12/12 at 12:30 PM, the physician stated he/she would expect the staff to give the treatment for [REDACTED]. On 12-11-12 at 3:30 pm review of Resident #21 medical record revealed a physician order [REDACTED]. On 12-11-12 at 3:45 pm review of Resident #21's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10-23-12 at 7 am, on 11-2-12 at 6 am and on 11-21-12 at 4:30 pm there was no evidence that the FSBSs were done as ordered. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. During a review of the Resident # 5's Nurses Notes on 12/10/12 at approximately 4 PM revealed a note dated 11/25/12 "Resident sent out to unclog picc line." Review of the Physicians Orders revealed "Flush Picc line with 5cc (cubic centimeters) before and after ABT (Antibiotic treatment)." The resident was also getting blood drawn every Monday from the picc line. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the MAR for November 2012, there were no flushes after antibiotic administration on the following dates: November 17th, 18th, 19th, 21st, and 24th for the 8Am dose and no documentation of flushes for the 4Pm and 12AM doses for the 11 days of administration in November. Perry and Potters Clinical Nursing Skills and Techniques, 7th edition, Copyright 2010, page 619 (8.b. Administer Medication) states "Flush IV site with 0.9% sodium chloride......Remove saline filled syringe, clean lock's injection port with antiseptic swab, insert syringe containing prepared medication through injection port of IV lock." "Flushing IV lines with saline prevents occlusion of IV access device and ensures all medication delivered. Maintains patency of central line by inhibiting clot formation (Guthrie and others, 2007)." During an interview with Licensed Practical Nurse #5 s/he verified there was no documentation that indicated nurses were flushing Resident #5's ICC as ordered by the physician. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. During an observation of the surgical wound care on 12/11/12 at 10:20 AM, Registered Nurse (RN) #1 cleaned with wound cleanser the periwound area of the most lateral right wound (Wound #1). Dried sero-sanguinous drainage was observed to remain on the periwound area after cleansing. An additional wound was noted approximately 1-2 inches below and lateral to the wound. RN #1 did not observe, clean or treat the area. The wound was noted to be approximately 1 inch in length and have a yellow center. RN #1, while dressing Wound #1, placed silk tape over the new wound. RN #1 proceeded to cleanse and dress Wounds #2, #3 without incident. RN #1 squeezed Hydrogel onto an applicator and treated Wound #4, however, RN #1 only treated 1/2 of the wound, leaving the remaining portion untreated. RN #1 then proceeded to clean and treat Wound #5. RN #1 was observed to cut a 2 inch piece of Silver Alginate and place the strip into a skin fold where Wound #5 was located. The open area was approximately 1 cm (centimeter) x 1 cm. RN #1 placed the Silver Alginate onto healthy, healed skin and proceeded to cover the entire fold with a dressing. RN #1 did not treat Wound #6. After the procedure, RN #1 was noted to initial all 6 treatments as completed and did not address the additional wound at any point. Review of the physician's orders [REDACTED].#2, #3, #4, #5 and #6 were to be cleaned with wound cleanser and then packed loosely with Silver Alginate daily. On 12/7/12, the Silver Alginate to Wound #4 was discontinued and was changed to Hydrogel daily. There were no other orders discontinuing or changing any other treatments. During an interview on 12/12/12 at 1:10 PM, RN #1 confirmed that s/he did not treat Wound #6 and confirmed that s/he had initialed the TAR (Treatment Record) signifying the treatment had been done. RN #1 also stated that s/he did not note the additional wound below Wound #1 and was not aware that tape had been placed over the wound. RN #1 also confirmed that s/he placed Silver Alginate onto healed skin and confirmed that s/he did not put Hydrogel onto the entire wound bed.

On the days of the Recertification and Complaint Survey based on observations, record review and interview, the facility failed to assure 4 of 13 sampled residents received the necessary care and services related to Foley Catheter Care/ Incontinent Care. Resident #32 did not receive Foley Catheter care and the resident developed a single organism Urinary Tract Infection. Resident #3, #35, #36 did not receive appropriate or timely incontinent care. Cross refer to F 323 related to inappropriate transfers. Cross refer to F 314 related to the failure to prevent new pressure areas from developing. The findings included: The facility admitted Resident #32 with [DIAGNOSES REDACTED]. Record review on 12/10/12 revealed Resident #32 had a deteriorating sacral pressure ulcer. A Foley catheter was in place to prevent excessive moisture. A physician's orders [REDACTED]. The resident was also noted to be always incontinent of bowel per the Admission Minimum (MDS) data set [DATE]. Review of the Treatment Record for May 2012 revealed no evidence the resident received Foley Catheter Care 9 out of 19 days. Further record review revealed the physician ordered a urinalysis and culture on 4/30/12. An antibiotic was ordered on [DATE] for a [DIAGNOSES REDACTED]. On 5/16/12 a re-check urinalysis/culture was requested and an IV antibiotic ordered. The resident passed away on 5/19/12. During an interview on 12/11/12 at 11 AM, Registered Nurse #2 stated that the Certified Nursing Assistants were responsible for Foley Cath care. She/he stated that the care was typically performed during morning care and the nurses were responsible for assuring the care was complete. The nurses were to document on the treatment record the care had been performed. During an interview on 12/12/12 at 11:10 AM, the Administrator and Director of Nurses confirmed there was no evidence Foley Catheter care was provided. The facility admitted Resident #36 with [DIAGNOSES REDACTED]. During continuous observation of Resident # 36 on 12/11/12 from 9:30 AM through 12:20 PM, s/he was observed to be in her/his gerichair on her/his right side slumped down with her/his head resting on the arm rest of the gerichair. Resident #36 was not observed to be provided incontinent care nor repositioned during that time frame. At 12:20 PM, Certified Nursing Assistant (CNA) #1 transferred the resident to her/his room and into the bed to provide care. Certified Nursing Assistant (CNA) #1 was observed to put on gloves without washing her/his hands, wet one washcloth, pull the resident's pants off and undo the resident's brief. The resident was observed to be both wet and soiled. The CNA proceeded to cleanse the resident's skin with one damp washcloth repeatedly using the same area of the cloth to remove the stool. The CNA was then observed to place a clean brief under the resident, arrange the resident's bedspread, and open the privacy curtain. The CNA then removed her/his gloves, gathered the trash and washed her/his hands. The facility admitted Resident #35 with [DIAGNOSES REDACTED]. During continuous observation of the resident on 12/11/12 from 9:30 AM through 12:45 PM, Resident #35 was noted to be in a reclined gerichair flat on his/her back. Resident #35 was not observed to receive incontinent care nor was the resident repositioned during that time frame. At 12:45 PM, CNA #1 was observed to transfer the resident to his/her room and provide incontinent care to the resident. CNA #1 donned gloves without washing her/his hands. She/he then removed the resident's pants and brief. The resident was noted to be both wet and soiled. CNA #1 then placed a new brief under the resident, then removed her/his gloves, pulled the resident's bedspread up, gathered the trash and then washed her/his hands. Cross Refer to F 315 related to the failure to prevent new pressure areas from developing. Review of the facility's policy on "Maintaining Good Skin Integrity and Preventing Skin Breakdown" revealed: "The facility will follow steps to minimize the risk of skin breakdown from occurring and maintain good skin integrity...2. Monitor for signs of pressure ulcer formation. These commonly occur over bony prominence's and affect residents who do not move or cannot change position for a long time. When prolonged redness or a break in the skin occurs, the charge nurse should be notified so treatment orders can be obtained and the cause of the skin breakdown can be assessed. 3. Keeping the skin clean, dry and moisturized is one of the keys to preventing pressure ulcers. Special consideration should be paid to those who suffer from incontinence...6. For incontinent residents...keep in mind that diapers and pads do not replace the need for diligent good skin hygiene...7. Friction and sheer can occur together when transferring or changing a resident's position. CNA's should keep in mind the following suggestions: Use lifting devices such as trapeze or lift to move residents rather than dragging them...10. Residents at risk for developing a pressure sore should avoid uninterrupted sitting in any chair. Reposition frequently..." The facility admitted Resident #3 with [DIAGNOSES REDACTED]. During continuous observation of the resident on 12/11/12 from 9:30 AM through 2 PM, Resident #3 was noted to be sitting in her/his wheelchair with a harness positioning device in place to prevent the resident from leaning over in her/his chair. The resident was not observed to receive incontinent care and was not repositioned during that time frame. At 2 PM, Resident #3 was wheeled to her/his room and transferred to her/his bed. . CNA #1 donned gloves without washing her/his hands first, removed the resident's pants and brief. The resident was noted to be both wet and soiled. CNA #1 repeatedly wiped the same area with the same portion of the wipe and wiped from back to front twice. CNA #1 placed a new brief under the resident, rearranged the resident's bedspread, then removed her/his gloves, gathered the trash and then washed her/his hands. During an interview on 12/11/12 at 3:45 PM, the Administrator and Director of Nurses was informed of the untimely and inappropriate incontinent care related to Resident #3, #35 and #36. CNA #1 was suspended by the facility related to the allegation and was not available for interview. Observations were made of the Resident # 3 on 12/10/12 at 2:30 PM lying in bed on his/her right side and covers pulled up to neck. At 3:45 PM the resident was observed in the same position. The call bell remained in the same place, and covers remained pulled up to neck. At 5:00 PM the resident was again observed in the exact same position.

