Every finding on record at Brightwater Skilled Nursing Center

Based on review of the facility policy, observation, and interviews, the facility failed to have a full-time Administrator to oversee the day-to-day operations of the facility.Findings include:Review of the facility's policy titled Administrator, Policy Statement, revised March 2021, indicates:A licensed administrator is responsible for the day-to-day functions of the facility.The governing board of this facility has appointed an administrator who is duly licensed in accordance with federal and state requirements. The administrator is responsible for, but not limited to:a. Managing day-to-day functions of the facility. An observation of the Administrator license on the wall of the facility, revealed the Administrator of a sister facility's license.A review of the Surveyor Notes Worksheet dated 10/30/2025 indicated the current Administrator's start date was 10/23/2025. The previous Administrator's end date was 10/22/2025. The current Director of Nurses (DON)'s start date was 01/23/24.An interview with the DON on 12/02/2025 at approximately 10:30 AM revealed that there was no Administrator in the building today, and the facility does not currently have a full-time administrator. The DON indicated that the Administrator is at the sister facility, which is her main location. She stated the facility utilizes Administrator services from a sister facility, and the Administrator from the sister facility maybe comes to facility one time a week. The DON reports she is in charge when the Administrator is absent, but she is not a licensed Administrator.

Based on record review and interview, the facility failed to provide a timely Five-Day Follow-up report for 1 of 7 reportable incident, as required by regulation. Findings include:Review of a reportable submitted to the State Agency revealed a 2-Hour Initial Report dated 10/07/25 indicating Resident (R)6 had a bone or joint fracture.An interview with the Director of Nursing (DON) on 12/02/2025 at approximately 2:15 PM revealed she was unable to find R6's Five Day Follow-up reportable. She stated, Nobody can find it; I did not send in the reportable for R6. The previous Administrator should have done it. The DON reported she is in charge when the Administrator is absent.

Based on observations, record review and interview, the facility failed to assist or offer residents hand hygiene before and/or after meals for 9 of 10 residents, Resident (R)8, R13, R15, R20, R26, R41, R44, R45, and R149. Findings include: Review of the electronic medical record (EMR) revealed R8 had an admission date of 04/14/25, with diagnoses including but not limited to: trimalleol fracture and orthostatic hypotension Review of R8's Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 04/20/25, revealed R8 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates R8 was cognitively intact. Review of the EMR revealed R13 had an admission date of 01/14/25, with diagnoses including but not limited to: muscle weakness, acute respiratory failure, and unsteadiness on feet. Review of R13's MDS with an ARD of 03/05/24, revealed R13 had a BIMS score of 15 out of 15, which indicates R13 was cognitively intact. Review of the EMR revealed R15 had an admission date of 04/08/25, with diagnoses including but not limited to: trauma subrac hem w/o loss of consciousness, fracture of orbital, lack of coordination, and dysphagia. Review of R15's MDS with an ARD of 04/14/25, revealed R15 had BIMS) score of 00 which indicates severe impairment/not able to complete the assessment. Review of the EMR revealed R20 had an admission date of 04/15/25, with diagnoses including but not limited to: parkinson's disease w/o dyskinesia, w/o mention of fluctuations. Review of R20's MDS with an ARD of 04/22/25, revealed R20 had a BIMS score of 00 which indicates severe impairment/unable to complete the assessment. Review of the EMR revealed R26 had an admission date of 02/14/25, with diagnoses including but not limited to: encephalopathy. Review of R26's MDS with an ARD of 02/20/25, revealed R26 had a BIMS score of 9 out of 15, which indicates R26 had moderately impaired cognition. Review of the EMR revealed R41 had an admission date of 03/24/25, with diagnoses including but not limited to: nontraumatic intracerebral hemorrhage. Review of R41's MDS with an ARD of 03/30/25, revealed R41 had a BIMS score of 15 out of 15, which indicates R41 was cognitively intact. Review of the EMR revealed R44 had an admission date of 04/07/25, with diagnoses including but not limited to: chronic kidney disease, major depressive disorder, and difficulty in walking. Review of R44's MDS with an ARD of 04/13/25, revealed R44 had a BIMS score of 00 which indicates severe cognitive impairment/unable to complete the assessment Review of the EMR revealed R45 had an admission date of 04/15/25, with diagnoses including but not limited to: Parkinson's disease with dyskinesis, with fluctuations, and hypotension. Review of R45's MDS with an ARD of 04/21/25, revealed R45 had a BIMS score of 13 out of 15, which indicates R45 was cognitively intact. Review of the EMR revealed R149 had an admission date of 04/23/25, with diagnoses including but not limited to: hemiplegia, affecting left nondominant side, aphasia, and difficulty in walking. Review of R149's MDS with an ARD of 04/29/25, revealed R149 had a BIMS score of 3 out of 15, which indicates severe cognitive impairment. During dining observation on 04/28/25 at 12:11 PM on the [NAME] Wing, none of the residents were offered hand hygiene before they were served their lunch. During an observation on 04/28/25 at 12:24 PM, resident in room [ROOM NUMBER] was served lunch and staff did not offer hand hygiene to the resident. During an observation on 04/28/25 at 12:28 PM, resident in room [ROOM NUMBER] was served lunch and staff did not offer hand hygiene to the resident. During an observation on 04/29/25 at 12:19 PM, R8 received her lunch meal tray from Certified Nursing Assistant (CNA)3, and was not offered hand hygiene, no handwipes were on the meal tray. During an interview on 04/28/25 at 12:28 PM, CNA2 revealed she had just washed the resident up and that is why she did not offer him to wash his hands before he was served lunch. During an interview on 04/29/25 at 12:19 PM, R8 confirmed that CNA3 did not offer to perform hand hygiene before her meal. During interview on 04/28/25 at 12:24 PM, R45 stated staff did not ask him if he would like to wash his hands before his meal. During an interview on 04/28/25 at approximately 12:32 PM, R149's representative stated that R149 was not offered handwashing or hand hygiene before she was served her lunch and when he is here he has never seen staff offer hand washing before any of her meals. During an interview on 04/29/25 at 12:56 PM, the Medical Records staff stated sometimes she is asked to help with passing meals trays so that meals will be timely to residents. Residents are offered hand hygiene or a wash cloth, and/or given a wet wipe. The Medical Records staff further stated she did not offer to either of the residents yesterday or today. The Medical Records staff concluded it is the policy and procedure residents must be offered to clean their hands. During an interview on 04/29/25 at 1:54 PM, the Resident Care Coordinator revealed she always offers to do hand washing to residents on memory care. She does not know what their policy is on the 500 unit, however she does offer each resident to wash their hands when she is passing trays to residents in their room. In the dining room, I'm not going to lie, I didn't offer them to wash their hands, as I had assumed whoever brought them to the table, had washed the resident's hands. During an interview on 04/29/25 at 2:08 PM, CNA3 revealed the policy and procedure is to wash residents hands before and after. She brought one resident into the dining room today. She did not wash his hands. During an interview on 04/29/25 at 2:13 PM, the Activities Assistant stated that she is not sure of the policy and procedure in regard to offering resident to wash their hands before/after meals. The Activities Assistant stated, I honestly didn't know that I was supposed to (provide hand hygiene), we are asked to help out with passing of trays at times because yall is here. During an interview on 04/29/25 at 2:21 PM, the Administrator revealed the policy and procedure is for residents' hands are to be washed or sanitized before/after meals; typically the CNAs will wash their hands before bringing them to the dining room. The Administrator stated it is his expectation that all residents be offered hand hygiene before/after meals.

Based on observation, interview, and review of facility policy, the facility failed to follow aspiration risk precautions for Resident (R)13 and R45 for 2 of 3 residents reviewed for Nutrition. Findings include: Review of the facility policy with a revision date of May 2013, titled, Speech Therapy- Purpose: The purpose of this procedure is to identify, assess and treat speech and language problems including swallowing disorders . General Guidelines, 1d. Dysphagia- difficulty in chewing and swallowing. Review of the facility policy with a revision date of April 2007, titled, Tray Identification: Appropriate identification/coding shall be used to identify various diets . Policy Interpretation and Implementation, 1. To assist in setting up and serving the correct food trays/diets to residents, the Food Services Department will use appropriate identification (e.g., color coded or computer-generated diet cards) to identify the various diets. 2. The Food services Manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas. 3. Nursing staff shall check each food tray for the correct diet before serving the residents. Review of R45's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to: Parkinson's Disease, hypotension, dysphagia, hyperlipidemia, history of falling and muscle weakness. Review of R45's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/21/25, revealed R45 had a Brief Interview of Mental Status (BIMS) score of 13 of 15, indicating that the resident is cognitively intact. Further review of the MDS revealed under section Section K - Swallowing/Nutrition that R45 had a swallowing disorder. Review of R45's Physicians Orders revealed, Precaution: Aspiration Precaution NO STRAW, with an order date of 04/15/25. Review of R45's Care Plan with start date of 04/15/25, revealed, [R45] is at risk for alteration in nutrition/hydration, r/t recent hospitalization, weakness, vitamin deficiency, vitamin D deficiency, dysphagia, dentures. Use of Mechanically altered diet. Interventions include aspiration precautions, no straws. Offer snacks/fluids. Review of R45's Speech Therapy Notes dated from 04/16/25, revealed R45's Functional Oral Intake Scale (FOIS) is 4/7. On 04/25/25, R45 Tolerating mechanical soft ground with no overt s/s of swallowing difficulties observed on this date. SLP provided education to pt regarding safe swallow strategies including alternation of solids/liquids, rate reduction, small bites/sips as well as risks of aspiration and complications associated. During an observation on 04/29/25 at 12:09 PM, R45 was sitting in the dining room eating lunch, R45's meal ticket states that he is not to have straws, yet he was given a straw today. During an observation on 04/29/25 at 12:15 PM, Licensed Practical Nurse (LPN)3 observed R45 sitting in the dining area eating lunch with the straw present for use. LPN3 immediately removed the straw from in front of the patient before use. During an interview on 04/29/25 at 12:15 PM, LPN3 reviewed R45's physicians orders that read no straws due to aspiration risk. He states that protocol is to follow the physician's orders and meal tickets for each resident, but somehow this was missed. During an interview on 04/29/25 at 12:25 PM, the Administrator states that he expects staff to follow all resident's meal ticket orders. He states that if the resident isn't supposed to have something it is to be removed. The Administrator states that he is about to meet with staff to identify the issue so that it won't be a subsequent event. During an interview on 04/29/25 at 3:55 PM, The Director of Nursing (DON) states that if the order and care plan states that R45 is not to have straws due to aspiration risk, she expects staff to follow guidelines and meal tickets and not provide resident with a straw. Review of R13's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to, muscle weakness, difficulty walking, heart disease, dysphagia, dysarthria, hypertension, hyperlipidemia, and GERD. Review of R13's Quarterly MDS with an ARD of 01/20/25, revealed R13 had a BIMS score of 14 of 15, indicating that the resident is cognitively intact. Further review of the MDS revealed under Section K - Swallowing/Nutritional status indicated that R13 doesn't have a swallowing disorder. Review of R13's Speech Therapy Notes dated from 01/20/25, revealed R13's Functional Oral Intake Scale (FOIS) is 5/7. Resident exhibited signs and symptoms of aspiration from coughing and choking. Resident benefits from cues not to eat and talk at the same time. R13 significantly benefits from no straw precaution. Review of R13's Care Plan with a start date of 01/14/25, revealed, [R13] is at risk for alteration in nutrition/hydration r/t recent hospitalization, weakness, dysphasia, vitamin deficiency, GERD, diarrhea, influenza A virus, ARF with hypoxia, Acute Bronchitis, Pneumonitis due to inhalation of food/vomit, Afib, sleep apnea, dysphagia following cerebral infarction, dementia, CKD, depression, GERD, OAB, constipation, elevated BMI, use of therapeutic diet, use of mechanically altered diet. Interventions include Diet: MS ground meat, NAS, thin liquids and no straws, aspiration precautions. During an observation on 04/28/25 at 11:00 AM, a no straw-aspiration precautions sign is located on the wall above R13's bed. Drinking straws were observed at the resident's bedside, and a straw was in the resident's water pitcher on the bedside table. During an observation on 04/28/25 at 3:40 PM, a no straw-aspiration precautions sign is located on wall above R13's bed. Drinking straws were observed at the resident's bedside, and a straw was in the resident's water pitcher on the bedside table. Surveyor was accompanied by LPN2. During an interview on 04/29/25 at 3:15 PM, LPN2 states that R13 wasn't supposed to have straws due to him being an aspiration risk. LPN2 states that is what the sign above the resident's bed states. LPN2 and surveyor observed two straws on R13's dresser in residents' room and one straw in R13's water pitcher. LPN2 left the straws in the room when exiting. During an interview on 04/29/25 at 3:40 PM, Certified Nursing Assistant (CNA)1 states that the sign above R13's bed states that he isn't supposed to have straws, and she doesn't know why. She does know that if a resident has a sign like that in their room, they have tendencies to aspirate. CNA1 states that R13 sits in the dining area sometimes to eat. CNA1 states that if she notices that a straw is on R13's tray she removes it. She states that when she is tiding up R13's room, it is her responsibility to remove items that don't belong, but she failed to remove the straws on 04/29/25. During an interview on 04/29/25 at 3:50 PM, [NAME] 1 states that she follows the meal ticket for each resident, and if it has no straws, she doesn't put a straw on their tray. The utensils are already prepared in a napkin that consists of a straw, fork, and a spoon. During an interview on 04/29/25 at 3:55 PM, the Director of Nursing (DON) reviewed R13's chart with surveyor, and R13 didn't have a negotiated risk form in his chart. The DON states that if the order and care plan states that R13 is not to have straws due to aspiration risk, she expects staff to follow guidelines and not provide the resident with a straw. During an interview on 04/29/25 at 4:10 PM, the Administrator states that he has provided staff with an in-service with topic, Utensil wrap- no straws included on 4/29/25. The in-service states that all utensils wrapped are to include utensils only- no straws- all straws are to be served separate. The in- service demonstrated the concerns regarding use of straws for residents with risk aspirations. Conduct RCA as indicated by IDT and produce recommendations. about following meal tickets, he isn't sure why dietary started wrapping the straws with the utensils, because that wasn't a part of the plan. The administrator admits that the Negotiated Risk Agreement wasn't scanned in resident's chart.

