Every finding on record at Broad Creek Care Center

Based on interview, record review, and facility policy review, the facility failed to ensure that Resident (R)1 had adequate supervision to prevent a successful elopement on 02/18/26, for 1 of 3 residents reviewed for accidents/hazards/supervision. Specifically, R1 was observed by facility staff outside the facility in the parking lot at approximately 9:00 PM.On 03/17/26 at 5:21 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 03/17/26 at 5:21 PM, the Administrator was notified that the failure to provide a resident with appropriate supervision, resulting in the resident successfully eloping from the facility, constituted Immediate Jeopardy (IJ) at F689.On 03/17/26 at 5:21 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 02/18/26. The IJ was related to 483.25 - Quality of Care.On 03/18/26 at 1:15 PM, the facility provided an acceptable IJ Removal Plan. On 03/18/26, the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the non-compliance. The SA is considering the IJ at Past Non-Compliance as of 02/19/2026.Findings include:Review of the facility policy titled, Wandering and Elopement last revised December 2017, revealed wandering is defined as a resident moving about inside or outside of the community without an appreciation for personal safety. A wander is a cognitively impaired resident who is not capable of protecting himself/herself from harm, when leaving the community unsupervised. Elopement is defined as an unassisted, unsupervised and unscheduled departure from the community by a resident. All staff who work in the licensed care venue receive training, regarding elopement, and elopement and wandering prevention during orientation and during elopement drills. Interventions are implemented for any resident who is identified as being at risk for elopement. These interventions are discussed with the resident and their family/responsible agent and documented in the resident's care plan. The effectiveness of the interventions is monitored. Elopement attempts by a resident are identified as Code Gold. Code Gold drills are conducted quarterly, as per the Elopement Protocol, these drills are evaluated and the results discussed at the Safety Committee Meetings. After an elopement attempt or successful elopement, the Resident Evaluation Committee and/or Interdisciplinary Team, assess whether the community can continue to meet resident's needs and the care plan is adjusted accordingly.Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with the diagnoses including but not limited to, traumatic subdural hemorrhage without loss of consciousness, muscle weakness, difficulty in walking, and need for assistance with personal care.Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/26, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated R1 had moderate cognitive impairment. Further review of the MDS revealed R1 utilized a wheelchair for mobility and needed substantial assistance for most transfers (rolling left and right/toileting) related to Activities of Daily Living (ADL).Review of R1's Physician Order Report dated 01/29/26 - 03/09/26 (admission - discharge date s), revealed an order dated 01/30/26 - 02/19/26 (admission - Elopement Dates) for Check Wander Guard for effectiveness and function every shift.Review of R1's Physician Order Report dated 01/29/26 - 03/09/26 revealed an order dated 02/19/26 - 03/09/26 (Elopement - discharge date s) for Check Wander Guard for effectiveness and function every shift, right lower extremity every shift.Review of R1's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 01/01/26 - 01/31/26, revealed no documentation related to the physician order to check the wander guard for effectiveness each shift. Review of R1's MAR/TAR dated 02/01/26 - 02/28/26, revealed an order to check R1's wander guard for effectiveness every shift, with a start date of 01/30/26 - 02/19/26; this order was only completed/signed on 02/19/26 (Date of Elopement) for Shift One. Review of R1's MAR/TAR dated 02/01/26 - 02/28/26, revealed an order to check R1's wander guard for effectiveness and function every shift right lower extremity, with a start dated of 02/19/26 - 03/09/26, this order was signed off each shift after the resident eloped from the facility until his discharge date . Review of R1's Progress Notes dated 02/06/26 at 3:30 PM, revealed, Resident needs frequent redirection because he wanders in and out of resident rooms. Spoke with [R1's Resident Representative (RR)] to see if there was an option to get a sitter for a few hours per day. [RR] stated that he was busy at the moment and could not talk but gave the facility staff permission to redirect [R1] by yelling. Informed [RR] that we could not yell at [R1] but will redirect him and for him to think about the information I gave him related to a sitter.Review of R1's Progress Notes dated 02/06/26 at 3:53 PM, revealed, Spoke with staffing agency, they stated that they may be able to provide a sitter from 12 PM - 8 PM, [RR] will visit tonight.Review of R1's Progress Note dated 02/08/26 at 1:15 AM, revealed, [Certified Nursing Assistant (CNA)] reported to nurse that resident was sitting on the floor. Nurse responded to the resident's room; he was seated on the fall mat with his back resting against his bed. Call light attached to bed 1/4 side rail, resident Level of Consciousness (LOC) and Range of Motion (ROM) remained at baseline, no injuries noted. Resident stated that he got out of bed to take the pictures off the wall and pack his bag. Resident denied falling or hitting his head . Review of R1's Progress Notes dated 02/19/26 at 2:02 AM, revealed, Resident was found wandering in the parking lot, and he was brought back in by the CNA. The door alarm wasn't going off, resident was put in bed, and Activities of Daily Living (ADL) care was provided. This writer/nurse performed a skin assessment, and no injury was noted, will continue to monitor every hour, and the Medical Doctor (MD) and Administration notified. Review of R1's Care Plan with a Start Date of 01/29/26 and revised on 02/19/26, revealed, Behavioral symptoms, wandering, and elopement related to traumatic subdural hemorrhage, impaired cognition, impulsivity. Interventions/approaches directed staff to, avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents); convey an attitude of acceptance towards the resident; follow familiar routines; identify contributing factors - for example elopement attempts in the past, type of wandering pattern, angry and combative, verbally abusive; type of diagnoses; Involve in appropriate therapeutic recreational activities; maintain a calm environment; Wander Guard. Equip [R1] with a device that alarms when the resident wanders upon admission for 48 hours. Reevaluate the need for the device after that time period. Check for the proper functioning of the device every shift; when resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.)During a phone interview on 03/17/26 at 12:41 PM, R1's RR revealed that the facility made him aware of the resident's elopement on 02/19/26. R1's RR further stated that he was made aware by facility staff and by another family member that the front door of the facility was and possibly still is not working properly. R1's RR stated that R1 had on a wander guard device that should have locked the door when he eloped but because it was not working correctly, R1 was able to get outside of the building. R1 did not suffer any injuries, but also attempted to leave the building on another occasion after this incident, which prompted the facility and family to want to discharge the resident to a memory care facility to better supervise R1 and manage his wandering behaviors.During a phone interview on 03/17/26 at 1:39 PM, Certified Nursing Assistant (CNA)1 revealed that she is an agency CNA and was unfamiliar with the resident until that night (02/18/26 - 02/19/26). CNA1 stated that she could recall when the Day Shift CNA was giving her report about R1 they stated that he was refusing ADL care and was hard to redirect/constantly pacing the unit in his wheelchair. CNA1 stated that R1 did allow her to provide ADL care and checked his blood pressure and she went to take care of another resident in their room. CNA1 stated that it was reported to her by another staff member that R1 was found outside of the building, CNA1 stated she was still providing care to another resident at this time, when she learned about R1's elopement but could not recall hearing any alarms going off at the time. CNA1 further stated that she was unsure if R1 had on a wander guard or not and has not worked back at this facility since this incident. R1 had no injuries after this incident and CNA1 stated that she provided extra rounding on R1 throughout that night to ensure that he was safe and in his room, he did eventually allow her to provide ADL care/change the resident as well.During an interview on 03/17/26 at 1:55 PM, the Director of Nursing (DON) and the Administrator revealed that they were informed of the Elopement on the night of 02/18/26 - 02/19/26. R1 was immediately assessed for injuries and was found to be injury free. The Administrator came to the facility and immediately initiated re-education to facility staff related to elopement. During the investigation process it was determined that the door/wander guard device was working properly because when staff assisted the resident back inside, the door closed/locked appropriately. The resident had on a device/wander guard on his leg/ankle, but another device was added to the resident's wheelchair to ensure that the device could properly signal the door. Re-education related to elopement was conducted on 02/18/26 - 02/19/26, and the facilitates Maintenance Director audits the doors daily.On 03/18/26 at 1:15 PM, the facility provided an acceptable IJ Removal Plan, which included the following:RESIDENT(S) AFFECTEDResident Identifier: R1Diagnosis/condition related to risk: TBI post auto accidentCORRECTIVE ACTION FOR AFFECTED RESIDENT(S)Resident was immediately located at 9pm 2/18/2026 and safely returned to the facility.Full nursing assessment completed by licensed nurse; no injuries noted.Physician/Medical Director and responsible party notified by administrator on 2/18/2026Resident placed on increased monitoring immediately.Wandering/elopement risk reassessed.Care plan updated to include enhanced interventioins:Wander guard applied/verified functioning.Staff education initiated 2/18/2026 by administrator.Incident reported per facility policy and state requirements.IDENTIFICATION OF OTHER RESIDENTS AT RISKFacility conducted a 100% audit of all residents for:Elopement riskVerified:Wander guard placement and functionAccuract of assessments and care plansHOW YOU WILL PREVENT RECURRENCEUpdated care plans to include individualized interventions such as:Secured unit placement/Discharge planStructured activities to reduce wanderingConducted environmental safety checks:All exit doors secured and alarmed-verfied by maintenance department weekly.Wander guard system tested by maintenance department with log weekly.All staff education completed on 2/19/2026 by DON/Administrator:Policy/Protocol for wandering and elopementImmediate response procedures if a resident is missingResults reviewed in QWAPI meetings monthly x3 months, with corrective actions implemented as needed.DATE OF FULL COMPLIANCE: 2/19/2026