On the days of the Complaint and Extended Survey based on observations, record review, and interview, Substandard Quality of Care and Immediate Jeopardy at a scope and severity of "J" was identified related to the facility's failure to provide the necessary care and services to prevent Resident #3 from sexually abusing other residents and the facility's failure to identify and protect those residents that were alleged to be sexually abused. On 8/5/2011 Resident #4 was allegedly sexually abused by Resident #3. Resident #3 also allegedly sexually harassed Resident #6. The facility failed to put interventions in place to protect Resident #4 and Resident #6 and other residents that had the potential to be sexually abused by Resident #3. In addition, a Certified Nursing Assistant failed to report to facility staff an allegation of resident to resident sexual abuse. The findings included: The facility admitted Resident #3 on 7/10/2009 with [DIAGNOSES REDACTED]. Observation of Resident #3 on 8/29/2011 at 12:30 PM, revealed him up in a wheelchair in his room with his back to the door. Resident #3's pants were unzipped and his shirt tails were loosely covering his groin area. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired in decision making abilities. No behaviors were coded as occurring during the assessment period. Resident #3 was coded as requiring one person limited assistance with transfers and was able to self propel himself in the wheelchair. Review of the Care Plan dated 11/24/2010 and printed on 7/27/2011, revealed a problem area of " resident has hx (history) of becoming aggressive leading him to strike at staff and peers. This could be related to impaired hearing and vision keeping him from understanding what is taking place. Has also been sexually inappropriate requiring psych hospitalization . " Approaches included " make all staff aware of the fact that resident can be aggressive and sexually inappropriate, approach resident carefully making sure you have gained his attention, check with resident to make sure he has heard and comprehended what you have said to him, work in pairs if indicated, if behaviors persist, obtain further medical intervention, Psych consult done [DATE]. Will ask for follow up related to recent behaviors, administer medications, observe closely for inappropriate sexual behavior and gently redirect and remove from situation. " The Care Plan was not updated with the resident's behaviors and no new interventions for the sexually inappropriate behaviors were added to the Care Plan. Review on 8/29/2011 of the Nurses Notes revealed an entry dated 6/21 at 12:15 PM, Resident #3 was placed on every 30 minute checks for sexually inappropriate behaviors. Review of the 30 minute check documentation from 6/21-6/24 revealed Resident #3 did not have documentation of his whereabouts on 6/22 from 5 PM to 7PM, 6/23 from 5AM-7AM, 6/23 from 11:30 PM to 7 AM on 6/24. On 6/24/2011 at 11:45 AM, Resident #3 was observed in " day room exposing private part. " There were no other 30 minute checks after 12 PM on 6/24/2011. Further review of the nurses notes revealed on 6/25 at 11:45 AM, " res(ident) up in front of nurses station exposing self to staff and other res. Res took in room and explained not to expose self to staff and res clothes helped back on and res taken back to nursing station per his request. " On 6/30 at 11AM, " res in hallway, parked in w/c (wheelchair) next to a female resident c (with) his pants open and his penis exposed-This nurse quickly went to res and asked him to please pull up his pants, Res looked angry and did pull his pants up also asked res to zip his pants, Res did this. Made DON (Director of Nurses) and Social Services aware. " At 12:20 PM, " nurse observed res back in hall exposing himself to a female resident and I immediately removed this res from hall and transferred to his room. I immediately notified DON of this as well. " At 1PM, the Attending Physician updated on (increasing) sexual behaviors and orders received to (increase) [MEDICATION NAME] back to 150 mg BID (twice daily), check U/A (urinalysis) and f/u (follow up) c Carolina Behavioral Health. " On 7/1/2011 at 1:30 PM, " Resident in front of nurses station touching a female resident's shoulder c pants open and penis hanging out. Separated from resident immediately and taken to room for lunch. DON notified. Resident ate lunch and then transported by transport to Carolina Behavioral Health. Sister notified and she stated she was waiting on him at the facility. " Resident #3 was admitted to Carolina Behavioral Health from 7/1-7/11/11. [MEDICATION NAME] 5 mg was added to Resident #3's medication regime. Continued review of the Nurses Notes revealed Resident #3 was admitted back to the facility on [DATE]. On 7/12/2011 at 7 PM, Resident #3 " hit this nurse on the left side of nurses' face, then hit this nurse in the face. DON notified. DON took resident to his room and talked with resident. " At 7:20 PM, " GNP (General Nurse Practitioner) notified, new orders received for [MEDICATION NAME] 10 mg PO PRN q 12 hours (by mouth as needed every 12 hours), continue [MEDICATION NAME] 10 mg IM (intramuscularly). " At 7:25 PM, sister notified by social worker of resident's behavior. " On 7/23 at 3:30 PM, " resident exposed his penis to (Certified Nursing Assistant). " On 7/25 at 2 PM, " Resident exposed himself in day room. Redirected to room. Laying down on bed. Will report to oncoming nurse. " On 7/26 at 3PM, " several episodes of inappropriate behavior this shift, nurse re-directed x2 of approaching female residents. Exposed himself in PT and in hallway, PRN [MEDICATION NAME] given 2 hours p (after) scheduled [MEDICATION NAME] report to oncoming nurse. " On 8/5 at 6:55 AM, " noted with hand between female resident's legs, touching inappropriately. Resident removed from the area and instructed not to touch other residents, that behavior was inappropriate. Resident was noted touching same resident inappropriately and moved to another area but went back to lounge sitting area, will monitor closely. " On 8/23 at 8 AM, " resident exposed himself to a female resident in TV area. Was redirected and taken back to room. " On 8/24 at 5 PM, " Res observed exposing himself in the hallway on Station 1. This nurse asked Res to please pull his underwear up and his pants-Res complied-Assisted back to the privacy of his room-DON immediately notified. " Review of the Social Service Progress Notes revealed on 7/12/2011 the Social Services Director (SSD) met with Resident #3 regarding him striking a staff member in the face causing a bloody nose. The SSD documented: " he has a PRN order for IM [MEDICATION NAME] but no PRN by mouth. Nurse called the NP and she gave order for PRN PO [MEDICATION NAME] every 12 hours. I called (RP) to let her know what had occurred. I asked her if she ever knew of (Res #3) being abused as a child and she said no...(the RP) felt (Resident #3's child hood residence) would have been a rough neighborhood. The nurse practitioner said if this behavior occurred again to send him out. We have tried this in the past but for emergent psychiatric care, they have to go through the ER and if he is calm when he gets there, they usually send them back with no treatment. There is not always an availability in a psych setting. " On 7/23, " DON notified me that (Res #3) had exposed himself to a CNA. When I visited he was sleeping as normal. " On 7/25, " DON spoke with (GNP) She increased dosage of [MEDICATION NAME] and gave scheduled dose of [MEDICATION NAME]. He did expose himself in the day room this day but was redirected by staff. " On 7/26, Res #3 " has continued with inappropriate behavior of exposing himself. Staff has intervened appropriately and resident has accepted redirection without aggression. I went to attempt to talk to (Res #3) regarding his behavior but he was sleeping soundly and did not (???) when I called his name. I will follow. " On 7/27 a care plan meeting was held and social services documented the following: " (Res #3) is unable to cognitively participate. He suffers from dementia with behavioral disturbances manifested by sexual acting out and aggressiveness as prior documentation shows. He has been followed by attending psychiatrist and has been in a psych setting recently with no [MEDICATION NAME] results... " On 8/5, " received word from nursing staff that (Res #3) was again exhibiting inappropriate sexual behaviors. They had already intervened appropriately asking and assisting him to his room for privacy. I visited (Res #3) in his room. When I talked with him about this behavior, he really seemed confused. I explained that exposing himself and touching people inappropriately was not acceptable behavior. I told him that this kind of behavior could be considered assault and people can be arrested for this. He responded, " oh. " I doubt full comprehension of this conversation. I will follow and continue to assist staff in observing for behavior. " On 8/24, " DON has notified me that inappropriate sexual behavior has again been noted by staff in the past two days. I had observed (Res #3) out of his room earlier today and assisted him through the day room and to the dining area which is where he was going. There were no other residents in the dining area when I left him. We keep MD updated on behavior and I will ask for follow up for psychiatrist. " Review of the 24 Hour Reports revealed on 7/12 Resident #3's behaviors were not included on the reports. On 7/23, Resident #3's behaviors were not on the report. On 7/25, Resident #3's exposing self and changes in orders were added. On 7/26, " PRN [MEDICATION NAME] was used, inappropriate behavior. " On 8/5, Resident #3's behaviors were not included on the report. On 8/9, " inappropriate touching " was added to the report for Resident #3. No other entries were recorded on the 24 hour reports for Resident #3 until 8/24 that indicated " exposing himself again this evening in hallway-redirected, DON made aware. " No consistent behavior monitoring was put in place for Resident #3. Incidents of inappropriate behavior that were documented usually did not provide enough details to determine who may be involved or what did occur. The documentation was often very limited and not found in a consistent location. Review of the Progress Notes revealed Resident #3 had a Psych Consult on 1/12/2010 and the medication [MEDICATION NAME] was added. On 1/26/2010, the Psychiatrist discontinued the [MEDICATION NAME] due to increased confusion. There was no other indication that the Psychiatrist had assessed the resident in the facility. Further review revealed no physician progress notes [REDACTED]. Review of the History and Physical dated 7/12/2011 revealed " elderly gentleman with history of dementia having increased agitation, aggression and sexual inappropriateness. He went to Carolina Center for Behavioral Health. Initially he was very pleasant; however, after admission he became sexually inappropriate. He had several medication changes made. He was also started on [MEDICATION NAME]. Behaviors gradually improved. He stabilized and was transferred here for further care. " Resident #3 was seen by the GNP for dry scaly skin. On 7/25, the GNP again saw Resident #3 for " sexually aggressive behaviors. I will increase his [MEDICATION NAME] and schedule [MEDICATION NAME] and monitor his behaviors. " No other progress notes were located. Review of the Incident Report dated 7/12 revealed the interventions put in place to prevent future reoccurrence's were: " 1. Provider updated on incident and [MEDICATION NAME] ordered orally along with his IM, 2. SS and DON interviewed resident and assisted resident to his room to eat supper and 3. Plans to f/u c (Psychiatrist) or provider (Attending physician/GNP). " No other incident reports were found related to Resident #3's sexually inappropriate behaviors. Review of the Physician order [REDACTED]. On 6/30 the [MEDICATION NAME] was increased to 150 mg BID. Review of the Cumulative Orders from July 1, 2011 revealed Resident #3 was prescribed [MEDICATION NAME] 4.5 mg BID, [MEDICATION NAME] 10 mg BID and [MEDICATION NAME] 75 mg BID. Resident #3's readmission orders [REDACTED]. On 7/12/2011, [MEDICATION NAME] 10 mg PO every 12 hours PRN was ordered in addition to the IM [MEDICATION NAME]. On 7/25/2011 the [MEDICATION NAME] was increased to 300 mg BID and [MEDICATION NAME] was scheduled 10 mg every day and 10 mg once daily PRN, all previous [MEDICATION NAME] PRN orders were discontinued. On 7/27 a U/A was ordered and on 8/2 [MEDICATION NAME] was started for a UTI. On 8/9 [MEDICATION NAME] 25 mg and then increased to 50 mg was started for " aggression. " Review of Nurses Notes revealed there were no nurses notes that corresponded to the orders for a UA (Urinalysis) on 7/27/2011 and for the [MEDICATION NAME] addition on 8/9/2011 for depression. During an interview