Every finding on record at Aiken Rehabilitation and Care Center

Based on record review, interview, facility document and policy review, the facility failed to notify the physician of an elevated blood sugar over 400 milligrams per deciliter (mg/dL) as per the physician order for 1 (Resident (R)136) of 1 resident reviewed for insulin administration. Findings included: Review of the facility's undated policy titled, Timely Administration of Insulin, indicated, All insulin will be administered in accordance with physician's orders. An admission Record revealed the facility admitted R136 on 03/30/26. According to the admission Record, the resident had a medical history that included the diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease. A 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/26, revealed R136 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS indicated the resident did not have injections of any type during the prior seven days or since admission/entry or reentry if less than seven days. Review of R136's Baseline Care Plan, undated, indicated a focus area for disease/illness management that indicated the resident was diabetic. The interventions directed staff to follow orders for treatments, monitor for complications of illness, monitor conditions and progress of illness, and report changes to the Director of Nursing (DON) and physician. Review of R136's April 2026 Order Summary Report for date range 03/30/26 through 04/30/26, contained an order, dated 04/04/26, for insulin lispro (1 unit dial) subcutaneous solution pen-injector 100 unit/milliliter (mL) per sliding scale before meals and at bedtime, with instructions to call the physician if results greater than 400 milligram (mg)/dL. In an email correspondence from Registered Nurse (RN)15 to the DON, dated 04/09/26 at 11:46 AM, revealed, On Sunday 4/5/2026 [sic] I was caring for [R136]. When I checked [his/her] evening blood sugar it was over 400. I should have called the provider but I failed to do so and I administered the top of the sliding scale which I believe was 12 units. During an interview on 04/08/26 at 10:59 AM, Nurse Practitioner (NP)2 stated she was not notified of R136's blood sugar result of 421. NP2 said she became aware through the resident's spouse. She stated there was no progress note by the nurse and no documentation in the communication book that was used by nursing to communicate to physicians. During an interview on 04/10/26 at 2:59 PM, NP16 stated she was the physician on call for the facility on 04/05/26. NP16 stated she was not notified R136's blood sugar was 421. NP16 stated she expected the nurse to call her for a blood sugar of 421 and she would give orders for insulin. She had no recollection of a call regarding this resident. During an interview on 04/11/26 at 2:46 PM, the DON stated that when R136 had a blood sugar of 421, the nurse did not notify a physician. She stated her expectation was that the nurse should have contacted the physician as the order directed. During an interview on 04/12/26 at 10:06 AM, the Administrator stated that if there was a physician's order to notify the physician, then staff should have followed the physician's order.

Based on interview, record review, and facility document and policy review, the facility failed to ensure a resident's allegation of physical abuse was reported to the state survey agency within two hours for 1 (Resident (R)95) of 3 sampled residents reviewed for abuse. Findings included: Review of an undated facility policy titled, Abuse, Neglect and Exploitation, indicated, VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. [exempli gratia, for example] law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of an admission Record revealed the facility admitted R95 on 02/14/24. According to the admission Record, the resident had a medical history that included a diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the non-dominant left side. Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/23/26, revealed R95 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident did not have any indication of psychosis, including hallucinations or delusions. The MDS indicated R95 was dependent on staff for rolling left and right, moving from sitting to lying, and moving from lying to sitting on the bed. The MDS indicated R95 did not attempt bed to chair transfers. Review of R95's Care Plan Report included a focus area, initiated 02/27/24, that indicated the resident had an Activities of Daily Living (ADL) self-care performance deficit related to a cerebrovascular accident (CVA) with left side hemiplegia, weakness, lack of coordination, and impaired mobility. Interventions directed staff that R95 required a mechanical lift with the assistance of two staff for transfers (initiated 02/27/24) and to monitor, document, and report as needed (PRN) any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function (initiated 02/27/24). Review of R95's Post Fall Evaluation, dated 10/02/25 at 4:06 AM, indicated the resident experienced a fall on 10/02/25 at 2:00 AM. The Post Fall Evaluation revealed that R95 stated someone tossed the resident out of bed and onto the floor. Review of a facility document titled, [State Agency] Initial Report, dated 10/04/25, indicated, On 10/02/25 at 2:00 AM, R95 sustained a fall which resulted in a one-inch laceration to the right side of their head. The Initial Report did not include an allegation of abuse.During an interview on 04/11/26 at 12:54 PM, the Director of Nursing (DON) stated that documentation that someone threw R95 out of the bed was an allegation of abuse. The DON stated she asked the nurse who completed the Post Fall Evaluation about the resident being thrown out of bed; the nurse did not remember making that documentation, and the nurse did not report the allegation. The DON stated she became aware of the allegation the next morning. The DON stated a report of abuse was not made by the facility to the state agency. The DON stated the requirement was to report an allegation of abuse within two hours to the state agency. The DON stated her expectation was that when staff received an allegation of abuse, they were to notify her or the Administrator immediately. During an interview on 04/12/26 at 10:15 AM, the Administrator (ADM) stated that when staff received an allegation of abuse, she expected them to report immediately to the ADM or DON, and she followed the regulation to report to the state within two hours or twenty-four hours.

Based on interview, record review, and facility document and policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated for 1 (Resident (R)95) of 3 residents reviewed for abuse. Findings included: Review of an undated facility policy titled, Abuse, Neglect and Exploitation, indicated, V. Investigation of Alleged Abuse, Neglect and Exploitation - A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Review of an admission Record revealed the facility admitted R95 on 02/14/24. According to the admission Record, the resident had a medical history that included a diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the non-dominant left side. Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/23/26, revealed R95 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident did not have any indication of psychosis, including hallucinations or delusions. The MDS indicated R95 was dependent on staff for rolling left and right, moving from sitting to lying, and moving from lying to sitting on the bed. The MDS indicated R95 did not attempt bed to chair transfers. Review of R95's Care Plan Report included a focus area initiated 02/27/24 that indicated the resident had an Activities of Daily Living (ADL) self-care performance deficit related to a cerebrovascular accident (CVA) with left side hemiplegia, weakness, lack of coordination, and impaired mobility. Interventions directed staff that R95 required a mechanical lift with the assistance of two staff for transfers (initiated 02/27/24) and to monitor, document, and report as needed (PRN) any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function (initiated 02/27/24). Review of R95's Post Fall Evaluation, dated 10/02/25 at 4:06 AM, indicated the resident experienced a fall on 10/02/25 at 2:00 AM. The Post Fall Evaluation revealed R95 stated someone tossed the resident out of bed and onto the floor. Review of a facility document titled, [State Agency] Initial Report, dated 10/04/25, indicated, On 10/02/25 at 2:00 AM, R95 sustained a fall which resulted in a one-inch laceration to the right side of their head. Review of a facility document titled, [State Agency] Five-Day Follow-Up Report, dated 10/08/25, for R95's fall on 10/02/25 at 2:00 AM did not include interviews with other residents about abuse or interviews with staff about abuse. During an interview on 04/11/26 at 12:54 PM, the Director of Nursing (DON) stated that documentation that someone threw R95 out of the bed was an allegation of abuse. During an interview on 04/12/26 at 10:15 AM, the Administrator (ADM) stated that when a resident had an allegation of abuse, she expected the investigation to be completed within five business days or request more time if needed.

Based on record review, interview, and facility policy review, the facility failed to provide wound treatments as ordered for 1 (Resident (R)39) of 1 resident reviewed for pressure ulcers/injuries. Findings include: Review of an undated policy titled, Pressure Injury Prevention and Management revealed, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries.Review of an undated policy titled, Documentation of Wound Treatments revealed, The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. The policy revealed, 3. Wound treatments are documented at the time of each treatment. Review of an admission Record revealed the facility admitted R39 on 12/02/25. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis (paralysis and weakness) following a cerebral vascular infarction (stroke) affecting the left non-dominant side, type II diabetes mellitus with diabetic neuropathy, gout, anemia, peripheral vascular disease, and a pressure ulcer to an unspecified site. Review of a significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/23/26, revealed R39 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident had one Stage 4 pressure ulcer that was not present on admission/readmission. Review of R39's Care Plan Report, included a focus area initiated 12/03/25, that indicated the resident had a pressure ulcer to the right heel. Interventions directed staff to administer treatments as ordered and monitor for effectiveness. Review of R39's Order Summary Report for active orders as of 04/11/26, revealed an order dated 03/26/26, to clean the right heel with normal saline, apply Santyl ointment (medicated ointment used to remove dead or damaged tissue from wounds) to the wound bed, and cover the area with a bordered gauze daily for wound healing. Review of R39's April 2026 Treatment Administration Record revealed no documented evidence that treatment was provided to the resident's right heel on 04/04/26 (Saturday) and 04/05/26 (Sunday). During an interview on 04/11/26 at 11:11 AM, Licensed Practical Nurse (LPN)11, who was also the Treatment Nurse, stated that she worked five days a week and provided all residents' wound treatments on weekdays. LPN11 stated that on weekends, floor nurses completed wound treatments. During an interview on 04/11/26 at 8:06 PM, LPN13 stated that she worked the day shift on 04/05/26 and did not provide wound treatment for R39. She stated that she worked for a contract agency, and 04/05/26 was the first shift that she worked at the facility. She further stated that if she had provided the treatments, she would have documented that they were provided in the resident's electronic health record. On 04/11/26 at 11:29 AM, an attempt to contact LPN12, the nurse responsible for R39's care on 04/04/26, was unsuccessful. During an interview on 04/11/26 at 1:10 PM, the Director of Nursing (DON) stated that she had spoken with LPN12 and LPN13, and they both told her that they did not provide R39's wound treatment the previous weekend. The DON stated that she expected all wound treatments to be provided as ordered. During an interview on 04/12/26 at 11:43 AM, the Administrator stated that she expected wound treatments to be completed as ordered.

Based on observation, record review, interview, facility policy review, and review of manufacturer information, the facility failed to ensure the medication error rate did not exceed 5 percent (%). The facility had 3 medication errors out of 29 total opportunities, resulting in a medication error rate of 10.3%, affecting 1 (Resident (R)137) of 8 residents reviewed during the medication administration task. Findings include: Review of a facility policy titled, Administration of Eye Drops or Ointments, copyright 2025, revealed, Policy: Eye medications are administered as ordered by the physician and in accordance with professional standards of practice to lubricate the eye or treat certain eye conditions. The policy continued, 6. If a second medication is required in the same eye, wait appropriate amount of time per manufacturer's specifications (usually five minutes). Review of a document titled, HIGHLIGHTS OF PRESCRIBING INFORMATION, for brimonidine tartrate ophthalmic solution, revised 11/2025, revealed under DOSAGE AND ADMINISTRATION, If more than one topical ophthalmic product is being used, the products should be administered at least five 5 minutes apart (2). Review of a document titled, DORZOLAMIDE HYDROCHLORIDE - dorzolamide hydrochloride solution/ drops Alembic Pharmaceuticals Inc. [Incorporated], revised 08/2024, revealed under 2 DOSAGE AND ADMINISTRATION, Dorzolamide hydrochloride ophthalmic solution may be used concomitantly with other topical ophthalmic drug products to lower intraocular pressure. If more than one topical ophthalmic drug is being used, the drugs should be administered at least five minutes apart. Review of a document titled, HIGHLIGHTS OF PRESCRIBING INFORMATION, for timolol maleate ophthalmic solution 0.5%, revised 03/2018, revealed under 17 PATIENT COUNSELING INFORMATION, If more than one topical ophthalmic drug is being used, the drugs should be administered at least five minutes apart. Review of R137's Order Summary Report revealed the facility admitted the resident on 04/03/26. According to the Order Summary Report, R137 had a medical history that included diagnoses of macular degeneration and type two diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema. During an observation of medication pass on 04/08/26 at 9:08 AM, Registered Nurse (RN)1 administered one drop of dorzolamide-timolol eye drop, one drop of brimonidine 0.2% eye drop, and one drop of timolol 0.5% eye drop in R137's left eye. RN1 administered the three eye drops one right after the other; without waiting any time between the drops. During an interview on 04/08/26 at 9:10 AM, RN1 stated she gave each of R137's three eye drops back-to-back, without waiting any time in between because they were all due to be administered at the same time. During a follow up interview on 04/08/26 at 10:56 AM, RN1 was asked to review R137's physician orders. RN1 stated Nurse Practitioner (NP)2 had just modified the resident's orders to include instructions for waiting five minutes between different eye drops. Review of R137's Order Summary Report, reflecting active orders as of 04/09/26, revealed orders dated 04/08/26 to administer brimonidine tartrate ophthalmic solution 0.2%, one drop in left eye two times a day; dorzolamide-timolol maleate 2%- 0.5%, one drop in left eye three times a day; and timolol maleate 0.5%, one drop in left eye two times a day. The orders specified to wait 5 minutes between each different eye drop when administering. During an interview on 04/08/26 at 11:06 AM, NP2 stated R137's eye drops were prescribed for glaucoma and ocular hypertension. NP2 stated the nurse should have known based on her professional nursing judgement to wait three to five minutes between each eye drop, but she had since modified the order to specify these instructions. NP2 stated not waiting three to five minutes between each eye drop could increase or decrease the eye drops' effectiveness or cancel out their effectiveness altogether. During an interview on 04/11/26 at 1:22 PM, the Director of Nursing (DON) stated she expected nurses to follow manufacturer guidelines when administering multiple eye drops in the same eye. During an interview on 04/12/26 at 11:31 AM, the Administrator stated she expected the medication error rate to be less than 5% and for nursing staff to follow manufacturer guidelines when administering multiple eye drops.

Based on interview, record review, and facility policy review, the facility failed to ensure a resident's fall was investigated to include a root cause analysis and implementation of immediate or new interventions to prevent future falls for 1 (Resident (R)136) of 6 residents reviewed for falls. Findings included: Review of an undated facility policy titled, Fall Prevention Program indicated, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy revealed, 9. When any resident experiences a fall, the facility will, and a. Assess the resident; b. Complete a post-fall assessment; c. Complete an incident report; d. Notify physician and family; e. Review the resident's care plan and update as indicated; f. Document all assessments and actions; and g. Obtain witness statements in the case of injury. Review of an admission Record revealed the facility admitted R136 on 03/30/26. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a type of stroke) affecting left non-dominant side, and muscle weakness (generalized). Review of a five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/26, revealed R136 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had one fall since admission, without injury. Review of R136's Care Plan Report included a focus area, initiated 04/02/26, that indicated the resident was at risk for falls and fall related injuries related to impaired mobility and decreased safety awareness. Interventions directed staff to anticipate and meet the resident's needs (initiated 04/02/26); ensure the resident's call light was within reach, encourage the resident to use it for assistance as needed, and promptly respond to all requests for assistance (initiated 04/02/26); follow facility fall protocol (initiated 04/02/26); and physical therapy staff to evaluate and treat as ordered and as needed (initiated 04/02/26). Review of a Nursing Note, dated 04/03/26 at 1:43 AM, indicated R136 was found on the floor, laying on [the resident's] right side beside the bed. The Nursing Note indicated: R136's bed was in the lowest position; the resident was assessed and then assisted back to bed with staff assistance; the resident did not show signs of or verbalize being in distress; the resident's blood pressure was 127/52 millimeters of mercury (mmHg), their temperature was 97.1 degrees Fahrenheit (F), their oxygen level was 94%, their pulse was 73 beats per minute, their respirations were 17 per minute; the resident was alert with confusion; a nurse practitioner, a supervisor, and the resident's family were notified; an incident report was initiated; the call light was within reach; the resident's bed was in a safe position; and staff would continue the plan of care. Review of R136's IDT [Interdisciplinary Team] Fall record, dated 04/03/26 and signed by Licensed Practical Nurse (LPN)17, indicated the resident had a fall on 04/03/26 at 12:50 AM. The IDT Fall record revealed the following portions were left blank: 4. List any diagnosis that can contribute to the residents [sic] risk for falls; 5. List any medications that put the resident at a risk for falls; 6. Are there any lab [laboratory] results that put the resident at an increased risk for falls?; 7. What is the Root Cause of the fall?; 8. What immediate interventions were put into place in response to the fall?; 9. Indicated that the IDT agreed with the immediate interventions that were implemented following the fall.; 9a. IDT Recommends a revision of the following interventions/follow up; 10. What additional interventions were put in place?: and 11. Indicated that the care plan had been reviewed and updated. During an interview on 04/10/26 at 3:40 PM, the Director of Nursing (DON) stated falls were reviewed in clinical meetings on Mondays through Fridays with the managers. The DON stated that when a fall occurred, the team reviewed progress notes, the incident report, the fall evaluation, any medication that may have changed, and any laboratory reports. During a telephone interview on 04/10/26 at 4:20 PM, LPN17 stated R136 had fallen on the floor between the window and the bed. LPN17 stated she did not determine the root cause and she did not implement new interventions following the fall. LPN17 stated there should have been a new intervention, and the care plan should have been updated. LPN17 stated she did not know why she left the root cause and interventions blank on the IDT Fall form. During an interview on 04/10/26 at 11:57 AM, the Administrator stated R136's fall had not been reviewed by the IDT team as of that day because it had happened on 04/03/26 and surveyors entered the building on 04/06/2026. During an interview on 04/11/26 at 2:16 PM, LPN/Unit Manager (LPN/UM)5 stated the IDT was in the process of reviewing R136's fall notes when surveyors entered the facility. LPN/UM5 stated that the review of R136's fall was not completed, no new interventions had been implemented, and the care plan had not been updated. LPN/UM5 stated the IDT had not met that week, and the root cause of R136's fall had not been determined because the IDT had not met. LPN/UM5 stated the nurse should not have signed the IDT Fall record, as the DON was to sign it when the IDT completed the review. LPN/UM5 stated when the IDT completed the IDT Fall record, the care plan was updated, family members were updated on new interventions for fall prevention, the root cause was investigated, and witness statements were reviewed. During an interview on 04/11/26 at 2:46 PM, the DON stated R136 did not have new interventions implemented following their fall and the care plan was not updated. The DON stated her expectation was that an intervention be implemented immediately by the nurse, and the care plan was to be updated after the IDT meeting. The DON stated the investigation for the fall, including determination of the root cause and updating the care plan, was not completed because surveyors were in the building the week after the fall occurred, and facility staff did not have a clinical meeting. During an interview on 04/12/26 at 10:11 AM, the Administrator stated her expectation was that when a resident experienced a fall, staff were to follow the facility policy.