Based on observation, interview, record review and review of facility policy, the facility failed to have a physician's order for the use of oxygen, for 1 of 1 resident reviewed for respiratory care, Resident (R)39. Findings include: Review of the facility's policy titled, Oxygen Administration dated 2001, revealed, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of R39's Electronic Medical Record (EMR) revealed R39 was admitted to the facility on [DATE], with diagnoses including but not limited to: Pneumonitis due to inhalation of food and vomit, Acute respiratory failure with hypoxia, Dyspnea, Chronic obstructive pulmonary disease, and Encounter for screening for respiratory tuberculosis. Review of R39's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 04/15/25, revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicates moderate cognitive impairment. Review of R39's Care Plan documented, Problems: O2-[R39] unable to maintain O2 Saturation, receives oxygen as ordered. Goals: [R39] will maintain an oxygen saturation as ordered. Interventions: Change tubing, check/fill humidifier, check/record oxygen saturation every 8 hours and PRN [as needed] when oxygen is in use. Effective: 4/9/2025-Present. Review of R39's Physician Order documented, Titrate oxygen (O2) to maintain O2 saturation Two Times Daily (oxygen flow rates should be adjusted (titrated) twice daily to achieve a target oxygen saturation level). During an observation on 04/28/25 at 11:29 AM, resident's oxygen levels were at 3. During an observation on 04/29/25 at 9:54 AM, Licensed Practical Nurse (LPN)3 verified R39's oxygen levels were at 2.5. During an interview on 04/29/25 at 9:44 AM, LPN3 revealed he has been in his position at for 2 years at facility; LPN3 verified oxygen levels were at 2 to 3 liters. LPN3 stated when R39 came from the hospital, his O2 levels were at 3 and that is what he was using as a reference and not the physicians' orders. LPN3 stated best practice is to always check residents' orders to administer medications. LPN3 further stated in relation to titrate levels there is no range, LPN3 states he was here when resident came back from the hospital and that is what he heard when he came back from the hospital. LPN3 could not locate an order for oxygen levels in the resident's chart. LPN3 stated he would normally follow the orders that are in the system. During interview on 04/29/25 at 10:00 AM, the Director of Nursing (DON) along with the surveyor, reviewed the resident's medical record and could not locate an oxygen titration order to include parameters of what to titrate the oxygen to. The DON stated they generally titrate 2-3 Liters but she admits there is no order in the resident's chart that reads that.

Based on the manufacturer's recommendation, observation and interview, the facility failed to ensure a medication administration error rate of less than 5 percent. The medication administration error rate was 7.14 percent for 2 out of 28 opportunities for error. Findings include: Review of the manufacturer's recommendations titled, Insulin Administration Using an Insulin Pen, under, How to Use, states: 7. Wipe the tip of the pen where the needle will attach with an alcohol swab or a cotton ball moistened with alcohol. 8. Remove the protective pull tab from the needle and screw it onto the pen until snug (but not too tight). 9. Remove both the plastic outer cap and inner needle cap. 10. Look at the doe window and turn the dosage knob to 2 units. 11. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. This will prime the needle and remove any air from the needle. Repeat this step if needed until a drop appears. 12. Dial the number of units ordered. 14. To hold the pen, wrap your fingers around the pen with your thumb free to reach the dosing knob. 15. With the other hand, gently pinch up the skin around where you will administer the shot subcutaneously. Insert the needle at a 45 to 90-degree angle. 16. While keeping needle under skin, press the button all the way returning to zero, and keep pressing for six to 10 seconds. (Larger doses may require the whole ten seconds). Withdraw from the skin. During an observation on 04/29/25 at 12:01 PM, Licensed Practical Nurse (LPN)1 failed to correctly prime the insulin pen and to administer the insulin correctly for Resident (R)35. Specifically during priming of the pen, LPN1 placed a needle on the pen, then removed the needle and wiped the hub with an alcohol prep and replaced the needle. LPN1 dialed up the 2 units to prime the pen and held the pen with the needle down and ejected the 2 units into the trash can. LPN1 did not ensure the air was out of the pen and did not see the insulin escape the needle. LPN1 then entered the room of R10 and proceeded to give the insulin injection into the abdomen of R10. LPN1 wiped the area with an alcohol prep and holding the skin injected the insulin and as soon as she had injected the insulin she removed the needle, not waiting the recommended 5 to 10 seconds to ensure the resident received the correct amount of insulin based on the fingerstick blood sugar. During an interview on 04/29/25 at 12:10 PM, LPN1 confirmed that she had primed the insulin pen ejecting the 2 units used to prime the pen into the trash, and then during the administration of the insulin she confirmed that after administering the insulin she did not hold the pen in the injection site for the required 5 to 10 seconds.

Based on the manufacturer's recommendation, observation and interview, the facility failed to ensure a medication administration error rate of less than 5 percent. The medication administration error rate was 7.14 percent for 2 out of 28 opportunities for error. Findings include: Review of the manufacturer's recommendations titled, Insulin Administration Using an Insulin Pen, under, How to Use, states: 7. Wipe the tip of the pen where the needle will attach with an alcohol swab or a cotton ball moistened with alcohol. 8. Remove the protective pull tab from the needle and screw it onto the pen until snug (but not too tight). 9. Remove both the plastic outer cap and inner needle cap. 10. Look at the doe window and turn the dosage knob to 2 units. 11. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. This will prime the needle and remove any air from the needle. Repeat this step if needed until a drop appears. 12. Dial the number of units ordered. 14. To hold the pen, wrap your fingers around the pen with your thumb free to reach the dosing knob. 15. With the other hand, gently pinch up the skin around where you will administer the shot subcutaneously. Insert the needle at a 45 to 90-degree angle. 16. While keeping needle under skin, press the button all the way returning to zero, and keep pressing for six to 10 seconds. (Larger doses may require the whole ten seconds). Withdraw from the skin. During an observation on 04/29/25 at 12:01 PM, Licensed Practical Nurse (LPN)1 failed to correctly prime the insulin pen and to administer the insulin correctly for Resident (R)35. Specifically during priming of the pen, LPN1 placed a needle on the pen, then removed the needle and wiped the hub with an alcohol prep and replaced the needle. LPN1 dialed up the 2 units to prime the pen and held the pen with the needle down and ejected the 2 units into the trash can. LPN1 did not ensure the air was out of the pen and did not see the insulin escape the needle. LPN1 then entered the room of R10 and proceeded to give the insulin injection into the abdomen of R10. LPN1 wiped the area with an alcohol prep and holding the skin injected the insulin and as soon as she had injected the insulin she removed the needle, not waiting the recommended 5 to 10 seconds to ensure the resident received the correct amount of insulin based on the fingerstick blood sugar. During an interview on 04/29/25 at 12:10 PM, LPN1 confirmed that she had primed the insulin pen ejecting the 2 units used to prime the pen into the trash, and then during the administration of the insulin she confirmed that after administering the insulin she did not hold the pen in the injection site for the required 5 to 10 seconds.

Based on record review, interview and review of the facility policy, the facility failed to accurately code the Minimum Data Set (MDS) for Resident (R)13, section K related to swallowing for 1 of 3 residents reviewed for Nutrition. Findings include: Review of the facility policy with a revision date of October 2023, titled, Electronic Transmission of the MDS- Policy Statement: All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records are completed and electronically encoded into out facility's MDS information system and transmitted to CMS' Internet Quality Improvement and Evaluation System (iQIES) system in accordance with current OBRA regulations governing the transmission of MDS data. Policy Interpretation and Implementation, documented, 8. The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking. Review of R13's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to: muscle weakness, difficulty walking, heart disease, dysphagia, dysarthria, hypertension, hyperlipidemia, and GERD. Review of R13's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/25, revealed R13 had a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating that the resident is cognitively intact. Further review of the MDS under Section K - Swallowing/Nutritional status revealed that R13 did not have a swallowing disorder. Review of R13's Speech Therapy Notes dated 01/20/25, revealed R13's Functional Oral Intake Scale (FOIS) was 5/7. Resident exhibited signs and symptoms of aspiration from coughing and choking. Resident benefits from cues not to eat and talk at the same time. R13 significantly benefits from no straw precaution. Review of R13's Care Plan with a start date of 01/14/25, revealed, [R13] is at risk for alteration in nutrition/hydration r/t recent hospitalization, weakness, dysphasia, vitamin deficiency, GERD, diarrhea, influenza A virus, ARF with hypoxia, Acute Bronchitis, Pneumonitis due to inhalation of food/vomit, Afib, sleep apnea, dysphagia following cerebral infarction, dementia, CKD, depression, GERD, OAB, constipation, elevated BMI, use of therapeutic diet, use of mechanically altered diet. Interventions include, Diet: MS ground meat, NAS, thin liquids and no straws, aspiration precautions. During an interview on 04/29/25 at 3:14 PM, Registered Nurse (RN)1 states that she wasn't the person who updated R13's MDS assessment. RN1 states that the last person who updated the 01/20/25 assessment in the MDS was the Certified Dietary Manager (CDM). RN1 states that if she would have completed the MDS for Section K she would've coded that there was a swallowing concern because of the dysphagia diagnosis. During an interview on 04/29/25 at 3:35 PM, the CDM states that the MDS on 01/20/25, Section K wasn't coded for a swallowing issue because R13's diet was changed to a regular diet with thin liquids that doesn't warrant a swallowing issue. During an interview on 04/29/25 at 3:37 PM, the Director of Rehab (DOR) states that chewing, swallowing, coughing, having a history of Gastroesophageal reflux disease, pneumonia or respiratory issues would warrant a resident to have a swallowing issue. The DOR also stated that she considers the sign that states at risk for aspiration, no straws is a swallowing concern that would need to be coded on the MDS.

Based on observation, interview, and facility policy review, the facility failed to keep the kitchen's two convection ovens, stove top, two drawers and two plastic containers with food preparation and service equipment stored in them, and food preparation and service pans clean and/or dry. This failure had the potential to affect all 47 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Sanitation, dated 11/22, indicated, Policy Statement The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation . 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. 7. Food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical. Drying food preparation equipment and utensils with a towel or cloth may increase risks for cross contamination. 8. When cleaning fixed equipment (e.g., mixers, slicers, and other equipment that cannot readily be immersed in water), the removable parts are: washed and sanitized and non-removable parts cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution (at the effective concentration); and the equipment is reassembled and any food contact surfaces that may have been contaminated during the process are re-sanitized (according to the manufacturer's instructions). 1. Observation during the initial inspection of the facility's main kitchen on 09/11/23 from 10:35AM to 10:55AM, with the Dining Director (DD) and Executive Chef (EC) present, revealed the following unclean food preparation and service equipment: a. The kitchen's two convection ovens had a heavy accumulation of blackened and dried food spills on their interior cooking compartment. b. The kitchen's stove top had a heavy accumulation of blackened and dried food spills. c. Two kitchen drawers, with food preparation and service equipment stored in them, had dried food spills and loose food debris in their interior storage area where the equipment was stored. Interview with the EC, during the initial kitchen inspection on 09/11/23 from 10:35 AM to 10:55 AM, confirmed the kitchen's two convection ovens, stove top and two drawers which housed food preparation and storage equipment were not clean. The EC stated the two ovens were scheduled to be cleaned weekly and as needed. 2. Observation of the kitchen on 09/12/23 from 2:50 PM to 3:10 PM, with the DD and EC present, revealed the following unclean food preparation and service equipment: a. Two large plastic containers, that contained metal and plastic lids, had accumulated of loose food debris in them. b. Food preparation and service pans stored ready for use were stacked directly on top of each other on a kitchen shelf. Eight of these pans were wet with accumulated moisture on them and two of these pans also had food residues on their surfaces. During an interview on 09/12/23 at 3:10 PM the DD confirmed the two large plastic containers, with lids stored in them, were not clean. The DD also confirmed the stored food preparation and service pans were not clean and/or wet. The DD stated staff should allow the pans to completely air dry prior to stacking them directly on top of each other for use.