on 8/29/11 at 2 PM, Licensed Practical Nurse #1 stated that she had witnessed Resident #3 touching female residents inappropriately. She stated that she immediately would remove the resident and redirect him. She stated that Resident #3 did not single out one resident in particular that it was whatever female resident happened to be near him. During an interview on 8/29/11 at 2:05 PM, CNA#1 (Certified Nursing Assistant) stated that she has witnessed Resident #3 inappropriately touching other female residents. She stated that Resident #3 " mostly goes after " Resident #4. However, she stated that Resident #6 had reported to her that Resident #3 touched her inappropriately. CNA#1 stated that she did not inform the nurse of the report of sexual abuse for Resident #6. CNA#1 then stated Resident #3 would go into other resident's rooms and lay down in their beds. During an interview with Resident "A" (a resident on the Unit identified as interviewable) on 8/29/2011 at 2:15 PM, Resident "A" stated that she/he had witnessed Resident #3 expose himself and touch Resident #4 inappropriately in the day room. Resident "A" then stated that this occurred last week around mid-morning. The resident stated that she/he informed LPN #1 of the incident and LPN#1 moved Resident #3 to the other side of the day room. Upon review there were no nurses notes, 24 hours reports or any reference in the records related to the incident identified by Resident "A". The facility admitted Resident #4 on 7/13/2009 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #4 had short term and long term memory problems and was severely impaired with decision making abilities. Review of the Care Plan dated 12/2010 revealed Resident #4 had a problem area identified related to combative behaviors and resisting care. The Care Plan had not been updated and no new interventions had been added related to the sexual assaults. Record Review revealed no documentation of any sexual abuse in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #4. Resident #4's Attending Physician and the Responsible Party had not been notified of the sexual abuse that had occurred. There was no evidence Resident #4 had been examined by a physician related to the sexual abuse. No interventions had been put in place related to the incidents. The facility admitted Resident #6 on 3/18/2011 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS score of 15. No behaviors were coded during the assessment period. During an interview on 8/29/2011 at 2:10 PM, Resident #6 stated Resident #3 was in the hallway and rubbed her arm and thigh and commented on how pretty she was and how nice her legs were. Resident #6 asked him to stop and he continued rubbing her leg. Resident #6 then removed Resident #3's hand from her body and left the area. Resident #6 stated that she reported the incident to CNA#1. Resident #6 stated that Resident #3 would also come to her doorway and expose himself to her. She stated that she would press the call light and staff would come down and move Resident #3. She stated that the staff did not do anything for her. Resident #6 stated that she felt uncomfortable and whenever she saw Resident #3 in the area she would leave and go in the other direction. Resident #6 stated that no staff member had come to speak with her about the incidents. Record review revealed no documentation of any sexual abuse in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #6. Resident #6's Attending Physician had not been notified of the incidents and no interventions had been put in place related to the incidents. During an interview on 8/29/2011 at 3PM, the SSD stated that she had spoken to Resident #3 regarding his behaviors and informed him that the behaviors were inappropriate and unacceptable. She then stated that Resident #3 did not know what he was doing and stated that he did not comprehend what she was saying. The SSD stated that the if the staff saw Resident #3 acting inappropriately they were to immediately remove him from the situation and redirect him. The SSD stated that no other interventions were put in place for Resident #3's behaviors. The SSD stated that she was aware of Resident #3 touching Resident #4 inappropriately. She stated that nothing was put in place for Resident #4. The SSD stated that she was not aware of any other residents, therefore nothing had been put in place for any other female residents that had been victimized. During an interview on 8/29 at 3:20 PM, LPN #2 stated that she was assigned to Resident #3 on third shift on 8/5/11. LPN#2 stated that a nursing assistant had notified her that Resident #3 had his hand down Resident #4's blouse fondling her breast. LPN#2 stated that she then moved Resident #3 to the other side of the day room. LPN#2 stated that approximately 30 minutes later, Resident #3 was reported to have his hands between Resident #4's legs touching her inappropriately. LPN#2 stated that she removed the resident from the day room and informed the resident that that behavior was inappropriate. She stated that he did come back out to the day room afterwards but did not touch any resident inappropriately again. LPN#2 stated that Resident #4 " had her pants on. " LPN#2 stated that she informed the DON of the incident but stated that she was not sure if she called the physician or the resident's responsible party. During an interview on 8/29/2011 at 3:25 PM, the Director of Nurses stated that she was not aware of the incident on 8/5 between Resident #3 and #4. She confirmed that neither the family or the physician were notified of the incident. The DON also confirmed there were not any incident reports related to Resident #3's sexually aggressive behavior. During an interview on 8/29/2011 at 3:40 PM, the Attending Physician stated that since Resident #3's readmission on 7/11/11 his behaviors were " manageable. " He stated that he was aware of only one incident that had occurred. The Attending Physician stated that he was not notified of Resident #3's increasing sexually inappropriate behaviors. He also stated that he was not notified of the incident on 8/5 and stated that he was not aware of any specific residents that Resident #3 had touched inappropriately. The Attending Physician stated that the " status quo was not working and there were other things we could have tried." He stated that if he was made aware he would have changed the medications, increased the [MEDICATION NAME], send the resident out to the hospital, monitor the behaviors, activities to keep him busy and to keep him away from women. The Attending Physician confirmed that Resident #4 and #6's psychosocial needs were not addressed. He stated that Social Services should have assessed the residents, both residents should be monitored closely for behavior changes and the facility should prevent the incidents and should protect the residents. During an interview on 8/30/11 at 10:10 AM, the Medical Director stated that he was aware of Resident #3's sexually aggressive behaviors prior to his psychiatric hospitalization . He stated that he was informed today (8/30) of Resident #3's sexually inappropriate behavior since his readmission on 7/11. The Medical Director stated that he was usually made aware of Resident issues if the facility had a concern, the severity of the incident or if the resident continued to have ongoing problems. He stated that he wouldn't be notified of every occurrence but should have been notified of Resident #3's behaviors. During an interview on 8/30/2011 at 10:20 AM, the Administrator and the Director of Nurses (DON) stated that they were aware of Resident #3's sexually inappropriate behaviors. The DON stated that she was aware of some of the incidents but not all. Both stated that they were not aware of the incident on 8/5 between Resident #3 and #4. Both stated that they were not aware of any particular resident involved. The Administrator and the DON stated that the staff acted appropriately by removing the resident from the situation. The DON stated that there " was nothing else to do. " She stated that the resident was on " the list to move to the men's unit. " When asked where the list was, the DON stated that there was not an actual list, it was " in our heads who is next to move. " The Administrator then stated that she couldn't " just move someone " and it was " based on bed availability " and there were no beds available. The Administrator confirmed that the "Men's Unit" was not a designated unit and female residents reside on the unit; she confirmed that that unit had a heavier concentration of male residents. Both the Administrator and the DON stated again that they were aware Resident #3 was exposing himself to other residents. The Administrator and the DON stated that there was no tool in place to monitor the behaviors specifically. However, both stated that during the morning meeting the 24 hour reports were reviewed and Resident #3's behaviors should be recorded on them. Review of the facility's In-Services revealed on June 1, 2011 an in-service was conducted that included: " what do you do if see/hear abuse-Report to Supervisor who report to Administrator and DON. " Also included were " How to manage difficult residents. " The types of Abuse were also included as well as " timely reporting " and " zero tolerance! " " Any abuse- not for us to decide its " just behavior, just normal. " On 6/21/2011 an in-service was conducted, topics included " Nursing Documentation: change in condition or unusual occurrence happens (behavior...). " Also attached to the in-service was an email from the Corporate Educator Administrator that revealed: " documentation in-service should cover legal aspects of documentation as well as how and when to document changes in condition and notification to responsible party. You could go over what is needed for...behavior monitoring...Social Services- would need to address any type of documentation that indicates a social need, clothing need, [MEDICAL CONDITION] medication/behavior monitoring... " On 7/5/2011 an in-service was conducted on Abuse and Neglect. " The 7 Types of Abuse: 7. Sexual-Inappropriate touching in private areas (genitalia, breasts etc.). " Twenty six CNAs attended the in-service and 14 nurses attended. CNA#1 attended on 7/5/2011 and attended the 6/1/2011 in-service Cross Refer to F-157 as it relates to the facility staff's failure to notify the physician and the responsible party of an increase in sexually inappropriate behaviors. The failure to notify the physician of two identified residents that were victims of the sexually inappropriate behavior. Cross Refer to F-223 as it relates to the facility's failure to provide the necessary care and services to prevent, identify and protect against sexual abuse. Cross Refer to F-226 as it relates to the facility's failure to implement the policy on sexual abuse related to the identification and protection of residents. Cross Refer to F-250 as it relates to the facility's failure to provide medically related social services for Resident #3's sexually inappropriate behavior and the facility failed to assure Resident #4 and #6 received the necessary social services following allegations of sexual abuse. Cross Refer to F-280 as it relates to the facility's failure to care plan interventions following an allegation of sexual abuse of Resident #4 and Resident #6. Resident #3's care plan was not updated and new interventions were not added related to an increase in sexually inappropriate behaviors. Cross Refer to F-319 as it relates to the facility's failure to address, monitor and implement effective interventions for Resident #3's sexually inappropriate behavior. Cross Refer to F-490 as it relates to the facility's failure to assure Resident #3's behaviors were monitored consistently and failed to assure effective interventions were put in place for the sexually inappropriate behaviors. The facility's Administration also failed to assure two identified residents that were victims of sexually inappropriate behavior received the necessary care and services related to the incidents. On 8/30/2011 at 10:50 AM the Administrator and the Director of Nursing was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F280, F-319, and F-490 at a scope and severity of "J". The findings were related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse and the failure to provide the proper care and treatment for one of one resident with sexually inappropriate behaviors. On 8/5/2011 independently mobile Resident #3, identified with a history of sexually inappropriate behaviors, was observed with his hand down cognitively impaired Resident #4's blouse fondling her breast and was redirected and moved to the other side of the dayroom, and then 30 minutes later found to have his hands between her legs. The Immediate Jeopardy was not removed upon exit from the facility on 8/30/2011 and remains ongoing.