Based on interviews, record review and facility policy review, the facility failed to ensure staff implemented the care plan for the level of staff assistance required for toileting for 1 of 5 sampled residents, Resident (R)1. Findings include: Review of the facility policy titled, Medical, Nursing and Personal Care, revised October 2017, revealed, Philosophy - Resident Care Policies are intended to describe the Company commitment to a customer-centered approach to care provided throughout the continuum of clinical services. Purpose - This policy outlines general requirements for care and services provided to residents in Skilled Nursing (SN). Process - SN provides the necessary care and services in order to attain or maintain the highest practicable physical, mental, and psychological well-being of the resident, in accordance with each resident's assessment and plan of care. Nursing care and personal care are provided to meet the needs of each resident. The policy indicated, 10. The licensed care staff provides and delegates care provision to the resident according to the individualized plan of care. Review of R1's Face Sheet revealed the facility admitted R1 on 10/18/21 with diagnoses that included but was not limited to; Parkinson's disease, dementia, altered mental status, and cognitive communication deficit. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/28/23, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident had moderate cognitive impairment. The MDS indicated R1 was totally dependent on two plus person physical assistance of staff for toilet use and always incontinent of bowel and bladder. Review of R1's Care Plan with a problem start date of 02/14/22, revealed the resident had verbally abusive behavioral systems. An intervention started on 05/03/23, directed the staff to provide paired care at all times to avoid resident complaints. Review of R1's Progress Notes dated 09/25/23 at 1:57 AM and written by Registered Nurse (RN)2, revealed at approximately 10:30 PM (on 09/24/23), RN 2 heard a resident yell for help. Per the Progress Note, RN2 entered the resident's room and observed R1 had a bloody nose with blood on the resident's fitted bedsheet. When asked what happened, RN2 reported the resident stated they were hit by Certified Nursing Assistant (CNA)1. According to the Progress Note, CNA1 reported that, as she tried to turn the resident and change their incontinence brief, the resident resisted, and hit the CNA. Per the Progress Note, when the CNA tried to block the hit from the resident, the resident hit themselves in the face. During an interview on 10/26/23 at 2:45 PM, CNA1 stated she began her rounds between 10:00 PM to 10:30 PM on 09/24/23. According to CNA1, she entered R1's room and explained to the resident that she was coming to check and change them. CNA1 stated as she lowered the head of the resident's bed, R1 informed her they wanted their head of bed to remain in the up position. CNA1 stated when she started to remove the resident's incontinent brief, the resident began to yell and say they were hurting and to let the head of their bed back up. CNA1 indicated R1 pushed back with their right hand and resisted care. CNA1 stated she told R1 that she was almost done. Per CNA1, R1 cursed at her, let go of the side rail, and hit her in the left eye. CNA1 reported R1 yelled help and RN2 entered R1's room. CNA1 stated RN2 asked what happened and R1 informed the RN they had been hit by CNA1. CNA1 acknowledged that when RN2 entered R1's room, the RN stated two staff were required to provide care for the resident due to accusations made by the resident. During an interview on 10/27/23 at 4:45 PM, R1 stated they did remember an instance when a CNA came in their room that they had never seen before. R1 stated they could not remember the date and explained that they were half asleep and the CNA startled them. According to R1, when they are turned, their left side hurt, so they told the CNA that they were too rough, but the CNA continued to provide incontinence care. R1 stated usually two CNAs provided their incontinence care. During an interview on 10/27/23 at 5:29 PM, the Clinical Reimbursement Manager/MDS Coordinator indicated CNA1 should have known about the resident's care or asked questions on how to find the information. The Clinical Reimbursement Manager/MDS Coordinator stated she expected CNAs to follow a resident's plan of care. During an interview on 10/27/23 at 6:45 PM, the Administrator indicated that it was his expectation that staff follow a resident's plan of care and ask questions, if needed.

Based on interviews, record review, and policy review, the facility failed to ensure staff immediately reported an allegation of physical abuse to the Director of Nursing (DON) or Administrator for 1 of 5 sampled residents reviewed for abuse, Resident (R)1. Findings include: Review of the facility's policy titled, Abuse/Neglect Prevention Protocol, revised March 2018, revealed, Internal Report Requirements and Identifications of Allegations: 1. Employees are required to report any occurrences of potential mistreatment they observe, hear about, or suspect to the Administrator. 2. All residents, visitors, volunteers, family members and others must report their grievances or suspected incidents of potential mistreatment to the Administrator. 3. Such reports may be made without fear of retaliation. Anonymous reports are thoroughly investigated. 4. In the Administrator's absence, the Director of Nursing is the 'Acting Administrator.' Review of R1's Face Sheet revealed the facility admitted R1 on 10/18/21 with diagnoses that included but was not limited to; Parkinson's disease, dementia, altered mental status, and cognitive communication deficit. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/28/23, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident had moderate cognitive impairment. The MDS indicated R1 was totally dependent on staff for toilet use and always incontinent of bowel and bladder. Review of R1's Care Plan with a problem start date of 02/14/22, revealed the resident had verbally abusive behavioral systems. Interventions directed the staff to stop and try the task later when the resident became verbally abusive. Review of R1's Progress Note dated 09/25/23 at 1:57 AM and written by Registered Nurse (RN)2, revealed at approximately 10:30 PM (on 09/24/23), RN2 heard a resident yell for help. Per the Progress Note, RN2 entered the resident's room and observed R1 had a bloody nose with blood on the resident's fitted bedsheet. When asked what happened, RN2 reported the resident stated they were hit by Certified Nursing Assistant (CNA)1. According to the Progress Note, CNA1 reported that, as she tried to turn the resident and change their incontinence brief, the resident resisted, and hit the CNA. Per the Progress Note, when the CNA tried to block the hit from the resident, the resident hit themselves in the face. During an interview on 10/27/23 at 4:45 PM, R1 stated they did remember an instance when a CNA came in their room that they had never seen before. R1 stated they could not remember the date and explained that they were half asleep and the CNA startled them. According to R1, when they are turned, their left side hurt, so they told the CNA that they were too rough, but the CNA continued to provide incontinence care. R1 further stated the CNA slapped them and gave them a black eye. R1 indicated the CNA did not come back in their room after the incident, but they heard the CNA up and down the hall screaming she was hit by a resident. R1 reported they felt safe in the facility. During an interview on 10/26/23 at 3:58 PM, RN2 stated on 09/24/23, she heard someone say help in the hallway and she went into R1's room. Per RN2, R1 stated CNA1 hit them in their eye. RN2 stated she saw blood on R1's pillow and the resident's left nostril was bleeding. RN2 indicated she worked as needed in the facility and did not now she had to report the incident immediately. RN2 stated she reported the allegation of abuse to the day supervisor when they came to work the next morning, on 09/25/23. During an interview on 10/27/23 at 5:29 PM, the Clinical Reimbursement Manager/MDS Coordinator indicated the RN on duty should have reported the allegation of abuse to the Director of Nursing or the Administrator immediately. During an interview on 10/27/23 at 6:45 PM, the Administrator indicated that it was his expectation that an allegation of abuse be reported immediately to a supervisor or the abuse coordinator.