Based on interviews, document review, and facility policy review, the facility failed to ensure that one Resident(R)196) of two residents sampled for abuse and neglect, out of a total of 14 sampled residents, was free from abuse from a staff member. Specifically, R196 had requested certified nurse aide (CNA)1 to stop brushing her hair due to how it hurt, and CNA1 did not stop. Failure to respect a resident's right to refuse care due to pain, has the potential for further residents to be abused during cares. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021, revealed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. Review of R196's undated Face Sheet located in R196's electronic medical record (EMR), under the Face Sheet tab, indicated the resident was admitted to the facility on [DATE], with diagnoses including chronic pain, major depressive disorder, and anxiety disorder. Review of R196's significant change Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23, located in the EMR under the MDS tab, Brief Interview of Mental Status (BIMS), revealed R196's BIMS score was 13 out of 15, indicating the resident was cognitively intact. Further review of the MDS assessment indicated the resident rejected care one to three days during the seven days look back period. Review of R196's quarterly MDS with an ARD of 06/03/23, located in the EMR under the MDS tab, BIMS revealed R196's score was nine out of 15, indicating the resident was moderately cognitively impaired. The resident was assessed as not displaying hallucinations or delusions, and there was no indication of any behaviors being exhibited during the assessment, including rejection of care. R196 required extensive assistance of at least one person for personal hygiene. Review of R196's investigative file provided by the facility, revealed the facility's investigation indicated that on 05/11/23 (time unknown) sometime between 7:00PM and 12:00AM, R196 reported to staff that CNA1 was rough with her. R196 reported to Registered Nurse (RN)1 and CNA2 that CNA1 was trying to comb the knots out of her hair, and it was very painful. R196 asked CNA1 to stop, but she did not. R196 began screaming for help. When CNA2 entered the room, R196 was screaming help and was crying. CNA2 observed CNA1 standing beside the bed holding a comb. R196 stated she (CNA1) pulled her hair out and wouldn't stop. RN1 entered R196's room and observed the resident to be visibly upset. Review of CNA1's email titled Statement dated 05/12/23 at 7:42PM located in the facility's investigation folder provided by the Administrator revealed .After I got done washing her (R196) up I started combing her hair and noticed that a knot was in her hair and wanted to take that extra mile for her to make her feel good about herself. I continued combing her hair and once I got to the knot, she did try to work with me with her fingers to get the knot out, but it wasn't working so I continued using the comb and she started yelling. When she started yelling I tried to encourage her to allow me to get the knot out to make her feel better because I was almost done she stilled yelled so then (CNA2) came in and saw me just combing hair [sic]then she started saying these awful things about me calling me a witch and how God sees how I'm treating patients . Review of RN1's written statement dated 05/11/23, located in the facility's investigation folder, provided by the Administrator, revealed On 05/11/23 while passing my AM medications, I heard a resident screaming help loudly. I determined the yelling was coming from (R196's) room and went in to investigate. When I entered, R196 was in bed on her back, with gown and covers on. She was notably upset and yelling about how CNA (CNA1) was combing and pulling my (R196) hair. I told her to stop, but she kept on doing it. She (R196) stated she did not want (CNA1) caring for her any longer. Resident was very agitated and upset . Review of CNA2's written statement dated 05/12/23, located in the facility's investigation folder, revealed Thursday, May 11th, I was standing in the hall talking to the nurse. I heard someone screaming help, so I went looking for where the sound was coming from. It was coming from (R196's) room. When I walked in, (R196) was screaming help and crying. CNA1 was beside the bed with a comb in her hands picking up hairs off the bed. R196 said that CNA1 pulled her hair out and wouldn't stop. She (R196) said that she (CNA1) was doing it to hurt her. I tried calming R196 down, then went to get the nurse. I [NAME] the nurse everything that happened and then she went into the room. During an interview with the Director of Nursing (DON) on 09/13/23 at 9:20 AM, the DON stated R196's family member called her and reported that she felt R196 was hurt with care she received when (CNA1) came into her room to brush the resident's hair and she hurt her. The resident started screaming because she wouldn't stop. The DON stated that although the two witnesses (CNA2 and RN1) did not observe CNA1 combing R196's hair, they did observe strands of the resident's hair on her bed. This deficient was cited due to intake#: SC00054838

Based on interview, review of facility policy and documentation, and review of Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance, the facility failed to ensure all staff working in the facility were tested and had documented results of COVID-19 status prior to working with residents. The facility's systemic failure of allowing staff with an unknown COVID-19 status to provide resident care increased the likelihood of transmission of COVID-19 which can lead to serious illness and death for all 47 residents residing in the facility. Immediate Jeopardy related to this failure was identified on 01/04/22 and was determined to first exist since 11/02/21, when the facility failed to ensure all staff were being tested for COVID-19 prior to providing resident care. On 01/04/22 at 10:20 PM, the facility's Administrator was notified of the Immediate Jeopardy at F886, COVID-19 Testing. The facility Administrator was notified that the Immediate Jeopardy was removed on 01/06/22 at 10:36 PM. The noncompliance remained at a scope and severity level of F (widespread with the potential for more than minimal harm) following the removal of the immediate jeopardy. Findings include: Review of CDC guidance, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 09/10/21, revealed . In nursing homes, unvaccinated HCP should continue expanded screening testing based on the level of community transmission as follows: In nursing homes located in counties with substantial to high community transmission, unvaccinated HCP should have a [CONDITION(S)] test twice a week. If unvaccinated HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift). In nursing homes located in counties with moderate community transmission, unvaccinated HCP should have a [CONDITION(S)] test once a week. In nursing homes located in counties with low community transmission, expanded screening testing for asymptomatic HCP, regardless of vaccination status, is not recommended. Per recommendations above, these facilities should prioritize resources to test vaccinated and unvaccinated symptomatic people and all close contacts, as well as be prepared to initiate outbreak response immediately if a nursing home-onset infection is identified among residents or HCP . Because of the risk of unrecognized infection among residents, a single new case of [CONDITION(S)]-CoV-2 infection in any HCP or a nursing home-onset [CONDITION(S)]-CoV-2 infection in a resident should be evaluated as a potential outbreak. Perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately (but not earlier than 2 days after the exposure, if known) and, if negative, again 5-7 days later. If no additional cases are identified during the broad-based testing, room restriction and full PPE use by HCP caring for unvaccinated residents can be discontinued after 14 days and no further testing is indicated. If additional cases are identified, testing should continue on affected unit(s) or facility-wide every 3-7 days in addition to room restriction and full PPE use for care of unvaccinated residents, until there are no new cases for 14 days . Review of CMS QSO-20-38-NH, revised 09/10/21, revealed, . The facility should test all unvaccinated staff at the frequency prescribed in the Routine Testing table based on the level of community transmission reported in the past week. Facilities should monitor their level of community transmission every other week (e.g., first and third Monday of every month) and adjust the frequency of performing staff testing according to . If the level of community transmission increases to a higher level of activity, the facility should begin testing staff at the frequency shown in the table . as soon as the criteria for the higher activity level are met. If the level of community transmission decreases to a lower level of activity, the facility should continue testing staff at the higher frequency level until the level of community transmission has remained at the lower activity level for at least two weeks before reducing testing frequency . Low (blue) testing not recommended; moderate (yellow) testing once a week; substantial (orange) twice a week; high (red) twice a week . Testing of Staff and Residents During an Outbreak Investigation. A new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a resident triggers an outbreak investigation. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [CONDITION(S)] transmission . Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately . in a facility that can identify close contacts, test all staff, vaccinated and unvaccinated, that had a higher-risk exposure with a COVID-19 positive individual. Test all residents, vaccinated and unvaccinated, that had close contact with a COVID-19 positive individual .in a facility that is unable to identify close contacts, test all staff, vaccinated and unvaccinated, facility-wide or at a group level if staff are assigned to a specific location where the new case occurred . test all residents, vaccinated and unvaccinated, facility-wide or at a group level (e.g., unit, floor, or other specific area(s) of the facility) . Review of the facility's Coronavirus Disease (COVID-19)-Testing and Return to Work Criteria for Healthcare Personnel, dated August 2020, revealed, Healthcare Personnel (HCP) in this facility, including all paid and unpaid individuals with potential for direct or indirect exposure to residents or infectious materials, are tested [CONDITION(S)]-CoV-2 virus to detect the presence of current infections ([CONDITION(S)] testing) and to help prevent the transmission of COVID-19 in the facility; and Testing: 3.If there is a COVID-19 outbreak in the facility, expanded [CONDITION(S)] testing of all HCP and residents, regardless of symptoms and/or exposure, will be initiated. a. An outbreak is defined as a new [CONDITION(S)]-CoV-2 infection in any HCP or any nursing home onset [CONDITION(S)]-CoV-2 infection in a resident. b. Expanded [CONDITION(S)] testing includes initial testing of all HCP followed by repeat testing of all previously negative HCP, generally between every 3 days to 7 days, until the testing identifies no new cases of [CONDITION(S)]-CoV-2 infection among residents or HCP for a period of at least 14 days since the most recent positive result. 4. Routine testing of HCP (those who are asymptomatic and have no known or suspected exposure to [CONDITION(S)]-CoV-2 is based on the extent of virus in the community. a. Frequency of testing consists of initial [CONDITION(S)] testing of all HCP, along with periodic retesting. b. Frequency of retesting is based on the following criteria: (1) Low COVID-19 activity (county positivity rate less than 5%) - once a month. (2) Medium COVID-19 activity (county positivity rate 5-10%)-once a week; or (3) High COVID-19 activity (county positivity rate (county positivity rate greater than 10%)-twice a week. Review of the CDC County positivity and transmission rates for [NAME] County, SC revealed Low COVID-19 County activity on 12/01/21, Medium COVID-19 County activity on 12/08/21, and High COVID-19 County activity on 01/03/22. The survey team was unable to access information related to the [NAME] County Activity Rates of COVID-19 Transmission between 11/02/21 and 12/01/21 to determine the testing frequency of unvaccinated staff. However, review of the facility COVID-19 Staff Testing Schedule, provided to the survey team, revealed staff testing for COVID-19 was to be done on Tuesdays (11/02/21, 11/09/21, 11/16/21, 11/23/21, 11/30/21, 12/07/21, 12/14/21, 12/21/21, 12/28/21, and 01/04/22.) Review of a list of current COVID-19 unvaccinated/partially vaccinated staff members, provided by the facility indicated a total of 17 unvaccinated/partially vaccinated staff members who were currently working in the facility (13 full-time staff members, four part-time staff members, and one per diem staff member). Review of facility work schedules revealed 16 of the 17 staff members had been working in the facility per their schedule and were in positions that placed them in regular direct contact with residents (ten Certified Nursing Assistants (CNAs), three Licensed Practical Nurses (LPNs), two Registered Nurses (RNs), the Housekeeping Supervisor, and one Maintenance staff member). Review of COVID-19 testing documents revealed two of the 17 unvaccinated/partially vaccinated staff members were tested for COVID-19 on 11/02/21, zero of the 17 staff members were tested for COVID-19 on 11/09/21, four of the 17 staff members were tested for COVID-19 on 11/16/21, zero of the 17 staff members were tested for COVID-19 on 11/23/21, one of the 17 staff members was tested for COVID-19 on 11/30/21, three of the 17 staff members were tested for COVID-19 on 12/07/21, three of the 17 staff members were tested for COVID-19 on 12/14/21, three of the 17 staff members were tested for COVID-19 on 12/21/21, and two of the 17 staff members were tested for COVID-19 on 12/28/21. The facility was unable to provide the survey team with any documentation to indicate any additional testing of any of the 17 staff members was done between 11/02/21 and 01/03/22. Review of the facility's COVID-19 tracking records indicated the facility entered COVID-19 outbreak status on 12/20/21 when Resident (R) 12 became symptomatic and tested positive for COVID-19. Despite the facility being in outbreak status, review of the facility's COVID-19 testing documents revealed only three of the 17 unvaccinated/partially vaccinated staff were tested on [DATE] and two of the 17 unvaccinated/partially vaccinated staff members were tested on [DATE]. Review of R12's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/15/21 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's COVID-19 Testing line listing, provided by the facility revealed R12 tested positive for COVID on 12/20/21. R12 exhibited symptoms of congestion/stuffy nose. During an interview with the Administrator on 01/03/22 at 7:07 PM, she stated COVID Testing for all staff members was to be done one time per week on Tuesdays. The Administrator stated during a COVID-19 outbreak and when county positivity was high, staff COVID-19 testing was to be done every 3 to five days. The Administrator confirmed testing was done according to the above indicated testing documents and confirmed that not all staff had not been testing for COVID-19 according to facility policy and CDC and CMS guidance since 11/02/21. The Administrator stated the facility did not have a system in place to determine which staff members tested each week and which staff members did not. The Administrator stated, There is no contingency plan for people who don't show up to test on those dates (Tuesdays). The Infection Preventionist/Director of Nursing (IP/DON) should be ensuring that all staff is being tested per current guidelines. During an interview with the IP/DON on 01/03/22 at 7:15 PM, the IP/DON stated she was aware she was supposed to be monitoring the facility testing efforts for COVID-19. The IP/DON stated she was not aware that all staff were not testing. The IP/DON stated she did not actually administer the COVID-19 testing to staff members herself, and that other staff were designated to ensure the actual testing was done every Tuesday. The IP/DON stated, I am trusting that they have handled this. They are aware that staff is tested on e time per week. The IP/DON stated she had not been conducting any type of monitoring to ensure all staff was being tested weekly per the current guidelines. The IP/DON stated her expectation was that staff who were not able to test on Tuesdays per the facility COVID-19 testing schedule should test before they worked the next time. During an interview with partially vaccinated Licensed Practical Nurse (LPN) 3 on 01/04/22 at 3:27 PM, she confirmed she worked in the facility full-time, worked on both units, and stated she tested positive for COVID-19 after becoming symptomatic for the disease on 12/28/21. LPN3 stated facility COVID-19 testing was done on Tuesdays, and she thought she had tested on ce weekly prior to testing positive for COVID-19 on 12/28/21, but that she wasn't sure. When LPN 3's testing documentation was reviewed with her (testing documentation was not found for LPN 3 on 11/02/21, 11/09/21, 11/23/21, 11/30/21, or 12/21), LPN3 stated, I never kept my testing papers. I am pretty sure I received tests every week, and if I didn't test on Tuesday, I tested when I came in the next time and put the test result under the DON's door or in the HR (Human Resources) box. LPN3 stated no one in administration had ever reached out to her to indicate her COVID-19 testing had not been done per the current guidelines and/or that she needed to test prior to working with residents the next time. During an interview with the partially vaccinated Housekeeping Supervisor on 01/04/22 at 3:47 PM, she confirmed she worked in the facility full-time and had direct contact with residents in all areas of the facility, and stated her understanding was that staff was supposed to be tested for COVID-19 once per week on Tuesdays, and that she was usually in the building on Tuesdays, but that she had missed quite a bit of testing because she got busy sometimes and could not make it to get tested at the scheduled time. When the Housekeeping Supervisor's COVID-19 testing documentation was reviewed with her (COVID-19 testing was not found for the Housekeeping Supervisor for 11/02/21, 11/09/21, 11/23/21, 11/28/21, 12/14/21, 12/21/21, or 12/28/21), the Housekeeping Supervisor stated no one ever reached out to her to indicate they did not have a record of testing for her per current guidelines or that she needed to receive a COVID-19 testing before working her next shift. During an interview with partially vaccinated Certified Nursing Assistant (CNA) 6 on 01/04/22 at 4:20 PM, she confirmed she worked full time in the facility and on both units as a float CNA. CNA6 stated, We usually get tested [for COVID-19] every week or two weeks. I'm not sure. I think it [COVID-19 testing] is on Wednesdays and Thursdays. I think the last time I tested [for COVID-19] was like December maybe the 22nd or 23rd. I think I might have not tested on some of those [required COVID-19 testing] dates because I live far away and I'm not able to come in [to the facility]. No one ever calls me to tell me that I miss testing. I did miss testing one time and the DON told me I could go to Walgreens to get tested . Maybe that was in December. She [the IP/DON] said to go in a pharmacy and get one [a COVID-19 test] done real fast and send her a picture. CNA6 stated she did test on the day the DON told her to go to a pharmacy to get tested and the test was negative. CNA6 said she thought she sent a picture of the test to the DON, but she was not sure and could not remember the exact date the testing was done. When CNA 6's COVID-19 tested documentation was reviewed with her (no COVID-19 testing documentation was found for any testing date between 11/02/21 and 12/28/21), CNA6 stated the documentation was probably correct. During an interview with partially vaccinated CNA1 on 01/04/22 at 4:35 PM, CNA1 confirmed she worked in the facility full time and was in contact with residents on both units of the facility. CNA1 stated she tested positive for COVID-19 on 12/25/21 after requesting a test after working with a COVID-19 positive resident in the facility and becoming symptomatic for COVID-19. CNA1 stated it was her understanding testing for COVID-19 had been recently done for staff once per week, but she thought testing for staff had recently been increased since there were currently residents with COVID-19 in the building. CNA1 stated testing was routinely done for staff members on Tuesdays. When CNA1's testing documentation was reviewed with her (COVID-19 testing documentation could not be found for 11/09/21, 11/23/21, 11/30/21, 12/07/21, or 12/21/21), she stated, Testing is always available [on Tuesdays and other days], but on days when there are only a couple of aides it is hard to get tested , and if I have to choose between feeding my residents lunch and testing I am going to pick feeding the resident. CNA1 stated no one followed up with her to ensure COVID-19 testing was done before working with residents on weeks when she was not able to test on Tuesday. During an interview with the Assistant Director of Nursing (ADON) on 01/04/22 at 5:35 PM, the ADON stated, Testing is done for three hours a day on Tuesdays from 12 to 3. The ADON stated if a staff member started having symptoms of COVID-19 they would be tested right away. The ADON stated staff members were to fill out a form, when they tested for COVID-19, which identified themselves, and at the end of the three-hour shift those forms were collected, but she was unsure of what happened to the forms after that. The ADON stated she was never instructed to cross check the forms about who had come in for testing on each testing date to ensure all staff members were tested per CDC guidelines. The ADON stated she was not aware that staff who were not able to test for COVID-19 on Tuesday were required to test prior to working their next scheduled shift. The facility provided an acceptable plan for removal of the Immediate Jeopardy on 01/06/22. Review of the facility's Removal Plan indicated all unvaccinated team members are subject to routine testing and outbreak being testing based on CDC guidance. A document will be created and monitored by the Administration to ensure compliance with testing. The DON has been educated on the COVID-19 testing policy. Staff who do not test will not be permitted to return to work until COVID-19 Testing occurs and the results are negative. The IP will audit the testing procedures and all audits will be reported during the QAPI Review. The survey team verified that the following actions were implemented to remove the immediacy: Interviews with facility staff revealed a system had been put into place to ensure administration was aware of current CDC guidelines and up-to-date information related to county transmission rates, that all staff working in all departments in the facility was being tested per the current CDC guidance (per facility outbreak status and/or community transmission rates), and that a system was in place to monitor all staff to ensure testing was completed per CDC guidelines and that staff who had not tested per guidelines were identified and required to test prior to contact with other staff and residents in the facility. Interviews with facility staff revealed all staff on duty had been educated related to COVID-19 testing requirements and understood testing was to take place for all staff based on facility outbreak status and/or county transmission data. Interviews with staff revealed all staff working in the facility had been tested per CDC Guidelines with a current negative result and that none of these staff members had any current symptoms of COVID-19. The facility's education records were reviewed and revealed no concerns. The survey team determined the immediacy had been removed on 01/06/22. The Administrator was informed on 01/06/22 at 10:36 PM.