On the days of the Complaint and Extended Survey, based on interviews, review of facility policy on Abuse and Neglect, and record review, the facility failed to ensure that one of one resident reviewed (Resident #3) with identified inappropriate sexual behaviors, received the necessary social service intervention to attain the highest practicable psychosocial well being and 2 of 2 residents reviewed (Resident #4 & #6) that were victims of alleged sexual abuse received assessment and followup by social services after the alleged incidents. The findings included: The facility admitted Resident #3 on 7/10/2009 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired in decision making abilities. No behaviors were coded as occurring during the assessment period. Resident #3 was coded as requiring one person limited assistance with transfers and was able to self propel himself in the wheelchair. Review on 8/29/2011 of the Nurses Notes revealed an entry dated 6/21 at 12:15 PM, Resident #3 was placed on every 30 minute checks for sexually inappropriate behaviors. Review of the 30 minute check documentation from 6/21-6/24 revealed Resident #3 did not have documentation of his whereabouts on 6/22 from 5PM to 7PM, 6/23 from 5AM-7AM, 6/23 from 11:30 PM to 7 AM on 6/24. On 6/24/2011 at 11:45 AM, Resident #3 was observed in " day room exposing private part. " There were no other 30 minute checks after 12 PM on 6/24/2011. Further review of the nurses notes revealed on 6/25 at 11:45 AM, " res(ident) up in front of nurses station exposing self to staff and other res. Res took in room and explained not to expose self to staff and res clothes helped back on and res taken back to nursing station per his request. " On 6/30 at 11AM, " res in hallway, parked in w/c (wheelchair) next to a female resident c (with) his pants open and his penis exposed-This nurse quickly went to res and asked him to please pull up his pants, Res looked angry and did pull his pants up also asked res to zip his pants, Res did this. Made DON (Director of Nurses) and Social Services aware. " At 12:20 PM, " nurse observed res back in hall exposing himself to a female resident and I immediately removed this res from hall and transferred to his room. I immediately notified DON of this as well. " At 1PM, the Attending Physician updated on (increasing) sexual behaviors and orders received to (increase) Trileptal back to 150 mg BID (twice daily), check U/A (urinalysis) and f/u (follow up) c Carolina Behavioral Health. " On 7/1/2011 at 1:30 PM, " Resident in front of nurses station touching a female resident's shoulder c pants open and penis hanging out. Separated from resident immediately and taken to room for lunch. DON notified. Resident ate lunch and then transported by transport to Carolina Behavioral Health. Sister notified and she stated she was waiting on him at the facility. " Resident #3 was admitted to Carolina Behavioral Health from 7/1-7/11/11. Provera 5 mg was added to Resident #3's medication regime during the admission. The resident returned to the nursing home on 7/11/2011. Further review of the nurse's notes revealed on 7/12/2011 at 7 PM, Resident #3 " hit this nurse on the left side of nurses' face, then hit this nurse in the face. DON notified. DON took resident to his room and talked with resident. " At 7:20 PM, " GNP (General Nurse Practitioner) notified, new orders received for Geodon 10 mg PO PRN q 12 hours (by mouth as needed every 12 hours), continue Geodon 10 mg IM (intramuscularly). " At 7:25 PM, sister notified by social worker of resident's behavior. " On 7/23 at 3:30 PM, " resident exposed his penis to (Certified Nursing Assistant). " On 7/25 at 2 PM, " Resident exposed himself in day room. Redirected to room. Laying down on bed. Will report to oncoming nurse. " On 7/26 at 3PM, " several episodes of inappropriate behavior this shift, nurse re-directed x2 of approaching female residents. Exposed himself in PT and in hallway, PRN Geodon given 2 hours p (after) scheduled Geodon...Will report to oncoming nurse. " On 8/5 at 6:55 AM, " noted with hand between female resident's legs, touching inappropriately. Resident removed from the area and instructed not to touch other residents, that behavior was inappropriate. Resident was noted touching same resident inappropriately and moved to another area but went back to lounge sitting area, will monitor closely. " On 8/23 at 8AM, " resident exposed himself to a female resident in TV area. Was redirected and taken back to room. " On 8/24 at 5PM, " Res observed exposing himself in the hallway on Station 1. This nurse asked Res to please pull his underwear up and his pants-Res complied-Assisted back to the privacy of his room-DON immediately notified. " During an interview on 8/29 at 3:20 PM, LPN #2 stated that she was assigned to Resident #3 on third shift on 8/5/11. LPN#2 stated that a nursing assistant had notified her that Resident #3 had his hand down Resident #4's blouse fondling her breast. LPN#2 stated that she then moved Resident #3 to the other side of the day room. LPN#2 stated that approximately 30 minutes later, Resident #3 was reported to have his hands between Resident #4's legs touching her inappropriately. LPN#2 stated that she removed the resident from the day room and informed the resident that that behavior was inappropriate. She stated that he did come back out to the day room afterwards but did not touch any resident inappropriately again. LPN#2 stated that Resident #4 " had her pants on. " LPN#2 stated that she informed the DON of the incident but stated that she was not sure if she called the physician or the resident's responsible party. Review of the Social Service Progress Notes revealed on 7/12/2011 the Social Services Director (SSD) met with Resident #3 regarding him striking a staff member in the face causing a bloody nose. The SSD documented: " he has a PRN order for IM Geodon but no PRN by mouth. Nurse called the NP and she gave order for PRN PO Geodon every 12 hours. I called (RP) to let her know what had occurred. I asked her if she ever knew of (Res #3) being abused as a child and she said no...(the RP) felt (Resident #3's child hood residence) would have been a rough neighborhood. The nurse practitioner said if this behavior occurred again to send him out. We have tried this in the past but for emergent psychiatric care, they have to go through the ER and if he is calm when he gets there, they usually sent them back with no treatment. There is not always an availability in a psych setting. " On 7/23, " DON notified me that (Res #3) had exposed himself to a CNA___. When I visited he was sleeping as normal. " On 7/25, " DON spoke with (GNP) She increased dosage of Trileptal and gave scheduled dose of Geodon. He did expose himself in the day room this day but was redirected by staff. " On 7/26, Res #3 " has continued with inappropriate behavior of exposing himself. Staff has intervened appropriately and resident has accepted redirection without aggression. I went to attempt to talk to (Res #3) regarding his behavior but he was sleeping soundly and did not (???) when I called his name. I will follow. " On 7/27 a care plan meeting was held and social services documented the following: " (Res #3) is unable to cognitively participate. He suffers from dementia with behavioral disturbances manifested by sexual acting out and aggressiveness as prior documentation shows. He has been followed by attending psychiatrist and has been in a psych setting recently with no lasting results... " On 8/5, " received word from nursing staff that (Res #3) was again exhibiting inappropriate sexual behaviors. They had already intervened appropriately asking and assisting him to his room for privacy. I visited (Res #3) in his room. When I talked with him about this behavior, he really seemed confused. I explained that exposing himself and touching people inappropriately was not acceptable behavior. I told him that this kind of behavior could be considered assault and people can be arrested for this. He responded, " oh. " I doubt full comprehension of this conversation. I will follow and continue to assist staff in observing for behavior. " On 8/24, " DON has notified me that inappropriate sexual behavior has again been noted by staff in the past two days. I had observed (Res #3) out of his room earlier today and assisted him through the day room and to the dining area which is where he was going. There were no other residents in the dining area when I left him. We keep MD updated on behavior and I will ask for follow up for psychiatrist. " Review of the Progress Notes revealed on 7/25, the GNP saw Resident #3 for " sexually aggressive behaviors. I will increase his Trileptal and schedule Geodon and monitor his behaviors. " No evidence of consistent monitoring of behavior or psychiatric evaluation was provided. Review of the Incident Report dated 7/12 revealed the interventions put in place to prevent future reoccurrence were: " 1. Provider updated on incident and Geodon ordered orally along with his IM, 2. SS and DON interviewed resident and assisted resident to his room to eat supper and 3. Plans to f/u c (Psychiatrist) or provider (Attending physician/GNP). " No other incident reports were found related to Resident #3's sexually inappropriate behaviors. During an interview on 8/29/2011 at 3PM, the SSD stated that she had spoken to Resident #3 regarding his behaviors and informed him that the behaviors were inappropriate and unacceptable. She then stated that Resident #3 did not know what he was doing and stated that he did not comprehend what she was saying. The SSD stated that the if the staff saw Resident #3 acting inappropriately they were to immediately remove him from the situation and redirect him. The SSD stated that no other interventions were put in place for Resident #3's behaviors. The SSD stated that she was aware of Resident #3 touching Resident #4 inappropriately. She stated that nothing was put in place for Resident #4. The SSD stated that she was not aware of any other residents, therefore nothing had been put in place for any other female residents that had been victimized. During an interview on 8/29/2011 at 3:40 PM, the Attending Physician stated that since Resident #3's readmission on 7/11/11 his behaviors were " manageable. " He stated that he was aware of only one incident that had occurred. The Attending Physician stated that he was not notified of Resident #3's increasing sexually inappropriate behaviors. He also stated that he was not notified of the incident on 8/5 and stated that he was not aware of any specific residents that Resident #3 had touched inappropriately. The Attending Physician stated that the " status quo was not working and there were other things we could have tried. " He stated that if he was made aware he would have changed the medications, increased the Provera, send the resident out to the hospital, monitor the behaviors, activities to keep him busy and to keep him away from women. The Attending Physician confirmed that Resident #4 and #6's psychosocial needs were not addressed. He stated that Social Services should have assessed the residents, both residents should be monitored closely for behavior changes and the facility should prevent the incidents and should protect the residents. During an interview on 8/30/2011 at 10:20 AM, the Administrator and the Director of Nurses (DON) stated that they were aware of Resident #3's sexually inappropriate behaviors. The DON stated that she was aware of some of the incidents but not all. Both stated that they were not aware of the incident on 8/5 between Resident #3 and #4. Both stated that they were not aware of any particular resident involved. The Administrator and the DON stated that the staff acted appropriately by removing the resident from the situation. The DON stated that there " was nothing else to do. " She stated that the resident was on " the list to move to the men's unit. " When asked where the list was, the DON stated that there was not an actual list, it was " in our heads who is next to move. " The Administrator then stated that she couldn't " just move someone " and it was " based on bed availability " and there were no beds available. Both the Administrator and the DON stated again that they were aware Resident #3 was exposing himself to other residents. The Administrator and the DON stated that there was no tool in place to monitor the behaviors specifically. However, both stated that during the morning meeting the 24 hour reports were reviewed and Resident #3's behaviors should be recorded on them. Review of the facility's policy on Abuse and Neglect revealed: " Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault. " " 4. Provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. 5. Identify events such as...occurrences, patterns and trends that may constitute abuse. 6. Investigate different types of incidents...7. Protect residents from harm during an investigation...8. Report all alleged violations and all substantiated incidents to the State Agency and all other agencies as required and take all necessary corrective actions depending on the results of the investigation. " The facility admitted Resident #4 on 7/13/2009 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired with decision making abilities. Review of the Care Plan dated 12/2010 revealed Resident #4 had a problem area identified related to combative behaviors and resisting care. The Care Plan had not been updated and no new interventions had been added related to the sexual abuse. Record Review revealed no documentation of any sexual assault in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #4. Resident #4's Attending Physician and the Responsible Party had not been notified of the sexual abuse that had occurred. There was no evidence Resident #4 had been examined by a physician related to the sexual abuse. No interventions had been put in place related to the incidents. The facility admitted Resident #6 on 3/18/2011 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS score of 15. No behaviors were coded during the assessment period. During an interview on 8/29/2011 at 2:10 PM, Resident #6 stated Resident #3 was in the hallway and rubbed her arm and thigh and commented on how pretty she was and how nice her legs were. Resident #6 asked him to stop and he continued rubbing her leg. Resident #6 then removed Resident #3's hand from her body and left the area. Resident #6 stated that she reported the incident to CNA#1. Resident #6 stated that Resident #3 would also come to her doorway and expose himself to her. She stated that she would press the call light and staff would come down and move Resident #3. She stated that the staff did not do anything for her. Resident #6 stated that she felt uncomfortable and whenever she saw Resident #3 in the area she would leave and go in the other direction. Resident #6 stated that no staff member has come to speak with her about the incidents. Record review revealed no documentation of any sexual abuse in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #6. Resident #6's Attending Physician had not been notified of the incidents. No interventions had been put in place related to the incidents. On 8/30/2011 at 10:50 AM the Administrator and the Director of Nursing was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F280, F-319, and F-490 at a scope and severity of "J". The findings were related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse and the failure to provide the proper care and treatment for one of one resident with sexually inappropriate behaviors. On 8/5/2011 independently mobile Resident #3, identified with a history of sexually inappropriate behaviors, was observed with his hand down cognitively impaired Resident #4's blouse fondling her breast and was redirected and moved to the other side of the dayroom, and then 30 minutes later found to have his hands between her legs. The Immediate Jeopardy was not removed upon exit from the facility on 8/30/2011 and remains ongoing.

