Every finding on record at Angel Oak Nursing and Rehabilitation Center, LLC

Based on interview, record review, and facility policy review, the facility failed to provide adequate supervision and accident prevention for 1 (Resident (R)65) of 3 residents reviewed for falls. The failure resulted in R65 sustaining a right 11th rib fracture on 09/02/2025 after the resident fell. Findings include: Review of a facility policy titled, Accidents and Supervision, revised on 10/06/2025, revealed, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. The policy revealed, . 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff, and d. Documenting interventions (e.g. [exempli gratia, for example], plans of action developed through the QAA [quality assessment and assurance] Committee or care plans for the individual resident) e. Ensuring that the interventions are put into action. Review of R65's admission Record revealed the facility admitted R65 on 05/06/2025. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of muscle weakness, cognitive communication deficit, limitation of activities due to disability, and aphasia (impaired ability to process, produce, or understand language). Review of R65's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/04/2026, revealed R65 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for transfer and ambulating assistance. Review of R65's Care Plan Report, included a focus area initiated on 06/30/2025, that indicated the resident had a risk for falls. Interventions directed staff to keep the call light within reach and encourage the resident to use it if not cognitively impaired (initiated 06/30/2025), anticipate the resident's needs (initiated 06/30/2025), and offer to assist the resident to bed after dinner (initiated 08/08/2025). Review of R65's Morse Fall Scale dated 05/06/2025, indicated R65 was at high risk for falls. Review of R65's Progress Notes dated 08/08/2025, written by the Director of Nursing (DON), revealed R65 fell on [DATE] at 8:25 PM. The notes indicated the resident was not injured and fell when transferring from the recliner without assistance. The notes further indicated that the summary of the interdisciplinary team (IDT) meeting included to offer to assist the resident to bed after dinner. Review of R65's Progress Notes dated 09/02/2025, written by Licensed Practical Nurse (LPN)1, revealed R65 fell onto the floor attempting to get out of a geriatric recliner. The notes revealed the fall was unwitnessed, and the resident reported hitting their head and having shoulder pain. The notes revealed a small amount of bleeding in the right ear and redness to the right side of the resident's back was noted. The notes revealed the Medical Director (MD) was present and ordered for the resident to be sent to the emergency room. Review of a Five-Day Follow-Up Report dated 09/08/2025, revealed R65 had a fall on 09/02/2025. The report revealed an attached typed summary indicated a staff member was walking down the hallway and saw the resident sitting on the floor near their bed. The summary revealed the Medical Director (MD) was in the building, assessed the resident, and ordered for the resident to be sent to the hospital for further evaluation because the fall was unwitnessed and the resident was taking anticoagulant medications. The summary revealed the resident later returned that evening with diagnoses of right rib fracture and a urinary tract infection. The summary revealed the resident was seen prior to the fall sitting in a recliner around 6:00 PM when staff picked up dinner trays. The summary revealed the resident fell when they attempted to get up without assistance. The summary further revealed that the new intervention was to offer the resident to go to bed after dinner as tolerated. Review of R65's Progress Notes dated 09/02/2025 at 11:31 PM, written by LPN2, revealed R65 returned from the hospital with diagnoses of a rib fracture and urinary tract infection. The notes also revealed the resident denied pain or discomfort. Review of R65's Emergency Provider Report dated 09/02/2025, revealed the resident was seen due to hitting their head after a fall, and a computer tomography (CT) was completed that showed no acute intracranial abnormality. The report revealed the resident was discharged back to the facility with diagnoses of a right 11th rib fracture and urinary tract infection. During an interview on 02/06/2026 at 11:34 AM, the DON stated Certified Nurse Assistant (CNA)2 was assigned to R65 on 09/02/2025 at the time of the fall. Review of a Witness Statement, completed by CNA2, dated 09/02/2025, revealed CNA2 did not witness the fall that occurred at 09/02/2025 at 6:55 PM. During an interview on 02/05/2026 at 3:09 PM, CNA2 stated she would know what fall interventions a resident had because the nurse would tell her in report. CNA2 stated she had never seen R65 fall, and no one had told her to assist the resident to bed after dinner. During a follow-up interview on 02/06/2026 at 4:25 PM, CNA2 stated she was able to look on the computer to see what type of transfer assistance residents needed. CNA2 stated she was assisting another resident when R65 fell on [DATE]. CNA2 stated she did not recall the last time she had seen the resident prior to the fall or what time the resident fell. CNA2 stated R65's call light was within reach because it was lying on the bed next to the resident's chair, within the resident's reach. Review of a Witness Statement completed by LPN1, dated 09/02/2025, revealed LPN1 did not witness the fall that occurred on 09/02/2025 at 6:55 PM. During an interview on 02/05/2026 at 3:20 PM, LPN1 stated that she had never accessed the care plans at the facility. LPN1 stated that you would know what interventions were in place for a resident because of your experience, and you would know your residents. LPN1 stated the MD went with her into the resident's room after the resident fell (on 09/02/2025) and sent the resident to the emergency room because the resident was taking anticoagulant medications. LPN1 stated the intervention that was in place at the time of the fall was to check on the resident frequently, and she was not aware of any other interventions at that time. LPN1 stated R65 was not able to use a call light appropriately or understand what it was for. During an interview on 02/06/2026 at 10:31 AM, the MD stated he saw R65 sitting on the floor when he was walking down the hallway. The MD stated he called for the nurse and assessed the resident. The MD stated the resident was taking anticoagulant medications and complained of pain, so the resident was sent to the hospital. The MD stated he discussed falls with the DON, and the DON would ultimately determine what intervention to put into place. The MD stated that he expected new interventions to be shared with staff. The MD stated that if interventions were not shared with staff, then it would not be helpful. The MD stated R65 had a rib fracture after the fall on 09/02/2025, but it had not caused the resident to decline. During an interview on 02/05/2026 at 3:46 PM, the Unit Manager (UM) stated that if a resident fell, the root cause of the fall would be determined during the morning meeting with the DON, Director of Therapy, Social Worker, UM, Minimum Data Set (MDS) Coordinators, and the admission Nurse. The UM stated all residents that had fallen would be discussed during the meeting, and the MDS Coordinators would add to the care plans the interventions that the team determined were appropriate. The UM stated she then notified the nurses of the new interventions, and the information would be passed along in report. The UM stated the nurses also had access to the care plans. The UM stated she did not think CNAs were able to access the care plans, but the nurses were able to and should have been communicating the information to the CNAs. During an interview on 02/05/2026 at 4:03 PM, MDS Coordinator 5 stated that after a resident fell, it would be discussed in the morning meeting. She stated that they would determine an appropriate intervention that had not been previously used and add it to the care plan. MDS Coordinator 5 stated she updated the residents' care plans after the morning meetings. MDS Coordinator 5 stated she assumed the DON and UM would notify the nurses of the change. MDS Coordinator 5 stated that after she added the care plans, she was able to add the interventions to the Kardex. MDS Coordinator 5 stated CNAs would be able to view the interventions on the Kardex, and the CNAs were supposed to look at the Kardex for the residents they were providing care for. During an interview on 02/06/2026 at 2:15 PM, the DON stated staff would know if a resident was a fall risk because it would be communicated from the nurses to the CNAs, and it would be listed on the resident's care plan. The DON stated that the nurses and CNAs were able to view residents' Kardex and care plans. The DON stated that if a care plan were updated, she would notify the nurses, and the nurses would inform the CNAs. The DON stated that any updates or changes would also be reflected on the care plan. The DON stated that when R65 fell on [DATE], the resident fell when attempting to get out of the recliner without assistance. The DON stated the fall occurred after dinner, and the intervention put into place was to assist the resident to bed after dinner. The DON stated that on 09/02/2025, the resident attempted to get out of the recliner without assistance after dinner and fell. The DON stated she did not know why R65 was not assisted to bed after dinner unless the resident did not want to go to bed. The DON stated R65 was diagnosed with a rib fracture after the fall on 09/02/2025 and did not decline after the fall. The DON stated the resident had not had any additional falls since 09/02/2025. The DON stated she expected fall interventions to be effective and to be in place. The DON stated she expected staff to be aware of the interventions and how to access the care plans. The DON stated she was responsible for ensuring the fall interventions were updated, and she was responsible for ensuring staff were able to access the care plans with fall interventions. During an interview on 02/06/2026 at 2:54 PM, the Executive Director (ED) stated she expected interventions to be communicated to the staff. The ED stated that the MDS Coordinators were responsible for updating the care plans, and the UM was responsible for relaying information to the staff.

Based on review of facility policy, record reviews and interviews, the facility failed to prevent missappropriation of resident property for Resident (R)2 and R3. Specifically, Licensed Practical Nurse (LPN)1 removed 5 pills from the narcotic locked box, belonging to R2 and R3. LPN1 did not administer the medications to the residents, for 2 of 2 residents reviewed. Findings include: Review of the facility policy titled, Abuse/Neglect/Exploitation/Misappropriation/Mistreatment/Injury, implemented on March 2022 and revised on April 6, 2023, documented, It is the policy of this facility to provide protections for the health, welfare, and the rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, mistreatment, including injuries of unknown sources and misappropriation of resident property. Compliance Guidelines: 2. D. c. Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belongings or money without the resident's consent. 3. The facility will provide ongoing oversight and supervision of staff to assure its policies are implemented as written. Review of R2's Face Sheet revealed the facility admitted R2 with diagnoses including, but not limited to: cerebrovascular accident with hemiparesis and hemiplegia, chronic obstructive pulmonary disease, and major depressive disorder. Review of R2's Physician Order revealed an order for Tramadol HCI 50mg 1 po q12 hours prn (as needed). Review of R2's Medication Administration Record (MAR) dated 10/01/24 - 10/31/24, revealed the medication Tramadol 50 milligrams, give 1 tablet every 12 hours as needed for pain. Review of R3's Face Sheet revealed the facility admitted R3 with diagnoses including, but not limited to: a fractured right femur and hemarthrosis of right knee and postpolio syndrome. Review of R3's Physician Order revealed an order for Oxycodone 5-325mg 2 tabs po q6 hours prn. Review of R3's MAR dated 10/01/24 - 10/31/24, revealed the medication Oxycodone 5-325 milligrams, give 2 tablets every 6 hours as needed for pain. Review of the Facility's Summary Report of Facility Investigation revealed, On 10/24/24 DON [Director of Nursing] completed a full investigation into the allegation of misappropriation of resident's property by an LPN [Licensed Practical Nurse] in the facility. After viewing video footage of the nurse on shift, it was confirmed that she had taken narcotics out of the narcotic drawer and did not administer them to the residents. In total it was 4 oxycodone 5/325 that belonged to [R3] and 1 Tramadol 50mg that belonged to [R2]. Employee was scheduled to work at 3pm that day. Incident was reported to the local police department, incident was reported to the SC ombudsman, DHEC, and the SC board of Nursing. Residents and residents' families were notified of the incident. The Nurse came in and DON and the Unit Manager both spoke with the nurse and asked her about the incident. LPN showed video footage of her taking the medication and she asked the DON please stop I know that you are showing me She did admit that she took the medication for herself. She stated that she ran out of her pain medication. She was immediately terminated and escorted outside the building. the Employee refused to take a drug test and said that it would come back positive. During review of the video footage, LPN1 was observed on the facility camera, taking Tramadol from the locked narcotic box. LPN1 removed 1 tablet from the blister pack and placed it in a cup. This was observed from the facility video by the director of nursing putting one Tramadol into the medicine cup. Furthermore, LPN1 could be seen removing 4 Oxycodone tablets from the blister pack for R3 and put them in a cup. LPN1 entered a resident room, in which neither of the medications was for. During an observation on 11/04/24 at an unspecified time, R2 was up in his wheelchair watching tv. R2 did not appear to be in distress or experiencing pain. R2 was unable to answer questions. During an interview on 11/04/24 at 11:20 AM, the Unit Manager (UM) stated, I viewed the video and saw her [LPN1] flip through the pages, it made me physically ill, all she said she wanted to do was have a party with her boyfriend. She admitted she took the pills, I walked her out and there was no remorse, what so ever. During multiple observations on 11/19/24, R2 was up and participating in activities and having lunch. R2 did not appear to be in distress or experiencing pain. During an interview on 11/04/24 at 1:06 PM, R3 stated she did not want anymore pain medications because she did not want to be addicted to anything. R3 further stated that she does not remember not getting her pain medications. During an interview on 11/04/24 at 10:40 AM, the DON stated LPN1 had the 5 pills in one cup and took the cup into another resident's room, which neither R2 or R3 resided in. When LPN1 came out of the room she did not have the cup in her hand. The DON stated that LPN1 admitted to taking the medications, and was terminated on 10/24/24. During an interview on 11/04/24 at 10:45 AM, the Administrator stated that she was not working at that time, and the investigation was handled by the DON. Multiple attempts were made to contact LPN1, with no success.