Based on interviews, record review, document review, and policy review, the facility failed to ensure Certified Nursing Assistant (CNA)1 was immediately removed from resident contact for 1 of 5 sampled residents reviewed for abuse. Specifically, Resident (R)1 alleged physical abuse perpetrated by CNA1 and CNA1 was not immediately removed from the situation. Findings included: Review of a facility policy titled, Abuse/Neglect Prevention Protocol, revised March 2018, revealed, 4. Employees of the community who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the Administrator or designee. Employees accused of possible mistreatment will not complete their shift and are placed on suspension until the investigation is completed. Review of R1's Face Sheet revealed the facility admitted R1 on 10/18/21 with diagnoses including but not limited to; Parkinson's disease, dementia, altered mental status, and cognitive communication deficit. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/28/23, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident had moderate cognitive impairment. The MDS indicated R1 was totally dependent on staff for toilet use and always incontinent of bowel and bladder. Review of R1's Care Plan with a problem start date of 02/14/22, revealed R1 had verbally abusive behavioral systems. Interventions directed the staff to stop and try the task later when the resident became verbally abusive. Review of R1's Care Plan edited on 07/26/23, revealed R1 was incontinent of bowel and bladder due to advanced aging process, an aging organ, and debility. Interventions directed the staff to assist and offer to toilet the resident every two hours and as needed, encourage independence, and check and change the resident's incontinent brief, if used, every two hours and as needed. Review of R1's Progress Notes dated 09/25/23 at 1:57 AM and written by Registered Nurse (RN)2, revealed at approximately 10:30 PM (on 09/24/23), RN2 heard a resident yell for help. Per the Progress Note, RN2 entered the resident's room and observed R1 had a bloody nose with blood on the resident's fitted bedsheet. When asked what happened, RN2 reported the resident stated they were hit by CNA1. According to the Progress Note, CNA1 reported that, as she tried to turn the resident and change their incontinence brief, the resident resisted, and hit the CNA. Per the Progress Note, when the CNA tried to block the hit from the resident, the resident hit themselves in the face. During an interview on 10/26/23 at 2:45 PM, CNA1 stated she began her rounds between 10:00 PM to 10:30 PM on 09/24/23. According to CNA1, she entered R1's room and explained to the resident that she was coming to check and change them. CNA1 stated as she lowered the head of the resident's bed, R1 informed her they wanted their head of bed to remain in the up position. CNA1 stated when she started to remove the resident's incontinent brief, the resident began to yell and say they were hurting and to let the head of their bed back up. CNA1 indicated R1 pushed back with their right hand and resisted care. CNA1 stated she told R1 that she was almost done. Per CNA1, R1 cursed at her, let go of the side rail, and hit her in the left eye. CNA1 reported R1 yelled help and RN2 entered R1's room. CNA1 stated RN2 asked what happened and R1 informed the RN they had been hit by CNA1. CNA1 reported she worked her entire shift from 7:00 PM to 7:00 AM and was the only CNA on the hall where R1 resided. During an interview on 10/26/23 at 3:58 PM, RN2 stated on 09/24/23, she heard someone say help in the hallway and she went into R1's room. Per RN2, R1 stated CNA1 hit them in their eye. RN2 stated she saw blood on R1's pillow and the resident's left nostril was bleeding. RN2 stated CNA1 worked her shift from 7:00 PM to 7:00 AM that began on 09/24/23 and continued to work with R1 for the remainder of the shift. Review of a Provider Assignment Record dated 09/24/23, revealed CNA1 worked the hall where R1 resided from 7:00 PM to 7:00 AM on 09/24/23 for a total of 11.5 hours. During an interview on 10/27/23 at 4:45 PM, R1 stated they did remember an instance when a CNA came in their room that they had never seen before. R1 stated they could not remember the date and explained that they were half asleep and the CNA startled them. According to R1, when they are turned, their left side hurt, so they told the CNA that they were too rough, but the CNA continued to provide incontinence care. R1 stated the CNA slapped them and gave them a black eye. R1 indicated the CNA did not come back in their room after the incident, but they heard the CNA up and down the hall screaming she was hit by a resident. R1 reported they felt safe in the facility. During an interview on 10/27/23 at 5:29 PM, the Clinical Reimbursement Manager/MDS Coordinator indicated CNA1 should have been sent home immediately after the allegation was made, until the investigation was completed. During an interview on 10/27/23 at 6:45 PM, the Administrator indicated that it was his expectation that the perpetrator be placed on administrative leave until after the investigation.

Based on observation, interview, and facility policy review, the facility failed to provide safe food storage and maintain sanitation in a safe and consistent manner. This had the potential to affect 22 residents who consumed food from the kitchen. Findings include: Review of the facility's policy titled Sanitation and Safety, revised June 2011, revealed . 2. F&B [Food and Beverage] staff is expected to practice good personal hygiene and cleanliness to protect residents and guests from potential foodborne illness. Hygiene standards include but are not limited to those listed below . 2.3 Approved hair restraints or head coverings are worn in food preparation areas . 4.2.2 Thermometers are chosen for specific purposes and are washed, rinsed, sanitized and air-dried before and after each use. When taking temperatures of several different food items at one time, special attention is devoted to preventing cross contamination . 5.2 Refrigerated stores 5.2.1 Foods prepared on the premises to be held cold will be labeled with the name and the date of preparation. This food will also be labeled with the date to discard or use by. The discard/use by date will be a maximum of 6 days after the preparation. 1. During an observation on 06/05/23 at 9:02 AM, Culinary Aide 1 walked through the kitchen without a hairnet while staff were preparing the lunch meal. During an interview on 06/05/23 at 9:04 AM with Culinary Aide 1 revealed, she arrived at 8:00 AM and forgot to apply a hairnet. Culinary Aide 1 stated that hairnets were located outside of the kitchen door in a box attached to the wall, and she should wear the hairnet in the kitchen to prevent hair from getting in the food. 2. During an observation on 06/05/23 at 9:12 AM of Cook 1, revealed a white container with a red lid contained a thick, white liquid and was not labeled, located on the second shelf in the walk-in refrigerator. During an interview on 06/05/23 at 9:12 AM, Cook 1 acknowledged the container did not have a label on it. Cook 1 stated when staff placed condensed milk in the container, a label should have been placed on it with the name of the item, the date the milk was poured in the container, and the use by date. Cook 1 also stated that the staff used labeling guidelines to determine the date the items should be discarded (three or seven days). 3. During an observation and interview on 06/05/23 at 11:40 AM of the Chef during tray line, revealed the Chef wiped the thermometer with a paper towel between temping the food items on the steam table prior to serving it to the residents. The Chef stated he was not trained to take the temperature of the foods and did not know he should have cleaned the thermometer with an alcohol wipe or thermometer wipe. The Chef also stated the Executive Chef was responsible for taking the temperature of the food items, but he resigned from the position three months ago. 4. During an observation and interview on 06/05/23 at 12:14 PM revealed the Chef and the Kitchen Attendant had beards but were not wearing a beard guard. An interview with the Chef revealed he had worked at the facility for over a year and was not told to wear a beard guard but should have, in order to keep hair out of the food when he cooked it. An interview with the Kitchen Attendant revealed he had worked at the facility for eight months and was not trained to wear a beard guard but should have worn it since he prepares the food. During an interview on 06/06/23 at 11:32 AM, the Dining Room Supervisor stated she expected staff working in the kitchen to wear a hair net or beard guard to prevent hair from falling in the food and hair nets were located outside of the doors to the kitchen. The Dining Room Supervisor indicated that the thermometer should be wiped with an alcohol wipe after taking the temperature of the food items. The Dining Room Supervisor indicated all opened food items or food items placed in containers should have a label on them with the item name, opened date and use by date. The Dining Room Supervisor also indicated that food items should be discarded by the use by date to prevent food borne illness. During an interview on 06/06/23 at 12:59 PM, the Director of Dining stated that he expected staff to follow the kitchen policy for safe food preparation which includes wearing hair nets and labeling and dating food items. During an interview on 06/07/23 at 8:36 AM, the Registered Dietician (RD) revealed that staff were expected to place a label on any food items placed in containers with the item name, date poured in the container, and use by date using the three-day or seven-day labeling guidelines to prevent food borne illness. The RD stated that all staff should wear hair nets and if applicable beard guards to prevent hair from falling into the food. The RD also stated that the Chef should have cleaned the thermometer with an alcohol wipe instead of a paper towel after taking the temperature of the food items on the tray line.