Based on record review, interview, facility document and policy review, the facility failed to ensure 1 (Resident (R)136) of 1 resident reviewed for insulin was free from a significant medication error. Findings included: Review of the facility's undated policy titled, admission Orders, indicated, A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the residents' immediate care and needs. Review of an admission Record revealed the facility admitted R136 on 03/30/26. According to the admission Record, the resident had a medical history that included the diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease. Review of a 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/26, revealed R136 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS indicated the resident did not have injections of any type during the prior seven days or since admission/entry or reentry if less than seven days. Review of R136's Baseline Care Plan, undated, indicated a focus area for disease/illness management that indicated the resident was diabetic. The interventions directed staff to follow orders for treatments, monitor for complications of illness, monitor conditions and progress of illness, and report changes to the Director of Nursing (DON) and physician. Review of R136's hospital Discharge Summary, dated 03/27/26, indicated the resident's discharge medications included insulin lispro 100 units/milliliter (mL) injectable solution 2-12 units subcutaneous before meals and at bedtime per sliding scale. Review of R136's April 2026 Order Summary Report for date range 03/30/26 through 04/30/26, contained an order, dated 04/04/26, for insulin lispro (1 unit dial) subcutaneous solution pen-injector 100 unit/mL per sliding scale before meals and at bedtime, with instructions to call the physician if results greater than 400 milligram (mg)/deciliter (dL). Review of R136's Progress Notes, dated 03/31/26, revealed it was the Nurse Practitioner's (NP's) initial visit with the resident. It further revealed the discharge (DC) summary, Medication Administration Record (MAR), and Plan of Care (POC) were reviewed. Insulin was not included on the resident's medication list on the Progress Note. The Progress Note was signed by NP2 on 04/01/26. Review of R136's April 2026 Medication Administration Record (MAR) revealed the resident's sliding scale insulin order was not transcribed to the MAR until 04/04/26. There was no documented evidence that the resident received insulin as ordered prior to 04/04/26 at 9:00 PM. During an interview on 04/11/26 at 3:28 PM, Licensed Practical Nurse/Unit Manager (LPN/UM)5 stated the insulin order for R136 was missed from their admission on [DATE] through 04/04/26. During an interview on 04/08/26 at 11:20 AM, NP2 stated she saw R136 on 03/31/26 for a hospital follow-up visit. She stated she overlooked the insulin during her hospital follow-up visit. During an interview on 04/09/26 at 3:37 PM, Registered Nurse/Supervisor (RN/SUP)14 stated she missed entering R136's insulin order when she entered the resident's admission orders. RN/SUP14 stated R136 missing their insulin could have resulted in the resident having elevated blood sugar levels, seizures, coma, and even death. During an interview on 04/11/26 at 2:46 PM, the DON stated R136's insulin order was missed from the hospital DC summary to the admitting orders for the facility. She stated her expectation was that orders be transcribed completely from the DC summary to the resident's medical record. During an interview on 04/12/26 at 10:06 AM, the Administrator stated her expectation was that admitting orders be transcribed to the resident's medical record from the hospital DC summary.

Based on record review, interview, facility document and policy review, the facility failed to transcribe an insulin order upon admission from the hospital for 1 (Resident (R)136) of 1 resident reviewed for insulin administration. Findings include: Review of the facility's undated policy titled, admission Orders, indicated, A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the residents' immediate care and needs. Review of an admission Record revealed the facility admitted R136 on 03/30/26. According to the admission Record, the resident had a medical history that included the diagnosis of type two diabetes mellitus with diabetic chronic kidney disease. Review of a 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/26, revealed R136 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS indicated the resident did not receive injections of any type during the prior seven days or since admission/entry or reentry if less than seven days. Review of R136's Baseline Care Plan, undated, indicated a focus area for disease/illness management that indicated the resident was diabetic. The interventions directed staff to follow orders for treatments, monitor for complications of illness, monitor conditions and progress of illness, and report changes to the Director of Nursing (DON) and physician. Review of R136's hospital Discharge Summary, dated 03/27/26, indicated the resident's discharge medications included insulin lispro 100 units/milliliter (mL) injectable solution 2-12 units subcutaneous before meals and at bedtime per sliding scale. Review of R136's April 2026 Order Summary Report for date range 03/30/26 through 04/30/26, contained an order, dated 04/04/26, for insulin lispro (1 unit dial) subcutaneous solution pen-injector 100 unit/mL per sliding scale before meals and at bedtime, with instructions to call the physician if results greater than 400 milligram (mg)/deciliter (dL). Review of R136's Progress Notes, dated 03/31/26, revealed it was the Nurse Practitioner's (NP's) initial visit with the resident. The Progress Notes further revealed the discharge (DC) summary, Medication Administration Record (MAR), and Plan of Care (POC) were reviewed. Insulin was not included on the resident's medication list on the Progress Note. The Progress Note was signed by NP2 on 04/01/26. During an interview on 04/09/26 at 3:37 PM, Registered Nurse/Supervisor (RN/SUP)14 stated she missed entering R136's insulin order when she entered the resident's admission orders. During an interview on 04/08/26 at 11:20 AM, NP2 stated she saw R136 on 03/31/26 for a hospital follow-up visit. She stated if insulin was on a DC summary from the hospital, then it should have been ordered on admission. NP2 reviewed the hospital DC summary and stated insulin lispro was on the DC medications list. She stated she overlooked the insulin during her hospital follow-up visit. During an interview on 04/11/26 at 2:46 PM, the DON stated R136's insulin order was missed from the hospital DC summary to the admitting orders for the facility. She stated her expectation was that orders be transcribed completely from the DC summary to the resident's medical record. During an interview on 04/12/26 at 10:06 AM, the Administrator stated her expectation was that admitting orders be transcribed to the resident's medical record from the hospital DC summary.

Based on observation and interview, it was determined the facility failed to ensure the menus were followed for correct portions and components of the pureed diets. This failed practice had the potential to affect all 104 residents who ate meals out of the kitchen. The findings include: Review of the facility policy, Standardized Menus, undated, documented under Policy: The facility shall provide nourishing, palatable meals to meet the nutritional needs of the residents based on the Recommended Daily Allowance (RDA) of the Food and Nutrition Board of the National Research Council, of the National Academy of Sciences, standardized cycle menus are planned in advance and utilized. Listed under Compliance Guidelines . 4. Menus should have portions stated in ounces, and/or measurements . 8. Menus will be planned to include 100% of RDA's. Review of the lunch menu, dated 3/5/25, revealed residents with pureed and general diets were supposed to receive 3 oz. (ounces) of fried chicken, 4 oz. of sweet potatoes, 4 oz. of winter blend vegetables, 1 dinner roll, 4 oz. of peaches, and 8 oz. of a beverage. The residents who received pureed diets were to receive 3 oz. pureed chicken, 4 oz. of pureed sweet potatoes, 4 oz. of pureed winter blend vegetables, 2 oz. of pureed dinner roll, 4 oz. of pureed peaches and 8 oz. of a beverage. Observation of the preparation of the lunch meal at 9:30 a.m., on 3/5/25 revealed the [NAME] prepared the meat, sweet potatoes and winter blend vegetables for the pureed diets in the blender. The [NAME] added chicken broth to the food to help blend it. The [NAME] was not observed to puree bread. During the tray line meal service, which started at approximately 11:42 a.m. on 3/5/25, it was observed that the regular diets consisted of 3 oz. of chicken, 3 oz. of vegetables and 3 oz. of sweet potatoes; the menu revealed they were to receive 4 oz. of vegetables and sweet potatoes. The pureed diets consisted of 3 oz. of chicken and 3 oz. of sweet potatoes, 4 oz. of vegetables, no bread. The menu revealed the pureed diets were to consist of 4 oz. of sweet potatoes and 2 oz. of pureed bread. The first cart, with approximately 16 trays on it, had already left the kitchen. When brought to the Certified Dietary Manager's (CDM) attention, she then brought the correct utensils to the tray line. The CDM asked the [NAME] where the pureed bread was, she/he said that they didn't have any. On 3/5/25 at 12:05 p.m., in an interview with the CDM, she/he acknowledged that the correct scoops and portions should have been used. She stated that they were in- servicing the staff on portion sizes to serve and following the menus. She/he stated that when they first arrived to the position, the kitchen didn't have the correct scoop sizes and she ordered some recently.

Based on review of facility policy, interview, and record review, the facility failed to ensure Resident (R)8 was free from misappropriation of (Oxycodone), a narcotic medication, for 1 of 1 resident. Findings Include: Review of the Facility Policy titled Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation last revised 05/01/24, states, All of our residents have the right to be free from abuse, neglect, exploitation and misappropriation of resident property. Furthermore, it states, D .Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a reside: belongings or money without the resident's consent. Acts that may constitute the misappropriation of resident property include but are not limited to: the theft or attempted of a resident's money or personal property of any value or type . Review of the Facility Policy titled Controlled Substances dated 01/02/24, states, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Furthermore, it states, Accurate accountability of the inventory of all controlled drugs is maintained at all times. Review of the Facility Policy titled Controlled Substance Storage dated 01/02/24, states .A. The Director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances.E. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed nurses and is documented. Review of R8's Face Sheet revealed R8 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's, dementia, palliative care, anxiety and chronic pain. Review of R8's Physician Orders dated 02/16/24, revealed the following orders: oxycodone 5 milligrams (mg) Twice a Day (BID). Review of R8's Medication Administration Record (MAR) dated December 2024, revealed on 12/01/24, R8 did not receive her 5:00 PM scheduled dose. Review of a facility document titled Packing Slip dated 11/22/24, revealed on 11/23/24, Licensed Practical Nurse (LPN)1 signed for 28 tablets of 5 mg oxycodone for R8. Review of a facility document titled Visit Note Report dated 11/27/24, revealed the hospice nurse for R8, reconciled her medications and noted there to be 20 tabs of oxycodone. During an interview on 12/12/24 at 1:57 PM, LPN1 stated, she first noticed R8 was missing her Oxycodone on 12/01/24 at 9:00 AM during medication administration. LPN1 stated she did not physically count the number of cards and number of narcotic sheets during shift exchange and that she just went with it and did not confirm with Registered Nurse (RN)1. LPN1 was unable to state the facility's policy regarding narcotic sign off and instead, reported that she has always done it this way. LPN1 stated she had to call the pharmacy, who reported that R8 should not be out of Oxycodone due to the dosage and the last shipment date. LPN1 had to obtain a new prescription order for R8's oxycodone. During an interview on 12/12/24 at 2:14 PM, the Director of Nursing (DON) and Facility Administrator (FA) stated, Nurses are supposed to do a shift to shift report, where the off-going nurse gives the on-coming nurse, report. During this report, a narcotic count is done to ensure accuracy before exchanging keys. The narcotic count involves looking at all of the controlled substance cards and the number of pills left in each individual card to ensure it matches the number on the card and sign-off sheet. The DON further stated, that facility policy is, during hand-off each controlled substance card should match each sheet, and at the end nurses should count the total number of card and sheets. Unit Nurse Manager (UNM) are responsible for reconciling medication carts, twice a month and they should be looking at the narcotic sheets to ensure that the number that is counted is the number that is in the cart. Interview attempts with RN1 were unsuccessful.

Based on review of facility policy, record reviews and interviews, the facility failed to ensure an allegation of misappropriation towards Resident (R)8 was reported within 2 hours and failed to report accident/incident for R6 within 24 hours. Findings include: Review of the Facility Policy titled Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation last revised 05/01/24, states, The facility's Policy requires that it report all instances of abuse, neglect, exploitation and misappropriation of resident property, and suspicious injuries of unknown source that might indicate abuse, neglect, as required by state and federal law. Furthermore, it states, Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a residents' belongings or money without the residents consent. Acts that may constitute the misappropriation of resident property include but are not limited to: the theft or attempted theft of a resident's money or personal property . and The Administrator/designee in administrator absence will report to the State Agency and all other required agencies, per regulations. Review of R8's Face Sheet revealed R8 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's, dementia, palliative care, anxiety and chronic pain. Review of the Facility 2 Hour Initial Reportable received by the department on 12/06/24 stated, On 12/1/24 @ 9AM Nursing staff discovered a missing narcotic card. MD, RR notified. Investigation initiated. DEA informed of missing medication card. two nurses suspended. 5 day to follow. The initial report was sent 5 days after the incident occurred. Review of a Witness Statement signed by Licensed Practical Nurse (LPN)1, dated 12/02/24, stated, While passing medication, R8's 5 milligrams (mg) Oxycodone was not available on cart. The pharmacy was notified and asked if the medication could be taken from the cubex. Pharmacy stated that a new prescription was needed. Unit manager notified, MDS Coordinator aware. Review of R6's Face Sheet revealed R6 was admitted to the facility on [DATE]. R6 has diagnoses including but not limited to: Parkinson's, gout, disorientation, head injury and osteoarthritis. Review of the Facility's 2 Hour Initial Reportable received by the department on 11/04/24, revealed, Date/time of reportable incident: 11/04/24 at 7:22 PM Resident sustained fracture of olecranon process of right ulna following a fall . 5 day to follow. Review of R6's electronic medical records, revealed, R6's fall occurred on 10/19/24 and he was sent to the hospital and admitted , however the reportable was not sent until 16 days later. Review of a progress noted dated 10/19/24 at 1523, revealed, 10/19/24 1332 I was sitting at the nurse's station when a loud noise was heard coming from the direction of this [R6's] room. Upon entering this room [R6] was noted to be laying on the floor on his right side. [NAME] was laying on the floor beside him. He stated that he had got up to go to the restroom, and when he turned around he lost his balance and fell to the floor. No obvious injuries were noted. He had complaints of right shoulder and right hip pain. ROM to right shoulder was decreased per resident. He requested his daughter be contacted. At the request of resident and his daughter he was transported to [local hospital] via ambulance for further eval. [R6] is his own responsible party. NP [Nurse Practitioner] on call was notified. During an interview on 12/12/24 at 1:57 PM, LPN1 stated, she first noticed R8 was missing her Oxycodone on 12/01/24 during medication administration. LPN1 stated she did not physically count the number of cards and number of narcotic sheets during shift exchange and that she just went with it and did not confirm with Registered Nurse (RN)1. LPN1 was unable to state the facility policy regarding narcotic sign off and instead reported that she has always done it this way. During an interview on 12/12/24 at 2:14 PM, the Facility Administrator (FA) and Director of Nursing (DON) confirmed the misappropriation occurred on 12/02/24. FA further states that she was unaware that misappropriation needed to be reported and then stated, it's really a theft. FA also stated that R6's fall was not reported timely because they did not receive a confirmed diagnosis of a fracture until 11/04/24, eventhough R6 sustained a fall on 10/19/24 requiring him to be hospitalized .