On the days of the Complaint and Extended Survey based on record review and interview, Immediate Jeopardy was identified at a scope and severity level of "J" related to the facility's failure to notify the physician of changes in condition and failed to notify the responsible party of changes in condition. Facility staff failed to notify Resident #3's physician and responsible party of an increase in sexually inappropriate behaviors. The facility also failed to notify Resident #4 and Resident #6's physician and or responsible party that they were the victims of sexually inappropriate behavior. The findings included: The facility admitted Resident #3 on 7/10/2009 with [DIAGNOSES REDACTED]. Review on 8/29/2011 of the Nurses Notes revealed an entry dated 8/5 at 6:55 AM, Resident #3 was "noted with hand between female resident's (Resident #4's) legs, touching inappropriately. Resident removed from the area and instructed not to touch other residents, that behavior was inappropriate. Resident was noted touching same resident inappropriately and moved to another area but went back to lounge sitting area, will monitor closely. " On 8/23 at 8 AM, " resident exposed himself to a female resident in TV area. Was redirected and taken back to room. " On 8/24 at 5 PM, " Res observed exposing himself in the hallway on Station 1. This nurse asked Res to please pull his underwear up and his pants-Res complied-Assisted back to the privacy of his room-DON immediately notified. " There was no evidence that the Physician or the Responsible party were notified of the incidents on 8/5, 8/23 or 8/24. There was no other documentation of Resident #3's sexually inappropriate behavior. No female residents were identified in the records. The facility admitted Resident #4 on 7/13/2009 with [DIAGNOSES REDACTED]. Record Review revealed no documentation of any sexual assault in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #4. Resident #4's Attending Physician and the Responsible Party had not been notified of the sexual assaults that had occurred and there was no evidence Resident #4 had been examined by a physician related to the sexual assaults. No interventions had been put in place related to the incidents. The facility admitted Resident #6 on 3/18/2011 with [DIAGNOSES REDACTED]. During an interview on 8/29/2011 at 2:10 PM, Resident #6 stated Resident #3 was in the hallway and rubbed her arm and thigh and commented on how pretty she was and how nice her legs were. Resident #6 asked him to stop and he continued rubbing her leg. Resident #6 then removed Resident #3's hand from her body and left the area. Resident #6 stated that she reported the incident to CNA#1. Resident #6 stated that Resident #3 would also come to her doorway and expose himself to her. She stated that she would press the call light and staff would come down and move Resident #3. She stated that the staff did not do anything for her. Resident #6 stated that she felt uncomfortable and whenever she saw Resident #3 in the area she would leave and go in the other direction. Resident #6 stated that no staff member had come to speak with her about the incidents. Record review revealed no documentation of any sexual assault in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #6. Resident #6's Attending Physician had not been notified of the incidents. No interventions had been put in place related to the incidents. During an interview with Resident "A" (a resident on the Unit identified as interviewable) on 8/29/2011 at 2:15 PM, Resident "A" stated that she/he had witnessed Resident #3 expose himself and touch Resident #4 inappropriately in the day room. Resident "A" then stated that this occurred last week around mid-morning. The resident stated that she/he informed LPN #1 of the incident and LPN#1 moved Resident #3 to the other side of the day room. Upon review there were no nurses notes, 24 hours reports or any reference in the records of Resident #3 or #4 related to the incident identified by Resident "A". During an interview on 8/29 at 3:20 PM, LPN #2 stated that she was assigned to Resident #3 on third shift on 8/5/11. LPN#2 stated that a nursing assistant reported to her that Resident #3 was touching Resident #4 inappropriately. LPN#2 stated that she informed the DON of the incident but stated that she was not sure if she called the physician or the resident's responsible party. During an interview on 8/29/2011 at 3:25 PM, the Director of Nurses stated that she was not aware of the incident on 8/5 between Resident #3 and #4. She confirmed that neither the family or the physician were notified of the incident. During an interview on 8/29/2011 at 3:40 PM, the Attending Physician stated that since Resident #3's readmission on 7/11/11 his behaviors were " manageable. " He stated that he was aware of only one incident that had occurred. The Attending Physician stated that he was not notified of Resident #3's increasing sexually inappropriate behaviors. He also stated that he was not notified of the incident on 8/5 and stated that he was not aware of any specific residents that Resident #3 had touched inappropriately. The Attending Physician stated that the " status quo was not working and there were other things we could have tried." He stated that if he was made aware he would have changed the medications, increased the [MEDICATION NAME], send the resident out to the hospital, monitor the behaviors, activities to keep him busy and to keep him away from women. The Attending Physician confirmed that Resident #4 and #6's psychosocial needs were not addressed. He stated that Social Services should have assessed the residents, both residents should be monitored closely for behavior changes and the facility should prevent the incidents and should protect the residents. Additional information provided by the physician and facility noted an order was written on 8/9/2011 to add the medication [MEDICATION NAME] for "aggression". No documentation was provided to clarify the type of "aggression". Review of the facility's policy on " Physician Notification " did not include any reference to WHEN staff should notify the physician. On 8/30/2011 at 10:50 AM the Administrator and the Director of Nursing was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F280, F-319, and F-490 at a scope and severity of "J". The findings were related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse and the failure to provide the proper care and treatment for one of one resident with sexually inappropriate behaviors. On 8/5/2011 independently mobile Resident #3, identified with a history of sexually inappropriate behaviors, was observed with his hand down cognitively impaired Resident #4's blouse fondling her breast and was redirected and moved to the other side of the dayroom, and then 30 minutes later found to have his hands between her legs. The Immediate Jeopardy was not removed upon exit from the facility on 8/30/2011 and remains ongoing.

On the days of the Complaint and Extended Survey based on observation, record review, interview and review of the facility's Abuse Neglect Policy, Substandard Quality of Care and Immediate Jeopardy was identified at a scope and severity of "J" related to the facility's failure to implement the policy on sexual abuse related to the protection of residents. The findings included: The facility admitted Resident #3 on 7/10/2009 with [DIAGNOSES REDACTED]. The facility admitted Resident #4 on 7/13/2009 with [DIAGNOSES REDACTED]. The facility admitted Resident #6 on 3/18/2011 with [DIAGNOSES REDACTED]. On 8/5 Resident #3 allegedly sexually abused Resident #4. Resident #6 reported an incident of sexual abuse/harassment to CNA#1. During an interview on 8/29 at 3:20 PM, LPN (Licensed Practical Nurse) #2 stated that a nursing assistant had notified her that Resident #3, independently mobile, had his hand down Resident #4's blouse fondling her breast. LPN#2 stated that she then moved Resident #3 to the other side of the day room. LPN#2 stated that approximately 30 minutes later, Resident #3 was reported to have his hands between Resident #4's legs touching her inappropriately. LPN#2 stated that she removed the resident from the day room and informed the resident that that behavior was inappropriate. She stated that he did come back out to the day room afterwards but did not touch any resident inappropriately again. During an interview on 8/29/11 at 2 PM, Licensed Practical Nurse #1 stated that she has witnessed Resident #3 touching female residents inappropriately. She stated that Resident #3 did not single out one resident in particular that it was whatever female resident happened to be near him. During an interview on 8/29/11 at 2:05 PM, CNA#1 (Certified Nursing Assistant) stated that she has witnessed Resident #3 inappropriately touching other female residents. She stated that Resident #3 " mostly goes after " Resident #4. However, she stated that Resident #6 had reported to her that Resident #3 had touched her inappropriately. CNA#1 stated that she did not inform the nurse of the report of sexual abuse for Resident #6. Review of the facility's policy on Abuse and Neglect revealed: " Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault. " " 4. Provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. 5. Identify events such as...occurrences, patterns and trends that may constitute abuse. 6. Investigate different types of incidents...7. Protect residents from harm during an investigation...8. Report all alleged violations and all substantiated incidents to the State Agency and all other agencies as required and take all necessary corrective actions depending on the results of the investigation. " Cross Refer to F-157 as it relates to the facility staff's failure to notify the physician and the responsible party of an increase in sexually inappropriate behaviors. The failure to notify the physician of two identified residents that were victims of the sexually inappropriate behavior. Cross Refer to F-223 as it relates to the facility's failure to provide the necessary care and services to prevent, identify and protect against sexual abuse. Cross Refer to F-250 as it relates to the facility's failure to provide medically related social services for Resident #3's sexually inappropriate behavior and the facility failed to assure Resident #4 and #6 received the necessary social services following allegations of sexual abuse. Cross Refer to F-280 as it relates to the facility's failure to care plan interventions following an allegation of sexual abuse of Resident #4 and Resident #6. Resident #3's care plan was not updated and new interventions were not added related to an increase in sexually inappropriate behaviors. Cross Refer to F-319 as it relates to the facility's failure to address, monitor and implement effective interventions for Resident #3's sexually inappropriate behavior. Cross Refer to F-490 as it relates to the facility's failure to assure Resident #3's behaviors were monitored consistently and failed to assure effective interventions were put in place for the sexually inappropriate behaviors. The facility's Administration also failed to assure two identified residents that were victims of sexually inappropriate behavior received the necessary care and services related to the incidents. On 8/30/2011 at 10:50 AM the Administrator and the Director of Nursing was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F280, F-319, and F-490 at a scope and severity of "J". The findings were related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse and the failure to provide the proper care and treatment for one of one resident with sexually inappropriate behaviors. On 8/5/2011 independently mobile Resident #3, identified with a history of sexually inappropriate behaviors, was observed with his hand down cognitively impaired Resident #4's blouse fondling her breast and was redirected and moved to the other side of the dayroom, and then 30 minutes later found to have his hands between her legs. The Immediate Jeopardy was not removed upon exit from the facility on 8/30/2011 and remains ongoing.