Based on interview, record review, and facility policy review, the facility failed to ensure that one (Resident (R)6) of five residents reviewed for unnecessary medications had a comprehensive care plan with interventions to reduce the risk of bleeding, a side effect of anticoagulant medications (a blood thinner). This failure had the potential to lead to an adverse event, related to bleeding for residents on blood thinners. Findings include: Review of the facility's policy titled Plan of Care, revised October 2017, . 4. A comprehensive person-centered care plan is developed for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . Both the baseline and comprehensive plans of care embody current standards of professional practice and also may reflect: A resident's needs, strengths, and preferences; Alternative means to address issues if the resident has refused initial treatment plan; Attempts to manage risk factors; and Interventions toward prevention of avoidable decline in function. A plan of care may encompass routine interventions (e.g., activities involvement) and at risk conditions (e.g., skin breakdown, falls) even if the at-risk situation is not actualized. Review of R6's undated Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, indicated R6 was admitted on [DATE] with a diagnosis including but not limited to; history of a cerebral vascular accident (CVA). Review of R6's Physician's Orders, dated 11/07/22, and located in the EMR under the Orders tab, revealed an order for Eliquis (a blood thinner) 5 milligrams (MG) take one tablet twice daily. Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/27/23 and located in the EMR under the MDS 3.0 Assessment tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R6 was cognitively intact. Further review of the MDS also indicated R6 had a diagnosis of CVA, had no falls, and had received seven anticoagulants in the last seven days. Review of R6's Care Plan, dated 01/18/22, and located in the EMR under the Care Planning tab, listed the problem as resident has cardiac diagnosis including history of CVA. The care plan included the following interventions: To administer medications as ordered, evaluate/record/report effectiveness/adverse side effects; assess for signs of dysrhythmias (palpitations, dizziness, fatigue, chest pain, syncope, pallor, diaphoresis, SOB [shortness of breath], tachycardia, bradycardia, hypotension, hypertension, anxiety, abdominal pain, altered level of consciousness, etc.); obtain blood pressure, apical pulse, radial pulse, respirations as ordered; and obtain diagnostic tests/labs per MD [medical doctor] order. However, the care plan did not include interventions to prevent possible bleeding. During an interview on 06/07/23 at 3:55 PM, the MDS Coordinator stated she was responsible for developing the care plans for the residents. The MDS Coordinator acknowledged that R6 had an order for an anticoagulant, and that she did not develop the care plan with interventions to prevent bleeding. The MDS Coordinator also stated she should have developed the care plan with interventions to prevent and monitor bleeding due to residents being at risk for it when taking blood thinners. The MDS Coordinator indicated the care plan was for the interdisciplinary team (IDT) to use to know what to look for specific to the resident's care. During an interview on 06/07/23 at 4:10 PM, the Director of Nursing (DON) stated she expected the MDS Coordinator to develop the care plan for residents on anticoagulants with interventions to monitor for adverse reactions, effectiveness of the medications, and laboratory results if applicable. The DON also stated the care plan should be developed to follow any physician orders regarding the administration of the medication.

Based on interviews, record review, and facility policy review, the facility failed to ensure three (Resident (R)1, R5, and R18) of five residents reviewed for unnecessary medications had a limited 14 day stop date on a psychotropic (PRN) [as needed] medication order. The facility's deficient practice increased the resident's risk of adverse drug reactions. Findings include: Review of facility's policy titled Behavior Management - Psychotropic/Antipsychotic Drugs, revised October 2017, revealed . Residents are not given psychotropic drugs unless such drug therapy is ordered by a healthcare provider with prescriptive authority and the reason for the drug is documented. A psychotropic drug is any drug that affects brain activities with mental processes and behavior. Psychotropic drugs include, but are not limited to, drugs in the following categories: Anti-psychotic; Anti-depressant; Anti-anxiety; and Hypnotic. Residents will not be given psychotropic drugs unless necessary to treat a specific condition that is documented in the resident's clinical record based upon a comprehensive assessment. 2.1 PRN orders for anti- psychotic drugs is limited to 14 days. If the physician believes it is appropriate to extend beyond 14 days, their rationale and the duration of the PRN order will be documented in the resident's clinical record. 2.2 PRN orders for anti-psychotic drugs is limited to 14 days and will only be renewed if the physician evaluates the resident for the appropriateness of the medication. 1. Review of R1's undated Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab revealed she was admitted to the facility on [DATE] with multiple diagnoses to include but not limited to; dizziness and giddiness, repeated falls, generalized anxiety disorder, and multiple fractures of ribs, left side, subsequent encounter for fracture with routine healing. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/17/23 and located in his EMR under the MDS 3.0 Assessment tab, revealed a Brief Interview for Mental Status (BIMS) with a score of 99 out of 15 indicating R1 was not interviewable. The facility assessed the resident as severely impaired in making decisions regarding daily tasks of living. The MDS also indicated R1 had anxiety disorder and received seven antianxiety medications in the last seven days. Review of R1's Physician's Orders dated 02/08/23 located in the EMR under the Orders tab revealed an order for Ativan (an antianxiety medication) 0.5 milligrams (MG) PRN (as needed) administer every four hours as needed for anxiety and agitation with a start date of 02/08/23 and no end date. Review of R1's Medication Administration Record (MAR) dated May 2023 located in the EMR under the Reports tab revealed Ativan 0.5 MG was administered on 05/11/23, 05/14/23, and 05/24/23. Review of R1's Comprehensive Care Plan, located in the EMR under the Care Planning tab, revealed R1 had no focus, goal, or interventions related to Ativan administration. Review of R1's Consultant Pharmacist's Medication Regimen Review, from February to June 2023, revealed the medications were reviewed with no recommendations related to the Ativan PRN medication order without a 14 day stop date. 2. Review of R5's undated Face Sheet, located in the EMR revealed she was initially admitted to the facility on [DATE] with multiple diagnoses to include but not limited to; major depressive disorder, moderate, and anxiety disorder. Review of R5's quarterly MDS with an ARD of 04/28/23, located in the EMR under the MDS 3.0 Assessment tab, revealed a BIMS with a score of 10 out of 15, indicating R5 was moderately cognitively impaired. Review of R5's Physician's Orders dated 06/13/22 and under the Orders tab located on her EMR revealed the following: Lorazepam [Ativan] tablet 0.5 mg, one tablet by mouth three times a day PRN for anxiety and agitation, with an ordered start date of 06/13/22 and an open-end date. Review of R5's Consultant Pharmacist's Medication Regimen Review, located under the resident's consults tab, dated 04/20/2022 reveals a Miscellaneous psychotropic therapy recommendation (MRR) Date 04/19/2022 .this resident is currently receiving Lorazepam 0.5 mg on a PRN basis. Per regulatory guidelines, the duration of treatment with such medication on a PRN basis should be limited to 14 days, however a new order may be written to extend the duration beyond 14 days if the prescriber believes it is appropriate. Please evaluate the continued need for this medication. If it is to be extended, please document the rationale for the extended time period in the medical record and indicate a specific duration. Further review of R5's chart revealed a second MMR dated 01/24/2023 from the Consultant pharmacy - This resident is currently receiving Lorazepam medication on a PRN basis. Per regulatory guidelines, the duration of treatment with such medications on a PRN basis should be limited to 14 days, however a new order may be written to extend the duration beyond 14 days if the prescriber believes it is appropriate. This resident last received a dose of Lorazepam on 01/13/23. Please evaluate the continued need for this medication. If it is to be extended, please document the rationale for the extended time period in the medical record and indicate a specific duration. 3. Review of R18's undated Face Sheet, located in the EMR under the Face Sheet tab revealed she was admitted to the facility on [DATE] with multiple diagnoses to include but not limited to; Alzheimer's disease, unspecified dementia with behavioral disturbance, and major depressive disorder. Review of R18's annual MDS with an ARD of 05/01/23 and located in his EMR under the MDS 3.0 Assessment tab, revealed a BIMS with a score of one out of 15 indicating the resident was severely cognitively impaired. The MDS indicated R18 had Alzheimer's disease, dementia, and depression and received an antianxiety medication three days in the last seven days. Review of R18's Physician's Orders dated 04/16/23 located in the EMR under the Orders tab revealed an order for Ativan 0.5 milligrams (MG) PRN administer one tablet every six hours as needed for anxiety and agitation with a start date of 04/16/23 and no end date. Review of R18's MAR dated May 2023 located in the EMR under the Reports tab revealed Ativan 0.5 MG was administered on 05/08/23, 05/16/23, 05/17/23, 05/18/23, 05/25/23, 05/26/23, 05/29/23 and 05/30/23. Review of R18's Consultant Pharmacist's Medication Regimen Review, from April to June 2023, revealed the medications were reviewed with no recommendations related to the Ativan PRN medication order without a 14 day stop date. During an interview on 06/06/2023 at 2:41 PM, the Medical Director revealed R5 was ordered and administered Lorazepam as needed for longer than a 14-day duration. The Medical Director stated the facility is not triggering for him to see PRN anti-anxiety medication residents to be re-evaluated. He states that he typically reviews the use of anti-anxiety psych medications every 30 days, and he felt R5 needed to continue the anti-anxiety medication. The Medical Director stated the facility needed a better system in place to remind him about the 14-day review and re-eval for residents on anti-anxiety medications PRN. During an interview on 06/06/23 at 6:00 PM, the Director of Nursing (DON) confirmed the time frame for administering psychotropic medication PRN was 14 days. The DON confirmed R1 and R18 were ordered and administered Ativan PRN. The DON confirmed R1 and R18 were on Ativan medication since the Medical Director ordered it and there was no break in the medication, which was over two weeks. The DON confirmed R1 and R18's Ativan medication was ordered ongoing. During an interview on 06/07/23 at 8:12 AM, the Pharmacy Consultant (PC) confirmed R1 and R18 were ordered Ativan PRN and for a duration longer than 14 days for anxiety. The PC stated that he reviewed the resident's medications monthly and made recommendations to the physician when a rationale for the continued use of the PRN medication was not provided in the physician's progress notes. The PC verified that he did not make any recommendations to the physician regarding R1 and R18's antianxiety medications since he found the rationale for the continued use in the physician's progress notes. The PC also stated that he thought that a PRN antianxiety medication was only limited to 14 days if not reevaluated by the physician and did not know that another order was needed for continued use past the 14 days. During an additional interview on 06/07/23 at 9:23 AM, the Medical Director revealed R1 and R18 were ordered and administered psychotropic medications, including Ativan as needed for longer than a 14-day duration. The Medical Director indicated he ordered R1 and R18's Ativan for an undefined duration (more than 14 days) because they had anxiety. The Medical Director also indicated he evaluated the use of the medication and documented the rationale for the continued use of the medication in the progress notes. The Medical Director stated that the antianxiety medication for PRN use was limited to 14 days, but he was not aware that a stop date was not on the order. During a secondary interview on 06/07/23 at 10:00 AM, the DON confirmed R5 was ordered/administered Ativan PRN. The DON confirmed the resident was on her Ativan medication from December 2022 to the present time of June 2023, and there was no break in the medication, which was over two weeks. The DON confirmed R5's Ativan, as needed order should have been administered for a duration of 14 days, and then reviewed but was not. The DON confirmed R5's Ativan medication was ordered ongoing. During a secondary interview on 06/07/23 at 11:36 AM, the PC confirmed R5 was ordered Lorazepam 0.5 mg tablet, one tablet by mouth three times a day PRN, for anxiety and agitation, with a start date of 06/13/22 and an open-end date. The PC confirmed the facility did not document discussions or rationale for R5's as needed psychotropic and should have. The PC confirmed R5's Lorazepam medication order was available for the staff to administer to R5 for use longer than two weeks without written documentation of reevaluation of the rationale for the medication. Continued interview with the PC revealed, he reviewed R5's pharmacy documentation which showed two pharmacy recommendations had been made to the physician on 01/24/23 and 4/19/22. The pharmacist stated his usual protocol is to follow-up by looking at the physician's recommendations reply or progress notes regarding the pharmacy recommendations. However, the pharmacist stated he did not follow-up and does not know why, states he will review going forward will follow-up with the physicians and nursing staff regarding the pharmacy recommendations monthly.