Based on interview, record review, and facility policy review, the facility failed to timely report an allegation of abuse to the state agency that involved 2 residents (Resident (R)2 and R3) of 4 sampled residents reviewed for abuse. Findings include: Review of the facility's policy, titled, Abuse Prevention, Intervention, Reporting and Investigation, revised 03/30/2023, indicated, The purpose of this policy is to ensure all resident have the right to be free from abuse, mistreatment, neglect, exploitation, corporal punishment, involuntary seclusion and misappropriation of property. The facility will ensure the prevention, protection, prompt reporting and interventions in response to alleged, suspected, or witnessed abuse, neglect, and exploitation of any resident. The policy specified, 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within the specified timeframe: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegations involve abuse or result in serious bodily injury, or . Not later than 24 hours if the events that cause the allegations do not involve abuse and do not result in serious bodily injury. Review of an Admission Record revealed the facility admitted R2 on 08/10/2023. According to the Admission Record, the resident had a medical history that included diagnoses of but not limited to: hemiplegia and hemiparesis following a cerebral infarction (stroke) affecting the right dominant side, osteoarthritis, aphasia, anxiety disorder, age-related cataract, rheumatoid arthritis, a left elbow contracture, and long-term (current) use of anticoagulants. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/29/2024, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Review of an Admission Record revealed the facility admitted R3 on 10/10/2023. According to the Admission Record, the resident had a medical history that included diagnoses of but not limited to: encephalopathy, cerebral infarction, atrial fibrillation, and atherosclerotic heart disease. Review of a quarterly MDS, with an ARD of 04/17/2024, revealed R3 had a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Review of an Initial Report, dated 03/15/2024, indicated the state survey agency was notified of the abuse allegation on 03/15/2024 at 3:59 PM. Review of a Resident to Resident Conflict report dated 03/14/2024 at 1:23 PM, revealed Licensed Practical Nurse (LPN)1 documented she heard yelling, entered R2's room, and observed R3 standing over R2 yelling with glasses in hand. According to the report, staff moved R3 to the hallway and evaluated the redness noted of R2's left lower arm. R2 stated R3 grabbed their arm. Review of R2's Progress Note, created by LPN1 with an effective date of 03/14/2024 at 1:30 PM, revealed LPN1 heard yelling coming from the resident's room and multiple staff members entered the room. The resident's roommate was observed standing over R2 yelling with glasses in hand. According to the note, staff moved R3 to the hallway and evaluated redness to the left lower arm. R2 stated the roommate had grabbed their arm. Review of R2's Weekly Skin Check, completed by Unit Manager (UM)2 on 03/15/24 at 3:57 PM, revealed the resident had a bruise to the left lower arm. Review of R2's social services Progress Notes, dated 03/15/2024 at 6:16 PM, revealed Master of Social Work (MSW)3 documented she met with R2 who reported there was a verbal dispute with their roommate that became physical. Review of R3's social services Progress Note, dated 03/15/2024 at 6:36 PM, revealed MSW3 documented she spoke with R3 and the resident reported they had a verbal altercation with their roommate, which accelerated to R3 removing R2's glasses. R3 denied any other physical allegations. During an interview on 06/15/2024 at 5:30 PM, the Administrator stated the verbal altercation occurred on 03/14/2024 between two residents who lived in the same room. The Administrator stated on 03/15/2024 there was a bruise observed on R2's arm which the resident claimed was caused by R3 grabbing their arm during the altercation on 03/14/2024. Per the Administration, at that point the facility submitted a report of abuse and initiated an investigation. The Administrator stated on 03/15/2024 the police were notified of the incident that occurred between R2 and R3 and a case number was assigned.

Based on interview, record review, and review of the facility policy, the facility failed to ensure Resident (R)1 was free from unnecessary antipsychotic medications. For 1 of 3 residents reviewed for unnecessary medications. Findings include: Review of facility policy titled Nursing Management Manual Psychotropic Medications last revised 12/18/22 revealed, The purpose of this policy is to guide employees on the use of psychotropic medications and to ensure that the resident has correct and proper medical diagnosis documented in the medical record to receive the medication ordered. The facility acknowledges the resident's right to be free from psychotropic medications administered for purposes of discipline or convenience and not required to treat the resident's medical symptoms. The goal of the federal guidelines for the use of psychotropic medications are to prevent the use of those drugs when the behavioral symptom exhibited by a resident is caused by conditions such as environmental stressors, psychosocial stressors, or treatable medical conditions. The facility supports the cooperative efforts of the physician, pharmacist, nursing staff, and mental health professionals to establish specific goals and objectives for review of the use of psychotropic medications. The facility encourages multi-disciplinary to determine factors responsible for resident behavior changes and to recommend consideration of alternate, non-pharmacological means of treating those factors. Consistent behavior monitoring is done to assess the risk/benefit relationship of psychotropic medication therapy, including the appropriateness of medication selection and dosage. Unnecessary drugs, as defined by federal regulations, are any drugs when used in excessive doses; excessive duration; without adequate monitoring; without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. The Consultant Pharmacist reports all potentially unnecessary drugs to the physician responsible for correcting the potential unnecessary drug or irregularity. Review of the Manufacture's Guidelines for the use of the medication Seroquel/Quetiapine revealed, Increased Mortality in Elderly Patients with Dementia-Related Psychoses: Atypical antipsychotic drugs, including quetiapine, are associated with an increased risk of death; causes of death are variable. Risk of death in the elderly with dementia: Medicines like Seroquel can raise the risk of death in elderly people who have lost touch with reality due to confusion and memory loss (dementia). SEROQUEL is not approved for treating psychosis in the elderly with dementia. Review of the Manufacture's Guidelines for the use of the medication Risperidone/Risperdal revealed, Increased mortality in elder patients with Dementia- Related Psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. PERSERIS is not approved for the treatment of patients with dementia-related psychosis. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with the diagnoses including but not limited to: dementia with agitation, repeated falls, unsteadiness on feet, and aphasia. Review of R1's Re-Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/02/24 revealed that R1 has a Brief Interview of Mental Status (BIMS) score of 08 out of 15 which indicates that she is moderately cognitively intact. Review of R1's Hospital Discharge Summary dated 12/21/24 revealed the following diagnoses for R1: acute Urinary Tract Infection (UTI), debility, dementia, frequent falls, history of pulmonary thrombosis, and hypertension. Further review of the Hospital Discharge Summary revealed the following discharge medications: 1. Risperidone 0.25 MG oral tablet - two tablets by mouth every eight hours as needed for agitation. (New) 2. Quetiapine 100 MG oral tablet - one tablet by mouth two times a day (changed) 3. Acetaminophen 325 MG oral tablet - two tablets by mouth every four hours for pain (unchanged) 4. Losartan 100 MG oral tablet - one tablet by mouth daily (unchanged) 5. Metoprolol (Metoprolol Succinate ER) 25 MG oral tablet - one tablet by mouth daily (unchanged). Review of R1's Medication Order Summary Report for January 2024 revealed the following Physician Orders: 1. Quetiapine Fumarate Oral Tablet 100 MG - give one tablet by mouth two times a day related to dementia with behaviors with a start date of 12/29/23, a hold date 01/20/24 - 01/25/24, and discharge date of [DATE]. 2. Risperidone Oral Tablet 0.5 MG - give one table by mouth every eight hours as needed related to agitation with a start date and discharge date of [DATE] - 01/12/24. 3. Risperdal Oral 0.5 MG - give one tablet by mouth every 12 hours related to dementia with behavioral disturbance with a start date of 01/20/24. 4. Risperdal Oral Tablet 1 MG - give 1 mg by mouth two times a day for schizophrenia with a start date of 01/12/24, a hold date of 01/20/24 - 01/25/24 and discharge date of [DATE]. 5. Seroquel Oral Tablet 25 MG - give three tablets by mouth two times a day related to dementia with behavioral disturbance with a start date of 01/20/24. 6. Monitor every shift for antipsychotic medication side effects; none; constipation; confusion; restlessness; dry mouth; pacing; decreased appetite; tardive dyskinesia; lip smacking/chewing; abnormal tongue movement; or spasmodic movement every shift. Review of R1's Medication Order Summary Report dated January 2024, revealed R1 did not have a Physician's Order for behavior monitoring while receiving antipsychotic medications. Review of R1's Medication Order Summary Report for February 2024 revealed the following Physician Orders: 1. Quetiapine Fumarate Oral Tablet 100 MG - give one tablet by mouth two times a day for dementia with behaviors with a start date of 01/12/24 and discharge date of [DATE]. 2. Risperdal Oral Tablet 1 MG - give one tablet by mouth two times a day for schizophrenia with a start date of 01/12/24 and discharge date of [DATE]. 3. Monitor every shift for antipsychotic medication side effects; none; constipation; confusion; restlessness; dry mouth; pacing; decreased appetite; tardive dyskinesia; lip smacking/chewing; abnormal tongue movement; or spasmodic movement every shift. Review of R1's Medication Order Summary Report dated February 2024, revealed R1 did not have a Physician's Order for behavior monitoring while receiving antipsychotic medications. Review of a Consultant Pharmacist Recommendation to the Medical Director dated 01/02/24 revealed, [R1] has an order for Risperidone 0.5 MG every eight hours as needed for agitation with no stop dated indicated. In accordance with State and Federal Guidelines, orders for psychotropic drugs are limited to 14 days, except when the attending physician or prescribing practitioner believes that it is appropriate for the PRN (as needed) order to be extended beyond 14 days. Then he or she should document the rationale in the medical record and indicate the duration for the PRN order. Note there is no clinical rational to justify PRN antipsychotic use beyond 14 days; response - continue PRN for 14 days, as the benefit outweighs the risk. Review of R1's Face Sheet printed on 03/13/24 revealed no medical diagnosis of schizophrenia during R1's stay at the facility. During an interview on 03/14/24 at 1:41 PM, the Director of Nursing (DON) revealed the facility policy is to follow Physician Orders, monitor for side effects, document behaviors, and we discuss residents daily in our stand-up meetings. The DON further stated that they are aware of the resident being on antipsychotic medication and the resident was placed on the medication due to her agitation. During an interview on 03/14/24 at 3:20 PM, the Administrator and DON revealed that residents on antipsychotic medications are reviewed by the Pharmacist and residents are discussed daily during morning meeting. The Administrator stated they were unable to locate R1 having a diagnosis of schizophrenia in her medical record prior to being admitted to the facility. During a phone interview on 03/14/24 at 3:57 PM, the Consultant Pharmacist (CP) revealed they completed their Monthly Medication Regimen Review (MRR) for R1 on 01/02/24 and had two recommendations related to R1's medications. Their first recommendation was adding Eliquis to R1's Physician Order's due to a diagnosis of atrial fibrillation. The second recommendation was related to R1 receiving Risperidone 0.5 mg as needed for agitation with no stop date indication. The CP further stated there was no clinical rationale to justify the PRN (as needed) antipsychotic use beyond 14 days. The CP finally stated that Risperidone cannot be used for agitation and that antipsychotic use with older adults with dementia increases the likelihood of falls. During a phone interview on 03/14/24 at 4:56 PM, R1's Physician revealed that R1 was first ordered Risperdal PRN every eight hours in the hospital for her dementia with behaviors and agitation. The Physician further stated that R1 does not have a diagnosis of schizophrenia and continued the PRN use of Risperdal as the benefit outweighs the risk due to the facility not allowing physical restraints to be used on residents. The Physician finally stated that they were unaware of the Center's of Medicare and Medicaid (CMS) guidelines and the facilities policy on antipsychotic and psychotropic medication usage with elderly adults with dementia.

Based on review of facility policy, observations, and interviews, the facility failed to ensure expired medications and biologicals, which were stored with active medications for residents, were removed from 5 of 6 medication carts and 2 of 3 medication storage rooms. Findings include: Review of the facility policy titled, Medication Storage with a revision date of 05/16/23, states, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. Number 8 under the Policy Explanation and Compliance Guidelines states, Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our, Destruction of Unused Drugs Policy. During an observation on 08/08/23 at 11:10 AM of the [NAME] Hall medication cart 1 revealed the following: Ten (10) tablets of Oxycodone 5 milligrams (mgs) with Lot # J220354A, RX #26667853 were expired on 04/30/2023. One (1) bottle of Zinc 50 mgs 100 tablets, Manufactured by Geri Care, Lot # 865V02, expired on 04/2023. Three bottles (3) of One Daily Multi Vitamin 1000 tabs, Manufactured by Geri Care, Lot #501T06, expired on 06/2023. One (1) bottle of Stool Softner Docusate Sodium 100 mgs, 200 soft gels, Manufactured by Geri Care, Lot #401T23, expired on 04/2023. One (1) Novolog Flex Pen - opened 07/15/23 and expired on 08/05/23. One (1) Lispro Kwik Pen, opened and in use with no open date. One (1) Novolog Flex Pen - opened and in use with no open date. One (1) bottle of Assure Platinum Blood Glucose Test Strips, Lot #052523A, open and in use with no open date. Assure Control Solution Lot #120321A, Exp 05/19/23. During an interview on 08/08/23 at 11:30 AM, Licensed Practical Nurse (LPN)1 confirmed the findings and removed the expired medications and biological's from storage. During an observation on 08/08/23 at 11:40 AM of the [NAME] Hall medication room refrigerator revealed the following: Ten (10) injections of Fluarix Quadrivalent Injections, RX #26703185, Lot #(10)EE5X3, expired on 06/30/23. One (1) bag of Cefazolin 2 grams (gms)/50mls of NS with RX#28506471, expired on 08/03/23. Four (4) bags of Cefazolin 2gm/50mls of NS with RX #28643530, expired on 08/01/23. The expired medications were confirmed by LPN1 and removed from storage. During an observation on 08/08/23 at 11:45 AM of the [NAME] Hall medication room cabinet revealed: Six (6) bottles of Biophix - Vitamin D-3, 60 capsules with Lot #2208051, expired on 07/2023. The expired medications were confirmed by LPN1 and removed from storage. During an observation on 08/08/23 at 1:13 PM of the [NAME] Hall medication cart 2 revealed: One (1) bottle of Stool Softener, manufactured by Geri Care with Lot #401T33, expired on 04/2023. Anti Diarrheal Loperamide, Lot #P132922 - 1/2 tab opened and remains on the cart. Assure Control Solution opened on 01/15023 and still in use. Per package insert the control solution is only good for 90 days after open date. During an interview on 08/08/23 at approximetly 1:20 PM, LPN2 confirmed the findings. During an observation on 08/10/23 at 10:35 AM of the Palmetto Hall medication room refrigerator revealed: One (1) bottle of Acetylcystine 20 percent with Lot #GK0857 opened on 04/24/23 and expires 96 hours after opening, which expired on 04/28/23. LPN 4 confirmed the expired bottle of Acetylcystine and removed it from the refrigerator. During an observation on 08/10/23 at 3:00 PM of the Dogwood Hall medication cart 1 revealed: One (1) bottle of Allergy Relief, [NAME], 24 hour relief, Batch #AC08935, expired on 11/2022. One (1) bottle of One Daily Multi Vitamin 1000 tabs with Lot #501T06, and manufactured by Geri Care, expired on 06/2023. One (1) bottle of Biscodyl 5 mgs, 100 tabs with Lot #441T02 and manufactured by Geri Care, expired on 12/2022. One (1) bottle of Calcium 600 mgs, 150 tabs with Lot #746T03 and manufactured Geri Care, expired on 02/2023. One (1) bottle of Aspirin 325 mgs, 100 tabs with Lot #P125797 and manufactured by Geri Care, expired on 06/2023. During an interview on 08/10/23 at 3:05 PM, LPN5 confirmed the expired medications. During an observation on 08/10/23 at 3:41 PM of the Dogwood Hall medication cart 2 revealed the following: One (1) Lantus Solostar Kwik Pen in use with no open date with RX #28647007, Lot # 3F8971A. One (1) bottle of Sterile Water 250 milliliters, manufactured by Steri Care, opened and placed back on the medication cart and no longer sterile. Sixteen (16) tablets of Loratadine 10 mgs and manufactured by [NAME] with Lot #1DE2449A, expired on 01/2023. One (1) bottle of Zinc 50 mgs and manufactured by Geri Care with Lot #865T05, expired on 02/2023. One (1) bottle of One Daily Multi Vitamin, 1000 caplets with Lot #501T06 and manufactured by Geri Care, expired on 06/2023. The expired medications were confirmed by LPN5. During an observation on 08/11/23 at 11:01 AM of the Palmetto Hall medication cart 1 revealed the following: One (1) roll of Derma View Roll, Adhesive Film Roll, manufactured by DermaRite with Lot #E2018081002, expired on 08/09/23. The expired roll of Adhesive Film was confirmed by LPN2.

Based on the facility document titled, Insulin Pen Skilled Competency Check Off, observation, and interview, the facility failed to ensure Resident (R)84 was free from significant medication errors. Specifically Licenced Practical Nurse (LPN)7 failed to first prime a Novolin Insulin Kwik Pen prior to administering insulin during 2 injections of Novolin Insulin. Therefore, it cannot be determined that R84 had received the full 75 units of Novolin Insulin as ordered by the physician. Findings include: Review of the facility's, Insulin Pen Skill Competency Check Off, states: 7. Check expiration date of insulin pen cartridge or disposable insulin pen. 8. Attach pen needle by twisting the needle onto end of insulin pen. Wipe top of insulin pen with alcohol swab if instructed to do so. 9. Pull off and remove outer pen needle protective cap and cover. 10. Prime pen. 11. Dial desired insulin dosage to be administered. 12. Choose an injection site. 13. Cleanse injection site with alcohol swab and allow to air dry. 14. Gently pinch skin of chosen injection site and insert pen needle at a 45 - 90 degree angle into the skin. 15. Push button (plunger) down at end of pen completely to give insulin. 16. Wait 10 seconds while keeping insulin pen and pen needle in place, to ensure all insulin is given. During an observation on 08/10/23 at 7:20 AM, of medication administration of Novolin 70/30, documented an ordered dose of 75 units. The medication was supplied via a Kwik Pen. The Kwik Pen was new and LPN7 wrote the date opened and put the expiration date on the pen. LPN7 then entered R84's room and administered the following to R84: 40 units subcutaneous without priming the pen and then gave the remaining 35 units without priming the Kwik Pen. During an interview on 08/10/23 at 7:25 AM, LPN7 confirmed that she had not primed the Novolin Kwik Pen before administering the 2 injections of Novolin Insulin.