On the days of the Complaint and Extended Survey, based on observations, interview, and record review, the facility failed to review and revise the care plan of 1 of 1 resident reviewed (Resident #3) with identified inappropriate sexual behaviors when the behaviors began to increase and involve other residents. The facility also failed to assess and revise the care plans of 2 of 2 residents reviewed (Residents #4 & #6) that were alleged victims of sexual abuse. The findings included: The facility admitted Resident #3 on 7/10/2009 with [DIAGNOSES REDACTED]. Observation of Resident #3 on 8/29/2011 at 12:30 PM, revealed him up in a wheelchair in his room with his back to the door. Resident #3's pants were unzipped and his shirt tails were loosely covering his groin area. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired in decision making abilities. No behaviors were coded as occurring during the assessment period. Resident #3 was coded as requiring one person limited assistance with transfers and was able to self propel himself in the wheelchair. Review of the Care Plan dated 11/24/2010 and printed on 7/27/2011, revealed a problem area of " resident has hx (history) of becoming aggressive leading him to strike at staff and peers. This could be related to impaired hearing and vision keeping him from understanding what is taking place. Has also been sexually inappropriate requiring psych hospitalization . " Approaches included " make all staff aware of the fact that resident can be aggressive and sexually inappropriate, approach resident carefully making sure you have gained his attention, check with resident to make sure he has heard and comprehended what you have said to him, work in pairs if indicated, if behaviors persist, obtain further medical intervention, Psych consult done [DATE]. Will ask for follow up related to recent behaviors, administer medications, observe closely for inappropriate sexual behavior and gently redirect and remove from situation. " The Care Plan was not updated with the resident's recent behaviors and no new interventions for the sexually inappropriate behaviors were added to the Care Plan. Review on 8/29/2011 of the Nurses Notes revealed an entry dated 6/21 at 12:15 PM, Resident #3 was placed on every 30 minute checks for sexually inappropriate behaviors. Review of the 30 minute check documentation from 6/21-6/24 revealed Resident #3 did not have documentation of his whereabouts on 6/22 from 5PM to 7PM, 6/23 from 5AM-7AM, 6/23 from 11:30 PM to 7 AM on 6/24. On 6/24/2011 at 11:45 AM, Resident #3 was observed in " day room exposing private part. " There were no other 30 minute checks after 12 PM on 6/24/2011. Further review of the nurses notes revealed on 6/25 at 11:45 AM, " res(ident) up in front of nurses station exposing self to staff and other res. Res took in room and explained not to expose self to staff and res clothes helped back on and res taken back to nursing station per his request. " On 6/30 at 11AM, " res in hallway, parked in w/c (wheelchair) next to a female resident c (with) his pants open and his penis exposed-This nurse quickly went to res and asked him to please pull up his pants, Res looked angry and did pull his pants up also asked res to zip his pants, Res did this. Made DON (Director of Nurses) and Social Services aware. " At 12:20 PM, " nurse observed res back in hall exposing himself to a female resident and I immediately removed this res from hall and transferred to his room. I immediately notified DON of this as well. " At 1PM, the Attending Physician updated on (increasing) sexual behaviors and orders received to (increase) [MEDICATION NAME] back to 150 mg BID (twice daily), check U/A (urinalysis) and f/u (follow up) c Carolina Behavioral Health. " On 7/1/2011 at 1:30 PM, " Resident in front of nurses station touching a female resident's shoulder c pants open and penis hanging out. Separated from resident immediately and taken to room for lunch. DON notified. Resident ate lunch and then transported by transport to Carolina Behavioral Health. Sister notified and she stated she was waiting on him at the facility. " Resident #3 was admitted from 7/1-7/11/11. [MEDICATION NAME] 5 mg was added to Resident #3's medication regime. On 7/12/2011 at 7 PM, Resident #3 " hit this nurse on the left side of nurses' face, then hit this nurse in the face. DON notified. DON took resident to his room and talked with resident. " At 7:20 PM, " GNP (General Nurse Practitioner) notified, new orders received for [MEDICATION NAME] 10 mg PO PRN q 12 hours (by mouth as needed every 12 hours), continue [MEDICATION NAME] 10 mg IM (intramuscularly). " At 7:25 PM, sister notified by social worker of resident's behavior. " On 7/23 at 3:30 PM, " resident exposed his penis to (Certified Nursing Assistant). " On 7/25 at 2 PM, " Resident exposed himself in day room. Redirected to room. Laying down on bed. Will report to oncoming nurse. " On 7/26 at 3PM, " several episodes of inappropriate behavior this shift, nurse re-directed x2 of approaching female residents. Exposed himself in PT and in hallway, PRN [MEDICATION NAME] given 2 hours p (after) scheduled [MEDICATION NAME] report to oncoming nurse. " On 8/5 at 6:55 AM, " noted with hand between female resident's legs, touching inappropriately. Resident removed from the area and instructed not to touch other residents, that behavior was inappropriate. Resident was noted touching same resident inappropriately and moved to another area but went back to lounge sitting area, will monitor closely. " On 8/23 at 8AM, " resident exposed himself to a female resident in TV area. Was redirected and taken back to room. " On 8/24 at 5PM, " Res observed exposing himself in the hallway on Station 1. This nurse asked Res to please pull his underwear up and his pants-Res complied-Assisted back to the privacy of his room-DON immediately notified. " Review of the Social Service Progress Notes revealed on 7/12/2011 the Social Services Director (SSD) met with Resident #3 regarding him striking a staff member in the face causing a bloody nose. The SSD documented: " he has a PRN order for IM [MEDICATION NAME] but no PRN by mouth. Nurse called the NP and she gave order for PRN PO [MEDICATION NAME] every 12 hours. I called (RP) to let her know what had occurred. I asked her if she ever knew of (Res #3) being abused as a child and she said no...(the RP) felt (Resident #3's child hood residence) would have been a rough neighborhood. The nurse practitioner said if this behavior occurred again to send him out. We have tried this in the past but for emergent psychiatric care, they have to go through the ER and if he is calm when he gets there, they usually sent them back with no treatment. There is not always an availability in a psych setting. " On 7/23, " DON notified me that (Res #3) had exposed himself to a CNA___. When I visited he was sleeping as normal. " On 7/25, " DON spoke with (GNP) She increased dosage of [MEDICATION NAME] and gave scheduled dose of [MEDICATION NAME]. He did expose himself in the day room this day but was redirected by staff. " On 7/26, Res #3 " has continued with inappropriate behavior of exposing himself. Staff has intervened appropriately and resident has accepted redirection without aggression. I went to attempt to talk to (Res #3) regarding his behavior but he was sleeping soundly and did not (???) when I called his name. I will follow. " On 7/27 a care plan meeting was held and social services documented the following: " (Res #3) is unable to cognitively participate. He suffers from dementia with behavioral disturbances manifested by sexual acting out and aggressiveness as prior documentation shows. He has been followed by attending psychiatrist and has been in a psych setting recently with no [MEDICATION NAME] results... " On 8/5, " received word from nursing staff that (Res #3) was again exhibiting inappropriate sexual behaviors. They had already intervened appropriately asking and assisting him to his room for privacy. I visited (Res #3) in his room. When I talked with him about this behavior, he really seemed confused. I explained that exposing himself and touching people inappropriately was not acceptable behavior. I told him that this kind of behavior could be considered assault and people can be arrested for this. He responded, " oh. " I doubt full comprehension of this conversation. I will follow and continue to assist staff in observing for behavior. " On 8/24, " DON has notified me that inappropriate sexual behavior has again been noted by staff in the past two days. I had observed (Res #3) out of his room earlier today and assisted him through the day room and to the dining area which is where he was going. There were no other residents in the dining area when I left him. We keep MD updated on behavior and I will ask for follow up for psychiatrist. " No evidence of any consistent behavior monitoring was put in place for Resident #3. Review of the Incident Report dated 7/12 revealed the interventions put in place to prevent future reoccurrence were: " 1. Provider updated on incident and [MEDICATION NAME] ordered orally along with his IM, 2. SS and DON interviewed resident and assisted resident to his room to eat supper and 3. Plans to f/u c (Psychiatrist) or provider (Attending physician/GNP). " No other incident reports were found related to Resident #3's sexually inappropriate behaviors. During an interview with Resident "A" (a resident on the Unit identified as interviewable) on 8/29/2011 at 2:15 PM, Resident "A" stated that she/he had witnessed Resident #3 expose himself and touch Resident #4 inappropriately in the day room. Resident "A" then stated that this occurred last week around mid-morning. The resident stated that she/he informed LPN #1 of the incident and LPN#1 moved Resident #3 to the other side of the day room. Upon review there were no nurses notes, 24 hours reports or any reference in the records related to the incident identified by Resident "A". During an interview on 8/29/2011 at 3PM, the SSD stated that she had spoken to Resident #3 regarding his behaviors and informed him that the behaviors were inappropriate and unacceptable. She then stated that Resident #3 did not know what he was doing and stated that he did not comprehend what she was saying. The SSD stated that the if the staff saw Resident #3 acting inappropriately they were to immediately remove him from the situation and redirect him. The SSD stated that no other interventions were put in place for Resident #3's behaviors. The SSD stated that she was aware of Resident #3 touching Resident #4 inappropriately. She stated that nothing was put in place for Resident #4. The SSD stated that she was not aware of any other residents, therefore nothing had been put in place for any other female residents that had been victimized. During an interview on 8/29/2011 at 3:40 PM, the Attending Physician stated that since Resident #3's readmission on 7/11/11 his behaviors were " manageable. " He stated that he was aware of only one incident that had occurred. The Attending Physician stated that he was not notified of Resident #3's increasing sexually inappropriate behaviors. He also stated that he was not notified of the incident on 8/5 and stated that he was not aware of any specific residents that Resident #3 had touched inappropriately. The Attending Physician stated that the " status quo was not working and there were other things we could have tried. " He stated that if he was made aware he would have changed the medications, increased the [MEDICATION NAME], send the resident out to the hospital, monitor the behaviors, activities to keep him busy and to keep him away from women. The Attending Physician confirmed that Resident #4 and #6's psychosocial needs were not addressed. He stated that Social Services should have assessed the residents, both residents should be monitored closely for behavior changes and the facility should prevent the incidents and should protect the residents. During an interview on 8/30/2011 at 10:20 AM, the Administrator and the Director of Nurses (DON) stated that they were aware of Resident #3's sexually inappropriate behaviors. The DON stated that she was aware of some of the incidents but not all. Both stated that they were not aware of the incident on 8/5 between Resident #3 and #4. Both stated that they were not aware of any particular resident involved. The Administrator and the DON stated that the staff acted appropriately by removing the resident from the situation. The DON stated that there " was nothing else to do. " She stated that the resident was on " the list to move to the men's unit. " When asked where the list was, the DON stated that there was not an actual list, it was " in our heads who is next to move. " The Administrator then stated that she couldn't " just move someone " and it was " based on bed availability " and there were no beds available. Both the Administrator and the DON stated again that they were aware Resident #3 was exposing himself to other residents. The Administrator and the DON stated that there was no tool in place to monitor the behaviors specifically. However, both stated that during the morning meeting the 24 hour reports were reviewed and Resident #3's behaviors should be recorded on them. The facility admitted Resident #4 on 7/13/2009 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired with decision making abilities. Review of the Care Plan dated 12/2010 revealed Resident #4 had a problem area identified related to combative behaviors and resisting care. The Care Plan had not been updated and no new interventions had been added related to the sexual abuse. Record Review revealed no documentation of any sexual abuse in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #4. Resident #4's Attending Physician and the Responsible Party had not been notified of the sexual abuse that had occurred. There was no evidence Resident #4 had been examined by a physician related to the sexual abuse. No interventions had been put in place related to the incidents. The facility admitted Resident #6 on 3/18/2011 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS score of 15. No behaviors were coded during the assessment period. During an interview on 8/29/2011 at 2:10 PM, Resident #6 stated Resident #3 was in the hallway and rubbed her arm and thigh and commented on how pretty she was and how nice her legs were. Resident #6 asked him to stop and he continued rubbing her leg. Resident #6 then removed Resident #3's hand from her body and left the area. Resident #6 stated that she reported the incident to CNA#1. Resident #6 stated that Resident #3 would also come to her doorway and expose himself to her. She stated that she would press the call light and staff would come down and move Resident #3. She stated that the staff did not do anything for her. Resident #6 stated that she felt uncomfortable and whenever she saw Resident #3 in the area she would leave and go in the other direction. Resident #6 stated that no staff member has come to speak with her about the incidents. Record review revealed no documentation of any sexual abuse in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #6. Resident #6's Attending Physician had not been notified of the incidents. No interventions had been put in place related to the incidents. On 8/30/2011 at 10:50 AM the Administrator and the Director of Nursing was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F280, F-319, and F-490 at a scope and severity of "J". The findings were related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse and the failure to provide the proper care and treatment for one of one resident with sexually inappropriate behaviors. On 8/5/2011 independently mobile Resident #3, identified with a history of sexually inappropriate behaviors, was observed with his hand down cognitively impaired Resident #4's blouse fondling her breast and was redirected and moved to the other side of the dayroom, and then 30 minutes later found to have his hands between her legs. The Immediate Jeopardy was not removed upon exit from the facility on 8/30/2011 and remains ongoing.