Based on staff interview and record review, the facility failed to develop a process for notifying residents and residents' representatives each time a confirmed COVID-19 test result is identified, and failed to develop a process for providing weekly cumulative updates on COVID-19. This affected 17 of 17 residents. The findings included: Review of dates of positive COVID-19 tests revealed the most recent positive resident test was on 09/02/20 and the most recent staff member was on 09/08/20. On 09/14/20 at 3:25 PM, an interview was completed with the facility Administrator. The Administrator said that no notices were sent in June. A weekly update notice was sent on 07/30/20, 08/21/20, 08/28/20 and 08/31/20; and then the last notice was sent on 09/12/20. There were no notices sent after the positive COVID-19 tests on 09/02/20 or 09/08/20. The Administrator said that the notices emailed to families were printed and given to residents.

Based on review of facility files, interview, and review of the facility's Abuse/Neglect Prevention Protocol, the facility failed to implement policies and procedures that prohibit and prevent abuse. Certified Nursing Assistant (CNA) #1 verbally abused Resident #77 (1 of 1 residents reviewed for abuse). The findings included: The facility admitted resident #77 on 09/05/2018 with [DIAGNOSES REDACTED]. Review of the facility reported incident revealed that on 09/23/2018 at 12:30 PM it was witnessed that CNA #1 pointed his/her finger in Resident #77's face and was yelling. Review of the facility's Abuse/Neglect Prevention Protocol revealed that, Verbal abuse is the use of oral, written, or gestures language that includes disparing and derogatory terms to a resident During an interview with the Administrator on 07/30/2019 at 3:08 PM, s/he stated that the CNA had yelled at the resident but it did not constitute abuse and that is why there was no 2 hour report and they did a 24 hour report when the previous Director of Nursing was here, but they could not find the hard copy. The Administrator further stated the CNA was escorted out of the building and put on administrative leave, but s/he never came back for the meeting after the investigation. S/he agreed that the CNA violated their policy and this was not reported this timely.

Based on review of facility files and interview, the facility failed to ensure residents were free from abuse. Certified Nursing Assistant (CNA) #1 verbally abused Resident #77 (1 of 1 residents reviewed for abuse). The findings included: The facility admitted resident #77 on 09/05/2018 with [DIAGNOSES REDACTED]. Review of the facility reported incident revealed that on 09/23/2018 at 12:30 PM it was witnessed that CNA #1 pointed his/her finger in Resident #77's face and was yelling. Review of the facility's Abuse/Neglect Prevention Protocol revealed that, Verbal abuse is the use of oral, written, or gestures language that includes disparing and derogatory terms to a resident During an interview with the Administrator on 07/30/2019 at 3:08 PM, s/he stated that the CNA had yelled at the resident but it did not constitute abuse and that is why there was no 2 hour report and they did a 24 hour report when the previous Director of Nursing was here, but they could not find the hard copy. The Administrator further stated the CNA was escorted out of the building and put on administrative leave, but s/he never came back for the meeting after the investigation. S/he agreed that the CNA violated their policy.

Based on review of the facility files and interview, the facility failed to ensure that all alleged violations of abuse were reported immediately to the State Agency, but not later than 2 hours after the allegation. The facility did not report an allegation of abuse within the required time frames (1 of 1 residents reviewed for abuse). The findings included: The facility admitted resident #77 on 09/05/2018 with [DIAGNOSES REDACTED]. Review of the Incident Report and Investigation for the incident that occurred on 09/23/2018 revealed the allegation was not reported to the State Agency within the required time frames. No documentation of a 2 hour report submitted to the State Agency was provided. A 5 day report was sent on 10/01/2018, which was late. During an interview with the Administrator on 07/30/2019 at 3:08 PM, s/he stated that the CNA had yelled at the resident but it did not constitute abuse and that is why there was no 2 hour report and they did a 24 hour report when the previous Director of Nursing was here, but they could not find the hard copy. The Administrator further stated the CNA was escorted out of the building and put on administrative leave, but s/he never came back for the meeting after the investigation. S/he agreed that the CNA violated their policy and this was not reported this timely.

Based on review of facility files and interview, the facility failed to have evidence that all alleged violations of abuse were thoroughly investigated. Resident #77 reported that Certified Nursing Assistant (CNA) #1 yelled at him/her (1 of 1 residents reviewed for abuse). The findings included: The facility admitted Resident #77 on 09/05/2018 with [DIAGNOSES REDACTED]. The facility reported an allegation of verbal abuse that occurred on 09/23/2018. Resident #77 reported that CNA #1 yelled at him/her. The incident was witnessed by another staff member and reported that CNA #1 was pointing his/her finger in the resident's face and yelling. The surveyor requested a copy of the facility's complete investigation. Review of the facility's investigation revealed there was no statement from the nurse assigned to Resident #77 on that date. In an interview with the surveyor on 07/30/2019 at approximately 3:08 PM, the Administrator stated s/he was unaware if the previous Director of Nursing reported the incident within 2 hours and that s/he could not locate the hard copy of the 24-hour report. The 5-day was submitted to the State Agency on 10/01/2018, which was late.