Based on the facility's policy titled, Resident Rights, and the facility policy titled, Hygiene and Grooming, and Assistance with Personal Care, record reviews and interviews, the facility failed to ensure Resident (R37) received Activities of Daily Living to include grooming and hygiene according to her preferences on a daily basis, for 1 of 5 residents reviewed for Activities of Daily Living (ADL)s. The findings included: Review of the facility's document titled, Resident Rights, states: 5. Self Determination: The resident has the right and the facility must promote and facilitate resident self-determination through support of resident choices, including but not limited to: b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. 9. Each resident has the right to considerate and respectful care and to be treated with honesty and dignity. It is recognized that every resident is an individual who has feelings, preferences, personal needs and requirements. Review of the facility's policy titled, Assistance with Personal Care, states under, Policy Explanation and Compliance Guidelines: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility policy titled, Hygiene and Grooming, the purpose states: Good hygiene and grooming help prevent the spread of infection and promote the resident's feelings of self-worth and dignity. The Process under section IV. Essential Points, states: a. Resident preferences for time of day, and type of bath should be honored, to the extent possible. The facility admitted R37 with diagnoses including, but not limited to, cerebrovascular accident, osteoarthritis, repeated falls, intervertebral disc degeneration of the lumbar region, post polio syndrome, stress incontinence, chronic pain syndrome and anxiety disorder. During an interview on 08/08/2023 at 2:14 PM with R37, she stated that the facility only has one,sit and stand lift. Because of this, the Certified Nursing Assistants, (CNAs) cannot get me up to get in the shower on my shower days. She stated that her shower days were supposed to be Monday, Wednesday and Fridays. She stated that she did not mind the bed baths on her off shower days, but she really wanted her hair shampooed during her shower days. She stated because of the only one sit and stand lift, the CNAs had to wait on it to be available, and it would be later before she got a shower if she got one at all. She was told by the CNAs that it would be quicker for her to get a bed bath eventhough R37 requested showers. R37 stated that some days there is not enough staff to ensure she got a bath of any kind. An interview on 08/10/2023 at 10:00 AM with R37 confirmed that she had not had a shower on 8/9/2023, her scheduled shower day. She stated the facility is short staffed on first shift most days. During an interview on 08/10/2023 at 10:30 AM with Licensed Practical Nurse (LPN8) the unit manager, he stated that residents get a shower on scheduled shower days and if they refuse the shower then they can get a bed bath. If the residents choose a bed bath or a shower each day then they get it. LPN8 also stated that residents do not get baths on days that they are not scheduled for showers. During an interview on 08/10/2023 at 10:45 AM with the Administrator, he stated that the orders are written to get a shower or a bed bath on scheduled days and if they refuse then the CNA will tell the nurse and then they go back and ask again. If they would like a shower daily the resident would let us know and then that is what we will give the residents. Review on 08/10/2023 at 12:19 PM of the bath and shower documentation for June, July and August to date for R37 revealed signed off dates for showers or bed baths on Tuesdays, Thursdays and Saturdays. The documentation did not specify if R37 received a shower or a bed bath on those days. R37 stated that her shower days were suppose to be Mondays, Wednesdays and Fridays and she really looked forward to receiving showers. Review on 08/10/2023 at 2:00 PM of the CNA schedules for groups of residents and for baths and showers revealed a schedule for 4 groups if the facility has 4 CNAs on the unit and one for 3 CNAs on the unit if the facility is short staffed for the day. If there are 4 CNAs working then R37 is on the schedule for a shower on Monday, Wednesday and Friday. If a CNA calls out or there is only 3 on the 7A - 3P shift schedule for the [NAME] Hall then R37 is not listed at all on the shower schedule for Monday, Wednesday and Friday.

Based on the facility policy titled, Medication Administration, and the facility,Insulin Pen Skill Competency Check Off, observations and interviews, the facility failed to ensure a medication error rate, during medications administration, less than five (5) percent. The med error rate was 19.23 percent for 5 out of 26 opportunities for error. The findings included: Review of the facility policy titled, Medication Administration, states under policy, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of the, Policy Explanation and Compliance Guidelines, states: 13. Remove medication from source, taking care not to touch medication with bare hand. An observation on 08/09/2023 at 8:47 AM of medication administration for Resident (R)24 revealed Licensed Practical Nurse (LPN)7 mixing 2 medications in one 5 ounce cup. The medications were Glycol 17 grams to be given daily and Veltassa 8.4 grams. The Physician's order read to give 1 packet of Veltassa daily in 6 ounces of water. The Physician's order for Glycol revealed to give Glycol Powder 17 grams in 4-8 ounces of liquid of choice. R24 was administered the 2 medications together in one cup and not with the ordered amount of fluids. During an interview with LPN7 on 08/09/2023 at 8:55 AM, she confirmed that the medications were administered together in the 5 ounce cup and that she had not following the Physician's orders. An observation on 08/09/2023 at 09:25 AM revealed Registered Nurse (RN)1 had dropped the medication Amlodipine 1 tablet, for R2 on top of the medication cart and then with her bare hands picked up the medication and placed it in the cup with other medications to be given. During an interview on 08/09/2023 at 9:30 AM, RN1 confirmed that she had touched the medication with her bare hands. She also stated that she had cleaned the cart earlier that morning. Review of the facility's, Insulin Pen Skill Competency Check Off, states: 7. Check expiration date of insulin pen cartridge or disposable insulin pen. 8. Attach pen needle by twisting the needle onto end of insulin pen. Wipe top of insulin pen with alcohol swab if instructed to do so. 9. Pull off and remove outer pen needle protective cap and cover. 10. Prime pen. 11. Dial desired insulin dosage to be administered. 12. Choose an injection site. 13. Cleanse injection site with alcohol swab and allow to air dry. 14. Gently pinch skin of chosen injection site and insert pen needle at a 45 - 90 degree angle into the skin. 15. Push button (plunger) down at end of pen completely to give insulin. 16. Wait 10 seconds while keeping insulin pen and pen needle in place, to ensure all insulin is given. An observation on 08/10/2023 at 7:20 AM of medication administration of Novolin 70/30 revealed an ordered dose of 75 units. The medication was supplied via a Kwik Pen. The Kwik Pen was new and LPN7 wrote the date opened and put the expiration date on the pen. The LPN then went into the room and administered R84, 40 units subcutaneous without first priming the pen and then gave the remaining 35 units without first priming the Kwik Pen. During an interview on 08/10/2023 at 7:25 AM, LPN7 confirmed that she had not primed the Novolin Kwik Pen before administering the 2 injections of Novolin Insulin.

Based on review of the facility policy, observation, and interview, the facility failed to provide assistance with Activities of Daily Living (ADLs) related to personal care for Resident (R)7, 1 of 3 reviewed for ADLs. Findings include: Review of the policy titled, Assistance with Personal Care revealed It is policy of this facility to offer assistance with completion of ADLs as residents require. The facility will [MEDICATION(S)] to ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This may include the resident's ability to: 1. Bathe, dress, and groom 2. Transfer and ambulate An observation and interview on 07/26/22 at 12:35 PM with R7 revealed R7 lying in bed, dressed in a nightgown and in need of personal care. R7 stated that she enjoys attending activities and prefers to be out of bed and dressed by mid-morning. She further stated she has not been able to attend activities, because she is not receiving her showers as scheduled (Monday,Wednesday, and Friday) and this has been an on-going issue for a few weeks. R7 stated that her last shower was on Wednesday (07/20/22) and did not receive her shower on Friday (07/22/22) or yesterday, (Monday 07/25/22). R7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 05/8/22 revealed R7 has a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicates she is cognitively intact. Record review of R7's shower log for the month of July 2022 revealed R7 received a shower on 07/01/22, 07/02/22, 07/03/22, 07/04/22, 07/07/22, and 07/16/22. The shower log documentation revealed no evidence that R7 received a shower on 07/20/22, as stated. Record review of R7's personal hygiene log for the month of July 2022 revealed personal hygiene was last performed on 07/23/22, per the documentation. Record review of R7's Individual Participation Record for July 2022 revealed she attended 1 activity involving socializing on 07/19/22. Review of R7's Care Plan revealed R7 requires assistance with ADL performance related to decreased mobility, weakness, and mood/behaviors. She will continue to be up out of bed, and dressed in appropriate clothes daily as tolerated. Shower three times weekly and needed with sponge bath in between. An interview with Certified Nursing Assistant (CNA)2 on 07/26/22 at 3:30 PM revealed CNAs are expected to chart in the ADL book after they provide care to a resident. An interview with the Director of Nursing on 07/27/22 at 5:00 PM revealed CNAs are expected to provide ADL care to residents daily to maintain quality of life.

Based on observation, record review and staff interview, the facility failed to ensure that efforts were made to prevent incidents and potential injury from wandering for a resident (#1) identified as a wandering/elopement risk. The facility also failed to reassess the resident in a timely manner in an effort to provide effective interventions for the prevention of incidents and injury for a one (1) of four (4) sampled residents. (Resident (R)1). Findings include: Review of the facility's Abuse, Neglect and Exploitation policy (reviewed/revised 9/1/2021) revealed the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Review of the facility's Elopements and Wandering Residents policy (reviewed/revised 9/30/2021) revealed the following: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. 6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan. d. Adequate supervision will be provided to help prevent accidents or elopements. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. Review of the Tips for Prevention of Elopements revealed the following tip: Consider the use of a Chain of Custody for High Risk Residents; develop a schedule for periodic checks on the resident. Review of the facility's Reviewing and Revising the Care Plan policy (reviewed/revised 9/30/2021) revealed the following: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Record review revealed R1 was admitted to the facility on [DATE] with the diagnoses: Dementia without Behavioral Disturbance, Restlessness and Agitation and Hypertensive [CONDITION(S)]. Review of R1's annual Minimum Data Set (MDS) dated [DATE] revealed R1's Brief Interview for Mental Status (BIMS) was noted as three (3), which indicated that resident had a severe cognitive deficit. The resident was coded for independence with mobility. Review of the Physician Orders revealed R1 was prescribed the following medications: [MEDICATION(S)] for depression, [MEDICATION(S)] for depression and [MEDICATION(S)] for anxiety. The resident also had an order for a Wander Guard device with instructions to check for placement and function every shift. Review of R1's clinical record revealed a care plan in place for the following: Risk for falls and or injury related to dementia as evidenced by: wandering aimlessly about the units, exit seeking behavior, in and out of other resident's rooms with difficulty to redirect at times; Potential for alteration in cognitive status due to dementia with behaviors; Resident cries frequently can become agitated and aggressive becoming combative with staff and resistive to care hitting and slapping and [R1] has a recent history of a resident to resident altercation. Review of R1's record revealed that an Elopement Risk Assessment was last completed on 5/26/21. According to the instructions, the assessment is supposed to be completed upon admission, quarterly and at any significant change and as needed (PRN). Further review of the form revealed R1 was assessed as wandering aimlessly, being cognitively impaired and expressing the desire to go home. The Summary of Assessment noted R1 was an elopement risk. The Potential Interventions listed Wander Guard, frequent monitoring and medication review as interventions. There were no elopement risk assessments completed after 5/26/21. Record review revealed R2 was admitted to the facility on [DATE] with the diagnoses: Acute Embolism and [CONDITION(S)], Chronic Venous Hypertension with Ulcer of Right Lower Extremity, Pure [CONDITION(S)], Alcohol Abuse, Venous Insufficiency, [CONDITION(S)], and Atherosclerosis of Native Coronary Artery. Review of R2's quarterly MDS dated [DATE] revealed the BIMS was noted as 15, which indicated R2 was cognitively intact. Review of the resident record and progress notes: 11/15/2021, 9:01 p.m. At approximately 8:20 p.m. this nurse answer resident calling out for help, when entered the room this nurse observe resident hold another resident by hands. This nurse asked resident to let other resident go. This nurse removed other resident from area. This nurse asked resident what happened. Resident stated I asked her to leave my room and other resident started to hit me so I grabbed other resident hands and called for help. This nurse asked resident are you ok. Resident stated Yes I am. Director of Nursing (DON), Medical Director (MD) notified. Responsible Party (RP) unable to be reach 3x attempt also tried second contact. Contact number not a working number. [sic] Review of the progress notes revealed R1 had behavior/aggression issues prior to and after the complaint incident. 12/15/2020, 02:14 p.m. Patient in hallway nursing attempted x4 to request patient wear mask and patient refuses, patient going in other residents rooms and nursing is redirecting without success, nursing asked patient to sit in his/her room and work on his/her puzzle books and patient tossed books in floor, nursing started protocol and updated nurse practitioner (NP), new order noted will continue to observe. [sic] 04/10/2021, 08:04 a.m. 8:30 upon entering room resident in bed, in offensive position with standing over him/her. residents separated and placed in another room resident had no complaints of pain. RP, DON and NP notified. continued to monitor throughout shift, no complaint of (c/o) pain. no signs or symptoms of (s/s) distress. [sic] 04/13/2021, 10:31 p.m. Resident showed increased aggressiveness this shift, resident refused care from staff would not allow them to touch him/her. Resident paced hall and cursed at staff when they would try and redirect him/her, nursing helped patient to room, resident allowed nursing to get him/her cleaned up and dressed for bed. Patient woke after about an hour and began walking up and down the hall. Nursing gave resident snack and redirected him/her to bed. Patient is in bed resting at this time [sic] 05/30/2021, 05:58 p.m. Writer was inform that resident had a physical altercation with another resident. Resident has no injuries or bruises noted at this time. Resident was separated at this time and kept apart. RP aware. [sic] Addendum: 05/30/2021, 06:26 p.m. Resident stated I don't know what happen. Resident continues to wander hallway. Resident continues to cry this shift. Resident was offered snacks and redirected. [sic] 11/09/2021, 08:30 p.m. Resident became very aggressive this afternoon, more than usual. Resident started wandering from unit to unit and refused to be redirected. Attempts to give resident po medication failed with resident throwing medication and water cup on nurse and attempted to hit nurse several time. Resident was on [hall] when Certified Nursing Assistant [CNA] attempted to redirect him/her. At that time resident became very violent and combative and started hitting CNA with his/her fist. CNA made another attempt to redirect resident which resulted in resident punching and hitting CNA over and over. We managed to bring resident back to his/her unit ([MEDICATION(S)]) as resident continue to be combative, trying to hit other residents. NP notified of residents condition and ordered [MEDICATION(S)] 5mg. Post administration of the [MEDICATION(S)], resident calmed down and is resting quietly at the present time. Will continue follow up as needed. [sic] 11/29/2021, 12:34 p.m. Resident became very aggressive during shift, more than usual. Resident started wandering from room to room and refused to be redirected. Attempts to give resident po medication failed with resident throwing medication and water cup on nurse and attempted to hit nurse several times made contact. At that time resident became very violent and combative and started hitting this nurse with his/her fist. This nurse made another attempt to redirect resident which resulted in resident hitting at staff over and over. NP notified of residents condition and ordered [MEDICATION(S)] 50mg Intramuscularly (IM). [sic] Addendum: 11/29/2021, 12:34 p.m. IM given 50mg in right buttocks. RP notified [sic] Evidence indicated that the resident-to-resident incident involving R1 occurred due to failure to adequately monitor R1. The facility failed to reassess the resident in a timely manner and potentially add interventions to prevent an avoidable incident. An observation of R1 on 12/15/21, was made at approximately 11:34 a.m. The resident was observed in hallway tearful and pacing. The resident was not interviewable and did not respond to this surveyor with eye contact. The resident was appropriately dressed and well groomed. An interview was conducted with the Administrator on 12/14/21 at approximately 1:35 p.m. The Administrator noted that s/he came to the building in September of 2021 and is learning and changing the systems. The Administrator confirmed that R1 is a challenging resident. An interview was conducted Licensed Practical Nurse (LPN)1 on 12/15/21 at approximately 10:35 a.m. LPN1 confirmed the information contained in the record regarding R1. The nurse confirmed that R1 wanders constantly and can be combative at times and has been for the length of time that the LPN has worked in the facility. An inquiry was made regarding the method used to monitor the resident. LPN1 noted that the resident is watched by observation and redirection as well as a Wander Guard check on each shift. An interview with R2 was conducted on 12/15/21 at approximately 11:42 a.m. near the business office. The resident, seated in a wheelchair, stated that s/he was waiting for batteries for an electronic device. R2 stated that s/he was doing fine and had no concerns regarding the incident involving R1 or otherwise. The resident was appropriately dressed and well groomed. An interview with the Administrator was conducted on 12/15/21 at approximately 11:50 a.m. The Administrator stated that s/he is going to be making changes in the way that the facility runs. The Administrator confirmed that more changes will be occurring in the care for R1 in regards to monitoring.