On the days of the Complaint and Extended Survey, based on record review, interview, review of facility policy Abuse and Neglect, and observation, the facility failed to ensure that 1 of 1 resident reviewed (Resident #3) with aggressive/sexually inappropriate behaviors was monitored consistently and had effective interventions put in place to prevent escalation of the problem and protect Resident #3 and/or other residents at the facility from harm. The findings included: The facility admitted Resident #3 on 7/10/2009 with [DIAGNOSES REDACTED]. Observation of Resident #3 on 8/29/2011 at 12:30 PM, revealed him up in a wheelchair in his room with his back to the door. Resident #3's pants were unzipped and his shirt tails were loosely covering his groin area. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired in decision making abilities. No behaviors were coded as occurring during the assessment period. Resident #3 was coded as requiring one person limited assistance with transfers and was able to self propel himself in the wheelchair. Review of the Care Plan dated 11/24/2010 and printed on 7/27/2011, revealed a problem area of " resident has hx (history) of becoming aggressive leading him to strike at staff and peers. This could be related to impaired hearing and vision keeping him from understanding what is taking place. Has also been sexually inappropriate requiring psych hospitalization . " Approaches included " make all staff aware of the fact that resident can be aggressive and sexually inappropriate, approach resident carefully making sure you have gained his attention, check with resident to make sure he has heard and comprehended what you have said to him, work in pairs if indicated, if behaviors persist, obtain further medical intervention, Psych consult done [DATE]. Will ask for follow up related to recent behaviors, administer medications, observe closely for inappropriate sexual behavior and gently redirect and remove from situation. " The Care Plan was not updated with the resident's behaviors and no new interventions for the sexually inappropriate behaviors were added to the Care Plan. Review on 8/29/2011 of the Nurses Notes revealed an entry dated 6/21 at 12:15 PM, Resident #3 was placed on every 30 minute checks for sexually inappropriate behaviors. Review of the 30 minute check documentation from 6/21-6/24 revealed Resident #3 did not have documentation of his whereabouts on 6/22 from 5PM to 7PM, 6/23 from 5AM-7AM, 6/23 from 11:30 PM to 7 AM on 6/24. On 6/24/2011 at 11:45 AM, Resident #3 was observed in " day room exposing private part. " There were no other 30 minute checks after 12 PM on 6/24/2011. Further review of the nurses notes revealed on 6/25 at 11:45 AM, " res(ident) up in front of nurses station exposing self to staff and other res. Res took in room and explained not to expose self to staff and res clothes helped back on and res taken back to nursing station per his request. " On 6/30 at 11AM, " res in hallway, parked in w/c (wheelchair) next to a female resident c (with) his pants open and his penis exposed-This nurse quickly went to res and asked him to please pull up his pants, Res looked angry and did pull his pants up also asked res to zip his pants, Res did this. Made DON (Director of Nurses) and Social Services aware. " At 12:20 PM, " nurse observed res back in hall exposing himself to a female resident and I immediately removed this res from hall and transferred to his room. I immediately notified DON of this as well. " At 1PM, the Attending Physician updated on (increasing) sexual behaviors and orders received to (increase) [MEDICATION NAME] back to 150 mg BID (twice daily), check U/A (urinalysis) and f/u (follow up) c Carolina Behavioral Health. " On 7/1/2011 at 1:30 PM, " Resident in front of nurses station touching a female resident's shoulder c pants open and penis hanging out. Separated from resident immediately and taken to room for lunch. DON notified. Resident ate lunch and then transported by transport to Carolina Behavioral Health. Sister notified and she stated she was waiting on him at the facility. " Resident #3 was admitted from 7/1-7/11/11. [MEDICATION NAME] 5 mg was added to Resident #3's medication regime. On 7/12/2011 at 7 PM, Resident #3 " hit this nurse on the left side of nurses' face, then hit this nurse in the face. DON notified. DON took resident to his room and talked with resident. " At 7:20 PM, " GNP (General Nurse Practitioner) notified, new orders received for [MEDICATION NAME] 10 mg PO PRN q 12 hours (by mouth as needed every 12 hours), continue [MEDICATION NAME] 10 mg IM (intramuscularly). " At 7:25 PM, sister notified by social worker of resident's behavior. " On 7/23 at 3:30 PM, " resident exposed his penis to (Certified Nursing Assistant). " On 7/25 at 2 PM, " Resident exposed himself in day room. Redirected to room. Laying down on bed. Will report to oncoming nurse. " On 7/26 at 3PM, " several episodes of inappropriate behavior this shift, nurse re-directed x2 of approaching female residents. Exposed himself in PT and in hallway, PRN [MEDICATION NAME] given 2 hours p (after) scheduled [MEDICATION NAME] report to oncoming nurse. " On 8/5 at 6:55 AM, " noted with hand between female resident's legs, touching inappropriately. Resident removed from the area and instructed not to touch other residents, that behavior was inappropriate. Resident was noted touching same resident inappropriately and moved to another area but went back to lounge sitting area, will monitor closely. " On 8/23 at 8AM, " resident exposed himself to a female resident in TV area. Was redirected and taken back to room. " On 8/24 at 5PM, " Res observed exposing himself in the hallway on Station 1. This nurse asked Res to please pull his underwear up and his pants-Res complied-Assisted back to the privacy of his room-DON immediately notified. " Review of the Social Service Progress Notes revealed on 7/12/2011 the Social Services Director (SSD) met with Resident #3 regarding him striking a staff member in the face causing a bloody nose. The SSD document: " he has a PRN order for IM [MEDICATION NAME] but no PRN by mouth. Nurse called the NP and she gave order for PRN PO [MEDICATION NAME] every 12 hours. I called (RP) to let her know what had occurred. I asked her if she ever knew of (Res #3) being abused as a child and she said no...(the RP) felt (Resident #3's child hood residence) would have been a rough neighborhood. The nurse practitioner said if this behavior occurred again to send him out. We have tried this in the past but for emergent psychiatric care, they have to go through the ER and if he is calm when he gets there, they usually sent them back with no treatment. There is not always an availability in a psych setting. " On 7/23, " DON notified me that (Res #3) had exposed himself to a CNA___. When I visited he was sleeping as normal. " On 7/25, " DON spoke with (GNP) She increased dosage of [MEDICATION NAME] and gave scheduled dose of [MEDICATION NAME]. He did expose himself in the day room this day but was redirected by staff. " On 7/26, Res #3 " has continued with inappropriate behavior of exposing himself. Staff has intervened appropriately and resident has accepted redirection without aggression. I went to attempt to talk to (Res #3) regarding his behavior but he was sleeping soundly and did not (???) when I called his name. I will follow. " On 7/27 a care plan meeting was held and social services documented the following: " (Res #3) is unable to cognitively participate. He suffers from dementia with behavioral disturbances manifested by sexual acting out and aggressiveness as prior documentation shows. He has been followed by attending psychiatrist and has been in a psych setting recently with no [MEDICATION NAME] results... " On 8/5, " received word from nursing staff that (Res #3) was again exhibiting inappropriate sexual behaviors. They had already intervened appropriately asking and assisting him to his room for privacy. I visited (Res #3) in his room. When I talked with him about this behavior, he really seemed confused. I explained that exposing himself and touching people inappropriately was not acceptable behavior. I told him that this kind of behavior could be considered assault and people can be arrested for this. He responded, " oh. " I doubt full comprehension of this conversation. I will follow and continue to assist staff in observing for behavior. " On 8/24, " DON has notified me that inappropriate sexual behavior has again been noted by staff in the past two days. I had observed (Res #3) out of his room earlier today and assisted him through the day room and to the dining area which is where he was going. There were no other residents in the dining area when I left him. We keep MD updated on behavior and I will ask for follow up for psychiatrist. " Review of the 24 Hour Reports revealed on 7/12 Resident #3's behaviors were not included on the reports. On 7/23, Resident #3's behaviors were not on the report. On 7/25, Resident #3's exposing self and changes in orders were added. On 7/26, " PRN [MEDICATION NAME] was used, inappropriate behavior. " On 8/5, Resident #3's behaviors were not included on the report. On 8/9, " inappropriate touching " was added to the report for Resident #3. No other entries were recorded on the 24 hour reports for Resident #3 until 8/24 that indicated " exposing himself again this evening in hallway-redirected, DON made aware. " No evidence of consistent behavior monitoring was put in place for Resident #3. Review of the Incident Report dated 7/12 revealed the interventions put in place to prevent future reoccurrence were: " 1. Provider updated on incident and [MEDICATION NAME] ordered orally along with his IM, 2. SS and DON interviewed resident and assisted resident to his room to eat supper and 3. Plans to f/u c (Psychiatrist) or provider (Attending physician/GNP). " No other incident reports were found related to Resident #3's sexually inappropriate behaviors. During an interview on 8/29/11 at 2 PM, Licensed Practical Nurse #1 stated that she has witnessed Resident #3 touching female residents inappropriately. She stated that she immediately would remove the resident and redirect him. She stated that Resident #3 did not single out one resident in particular that it was whatever female resident happened to be near him. During an interview on 8/29/11 at 2:05 PM, CNA#1 (Certified Nursing Assistant) stated that she has witnessed Resident #3 touching inappropriately other female residents. She stated that Resident #3 " mostly goes after " Resident #4. However, she stated that Resident #6 had reported to her that Resident #3 touched her inappropriately. CNA#1 stated that she did not inform the nurse of the incident between Resident #3 and #6. CNA#1 then stated Resident #3 would go into other resident's rooms and lay down in their beds. During an interview with Resident "A" (a resident on the Unit identified as interviewable) on 8/29/2011 at 2:15 PM, Resident "A" stated that she/he had witnessed Resident #3 expose himself and touch Resident #4 inappropriately in the day room. Resident "A" then stated that this occurred last week around mid-morning. The resident stated that she/he informed LPN #1 of the incident and LPN#1 moved Resident #3 to the other side of the day room. Upon review there were no nurses notes, 24 hours reports or any reference in the records related to the incident identified by Resident "A". During an interview on 8/29/2011 at 3PM, the SSD stated that she had spoken to Resident #3 regarding his behaviors and informed him that the behaviors were inappropriate and unacceptable. She then stated that Resident #3 did not know what he was doing and stated that he did not comprehend what she was saying. The SSD stated that the if the staff saw Resident #3 acting inappropriately they were to immediately remove him from the situation and redirect him. The SSD stated that no other interventions were put in place for Resident #3's behaviors. The SSD stated that she was aware of Resident #3 touching Resident #4 inappropriately. She stated that nothing was put in place for Resident #4. The SSD stated that she was not aware of any other residents, therefore nothing had been put in place for any other female residents that had been victimized. During an interview on 8/29 at 3:20 PM, LPN #2 stated that she was assigned to Resident #3 on third shift on 8/5/11. LPN#2 stated that a nursing assistant had notified her that Resident #3 had his hand down Resident #4's blouse fondling her breast. LPN#2 stated that she then moved Resident #3 to the other side of the day room. LPN#2 stated that approximately 30 minutes later, Resident #3 was reported to have his hands between Resident #4's legs touching her inappropriately. LPN#2 stated that she removed the resident from the day room and informed the resident that that behavior was inappropriate. She stated that he did come back out to the day room afterwards but did not touch any resident inappropriately again. LPN#2 stated that Resident #4 " had her pants on. " LPN#2 stated that she informed the DON of the incident but stated that she was not sure if she called the physician or the resident's responsible party. During an interview on 8/29/2011 at 3:40 PM, the Attending Physician stated that since Resident #3's readmission on 7/11/11 his behaviors were " manageable. " He stated that he was aware of only one incident that had occurred. The Attending Physician stated that he was not notified of Resident #3's increasing sexually inappropriate behaviors. He also stated that he was not notified of the incident on 8/5 and stated that he was not aware of any specific residents that Resident #3 had touched inappropriately. The Attending Physician stated that the " status quo was not working and there were other things we could have tried. " He stated that if he was made aware he would have changed the medications, increased the [MEDICATION NAME], send the resident out to the hospital, monitor the behaviors, activities to keep him busy and to keep him away from women. The Attending Physician confirmed that Resident #4 and #6's psychosocial needs were not addressed. He stated that Social Services should have assessed the residents, both residents should be monitored closely for behavior changes and the facility should prevent the incidents and should protect the residents. During an interview on 8/30/2011 at 10:20 AM, the Administrator and the Director of Nurses (DON) stated that they were aware of Resident #3's sexually inappropriate behaviors. The DON stated that she was aware of some of the incidents but not all. Both stated that they were not aware of the incident on 8/5 between Resident #3 and #4. Both stated that they were not aware of any particular resident involved. The Administrator and the DON stated that the staff acted appropriately by removing the resident from the situation. The DON stated that there " was nothing else to do. " She stated that the resident was on " the list to move to the men's unit. " When asked where the list was, the DON stated that there was not an actual list, it was " in our heads who is next to move. " The Administrator then stated that she couldn't " just move someone " and it was " based on bed availability " and there were no beds available. Both the Administrator and the DON stated again that they were aware Resident #3 was exposing himself to other residents. The Administrator and the DON stated that there was no tool in place to monitor the behaviors specifically. However, both stated that during the morning meeting the 24 hour reports were reviewed and Resident #3's behaviors should be recorded on them. Review of the facility's policy on Abuse and Neglect revealed: " Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault. " " 4. Provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. 5. Identify events such as...occurrences, patterns and trends that may constitute abuse. 6. Investigate different types of incidents...7. Protect residents from harm during an investigation...8. Report all alleged violations and all substantiated incidents to the State Agency and all other agencies as required and take all necessary corrective actions depending on the results of the investigation. " On 8/30/2011 at 10:50 AM the Administrator and the Director of Nursing was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F280, F-319, and F-490 at a scope and severity of "J". The findings were related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse and the failure to provide the proper care and treatment for one of one resident with sexually inappropriate behaviors. On 8/5/2011 independently mobile Resident #3, identified with a history of sexually inappropriate behaviors, was observed with his hand down cognitively impaired Resident #4's blouse fondling her breast and was redirected and moved to the other side of the dayroom, and then 30 minutes later found to have his hands between her legs. The Immediate Jeopardy was not removed upon exit from the facility on 8/30/2011 and remains ongoing.

On the days of the survey, based on observation, record review, facility policy review, and interview, the facility administration failed to use its resources effectively and efficiently to attain the highest practicable well-being for 1 of 1 resident with identified inappropriate sexual behaviors (Resident #3) and 2 of 2 residents alleged to have been sexually abused (Resident #4 & #6). In addition, the facility Administration failed to ensure the facility Medical Director had reviewed and acknowledged acceptable all Policies followed in the facility. The findings included: Cross Refer to F-157 as it relates to the facility staff's failure to notify the physician and the responsible party of an increase in sexually inappropriate behaviors. The failure to notify the physician of two identified residents that were victims of the sexually inappropriate behavior. Cross Refer to F-226 as it relates to the facility's failure to implement the policy on sexual abuse related to the identification and protection of residents. Cross Refer to F-250 as it relates to the facility's failure to provide medically related social services for Resident #3's sexually inappropriate behavior and the facility failed to assure Resident #4 and #6 received the necessary social services following allegations of sexual abuse. Cross Refer to F-280 as it relates to the facility's failure to care plan interventions following an allegation of sexual abuse of Resident #4 and Resident #6. Resident #3's care plan was not updated and new interventions were not added related to an increase in sexually inappropriate behaviors. Cross Refer to F-319 as it relates to the facility's failure to address, monitor and implement effective interventions for Resident #3's sexually inappropriate behavior. The facility admitted Resident #3 on 7/10/2009 with [DIAGNOSES REDACTED]. Observation of Resident #3 on 8/29/2011 at 12:30 PM, revealed him up in a wheelchair in his room with his back to the door. Resident #3's pants were unzipped and his shirt tails were loosely covering his groin area. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired in decision making abilities. No behaviors were coded as occurring during the assessment period. Resident #3 was coded as requiring one person limited assistance with transfers and was able to self propel himself in the wheelchair. The facility admitted Resident #4 on 7/13/2009 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired with decision making abilities. The facility admitted Resident #6 on 3/18/2011 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS score of 15. No behaviors were coded during the assessment period. During an interview on 8/30/2011 at 10:20 AM, the Administrator and the Director of Nurses (DON) stated that they were aware of Resident #3's sexually inappropriate behaviors. The DON stated that she was aware of some of the incidents but not all. Both stated that they were not aware of the incident on 8/5 between Resident #3 and #4. Both stated that they were not aware of any particular resident involved. The Administrator and the DON stated that the staff acted appropriately by removing the resident from the situation. The DON stated that there " was nothing else to do. " She stated that the resident was on " the list to move to the men's unit. " When asked where the list was, the DON stated that there was not an actual list, it was " in our heads who is next to move. " The Administrator then stated that she couldn't " just move someone " and it was " based on bed availability " and there were no beds available. Both the Administrator and the DON stated again that they were aware Resident #3 was exposing himself to other residents. The Administrator and the DON stated that there was no tool in place to monitor the behaviors specifically. However, both stated that during the morning meeting the 24 hour reports were reviewed and Resident #3's behaviors should be recorded on them. Review of the facility's policy on Abuse and Neglect revealed: " Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault. " " 4. Provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. 5. Identify events such as...occurrences, patterns and trends that may constitute abuse. 6. Investigate different types of incidents...7. Protect residents from harm during an investigation...8. Report all alleged violations and all substantiated incidents to the State Agency and all other agencies as required and take all necessary corrective actions depending on the results of the investigation. " During an interview on 8/30/11 at 10:10 AM, the Medical Director stated that he was aware of Resident #3's sexually aggressive behaviors prior to his psychiatric hospitalization . He stated that he was informed today (8/30) of Resident #3's sexually inappropriate behavior since his readmission on 7/11. The Medical Director stated that he was usually made aware of Resident issues if the facility had a concern, the severity of the incident or if the resident continued to have ongoing problems. He stated that he wouldn't be notified of every occurrence but should have been notified of Resident #3's behaviors. Review of the facility's Nursing Policies and Procedures and the Infection Control Manual revealed they had not been approved with signature by the Medical Director or the Director of Nursing. During an interview on 8/30/2011 at 4 PM, the Administrator confirmed the Medical Director and the DON had not approved with signature the Nursing Policies and Procedures and confirmed the Medical Director had not approved the Infection Control Manual. She stated that the Medical Director had approved the facility's " Glow and Grow " Manual which is the Quality Assurance Manual. However, she stated that the Medical Director's approval with signature of all policy and procedure manuals had not been completed as of the time of the survey. The Administrator confirmed the Medical Director accepted the position on April 1, 2011. Review of the Duties and Responsibilities of Medical Director located in the Medical Directors Service Agreement revealed " 10. Review and approve standardized procedures which registered nurses may utilize in the performance of patient care services. 11. Review reports of incidents and accidents occurring on the facility's premises which may pose a potential danger for patients, visitors or employees of the facility. " On 8/30/2011 at 10:50 AM the Administrator and the Director of Nursing was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F280, F-319, and F-490 at a scope and severity of "J". The findings were related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse and the failure to provide the proper care and treatment for one of one resident with sexually inappropriate behaviors. On 8/5/2011 independently mobile Resident #3, identified with a history of sexually inappropriate behaviors, was observed with his hand down cognitively impaired Resident #4's blouse fondling her breast and was redirected and moved to the other side of the dayroom, and then 30 minutes later found to have his hands between her legs. The Immediate Jeopardy was not removed upon exit from the facility on 8/30/2011 and remains ongoing.