Based on review of facility policy, observations, interviews and record reviews, the facility failed to ensure a procedure was followed during wound care, to prevent the spread of infection for Resident (R)9, for 1 of 1 residents reviewed for wound care. Findings include: Review of the facility policy titled, Hand Hygiene, dated 06/14/23 and revised on 10/26/23, documents, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. Review of the undated facility policy titled, Dressing Change (clean Technique), states: 9. Wash hands/use sanitizer and apply gloves. 10. Remove the soiled dressing and discard in trash bag at bedside. 11. Remove gloves and discard. 13. Wash hands/use hand sanitizer. 14. Put on gloves. 15. Clean the wound according to order. Clean from the center outward. Linear wounds may be cleansed from top to bottom. 16. Discard soiled gauze or Q-tip used for cleaning. 17. Remove gloves and discard if contaminated during cleaning. 18. Wash hands/use hand sanitizer. 19. Put on gloves. 20. Apply clean dressing as ordered. 21. Remove gloves and discard. 22. Wash hands/use hand sanitizer 23. Document the treatment on the treatment record. Review of R9's Face Sheet revealed the facility admitted R9 with diagnoses including, but not limited to: paraplegia, stage 4 pressure ulcer of the sacral area, neurogenic bladder, and multiple sclerosis. Review of R9's Physician Order revealed, Cleanse the wound with wound cleanser, apply calcium alginate to wound bed. Cover with bordered gauze daily and as needed. During an observation of wound care for R9 on 11/21/24 at 9:50 AM, revealed the following: Registered Nurse (RN)1 was assisted with wound care by RN2. RN1 and RN2 gowned up outside the door, then entered the room and washed their hands and applied gloves. RN2 explained the procedure to the resident then removed the bed sheet from the resident and aided the resident in turning to her left side. RN1 removed the soiled dressing, removed her gloves and washed her hands and then applied gloves, the wound bed is clean, does not have an odor, with some redness around the outside of the wound. RN1 removed her gloves and washed her hands and applied gloves, she had cleaned the scissors and the marker. RN1 opened the supplies and put them on the clean field on the over bed table. She wet a 4x4 with the wound cleanser and cleaned the wound inside out and then folded the 4x4 and and wiped around the outside of the wound. RN1 then took a dry 4x4 and wiped around the outside of the wound to dry it off. RN1 failed to remove her gloves and wash her hands, then cut a piece of the calcium alginate for the wound bed, and took the marker and wrote the date, time and her initials onto the border gauze. She placed the calcium alginate into the wound bed and then covered it with the bordered gauze. She then removed her gloves and washed her hands. The 2 nurses remained in the room to dress the resident for an outing with activities. During an interview on 11/21/24 at 10:46 AM, RN1 confirmed that she had not removed her gloves and washed her hands after cleaning the wound and proceeded to apply the clean dressing.

Based on review of the facility's policy, record review, video surveillance review and interviews, the facility failed to protect Resident (R)4 from physical abuse by R5, 2 of 8 residents reviewed for abuse. Findings include: Review of the facility policy titled, Abuse, Neglect, and Exploitation last revised 9/22, revealed It is 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. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect: the failure of the facility, its employees, or service to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to congestive heart failure, type 2 diabetes, and dementia with behaviors. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/05/23, revealed R4 had a Brief Interview of Mental Status (BIMS) score of 7 out of 15, indicating cognitive impairment. R5 was admitted to the facility on [DATE] with diagnoses including, but not limited to heart failure, type 2 diabetes, and muscle weakness. Review of the discharge with return not expected MDS with an ARD date of 02/02/23, revealed R5 has a BIMS score of 15 out of 15, which indicates they are cognitively intact. R8 was admitted to the facility on [DATE] with diagnoses including, but not limited to hypertension, type 2 diabetes, and hypertension. Review of the Annual MDS with an ARD date of 12/28/22 revealed R8 has a BIMS score of 13 out of 15, which indicates they are cognitively intact. Review of a witness statement written by Licensed Practical Nurse (LPN)2, dated 12/29/22, revealed Around 8:30 PM resident came out of dining room and hollered help they are fighting. This nurse and 2 Certified Nursing Assistants (CNA)s ran to help. At the time I arrived, R4 was rolling away from the table where R5 and R8 sat. When I asked what happened, R8 stated R4 was digging in R5's basket that's on his motorized wheelchair. When I spoke with R4 she only stated that people are mean to her. The following morning R4 asked her nurse if she had any bruises on her face, when the nurse questioned why, she stated he hit me really hard last night. Nurse asked R8 if anyone hit each other last night and she said R5 hit R4 but he (R5) was hit first. R5 stated she (R4 smacked my glasses off of me so I smacked her (R4). An observation and interview on 03/20/23 at 11:15 AM of R4 revealed them wandering and self-propelling on the unit, appropriately dressed. R4 was unable to recall the resident to resident altercation with R5, but stated she feels safe living at the facility. An observation and interview on 03/20/23 at 12:45 PM of R8 revealed that they were unable to recall a resident to resident altercation between R4 and R5 in the dining room. An interview with Social Services (SS) on 03/21/23 at 9:20 AM revealed R4 was hit on purpose by R5 while they were in the dining room. R5 was upset because R4 touched his basket on his motorized wheelchair. R4 has been known to wander into other resident rooms and touch their things but she has never damaged any property and does not take others belongings. After the incident the altercation another resident (R8) reported to nursing staff that R5 was hitting R4. The residents were separated and police were notified along with the resident representative, ombudsman, and the state agency. After the police watched the camera footage they reached out to R4 resident rep and pressed charges on R5 and he was later taken to jail for striking R4 multiple times. An interview with the Administrator and SS on 03/21/23 at 9:45 AM revealed We have video footage of the incident. Upon review of the footage, R5 was observed striking R4, 5 times along with waving his hands in a threatening motion towards R4. R4 was observed putting up their hands and attempting to block the hits from R5 while grimacing, there was no sound on this video evidence. We spoke with R4's Resident Representative and they stated they wanted to press charges on R5. The police reviewed the footage as well and R5 was taken to jail and given the option to pay $100 or face jail time/ have a court case with a [NAME]. R5 decided to pay the fine and was admitted back into the facility under supervision to avoid contact with R4 and was later discharged home with home health services because of the incident. Review of the video surveillance on 03/21/23 at 10:00 AM of the resident to resident altercation on 12/28/22 revealed R5 in the dining room using his motorized wheelchair to grab and shove R4. R5 was observed striking R4 in the face, back of the head, arms, and holding R4's left arm behind her back. Other residents were observed in the video and witnessed this altercation and then went to alert staff. Review of a Progress Note dated 12/29/22 for R4 revealed, R4 asked nurse this morning if she had any bruises on her face, when nurse questioned why she would ask that, resident stated another resident hit her really hard last night. Incident reported to Medical Director (MD) and Director of Nursing (DON). Skin audit completed, and no new bruising or injuries noted, resident is safe and separated from other resident, will continue to monitor. Review of a Progress Note dated 12/29/22 for R4 revealed spoke with resident husband regarding resident being hit by another resident. He was updated on the reporting process and that the investigation is in process. Review of a Progress Note dated 12/28/22 for R5 revealed fell ow resident with complaints of this resident (R5) hitting another resident last night in the dining room. When asked, this resident stated the other resident involved smacked his glasses off and so he hit her back. No new injuries visible, MD and DON made aware, resident is safe and separated from other involved party, will continue to monitor. Review of a SS Progress Note dated 12/29/22 for R5 revealed This morning around 8:30 am resident-on-resident incident was reported to me that occurred last evening 12/28/22 around 8:30 pm. R5 who is alert and oriented made physical contact with a cognitively impaired resident, R4. Police Department was then called to report the incident and officer arrived to interview the residents that were involved in the incident. I escorted him to R5's room and stated that R4 was looking and touching things that were in his basket attached to his wheelchair. R5 made claims that R4 made contact to his face causing his glasses to fall off. He admitted that he pushed her away, hit her and then refrained himself from hitting her again. The officer was able to watch on video as there are cameras in the room that this incident occurred in (dining room). The officer spoke with R4 and determined that she is non-interviewable and then spoke with her Resident Representative. R4's Resident Representative explained to the office that he would like to file charges against R5 for assault. The officer informed staff that he would have to get in contact with a judge to issue a warrant for R5 arrest and there was no timeline on how long that may take to get. R5 will be under 1:1 supervision until he is placed under arrest by the Police Department. DON and I went down and explained this situation to R5. He is his own responsible party, we offered to call his family and he stated that he would call them himself. This is an ongoing case with the Police Department and will be handled by them now. Social Services will continue to offer psychosocial support throughout the remainder of this situation. Review of a Progress Note for R5 dated 12/30/22 revealed Police showed up at facility to transport resident to jail. Resident left facility with Police Officer at 1:14 pm. A phone interview on 03/21/23 at 1:27 PM with LPN2 revealed that she confirmed her witness statement and was able to recall the resident asking her if she had bruises on her face from being hit by another resident. Review of a Police Incident Report dated 12/28/22 revealed The Victim (R4) advised she saw the Suspect (R5) and other residents playing a card game in the dining hall. The Victim advised while playing the Suspect was making rude remarks towards her. The Victim advise the Suspect then approached her and began to pull her by the arm. The Victim advised she was then slapped in the face by the Suspect. The Victim advised her left arm was hurting after the incident, no visible injuries during time of report. After speaking with R4 Resident Representative, charges will be pursed against R5, a warrant for Assault of 3rd degree.

Based on review of the facility policy titled, Abuse, Neglect and Exploitation, record review, and interview, the facility failed to report an allegation of resident to resident abuse between Resident (R1) and R2, no later than 2 hours after the witnessed altercation occurred for 2 of 11 residents reviewed for Abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, states under section 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., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, it the events that cause the allegation involve abuse or result in serious bodily injury. b. Not later than 24 hours if the events that cause the allegation do no involve abuse and do not result in serious bodily injury. B. The Administrator will follow up with the government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by the state agencies. The facility admitted R1 with diagnoses including but not limited to, Alzheimer's Disease, anxiety disorder and depression. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/22 revealed a Brief Interview of Mental Status (BIMS) score of 5 out of 15, indicating cognitive deficits. The facility admitted R2 with diagnoses including but not limited to, dementia, aphasia, osteoarthritis, muscle weakness and abnormality of gait and mobility. Review of the quarterly MDS with an ARD of 03/30/23 revealed a BIMS score of 99, indicating cognitive deficits. Review on 03/21/23 at 10:15 AM of the reportable of resident to resident abuse, indicated R1 and R2 had an altercation on 11/20/22 at 21:59 (9:59 PM). No documentation could be found to ensure the altercation between R1 and R2 was reported to the state agency within the 2 hour time frame as required. An interview on 03/21/23 at 2:39 PM with Licensed Practical Nurse (LPN)3 confirmed that the incident between the 2 residents had occurred on 11/20/22 at 10:00 PM and was not reported to the state agency within the 2 hour time frame as required. During an interview on 03/21/23 at 03:38 PM, the Director of Nursing (DON) could not find documentation to ensure the altercation between R1 and R2 was reported to the state agency within the required 2 hours. At this time, the surveyor also made the DON aware that the 5 day follow up was late and was sent to the state agency on 12/02/22 at 18:44 (6:44 PM) more than the 5 days as required.

Based on record review, observations and interviews, the facility failed to provide personal care to Resident (R)7 within a timely manner, prior to a Dialysis appointment. 1 of 1 resident reviewed for activities of daily living (ADL)s. Findings include: R7 was admitted to the facility on [DATE] with diagnoses including, but not limited to end stage renal disease, type 2 diabetes, and muscle weakness. Review of the Annual Mininum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/22 revealed R7 has a Brief Interview of Mental Status (BIMS) score of 13 out of 15, which indicates they are cognitively intact. R7 requires extensive assistance with ADLs. An observation and interview on 03/20/23 at 10:46 AM with R7 revealed them lying in bed in a T-shirt and pajama bottoms. R7 stated the facility has been short staffed on the weekends and at times during the week as well. There have been times that I have had to wait for someone to help me go to the bathroom for over an hour. Right now I am wet and I've been waiting for someone to come back to help me get dressed so I can go to Dialysis. Upon exit of R7's room on 03/20/23 at 11:06 AM, transport staff was waiting at the door to transfer R7 from the facility to their Dialysis appointment. Transport staff then went to alert facility staff that resident needed to use restroom and get dressed for appointment. An observation on 03/20/23 at 11:10 AM revealed 2 nursing staff went to assist R7 with ADL care. Further observation on 03/20/23 at 11:14 AM revealed Certified Nursing Assistant (CNA)1 entering R7's room to assist with care. During an interview on 03/20/23 at 11:15 AM, CNA1 stated that they were helping with another resident, in another room, and was unaware that R7 had to use the restroom or go to an appointment. CNA1 further stated that the facility is short on nursing aides today, because someone called out. An observation on 03/20/23 at 11:18 AM of R7 revealed them exiting their room with transportation staff to transport to their Dialysis appointment. A phone interview on 03/20/23 at 2:57 PM with R7's Resident Representative (RR) revealed R7 has had to wait long periods of time to be changed or assisted to the restroom. This has been ongoing for months. R7 is able to use the toilet however, if staff came in a decent time, R7 wouldn't have to use his brief or wet himself. I haven't been able to visit him because I live far away, but when R7 calls me about being left wet, I call the facility and tell them they need to change him. However, I'm told that he only has to wait for a long time because it's a shift change or before mealtime, so it takes a while at times. Record review of R7's Care Plan last revised 12/5/22, revealed R7 has bowel and bladder incontinence with the potential for constipation. Interventions are to check routinely for incontinence, change clothing as needed after incontinence episodes, monitor and document bowel movement, and monitor/document for signs of Urinary Tract Infection (UTI). An interview on 03/21/23 at 3:25 PM with the Director of Nursing (DON) revealed that the facility has been working 1:1 with this resident related to his concerns of having to wait a long time to receive care. The DON further stated that they have been reviewing the cameras when the resident calls for help to document call light response times because the resident can over-exaggerate how long he has to wait for help at times. The DON confirmed staff are expected to answer and respond to call lights in a timely manner.