Based on observation, interview and policy review, the facility failed to ensure resident meals were served in a timely manner to ensure the residents receiving food from the kitchen were served meals that were hot enough to be palatable. This failure had the potential to affect any of the 104 of 106 current residents that receive food from the facility kitchen. Findings include: During an interview with Resident (R)100, along with his spouse, on 11/03/21 at 2:15 PM, the couple agreed stating, food could be better. During an interview on 11/03/21 at 2:41 PM regarding food, R11 stated that he would like to have condiments with it like salt, sweet & low; and they cook the chicken tenders too hard. During an interview on 11/03/21 at 2:46 PM, R29 was asked how the food was and responded, Terrible. The turkey and ham - you can taste the fakeness in it. During the Resident Council meeting, attended by seven residents on 11/04/21 at 10:30 AM, R51 stated the only concern was the food was cold, especially breakfast. All other Resident Council attendees concurred with R51's complaint. Observation of the midday meal service on 11/05/21 at 12:50 PM showed the steam table food temperatures in the kitchen to be over 140 degrees Fahrenheit (F) and all foods were steaming hot. At 1:26 PM, Dietary Aide (DA) 4 served the last resident meal and a test tray was plated, covered with plastic wrap, and placed on the tray cart. The cart was pushed to the 400 (Dogwood) hall by DA5 at 1:30 PM. Upon arriving at the Dogwood dining room, a sign was noted on the door that stated the facility's main dining room lunch service was at 12:00 noon, the [NAME] (300) hall, Dogwood (400) hall, and [MEDICATION(S)] (500) hall lunches were at 12:30 PM. There were four people waiting in the Dogwood dining room upon the cart arrival. At 1:35 PM (11/05/21) three Nurse Aides came down to the dining room. At 1:41 PM, the first tray was removed and served to a room resident. At 2:08 PM, the last resident meal tray was served from the cart. The test tray was removed and taken directly across from the dining room door to the 400 Hall Nurses Station. The Dietary Manager (DM) performed the food temperatures: Fish 98 degrees F Broccoli 99 degrees F Mashed potatoes 100 degrees F The middle area of the breaded fish filet was taste tested by the DM and surveyor and the DM stated, Yeah, it's just warm. At 2:15 PM, a calibration test was performed on the food thermometer used during the temperature checks and found to be accurate. The DM stated the facility normally serves resident meal plates from a steam table located in each hall dining room, however, staff shortages do not allow that right now. Review of the undated facility policy titled Meal Service showed: Purpose: To ensure that residents receive meals in a timely, courteous, and helpful manner. Procedure: .2. All staff are to be available at the residents' mealtime. The staff mealtimes should be scheduled around the residents' mealtimes so all staff can be utilized 3. d. The delivery of food/meal trays to the residents in a timely manner The policy did not address the palatability/temperature of the food. Review of the undated facility policy titled Safe Food Temperatures revealed temperatures of the food while being held on the steam table but did not address the palatability/temperature of food when the resident receives the meal tray.

Based on review of facility files and interview, the facility failed to develop and implement policies and procedures that prohibit and prevent abuse. Resident #1 was found to have displaced fractures of the distal ulnar and radius after complaints of pain and stating that CNA (certified nurse aide) #1 hit him. One of three residents reviewed for abuse. The findings included: Review of the facility's Five-Day Follow-Up Report dated 7/6/18 revealed Resident #1 was sitting in the solarium and complained of severe pain to his/her left forearm on 7/3/18 at 5:33 PM. Resident #1 was noted with bruising and swelling to his/her left forearm. The resident was hitting and biting at the CNA while care was rendered and the CNA pushed the resident's arm away several times to prevent the resident from hitting him/her. The resident was sent to the emergency room for evaluation and was diagnosed with [REDACTED]. Through investigation it was not determined that CNA provided any willful intent to injure the resident. Review of the Resident Incident Report dated 7/3/18 revealed Resident #1 stated s/he was hit in the arm. LPN (licensed practical nurse) #1 observed the resident's left forearm was bruised and swollen. Review of the resident's hospital Imaging Report dated 7/3/18 revealed the resident had displaced fractures involving the distal shaft of the left radius and ulna with volar angulation of the fracture. Bones are diffusely osteopenic. Impression was displaced fractures of the distal ulnar and radius. LPN #1's facility-obtained statement dated 7/3/18 indicated Resident #1 stated to him/her that the (wo/man) hit me in the arm in my room. The resident's left forearm was swollen and bruised. In an interview with the surveyor on 7/26/18 at approximately 7:30 PM, LPN #1 stated s/he was assigned to Resident #1 on 7/3/18. CNA #2 told LPN #1 about the resident's complaint, the resident had voiced complaints to CNA #1. The resident said his/her arm hurt and it was swollen. LPN #1 went to look at the resident's arm and the resident was holding his/her left arm when LPN #1 got to the solarium. The resident's arm was swollen and bruised, the left forearm area was bruised. LPN #1 asked Resident #1 what happened and the resident said s/he hit me in my room. Dietary Staff #1's facility-obtained statement dated 7/3/18 indicated s/he heard Resident #1 tell CNA #1 to go away, you hurt me and you broke my arm. In an interview with the surveyor on 7/26/18 at approximately 7:50 PM, Dietary Staff #1 stated s/he was in the solarium dining room serving dinner. CNA #1 pushed Resident #1 into the dining room and to the table. Resident #1 told CNA #1 to get away from him/her, they hurt his/her arm. Resident #1 stated his/her arm was broken and s/he needed to go to the ER. CNA #1 tried to act like s/he didn't hear the resident, s/he started taking trays down the hall to other residents. Resident #1 usually eats in the dining room and does not usually make accusations against staff. Dietary Staff #1 stated Resident #1 looked scared. Another employee in the room went to the Nurses' station and told the nurse. CNA #3's facility-obtained statement dated 7/3/18 indicated s/he heard Resident #1 say s/he broke my arm, get away from me. RN (registered nurse) #1's facility-obtained statement dated 7/3/18 indicated on 7/3/18 at approximately 5:30 PM Resident #1 was sitting in the solarium clutching his/her left forearm. During assessment of his/her arm, bruising was noted with severe pain. Resident #1 stated that someone hit his/her arm but s/he did not know their name. RN #1 asked Resident #1 if s/he could point them out if s/he saw them and Resident #1 replied yes. The DON's (director of nursing) facility-obtained statement dated 7/4/18 indicated CNA #1 was asked to re-enact the care s/he provided for Resident #1 on 7/3/18. During the re-enactment CNA #1 demonstrated providing incontinent care for Resident #1. CNA #1 demonstrated how Resident #1 was attempting to hit and bite him/her while providing ADL (activities of daily living) care. CNA #1 demonstrated how s/he prevented Resident #1 from biting and hitting him/her by pushing the resident's arm out of the way. In an interview with surveyor on 7/26/18 at approximately 8:00 PM, the DON stated LPN #1 stopped him/her and said s/he needed to go look at Resident #1. The DON went to the solarium and Resident #1 was holding his/her arm. The resident's arm was swollen and warm to the touch. The DON asked Resident #1 what happened and s/he replied a (guy/girl) hit me. The DON asked the resident who and the resident couldn't say who. The resident stated it happened about an hour before. CNA #1 was assigned to the resident that day. The DON asked CNA #1 if anything happened while taking care of the resident. CNA #1 said s/he went to get the resident cleaned and up for dinner. The DON asked if the resident complained of pain. CNA #1 said the resident did complain of pain. CNA #1 said the resident became combative with care and was hitting and trying to bite him/her. CNA #1 was trying to calm the resident down, s/he had his/her hands up trying to keep the resident from hitting him/her. CNA #1 was telling the resident not to hit or bite him/her. CNA #1 was turning the resident from side to side, trying to clean him/her up and the resident was fighting. The DON stated staff is trained to try to reorient the resident and calm them if they become combative with care. The staff should leave the resident and get another staff member or leave and come back and try again later. The DON stated CNA #1 did not give a reason why s/he did not leave the resident and try again later. CNA #1's facility-obtained statement dated 7/4/18 indicated s/he went in to get Resident #1 up and CNA #1 was in a hurry. CNA #1 turned the resident from side to side to clean him/her up, and the resident was trying to bite and hit him/her. CNA #1 was telling the resident not to bite him/her, and pushed the resident's arm away as s/he tried to hit him/her. CNA #1 stopped Resident #1 from hitting and biting him/her several times by pushing the resident's arm away and moving out of the way. After CNA #1 got Resident #1 up, the resident was upset with him/her, so CNA #1 took the resident to the solarium for dinner. CNA #1 stated s/he did not hit the resident. Review of the facility's Abuse and Neglect Policy and Procedures revealed every resident has the right to be free from all types of abuse.

Based on review of facility files and interview, the facility failed to ensure each resident was free from abuse. Resident #1 was found to have displaced fractures of the distal ulnar and radius after complaints of pain and stating that CNA (certified nurse aide) #1 hit him. One of three residents reviewed for abuse. The findings included: Review of the facility's Five-Day Follow-Up Report dated 7/6/18 revealed Resident #1 was sitting in the solarium and complained of severe pain to his/her left forearm on 7/3/18 at 5:33 PM. Resident #1 was noted with bruising and swelling to his/her left forearm. The resident was hitting and biting at the CNA while care was rendered and the CNA pushed the resident's arm away several times to prevent the resident from hitting him/her. The resident was sent to the emergency room for evaluation and was diagnosed with [REDACTED]. Through investigation it was not determined that CNA provided any willful intent to injure the resident. Review of the Resident Incident Report dated 7/3/18 revealed Resident #1 stated s/he was hit in the arm. LPN (licensed practical nurse) #1 observed the resident's left forearm was bruised and swollen. Review of the resident's hospital Imaging Report dated 7/3/18 revealed the resident had displaced fractures involving the distal shaft of the left radius and ulna with volar angulation of the fracture. Bones are diffusely osteopenic. Impression was displaced fractures of the distal ulnar and radius. LPN #1's facility-obtained statement dated 7/3/18 indicated Resident #1 stated to him/her that the (wo/man) hit me in the arm in my room. The resident's left forearm was swollen and bruised. In an interview with the surveyor on 7/26/18 at approximately 7:30 PM, LPN #1 stated s/he was assigned to Resident #1 on 7/3/18. CNA #2 told LPN #1 about the resident's complaint, the resident had voiced complaints to CNA #1. The resident said his/her arm hurt and it was swollen. LPN #1 went to look at the resident's arm and the resident was holding his/her left arm when LPN #1 got to the solarium. The resident's arm was swollen and bruised, the left forearm area was bruised. LPN #1 asked Resident #1 what happened and the resident said s/he hit me in my room. Dietary Staff #1's facility-obtained statement dated 7/3/18 indicated s/he heard Resident #1 tell CNA #1 to go away, you hurt me and you broke my arm. In an interview with the surveyor on 7/26/18 at approximately 7:50 PM, Dietary Staff #1 stated s/he was in the solarium dining room serving dinner. CNA #1 pushed Resident #1 into the dining room and to the table. Resident #1 told CNA #1 to get away from him/her, they hurt his/her arm. Resident #1 stated his/her arm was broken and s/he needed to go to the ER. CNA #1 tried to act like s/he didn't hear the resident, s/he started taking trays down the hall to other residents. Resident #1 usually eats in the dining room and does not usually make accusations against staff. Dietary Staff #1 stated Resident #1 looked scared. Another employee in the room went to the Nurses' station and told the nurse. CNA #3's facility-obtained statement dated 7/3/18 indicated s/he heard Resident #1 say s/he broke my arm, get away from me. RN (registered nurse) #1's facility-obtained statement dated 7/3/18 indicated on 7/3/18 at approximately 5:30 PM Resident #1 was sitting in the solarium clutching his/her left forearm. During assessment of his/her arm, bruising was noted with severe pain. Resident #1 stated that someone hit his/her arm but s/he did not know their name. RN #1 asked Resident #1 if s/he could point them out if s/he saw them and Resident #1 replied yes. The DON's (director of nursing) facility-obtained statement dated 7/4/18 indicated CNA #1 was asked to re-enact the care s/he provided for Resident #1 on 7/3/18. During the re-enactment CNA #1 demonstrated providing incontinent care for Resident #1. CNA #1 demonstrated how Resident #1 was attempting to hit and bite him/her while providing ADL (activities of daily living) care. CNA #1 demonstrated how s/he prevented Resident #1 from biting and hitting him/her by pushing the resident's arm out of the way. In an interview with surveyor on 7/26/18 at approximately 8:00 PM, the DON stated LPN #1 stopped him/her and said s/he needed to go look at Resident #1. The DON went to the solarium and Resident #1 was holding his/her arm. The resident's arm was swollen and warm to the touch. The DON asked Resident #1 what happened and s/he replied a (guy/girl) hit me. The DON asked the resident who and the resident couldn't say who. The resident stated it happened about an hour before. CNA #1 was assigned to the resident that day. The DON asked CNA #1 if anything happened while taking care of the resident. CNA #1 said s/he went to get the resident cleaned and up for dinner. The DON asked if the resident complained of pain. CNA #1 said the resident did complain of pain. CNA #1 said the resident became combative with care and was hitting and trying to bite him/her. CNA #1 was trying to calm the resident down, s/he had his/her hands up trying to keep the resident from hitting him/her. CNA #1 was telling the resident not to hit or bite him/her. CNA #1 was turning the resident from side to side, trying to clean him/her up and the resident was fighting. The DON stated staff is trained to try to reorient the resident and calm them if they become combative with care. The staff should leave the resident and get another staff member or leave and come back and try again later. The DON stated CNA #1 did not give a reason why s/he did not leave the resident and try again later. CNA #1's facility-obtained statement dated 7/4/18 indicated s/he went in to get Resident #1 up and CNA #1 was in a hurry. CNA #1 turned the resident from side to side to clean him/her up, and the resident was trying to bite and hit him/her. CNA #1 was telling the resident not to bite him/her, and pushed the resident's arm away as s/he tried to hit him/her. CNA #1 stopped Resident #1 from hitting and biting him/her several times by pushing the resident's arm away and moving out of the way. After CNA #1 got Resident #1 up, the resident was upset with him/her, so CNA #1 took the resident to the solarium for dinner. CNA #1 stated s/he did not hit the resident. Review of the facility's Abuse and Neglect Policy and Procedures revealed every resident has the right to be free from all types of abuse.

Based on interview and record review, the facility failed to ensure Resident #4 was free from restraints, for 1 of 3 facility reported incidents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/20/18, an incident occurred with Resident #4 and the Certified Nursing Aide (CNA) assigned to care for him/her that evening. Cross refer to F0[AGE]0. Resident #4 had a routine per CNA #2 and Licensed Practical Nurse (LPN) #1, to propel her/himself up and down the hallway, using the handrails for momentum until the hours of 2:00 a.m., before going to bed. Based on an interview with LPN #1 on 04/20/18, Resident #4 was in the solarium with CNA#1 and her/his wheelchair brakes were noted to be in the locked position. Per LPN #1, Resident #4 was not capable of locking/unlocking the brakes of her/his wheelchair. This information was consistent with the noted Activities of Daily Living (ADL) functionality indicated on the Minimum Data Set assessment dated , 01/23/18, indicated the resident required extensive assistance for most ADLs - bathing, dressing, grooming and total dependence for eating. LPN #1 instructed the aide to unlock the resident's chair and assist her/him to the restroom. During an interview with the Director of Nursing (DON), s/he stated the resident did not have any restraints in place and therefore would have no restraint assessments.

Based on record review and provided surveillance, the facility failed to ensure established policies were implemented and appropriate interventions were initiated and implemented to prevent the verbal abuse of Resident # 4, for 1 of 3 facility reported incidents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Based on the information provided on the complaint intake form in the facility's investigative file, the behavior of Resident #4 occurred often enough that it was common knowledge to the night staff that s/he would propel her/his self through the hallways and then be assisted to bed at a later hour. Review of the resident's comprehensive care plan failed to reflect the behavior deemed common knowledge or any appropriate interventions. A video was recorded by CNA (Certified Nursing Aide) #2 and was shown to Registered Nurse (RN) #1 on 02/20/18 at approximately 7:00 a.m. The identity of the persons in the recording was confirmed by both CNA #2 and LPN (Licensed Practical Nurse) #1 by admission in their provided statements. A copy of the recording was provided for review by the facility's Administrator. The video which is 2 minutes and 38 seconds in length shows 2 persons, identified as Resident #4 and CNA #1. In the video, the person identified as CNA #1 can be heard at 0:03 stating, Stop hitting me! Will you stop? That is not okay for you to put your hands on me. The person identified as the Resident was noted to be attempting to stand at approximately 0:30. At 1:24, the Resident is observed standing and the CNA stated, Sit down, baby, please. You need to, you're going to hurt yourself. Why are you being so angry tonight? What's up? At 1:40, a noted inflection in CNA #1's voice stating, Sit down! You are something else. The resident is then observed hitting the aide, to which s/he replied, Stop hitting me, I'm for real. You need to sit down. At approximately 1:55, LPN #1 enters the frame and asks what is going on. The aide replied in a louder tone than previously noted, S/he jumping up and hitting me up in here! Both staff members attempted to get the resident to stay seated. At 2:16, the aide stated, Oh, why you ain't hit me that time? Show him/her what you been in here doing! LPN #1 is then heard telling the resident not to hit CNA #1, You know s/he can call the police. The resident is then asked if s/he needed to use the restroom and the recording ends. During the duration of the recording the proximity of CNA #1 and Resident #4 does not change. The CNA remained seated the duration of the recording. Review of the facility's policy entitled, Pepper Hill Nursing and Rehab Center, LLC Resident Abuse and Neglect Policy and Procedures on 03/28/18 at 9:14 a.m. revealed the definition of 'Verbal Abuse'. Verbal abuse includes using spoken, written or gestured language that includes insulting, offensive or disapproving terms to any resident. The recording was provided to the authorities and administration. The facility provided the contact information for the staff members identified in the incident, as well as the staff member responsible for providing the recording. During a phone interview with LPN #1 on 04/20/18, s/he stated s/he recalled the incident between Resident #4 and CNA #1. Per LPN #1, as s/he was signing in the narcotics from the pharmacy, the television was heard to be very loud in the solarium. It was at that time s/he noted CNA #1 was speaking inappropriately to the resident. LPN #1 stated s/he instructed the aide to assist the resident to the restroom and there were no other concerns for the remainder of the evening. Interviews with the Director of Nursing and RN #1, the unit manager, revealed the facility's investigation substantiated the allegation and resulted in the termination of CNA#1.