Based on observations, interviews, record reviews, policy reviews, and review of the Centers for Disease Control and Prevention (CDC) Guidelines, the facility failed to have an effective Infection Prevention and Control Program (IPCP) to properly contain and prevent the transmission of COVID-19. The facility failed to: 1. Place Resident (R) 24, who was not fully vaccinated, on Transmission Based Precautions (TBP) for the required amount of time after testing positive for COVID-19. 2. Complete contact tracing for potentially exposed residents and staff after facility staff who were symptomatic of COVID-19 tested positive for COVID-19. 3. Ensure staff were restricted from work and from providing resident care for the required time frame after being symptomatic and testing positive for COVID-19. 4. Failed to ensure all staff were screened for the absence of signs and symptoms of COVID-19 prior to coming into residents' environment; and prior to providing care to residents. These failures placed the 14 residents (R21, R14, R191, R34, R192, R193, R194, R189, R24, R39, R240, R35, R37, and R15) that were not vaccinated or fully vaccinated out of the 22 residents residing on the [NAME] Unit at risk for serious harm or death out of a total sample of 28 residents. An Immediate Jeopardy was identified on 01/04/22 and was determined to begin on 12/25/21 when Certified Nursing Assistant (CNA) 1 tested positive for COVID-19 and the facility failed to complete contact tracing to prevent the spread of COVID-19. On 01/04/22 at 10:20 PM, the facility's Administrator was notified and issued the Immediate Jeopardy Template at F880, Infection Control. The Administrator was notified that the Immediate Jeopardy was removed on 01/06/22 at 10:36 PM. The noncompliance remained at an E (pattern of potential for more than minimal harm) scope and severity level following the removal of the Immediate Jeopardy. Findings include: 1. Review of the DHEC [Department of Health and Environmental Control] Health Update, dated 12/02/20 and provided by the facility, revealed Options to Shorten Quarantine for COVID-19 .A full (14) day quarantine after exposure to a COVID-19 case remains the most effective strategy for preventing additional transmission of [CONDITION(S)]-CoV-2 from asymptomatic or pre-symptomatic cases. Updated CDC guidance also offers two (2) additional options to shorten quarantine to reduce burden on individuals and increase compliance. Day 10: Discontinuing after Day 10 may be considered if the contact has no symptoms reported throughout the quarantine period .Day 7: Discontinuing after Day 7 may be considered if the contact has no symptoms reported throughout the quarantine period and has been tested negative for COVID-19 by a polymerase chain reaction (PCR) or [MEDICATION(S)]-based test collected no sooner than Day 5. Quarantine may NOT discontinue sooner than Day 7 even if the negative rest result is returned prior to that . Review of the CDC guidance titled CDC Updates and Shortens Recommended Isolation and Quarantine Period for General Population, updated 12/27/21, revealed Given what we currently know about COVID-19 and the Omicron variant, CDC is shortening the recommended time for isolation for the public. People with COVID-19 should isolate for 5 days and if they are asymptomatic or their symptoms are resolving (without fever for 24 hours), follow that by 5 days of wearing a mask when around others to minimize the risk of infecting people they encounter. The change is motivated by science demonstrating that the majority of [CONDITION(S)]-CoV-2 transmission occurs early in the course of illness, generally in the 1-2 days prior to onset of symptoms and the 2-3 days after . Review of the American Health Care Association (AHCA) and the National Center for Assisted Living (NCAL), handwritten, dated 12/28/21 and provided by the facility, revealed Correction: New CDC Guidance for Isolation and Quarantine Does Not Apply to Residents. Yesterday AHCA/NCAL reported that the CDC had updated and shortened their guidance for quarantine and isolation periods. Our update incorrectly stated that this new guidance applies to residents. Review of R24's undated Face Sheet, located in the resident's electronic medical record (EMR) under the [resident's name] tab, revealed the resident was admitted to the facility on [DATE]. Review of R24's COVID-19 Immunization Record, provided by the facility, revealed the resident received her first COVID-19 vaccination of a series of two on 11/02/21; however, the resident had not received her second dose, which indicated the resident was not fully vaccinated. Review of R24's Clinical Notes, located in the EMR under the Clinical tab, revealed nursing notes, dated 12/28/21, indicated, Resident COVID tested with a positive result. Isolation precautions placed into effect; family notified. All administrative staff notified . [Resident's Name] is positive for COVID-19. She is on droplet isolation precautions . Observation on 01/03/22 at 10:36 AM of R24's door revealed no signage to indicate the resident was on any TBP related to COVID-19. Observation on 01/03/22 at 10:46 AM of Licensed Practical Nurse (LPN) 7 revealed LPN7 entered R24's room without donning any PPE other than the surgical mask she was already wearing. Continued observation revealed LPN7 removed all of R24's bed linen without any gloves and remade the resident's bed. LPN7's clothes came into direct contact with R24's bed linens. Interview on 01/03/22 at 10:51 AM with LPN7, directly after she exited R24's room, revealed R24 was started on droplet isolation TBP on 12/28/21; however, the resident came off the TBP on 01/02/22, five days after being placed on the TBP. During an interview on 01/03/22 at 12:02 PM, the Director of Nursing/Infection Preventionist (DON/IP) revealed when R24 tested positive for COVID-19, the facility tested all residents on the [NAME] Unit where R24 resided and tested all facility employees. The DON/IP stated at that time, no other residents or staff tested positive for COVID-19. Continued interview with the DON/IP revealed that depending on a resident's vaccination status, a resident's isolation period could be anywhere between five and 10 days. During an interview on 01/03/22 at 12:10 PM, the Administrator confirmed R24 was not fully vaccinated for COVID-19. Interview on 01/03/22 at 2:23 PM with the facility's Co-Medical Director revealed the minimum isolation period for a resident who was COVID-19 positive was seven days, if the resident was completely asymptomatic. The Co-Medical Director stated R24 came off of TBP over the weekend and she should have remained on TBP for the full seven days to minimize the spread of the disease. Interview on 01/03/22 at 2:26 PM with the DON/IP revealed she was the person who made the decision to discontinue the TBP for R24 on 01/02/22. 2. Review of the CDC Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 09/10/21, revealed .New Infection in Healthcare Personnel or Resident When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. Respond to a Newly Identified [CONDITION(S)]-CoV-2-infected HCP or Resident Because of the risk of unrecognized infection among residents, a single new case of [CONDITION(S)]-CoV-2 infection in any HCP or a nursing home-onset [CONDITION(S)]-CoV-2 infection in a resident should be evaluated as a potential outbreak. The approach to an outbreak investigation should take into consideration whether the facility has the experience and resources to perform individual contact tracing, the vaccination acceptance rates of staff and residents, whether the index case is a healthcare worker or resident, whether there are other individuals with suspected or confirmed [CONDITION(S)]-CoV-2 infection identified at the same time as the index resident, and the extent of potential exposures identified during the evaluation of the index resident. Consider increasing monitoring of all residents from daily to every shift, to more rapidly detect those with new symptoms. Review of the facility's undated and untitled COVID-19 Positive line listing for facility staff revealed Certified Nursing Assistant (CNA) 1 tested positive for COVID-19 on 12/25/21. The line listing also revealed CNA1 was not fully vaccinated and exhibited the symptoms of headache and loss of smell. Review the facility's Daily Assignment Sheet [NAME], dated 12/24/21, revealed CNA1 was assigned to the [NAME] Unit. Telephone interview on 01/04/22 at 4:36 PM with CNA1 revealed she worked with R24 on 12/24/21. CNA1 stated she left work early on 12/24/21 due to symptoms of fatigue and runny nose. CNA1 stated she was not tested before she left work. CNA1 stated on 12/25/21 she lost her smell, so she called the facility and came to the parking lot and was tested with the result of positive for COVID-19. The CNA stated she was not asked any contact tracing question such as residents she could have exposed or close contact with other staff members. Review of CNA1's Human Infection with 2019 Novel Coronavirus Case Report Form, dated 12/26/21, revealed CNA1 tested positive for COVID-19 on 12/25/21, worked during her infection period, and was assigned to the [NAME] Unit. The Case Report Form indicated close contact was being face to face with an infected person within six feet for at least 15 minutes starting from 48 hours before the infected person became ill or with no symptoms, two days prior to their positive test collection through the time the infected person was isolated. The form indicated CNA1 had no close contact with residents. Review of the facility's undated and untitled COVID-19 Positive line listing for facility staff revealed Registered Nurse (RN) 2 tested positive for COVID-19 on 12/26/21. The line listing also revealed RN2 was fully vaccinated and exhibited the symptoms of body aches, sore throat, and loss of smell. Review the facility's Daily Assignment Sheet Cypress, dated 12/25/21, revealed RN2 was assigned to the Cypress Unit. Review of RN2's Human Infection with 2019 Novel Coronavirus Case Report Form, dated 12/26/21, revealed RN2 became symptomatic on 12/26/21. The Case Report Form indicated close contact was being face to face with an infected person within six feet for at least 15 minutes starting from 48 hours before the infected person became ill or with no symptoms, two days prior to their positive test collection through the time the infected person was isolated. The form indicated RN2 had no close contact with residents and her last day worked prior to testing positive was 12/25/21 and she was assigned to the Cypress Unit who housed one unvaccinated resident, R19. Interview on 01/04/22 at 5:30 PM with RN2 revealed after she tested positive for COVID-19 she did not complete any contact tracing with the facility. Review of the facility's undated and untitled COVID-19 Positive line listing for facility staff revealed CNA4 tested positive for COVID-19 on 01/01/22. The line listing also revealed CNA4 was fully vaccinated and was symptomatic (did not list specific symptoms). Review the facility's Daily Assignment Sheet [NAME], dated 12/25/21, 12/26/21, and 01/01/22 revealed CNA4 worked on the [NAME] Unit. Interview on 01/04/22 at 5:44 PM with CNA4 revealed she worked the [NAME] Unit on 01/01/22. When asked if she provided care to any resident that consisted of close contact, CNA4 stated yes, she was with [R30] for approximately one hour providing care, transferring the resident, providing hygiene, and making her bed. CNA4 stated while on shift, she completed first test (specimen collection) and then went back to her assigned unit and continued working with her assigned residents. CNA4 further stated the nurse who completed the test came and told her that she tested positive but with a faint line; so, she completed a second test and did not return to her assigned area until the results came back, which were positive. CNA4 stated after she tested positive twice on 01/01/22, she was not asked any contact tracing questions. Review of CNA4's Human Infection with 2019 Novel Coronavirus Case Report Form, dated 01/01/22, revealed CNA4 was symptomatic, worked the [NAME] Unit, and tested positive on 01/01/22. The Case Report Form indicated close contact was being face to face with an infected person within six feet for at least 15 minutes starting from 48 hours before the infected person became ill or with no symptoms, two days prior to their positive test collection through the time the infected person was isolated. The form indicated CNA4 had no close contact with residents. Interview on 01/03/22 at 12:02 PM with the DON/IP revealed when asked about contact tracing after COVID-19 positive staff potentially exposed residents and other staff, the DON/IP stated she went back and looked at all employees and determined no employee was in close contact with residents; meaning they were not within six feet of a resident for 15 minutes. Interview on 01/04/22 at 9:31 PM with the Administrator revealed no other residents other than R24 were placed on TBP based on she could not locate any guidance from the CDC or the Centers for Medicare and Medicaid Services about the need to place any residents on TBP. 3. Review of the CDC Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2, updated 12/23/21, revealed Due to concerns about increased transmissibility of the [CONDITION(S)]-CoV-2 Omicron variant, this guidance is being updated to enhance protection for healthcare personnel (HCP), patients, and visitors, and to address concerns about potential impacts on the healthcare system given a surge of [CONDITION(S)]-CoV-2 infections .The following are criteria to determine when HCP with [CONDITION(S)]-CoV-2 infection could return to work . HCP with mild to moderate illness who are not moderately to severely immunocompromised: At least 7 days if a negative [MEDICATION(S)] or NAAT is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7) have passed since symptoms first appeared .At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved. HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised: At least 7 days if a negative [MEDICATION(S)] or NAAT is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or a positive test at day 5-7) have passed since the date of their first positive [CONDITION(S)] test . Review of the facility's undated and untitled COVID-19 Positive line listing for facility staff revealed RN2 tested positive for COVID-19 on 12/26/21. The line listing also revealed RN2 was fully vaccinated and exhibited the symptoms of body aches, sore throat, and loss of smell. Review of RN2's Human Infection with 2019 Novel Coronavirus Case Report Form, dated 12/26/21 revealed RN2 became symptomatic on 12/26/21, the same date she tested positive for COVID-19. Review the facility's Daily Assignment Sheet Cypress, dated 12/30/21 revealed RN2 was assigned to the [NAME] Unit, which indicated RN2 returned to work four days after testing positive for COVID-19 and was exhibiting symptoms of COVID-19 During an interview on 01/04/22 at 5:30 PM, RN2 stated she returned to work on 12/30/21 at the facility's request and started her shift assigned to the Cypress unit and then reassigned to the [NAME] Unit. RN2 stated she tested positive on 12/26/21. During an interview on 01/04/22 at 6:20 PM, the Administrator stated per the CDC guidance, RN2 should not have returned to work on 12/30/21, four days after she tested positive for COVID-19. Interview on 01/04/22 at 5:44 PM with CNA4 revealed she arrived at work on 01/01/22 experiencing COVID-19 symptoms of chills, sweats, and coughing. CNA4 stated she took her temperature and did not have a fever; however, she did not complete any screening questions for signs and symptoms of COVID-19 prior to the start of her shift. CNA4 stated she started getting worse approximately three hours into her shift and asked to be tested . The test did not immediately show positive but was told by the nurse sometime later it was positive and that she needed to stop providing care to residents and take another test which resulted in a positive result. During an interview on 01/04/22 at 6:20 PM, the Administrator confirmed there was no documented evidence CNA4 completed screening for signs and symptoms of COVID-19 on 01/01/22. Review of the facility's Removal Plan for F880 indicated the facility will place R24 back in Transmission Based Precautions (TBP) along with placing proper signage on the door to ensure staff are wearing the appropriate Personal Protective Equipment (PPE). All residents who were not fully vaccinated were placed on TBP for 14 days from the last known exposure. Contact tracing for all residents and staff who tested positive after 01/05/22 will be conducted by the Infection Preventionist (IP) or designee. Facility-wide COVID-19 testing will continue every three to seven days until there are no new cases for 14 days. The facility administration will maintain a document, which identifies staff who test positive along with the test date and follow CDC Guidance on when to return work. The IP or designee will conduct rounding audits to ensure compliance with COVID-19 Testing results as well as ensuring staff are following the guidance for wearing PPE. There will be a designated staff member to ensure all staff are screened prior to entering the building. Staff will no longer be able to enter an alternate doors in the building. All concerns regarding COVD-19 testing TBP and staff screening will be reviewed during the monthly QAPI Meeting. The facility updated their COVID-19 policies and procedures. The survey team verified that the following actions were implemented to remove the immediacy: Observations were made to confirm residents who were not vaccinated or fully vaccinated were placed on the appropriate TBP. Observations were made to ensure R24 was placed back on TBP per the required amount of time and that staff were donning and doffing the required PPE. Interviews with facility staff revealed all staff on duty had been educated related to placing residents on propter TBP, Screening, Contact Tracing, and PPE usage. The facility's education records were reviewed and revealed no concerns. The survey team determined the immediacy had been removed on 01/06/22. The Administrator was informed on 01/06/22 at 10:36 PM.