Based on review of the facility policy, observations, and interviews, the facility failed to provide food storage in a safe manner in 1 of 1 main kitchen. This had the potential to affect all residents who consume food from the kitchen. Findings Include: Review of the facility policy titled, Date Marking for Food Safety with an implementation date of March 2022, revealed Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Policy Explanation and Complaisance for Staffing: 6. The head cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. Review of the facility policy titled, Sanitation Inspection with an implementation date of March 2022, revealed Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food services areas are clean, sanitary and in compliance with . Policy Explanation and Compliance Guidelines: 4. Sanitation inspections will be conducted in the following manner: Daily. Food service staff shall inspect refrigerators/coolers, freezers storage area temperatures 5. Inspections will be conducted but not limited to the following areas: c. Refrigerator. Review of the Kitchen Inspection Audit form dated 09/22/2022 revealed the last inspection documented was performed on 09/18/2022. An observation during the initial kitchen walk through on 10/16/2022 at 11:36 AM revealed the following: 1. A case containing approximately 15 tomatoes in the refrigerator. The tomatoes appeared to be rotten with broken skin and leaking, the tomatoes also appeared to be moldy with a white and black fuzzy substance covering parts of all the tomatoes. 2. A tray containing 2 personalized cups of dressing. 1 cup spilled over with the dressing leaking on to the tray and both cups not properly covered. In an interview on 10/16/2022 at 11:45 AM with the Kitchen Manager (KM), verified the tomatoes and dressing, which were removed by the KM and discarded. In an interview on 10/19/2022 at 12:02 PM with the Administrator, revealed they are supposed to being doing audits everyday to monitor those things. The tomatoes are something that they overlooked. The Administrator further stated she was not able to get in touch with the KM to get clarification on why the last documented inspection on the Kitchen Inspection Audit form was 09/18/2022.

Based on review of the facility policy, observations, record reviews, and interviews, the facility failed to ensure 4 of 8 residents, (Resident (R)13, R68, R53, and R73), had their call light within reach. Findings Include: Review of the facility's policy titled, Call Lights: Accessibility and Timely Response dated August 2022, revealed, Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside . to allow residents to call for assistance. Policy Explanation and Compliance Guidelines: 1. All staff will be educated on . ensuring resident access to call light. 5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed. Review of R13's Face Sheet located in the electronic medical record (EMR) revealed an admitted [DATE] with medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R13's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/12/2022 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately impaired and required extensive assistance with one person physical assist with bed mobility, transfers, toilet use, and personal hygiene. Review of R13's Care Plan with a review date of 10/13/2022 revealed The resident is at risk for falls [related to] r/t weakness, impaired balance, poor endurance, potential medication effects, [history]hx of falls with interventions that included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review of R68's Face Sheet located in the EMR revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R68's admission MDS with an ARD of 09/21/2022 revealed a BIMS score of 12 out of 15, which indicated the resident was moderately impaired and required extensive assistance with one person physical assist with bed mobility, dressing, toilet use, and personal hygiene. Review of R68's Care Plan with a review date of 10/03/2022 revealed The resident is at risk for falls r/t impaired mobility weakness and short term memory loss with interventions that included Call light within reach and encourage the resident to use it, if not cognitively impaired, for assistance as needed. Review of R53's Face Sheet located in the EMR revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R53's Medicare 5-day MDS with an ARD of 09/11/2022 revealed a BIMS score of 14 out of 15, which indicated the resident was cognitively intact and required extensive assistance with two person physical assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of R73's Face Sheet located in the EMR revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R73's quarterly MDS with an ARD of 09/25/2022 revealed a BIMS score of 8 out of 15, which indicated the resident was moderately impaired and required extensive assistance with two person physical assist with bed mobility, transfers, and toilet use. Review of R73's Care Plan with a review date of 10/16/2022 revealed [R73] is at risk for falls r/t [[CONDITION(S)]] [CONDITION(S)] with residual effects, incontinence, Psychoactive drug use with interventions that included Call light within reach and encourage the resident to use it, if not cognitively impaired, for assistance as needed. During an observation on 10/19/2022 at 10:30 AM, R13's call light was on the floor underneath the resident's bed. During an observation and interview on 10/19/2022 at 10:39 AM, R53's call light was wrapped around the right bed rail and on the floor. R53 revealed that she could not find her call light and she does not receive assistance until someone comes to check on her and this has happened in the past. R53 further revealed, Staff don't make sure that I can reach my call light, they just change my brief and leave. During an observation and interview on 10/19/2022 at 10:45 AM, R73's call light was on the floor to the right side of the bed. R73 stated I don't use my call light, I just yell for them. During a random observation on 10/20/2022, R68's call light was wrapped around the side rail hanging off the side of the bed, out of the resident's reach. An interview on 10/19/2022 at 10:48 AM with Licensed Practical Nurse (LPN)1 revealed there have been no issues with the call lights on this unit. No residents or staff have notified me of any complaints regarding call lights on the floor. An interview on 10/19/2022 at 10:50 AM with Certified Nursing Assistant (CNA)2 revealed when my shift gets here in the morning, we have some issues with call lights not accessible to the residents. Before I leave a resident's room, I make sure they have their call light. An interview on 10/19/2022 at 10:53 AM with Housekeeping staff (HK)1 and HK2 revealed sometimes when we clean rooms the residents have asked us to move their call light closer so they can reach it. An interview on 10/19/2022 at 11:30 AM with the Director of Nursing (DON) revealed sometimes we get residents expressing concerns about response time but not about them (call lights) being in reach. The call lights should always be accessible to residents. That's the way the residents can call for help. Before the staff leave the residents room, they should be making sure the call light is in reach.

Based on review of the facility policy titled, Medication Storage, observations, and interviews, the facility failed to ensure expired medications and biologicals were removed from 2 of 2 treatment carts and not stored with other medications and biologicals for resident use on 2 of 2 halls, Green and Rose. Findings include: Review of the facility policy titled, Medication Storage, number 8 states, Unused medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. An observation on 10/18/22 at 9:40 AM of the treatment cart on Rose Hall revealed, 2 bottles of DUKAL [MEDICATION(S)] sterile wound packing medicated gauze, Lot A . One bottle contained an open date, but no expiration date. The second bottle did not contain an open date or an expiration date. Further observation on 10/19/22 at 9:40 AM of the treatment cart on Rose Hall revealed 1 packaged sheet of Aqua Derm Wound Dressing 5 x 9 Lot# B 960 with an expiration date of 06/01/24, opened and partially used, no longer sterile, and placed back on the treatment cart for use. An observation on 10/18/22 at 10:00 AM of the treatment cart on the Green Hall revealed 2 bottles of DUKAL sterile [MEDICATION(S)] wound packing, medicated gauze with Corp. Ref 273 - Lot A . One bottle was opened and partially used, without an expiration date. The second bottle was unopened with no expiration date. Further review of the treatment cart revealed an opened DermaRite dressing, no longer sterile, 4 x 4 with lot #F- 508 that expires on 05/07/25. One bottle of T/Gel Shampoo Original Formula - manufactured by Neutrogena, 1 application expired on 8/22/22, and one bottle 16 fluid ounces of Instant Hand Sanitizer with Vitamin E, Lot # A expired on 3/2022. An interview on 10/18/22 at 1:10 PM with the Director of Nursing (DON) confirmed the findings. The DON stated that she spoke with the pharmacy and was told that the [MEDICATION(S)] should not be put back into the bottle for resident use once it is pulled out and cut. She also stated the pharmacy representative told her that the medication does not expire. The pharmacy provided a copy of the safety data sheet for DUKAL [MEDICATION(S)] packing strips. The section titled, Storage Section 7 states, Non-hazardous storage: Store in original package. Discard used portion. Do not reuse. No special storage conditions required. The safety data sheet did not indicate that the [MEDICATION(S)] does not expire.

Based on review of the facility policy, record review, and interviews, the facility failed to ensure Resident(R)33 was invited to attend care planning meetings and to have input on focused care areas, goals and interventions recognized by the facility for 1 of 1 resident reviewed for care planning. Findings include: Review of the facility's policy titled, Comprehensive Care Plans dated Sept. 2022 revealed . The comprehensive care plan will be prepared by an interdisciplinary team, that's includes, but is not limited to: . d. The resident and the resident representative, to the extent practicable. R33 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/22/22 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicated she was cognitively intact. During an interview on 10/16/22 at 1:28 PM, R33 stated that she was not invited to care plans and did not know what a care plan was. Review on 10/18/22 of the medical record for R33 revealed no care planning attendance sheet nor any documentation indicating resident's refusal to attend the care plan meeting. During an interview on 10/18/22 at 11:37 AM with the Social Services Director (SSD) revealed that the resident does not go to care plan meetings because the resident refuses. The SSD had no documentation of resident refusing to attend care plan meetings. During an interview on 10/18/22 at 11:52 AM with the Care Plan Coordinator (CPC) revealed that she has only been working at the facility for two weeks. The CPC revealed that prior to her working, a regional employee was taking care of all the care plans. When asked to provide sign in sheets for the care plan meetings, she revealed that there was none that she knew of. There was no documentation of care plan meetings for this resident. During an interview on 10/18/22 at 12:45 PM, the Director of Nursing (DON) provided documentation of one email from R33's daughter, as well as a Payer Source Verification for Therapy. The DON did not provide documentation of refusal of attending care plan meetings. The DON also did not provide documentation of care plan meeting sign-in sheets.

Based on review of the facility policy, observations, and interviews, the facility failed to maintain the dumpster area in a sanitary manner to prevent the harborage of pests for 1 out of 2 dumpsters. Findings Include: Review of the facility policy titled, Disposal of Garbage and Refuse with an implementation date of March 2022 revealed, Policy: The facility shall properly dispose of kitchen garbage and refuse. Policy Explanation and Compliance Guidelines: 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. During the initial kitchen tour on 10/16/2022 at 11:36 AM, observations were made of the facility's dumpster area. There were 2 large dumpsters and a large recycle bin labeled Cardboard Only. Of the two dumpsters, one dumpster did not have a lid. In an interview on 10/16/2022 at 12:10 PM, the Kitchen Manager (KM) verified the lid was missing on one of the two dumpsters. The KM further stated the garbage man broke it. In an interview on 10/19/2022 at 12:02 PM, the Administrator revealed she was unaware of the missing lid on the dumpster and they just made her aware of it.