Based on review of record review and interviews, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. Resident #1 fell while being transferred by a Certified Nurse Aide (CNA). The Certified Nurse Aide did not use a gait belt per the resident's care plan and facility policy. Resident #1 received a laceration to the head as a result of the fall. One of one resident reviewed for a reportable incident. The findings included: The facility submitted a reportable incident to the State Agency for Resident #1. Review of the facility's Five-Day Follow-Up Report dated 10/22/14 indicated CNA #1 transferred the resident without a gait belt. The resident resisted care, jerked backwards and fell hitting the back of his/her head, causing a laceration. Review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status (BIMS) score of 3. The Quarterly MDS dated [DATE] coded Resident #1 as having a BIMS score of 0. The Quarterly MDS coded Resident #1 as requiring extensive assistance for transfers with no behaviors coded as occurring during the assessment period. Review of the Nursing Assistant Report Sheet for Resident #1 revealed s/he required 1 person assistance and a gait belt for transfers. Review of the Emergency Department report dated 10/17/14 revealed Resident #1 had a laceration on his/her scalp that was 4 centimeters in length. The report indicated the resident fell during an assisted transfer and hit his/her head. Resident #1 received two staples to close the laceration. Review of the Resident Incident Report dated 10/17/14 for Resident #1 revealed that after morning Activities of Daily Living care staff stood the resident to assist him/her to the wheelchair. Upon standing the resident began to pull back and fell to the right causing a laceration to the back right side of his/her head. CNA #1 was listed as the only witness. Licensed Practical Nurse (LPN) #1's facility-obtained statement indicated s/he was called to Resident #1's room by staff and was asked to bring the vital sign machine. As s/he entered the room, Resident #1 was on the floor and blood was coming from his/her head. LPN #1 asked what happened and was told that CNA #1 stood the resident to pull up his/her pants. After pulling up the resident's pants the resident was instructed to sit in the wheelchair but the resident began to pull back and fell to the floor. There was no gait belt present. In a telephone interview with the surveyor on 11/25/14 at approximately 2:17 PM, the Director of Nursing stated that CNA #1 admitted s/he knew s/he needed a gait belt to transfer Resident #1. CNA #1 signed the facility's Gait Belt Policy form that indicated wearing a gait belt is a mandatory issue for all Certified Nursing Assistants. The facility's Safe Resident Handling and Movement Policy was reviewed. The policy indicated that gait/transfer belts would be used where manual assistance is required for ambulation and transfer activities.

Based on record review and interview, the facility failed to follow the plan of care for Resident # 1 related to the use of assistive devices to prevent accidents. Resident #1 fell while being transferred by a Certified Nurse Aide (CNA). The Certified Nurse Aide (CNA) did not use a gait belt per the resident's care plan. One of one resident reviewed for falls. The findings included: The facility submitted a reportable incident to the State Agency for Resident #1. Review of the facility's Five-Day Follow-Up Report indicated Certified Nurse Aide (CNA) #1 transferred Resident #1 without a gait belt. The resident resisted care, jerked backwards and fell hitting the back of his/her head, causing a laceration. Review of the Resident Incident Report dated 10/17/14 for Resident #1 revealed that after morning ADL (Activities of Daily Living) care staff stood the resident to assist him/her to the wheelchair. Upon standing the resident fell and was injured. Review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status (BIMS) score of 3. The Quarterly MDS dated [DATE] coded Resident #1 as having a BIMS score of 0. The Quarterly MDS coded Resident #1 as requiring extensive assistance for transfers with no behaviors coded as occurring during the assessment period. Review of the Care Plan initiated 4/1/14 for Resident #1 identified a risk for falls with interventions that included "assist Resident with one staff member for all ambulation". The facility "Safe Resident Handling and Movement Policy" stated, "...Gait/Transfer belts will be used where manuel assistance is required for ambulation and transfer activities..." Review of the Nursing Assistant Report Sheet (care plan) updated 9/12/14 for Resident #1 revealed s/he required 1 person assistance and a gait belt for transfers. In a telephone interview with the surveyor on 11/25/14 at approximately 2:17 PM, the Director of Nursing stated that CNA #1 admitted s/he knew s/he needed a gait belt to transfer Resident #1.

On the days of the Recertification and Complaint Survey, based on full and/or limited record reviews, interviews, review of the policy provided by the facility entitled "General Wound Guidelines for Pressure Ulcers", and review of Advisory Opinion #46 from the South Carolina Department of Labor, Licensing, and Regulation; the facility failed to provide appropriate care and treatment for 2 of 5 sampled residents reviewed with Pressure Ulcers, Resident #22 and Resident #8. Resident #22 developed a sacral pressure ulcer after admission to the facility which worsened and became infected. The facility nursing staff did not notify the Physician timely or change the ordered treatment in response to the deterioration of the wound. There was no documentation that the Physician had been notified of new wounds that had developed to the right buttock and left hip on [DATE] and [DATE]. The wound treatment nurse who was a Licensed Practical Nurse (LPN), did not have the oversight of a Registered Nurse (RN) and was staging wounds and developing treatment plans. Wound Assessment Reports were not documented timely. There was conflicting information between the body audit documentation and the Wound Assessment Reports as to when the sacral wound had first been identified. The sacral wound had been documented by the treatment nurse as having been identified on [DATE]; but there was no treatment orders implemented until [DATE]. The Admission Minimum Data Set (MDS) skin assessment was not accurate and indicated the pressure ulcer was inherited rather than acquired by the facility. The findings included: The facility admitted Resident #22 on [DATE] with [DIAGNOSES REDACTED]., and [MEDICAL CONDITION]. A review of the facility's Discharge Summary dated [DATE] revealed Resident #22 had been sent to the ER (emergency room ) due to a decreased level of consciousness; was admitted on [DATE]; and had a decline in condition at the hospital and expired on [DATE]. The resident's care was reviewed as part of a closed record review. Record review on [DATE] at 3:18 PM revealed a Hospital Admission History and Physical dated [DATE] which documented the resident was admitted [MEDICAL CONDITION] and a grossly infected necrotic sacral decubiti, stage IV. According to the report, the resident's [MEDICATION NAME] level was low at 1.5, and his/her White Blood Cell count was elevated at 24,000. After discussion with the resident's family, surgical intervention for the wound was ruled out, and comfort care measures were implemented. A review of facility obtained lab results dated [DATE] revealed the resident's [MEDICATION NAME] level and White Blood Cell count were within normal limits. Resident #22 had an [MEDICATION NAME] level of 3.5 on [DATE], with the normal range documented as being between 3.5 and 5.0. His/Her White Blood Cell Count was 6.8, with the normal range documented as being between 3.5 and 11.0. A review of Nutrition documentation revealed a note dated [DATE] in which the Registered Dietician (RD) documented increased needs related to wound healing relative to a stage 2 Pressure Ulcer on the Sacrum. The RD recommended [MEDICATION NAME] 125 ml twice daily to help stabilize weight and promote healing. According to the assessment, the resident's protein stores were within normal limits and the goal was to maintain weight without any significant changes and heal the wound. A physician's orders [REDACTED]. A review of the Admission MDS Assessment with an Assessment Reference Date of [DATE] revealed Resident #22 had been coded as having long term and short term memory problems. The resident had been coded as having been totally dependent on staff for bed mobility with one person physical assist and totally dependent for transfers with two plus persons physical assist; with impairment of his/her upper and lower extremities on one side. The resident had been coded as having been always incontinent. According to the assessment, the resident had (1) stage 2 pressure ulcer on admission (granulation tissue) with the date of the oldest pressure ulcer documented as of [DATE]. A review on [DATE] at 3:55 PM of skin evaluations revealed an admission body audit dated [DATE] that documented there were no pressure ulcers or wound concerns on admission; just some discoloration to the hand and dryness noted to the resident's shins. A body audit done [DATE] revealed nothing to indicate the resident had a pressure ulcer to the sacrum. On [DATE], the body audit documented the presence of a sacral wound. A body audit dated [DATE] documented a "skin tear" to the sacral area and indicated there were no pressure ulcers. A review on [DATE] at 3:25 PM of Admission Physician order [REDACTED]. A review on [DATE] at 4:02 PM of weekly Wound Assessment Reports from [DATE] through [DATE] revealed some reports had been electronically signed by the treatment nurse on [DATE] and some had been signed on [DATE]. During an interview on [DATE] at 9:30 AM, LPN #3 (the treatment nurse) verified s/he had documented the reports late because s/he had been running behind on the documentation. According to the [DATE] Wound Assessment Report, there was an unstageable wound (due to suspected deep tissue injury) noted on the sacrum that measured 1.5 cm x 2.0 cm. This was a new wound, not present on admission. The "Notes" section included information that on [DATE], there was an open wound on the sacrum noted to be pink in color with scant drainage. The treatment for [REDACTED]. According to the report, the RP (Responsible Party) had been notified on [DATE] and the Physician notified on [DATE] of this new wound. A review of Physician order [REDACTED]. The first mention of a sacral wound was a Telephone Order dated [DATE] that said to apply [MEDICATION NAME] every 3 days to a skin tear on the sacrum until resolved. Further review revealed Telephone Orders dated [DATE] and [DATE] indicating the wound was a pressure ulcer. These orders changed the treatment from the [MEDICATION NAME] to the use of [MEDICATION NAME] thin on shower days (after cleaning the wound with Normal Saline). A Wound Assessment Report dated [DATE] revealed a Stage 2 to the sacrum; wound status- unchanged, which measured 1.5 cm x 2 cm x 0.2 cm with a small amount of serous drainage. The wound bed was noted to be 100% granulation tissue. The "Notes" section included information that on [DATE], the open wound on the sacrum was pink with scant drainage and the treatment was to apply [MEDICATION NAME] thin on shower days; turn side to side; and follow the progress. The documentation indicated the RP and Physician had been notified on [DATE]. A Wound Assessment Report dated [DATE] documented the wound status had deteriorated; with the sacral wound now measuring 4.3 cm x 4.0 cm 0.2 cm. The wound was unstageable due to slough/eschar and had a small amount of serous drainage. The wound bed was composed of 50% granulation tissue and 50% slough. The "Notes" section included information that on [DATE], the resident had been placed on an air mattress and a foley catheter had also been placed for wound healing. The treatment had been changed from [MEDICATION NAME] thin to ,[DATE] [MEDICATION NAME] gauze, foam, and a repel dressing. According to the report, the RP had been notified of this change on [DATE] and the Physician had been notified on [DATE]. A Wound Assessment Report dated [DATE] documented the wound status had deteriorated; was unstageable due to slough/eschar with a moderate amount of serous drainage and measured 5.5 cm x 5.5 cm and was 100% slough. The "Notes" section did not include any updated information related to the wound. According to the report, the RP had been notified on [DATE] and the Physician had been notified on [DATE]. A Telephone Order dated [DATE] stated, "Clarification order: Cleanse pressure ulcer on Sacrum (with) NS, apply 3 x 3 [MEDICATION NAME] gauze, 4 x 4 foam dressing, 6 x 6 repel daily." A Wound Assessment Report dated [DATE] revealed the wound on the Sacrum had deteriorated; was unstageable due to slough/eschar with a large amount of serous drainage and measured 5.5 cm x 8.5 cm. "Symptoms of Infection" included increased pain, increased drainage, and malodorous or purulent drainage. The wound bed had 25 % granulation tissue and 75% slough. The resident's average meal intake had decreased. The "Notes" section included information that the resident had been admitted to the hospital on [DATE]. According to the report, the RP and the Physician had been notified on [DATE]. A review of Physician order [REDACTED]. There were two additional Wound Assessment Reports dated [DATE]. One of the assessments identified a left hip pressure ulcer on [DATE] and indicated this was a new wound not present on admission. The report documented the wound was a Stage 2 with scant serous drainage measuring 0.5 cm x 1.5 cm x .1 cm with 100% granulation tissue in the wound bed. The "Notes" section included information that on [DATE], a small open wound was noted on the left hip, wound bed pink. The treatment was to apply [MEDICATION NAME] thin on shower days. A physician's orders [REDACTED]. According to the report, the RP and MD was notified on [DATE]. The second Wound Assessment Report dated [DATE] documented a new pressure ulcer to the right buttock identified on [DATE]. This wound was unstageable due to 100% eschar and measured 9.5 cm x 3.4 cm. According to the report, the wound was infected with no drainage but increased pain and [DIAGNOSES REDACTED] was noted (with the surrounding skin being red and indurated). The "Notes" section included information that on [DATE], while dressing the sacral wound, the treatment nurse noticed a large area of eschar on the right buttock with bright redness noted on the periwound which was blanching, and tender to touch. Dermadrox was ordered to be applied every shift. According to the report, the RP and MD had been notified on [DATE]. A review of facility Departmental Notes revealed a late entry dated [DATE] at 11:13 AM. The Wound Assessment Note had been documented by LPN #3, and was a late note for [DATE] and stated, "This writer noted wound on sacrum to be showing signs of possible infection. This writer notified DON (Director of Nursing). DON evaluated wound and was going to notify Physician to get orders. Resident was sent out to (hospital) before orders were received." During an interview on [DATE] at 9:15 AM, LPN #3 reviewed the Wound Assessment Reports, Physician Orders, and Body Audit documentation with the surveyor. When asked about the Wound Assessment Report dated [DATE], LPN #3 stated that the date of the assessment was the date s/he had measured the wound. LPN #3 stated that when s/he saw the sacral wound, the wound was not open but probably purple in color like a suspected deep tissue injury. When asked about the conflicting information in the "Notes" section that indicated the wound was open at the time and a stage 2, LPN #3 verified this was her/his note and said it may have been open, but that s/he was not sure how far the deep tissue injury extended. LPN #3 verified the documentation indicated the wound had been identified on [DATE]; but that no orders had been written until [DATE] by the night shift nurse relative to a treatment for [REDACTED]. LPN #3 stated the night shift nurse had incorrectly identified the pressure ulcer as a skin tear. According to LPN #3, s/he would have to look in the computer and check the orders since s/he may have forgotten to write an order for [REDACTED]. When asked about how s/he had notified the Physician about the wound, LPN #3 stated that s/he left communication notes for the doctor who came in every Tuesday and Thursday or that s/he verbally relayed this information to the nurse working with the doctor who would then inform the doctor of any changes. LPN #3 thought the Physician may have been notified of the sacral wound that developed [DATE] when s/he came in on [DATE] but was not sure. LPN #3 was unsure why all the body diagrams on the Wound Assessment Reports indicated not only a pressure to the sacrum but to the left and right hip areas also. When asked about the documentation on the [DATE] Wound Assessment Report indicating the Physician had been notified on [DATE], LPN #3 stated that s/he didn't notify the Physician every week, and that as long as the wound did not worsen there was not any communication. LPN #3 stated the Physician had initially been notified of the wound on [DATE]. According to LPN #3, the date the Physician was notified would stay the same until it was changed in the system. When asked about the [DATE] Wound Assessment report that documented the sacral wound had deteriorated, LPN #3 verified the documentation indicated the date the Physician had been notified had not been changed and still contained the previous notification date of [DATE]. LPN #3 verified the documentation on the [DATE] Wound Assessment report that documented the wound had deteriorated. According to LPN #3, the Physician had not been notified until [DATE] when s/he believed the Physician would have come in. LPN #3 couldn't say for sure whether the worsening of the wound had been communicated to the Physician by a Communication sheet or by verbally reporting this information to the nurse. LPN #3 stated s/he would not have called the Physician her/himself. When asked about the change in the treatment order on [DATE], LPN #3 verified the type of wound treatment had not changed, just the size of the dressings since the wound had gotten larger and the 4 x 4 foam would absorb more drainage. After reviewing the [DATE] Wound Assessment Reports, LPN #3 verified the wound documentation and stated that when you have dead tissue, it smells and had been getting more odorous. LPN #3 also verified the documentation indicated the resident was eating less and stated that s/he obtained this information by asking the nurses. When asked about the documentation indicating the Physician had been notified on [DATE], LPN #3 stated s/he had let the DON know about the sacral wound infection and deterioration along with the eschar on the right buttock, s/he believed this was on [DATE]. When asked why s/he hadn't called the Physician her/himself, LPN #3 stated the DON was the one who would communicate with or contact the Physician. When asked if s/he ever called the doctor related to any treatment changes, LPN #3 stated that since the doctor came in twice a week s/he just communicated with communication slips. LPN #3 was asked if s/he had filled out a communication slip on [DATE] related to the new wound on the right buttock. LPN #3 was not sure if this had been done and stated that s/he was unsure if the doctor was made aware of the new wound on [DATE]. According to LPN #3, s/he had not noticed any concerns with the right buttock before and s/he was unsure if any of the nursing staff had noticed it. LPN #3 stated the eschar just appeared. When asked, LPN #3 verified that CNAs do his daily care and help to turn the resident, but s/he didn't know if they saw the eschar there and just didn't say anything. LPN #3 verified the right buttock wound measured 9.5 cm x 3.4 cm. LPN #3 was not sure if the doctor had been notified on [DATE] of the new Stage 2 ulcer to the left hip. During an interview on [DATE] at 10:55 AM, the DON was asked about the late entry note dated [DATE] and stated that LPN #3 had spoken with her/him on [DATE] about the worsening sacral wound and the new wounds that had popped up overnight; and that s/he had gone with LPN #3 to observe the wounds. According to the DON, the doctor was going to be in later that day but the resident went out to the hospital before the wound information could be communicated to him/her. A review of the facility Physician's Initial Evaluation dated [DATE] and Progress Notes for [DATE] revealed nothing documented about any wounds for Resident #22. Two Physician Communication Forms dated [DATE] and [DATE] were provided to the surveyor upon request. The Communication form dated [DATE] included information that the Pressure ulcer to the sacrum was 50% [MEDICATION NAME] and 50% pink and included the current treatment of [REDACTED]. There was nothing on the Communication form to indicate the wound had gotten larger; from 1.5 cm x 2 cm x 0.2 cm on [DATE], to 4.3 cm x 4 cm x 0.2 cm on [DATE]. The Communication form dated [DATE] included inconsistent information related to the wound bed. On the communication form, the wound was noted to be 50% slough/necrotic and 50% pink tissue with [MEDICATION NAME]; however, the Wound Assessment report dated [DATE] indicated the wound bed was 100% slough. The measurements of the wound were given- 5.5 cm x 5.5 cm and it was noted the wound had a slight odor; but there was no indication from the communication form that the wound had gotten larger from the previous measurements on [DATE]. During an interview on [DATE] at 8:25 AM, the resident's Physician reviewed the resident's Initial Evaluation dated [DATE] along with the discharge note and hospital admission information. The Physician was told of the concerns about the wound treatment and was asked about the notification process for wound changes. According to the Physician, s/he comes in 3 times a week to the facility. If there are any concerns or questions, s/he would go and assess the resident to talk to the resident face to face to try to get the whole story. When asked if s/he would document these encounters or concerns, the Physician stated that 90% of the time, s/he would document something in a Progress note. When asked specifically about any documentation relative to any wound assessments or concerns that s/he may have been made aware of (since there were no Physician notes in the closed chart relative to any wounds); the Physician stated that the facility staff would have to be asked to provide any other documentation that may not be in the record. When presented with the Physician Communication Forms dated [DATE] and [DATE], the Physician was unsure if s/he had seen them before because if s/he had seen them and assessed the resident, s/he probably would have written a note. According to the Physician, the facility staff are very involved in each resident's care. The Physician stated that there are multiple contributing factors in each scenario and that only part of the whole picture may have been depicted in the the hospital note. The Physician stated that it would be difficult to determine the effectiveness other measures like antibiotic therapy or debridement would have had on the situation. On [DATE], the DON was asked for any additional physician progress notes [REDACTED]. During an interview on [DATE] at 11:42 AM, LPN #3 (the treatment nurse) stated that s/he staged the wounds; and went into detail about how s/he staged the wounds depending on what layers of the skin were affected. LPN #3 also discussed briefly how s/he determined which wounds required what treatments. When asked if anyone else signed off on her/his work or staged/measured the wounds, LPN #3 stated that s/he did this her/himself. According to LPN #3, if other nurses staged the wounds, their would be discrepancies. According to LPN #3, s/he has had no formal wound training except for seminars and inservices that s/he attends; some of which go over wound staging. A review of the facility's "General Wound Care Guidelines for Pressure Ulcers" revealed information that "...Nurses do not stage (Tx Nurse Only)...". A review of information from the South Carolina Board of Nursing (LLR), Advisory Opinion #46, dated [DATE] and reviewed [DATE], revealed "Is it within the role and scope of responsibilities of the licensed practical nurse (LPN) to evaluate and/or stage vascular, diabetic, or pressure ulcer?" The opinion of the Board of Nursing was that "The LPN may collect health care data related to vascular, diabetic, and/or pressure ulcer(s) in order to assist with classifying or staging. However, the analysis and synthesis of clinical information and the formulation of problem statements, nursing [DIAGNOSES REDACTED]. It is recommended that agencies develop and implement written policies and guidelines requiring assessment and frequent reassessment by the RN. This statement is an advisory opinion of the South Carolina Board of Nursing as to what constitutes competent and safe nursing practice." The facility admitted Resident #8 with [DIAGNOSES REDACTED]. On [DATE] at 4:30 p.m., the Wound Care Nurse was observed providing wound care to Resident #8. After washing her/his hands and donning gloves, nurse patted the wound with a normal saline soaked 2 x 2 gauze. The Wound Care Nurse proceeded to pat back and forth from the peri-wound and wound bed 6 times with the same gauze. The nurse discarded the gauze and obtained a second 2 x 2 gauze and patted first the wound bed, then the peri-wound and then the wound again. The Nurse then covered Resident #8 with the bed linens while s/he removed the gloves, washed her/his hands and donned clean gloves. The Nurse then removed the resident's bed linens and applied the clean dressing to the wound. During an interview at 4:38 p.m., the Wound Care Nurse confirmed the above findings and stated she/he should have used one continuous motion from the center outward and then discarded the gauze. On [DATE] at 10:45 a.m., review of the facility's policy entitled Dressing Change, in the section labeled Procedure, revealed "9. Clean the wound with 4 x 4's and normal saline (N/S)." There were no instructions in the policy related to not contaminating the wound by using the same gauze on both the peri-wound and the wound bed.