Based on interview, document review, review of the facility's policy, and review of the facility's Quality Assurance Performance Improvement (QAPI) program procedure, the facility failed to ensure the required members of the committee attended the QAPI meetings at least quarterly. The facility's Medical Directors did not attend any QAPI meetings for the four quarters of 2021. Findings include: During an interview and QAPI review on 01/06/22 at 7:05 PM, the Administrator confirmed the Medical Director had not attended any QAPI meetings for the year 2021. The Administrator stated she informed the Medical Director of the meeting date and times; however, they never attended. Interview on 01/06/22 at 8:58 PM with the Co-Medical Director revealed the main Medical Director (who was out of the country) would have been the person responsible for attending the QAPI meetings. Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership, revised March 2020 revealed The quality assurance and performance improvement program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the administrator and governing body .6. The following serve on the committee: .c. Medical Director .7. The committee meets at least quarterly (or more often as necessary) .

Based on record review, interview and policy review, the facility failed to ensure the Consultant Pharmacist identified the inappropriate use of anti-psychotic medication for one of five residents (Resident (R) 15 reviewed for unnecessary medication. Findings include: Review of R15's undated Face Sheet, located in the resident's electronic medical record under the [resident's name] tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance. Review of R15's Physician Order Sheet, located in the resident's EMR under the Orders tab revealed an order dated 12/01/21 of [MEDICATION(S)] [an antipsychotic medication] 25 mg [milligram] (1) tablet oral at hour of sleep. The order indicated the medication was for Agitation/Dementia. Interview on 01/06/22 at 4:54 PM with the facility's Consultant Pharmacist revealed during her December 2021 medication regimen review of R15's medications, she did not catch R15 was prescribed an antipsychotic medication for dementia/agitation. The Consultant Pharmacist stated this was not an appropriate diagnosis for the use of [MEDICATION(S)]. Interview on 01/06/22 at 8:58 PM with the Co-Medical Director revealed she was the provider who prescribed R15 the [MEDICATION(S)]. The Co-Medical Director stated she prescribed the medication because of dementia with behaviors. Review of the facility's policy titled Medication Utilization and Prescribing-Clinical Protocol, revised April 2018, revealed .1. When a medication is prescribed for any reason, the physician and staff will identify the indications (condition or problem for which it is being given, or what the medication is supposed to do or prevent), considering the resident's age, medical, and psychiatric conditions, risks, health status, and existing medication regimen .2. As part of the overall review, the physician and staff will evaluate the rationale for existing medications that lack a clear indication or are being used intermittently on a PRN (as needed) basis .The consultant pharmacist should use the monthly and interim drug regimen review to help identify potentially problematic medications, including medication regimens that are not supported based on clinical signs or symptoms . The policy did not address the physician's response to the consultant pharmacist's recommendations. Review of the facility's policy titled Pharmacy Services-Role of the Consultant Pharmacist, revised April 2019, revealed .3. The consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility, and collaborate with the facility medical director .e. Develop mechanisms for communicating, addressing and resolving issues related to pharmaceutical services .

Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with dementia for one of three residents reviewed for dementia care out of 17 sampled residents (Resident (R) 6). Findings included: Review of Resident (R)6's Face Sheet, located under the Admission tab in the Electronic Medical Record (EMR) revealed an admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R6's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/21, found in R6's EMR under the MDS tab revealed R6 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was cognitively intact. The MDS also revealed R6 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R6's comprehensive Care Plan, dated 10/26/21, found in R6's EMR under the Care Plan tab revealed a problem for dementia was not addressed on the care plan. Interview on 01/06/22 at 5:50 PM with the MDS Coordinator revealed she began employment with the facility two months ago and she was in the process of reviewing and updating all the care plans. The MDS Coordinator verified that R6 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 01/06/22 at 5:56 PM with the Regional Staff Development Specialist revealed that she expected the Director of Nursing (DON) to audit the resident's care plan to ensure high risk diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 01/06/22 at 6:39 PM with the Administrator revealed she expected the MDS Coordinator to develop the comprehensive care plan to address the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised December 2016, revealed .8. The comprehensive, person-centered care plan will: a. include measurable objectives and timeframes; b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .g. incorporate identified problem areas .l. identify the professional services that are responsible for each element of care .12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).