Based on observation, interview and limited record review, the facility failed to ensure that one of one resident reviewed for accidents received accurate Minimum Data Set (MDS) assessments. Resident #9 was incorrectly coded regarding use of wandering/ elopement alarm on annual MDS with Assessment Reference Date of 11/30/17. The findings included: Medical record review on 7/1/18 at 1:45 PM revealed that Resident #9 was admitted to the facility with the [DIAGNOSES REDACTED]. Additional review of medical record on 7/1/18 at 1:50 PM revealed that annual Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 11/30/17 was coded in section P to reflect that no wander/ elopement alarms were used during assessment period with P0200E coded as 0. Further review of the medication administration record/ treatment administration record for (MONTH) (YEAR) on 7/1/18 at 2:28 PM revealed that a wander guard in place at all times was initiated every shift as being in place and functional during the assessment period of 11/24/17 through 11/30/17. During interview with MDS Nurse #1, s/he verified that there was a wander guard alarm in place during the assessment period 11/24/17 through 11/30/17 and the Annual MDS assessment was incorrectly coded for item P0200E with 0 to reflect wander/ elopement alarm was not used. S/he further verified that item P0200E should have been coded as 2 to reflect that the wander/ elopement alarm was used daily during the assessment period of 11/24/17 through 11/30/17. MDS Nurse #1 provided documentation to reflect that a modification was completed to correct Annual MDS assessment with ARD 11/30/17. This modification was completed to correct item P0200E, with this item coded as 2 reflecting that wander/ elopement alarm used daily during the assessment period of 11/24/17 through 11/30/17.

Based on interviews and record reviews, the facility failed to ensure that baseline care plans were developed in 48 hours or that residents and/or responsible parties were involved in the development of the baseline care plan. Resident #18 baseline care plan was not developed timely. 1 of 2 sampled residents reviewed for hospitalization . The findings included: The facility admitted Resident #18 on 6/06/18 with [DIAGNOSES REDACTED]. A review of the closed medical record revealed Resident #18 was admitted on [DATE] and there was no baseline care plan developed within 48 hours of admission. There was documentation that a care plan conference was held on 6/12/18 with a note that the care plan was issued to the resident's spouse. The CARE PLAN CONFERENCE SUMMARY with a conference date of 6/12/18 indicated the care plan was discussed with the resident and spouse. There was no documentation to indicate the care plan was developed in 48 hours. An interview on 7/02/18 at approximately 9:24 AM with the Director of Nursing (DON) confirmed the 6/12/18 care plan conference.

Based on record review and interview, the facility failed identify drug irregularities through monthly pharmacy reviews related to as needed (PRN) [MEDICAL CONDITION] medications for 1 of 5 sampled residents reviewed for unnecessary medications. Resident #7 had repeated physician's orders [REDACTED]. The findings included: The facility admitted Resident #7 on 10/26/17 with [DIAGNOSES REDACTED]. A review of the medical record on 7/01/18 at approximately 3:03 PM revealed several physician's orders [REDACTED]. an order for [REDACTED]. The [MEDICATION NAME] order was written again on 4/12/18 to 4/27/18. Review of Consultant Pharmacist's Drug Regimen Review forms for 3/22/18 and 4/20/18 indicated No recommendations at this time. The drug regimen review did not address the continued use of as needed medication without a written reason to the physician. An interview on 7/01/18 at approximately 3:47 PM confirmed the findings that the pharmacy reviews did not address the resident's use of as needed (PRN) [MEDICAL CONDITION] medications beyond 14 days without documentation of reason/justification for its continued use.

Based on record review and interview, the facility failed to ensure that a medical record was complete and accurately documented for 1 of 2 sampled residents reviewed for hospitalization . Resident #18 had inconsistent information in the medical record regarding health care decision making. The findings included: The facility admitted Resident #18 on 6/06/18 with [DIAGNOSES REDACTED]. A review of the closed medical record on 7/02/18 at approximately 9:26 AM revealed Emergency Medical Services Do Not Resuscitate Order signed on 6/06/18 by the Resident #18 spouse. The medical record indicated the resident as admitted to the facility with hospice services. An interview on 7/02/18 at approximately 9:35 AM with the Director of Nursing (DON) revealed the facility uses the Emergency Medical Services for as the resident's consent for Do Not Resuscitate (DNR). The DON confirmed the DNR was signed by the resident's spouse and stated there was no documentation in the medical record with a physician's signature to indicate the resident could not make a health care decisions. The DON stated he/she will go to medical records to get additional information. An interview on 7/02/18 at approximately 10:10 AM with the DON who provided a second DNR form that reportedly located in the medical records office and signed by the resident on 6/06/18. The DON stated the resident made the health care decision for DNR. Further review of the medical record revealed health care decisions for hospice was signed by the spouse and not the resident, the consent for use of [MEDICAL CONDITION] medications were signed by the spouse and not the resident and the medicare beneficiary notice of non coverage was signed by spouse and not the resident. The DON confirmed that the other documents were signed by the resident's spouse but stated the DNR was second DNR as signed by the resident.

Based on record review and interview, the facility failed to maintain current documentation of Coordination of Hospice Care Services for Resident #24 in the facility. The Hospice Care Plan and certification documents ended effective 07/11/17 for 1 of 1 sampled resident reviewed for Hospice. The findings included: The facility admitted Resident #24 with [DIAGNOSES REDACTED]. and [MEDICAL CONDITION]. Record review on 08/02/17 at 3:24 PM, revealed the Hospice Certification document in the Hospice Communication book for Resident #24 covered the period 04/13/17 through 07/11/17. No certification document for the period beginning 07/12/17 was found in the chart. In an interview on 08/03/17 at 11:36 AM, the DON attempted to locate the current certification documents and could not. The DON contacted the Hospice Care provider to have them faxed to the facility. An incomplete document was received by the facility on 08/03/17 at 3:48 PM.

Based on record review and interview, the facility failed to ensure as needed blood pressure medications had physician ordered parameters for use for 2 of 5 residents reviewed for unnecessary medications. (Resident #2 and #82) The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Medication Reconciliation-Transfer/Post/Operative physician's orders [REDACTED]. No systolic or diastolic blood pressure parameters were set by the physician. There was no documentation the physician had been notified to clarify the parameters which would define an elevated blood pressure for which the [MEDICATION NAME] would be administered. During an interview with the Director of Nursing on 5/7/15 at approximately 2:37 PM, he/she stated once a resident is admitted from the hospital, the nurse places the orders into the matrix. He/she continued by stating the physician had signed the orders and the nurses nor the physician had picked up the [MEDICATION NAME] did not have blood pressure parameters. The DON stated the facility did not have a policy related to checking orders for accuracy. The facility admitted Resident #82 to the facility with Hypertension, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] Fibrillation, and Pacemaker Placement. Review of the physician orders [REDACTED]. The physician had not been contacted by a nurse or the pharmacists to clarify parameters of an elevated blood pressure for which the [MEDICATION NAME] was to be administered. During an interview on 5/7/2015 at approximately 2:37 PM with the Director of Nurses (DON), he/she verified that neither the nurses nor the pharmacist had notified the physician to get parameters for administering the [MEDICATION NAME]. He/she did state, when a resident is admitted with hospital orders the nurse keys them into the computer system. The physician will sign the orders, but, neither the nurse nor the physician noticed that there were no parameters for an elevated blood pressure in which to administer the [MEDICATION NAME]. An interview with the facility Pharmacist on 5/7/2015 at approximately 3:15 PM, he/she stated, there should have been parameters set for the elevated blood pressure for which the medication, [MEDICATION NAME], was to be administered. During an interview with Registered Nurse (RN)#1 on 5/7/2015 at approximately 3:39 PM, he/she stated, the resident has not received any of the as needed, blood pressure medication since admission.