On the days of the Recertification and Complaint Survey, based on full and/or limited record reviews and interviews, the facility failed to notify the Physician and/ or Responsible Party (RP) timely for changes in condition and/or planned treatment for 1 of 5 sampled residents reviewed for Pressure Ulcers and 1 of 3 sampled residents reviewed with Urinary Tract Infections. The facility failed to notify the Physician timely of a worsening sacral wound for Resident #22. The Physician for Resident #23 was not notified timely of a Urinalysis/Culture result on [DATE] which resulted in a delay in treatment. The RP for Resident #23 was not notified timely of the orders to obtain the Urinalysis and Culture on [DATE]. Cross Refer to F-314 related to the treatment of [REDACTED]. The findings included: The facility admitted Resident #22 on [DATE] with [DIAGNOSES REDACTED]., and [MEDICAL CONDITION]. A review of the facility's Discharge Summary dated [DATE] revealed Resident #22 had been sent to the ER (emergency room ) due to a decreased level of consciousness; was admitted on [DATE] and had a decline in condition at the hospital and expired on [DATE]. The resident's care was reviewed as part of a closed record review. Resident #22 developed a sacral pressure ulcer after admission to the facility which worsened and became infected. The facility nursing staff did not notify the Physician timely or change the ordered treatment in response to the deterioration of the wound. The treatment nurse was unsure whether the Physician had been notified of new wounds that had developed to the right buttock and left hip on [DATE] and [DATE]. A review of the Hospital's Admission History and Physical dated [DATE] revealed the resident was admitted [MEDICAL CONDITION] and a grossly infected necrotic sacral decubiti, stage IV. A review of Wound Assessment Reports for Resident #22 on [DATE] at 4:02 PM revealed the following: A Wound Assessment Report dated [DATE] documented an unstageable wound (due to suspected deep tissue injury) on the sacrum that measured 1.5 cm x 2.0 cm. This was a new wound, not present on admission. According to the report, the RP (Responsible Party) had been notified on [DATE] and the Physician notified on [DATE] of this new wound. A Wound Assessment Report dated [DATE] revealed a Stage 2 to the sacrum; wound status- unchanged, and measured 1.5 cm x 2 cm x 0.2 cm with a small amount of serous drainage. The wound bed was noted to be 100% granulation tissue. The documentation indicated the RP and Physician had been notified on [DATE]. A Wound Assessment Report dated [DATE] documented the wound status had deteriorated; with the sacral wound now measuring 4.3 cm x 4.0 cm 0.2 cm. The wound was unstageable due to slough/eschar and had a small amount of serous drainage. The wound bed was composed of 50% granulation tissue and 50% slough. According to the report, the RP had been notified of this change on [DATE] and the Physician had been notified on [DATE]. A Wound Assessment Report dated [DATE] documented the wound status had deteriorated; was unstageable due to slough/eschar with a moderate amount of serous drainage and measured 5.5 cm x 5.5 cm and was 100% slough. According to the report, the RP had been notified on [DATE] and the Physician had been notified on [DATE]. A Wound Assessment Report dated [DATE] revealed the wound on the Sacrum had deteriorated; was unstageable due to slough/eschar with a large amount of serous drainage and measured 5.5 cm x 8.5 cm. "Symptoms of Infection" included increased pain, increased drainage, and malodorous or purulent drainage. The wound bed had 25 % granulation tissue and 75% slough. The resident's average meal intake had decreased. According to the report, the RP and the Physician had been notified on [DATE]. A review of Physician order [REDACTED]. There were two additional Wound Assessment Reports dated [DATE]. One of the assessments identified a left hip pressure ulcer on [DATE] and indicated this was a new wound not present on admission. The report documented the wound was a Stage 2 with scant serous drainage measuring 0.5 cm x 1.5 cm x .1 cm with 100% granulation tissue in the wound bed. According to the report, the RP and MD were notified on [DATE]. The second Wound Assessment Report dated [DATE] documented a new pressure ulcer to the right buttock identified on [DATE]. This wound was unstageable due to 100% eschar and measured 9.5 cm x 3.4 cm. According to the report, the wound was infected with no drainage but increased pain and [DIAGNOSES REDACTED] was noted (with the surrounding skin being red and indurated). According to the report, the RP and MD had been notified on [DATE]. A review of facility Departmental Notes revealed a late entry dated [DATE] at 11:13 AM. The Wound Assessment Note had been documented by LPN #3, and was a late note for [DATE]. "This writer noted wound on sacrum to be showing signs of possible infection. This writer notified DON (Director of Nursing). DON evaluated wound and was going to notify Physician to get orders. Resident was sent out to (hospital) before orders were received." During an interview on [DATE] at 9:15 AM, LPN #3 reviewed the Wound Assessment Reports and other documentation pertaining to wounds with the surveyor. According to LPN #3, the resident's Responsible Party was at the facility frequently to visit and s/he would notify the RP of any wound changes when s/he saw her/him. When asked about how s/he had notified the Physician about the wound, LPN #3 stated that s/he had left communication notes for the doctor who came in every Tuesday and Thursday or that s/he verbally relayed this information to the nurse working with the doctor who would then inform the doctor of any changes. LPN #3 thought the Physician may have been notified of the sacral wound that developed [DATE] when the doctor came in for rounds on [DATE], but was not sure. When asked about the documentation on the [DATE] Wound Assessment Report indicating the Physician had been notified on [DATE], LPN #3 stated that s/he didn't notify the Physician every week, and that as long as the wound did not worsen there was not any communication. LPN #3 stated the Physician had initially been notified of the wound on [DATE]. According to LPN #3, the date the Physician was notified would stay the same on the report until it was changed in the system. When asked about the [DATE] Wound Assessment report that documented the sacral wound had deteriorated; LPN #3 verified the documentation indicated the date the Physician had been notified had not been changed and still contained the previous notification date of [DATE]. LPN #3 verified the documentation on the [DATE] Wound Assessment report that documented the wound had deteriorated. According to LPN #3, the Physician had not been notified until [DATE] when s/he believed the Physician would have come in. LPN #3 couldn't say for sure whether the worsening of the wound had been communicated to the Physician by a Communication sheet or by verbally reporting this information to the nurse. LPN #3 stated s/he would not have called the Physician her/himself. After reviewing the [DATE] Wound Assessment Reports, LPN #3 verified the wound documentation and stated that when you have dead tissue, it smells and the wound had been getting more odorous. LPN #3 also verified the documentation indicated the resident was eating less and stated that s/he obtained this information by asking the nurses. When asked about the documentation indicating the Physician had been notified on [DATE], LPN #3 stated s/he had let the DON know about the sacral wound infection and deterioration along with the eschar on the right buttock; s/he believed this occurred on [DATE]. When asked why s/he hadn't called the Physician her/himself, LPN #3 stated the DON was the one who would communicate with or contact the Physician. When asked if s/he ever called the doctor related to any treatment changes, LPN #3 stated that since the doctor came in twice a week, s/he just communicated with communication slips. During an interview on [DATE] at 10:55 AM, the DON was asked about the late entry note dated [DATE] and stated that LPN #3 had spoken with her/him on [DATE] about the worsening sacral wound and the new wounds that had popped up overnight; and that s/he had gone with LPN #3 to observe the wounds. According to the DON, the doctor was going to be in later that day but the resident went out to the hospital before the wound information could be communicated to him/her. LPN #3 was asked if s/he had filled out a communication slip on [DATE] related to the new wound on the right buttock. LPN #3 was not sure if this had been done and stated that s/he was unsure if the doctor had been made aware of the new wound on [DATE]. LPN #3 was not sure if the doctor had been notified on [DATE] of the new Stage 2 ulcer to the left hip. A review of the facility Physician's Initial Evaluation (Admission History and Physical) dated [DATE] and Progress Notes for [DATE] revealed no documentation concerning wounds for Resident #22. The surveyor requested any Communication slips that had been filled out about the resident's wounds, and was provided with two Physician Communication Forms dated [DATE] and [DATE]. The Communication form dated [DATE] included information that the Pressure ulcer to the sacrum was 50% [MEDICATION NAME] and 50% pink and included the current treatment of [REDACTED]. The Communication included information that the resident had a foley catheter for wound healing. There was nothing on the Communication form to indicate the wound had gotten larger; from 1.5 cm x 2 cm x 0.2 cm on [DATE], to 4.3 cm x 4 cm x 0.2 cm on [DATE]. The Communication form dated [DATE] included inconsistent information about the assessment of the wound bed. On the communication form, the wound was noted to be 50% slough/necrotic and 50% pink tissue with [MEDICATION NAME] (on [DATE]); however, the Wound Assessment report dated [DATE] indicated the wound bed was 100% slough. The measurements of the wound were given- 5.5 cm x 5.5 cm and it was noted the wound had a slight odor; but there was no indication from the communication form that the wound had gotten larger from the previous measurements on [DATE]. During an interview on [DATE] at 8:25 AM, the resident's Physician reviewed the resident's Initial Evaluation dated [DATE] along with the facility discharge note and hospital admission information. The Physician was told of the concerns about the wound treatment and was asked about the notification process for wound changes. According to the Physician, s/he comes in 3 times a week to the facility. If there are any concerns or questions, s/he would go and assess the resident and/or talk to the resident face to face to try to get the whole story. When asked if s/he would document these encounters or concerns, the Physician stated that 90% of the time, s/he would document something in a Progress note. When asked specifically about any documentation relative to any wound assessments or wound concerns that s/he may have been made aware of for Resident #22, (since there were no Physician notes in the closed chart relative to any wounds); the Physician stated that the facility staff would have to be asked to provide any other documentation that may not be in the record. When presented with the Physician Communication Forms dated [DATE] and [DATE], the Physician was unsure if s/he had seen them before because if s/he had seen them and assessed the resident, s/he probably would have written a note. On [DATE], the DON was asked for any additional physician progress notes [REDACTED]. None were provided prior to exit. The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Resident #23 was sent out to the hospital on [DATE] and the record was reviewed as part of a closed record review. Record review on [DATE] at approximately 4:00 PM revealed a Physician's Telephone Order dated [DATE] at 3:00 PM for a Urinalysis and Culture and Sensitivity. The box to notify the family of the above treatment change had not been checked and there was nothing on the order to indicate the family had been made aware of this information. During an interview on [DATE], RN #2 verified there was nothing in the nursing notes or on the Telephone Order to indicate the RP had been notified. A Nurse's Note dated [DATE] at 6:48 PM documented that the previous shift had obtained a urine sample that was in the refrigerator awaiting lab pickup. Another Nurse's Note dated [DATE] at 9:06 AM documented that a Urinalysis and Culture had been done and a message left for the RP. The RP had not been notified of the need for a Urine test for approximately 2 ,[DATE] days. A review on [DATE] at approximately 3:50 PM of lab results and Physician order [REDACTED]. A Urinalysis/Culture report dated [DATE] documented 1+ bacteria along with a colony count of 70,000 [DIAGNOSES REDACTED] Pneumoniae. According to documentation on the lab report, this information had been reported on [DATE]. There was nothing on the lab report to indicate when the Physician may have been notified. A Physician's Telephone Order dated [DATE] revealed an order to start [MEDICATION NAME] DS (Organism documented as being Sensitive to this antibiotic), one tablet twice daily for 7 days. According to documentation on the Telephone Order, the RP had been notified of the new order for the antibiotic. A review of the Medication Administration Record [REDACTED]. During an interview on [DATE] at approximately 3:00 PM, the DON was informed of the surveyor's concern about the delay in starting the antibiotic treatment for [REDACTED].