Based on observation, interview, record review, and facility policy review, the facility failed to implement their abuse policies for one of 28 sampled residents (Resident (R) 24). There was no documented evidence the facility completed a thorough investigation when an injury of unknown origin was identified on R17 and reported to the Director of Nursing (DON) by Registered Nurse (RN) 8 on 01/01/22. Findings include: Review of the facility's policy tilted Recognizing Signs and Symptoms of Abuse/Neglect, revised January 2011, revealed .To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately .3. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported .a. Signs of Actual Physical Abuse: (1) Welts or Bruises .of questionable origin . Review of the facility's policy titled Investigating Injuries, revised December 2016, revealed 1. The Director of Nursing Services or a designee will assess all injuries and document clinical findings in the clinical record. 2. If an incident/accident is suspected, a nurse or nurse supervisor will complete a facility-approved accident/incident form. 3. Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. the injury is suspicious because of: (1) the extent of the injury; or (2) the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or (3) the number of injuries observed at one particular point in time; or (4) the incidence of injuries over time. 4. Documentation shall include information relevant to risk factors and conditions that could cause or predispose someone to similar signs and symptoms. 5. The nursing staff shall discuss the situation with the Attending Physician or Medical Director to consider whether medical conditions or other risk factors could account for the findings. 6. With the help of the staff and management, the investigator will compile a list of all personnel, including consultants, contract employees, visitors, family members, etc., who have had contact with the resident during the last 48 hours. 7. The investigation will follow the protocols set forth in our facility's established abuse investigation guidelines. Review of R17's Face Sheet found in R17's Electronic Medical Record (EMR) under the Admission tab revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R17's Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/22/21, found in R17's EMR under the MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated she was unable to complete the interview. Facility staff accessed R17 as severely impaired in making decisions. The MDS also indicated that R17 had not received an anticoagulant in the last seven days of the look back period. Observations of R17 on 01/03/22 at 11:43 AM, and on 01/04/22 at 12:45 PM revealed R17 was sitting in a wheelchair in the dining room with a large green bruise noted to the left side of her forehead. Observation of R17 on 01/05/21 at 2:45 PM with the DON, verified R17 had a large green bruise on the left side of her forehead and face. Interview with the DON at this time revealed R17's injury had not been reported to her and she was unaware RN8 had completed an incident report on 01/01/22. Review of facility's Resident Incident Reporting Form, dated 01/01/22, provided by the facility documented a Certified Nursing Assistant (CNA) noticed a bruise above R17's left eye that went into the top of her head at 6:10 PM, R17 was up in wheelchair without incident during the day, vital signs were within normal limits, on call Nurse Practitioner was notified and brother was informed. Review of the R17's Nursing Progress notes, dated 01/01/22, located in the Notes tab in the EMR revealed RN8 documented noted bruising and bump on left side of head above eye, starting at eyebrow into top of head where it is semi-soft, called on call and nurse practitioner returned call and wants resident on neuro checks. Review of R17's Skin Assessment, dated 01/06/22, located in the Assessment tab in the EMR revealed RN8 documented the resident had a left side head bruise that measured 10 centimeters (cm) in length and 7.5 cm in width. Interview on 01/06/22 at 9:01 AM with the Administrator revealed she became aware of R17's injury of unknown source on 01/05/22 when queried by the surveyor. The Administrator stated she expected RN8 to immediately notify the DON of R17's injury, to complete an assessment of R17, complete an incident report, notify the Physician and the family, then treat R17's injury per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator stated once the injury of unknown origin was reported to her last night, she reported it to the State Agency (SA), began the abuse investigation, then she in serviced the DON on the abuse prevention, investigation and reporting policy. The Administrator also stated that not investigating the injury of unknown origin could have led to a serious injury, death or hospitalization , or abuse to other residents. Interview on 01/06/22 at 9:45 AM with RN8 revealed she provided care for R17 on 01/01/22 when the CNA called her to the dining room to look at the bruise to the left side of R17's face. RN8 stated she assessed R17, completed an incident report, called the on-call Nurse Practitioner, informed the family, completed neurological checks as ordered by the Nurse Practitioner, and reported the injury to the DON. Interview on 01/06/22 at 10:08 AM with the DON revealed it was her weekend on call when she received a text from RN8 that R17 had a bruise to her left forehead. The DON stated she didn't fully read the text and expected staff to call her instead of texting her when reporting emergencies. The DON also stated it was her responsibility to ensure full understanding of the text messages she received from staff, and she should have come in the facility, assessed the resident, interviewed the resident and staff, reviewed the nurses' notes, and reviewed the incident reports to see if the injury corresponded with a fall. The DON indicated if she had deemed the injury to be an injury of unknown origin then she would notify the Administrator then the Administrator would have reported it to the SA within two hours. The DON acknowledged she didn't follow the abuse policy and it's a very serious issue that could have resulted in resident harm.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure [CONDITION(S)] drugs (defined as any drug that affects brain activities associated with mental processes and behavior) when ordered PRN (as needed), was limited to fourteen (14) days unless extended by the Physician or prescribing practitioner with a documented rationale in the resident's medical record for one of five residents reviewed for unnecessary medications (Resident (R) 13). The facility also failed to ensure residents on anti-psychotic medication was monitored for behaviors as well as ensure the prescribed anti-psychotic had the appropriate rationale for one of five residents (R15) reviewed for unnecessary medication. Findings include: 1. Review of R13's Face Sheet found in R13's Electronic Medical Record (EMR) under the Admission tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included major depressive disorder recurrent, and unspecified mood affective disorder. Review of R13's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/15/21, found in R13's EMR under the MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated she was unable to complete the interview. The MDS also indicated R13 had not received an antianxiety medication in the last seven days of the look back period. Review of R13's Physician's Order found in R13's EMR under the Orders tab, dated 12/17/21, revealed an order for [MEDICATION(S)] (an antianxiety) 1 milligram (mg) tablet oral as needed (PRN) three times daily for anxiety and agitation. Interview on 01/06/22 at 4:52 PM with the Pharmacy Consultant revealed she reviewed the medication orders for R13 the first week of December 2021 so she wouldn't have caught that there was no stop date or that the medication should have been limited to 14 days until next week. The Pharmacy Consultant stated that the Physician should have written the medication for 14 days and added a stop date because the Physician knew the rules. Interview on 01/06/22 at 6:49 PM with the Administrator and the Regional Staff Development Specialist revealed the Physician should not have ordered [MEDICATION(S)] for more than 14 days and an end date should have been added to the order. The Administrator stated the Director of Nursing (DON) should have identified this when she reviewed the 24-hour report that showed the new orders for the residents. The Administrator also stated the DON was expected to query the physician about the order then update the order to reflect the 14 days and add a stop date. Interview on 01/06/22 at 8:50 PM with R13's Physician revealed she rounded on the residents monthly and the order for [MEDICATION(S)] was written because the nurses stated R13 was grinding her teeth and really anxious on 12/17/21. The Physician stated she added the order and doesn't usually put a stop date on the medications but should have limited the medication to 14 days. The Physician indicated that someone at the facility was supposed to evaluate the order and add the stop date, but it didn't happen. 2. Review of R15's undated Face Sheet, located in the resident's EMR under the [resident's name] tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance. Review of R15's Physician Order Sheet, located in the resident's EMR under the Orders tab revealed an order dated 12/01/21 of [MEDICATION(S)] [an antipsychotic medication] 25 mg [milligram] (1) tablet oral at hour of sleep. The order indicated the medication was for Agitation/Dementia. Review of R15's Medication Administration Record (MAR), dated for December 2021 revealed R15 had been administered the medication every day in December 2021. The MAR lacked any documented evidence any behavior monitoring was completed for R15. Interview on 01/06/22 at 6:32 PM with the Regional Staff Development Specialist, confirmed the facility had not completed any behavior monitoring related to R15's antipsychotic medication of [MEDICATION(S)]. The Regional Staff Development Specialist stated there should have been behavior monitoring for December 2021 and January 2022 to support the use of [MEDICATION(S)]. Interview on 01/06/22 at 4:54 PM with the facility's Consultant Pharmacist revealed the diagnosis of dementia/agitation was not an appropriate diagnosis for the use of the antipsychotic [MEDICATION(S)]. Interview on 01/06/22 at 6:38 PM with the Administrator revealed it was her expectation the physician would have thoroughly explained their rational for prescribing an antipsychotic medication to R15. Review of the facility's policy titled, Medication Utilization and Prescribing-Clinical Protocol, revised April 2018, revealed, .1. When a medication is prescribed for any reason, the physician and staff will identify the indications (condition or problem for which it is being given, or what the medication is supposed to do or prevent), considering the resident's age, medical, and psychiatric conditions, risks, health status, and existing medication regimen .2. As part of the overall review, the physician and staff will evaluate the rationale for existing medications that lack a clear indication or are being used intermittently on a PRN (as needed) basis .The consultant pharmacist should use the monthly and interim drug regimen review to help identify potentially problematic medications, including medication regimens that are not supported based on clinical signs or symptoms . Review of the facility's policy titled, Antipsychotic Medication Use, revised December 2016, revealed Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed .1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medial condition, specific symptoms, and risks to the resident and others .7. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record .a. [CONDITION(S)], b. [CONDITION(S)] disorder, c. Schizophreniform disorder, d. Delusional disorder, e. Mood disorders, f. [CONDITION(S)] in the absence of dementia, g. Medical illness with psychotic symptoms and/or treatment-related [CONDITION(S)] or [CONDITION(S)], h. [CONDITION(S)] Disorder, i. [CONDITION(S)] Disease; Hiccups; Nausea and vomiting associated with cancer or [CONDITION(S)]. 8. Diagnoses alone do not warrant the use of antipsychotic medication .13. Residents will not receive PRN doses of [CONDITION(S)] medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. 14. The need to continue PRN orders for [CONDITION(S)] medications beyond 14 days requires that the practitioner document the rational for the extended order. The duration of the PRN order will be indicated in the order .

Based on record review, staff interview and review of the Long-Term Care (LTC) Resident Assessment Instrument (RAI) 3.0, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for three (3) of 21 sampled residents (Resident #2, Resident #3 and Resident #288). The findings include: 1. Based on record review, observation, and interview, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for Resident #2 related to pressure ulcers. The findings included: The facility admitted Resident #2 on 07/03/2018 with [DIAGNOSES REDACTED]. During review of the 09/29/2020 Quarterly Minimum Data Set (MDS), section M Skin Conditions, M0300 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage C Stage 3 #1 was coded blank = Number of Stage 3 pressure ulcers?. Review of the 07/09/2020 Quarterly Minimum Data Set (MDS), section M Skin Conditions, M0300 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage C Stage 3 #1 was coded blank = Number of Stage 3 pressure ulcers?. Review of the Resident record revealed documentation of pressure ulcer measurements from the Wound Nurse of: 7/28/20-Sacrum unstageable 5.5 x 2.6 x 0.1 8/4/20-Sacrum Stage IV 9.5 x 3.0 x 0.3 8/11/20-Sacrum Stage IV 7.0 x 5.0 x 0.5 8/18/20-Sacrum Stage IV 6.5 x 4.9 x 0.9 8/25/20-Sacrum Stage IV 9.5 x 3.0 x 0.6 9/1/20-Sacrum Stage IV 8.5 x 2.5 x 1.0 9/8/20-Sacrum Stage IV 8.5 x 3.0 x 2.0 9/15/20-Sacrum Stage IV 8.2 x 3.0 x 2.0 9/22/20-Sacrum Stage IV 7.0 x 5.0 x 1.0 9/22/20-Sacrum Stage IV 8.5 x 4.5 x 2.5 The Director of Nursing (DON) confirmed on 10/6/20 at 3:15 PM that the Resident has kennedy ulcers. During an interview with Certified Nursing Assistant (CNA) # 1 on 10/6/20 at 2:57 PM, s/he confirmed that the Resident does have a pressure ulcer on his/her sacrum for at least 1 month since I've been here. 2. Review of Resident #3's Face Sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record Review of physician's orders [REDACTED]. Review of Resident #3's quarterly Minimum Data Set sated 6/22/2020 revealed the resident was assessed as having long and short-term memory problems. Resident #3 was severely impaired in cognitive skills for daily decision-making. Resident #3 was assessed as receiving seven (7) days of antipsychotic medication during the look back period as per N0410: Medications Received. Review of N0450: Antipsychotic Medication Review revealed No - Antipsychotics were not received. Record Review of the LTC Facility RAI 3.0 revealed N0450: Antipsychotic Medication Review: Coding Instructions for N450A: Code, 0 no: if antipsychotics were not received: Skip N450B, N450C, N450D and N450E. Code 1, yes if antipsychotics were received on a routine basis only: Continue to N450B, Has a GDR (gradual dose reduction) been attempted?; Code 3, yes: if antipsychotics were received on a routine and PRN basis: Continue to N0450B, Has a GDR been attempted? Coding Tips and Special Populations: Any medications that has a pharmacological classification or therapeutic category of antipsychotic medication must be record in this section, regardless of why the medication is being used. During an interview on 10/07/2020 at 12:29 p.m., RN - MDS Nurse #1 revealed Resident #3 receive antipsychotic medications so the MDS should reflect the antipsychotic was received routinely. She/he stated she/he would correct the MDS. She/he stated the nurse who completed the MDS was new. She/he has been completing MDS assessments for about two (2) months. 3. Review of Resident #288's Face Sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record Review of Resident #288's Admission MDS dated [DATE] revealed Section O: Special Treatments, Procedures, and Programs - O0100J: [MEDICAL TREATMENT] was not completed. The resident was not assessed as receiving [MEDICAL TREATMENT] while a resident or while not a resident. During an interview on 10/07/2020 at 9:46 a.m., Licensed Practical Nurse (LPN) #2 revealed Resident #288 was receiving [MEDICAL TREATMENT] when he was admitted . She/he stated the resident's [MEDICAL TREATMENT] days were Monday, Wednesday and Friday. During an interview on 10/07/2020 at 12:45 p.m., Registered Nurse (RN) - MDS Nurse #1 revealed Resident #288 received [MEDICAL TREATMENT] and it should have been coded on his MDS. She/he stated she would make the correction. During an interview on 10/07/20 at 12:51 p.m., the Director of Nursing stated the MDS Nurse, who completed the assessment for Resident #3 and Resident #288, was new. She/he stated the older MDS nurse usually watched over the new MDS nurse, but it may have slipped through the cracks. She/he stated they use the RAI manual for guidance. Record Review of the LTC Facility RAI 3.0 revealed O0100J, [MEDICAL TREATMENT]: Code peritoneal or [MEDICAL TREATMENT] which occurs at the nursing home or at another facility, record treatments of hemofiltration, Slow Continuous Ultrafiltration (SCUF), Continuous Arteriovenous Hemofiltration (CAVH), and Continuous Ambulatory Peritoneal [MEDICAL TREATMENT] (CAPD) in this item. Intravenous (IVs), IV medication, and blood [MEDICAL CONDITION] administered during [MEDICAL TREATMENT] are considered part of the [MEDICAL TREATMENT] procedure and are not to be coded under items K0510A ([MEDICATION NAME]/IV), O0100H (IV medications), or O0100I ([MEDICAL CONDITION]). This item may be coded if the resident performs his/her own [MEDICAL TREATMENT]. Resident #2 Pressure Ulcer/Injury