Based on record review, interview, and facility policy review the facility failed to electronically submit Minimum Data Set (MDS) information within 14 days for 23 of 50 residents reviewed of MDS submission. (Resident #1, #3, #7, #8, #9, #12, #13, #15, #18, #22, #24, #26, #27, #28, #29, #36, #37, #40, #43, #46, #47, #48, #49) Findings include: Review of the facility policy titled MDS - Minimum Data Set, dated dated dated ,d+[DATE] revealed .7. Transmission Requirements: a. All assessments shall be transmitted to the designated CMS system (QIES [Quality Improvement and Evaluation] ASAP [Assessment Submission and. Processing]) within 14 days of completion. b. Each assessment must be accepted into the system and verified on the Validation Reports Resident #7 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH (Nursing Home) Final Validation Report dated 6/10/21 revealed Resident #7's Omnibus Budget Reconciliation Act (OBRA) Entry Tracking Assessment was completed on 5/19/21 and submitted on 6/10/21, more than 14 days after the entry. Review of the facility MDS 3.0 NH Final Validation Report dated 6/16/21 revealed Resident #7 had an Admission Assessment completed on 5/28/21 and submitted on 6/16/21, more than 14 days after the Care Plan completion date of 5/28/21. Resident #28 was admitted to the facility on [DATE] and was discharged to the hospital on 5/3/21. Review of the facility MDS 3.0 NH Final Validation Report dated 6/10/21 revealed Resident #28 had an Entry Tracking Assessment completed on 5/5/21 and submitted on 6/10/21, more than 14 days after the completion date. Further review revealed Resident #28 had a Discharge Assessment completed on 5/10/21 and submitted on 6/10/2021, more than 14 days after the completion date. Resident #1 was admitted to the facility on [DATE] and was discharged on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/10/21 revealed Resident #1 had a Discharge Assessment completed on 5/18/21 and submitted on 6/10/21, more than 14 days after the completion date. Resident #27 was admitted to the facility on [DATE] and was discharged (death in facility) on 5/8/21. Review of the facility MDS 3.0 NH Final Validation Report dated 6/10/21 revealed Resident #27 had a discharge date of [DATE]; the Discharge Assessment was submitted on 6/10/21, more than 14 days after the resident's discharge date . Resident #3 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/10/21 revealed Resident #3 had a Quarterly Assessment completed on 5/18/21 and submitted on 6/10/21, more than 14 days after the completion date. Resident #48 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/10/21 revealed Resident #48 had an Entry Tracking Record completed on 5/24/21 and submitted on 6/10/21, more than 14 days after the entry date. The MDS 3.0 NH Final Validation Report dated 6/24/21 revealed Resident #48 had a Discharge Assessment completed on 6/24/21, more than 14 days after the ARD of 5/26/21. Resident #22 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/10/21 revealed Resident #22 had a Quarterly Assessment completed on 5/14/21 and submitted on 6/10/21, more than 14 days after the completion date. Resident #43 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/10/21 revealed Resident #43 had a Quarterly Assessment completed on 5/14/21 and submitted on 6/10/21, more than 14 days after the completion date. Resident #29 was admitted to the facility on [DATE], was discharged on [DATE] and returned to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/10/21 revealed Resident #29 had a Discharge Assessment completed on 5/14/21 and submitted on 6/10/21, more than 14 days after the completion date. Review of the facility MDS 3.0 NH Final Validation Report dated 6/24/21 revealed Resident #29 had an Entry Tracking Record completed on 5/21/21 and submitted on 6/24/21, more than 14 days after the entry date. Resident #49 was admitted to the facility on [DATE], was discharged on [DATE] and readmitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/10/21 revealed Resident #49 had an Entry Tracking Record dated 5/26/21 and submitted on 6/10/21, more than 14 days after the entry date. Review of the facility MDS 3.0 NH Final Validation Report dated 6/24/21 revealed Resident #49 had a Discharge Assessment completed on 5/28/21 and submitted on 6/24/21, more than 14 days after the completion date. Resident #15 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/10/21 revealed Resident #15 had a Quarterly Assessment completed 5/14/21 and submitted on 6/10/21, more than 14 days after the completion date. Resident #8 was admitted to the facility on [DATE], was discharged on [DATE] and readmitted on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/25/21 revealed Resident #8 had an Entry Tracking Record dated 6/2/21 and submitted on 6/25/21, more than 14 days after the entry date. Resident #24 was admitted to the facility on [DATE] and was discharged from the facility on 5/16/21. Review of the facility MDS 3.0 NH Final Validation Report dated 6/25/21 revealed Resident #24 had a Discharge Assessment completed on 5/18/21 and submitted on 6/25/21, more than 14 days after the completion date. Resident #26 was admitted to the facility on [DATE] and was discharged on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/25/21 revealed Resident #26 had a Death in Facility Tracking Record completed on 5/13/21 and submitted on 6/25/21, more than 14 days after the discharge date . Resident #40 was admitted to the facility on [DATE] and was discharged on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/25/21 revealed Resident #40 had a Death in Facility Tracking Record dated 5/22/21 that was submitted on 6/25/21, more than 14 days after the discharge date . Resident #37 was admitted to the facility on [DATE] and was discharged from the facility on 6/8/21. Review of the facility MDS 3.0 NH Final Validation Report dated 6/16/21 revealed Resident #37 had an Entry Tracking Record completed on 5/26/21 and submitted on 6/16/21, more than 14 days after the completion date. Resident #9 was admitted to the facility on [DATE] and was discharged on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/24/21 revealed Resident #9 had a Death in Facility Tracking Record completed on 5/11/21 and submitted on 6/24/21, more than 14 days after the entry date. Resident #12 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/24/21 revealed Resident #12 had an entry tracking record completed on 6/9/21 and submitted on 6/24/21, more than 14 days after the completion date. Resident #36 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/16/21 revealed Resident #36 hand an Entry Tracking Record completed on 5/26/21 and submitted on 6/16/21, more than 14 days after the entry date. Resident #18 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/16/21 revealed Resident #18 had a Quarterly Assessment with an entry date of 5/28/21 submitted on 6/16/21, more than 14 days after the entry date. Resident #13 was admitted to the facility on [DATE] and was discharged on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/10/21 revealed Resident #13 had a Discharge Assessment completed on 5/31/21, more than 14 days after the ARD (Assessment Reference Date). Resident #47 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/24/21 revealed Resident #47 had an Entry Tracking Record completed on 6/24/21, more than 14 days after the entry date of 6/7/21. Resident #46 was admitted to the facility on [DATE] and was discharged on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/25/21 revealed Resident #46 had a Discharge Assessment completed on 6/24/21, more than 14 days after the ARD date of 6/8/21. During an interview on 6/23/21 at 2:43 p.m., Licensed Practical Nurse (LPN) #1stated that s/he worked at a sister facility and was filling in part-time as the MDS Coordinator in this facility. S/he stated that the MDS assessments were behind, and s/he was working on helping the facility get caught up. During an interview on 6/23/21 at 2:55 p.m., the Director of Nursing (DON)stated that the full-time MDS Coordinator resigned on 6/21/21. The MDS Coordinator from a sister facility was helping part-time, and someone from corporate was coming in to help. The DON stated that s/he had not reviewed the facility MDS reports for completion or timely submission but would be reviewing them while the facility was without a full-time MDS Coordinator. The DON stated that the previous MDS Coordinator informed her/him that the facility was caught up with completing and submitting MDS data on time. During an interview on 6/25/21 at 8:37 a.m., the Administrator stated that the facility had IT (Information Technology) issues when the facility transitioned to a new company on 5/1/2021. The Administrator stated that the facility computer system did not go live for several weeks and MDS data was not submitted during that time.

Based on record review, interview, and facility policy review the facility failed to complete non-comprehensive assessments at least every 92 days following the previous Omnibus Budget Reconciliation Act (OBRA) assessment for 7 (seven) of 50 residents reviewed for Minimum Data Set (MDS) submission. (Residents #17, #14, #19, #23, #28, #30, #32) Findings include: Review of the facility policy titled MDS - Minimum Data Set, dated dated dated ,d+[DATE] revealed .e. Quarterly Assessment - completed using an ARD no > [greater than] 92 days from the most recent prior quarterly or comprehensive assessment (counting ARD [Assessment Reference Date] to ARD) Resident #17 was admitted to the facility on [DATE]. Review of the facility report titled MDS 3.0 Assessment Summary Report dated 5/1/2021 through 6/23/21 revealed the resident's Quarterly Assessment was due on 6/16/21 and was not completed. Resident #28 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH (Nursing Home) Final Validation Report dated 6/24/21 revealed Resident #28 had a Quarterly Assessment completed on 6/24/21, more than 14 days after the ARD of 6/9/21. Resident #19 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/25/21 revealed Resident #19 had a Quarterly Assessment completed on 6/24/21, more than 14 days after the ARD of 6/2/21. Resident #14 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/24/21 revealed Resident #14 had a Quarterly Assessment completed on 6/24/21, more than 14 days after the ARD of 5/28/21. Resident #30 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/24/21 revealed Resident #30 had a Quarterly Assessment completed on 6/24/21, more than 14 days after the ARD of 5/28/21. Resident #32 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/24/21 revealed Resident #32 had a Quarterly Assessment completed on 6/16/21, more than 14 days after the ARD of 5/28/21. Resident #23 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/25/21 revealed Resident #23 had a quarterly assessment completed on 6/24/21, more than 14 days after the ARD of 6/9/21. During an interview on 6/23/21 at 2:43 p.m., Licensed Practical Nurse (LPN) #1 stated that s/he works at a sister facility and is filling in part-time as the MDS Coordinator at this facility. S/he stated that the MDS assessments were late, and s/he was working on helping the facility get caught up. During an interview on 6/23/21 at 2:55 p.m., the Director of Nursing (DON)stated that the full-time MDS Coordinator resigned on 6/21/21. The MDS Coordinator from a sister facility was helping part-time, and someone from corporate was coming in to help. The DON stated that s/he had not reviewed the facility MDS reports for completion or timely submission but will be reviewing them while the facility was without a full-time MDS Coordinator. The DON stated that the previous MDS Coordinator informed her/him that the facility was caught up and completed and submitted the MDS data on time.

Based on record review, interview, and facility policy review the facility failed to complete Comprehensive Assessments within 14 calendar days after admission and not less than once every 12 months for 8 (eight) out of 50 residents reviewed for Minimum Data Set (MDS) submission. (Resident #29, #31, #34, #35, #37, #41, #42, #44) Findings include: Review of the facility policy titled MDS - Minimum Data Set, dated dated dated ,d+[DATE] revealed .OBRA [Omnibus Budget Reconciliation Act] Assessments: a. Entry Tracking complete and submit with every entry into the facility no later than entry date +7 calendar days. b. Admission Assessment - completed within 14 days of admission counting the day of admission as day #1 when: The resident has no prior admission, or Prior admission was less than 14 days and no admission assessment were completed during the prior admission, or Prior admission ended with a Discharge Return not Anticipated; or Prior admission ended with a discharge Return Anticipated and re-entry occurred > [greater than] 30 days after the discharge date . c. Annual Assessment - a comprehensive assessment completed using an ARD no >366 days from the most recent prior comprehensive assessment and no > 92 days from the most recent quarterly assessment (counting ARD [Assessment Reference Dat] to ARD) Resident #29 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH (Nursing Home) Final Validation Report dated 6/25/21 revealed Resident #29 had an Annual Comprehensive Assessment completed on 6/24/21, more than 14 days after the ARD of 5/28/21. Resident #34 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/25/21 revealed the resident had an Admission Assessment completed 6/24/21, more than 14 days after the ARD date of 6/9/21. Resident #37 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/16/21 revealed Resident #37 had an Admission Assessment completed on 6/16/21, more than 14 days after the entry date of 5/26/21. Resident #35 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/24/21 revealed Resident #35 had an Admission Assessment completed on 6/24/21, more than 14 days after the entry date of 5/28/21. Resident #31 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/24/21 revealed Resident #31 had an Annual Assessment completed on 5/14/21. The CAA (Care Area Assessment) was completed on 6/24/21, more than 14 days after the ARD of 5/14/21. Resident #44 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/16/21 revealed Resident #44 had an Admission Assessment completed on 6/16/21 more than 14 days after the entry date of 6/2/21. Resident #42 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/16/21 revealed Resident #42 had an Admission Assessment completed on 6/16/21, more than 14 days after the ARD or 5/28/21. Resident #41 was admitted to the facility on [DATE]. Review of the facility MDS 3.0 NH Final Validation Report dated 6/16/21 revealed Resident #41 had an Admission Assessment completed on 6/16/21, more than 14 days after the ARD of 5/28/21. During an interview on 6/23/21 at 2:43 p.m., Licensed Practical Nurse (LPN) #1 stated that s/he worked at a sister facility and was filling in part-time as the MDS Coordinator in this facility. S/he stated that the MDS assessments were behind, and s/he was working on helping the facility get caught up. During an interview on 6/23/21 at 2:55 p.m., the Director of Nursing (DON) stated that the full-time MDS Coordinator resigned on 6/21/21. The MDS Coordinator from a sister facility was helping part-time, and someone from corporate was coming in to help. The DON stated that s/he had not reviewed the facility MDS reports for completion or timely submission but would be reviewing them while the facility was without a full-time MDS Coordinator. The DON stated that the previous MDS Coordinator informed her/him that the facility was caught up with completing and submitting MDS data on time.