On the days of the survey, based on record review, interview, and review of the policy provided by the facility entitled "[MEDICATION NAME] Therapy", nursing staff failed to monitor anticoagulant therapy appropriately for Resident #2, one of eight sampled residents reviewed with [MEDICATION NAME] (anticoagulant) therapy. The findings included: The facility admitted Resident #2 on 3/24/03 and readmitted her on 10/27/10 with [DIAGNOSES REDACTED]. Record review on 7/12/11 at 9:30 AM of the July 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. [MEDICATION NAME] 3 mg had also been initialed as having been given at 5:00 PM on 7/11/11. Review of July Physician's Telephone Orders revealed [MEDICATION NAME] had not been given as ordered and the Resident had received an additional/unordered dose of [MEDICATION NAME] on 7/11/11. During an interview on 7/13/11 at 2:20 PM, the Director of Nursing (DON) stated that they had not informed the Physician on 7/12/11 of the extra dose of [MEDICATION NAME] received by Resident #2. She stated they had waited to get the [MEDICATION NAME]/International Normalization Ratio (PT/INR) lab result today (7/13/11). When asked to clarify if the Physician had ordered a special lab to be drawn today in response to the extra dose of [MEDICATION NAME], she stated that the lab ordered today was the routine lab that had been ordered on [DATE] (along with the order for the decreased dosage of [MEDICATION NAME]). The DON was asked to provide the PT/INR result for 7/13/11 and the MAR for 7/11/11 through 7/13/11. Review of the PT/INR result dated 7/13/11 revealed a PT of 28.6 H(igh) and an INR of 4.4 H(igh). Review of Physician's Telephone Orders dated 7/13/11 revealed an order to "Hold [MEDICATION NAME] Wed(nesday), Thurs(day), Vitamin K 5 mg X 1 by mouth, PT/INR on Fri(day) 7/15/11". When asked why the Vitamin K was ordered by mouth, the DON explained that there was a risk of bleeding if they gave the Vitamin K by injection since the INR was high. Review of the July 2011 MAR indicated [REDACTED]' attention that an extra dose of [MEDICATION NAME] had been initialed as having been given on 7/11/11. The DON was informed that this was a concern since the Physician had not been notified until 7/13/11 of any [MEDICATION NAME] concerns related to Resident #2 and had not been approached by nursing prior to the 7/12/11 [MEDICATION NAME] administration as to whether the 7/12/11 dosage of [MEDICATION NAME] should have been put on hold or if he wanted a PT/INR drawn sooner than 7/13/11. Additionally, record review on 7/13/11 revealed [MEDICATION NAME] therapy had not been monitored appropriately as evidenced by delays in implementing [MEDICATION NAME] orders for dosage adjustments in relation to PT/INR results. The July 2011 cumulative Physician order [REDACTED]. Review of the MAR for July 2011 revealed [MEDICATION NAME] 3 mg had been given as ordered from July 1st through July 4th at 5:00 PM. Review of the labs revealed an INR result dated 7/5/11 of 1.8 L(ow) (Normal 2-3). A telephone order dated 7/5/11 at 2:45 PM revealed [MEDICATION NAME] had been increased to 4 mg daily. Review of the July 2011 MAR indicated [REDACTED]. July 2011 MAR indicated [REDACTED]. Review of Physician's Telephone Orders for Resident #2 on 7/13/11 at 10:17 AM revealed an order dated 4/13/11 that stated "1. Increase [MEDICATION NAME] to 5 mg by mouth daily 2. PT/INR on Fri(day) 4/15/11". The "Time Ordered" section had been left blank along with the time the nurse received the order. Review of lab results dated 4/13/11 revealed a PT of 14.9 H(igh) and an INR of 1.3 L(ow). Review of the April 2011 MAR indicated [REDACTED]. The first dose of [MEDICATION NAME] 5 mg had been initialed as having been given on 4/14/11 at 5:00 PM. According to the April 2011 MAR indicated [REDACTED]. Record review on 7/13/11 at 10:10 AM revealed a lab result dated 3/23/11 with a PT result of 20.8 and an INR result of 2.4 (normal 2-3). Review of Physician's Telephone Orders revealed an order dated 3/23/11 that stated "1. Start [MEDICATION NAME] to 3 mg daily 2. PT/INR on 3/25/11". Review of the MAR for March 2011 revealed no entry for [MEDICATION NAME] 3 mg after it had been discontinued on 3/18/11. The resident's [MEDICATION NAME] 3 mg had previously been discontinued on 3/18 and an order had been written on 3/21/11 to continue to hold it though 3/22/11. There was no indication on the March 2011 that the resident had received [MEDICATION NAME] 3 mg daily on 3/23/11 or 3/24/11 as ordered. Record review on 7/13/11 at 9:46 AM revealed a lab result for Resident #2 dated 2/16/11 in which the PT was 21.8 and the INR 2.4 (Normal 2-3). Review of Physician's Telephone Orders revealed an order dated 2/16/11 that stated "1. Restart [MEDICATION NAME] 4 mg by mouth daily 2. PT/INR on 2-18-11". The "Time Ordered" section had been left blank along with the time the nurse received the order. Review of the February 2011 MAR indicated [REDACTED]. There was no indication that any [MEDICATION NAME] had been given on 2/16/11 as ordered. During an interview on 7/13/11, Registered Nurse (RN) #2 verified the above findings after reviewing the orders, MAR's, and lab results. RN #2 stated the facility utilized a contracted lab service to draw labs. She stated that the lab personnel came early in the morning and usually left the facility at about 6:45 AM after drawing the PT/INR's and any other ordered labs. She stated that the labs (PT/INR's) are resulted and back to the facility in enough time for [MEDICATION NAME] dosages to be adjusted by 5:00 PM. During an interview on 7/13/11 at 2:20 PM, the Consultant Pharmacist stated there was [MEDICATION NAME] in the Emergency Kit in 1 mg doses and that there is a backup pharmacy that is utilized and ordered medications can usually get to the facility in about an hour. Record review on 7/11/11 and 7/13/11 revealed [MEDICATION NAME] therapy had not been monitored appropriately related to PT/INR's that were not done as ordered. Eight PT/INR labs had not been drawn as ordered from December 29, 2010 through June 20, 2011. Review of Physician's Telephone Orders for Resident #2 dated 12/28/10 revealed an order to "D/C (Discontinue) [MEDICATION NAME] 4 mg (1) PO (By Mouth) daily 2. Adm(inister) [MEDICATION NAME] 5 mg (1) PO daily 3.(Check) PT/INR on 12/29/10". Review of lab results revealed no PT/INR result for 12/29/10 in the chart. Further review revealed a Physician's Telephone Order dated 12/30/10 that stated "(Check) PT/INR on 1/3/11". Review of lab results revealed no PT/INR result for 1/3/11 in the chart. A lab result dated 1/4/11 (which had no order)revealed a PT of 24.3 and an INR of 2.8. Review of Physician's Telephone Orders dated 1/7/11 revealed an order to "1. DC [MEDICATION NAME] 5 mg (1) PO daily 2. Adm(inister) [MEDICATION NAME] 4 mg daily on 1/8/11 3. (Check) PT/INR on 1/10/11". Review of lab results revealed no PT/INR result for 1/10/11. A lab result dated 1/12/11(which had no order) revealed a PT of 23.4 and an INR of 2.6. Review of Physician's Telephone Orders dated 2/25/11 revealed an order to "1. hold [MEDICATION NAME] Fri(day), Sat(urday), Sun(day) 2. PT/INR on Mon(day) 2/28". Review of lab results revealed no PT/INR result for 2/28/11. Review of Physician's Telephone Orders dated 2/28/11 revealed an order to "1. Start [MEDICATION NAME] 4 mg by mouth daily 2. PT/INR on 3/1/11 (Not drawn 2/28)". Review of Physician's Telephone Orders dated 3/1/11 revealed an order for [REDACTED]. Review of lab results revealed no PT/INR result for 3/4/11. Review of Physician's Telephone Orders dated 4/6/11 revealed an order to "1. Hold [MEDICATION NAME] Wed(nesday), Thurs(day) 2. PT/INR on Fri(day) 4/8/11". Review of lab results revealed no PT/INR result for 4/8/11 in the chart. The next PT/INR in the chart (without an order) was dated 4/11/11 and revealed a PT of 15.7 and an INR of 1.4 L(ow). Review of Physician's Telephone Orders dated 4/11/11 stated "1. Start [MEDICATION NAME] 4 mg PO daily ...". Review of Physician's Telephone orders dated 4/26/11 revealed an order for [REDACTED]. Review of lab results revealed no PT/INR result for 5/2/11. The next PT/INR in the chart was dated 5/3/11 and had no order. Review of Physician's Telephone Orders dated 6/13/11 revealed an order for [REDACTED]. Review of lab results in the chart revealed no PT/INR result for 6/20/11. A physician's orders [REDACTED]. A Physician's Telephone Order dated 6/22/11 revealed an order to "1. hold [MEDICATION NAME] Wed(nesday) Thurs(day) 2. PT/INR on Fri(day) 6/24". Review of the lab request book revealed a request for the 6/22 PT/INR to be drawn but no request for the 6/20 PT/INR was found. During an interview on 7/13/11, RN #2 verified the above findings after reviewing the orders and lab results. She stated that she would let the DON know to see if she could find any of the missing PT/INR results, however, none were provided. During an interview on 7/13/11 at 4:13 PM, the DON stated that if a lab was missed on one day, they would have it drawn the next. She stated she did not know if the resident refused the labs of if they were just missed. She provided a tracking sheet that she used to monitor PT/INR results, however, except for one missed PT/INR on 5/9/11 that had been marked as the resident refused, there was no explanation as to why the PT/INR's had not been drawn on the dates ordered. Review of the policy provided by the facility entitled "[MEDICATION NAME] Therapy" revealed under "Protocol" that "1. Residents receiving [MEDICATION NAME] therapy will have PT/INR's performed per physician order. PT/INR's will routinely be drawn in the a.m.". Cross refer to F333. [MEDICATION NAME] therapy had not been monitored appropriately related to an extra dose of [MEDICATION NAME] given by nursing staff to Resident #2 on 7/11/11.

On the days of the survey, based on record review, interview, and review of the policy provided by the facility entitled "[MEDICATION NAME] Therapy", the facility nursing staff failed to give [MEDICATION NAME] as ordered for Resident #2, one of eight residents reviewed with [MEDICATION NAME] therapy. The findings included: The facility admitted Resident #2 on 3/24/03 and readmitted her on 10/27/10 with [DIAGNOSES REDACTED]. Record review on 7/12/11 at 9:30 AM revealed Physician's Telephone Orders dated 7/8/11 which stated "1. Cont(inue) [MEDICATION NAME] 4 mg (milligrams) daily. 2. PT/INR ([MEDICATION NAME]/International Normalization Ratio) on 7/11/11. Review of the July 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of labs revealed a PT/INR result dated 7/11/11 with a PT of 24.4 H(igh) and an INR of 3.2 H(igh). A Physician's Telephone Order dated 7/11/11 revealed an order to "1. decrease [MEDICATION NAME] to 3 mg by mouth daily 2. PT/INR on 7/13/11 (Wed(nesday)". Continued review of the July 2011 MAR revealed an entry for "[MEDICATION NAME] 3 mg tablet give one tab (tablet) by mouth daily..." which had been initialed as having been given at 5:00 PM on 7/11/11. Two separate doses of [MEDICATION NAME] had been initialed as having been given on 7/11/11 at different times of the day with a high INR result. During an interview on 7/12/11 at 9:45 AM, Registered Nurse (RN) #2 verified the above findings after reviewing the MAR, lab result, and Physician Telephone Orders. She called the Director of Nursing (DON) over who also verified the above findings. During an interview on 7/12/11 at approximately 3:45 PM, Licensed Practical Nurse (LPN) #2 stated she had given the 5:00 PM dose of [MEDICATION NAME] on 7/11/11. She stated she had not been aware [MEDICATION NAME] had already been given that day at 9:00 AM since [MEDICATION NAME] was routinely scheduled in the afternoon. When asked, she stated she had taken off the new order dated 7/11/11 for the decreased dosage of [MEDICATION NAME] and had added it to the MAR for 5:00 PM, and had given it. Record review on 7/13/11 at 2:05 PM revealed a Nursing Note dated 7/13/11 at 1:09 PM which stated "Called (Physician) R/T (Related To) lab results. New order to hold [MEDICATION NAME] Wednesday and Thursday. Give Vit(amin) K 5 mg by mouth now and recheck PT/INR on Friday". During an interview on 7/13/11 at 2:20 PM, the DON stated that they had not informed the Physician on 7/12/11 that the resident had received the incorrect dosage of [MEDICATION NAME] on 7/11/11. She stated they had waited to get the lab (PT/INR) result today. When asked to clarify if the Physician had ordered a special lab to be drawn today in response to the extra dose of [MEDICATION NAME], she stated that the lab ordered today was the routine lab that had been ordered on [DATE]. The DON was asked to provide the PT/INR result for 7/13/11 and the MAR from 7/11/11 through 7/13/11. Review of the PT/INR result dated 7/13/11 revealed a PT of 28.6 H(igh) and an INR of 4.4 H(igh). Review of Physician's Telephone Orders dated 7/13/11 revealed an order to "Hold [MEDICATION NAME] Wed(nesday), Thurs(day), Vitamin K 5 mg X 1 by mouth, PT/INR on Fri(day) 7/15/11". When asked why the Vitamin K was ordered by mouth the DON explained that there was a risk of bleeding if they gave the Vitamin K by injection since the INR was high. Review of the July 2011 MAR indicated [REDACTED]' attention that an extra dose of [MEDICATION NAME] had been initialed as having been given on 7/11/11. During sharing the DON was informed this was a concern since the Physician had not been notified until 7/13/11 of any [MEDICATION NAME] concerns related to Resident #2 and had not been approached by nursing prior to the 7/12/11 [MEDICATION NAME] administration as to whether the 7/12/11 dosage of [MEDICATION NAME] should have been put on hold or if he wanted a PT/INR drawn sooner than 7/13/11. Review of the July 2011 cumulative Physician order [REDACTED]. Review of the MAR for July 2011 revealed [MEDICATION NAME] 3 mg had been given as ordered from July 1st through July 4th at 5:00 PM. Review of the labs revealed an INR result dated 7/5/11 of 1.8 L(ow). A Physician's Telephone Order dated 7/5/11 at 2:45 PM revealed [MEDICATION NAME] had been increased to 4 mg daily. Review of the July 2011 MAR indicated [REDACTED]. July 2011 MAR indicated [REDACTED]. Review of Physician's Telephone Orders for Resident #2 on 7/13/11 at 10:17 AM revealed an order dated 4/13/11 that stated "1. Increase [MEDICATION NAME] to 5 mg by mouth daily 2. PT/INR on Fri(day) 4/15/11". The "Time Ordered" section had been left blank along with the time the nurse received the order. Review of lab results dated 4/13/11 revealed a PT of 14.9 H(igh) and an INR of 1.3 L(ow). Review of the April 2011 MAR indicated [REDACTED]. The first dose of [MEDICATION NAME] 5 mg had been initialed as having been given on 4/14/11 at 5:00 PM. According to the April 2011 MAR indicated [REDACTED]. Review of Physician's Telephone Orders for Resident #2 on 7/13/11 at 10:10 AM revealed an order dated 3/23/11 that stated "1. Start [MEDICATION NAME] to 3 mg daily 2. PT/INR on 3/25/11". Review of the MAR for March 2011 revealed no entry for [MEDICATION NAME] 3 mg after it had been discontinued on 3/18/11. The resident's [MEDICATION NAME] 3 mg had previously been discontinued on on 3/18 and a Physician's Telephone Order had been written on 3/21/11 to continue to hold it though 3/22/11. There was no indication on the March 2011 MAR indicated [REDACTED]. Review of Physician's Telephone Orders for resident #2 on 7/13/11 at 9:46 AM revealed an order dated 2/16/11 that stated "1. Restart [MEDICATION NAME] 4 mg by mouth daily 2. PT/INR on 2-18-11". The "Time Ordered" section had been left blank along with the time the nurse received the order. Review of the February 2011 MAR indicated [REDACTED]. There was no indication that any [MEDICATION NAME] had been given on 2/16/11 as ordered. During an interview on 7/13/11, RN #2 verified the above findings after reviewing the orders, MAR's, and lab results. RN #2 stated the facility utilized a contracted lab service to draw labs. She stated that the lab personnel came early in the morning and usually left the facility at about 6:45 AM after drawing the PT/INR's and any ordered labs. She stated that the labs (PT/INR's) are resulted and back to the facility in enough time for [MEDICATION NAME] dosages to be adjusted by 5:00 PM. During an interview on 7/13/11 at 2:20 PM, the Consultant Pharmacist stated there was [MEDICATION NAME] in the Emergency Kit in 1 mg doses and that there is a backup pharmacy that is utilized and ordered medications can usually get to the facility in about an hour. Review of the policy provided by the facility entitled "[MEDICATION NAME] Therapy" revealed under Protocol that "[MEDICATION NAME] administration will be 5:00 PM unless otherwise ordered by the physician".