Based on record review, staff interview and review of the Long-Term Care (LTC) Resident Assessment Instrument (RAI) 3.0, the facility failed to develop a comprehensive care for two (2) of 21 sampled residents (Resident #3 and Resident #288). Care plans were not developed to address Resident #3's use of antipsychotic medication and Resident #288's [MEDICAL TREATMENT] treatments. The findings included: 1. Review of Resident #3's Face Sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed as severely impaired in cognitive skills for daily decision-making. Resident #3 was assessed as not having any mood or behavior concerns during this assessment. The resident required extensive physical assistance of two or more staff for bed mobility, dressing, toilet use and personal hygiene; total physical assistance of two or more staff for transfers and bathing; and supervision by one staff for eating. Resident #3 was assessed as receiving seven (7) days of antipsychotic medication during the look back period as per N0410: Medications Received. Review of Resident #3's physician's orders [REDACTED]. Record Review of Physician's Progress Note dated 9/17/2020 revealed . 7. Depression: pt. (patient). on [MEDICATION NAME] (antidepressant) 120, [MEDICATION NAME] 5 mg, [MEDICATION NAME] (stimulant) 5mg and [MEDICATION NAME] (anticonvulsant) 100mg. Psych cont. (continue). to f/u (follow-up) pt. Review of a Psychiatric Consultation Note dated 7/31/2020 revealed . Diagnoses: [REDACTED]. Increase [MEDICATION NAME] to 120 mg po (by mouth) every day 2. Increase [MEDICATION NAME] to 5 mg po every day. Follow up as needed. Review of Psychiatric Follow-up Note dated 8/29/2020 revealed Recommendation: Increase Ability to 10 mg po every day. Record Review of Resident #3's Comprehensive Care Plans with an effective date of 3/30/2020 to present revealed there was not a care plan addressing the use of [MEDICATION NAME], an antipsychotic medication. During an interview on 10/07/20 at 12:29 p.m. Registered Nurse (RN) - MDS Nurse #1 revealed Resident #3 received antipsychotic medications. She/he stated a care plan should have been developed showing his/her antipsychotic use and interventions. She/he stated she/he would develop a care plan addressing the antipsychotic use. 2. Review of Resident #288's Face Sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #288's Admission MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident was moderately impaired in cognitive skills for daily decision-making. Resident #288 was assessed as requiring extensive physical assistance of one staff for bed mobility and dressing; extensive physical assistance of two or more staff for transfers and toilet use; supervision of one staff for eating; limited physical assistance of one staff for personal hygiene; and total physical assistance of two or more staff for bathing. Section O: Special Treatments, Procedures, and Programs - O0100J: [MEDICAL TREATMENT] was not completed. The resident was not assessed as receiving [MEDICAL TREATMENT] while a resident or while not a resident. Review of Resident #288's physician's orders [REDACTED]. 9/21/2020: [MEDICAL TREATMENT] Monday - Wednesday - Friday at Fresinious North(NAME)Beach. Pick up at 11:45 a.m. with chair time at 12:45 p.m. Transport back at 17:30. Must have early lunch these days and send snack. Check for bruit and thrill upon return from [MEDICAL TREATMENT] and document in nurses note. During an interview on 10/07/2020 at 9:46 a.m., Licensed Practical Nurse (LPN) #2 revealed Resident #288 was receiving [MEDICAL TREATMENT] when he/she was admitted to the facility. She/he stated the resident's [MEDICAL TREATMENT] days were Monday, Wednesday and Friday. During an interview on 10/07/2020 at 12:45 p.m., RN - MDS Nurse #1 revealed Resident #288 received [MEDICAL TREATMENT] three (3) days a week and it should have been care planned. She/he stated she would develop the care plan immediately. During an interview on 10/07/20 at 12:51 p.m., the Director of Nursing stated the MDS Nurse, who completed the assessment for Resident #3 and Resident #288, was new. She/he stated the older MDS nurse usually watched over the new MDS nurse, but it may have slipped through the cracks. She/he stated they use the RAI manual for guidance. Record Review of the LTC Facility RAI 3.0 revealed the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. Good assessment is the starting point for good clinical problem solving and decision making and ultimately for the creation of a sound care plan. The CAAs (Care Area Assessments) provide a link between the MDS and care planning. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving (see 42 CFR 483.21(b), Comprehensive Care Plans). The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs. A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents.

Based on observation, medical record review, staff interview and the facility's policy entitled, Quality of Life - Dignity, the facility failed to maintain privacy of a resident's urinary collection device for one (1) of two (2) residents (Resident #1). The findings include: Review of the Minimum Data Set completed on 04/17/2020, revealed, Resident #1's decision making was severely impaired. Extensive assistance of two (2) persons' physical assist was required with bed mobility. During an observation on 04/22/2020 at 3:03 p.m., the Director of Nursing (DON) confirmed that Resident #1's urinary collection device was not located inside of the dignity cover; exposing the resident's urine in the device, to public view. The DON stated, she expected the drainage device to be located inside of the dignity bag, to prevent unnecessary exposure of the resident's bodily fluids. Review of the facility policy, revised on August 2009, revealed, .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident keep urinary catheter bags covered .

Based on record review and interview, the facility failed to review and revise Resident #45 care plan for elopement. Resident #42 eloped on 9/2/18 with no evidence that the care plan was reviewed and revised to include interventions to prevent elopement. Resident #45 eloped on 9/7/18, care plan was reviewed and revised on 9/7/18 to include new interventions for elopement. Resident #45 eloped on 9/17/18 with no evidence that the care plan was reviewed and revised to include intervention to prevent elopement. On 4/18/19 at 2:02 PM, the facility Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified related to Complaint SC 940 and cited at a scope and severity of J. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on 9/2/18 and is ongoing. Additionally, there was no evidence of participation in the care planning process by all relevant staff for 1 of 1 residents reviewed for hospice (Resident #7) and 1 of 5 residents reviewed for unnecessary medication (Resident #30). The findings included: Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the 08/23/2018 nurses notes for Resident #45 documented that the resident was wandering in room and hallways and calling for his/her son/daughter. Acts of diversion and reorientation were used as requested by the son/daughter. No new wandering/elopement risk screening was performed, and no new interventions were added to the resident's care plan. Review of the 9/2/2018 nurses' notes revealed Resident #45 wandered outside at midnight stating that s/he was unsure of where s/he was. No new wandering/elopement risk screening was performed, and no new interventions were added to the resident's care plan. During an interview with the Director of Nursing (DON) on 4/17/2019 at 2:48 PM s/he confirmed that no new interventions were added to Resident #45's care plan after the 9/2/2018 elopement to prevent further elopement. Review of Resident #45's nurses notes dated 9/7/2018 revealed Resident #45 wandered from the facility down the road and across the street. The facility courtesy officer went on a golf cart and brought the resident back to the facility. On 9/7/2018 after the elopement, Resident #45 was reassessed for wandering/elopement and scored a 4 out of 0-9 with 9 being the highest risk. On 9/7/2018 the facility placed a wanderguard on Resident #45 and updated Resident #45's care plan to reflect the new intervention. During an interview with the facility Administrator and DON on 4/18/2019 at approximately 1:51 PM The DON reviewed Resident #45's care plan intervention for a wanderguard device and confirmed that this intervention was not implemented until after the 9/7/2018 elopement incident. Review of Resident #45's nurse's notes revealed another elopement by Resident #45 was documented on 9/17/2018. Resident #45 was found right outside the gates on the sidewalk. Resident #45 was brought back into the facility. There was no documentation that a new wandering/elopement assessment was performed and there were no new care plan interventions. Review of the facility policy titled Wandering, Unsafe Residents revealed under Policy Interpretation and Implementation 3. Resident care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. The facility submitted a Removal Plan dated 4/19/19 and accepted on 4/19/19 at 12:30 PM: - The resident no longer resides in our community. - All current residents will be assessed for elopement risk by RN (Registered Nurse) supervisors by 4/18/19. - All staff that work in the 400-500 halls will be in serviced on Signs of Elopement Risk and Review of Wondering, Unsafe Resident Policy Statement, will be in serviced by RN supervisor/designee. (Any staff not on duty will be in serviced at start of next shift), as well as all employees will receive an email regarding the Policy/Inservice on elopement 04/19/2019. New and readmitted residents will be assessed for elopement within 24 hours of admission/readmission. Residents will also be reassessed quarterly or as needed. If the resident triggers for a risk, the care plan will be updated as needed with new interventions. DON or designee will review chart of new admissions for elopement risk. - Random Audit of elopement risks will occur 3 times per week for 1 month then 1 time per week for 3 months until compliance is achieved. All audits will be reported to QA (Quality Assurance) committee. As part of verifying the facility Removal Plan, facility staff interviews were conducted with 15 staff members on 4/19/2019 from approximately 2:30 PM through 3:00 PM by three different surveyors. During interview with a Certified Nursing Assistant (CNA) on 4/19/2019 at 2:52 PM, the CNA was asked when s/he was last trained on elopement/wandering. The CNA stated, I don't remember the exact date. It was a couple of weeks ago. The surveyor asked why s/he signed the sign in sheet attached to the training information. The CNA stated, because they told me to. The surveyor asked if s/he received any training before signing the form. The CNA stated, no, (s/he) didn't. (S/he) just signed it. The CNA stated, s/he usually does trainings from home but had not done any in a while. On 4/19/19 at approximately 3:45 PM the Administrator was notified that the facility Removal Plan was verified as not implemented based on staff interview regarding training and that the Immediate Jeopardy is ongoing. The facility admitted Resident #7 on 7/13/18 with [DIAGNOSES REDACTED]. Care plan reviewed on 4/17/19 at 2:37 PM revealed that the facility conducted a care plan meeting on 2/13/19 without the participation of the resident's nurse, Certified Nursing Assistant (CNA), and hospice services. During an interview on 4/17/19 at 3:56 PM with the Minimum Data Set (MDS) coordinator s/he confirmed that the resident's nurse, CNA and hospice services did not participate in the resident's care plan meeting held on 2/13/19. The facility admitted Resident #30 on 1/31/19 with [DIAGNOSES REDACTED]. Review of the Care Plan participation records for Resident #30 on 4/16/19 at 10:11 PM revealed no evidence of participation in the care planning process by the Registered Nurse (RN) with responsibility for the resident. During an interview on 4/17/19 at 8:49 AM, the Director of Nurses reviewed participation records for Resident #30 and confirmed that the RN responsible for the care of the resident did not participate in the Care Plan development/meeting. S/he verified that the only RN represented was the MDS (Minimum Data Set) Coordinator.