Based on observation, interview, and record review, the facility failed to provide appropriate oxygen care to Resident #52 for 1 of 1 observed. Resident #52 was admitted to this facility on 09/10/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation and interview on 06/15/21 at 12:50 PM with Licensed Practical Nurse (LPN) #1 revealed that the tubing and humidifier was dated 6/6/21 and the water bottle/humidifier was empty, and the filter of the oximeter needed changing. A record review on 6/15/2021 at approximately 2:30 PM revealed a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, interviews, and record review, the facility failed to implement an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the spread of the Coronavirus (COVID-19) and other infections. Specifically, the facility failed to: 1. Ensure multi-use vital sign equipment (blood pressure curve and pulsed oximeter) was disinfected between residents' use for four of four residents (Rooms #217, #218, #220, and #222) observed; and 2. Ensure staff donned gloves and had access to hand hygiene opportunity before they went into the rooms of residents who were persons under investigation (PUI) for COVID-19 for one (200 hall) of two units with residents on isolation. This deficient practice occurred during the COVID-19 pandemic and had the potential to affect all residents. Findings included: A publication by Occupational Safety and Health Administration (OSHA): Title 29 Part 1910.1030. Bloodborne pathogens (accessed on 01/15/2021 from http://www.ecfr.gov/cgi-bin/textidx?SID=4e5245f d270bc2bd f6a92d&mc=true&node=se29.6.1910_ &rgn=div8), included the following: Standard Precautions: equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents (e.g., wear gloves for direct contact, properly clean and disinfect or sterilize reusable equipment before use on another patient). A Centers for Disease Control and Prevention (CDC) publication on Hand Hygiene Guidance, retrieved from: https://www.cdc.gov/handhygiene/providers/guidelin.html (updated 1/30/2020, retrieved on 01/15/2021), read in part, Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores. When using alcohol-based hand sanitizer, put the product on hands and rub hands together. Cover all surfaces until hands feel dry. This should take around 20 seconds. When cleaning hands with soap and water, wet hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. On 01/14/2021 at 8:47 AM, an initial tour of the facility revealed the facility had signage which cautioned staff about what personal protective equipment (PPE) was required when they went in the rooms of residents who were persons under investigation (PUI) for COVID-19. A count of 22 rooms was made, however, the observation revealed there were only two isolation carts on the entire hallway. There was no observation of hand sanitizer dispensers outside the residents' rooms. Staff were not carrying hand sanitizers. On 01/14/2020 at 9:34 AM, Licensed Practical Nurse (LPN) #1 was observed as s/he pushed mounted vital sign equipment towards room [ROOM NUMBER]. The room had a resident in isolation. Upon his/her arrival at the room door, s/he knocked and announced his/her presence. S/he told the resident s/he was there to pass medication and to record the resident's vital signs. After the announcement, the LPN opened the door and pushed the mounted vital sign equipment with him/her into the room. After s/he had entered the room, the LPN set the vital sign equipment up directly in front of the resident who lived in the room. S/he wrapped the blood pressure (BP) cuff (an inflatable portion of the blood pressure machine) around the resident's left arm and clipped a pulse oximeter (a device used to measure a person's blood oxygen level) on a finger on the same arm. The LPN had poured the resident's pills in a small disposable clear cup. The LPN sat the cup containing the pills on a bedside table which was positioned in front of the resident. S/he unwrapped the BP cuff and then unclipped the pulse oximeter from the resident's finger. The LPN immediately sat the equipment back on the mount. S/he advised the resident to take the pills which sat on the table and waited with the resident until the resident took all the pills. After the resident was done taking the pills, the LPN retrieved the cup described above and placed it in the trash can. Afterwards, the LPN dragged the vital sign machine behind him/her into the hallway. When out in the hallway, the LPN's next stops were Rooms #218, #220, and #222. S/he repeated the exact sequence described above while in the rooms. After s/he was done providing care for the resident in room [ROOM NUMBER], the LPN pushed the vital sign equipment back to the nursing station. The LPN failed to ensure s/he donned gloves as part of the PPE required when s/he went in a PUI room as instructed on the signage on the doors leading into the residents' rooms. S/he failed to offer hand hygiene to the residents when s/he passed the medication. The LPN failed to perform any sort of hand hygiene in between caring for the residents in the event described above. The LPN failed to disinfect the vital sign equipment after potentially exposing them to contaminant on and within the residents' rooms. By not performing hand hygiene between residents' care, the LPN failed to ensure s/he was not cross contaminating the residents with whatever contaminant was picked up on and within the residents' rooms. On 01/14/2021 at 9:52 AM, LPN #1 was interviewed. The LPN said s/he received training on frequent handwashing, social distancing, use of face mask, timely reporting of symptoms, and cleaning of equipment. The LPN said when s/he passed medication or took residents' vital signs, s/he ensured s/he wore a mask going in the resident's room. S/he said s/he greeted the resident when in the room and made the resident aware of what s/he was there to do. S/he said s/he would offer hand hygiene to the resident and performed the same on her/himself. The LPN said s/he would disinfect the equipment before and after use with the resident. The LPN however acknowledged s/he did not perform hand hygiene nor offered the same to the residents s/he cared for in the events above. S/he acknowledged s/he did not disinfect the identified equipment between residents' care. S/he said there was the potential to transmit infection when s/he failed to perform hand hygiene and disinfect the identified equipment between residents' care. On 01/14/2021 at 10:29 AM, LPN #2 was observed as s/he passed medication in Rooms #201 through room [ROOM NUMBER]. The rooms had residents on isolation. There was signage on the door which advised staff of what PPE was required going into the resident's rooms. The LPN failed to perform hand hygiene when s/he went in the resident rooms. S/he also failed to don gloves as part of the PPE required when s/he went in as they were isolation rooms as discussed above. On 01/14/2021 at 11:57 AM, LPN #2 was interviewed. S/he said s/he was not performing hand hygiene as described above because s/he ran out of hand sanitizer on her medication cart and did not go to get it refilled. S/he acknowledged that although, s/he knew the residents s/he cared for were PUI's, s/he did not don gloves when s/he went in residents' rooms to pass medication. On 01/14/2021 at 10:43 AM, Registered Nurse (RN) #1 went into Rooms #230, #232, and #233. The rooms had a residents on droplet precautions. The RN did not perform hand hygiene prior to donning gloves. On 01/14/2020 at 12:07 PM, RN #1 was interviewed. S/he said s/he missed hand hygiene prior to donning gloves because there was no hand sanitizer on isolation carts. S/he said the only other place s/he was able to access hand hygiene supplies was in the residents' rooms. On 01/14/2021 at 4:48 PM, the infection control preventionist (ICP) was interviewed in company of the Director of Nursing (DON) and Executive Director (ED). The ICP said s/he was part of the quality assessment (QA) committee and conducted training with staff on infection control and prevention practices. S/he said s/he in-serviced with staff on a weekly and as needed (PRN) basis. S/he enumerated the training s/he had provided to staff which included handwashing, cough etiquette, social distancing, use of face covering, timely reporting of symptoms, and cleaning of equipment. The ICP went through an overview of the importance of hand hygiene and disinfecting shared care equipment. S/he said hand hygiene was a standard infection control practice in a healthcare setting. S/he said direct care staffs' failure to perform proper hand hygiene was a fast way to spread germs. S/he said staff should perform hand hygiene between tasks, in-between residents' care, when they went in the toilet, when they adjusted their masks, and before they donned new gloves. S/he said the isolation cart was essential to ensure staff had access to the required PPE and alcohol-based hand rubs. S/he said shared equipment should be cleaned between each use to prevent spread of infection.

Based on observations, staff interviews and record review, the facility failed to store controlled substances (schedule III and IV medications) in a permanently affixed locked compartment for 1 of 2 medication rooms. The findings included: During an observation of the Rose Wing medication room on 04/17/2020 at 5:55 PM, a locked controlled substances drug box was observed in the medication room refrigerator. The controlled substances drug box contained 3 separated locked compartments within the box. The box was not permanently affixed to the refrigerator, and the refrigerator was not locked or permanently affixed. The controlled substances drug box contained the following: - Compartment #2 contained Resident #4's Schedule IV medication of [MEDICATION NAME] 2 mg/ml (milligrams/milliliter) (an anti-anxiety). There was 27.75 mg left in the bottle, after dispensed on 03/30/2020. According to the Federal Drug Administration (www.fda.gov), [MEDICATION NAME] ([MEDICATION NAME]) is a federal controlled substance (C-IV) because it can be abused or lead to dependence. - Compartment #1 contained Resident #5's Schedule III medication of dronabinol 5 mg and there were 6 capsules left in the bottle, after dispensed on 04/17/2020. According to the Federal Drug Administration (www.fda.gov), [MEDICATION NAME]® (Dronabinol) Capsules is one of the psychoactive compounds present in cannabis, and is abusable and controlled (Schedule III (CIII)) under the Controlled Substances Act. - Compartment #1 contained Resident #6's Schedule III medication of dronabinol 2.5 mg and there were 82 capsules left in the bottle, after dispensed on 04/17/2020. An interview with Nurse #1 on 04/17/2020 at 6:05 PM indicated the scheduled nurse on the hall had a key to the medication room and a key to the locked compartment (#2) of the controlled drug box for their assigned residents (Resident #4). An interview with Nurse #2 on 04/17/2020 at 6:05 PM indicated the scheduled nurse on the hall had a key to the medication room and a key to the locked compartment (#1) of the controlled drug box for their assigned residents (Resident #5 and Resident #6). An interview with the Consultant Pharmacist on 04/18/2020 at 10:45 AM indicated that she did not look for the medication box being permanently affixed, just that the controlled medications were under double lock. She further stated the medication room was kept locked and the 3-compartment box was locked. An interview with the Director of Nursing on 04/18/2020 at 1:20 PM indicated the refrigerator would be locked until Monday. She further stated she would get with the Maintenance Director to see how they could go about permanently affixing the controlled substances medication box in the refrigerator. Review of the facility's policy dated 04/2019 entitled Controlled Substances, didn't speak to the controlled substances being in a permanently affixed compartment.

Based on observation and interview, the facility failed to ensure it was free of expired medications. Expired medications were observed in 3 of 4 medication carts. The findings included: Observation on 6/20/19 at approximately 3:04 PM of the medication cart for the front hall of the Rose Wing revealed (1) box of [MEDICATION NAME] tablets with an expiration date of 6/8/19. At the time of the observation, the Director of Nursing removed the expired box of [MEDICATION NAME] tablets from the medication cart. Observation on 6/20/19 at approximately 5:45 PM of the medication cart for the front hall of the Green Wing revealed (1) box of [MEDICATION NAME] with an expiration date of 1/19. Review on 6/20/19 at 5:40 PM of the medication cart for the back hall of the Green Wing revealed the following: (1) bottle of Aspirin 81 milligrams with an expiration date of 12/17; (1) bottle of Sugar Free(SF) Prostat 30 fluid ounces opened on 5/2/19 with an expiration date of 5/8/19. At the time of the observation, Licensed Practical Nurse #1 confirmed the Aspirin and SF Prostat had expired.

Based on record review and interview, the facility failed to have Hospice documentation in the facility for 1 of 2 residents reviewed for Hospice services (Resident #229). The findings included: The facility admitted Resident #229 to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/19/19 at 11:00 AM, during review of Resident #229's medical record, this Surveyor asked the Administrator and Unit Manager for the Hospice documentation. The Administrator stated, Hospice documentation is kept in a separate record for each resident depending on their Hospice provider. The Administrator and Surveyor both looked for Resident #229's documentation and it was not present. On 6/19/19 at 5:30 PM, the Administrator provided a Hospice binder for Resident #229. The documents inside the binder had all been facsimiled, time stamped, and dated with times ranging from 4:01 PM to 5:08 PM on 6/19/19, indicating the chart had just been been created. During an interview with the Hospice nurse on 6/19/2019, s/he stated Hospice documentation was kept in the facility, with the notebook being created by the Admitting Hospice Nurse upon admission. The Administrator confirmed the notebook had just been created and that the documentation had been faxed over to the facility and was not in-house. Review of the Hospice policy on 6/20/19 at 4:15 PM revealed it stated, Information from Hospice may include the election form, Physician certification and recertification of the terminal illness, contact information for Hospice, and additional information as indicated. It also stated, Staff communicates with Hospice and coordinates care for the residents and provides information on policy and procedures as indicated including appropriate forms, and documentation requirements.

Based on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing and in a language and manner they understand upon transfer to the hospital for Residents #71, #42 and #60. (3 of 9 residents reviewed for hospitalization ) The findings included: The facility admitted Resident #60 with [DIAGNOSES REDACTED]. Record review on 5/1/18 at 4:36 PM revealed Resident #60 was discharged to the hospital on [DATE] and 3/4/18 due to chest pain. Further record review revealed there was no documentation Resident #60 received the information in writing of why s/he was being transferred to the hospital. The facility admitted Resident #71 with [DIAGNOSES REDACTED]. Record review on 5/3/18 at 1:54 PM revealed Resident #71 was discharged to the hospital on [DATE] at 1:09 PM. Further review revealed there was no documentation Resident #71 received the information in writing of why s/he was being transferred to the hospital. During an interview with the Social Service Director on 5/4/18 at 9:15 AM, s/he stated was unaware of what information was sent with the resident upon discharge to the hospital. The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Record review on 05/01/18 at approximately 4:25 PM revealed a Nurses Note dated 03/21/18 stating, MD evaluated resident, looked over labs, kidneys worsening, high white blood count, order to send to emergency room for evaluation. Further review revealed a subsequent note dated 03/22/18 Patient admitted to the hospital under 10 day Medicaid BH (Bedhold) 03/21-03/30/18. Spoke with Case Manager. No documentation of written Transfer/Discharge notice provided to resident at time of transfer or Resident Representative.

Based on full and/or limited record reviews, interviews, and review of the facility policies, it was determined on [DATE] at 10:45 PM Immediate Jeopardy and/or Substandard Quality of Care existed for CFR483.75 F-520 which was identified at a scope and severity level of (J). Starting on [DATE], the facility failed to identify quality deficiencies related to Cardiopulmonary Resuscitation. The facility failed to identify, clarify, and implement a plan of action related to Advance Directives for Cardiopulmonary Resuscitation(CPR) and initiation of CPR. Failure of the Quality Assurance(QA) Committee to identify and implement action plans to ensure a resident who exhibited absence of pulse and respirations and did not receive Cardiopulmonary Resuscitation resulted in Immediate Jeopardy for Resident #125. The findings included: Based on record reviews and interviews, the facility failed to identify a concern related to initiating Cardiopulmonary resuscitation. During an interview with the Assistant Director of Nursing(ADON) on [DATE] at 10:03 PM, he/she stated Resident #125's chart had not been audited. Further interview with the ADON on [DATE] at 4:09 PM revealed closed records were not reviewed in the Quality Assurance process. The only item reviewed was physician orders [REDACTED]. Based on full and/or limited record reviews, interviews, and review of the facility policies, it was determined on [DATE] at approximately 10:40 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility. The facility Administrator, Director of Nursing and Assistant Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 10:45 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on [DATE] at 3:44 PM and the Immediate Jeopardy at F-155, F-250, F-309, F-490, F-501 and F-520 was removed but the citation remained. The AOC included the following: 1. Resident No. 125 no longer resides in the facility. All other residents are at risk. 2. We have revived our policy and procedure/protocol concerning Advance Directives and made the following revisions: (1) added language to make it clear that we do not provide legal advice, make decisions for residents or interfere or influence a resident's decision; and (2) if a do not resuscitate directive is desired, a doctor's order should be documented on the chart and a red sticker placed on the chart next to the resident's name for easy identification. 3. An audit of all current residents' charts was conducted on [DATE], by the Director of Nursing (DON), Assistant Director of Nursing(ADON), Unit Manager, MDS Coordinator, and Staff Development Coordinator (SDC) to ensure that all residents who wish to have an Advance Directive have the Advance Directive documented on their chart; that a doctor's order for DNR is present on the chart; and the chart is labeled with a red sticker next to the resident's name for easy identification. all other residents will be treated as a full code. The resident, resident's family/RP, and attending physician will be notified of each resident's desire for a DNR. The family/RP and attending physician will be notified of any change of condition. 4. All licensed nurses and CNA's were in-serviced by the DON, ADON, and SDC on [DATE] on our revised policies; properly identifying each resident's code status and ensure that it is documented on the resident's chart if the resident is a DNR; on assessing the resident and documenting any change in condition; and documenting that the doctor and family/RP were notified. All licensed nurses and CNA's who were not available will be in-serviced as soon as they are available prior to being able to work. All newly-hired licensed nurses, agency nurses, CNA's, and agency CNA's will be inserviced during the orientation process. The DON and SDC will provide annual training for all licensed nurses. The DON will be responsible for all Advance Directives, obtaining a DNR where appropriate, and obtaining the signatures of two physicians when the resident is incapacitated. the ADON will be responsible in the absence of the DON. 5. The Unit Managers will monitor weekly x 4, then monthly x 3, and quarterly thereafter to ensure this deficiency does not recur.