Based on observation, interviews and review of the facilities policies, the facility failed to prepare, distribute, and serve food under sanitary conditions in 1 of 2 kitchens. Dietary staff failed to date opened food and remove outdated food, wear hair restraints, and clean pans to ensure food safety. The findings included: During initial tour of the main kitchen on 5/5/15 at approximately 9:00 AM with the Executive Chef revealed in the walk-in refrigerator a bag of ham with an open date of 3/28, another bag of ham with an open date of 4/27 and a third loosely wrapped piece of ham that was undated. Also, a bin of seasoned chicken undated and a container of egg whites dated 4/27. Following the observation the Executive Chef was asked, What was the procedure for dating opened food, and s/he stated Opened food should be dated and kept for a maximum of 3 days. On 5/6/15 at 3:48 PM, observations were made in the main kitchen of the Sous Chef preparing food without a facial hair restraint covering his/her mustache and beard. Also, in the walk-in refrigerator revealed a loosely wrapped piece of ham and containers of horse radish, creamed key lime and syrup that were opened and undated. Furthermore, pans on the clean dishware storage rack were stacked with water between the pans. On 5/7/15 at 10:30 AM, during an observation with the Executive Chef of the main kitchen walk-in refrigerator revealed a loosely wrapped piece of ham and containers of horse radish, creamed key lime and syrup that were opened and undated. Also, pans on the clean dishware storage rack were stacked with water between the pans. Following the observations the Executive Chef verified the opened and undated food and the stacking of wet pans and stated, This is an ongoing problem. Also, the Executive Chef was asked, Should all personnel with facial hair in the kitchen preparing food have a facial hair restraint. S/he stated, Yes. On 5/7/15 at 1:30 PM, review of the facility policy entitled Sanitization and Safety, revealed under procedure 5.) Labeling and dating foods; Prepared and packaged foods will be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality product for the residents and minimize waste. Also, under subsection 5.2) Refrigerated stores, states under 5.2.1) Foods prepared on the premises to be held cold will be labeled with the name and the date of preparation. This food will also be labeled with the date to discard or use by . The discard/use by date will be a maximum of 6 days after the preparation. Furthermore, 14.1) states, All stored items must be placed in containers with tight fitting lid, labeled and dated. Review of the Dress Code, policy revealed under procedure 7.) Beards and mustaches are neatly trimmed at all times and are not permitted for back of the house personnel. Also, 7.1) states, Beards and mustaches must be covered. Review of the Warewashing SOP policy revealed under procedure 9.) Air-dry all items.

Based on record review, interviews and review of a form titled, Admission Medication Review, the pharmacist failed to ensure as needed blood pressure medications had parameters for use for 2 of 5 residents reviewed for unnecessary medications. Resident #82 and #2. The findings included: The facility admitted Resident #82 to the facility with Hypertension, Pulmonary Edema, Congestive Heart Failure, Atrial Fibrillation, and Pacemaker Placement. Review of the physician orders [REDACTED]. The physician had not been contacted neither by a nurse nor the pharmacists to clarify parameters of an elevated blood pressure for which the Hydralazine was to be administered. During an interview on 5/7/2015 at approximately 2:37 PM with the Director of Nurses, (DON), h/she verified that neither the nurses nor the pharmacist had notified the physician to get parameters for administering the Hydralazine. He/she did state, when a resident is admitted with hospital orders the nurse keys them into the computer system. The physician will sign the orders, but, neither the nurse nor the physician noticed that there were no parameters for an elevated blood pressure in which to administer the Hydralazine. Review of a form titled, Admission Medication Review, on 5/7/2015 at approximately 3:15 PM revealed the medication Hydralazine 25 mg every 8 hours as needed for elevated blood pressure. The Admission Medication Review form was signed by the pharmacist with no parameters for the blood pressure in which to administer the as needed medication Hydralazine. An interview with the facility Pharmacist on 5/7/2015 at approximately 3:15 PM, he/she stated, there should have been parameters set for the elevated blood pressure for which the medication, Hydralazine, was to be administered. During an interview with Registered Nurse (RN)#1 on 5/7/2015 at approximately 3:39 PM, he/she stated, the resident has not received any of the as needed, blood pressure medication since admission. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 5/7/15 of the Medication Reconciliation Transfer/Post/Operative physician's orders [REDACTED]. Further record review revealed there was no documentation the physician had been notified to clarify the parameters which would define an elevated blood pressure for which the Clonidine would be administered. Review of Admission Medication Review by the Pharmacist dated 5/1/15 revealed the Pharmacist wrote Clonidine .1 mg every 8 hours. No recommendation was written by the Pharmacist related to parameters for Clonidine administration On 5/7/15 at 3:20 PM, during an interview with the Pharmacist, he/she stated the orders had been copied off of the hospital discharge orders. He/she continued by stating someone should have picked up there were no blood pressure parameters related to the Clonidine.

On the days of the Recertification and Extended Surveys based on observations, interviews and full and/or limited record reviews, the facility's administrator failed to assure that the facility established and maintained services in the building that met Professional Standards of Practice. The administrator failed to develop a system to ensure that outside resources were utilized effectively and that systems were in place within the facility to ensure well being of the residents. The findings included: Cross refers to the following citations: 483.20 (k)(3) Professional Standards F281, with a scope and severity of "K" due to facility failure to clarify orders for Peripherally Inserted Central Catheter (PICC Line) Flushes, Licensed Practical Nurses (LPNs) administering Intravenous (IV) medications via PICC Line and [MEDICATION NAME] Flushes without evidence of advance practice certification. 483.30 (b) Nursing Services F354 with a scope and severity level of "F" due to failure to ensure an (RN) Registered Nurse was working 8 consecutive hours every day and the facility employs a full time Director of Nurses not to be shared with another facility. 483.60 Pharmacy Services F425 with a scope and severity level of "J" due to the facility's failure to ensure that expired medications were not stored with medications available for resident use. 483.75 (l) Clinical Records F514 with a scope and severity of "J" due to inaccurately documenting Medication Administration Records (MARs). Interview with the Nursing Home Administrator was held on 12/8/2010 and again on 12/13/2010. The Nursing Home Administrator confirmed the Director of Nursing was shared with the Senior Community Assisted Living Facility. Time sheets were provided to the surveyors and did reveal there were dates without 8 consecutive hours of RN coverage. The NHA also confirmed that there was not a security feature on the electronic records and if the nurse did not completely log off before leaving the facility, her/his name would be listed as giving medications on the MAR (Medication Administration Record) as opposed to the nurse that was on duty. In addition, the Administrator confirmed that she did not have evidence that an employed LPN did have advanced training required to access and administer medications to a resident with a Peripherally Inserted Central Catheter. Immediate Jeopardy was cited at F490 with a scope and severity of "K" related to the facility administrator's failure to assure that the facility establish and maintain services in the building that meet Professional Standards of Practice. The administrator failed to develop a system to ensure that the Pharmacy was providing the contracted services, that outside resources were utilized effectively and that systems were in place within the facility to ensure well being of the residents. On 12/8/2010 at 5:25 PM the survey team met with the Administrator and Director of Nursing to inform them of the determination of Immediate Jeopardy with a start date of 11/16/2010 related to the system failure identified with using expired [MEDICATION NAME] to flush a PICC line; the failure to follow the facility policy for the care and maintenance of a central line and the failure to follow the South Carolina Board of Nursing policy related to the extended role of practice of the LPN. The Immediate Jeopardy was not removed at the time the survey team exited from the facility 12/13/2010 and is ongoing. First Follow-Up Visit During an unannounced onsite visit on 12/29/2010 at 11:30 AM, it was determined based on interviews, observations, review of records, and review of facility policies, that the Allegation of Compliance submitted by the facility on 12/13/2010 with an addendum submitted on 12/23/2010 had been implemented by the facility and was in practice as of 12/18/2010, removing the immediacy of the deficient practice. The citation at F-490 remained at a lowered scope and severity of " E". The facility will be in compliance at -490 when an acceptable Plan of Correction is submitted and a follow up visit, to determine that the facility has implementted their Plan of Correction, is conducted.