Based on closed record review, staff interviews, and review of the facility's investigation, the facility failed to provide adequate supervision for 1 of 1 resident reviewed for elopement (Resident #45). The facility failed to assess elopement risk and implement interventions in a timely manner resulting in Resident #45 wandering out of the facility on three separate occasions (9/2/2018, 9/7/2018, and 9/17/2018). On 4/18/19 at 2:02 PM, the facility Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified related to Complaint SC 940 and cited at a scope and severity of J. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on 9/2/18 and is ongoing. The findings included: Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility assessed the resident on admission with a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Resident #45's Wandering/Elopement Risk Screening dated 8/21/2018 documented a score of 0 out of 0-9 with 9 being the highest risk. Record review revealed the 08/23/2018 nurses notes for Resident #45 documented that the resident was wandering in room and hallways and calling for his/her son/daughter. Acts of diversion and reorientation were used as requested by the son/daughter. No new wandering/elopement risk screening was performed, and no new interventions were added to the resident's care plan. Review of the 9/2/2018 nurses' notes revealed Resident #45 wandered outside at midnight stating that s/he was unsure of where s/he was. No new wandering/elopement risk screening was performed, and no new interventions were added to the resident's care plan. Review of Resident #45's nurses notes dated 9/7/2018 revealed Resident #45 wandered from the facility down the road and across the street. The facility courtesy officer went on a golf cart and brought the resident back to the facility. On 9/7/2018 after the elopement, Resident #45 was reassessed for wandering/elopement and scored a 4 out of 0-9 with 9 being the highest risk. On 9/7/2018 the facility placed a wanderguard on Resident #45 and updated Resident #45's care plan to reflect the new intervention. During an interview with the facility Administrator and Director of Nursing (DON) on 4/18/2019 at approximately 1:51 PM confirmed that education related to the incident was not performed or completed for all staff who work on the 400 and 500 units in the facility. The DON reviewed Resident #45's care plan intervention for a wanderguard device and confirmed that this intervention was not implemented until after the 9/7/2018 elopement incident. During record review of the incident logs since last Recertification Survey on 3/11/2018 and interview with the DON on 4/18/2019 at approximately 2:00 PM the DON stated that no residents have had any elopements since 9/7/2018; however, further review of the nurse's notes revealed another elopement by Resident #45 was documented on 9/17/2018. Resident #45 was found right outside the gates on the sidewalk. Resident #45 was brought back into the facility. There was no documentation that a new wandering/elopement assessment was performed and there were no new care plan interventions. The facility did not provide any further education to staff regarding elopement and wandering risks after the 9/17/2018 elopement incident. Resident #45 was discharged home with home health services on 9/19/2018 with his/her son/daughter. The facility submitted a Removal Plan dated 4/19/19 and accepted on 4/19/19 at 12:30 PM: - The resident no longer resides in our community. - All current residents will be assessed for elopement risk by RN (Registered Nurse) supervisors by 4/18/19. - All staff that work in the 400-500 halls will be in serviced on Signs of Elopement Risk and Review of Wondering, Unsafe Resident Policy Statement, will be in serviced by RN supervisor/designee. (Any staff not on duty will be in serviced at start of next shift), as well as all employees will receive an email regarding the Policy/Inservice on elopement 04/19/2019. New and readmitted residents will be assessed for elopement within 24 hours of admission/readmission. Residents will also be reassessed quarterly or as needed. If the resident triggers for a risk, the care plan will be updated as needed with new interventions. DON or designee will review chart of new admissions for elopement risk. - Random Audit of elopement risks will occur 3 times per week for 1 month then 1 time per week for 3 months until compliance is achieved. All audits will be reported to QA (Quality Assurance) committee. As part of verifying the facility Removal Plan, Facility staff interviews were conducted with 15 staff members on 4/19/2019 from approximately 2:30 PM through 3:00 PM by three different surveyors. During interview with a Certified Nursing Assistant (CNA) on 4/19/2019 at 2:52 PM, the CNA was asked when s/he was last trained on elopement/wandering. The CNA stated, I don't remember the exact date. It was a couple of weeks ago. The surveyor asked why s/he signed the sign in sheet attached to the training information. The CNA stated, because they told me to. The surveyor asked if s/he received any training before signing the form. The CNA stated, no, (s/he) didn't. (S/he) just signed it. The CNA stated, s/he usually does trainings from home but had not done any in a while. On 4/19/19 at approximately 3:45 PM the Administrator was notified that the facility Removal Plan was verified as not implemented based on staff interview regarding training and that the Immediate Jeopardy is ongoing.

Based on closed record review, staff interviews, review of the facility's investigation, and review of the facility's policy titled Wandering, Unsafe Residents, the facility failed to be administered in a manner to prevent elopement for 1 of 1 resident reviewed for elopement (Resident #45). The facility failed to adequately assess wandering/elopement, implement interventions for elopement, and provide education to all staff on the 400 and 500 units to prevent further elopement by Resident #45. On 4/18/19 at 2:02 PM, the facility Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified related to Complaint SC 940 and cited at a scope and severity of J. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on 9/2/18 and is ongoing. The findings included: Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #45 was admitted with a BIMS (Brief Interview for Mental Status) score of 3 indicating severe cognitive impairment. Review of nurse's notes dated 8/21/2018 through 9/19/2018 revealed Resident #45 wandered out of the facility on 9/2/2018, 9/7/2018, and 9/17/2018. Review of Resident #45's care plan revealed it did not include new interventions after the elopement on 9/2/2018. Review of Resident #45's care plan after the 9/7/2018 elopement revealed a wanderguard device was added as an intervention. Review of the 9/17/2018 nurses' notes revealed Resident #45 was found outside of the facility and a wanderguard was placed. No new interventions were documented. During an interview with the facility Administrator on 04/17/2019 revealed s/he did not recall the incident on 9/7/2018. The Administrator stated s/he had been employed there approximately a week. S/he stated, we try so hard not to restrict residents' movement. During an interview with the Director of Nursing (DON) on 4/17/2019 confirmed documentation in the nurses notes of the elopement on 9/2/2018 with no new interventions. The DON stated they should have put a wanderguard on then. During an interview with Certified Nursing Assistant (CNA) #3 on 4/17/2019 at 6:20 PM regarding the 9/7/2018 elopement, s/he stated, I remember like it was yesterday. I saw someone outside wearing clothing that looked like (him/her). I ran. (S/he) said (his/her) knees were getting weak. The courtesy officer on the golf cart came and took (him/her) to Willows. (S/he) wanted to talk to (his/her) (son/daughter). We called (his/her) (son/daughter), got (his/her) vital signs. (S/he) said (s/he) wanted to go home and then we gave (him/her) some water. They put a wanderguard on (him/her) on the same night and reported to the next shift. We were to keep an eye on (him/her). During an interview with the DON on 4/18/2019 at approximately 2:00 PM, the DON stated that no residents have had any elopements since 9/7/2018; however, further review of the nurse's notes revealed another elopement by Resident #45 was documented on 09/17/2018, which was two days prior to Resident #45's discharge home with his/her son/daughter. Resident #45's care plan did not include any further updates after the 9/17/2018 elopement. Review of the facility policy titled Wandering, Unsafe Residents revealed under Policy Interpretation and Implementation 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. Resident care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: .e. Complete and file an incident report; and f. Document relevant information in the resident's medical record. An incident report was not provided by the facility for the 9/2/2018 and the 9/17/2018 elopement incidents. Relevant information related to the incidents ( i.e., witness statements, supportive documentation in the medical record) was not provided to the State Agency. Facility Removal Plan dated 4/19/19 and accepted on 4/19/19 at 12:30 PM: - The resident no longer resides in our community. - All current residents will be assessed for elopement risk by RN (Registered Nurse) supervisors by 4/18/19. - All staff that work in the 400-500 halls will be in serviced on Signs of Elopement Risk and Review of Wondering, Unsafe Resident Policy Statement, will be in serviced by RN supervisor/designee. (Any staff not on duty will be in serviced at start of next shift), as well as all employees will receive an email regarding the Policy/Inservice on elopement 04/19/2019. New and readmitted residents will be assessed for elopement within 24 hours of admission/readmission. Residents will also be reassessed quarterly or as needed. If the resident triggers for a risk, the care plan will be updated as needed with new interventions. DON or designee will review chart of new admissions for elopement risk. - Random Audit of elopement risks will occur 3 times per week for 1 month then 1 time per week for 3 months until compliance is achieved. All audits will be reported to QA (Quality Assurance) committee. As part of verifying the facility Removal Plan, Facility staff interviews were conducted with 15 staff members on 4/19/2019 from approximately 2:30 PM through 3:00 PM by three different surveyors. During interview with a Certified Nursing Assistant (CNA) on 4/19/2019 at 2:52 PM, the CNA was asked when s/he was last trained on elopement/wandering. The CNA stated, I don't remember the exact date. It was a couple of weeks ago. The surveyor asked why s/he signed the sign in sheet attached to the training information. The CNA stated, because they told me to. The surveyor asked if s/he received any training before signing the form. The CNA stated, no, (s/he) didn't. (S/he) just signed it. The CNA stated, s/he usually does trainings from home but had not done any in a while. On 4/19/19 at approximately 3:45 PM the Administrator was notified that the facility Removal Plan was verified as not implemented based on staff interview regarding training and that the Immediate Jeopardy is ongoing.

Based on full and/or limited record reviews, interviews, and review of the facility policies, it was determined on [DATE] at approximately 12:50 PM Immediate Jeopardy and/or Substandard Quality of Care existed for CFR 483.75 F-520 which was identified at a scope and severity level of (J). Starting [DATE], the facility failed to identify quality deficiencies related to Advance Directives for Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR). The facility failed to identify, clarify, and implement a plan of action related to conflicting information related to Advance Directives for Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR). 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 (CPR) resulted in Immediate Jeopardy for Resident #188. The findings included: 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 #188 on [DATE] who exhibited absence of pulse and respirations and did not receive Cardiopulmonary Resuscitation (CPR). Based on record reviews and interviews, the facility failed to identify a concern related to conflicting information related to Advance Directives for Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR). During an interview on [DATE] at approximately 10:45 AM, the facility Administrator confirmed the facility had not identified conflicting information related to Advance Directives for Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR) for Resident #188. Based on full and/or limited record reviews, interviews, and review of the facility policies, it was determined on [DATE] at approximately 12:50 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility. The facility Administrator was informed of the Immediate Jeopardy on [DATE] at 12:55 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on [DATE] at 12:00 PM the Immediate Jeopardy at F-309, F-490, and F-520 was removed but lowered in scope and severity to a "D". The AOC included the following: 1. Resident #188's medical record was reviewed and revealed there had not been a signed Physician order [REDACTED].#188 did not have CPR administered and no longer resides in the facility. 2. An audit of all current residents' charts for Advance Directive status to ensure supporting documentation was present was conducted by the Director of Nursing (DON), Registered Nurse (RN) Supervisor, and the Social Worker on [DATE] by using a Code Status Audit tool. There were no any additional residents' charts identified with conflicting information related to Advance Directives for Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR). 3. The Staff Development Coordinator provided an inservice on verifying the resident's Code Status and ensuring the supporting documentation is present in the medical record to all currently licensed nurses on duty. All licensed nurses who have not received the inservice on this topic will be inserviced by a RN Supervisor prior to working by [DATE]. All newly hired licensed nurses or agency nurses will be inserviced during the orientation process. Annual training by the DON or the RN Supervisor will be provided for all licensed nurses.

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 conflicting information related to Advance Directives for Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR). The findings included: Cross refer to F-309 related to CPR not initiated for a resident with a change in condition: absence of pulse and respirations. 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 conflicting information related to Advance Directives for CPR and DNR. The Administration failed to ensure appropriate policies and procedures were implemented to identify and clarify conflicting information related to Advance Directives for Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR), 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 conflicting information related to Advanced Directives for Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR). Review of the facility's policy "Cardiac and/or Respiratory Arrest" Under "Procedure" #2 "If patient/healthcare decision maker request a Do No Resuscitate (DNR) order, notify the attending physician. Under section 2.1: "The physician, in collaboration with designated Center staff, will discuss CPR with the patient/health care decision maker and, if DNR is chosen, the physician will provide the following: 2.1.1 "A written DNR order based on the discussion (telephone or fax order may be accepted)". Further review of the facility's policy "Cardiac and/or Respiratory Arrest" Under "Procedure" #5 "If a patient has a DNR order, clearly identify the DNR status on the patient's medical record. #7."If there is no visual identification of DNR status or no DNR order on the patients's medical record: 7.1 Regardless of patient's condition, CPR/AED certified staff will initiate CPR/AED application." In section 7.3 "Designate an individual to record events on the CPR/AED Flow Sheet. An interview on [DATE] at approximately 12 PM with the facility's Administrator and the Administrator in training revealed the facility considered the EMS (Emergency Medical Service) form from the State of North Carolina to be the resident's DNR order. . Based on full and/or limited record reviews, interviews, and review of the facility policies, it was determined on [DATE] at approximately 12:50 PM Immediate Jeopardy and/or Substandard Quality of care existed in the facility. The facility Administrator was informed of the Immediate Jeopardy on [DATE] at 12:55 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on [DATE] at 12:00 PM and the the Immediate Jeopardy at F-309, F-490, and F-520 was removed but the citation remained and was lowered in scope and severity to a "D". The AOC included the following: 1. Resident #188's medical record was reviewed and revealed there had not been a signed Physician order [REDACTED].#188 did not have CPR administered and no longer resides in the facility. 2. An audit of all current residents' charts for Advance Directive status to ensure supporting documentation was present was conducted by the Director of Nursing (DON), Registered Nurse (RN) Supervisor, and the Social Worker on [DATE] by using a Code Status Audit tool. There were no any additional residents' charts identified with conflicting information related to Advance Directives for Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR). 3. The Staff Development Coordinator provided an inservice on verifying the resident's Code Status and ensuring the supporting documentation is present in the medical record to all currently licensed nurses on duty. All licensed nurses who have not received the inservice on this topic will be inserviced by a RN Supervisor prior to working by [DATE]. All newly hired licensed nurses or agency nurses will be inserviced during the orientation process. Annual training by the DON or the RN Supervisor will be provided for all licensed nurses.