Based on record review, interviews, and review of facility policies entitled Changes in a Resident's Condition or Status and deceased Residents, the facility failed to notify the resident's physician or legal representative of an accident, significant change in condition, or until after death for 2 of 10 residents reviewed for death and 1 of 3 residents reviewed for accidents. The facility failed to notify the physician of a significant change in condition and death for Resident #125, failed to notify the physician and responsible party until after death for Resident #69, and failed to notify the physician and responsible party of an accident for Resident #38. It was determined on [DATE] at approximately 10:45 PM Immediate Jeopardy existed at F157. The Immediate Jeopardy existed on [DATE] when licensed nursing staff failed to notify the physician of a decline and significant change in condition for Resident #125. The findings included: The facility admitted Resident #125 with [DIAGNOSES REDACTED]. Review of the closed medical record revealed Physician's Progress Notes dated [DATE] and [DATE] indicating the physician evaluated the resident on those dates. The Nurses Notes dated [DATE] at 10::29 PM indicated, family at bedside during this shift. The notation dated [DATE] at 10:10 PM indicated, Call by LPN (Licensed Practical Nurse) to declare death, BP-0, respiration-0, pain stimuli-0, pupil fixated. The notation dated [DATE] at 10:12 PM indicated, At 9:30 PM R/P (responsible party) notified of res (resident) declining condition, res noted (with) shallow breathing/periods of apnea, labored breathing, bil (bilateral) pupils in a fixed position, at 9:50 PM res noted (with) no vital signs, R/P arrived at 9:55 PM, funeral home called at 10:05 PM, at this time family at bedside. The Nurses Note dated [DATE] at 10:13 PM revealed, Time of death 9:50 PM. There were no further Nurses Notes in the medical record. Review of the vital signs record indicated, Res alert, non-labored breathing, no noted pain/discomfort was documented on [DATE] at 10:24 PM by LPN #1. Further review of the vital signs record indicated the resident's vital signs recorded on [DATE] at 2:03 PM were within range of those previously recorded during the resident's admission. During an interview on [DATE] at approximately 9:52 PM, the surveyor informed LPN #1 that, after reviewing Resident #125's record, there were some questions related to the Nurses Notes dated [DATE]. LPN #1 reviewed the Nurses Notes and Social Services notes. LPN #1 stated that the resident was declining, and he/she called the resident's responsible party. On [DATE] at approximately 10:00 PM, the surveyor asked the Assistant Director of Nursing (ADON) for information related to staff notifying the physician on [DATE] and requested LPN #1 to return to the conference room. The ADON returned to the conference room and stated that LPN #1 informed him/her (the ADON) that he/she (LPN #1) did not remember notifying the physician, but would have thought that he/she would have notified the physician. At that time, the ADON confirmed that there was no documentation in the record related to physician notification. During an interview on [DATE] at approximately 3:30 PM, the surveyor asked the Medical Director and resident's physician of record his/her expectations related to physician notification by staff. The Medical Director stated that he/she expected to be notified of any need for medication changes and any change in condition requiring physician attention. Record review revealed that the Physician's Orders and other documents in the record were signed by the Medical Director. When asked if he/she was familiar with Resident #125, the Medical Director stated, No. When asked if he/she was aware of the circumstances when the resident expired on [DATE], he/she stated that he/she heard that the resident expired, that he/she was only aware that the resident had expired. When asked when and how he/she became aware of this, the Medical Director stated that staff informed him/her that Resident #125 had expired after the fact. Review of the facility's policy entitled, Changes in a Resident's Condition or Status indicated under Policy, Our facility shall promptly notify the resident, his/her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . Under Policy and Implementation, #1 indicated, The Nurse Supervisor/Charge Nurse will notify the resident's attending physician or On-Call Physician when there has been: d. A significant change in the resident's physical/emotional/mental condition and e. A need to alter the resident's medical treatment significantly. Review of the policy entitled deceased Residents, revealed the policy stated, In the event a resident .shall become deceased while still in the facility, we should implement the following procedure: 1. Contact the physician . The policy further indicated, 9. All charting must reflect what you have done. Be sure to date and sign each entry . The facility admitted Resident #38 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 4:15 PM of the Incident Reports for Resident #38 had a fall on [DATE], [DATE] and [DATE]. On [DATE] Resident #38 fell and hit his/her head. Further review of the Incident Report dated [DATE] indicated that the physician was notified by fax and the family/responsible party was not notified at all of this fall. Review of the facility policy on [DATE] at approximately 4:40 PM of the facility policy titled, Falls-Policy and Procedures, number 5 states, Call physician if there is a blow to the head, any suspected serious injury, (i.e., fracture), any hip pain or more than minor pain elsewhere. If in doubt, call physician! In any case, fax copy of incident report to the physician and notify family. An interview on [DATE] at approximately 9:30 AM with Registered Nurse (RN) #2 confirmed that he/she would assess the resident and start neuro checks. RN #2 stated, he/she would certainly call the physician if the resident fell and hit his/her head. S/he went on to say that he/she would also notify the family or the responsible party. The family/responsible party were not notified of the fall on [DATE]. During an interview on [DATE] at approximately 9:49 AM with the Director of Nursing (DON) revealed that he/she would expect the nurse to call the physician if the resident fell and hit their head. He/she went on to say that the family/responsible party most definitely should be notified. The facility admitted Resident #69 with [DIAGNOSES REDACTED]. Resident #69 was also a Hospice patient. Review of the Nurses Notes on [DATE] at approximately 3:21 PM revealed a nurses note dated [DATE] at 10:37 AM and states, Resident seen by nurse, no complaints of pain and no signs or symptoms of distress or discomfort noted at this time. Further review of the Nurses Notes on [DATE] at approximately 3:21 PM revealed a nurses note dated [DATE] at 3:56 PM and states, Called by LPN (Licensed Practical Nurse) to declare death, BP-0, Apical Pulse-0, Respirations-0, Pupils dilated, Pain stimuli-0. A nurses note dated [DATE] at 4:05 PM states, Doctor notified. Hospice and family notified of resident's passing. Funeral home notified. The physician, Hospice nurse nor the family were notified until after the resident had expired. Review on [DATE] at approximately 3:36 PM of the facility policy titled, Changed in a Resident's Condition or Status, states, Our facility shall promptly notify the resident, his or her attending physician, and or representative (sponsor) of changes in the resident's medical/mental condition and/or status. During an interview on [DATE] at approximately 3:51 PM with the DON, he/she was very surprised that the Hospice Nurse, the Physician and the family were not notified until after Resident #69 had expired. The DON went on to say that he/she would expect the nurse to notify them promptly. Based on record review, interviews, and review of facility policies, it was determined on [DATE] at approximately 10:45 PM Immediate Jeopardy existed in the following area: CFR 483.10 F-157 was identified at a scope and severity level of (J). The Immediate Jeopardy existed on [DATE] when licensed nursing staff failed to notify the physician of a significant change in condition for Resident #125. The facility Administrator, Director of Nursing (DON), and ADON were informed of the Immediate Jeopardy on [DATE] at approximately 10:45 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on [DATE] at approximately 3:40 PM, and the Immediate Jeopardy at F-157 was removed and lowered in scope and severity to D. The AOC included the following: 1. Resident #125 no longer resides in the facility. All other residents are at risk. 2. We have reviewed our policy and procedure/protocol concerning Advance Directives and made the following revisions: (1) added language to make it clear that we do not provide legal advice, make decisions for residents or interfere or influence a resident's decision; and (2) if a do not resuscitate directive is desired, a doctor's order should be documented on the chart and a red sticker placed on the chart next to the resident's name for easy identification. 3. An audit of all current residents' charts was conducted on [DATE] by the DON, ADON, Unit Manager, MDS Coordinator, and Staff Development Coordinator (SDC) to ensure that all residents who wish to have an Advance Directive have the Advance Directive documented on their chart; that a doctor's order for DNR is present on the chart; and the chart is labeled with a red sticker next to the resident's name for easy identification. All other residents will be treated as a full code. The resident, resident's family/RP, and attending physician will be notified of each resident's desire for a DNR. The family/RP and attending physician will be notified of any change of condition. 4. All licensed nurses and CNAs were in-serviced by the DON, ADON, and SDC on [DATE] on our revised policies; properly identifying each resident's code status and ensuring that it is documented on the resident's chart if the resident is a DNR; on assessing the resident and documenting any change in condition; on documenting that the doctor and family/RP were notified. All licensed nurses and CNAs who were not available will be in-serviced as soon as they are available prior to being able to work. All newly-hired licensed nurses, agency nurses, CNAs and agency CNAs will be in-serviced during the orientation process. The DON and SDC will provide annual training for all licensed nurses. The DON will be responsible for all Advance Directives, obtaining a DNR where appropriate, and obtaining the signatures of two physicians when the resident is incapacitated. The ADON will be responsible in the absence of the DON. 5. The Unit Managers will monitor weekly x4, then monthly x3, and quarterly thereafter to ensure this deficiency does not recur.

Based on record review, interview, and review of the facility Admissions packet and policy entitled Advance Directive Protocol, the facility failed to provide medically-related social services for 1 of 31 residents reviewed for advance directives. Resident #125 was not afforded the right to formulate an Advanced Directive and proper paperwork filed within the facility/resident's medical record. It was determined on 1/29/16 at approximately 10:45 PM Immediate Jeopardy and Substandard Quality of Care existed at F250 for failure of the facility to ensure that advance directive information was documented and completed for Resident #125. The findings included: Cross refer to F-155 related to the facility's failure to afford Resident #125 or his/her responsible party the opportunity to formulate advance directives as evidenced by lack of documentation related to advance directives in the closed medical record. The facility admitted Resident #125 with [DIAGNOSES REDACTED]. Review of the closed medical record revealed the Physician's admission orders [REDACTED]. Review of the Physician's Progress Notes and Social Services progress notes revealed there was no documentation indicating the resident's code status or that this had been addressed upon admission with either the resident or resident's responsible party. Further review indicated no advance directive paperwork could be located in the record. On 1/29/16 at approximately 8:00 PM, the surveyor informed staff that the surveyor was unable to find any documentation in the medical record related to Resident #125's code status and no paperwork related to advance directives. The surveyor asked staff to review the medical record and provide any documentation related to advance directives. On 1/29/16 at approximately 9:50 PM, the Assistant Director of Nursing (ADON) returned the medical record and informed the surveyor that the record contained no documentation related to advance directives. During an interview on 1/30/16 at approximately 4:30 PM, Social Services staff #1 reviewed the medical record. At that time, Social Services staff #1 confirmed that the Social Services Notes did not address advance directives, the record did not contain any documentation related to advance directives, and there was no documentation related to the resident or resident's responsible party being afforded the opportunity to formulate advance directives. Review of the Social Services notes indicated the notations dated 10/28/15 and 1/30/15 were documented by Social Services staff #2. At that time, Social Services staff #1 was asked about the process for completing advance directives for newly admitted residents. Social Services staff #1 stated that this paperwork was done upon admission by either of the facility's two social services staff members. Social Services staff #1 indicated that the admission process would have been completed by Social Services staff #2 since the Social Service notes were documented by that staff member. During a telephone interview on 2/02/16 at approximately 9:45 AM, Social Services staff #2 was asked about the process for completing advance directives for newly admitted residents. Social Services staff #2 stated that this was done upon admission by the Social Services department. Social Services staff #2 further stated that if family members do not come in with a resident upon admission, the process is completed when the responsible party is available. When asked if he/she had completed the admission paperwork for Resident #125, he/she stated, No. During a telephone interview on 2/03/16 at approximately 12:50 PM, Social Services staff #1 stated that after the survey team exited the facility on 1/30/16, the admission information packet for Resident #125 had been located in some folders. Social Services staff #1 stated that he/she had completed the admission process with the resident's responsible party, and the last page of the admission packet was signed by the responsible party indicating information in the admission packet had been provided. Social Services staff #1 stated that the responsible party indicated during the admission process that existing advance directive documents would be reviewed and provided at a later time. Social Services staff #1 stated that he/she did not remember this information when talking with the survey team during the survey. Social Services staff #1 further stated that the resident's responsible party did not bring any advance directive paperwork back to the facility and stated that he/she never saw the resident's (responsible party) after admission to get the paperwork done. Social Services staff #1 confirmed that there was no advance directive paperwork in the admission papers which were located after the survey exit. Review of the Nursing Discharge Summary dated 11/01/15 indicated under Psychosocial: (family member) visits daily. Review of the facility's Admissions packet indicated under section f, Each resident has the right to make an informed decision concerning his/her medical care, including his/her right .to formulate advance directives .Copies of any advance directives made by the resident should be presented upon admission and will be maintained in the Business Office and on the medical record. Information included under the section entitled Medical Records, indicated, Records are maintained uniformly for all residents For each resident admitted to the facility, admission records will be completed including but not limited to: .#13 Advance directives . Review of the facility's policy entitled Advance Directive Protocol revealed information under bullet #3 stated, Advance Directives concerning an individual resident's medical care should be documented on the Assistant Director of Nursing on 1/29/16 resident's chart . The above information concerning the absence of documentation related to advance directives for Resident #125 was shared with the Administrator, Director of Nursing, and ADON on 1/29/16 at approximately 10:45 PM. CFR 483.15(9)(11) F-250 Medically related Social Services was identified at a scope and severity level of (J). The facility Administrator, Director of Nursing (DON), and ADON were informed of the Immediate Jeopardy and Substandard Quality of Care on 1/29/16 at approximately 10:45 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on 1/30/16 at approximately 3:40 PM, and the Immediate Jeopardy at F-250 was removed and lowered in scope and severity to D. The AOC included the following: 1. Resident #125 no longer resides in the facility. All other residents are at risk. 2. We have reviewed our policy and procedure/protocol concerning Advance Directives and made the following revisions: (1) added language to make it clear that we do not provide legal advice, make decisions for residents or interfere or influence a resident's decision; and (2) if a do not resuscitate directive is desired, a doctor's order should be documented on the chart and a red sticker placed on the chart next to the resident's name for easy identification. 3. An audit of all current residents' charts was conducted on 1/30/16 by the DON, ADON, Unit Manager, MDS Coordinator, and Staff Development Coordinator (SDC) to ensure that all residents who wish to have an Advance Directive have the Advance Directive documented on their chart; that a doctor's order for DNR is present on the chart; and the chart is labeled with a red sticker next to the resident's name for easy identification. All other residents will be treated as a full code. The resident, resident's family/RP, and attending physician will be notified of each resident's desire for a DNR. The family/RP and attending physician will be notified of any change of condition. 4. All licensed nurses and CNAs were in-serviced by the DON, ADON, and SDC on 1/30/16 on our revised policies; properly identifying each resident's code status and ensuring that it is documented on the resident's chart if the resident is a DNR; on assessing the resident and documenting any change in condition; on documenting that the doctor and family/RP were notified. All licensed nurses and CNAs who were not available will be in-serviced as soon as they are available prior to being able to work. All newly-hired licensed nurses, agency nurses, CNAs and agency CNAs will be in-serviced during the orientation process. The DON and SDC will provide annual training for all licensed nurses. The DON will be responsible for all Advance Directives, obtaining a DNR where appropriate, and obtaining the signatures of two physicians when the resident is incapacitated. The ADON will be responsible in the absence of the DON. 5. The Unit Managers will monitor weekly x4, then monthly x3, and quarterly thereafter to ensure this deficiency does not recur.

Based on record review, interviews, review of facility policies and procedures entitled Admissions (policies and procedures), Advance Directive Policy, Advance Directive Protocol, and deceased Residents policy, and review of Centers for Medicare and Medicaid Services (CMS) S&C: ,[DATE]-NH, the facility failed to provide the necessary care and services for 1 of 2 closed records reviewed for care and services upon death. Resident #125 did not receive Cardiopulmonary Resuscitation when indicated. Immediate Jeopardy and Substandard Quality of Care existed on [DATE] when licensed nursing staff failed to provide the necessary care and services for Resident #125 who exhibited absence of pulse and respirations, did not have a DNR order, and did not receive Cardiopulmonary Resuscitation (CPR) when indicated. The findings included: Cross Refer to F155 as it relates to Resident #125 with no paperwork in place to indicate the resident was a Do Not Resuscitate and Cross Refer to F157 as it relates to the failure of the facility to notify the physician when Resident #125 had a significant decline in health status. The facility admitted Resident #125 with [DIAGNOSES REDACTED]. Review of the closed medical record revealed the resident was hospitalized prior to admission to the facility. Review of the Hospital History and Physical dated [DATE] indicated in the section under Assessment and Plan: #7 Code Status Full Code. Review of the Hospital Consultation Report dated [DATE] indicated under Code status, (He/she) is a full code. Review of the facility's Physician's Orders dated [DATE] through [DATE], [DATE] through [DATE], and the cumulative Physician's Orders for [DATE] revealed no order related to Resident #125's code status. Further record review revealed there were no documents in the record addressing the resident's code status. There were no documents indicating the resident or resident's responsible party's preference pertaining to advance directives was addressed or completed upon admission. Review of the Physician's Progress Notes indicated the physician assessed the resident on [DATE] and [DATE]. The Physician's Progress Notes did not address the resident's code status. Review of the Nurses Notes revealed the resident was frequently combative with staff and requires frequent 1:1 to maintain safety. Review of the Nurses Notes dated [DATE] at 10:29 PM indicated, Family at bedside during this shift, all needs anticipated by staff, poor appetite/fluid intake. The Nurses Note dated [DATE] at 10:12 PM noted, At 9:30 PM R/P (Responsible Party) notified of res (resident's) declining condition, Res noted (with) shallow breathing/periods of apnea, labored breathing, bil (bilateral) pupils in a fixed position, at 9:50 PM res noted (with) no vital signs, R/P arrived at 9:55 PM, funeral home called at 10:05 PM, at this time family at bedside. The Nurses Note was documented by Licensed Practical Nurse (LPN) #1. The Nurses Note dated [DATE] at 10:10 PM indicated, Call by LPN to declare death, BP-0, apical pulse - 0, respiration - 0, pain stimuli - 0, pupil fixated. The Nurses Note dated [DATE] at 10:13 PM revealed, Time of death 9:50 PM. Both of these Nurses Notes were documented by Registered Nurse (RN) #3. There were no additional Nurses Notes in the medical record. Review of the vital signs record indicated, Res alert, non-labored breathing, no noted pain/discomfort was documented on [DATE] at 10:24 PM by LPN #1. Further review of the vital signs record indicated the resident's vital signs recorded on [DATE] at 2:03 PM were within range of those previously recorded during the resident's admission. Review of the Physician's Discharge Summary, signed by the physician of record, noted Discharge Diagnosis as deceased . The Nursing Discharge summary noted under Psychosocial that (family member) visits daily. On [DATE] at approximately 8:00 PM, the surveyor asked staff to review the closed record for information related to the resident's code status. The surveyor informed staff that the surveyor was unable to find any documentation in the resident's record related to Advance Directives. On [DATE] at approximately 9:50 PM, staff returned the closed record and informed the surveyor that no documentation related to the resident's code status was located in the record. The surveyor asked the Assistant Director of Nursing (ADON) to review the Nurses Notes at that time. The surveyor asked the ADON what he/she would have expected staff to do related to the events of [DATE] considering that the record did not contain a DNR order or other Advance Directive paperwork. The ADON stated that he/she would have expected staff to perform CPR unless the resident's family asked them not to. The ADON confirmed that the medical record contained no physician's order for DNR and no written documentation related to code status; and therefore, the resident would have been considered a full code. During an interview on [DATE] at approximately 9:52 PM, the surveyor asked LPN #1 to review the Nurses Notes. LPN #1 documented the Nurses Notes dated [DATE] at 10:12 PM. LPN #1 stated that the resident was declining, he/she called the resident's family member, and that the family member wanted to come. When the surveyor asked LPN #1 what code status the resident was at that time, LPN #1 stated that he/she was unsure. During an interview on [DATE] at approximately 10:00 PM, RN #3 confirmed that he/she documented the Nurses Notes dated [DATE] at 10:10 PM and [DATE] at 10:13 PM. RN #3 stated that he/she was working on the other unit the night of [DATE] and was called to pronounce the resident. On [DATE] at approximately 10:00 PM, the surveyor asked the ADON for information related to staff notifying the physician on [DATE] and requested LPN #1 to return to the conference room. The ADON returned to the conference room and stated that LPN #1 informed him/her (the ADON) that he/she (LPN #1) did not remember notifying the physician, but would have thought that he/she would have notified the physician. At that time, the ADON stated that there was no documentation in the record related to physician notification. During an interview on [DATE] at approximately 4:30 PM, Social Services staff #1 stated that paperwork related to Advance Directives for newly admitted residents was completed upon admission by either of two social services staff members. Social Services staff #1 reviewed the social services notes for Resident #125 and confirmed that the notes did not indicate the resident's code status and confirmed that the closed record did not contain any documentation related to Advance Directives. On [DATE] at approximately 12:50 PM, the surveyor spoke with Social Services staff #1 in response to a phone call from the staff member. At that time, Social Service staff #1 indicated that after the team exited the facility, he/she located the admission information packet completed upon Resident #125's admission. The staff member confirmed that there was no Advance Directive paperwork in the admission papers and confirmed that there was no signed DNR form or other Advance Directive documentation in the record or admission paperwork. During the interview, Social Services #1 confirmed that the resident's responsible party was aware the resident would be considered a Full Code until the Advance Directive paperwork was completed. Following the interview, Social Services staff #1 faxed a copy of the information provided upon admission. The last page of the document contained the resident's responsible party's signature with no date. During an interview with the Medical Director and resident's physician of record on [DATE] at approximately 3:30 PM, he/she stated that he/she reviewed the facility's policies and procedures. When asked for his/her expectation of a resident's code status if there was no Advance Directive paperwork and no written DNR order in the medical record, the Medical Director stated that, given those facts and no written documentation in the record related to family desires, the resident would be considered a Full Code. During the interview, the Medical Director stated that he/she only became aware that Resident #125 had expired after this had occurred. Review of the facility's Admissions policies and procedures revealed information provided upon admission included under Admission to the Nursing Home section (f): Each resident has the right to make an informed decision concerning his/her medical care, including his/her right to refuse or accept medical and surgical treatment, and to formulate advance directives .Advance Directives are not a condition of admission to the facility. Copies of any advance directives made by the resident should be presented upon admission and will be maintained in the Business Office and on the medical record. In the absence of an advanced directive, the resident will be treated as a 'Full Code' and preventive measures will be taken. The section of the Admissions information entitled Medical Records #13 indicates, Records are maintained uniformly for all residents. For each resident admitted to the facility, admission records will be completed including but not limited to: (13) Advance Directives . The section of the Admissions information entitled Advance Directive Information revealed, If a resident does not have a valid advance directive and is unable to consent to medical treatment due to his or her condition, then decisions concerning the resident's health care may be made for the resident, as authorized by the Adult Health Care Consent Act, by certain persons designated in the Act in the order of priority established by the Act. A resident's inability to consent must be certified by two licensed physicians, each of whom has examined the resident .The resident's attending physician will issue a 'Do Not Resuscitate' order, if the Advance Directive requires it, and the individual will be treated as a 'No Code.' In the absence of such an order, the individual will be treated as a 'Full Code' and we will provide treatment within accepted practices and the resident's wishes. Review of the Admissions information document revealed the last page contained a space for the signature of the resident or Responsible Party. Review of the facility's Advance Directive Policy indicated in Section 1. .every person, age 18 or older, has the right to make decisions concerning his/her medical care, including .the right to formulate Advance Directives, which may include a 'Do Not Resuscitate' (DNR) Directive. An Advance Directive is intended as a way for the resident to tell us how they want to be treated, and also to name an agent to make health care decisions for them if they are unable to make medical decisions for themselves. The resident and/or family/legal representation is to be informed of our policy at the time of admission . Each resident will be given an opportunity to formulate an Advance Directive if they wish to do so. Section 5 of the Advance Directive Policy indicates, A copy of any Advance Directive should be documented on the individual chart, with the original to be kept in the individual file in the business office. Section 6 of the Advance Directive Policy indicates, If the Advance Directive and/or resident's condition requires it, the attending physician will write an order to 'DO NOT RESUSCITATE' (DNR), and the resident will be treated as a 'NO CODE', and the chart is to be labeled accordingly. In the absence of such an order, the resident will be treated as a 'FULL CODE' and our staff will provide health care within accepted practices and the resident's wishes. Section 10 of the Advance Directive Policy indicates, Appropriate staff, such as the Director of Nursing, Nurse Supervisors, and Social Services Director, should be familiar with our policy and procedures on Advance Directives and able to discuss them with our residents or legal representatives to help them understand their individual status . Review of the Advance Directive Protocol indicates in the first bullet, the facility will, Inform each resident/family/responsible party/legal representative of his/her right to .formulate Advance Directives or not, and the facility's policies and procedures regarding these rights. Each resident must be given the opportunity to formulate an Advance Directive if they wish to do so. The third bullet of the Advance Directive Protocol states, Advance Directives .should be documented on the resident's chart. If a Do Not Resuscitate Directive is desired, a doctor's order should be documented on the chart, and a red sticker placed on the chart next to the resident's name for easy identification. In the absence of such an order, the resident will be treated as a full code and we will provide treatment within accepted practices and the resident's wishes. The fourth bullet states, A resident without an Advance Directive is considered a full code. The sixth bullet of the Advance Directive Protocol indicates, The resident and/or responsible party/legal representative, along with the attending physician, are to be notified in any event of a change in condition and we will comply with any instructions they may give related to revoking or modifying the advance directive. The seventh bullet of the Advance Directive Protocol states, Failure of a vital function means the resident is not breathing and has no pulse, respiration, or other vital signs. In such case, we would follow the Advance Directives, if any. If the resident is a Full Code, CPR will be initiated, and we would call 911 for transfer to the hospital. If the resident is a Do Not Resuscitate and there is a doctor's order to that effect in place, we would not implement CPR, and we would not call 911 or transfer the resident to the hospital. Review of the deceased Residents policy indicates under #9, All charting must reflect what you have done. Be sure to date and sign each entry. Notes should indicate the funeral home has received the body. Review of CMS S&C: ,[DATE]-NH Section A indicates, AHA (American Heart Association) urges all potential rescuers to initiate CPR unless: 1) a valid DNR order is in place; 2) obvious signs of clinical death . are present; or 3) initiating CPR could cause injury or peril to the rescuer. AHA guidelines for CPR provide the standard for the American Red Cross, state EMS agencies, healthcare providers, and the general public. Based on record reviews, interviews, and review of facility policies, it was determined on [DATE] at approximately 10:45 PM Immediate Jeopardy and Substandard Quality of Care existed in the following area: CFR 483.25 F-309 was identified at a scope and severity level of (J). The Immediate Jeopardy existed on [DATE] when licensed nursing staff failed to provide the necessary care and services for Resident #125 who exhibited absence of pulse and respirations, did not have a DNR order, and did not receive Cardiopulmonary Resuscitation (CPR) when indicated. The facility Administrator, Director of Nursing (DON), and ADON were informed of the Immediate Jeopardy on [DATE] at approximately 10:45 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on [DATE] at approximately 3:40 PM, and the Immediate Jeopardy at F-309 was removed and lowered in scope and severity to D. The AOC included the following: 1. Resident #125 no longer resides in the facility. All other residents are at risk. 2. We have reviewed our policy and procedure/protocol concerning Advance Directives and made the following revisions: (1) added language to make it clear that we do not provide legal advice, make decisions for residents or interfere or influence a resident's decision; and (2) if a do not resuscitate directive is desired, a doctor's order should be documented on the chart and a red sticker placed on the chart next to the resident's name for easy identification. 3. An audit of all current residents' charts was conducted on [DATE] by the DON, ADON, Unit Manager, MDS Coordinator, and Staff Development Coordinator (SDC) to ensure that all residents who wish to have an Advance Directive have the Advance Directive documented on their chart; that a doctor's order for DNR is present on the chart; and the chart is labeled with a red sticker next to the resident's name for easy identification. All other residents will be treated as a full code. The resident, resident's family/RP, and attending physician will be notified of each resident's desire for a DNR. The family/RP and attending physician will be notified of any change of condition. 4. All licensed nurses and CNAs were in-serviced by the DON, ADON, and SDC on [DATE] on our revised policies; properly identifying each resident's code status and ensuring that it is documented on the resident's chart if the resident is a DNR; on assessing the resident and documenting any change in condition; on documenting that the doctor and family/RP were notified. All licensed nurses and CNAs who were not available will be in-serviced as soon as they are available prior to being able to work. All newly-hired licensed nurses, agency nurses, CNAs and agency CNAs will be in-serviced during the orientation process. The DON and SDC will provide annual training for all licensed nurses. The DON will be responsible for all Advance Directives, obtaining a DNR where appropriate, and obtaining the signatures of two physicians when the resident is incapacitated. The ADON will be responsible in the absence of the DON. 5. The Unit Managers will monitor weekly x4, then monthly x3, and quarterly thereafter to ensure this deficiency does not recur.

Based on full and/or limited record reviews, interviews and review of the facility policies, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being for residents with Advance Directives for Cardiopulmonary Resuscitation(CPR). It was determined on [DATE] at approximately 10:40 PM Immediate Jeopardy existed in the facility. The findings included: Cross refer to F-155 related to residents not being afforded the opportunity to formulate advance directives. Cross refer to F-157 related to the physician not notified of a change in condition. Cross refer to F-250 related to Social Services as Resident #125 was not afforded the right to formulate an Advanced Directive and proper paperwork filed within the facility/resident's medical record. Cross refer to F-309 related to CPR not initiated for a resident with a change in condition. Cross refer to F-520 related to facility Administration's failure to ensure the Quality Assurance process was utilized to identify, clarify, and implement a plan of action related to Advance Directives and when to perform CPR. The facility Administration failed to ensure appropriate policies and procedures were implemented to identity and clarify Advance Directives, to provide appropriate care and services as indicated with resident's changes in condition, and to ensure the Quality Assurance process was utilized to identify, clarify, and implement a plan of action related to such. Review of the facility's policy titled CPR Policy states all licensed nurses are required to have a current CPR certification on file. These certifications are to be renewed every two years. Review of the facility's policy titled Changes in a Resident's Condition or Status revealed under 1d. the following: The Nurse Supervisor/Charge Nurse will notify the resident's attending physician or On-Call Physician when there as been: A significant change in the resident's physical/emotional/mental condition. Based on full and/or limited record reviews, interviews, and review of the facility policies, it was determined on [DATE] at approximately 10:40 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility. F-490 was cited at a scope and severity of J. The facility Administrator, Director of Nursing and Assistant Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 10:45 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on [DATE] at 3:44 PM and the Immediate Jeoparday at F-490 was removed but the citation remained and the scope and severity was lowered to a D. The AOC included the following: 1. Resident No. 125 no longer resides in the facility. All other residents are at risk. 2. We have revived our policy and procedure/protocol concerning Advance Directives and made the following revisions: (1) added language to make it clear that we do not provide legal advice, make decisions for residents or interfere or influence a resident's decision; and (2) if a do not resuscitate directive is desired, a doctor's order should be documented on the chart and a red sticker placed on the chart next to the resident's name for easy identification. 3. An audit of all current residents' charts was conducted on [DATE], by the Director of Nursing (DON), Assistant Director of Nursing(ADON), Unit Manager, MDS Coordinator, and Staff Development Coordinator (SDC) to ensure that all residents who wish to have an Advance Directive have the Advance Directive documented on their chart; that a doctor's order for DNR is present on the chart; and the chart is labeled with a red sticker next to the resident's name for easy identification. all other residents will be treated as a full code. The resident, resident's family/RP, and attending physician will be notified of each resident's desire for a DNR. The family/RP and attending physician will be notified of any change of condition. 4. All licensed nurses and CNA's were in-serviced by the DON, ADON, and SDC on [DATE] on our revised policies; properly identifying each resident's code status and ensure that it is documented on the resident's chart if the resident is a DNR; on assessing the resident and documenting any change in condition; and documenting that the doctor and family/RP were notified. All licensed nurses and CNA's who were not available will be in-serviced as soon as they are available prior to being able to work. All newly-hired licensed nurses, agency nurses, CNA's, and agency CNA's will be inserviced during the orientation process. The DON and SDC will provide annual training for all licensed nurses. The DON will be responsible for all Advance Directives, obtaining a DNR where appropriate, and obtaining the signatures of two physicians when the resident is incapacitated. the ADON will be responsible in the absence of the DON. 5. The Unit Managers will monitor weekly x 4, then monthly x 3, and quarterly thereafter to ensure this deficiency does not recur.

Based on record review, interviews, and review of the facility's Admission packet and policies titled Advance Directive Protocol and Advance Directive Policy, the facility failed to provide the opportunity to formulate an Advance Directive for 3 of 31 residents reviewed for Advance Directives. Resident #125 identified as having a decline in healthcare status, had no documentation available related to advance directives, and Residents #70 and #98 were not afforded the opportunity to formulate their own Advance Directive. It was determined on 1/29/16 at 10:45 PM Immediate Jeopardy existed for F-155 which was identified at a scope and severity level of (J). The findings included: The facility admitted Resident #125 with [DIAGNOSES REDACTED]. Review of the closed medical record indicated Resident #125 was hospitalized prior to admission to the facility. Review of the Hospital History and Physical dated 9/24/15 indicated in the section under Assessment and Plan #7 that the resident was a full code. Review of the Hospital Consultation Report dated 10/02/15 indicated in the section entitled Code Status that the resident was a full code. Review of the facility Physician's admission orders [REDACTED]. Review of the Physician's Progress Notes and Social Services progress notes revealed there was no documentation indicating the resident's code status or that this had been addressed upon admission with either the resident or resident's responsible party. On 1/29/16 at approximately 8:00 PM, the surveyor informed staff that the surveyor was unable to find any documentation in the medical record related to Resident #125's code status. The surveyor asked staff to review the medical record and provide documentation related to advance directives. On 1/29/16 at approximately 9:50 PM, the Assistant Director of Nursing (ADON) returned the medical record and informed the surveyor that the medical record contained no documentation related to advance directives. During an interview on 1/30/16 at approximately 4:30 PM, Social Services staff #1 reviewed the medical record. At that time, Social Services staff #1 confirmed that the Social Services Notes did not address advance directives, the record did not contain any documentation related to advance directives, and there was no documentation related to the resident or resident's responsible party being afforded the opportunity to formulate advance directives. Review of the facility's Admissions packet indicated under the section f, Each resident has the right to make an informed decision concerning his/her medical care, including his/her right .to formulate advance directives .Copies of any advance directives made by the resident should be presented upon admission and will be maintained in the Business Office and on the medical record. Information included under the section entitled Medical Records, indicated, Records are maintained uniformly for all residents For each resident admitted to the facility, admission records will be completed including but not limited to: .#13 Advance directives . Review of the facility's Advance Directive Protocol indicated bullet #1 stated, Inform each resident/family/responsible party/legal representative of his/her right .to formulate Advance Directives or not, and the facility's policies and procedures regarding these rights. Each resident must be given the opportunity to formulate an Advance Directive if they wish to do so. Information under bullet #3 indicated, Advance Directives concerning an individual resident's medical care should be documented on the resident's chart . Review of the facility's policy entitled, Advance Directive Policy indicated under section 1, .Each resident will be given an opportunity to formulate an Advance Directive if they wish to do so. The facility admitted Resident #98 with [DIAGNOSES REDACTED]. Record review on 1/28/16 revealed a Do Not Resuscitate(DNR) Order and a red dot on the outside of the chart indicating the resident was a DNR. No paperwork was observed on the chart indicating the resident and/or family had signed for a DNR or that the resident had been deemed incapable of making health care decisions by two physicians. During an interview with Social Services on 1/28/16, he/she confirmed there was no paperwork on the resident's chart nor could he/she find paperwork signed by the two physicians. Further interview with Social Services on 1/29/16 at 2:52 PM revealed on 1/28/16 Resident #98 had been deemed a Full Code and paperwork related to the resident being a DNR had been removed from the chart until all paperwork was completed for a DNR. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Review on 1/30/2016 at approximately 11:43 AM of Resident #70's medical record revealed a physician order [REDACTED]. Further review on 1/30/2016 at approximately 11:43 AM of the medical record for Resident #70 revealed that he/she had not been afforded the opportunity to formulate his/her own Advanced Directive. Resident #70 did not have documentation on the medical record in which 2 physician's had indicated that he/she was not able to make his/her own health care decisions. Review on 1/30/2016 at approximately 12:00 Noon of the facility's protocol titled, Grand Strand Healthcare, Inc., Advance Directive Protocol, states under the second * A resident is considered competent to make medical decisions for themselves unless two licensed physicians, one of which is the attending physician, have examined the resident and determined in writing, that the resident is incompetent/incapacitated and unable to make such decisions; or the resident has been declared incompetent/incapacitated by a lawful court of competent jurisdiction. Further review on 1/30/2016 at approximately 12:15 PM of the facility policy titled, Grand Strand Healthcare, Inc. Advance Directive Policy, under 1. states: Grand Strand Healthcare, Inc., recognizes that under South Carolina Law, every person, age 18 or older, has the right to make decisions concerning his/her medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives, which may include a Do Not Resuscitate (DNR) Directive. An Advance Directive is intended as a way for the resident to tell us how they want to be treated, and also to name an agent to make health care decisions for them if they are unable to make medical decisions for themselves. The resident and or the family/legal representative is to be informed of our policy at the time of admission. We will gladly discuss it and answer any questions they may have. However, we do not provide legal advice, make decisions for the resident, or interfere with or influence a resident's decision. Each resident will be given an opportunity to formulate an Advance Directive if they wish to do so. During an interview on 1/30/2016 at approximately 5:02 PM with the Director of Nurses, he/she verified and confirmed that 2 physicians had not deemed Resident #70 unable to make his/he own health care decisions before obtaining a No Code status. And he/she had not been able to formulate his/her own Advance Directive. Based on record review, interviews, and review of facility policies, it was determined on 1/29/16 at approximately 10:45 PM Immediate Jeopardy existed in the following area: CFR 483.10(b)(4) F-155 Right to formulate an Advance Directive was identified at a scope and severity level of (J). The facility failed to afford all residents the right to formulate an Advanced Directive. The facility Administrator, Director of Nursing (DON), and ADON were informed of the Immediate Jeopardy on 1/29/16 at approximately 10:45 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on 1/30/16 at approximately 3:40 PM, and the Immediate Jeopardy at F-157 was removed and lowered in scope and severity to a D. The AOC included the following: 1. Resident #125 no longer resides in the facility. All other residents are at risk. 2. We have reviewed our policy and procedure/protocol concerning Advance Directives and made the following revisions: (1) added language to make it clear that we do not provide legal advice, make decisions for residents or interfere or influence a resident's decision; and (2) if a do not resuscitate directive is desired, a doctor's order should be documented on the chart and a red sticker placed on the chart next to the resident's name for easy identification. 3. An audit of all current residents' charts was conducted on 1/30/16 by the DON, ADON, Unit Manager, MDS Coordinator, and Staff Development Coordinator (SDC) to ensure that all residents who wish to have an Advance Directive have the Advance Directive documented on their chart; that a doctor's order for DNR is present on the chart; and the chart is labeled with a red sticker next to the resident's name for easy identification. All other residents will be treated as a full code. The resident, resident's family/RP, and attending physician will be notified of each resident's desire for a DNR. The family/RP and attending physician will be notified of any change of condition. 4. All licensed nurses and CNAs were in-serviced by the DON, ADON, and SDC on 1/30/16 on our revised policies; properly identifying each resident's code status and ensuring that it is documented on the resident's chart if the resident is a DNR; on assessing the resident and documenting any change in condition; on documenting that the doctor and family/RP were notified. All licensed nurses and CNAs who were not available will be in-serviced as soon as they are available prior to being able to work. All newly-hired licensed nurses, agency nurses, CNAs and agency CNAs will be in-serviced during the orientation process. The DON and SDC will provide annual training for all licensed nurses. The DON will be responsible for all Advance Directives, obtaining a DNR where appropriate, and obtaining the signatures of two physicians when the resident is incapacitated. The ADON will be responsible in the absence of the DON. 5. The Unit Managers will monitor weekly x4, then monthly x3, and quarterly thereafter to ensure this deficiency does not recur.