On the days of the Recertification and Extended Surveys based on observations, interviews and full and/or limited record reviews, the facility's administrator failed to assure that the facility established and maintained services in the building that met Professional Standards of Practice. The administrator failed to develop a system to ensure that outside resources were utilized effectively and that systems were in place within the facility to ensure well being of the residents. The findings included: Cross refers to the following citations: 483.20 (k)(3) Professional Standards F281, with a scope and severity of "K" due to facility failure to clarify orders for Peripherally Inserted Central Catheter (PICC Line) Flushes, Licensed Practical Nurses (LPNs) administering Intravenous (IV) medications via PICC Line and [MEDICATION NAME] Flushes without evidence of advance practice certification. 483.30 (b) Nursing Services F354 with a scope and severity level of "F" due to failure to ensure an (RN) Registered Nurse was working 8 consecutive hours every day and the facility employs a full time Director of Nurses not to be shared with another facility. 483.60 Pharmacy Services F425 with a scope and severity level of "J" due to the facility's failure to ensure that expired medications were not stored with medications available for resident use. 483.75 (l) Clinical Records F514 with a scope and severity of "J" due to inaccurately documenting Medication Administration Records (MARs). Interview with the Nursing Home Administrator was held on 12/8/2010 and again on 12/13/2010. The Nursing Home Administrator confirmed the Director of Nursing was shared with the Senior Community Assisted Living Facility. Time sheets were provided to the surveyors and did reveal there were dates without 8 consecutive hours of RN coverage. The NHA also confirmed that there was not a security feature on the electronic records and if the nurse did not completely log off before leaving the facility, her/his name would be listed as giving medications on the MAR (Medication Administration Record) as opposed to the nurse that was on duty. In addition, the Administrator confirmed that she did not have evidence that an employed LPN did have advanced training required to access and administer medications to a resident with a Peripherally Inserted Central Catheter. Immediate Jeopardy was cited at F490 with a scope and severity of "K" related to the facility administrator's failure to assure that the facility establish and maintain services in the building that meet Professional Standards of Practice. The administrator failed to develop a system to ensure that the Pharmacy was providing the necessary contracted services, that outside resources were utilized effectively and that systems were in place within the facility to ensure well being of the residents. On 12/8/2010 at 5:25 PM the survey team met with the Administrator and Director of Nursing to inform them of the determination of Immediate Jeopardy with a start date of 11/16/2010 related to the system failure identified with using expired [MEDICATION NAME] to flush a PICC line; the failure to follow the facility policy for the care and maintenance of a central line and the failure to follow the South Carolina Board of Nursing policy related to the extended role of practice of the LPN. The Immediate Jeopardy was not removed at the time the survey team exited from the facility 12/13/2010 and is ongoing.

On the days of the Recertification and Extended Survey, based on chart reviews, interviews, review of The South Carolina State Board of Nursing Advisory Option # 9 B, and review of the facility policies, the facility failed to provide care and services that met professional standards of practice for one of one sampled resident reviewed with a PICC (Peripheral Inserted Central Catheter) line (Resident # 11). The facility nurses failed to clarify with the Physician a discontinued order related to flushing a PICC line. In addition, LPNs (Licensed Practical Nurses) documented that they administered medications through the PICC line with no documentation of advanced training and there was no RN (Registered Nurse) on site when the LPN administered the medications via the PICC line. The facility nurses failed to document consistently that they were flushing the PICC line and failed to note medications used for the flush were taken from a container of expired [MEDICATION NAME] Lock Flushes with a large number of expired [MEDICATION NAME] syringes. In addition the facility nurses failed to recognize signs and symptoms of infection of a surgical wound in a timely manner for Resident # 11, which delayed treatment. The findings included: The facility originally admitted Resident # 11 on [DATE] and after a brief hospital stay readmitted Resident #11 on [DATE] with diagnoses, which included Aftercare for Reverse Total Shoulder Arthroplasty, Hypertension, [MEDICAL CONDITION] and [MEDICATION NAME] Degeneration. On [DATE], review of the progress notes revealed that on [DATE] at 3:15 PM LPN # 3 documented that the surgical wound had intact staples, and a small amount of serous yellow tinged drainage. On [DATE] at 3:56 PM, LPN # 3 documented that the wound had increased serous yellow tinged drainage and increased pain. On [DATE] at 2:42 PM. LPN # 3 documented that the wound continued to drain a moderate amount of serous yellow drainage that was blood tinged. There was no documentation of the Physician being notified. At 2:35 PM on [DATE] LPN # 3 documented a moderate amount of blood tinged yellow drainage was observed on the dressing when removed. On [DATE] an order for [REDACTED]." Interview on [DATE] with the DON (Director of Nurses) at approximately 12:00 PM, revealed that the nursing staff should document Physician notification in the progress notes. She confirmed that the nursing staff failed to recognize signs and symptoms of the surgical wound being infected even though the nurse had documented possible signs and symptoms on [DATE] and that there was a delay in treatment. On [DATE] the resident was transferred to the hospital at 5:00 AM for Incision and Drainage of the right shoulder surgical wound. Further review of the record revealed that Resident # 11 returned to the facility on [DATE] with a PICC line in the "left upper arm." Review of the Physician orders [REDACTED]. The first dose was to be given at 8:00 PM on [DATE], the evening she was readmitted to the facility. The final dose was to be given [DATE]. In addition the Physician ordered to flush the PICC line with 5 ccs (cubic centimeters) normal saline before and after each use, followed by 3 ccs of [MEDICATION NAME]. On [DATE], observation of the facility's Medication Room revealed a brown cardboard box located on the top shelf of an open cart to the right of the doorway as you entered the room. The box contained ,[DATE] millimeter (ml) [MEDICATION NAME] Lock Flushes. Review of the flushes revealed that 75 of the 79 had expired. The 4 unexpired flushes were located at the bottom of the box. The expiration dates were: ,[DATE] ml. [MEDICATION NAME] Lock Flush syringes expired [DATE]; ,[DATE] ml. [MEDICATION NAME] Lock Flush expired [DATE], ,[DATE] ml. [MEDICATION NAME] Lock Flush syringes expired [DATE]. Interview on [DATE] at 4:00 PM was held with RN #1. The RN confirmed that the [MEDICATION NAME] used to flush Resident #11's PICC line was taken from the box to the right of the medication room door. The box identified by RN #1 contained the [MEDICATION NAME] syringes that were noted by the surveyor and LPN #1 to have 75 of 79 syringes expired. Review of the MAR (Medication Administration Sheets) for November and [DATE], revealed that the IV flush was discontinued on [DATE] on the MAR without an order to discontinue the IV flush. Review of the resident progress notes (interdisciplinary notes used by all disciplines at the facility) revealed documentation that the PICC line had been flushed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] however there was no documentation as to what medication had been used to flush the IV or PICC line. On [DATE] during an interview with the DON she stated that there was no formal system in place to review that orders were entered into the computer system correctly. She stated that the facility pharmacy had discontinued the IV flush in error. The DON confirmed that the staff had documented on the MAR that the IV flushes had been done. Interview with RN # 1 on [DATE] at 4:00 PM, revealed that she had been flushing the PICC line with 5 cs of normal saline before and after administration of the IV antibiotic and following with 3 ccs of [MEDICATION NAME]. When questioned where this would be documented, she initially stated on the MAR. The surveyor shared with her that the IV flush had been discontinued on the MAR beginning [DATE]. She stated that maybe she had documented this in the progress notes. Asked why she had not questioned the IV flush not being on the MAR and calling the Physician, she confirmed that she had not called the MD that she had continued the IV flush of the PICC line because it was a standard of practice. When RN #1 was questioned if the nurses should have been documenting that the IV flushes were done and what medication was to be used per standards of practice, she stated yes. Further review of the MARs for November and [DATE], revealed that on [DATE], [DATE], [DATE] and [DATE] LPNs had initialed in the EMAR (Electronic Medication Administration Record) that they had administered the IV [MEDICATION NAME] via the PICC line. Review of the South Carolina Board of Nursing document related cardiovascular system Licensed Practical Nurse with Specialized Education and Training revealed that any LPN that administered medication via a PICC line must complete an intravenous therapy course relative to the administration of fluids and medications via peripheral and central venous devices. This document also stated: see Advisory Opinion # 9 B on the role of LPNs in IV (intravenous) therapy. Review of the South Carolina Department of Labor, Licensing and Regulation State Board of Nursing Advisory Opinion # 9 revealed that the Board of Nursing for South Carolina acknowledges it is within the extended role practice of the selected LPN to perform procedures and to administer ordered treatments via peripheral and central venous access devices and lines according to the following stipulations: 1. The agency has established policy and procedures that are approved by the nursing administrator and applicable medical director. Procedures include: a.criteria for the qualification and selection of the LPN; b. description of the additional education and training necessary for assuming additional rates.c. specific standing orders for the administration, monitoring and discontinuation of peripheral and central venous lines.d. specific standing orders to deal with potential complications or emergency situations and provision for supervision by the RN.2. The selected LPN shall document completion of special education and training to include:a. Cardiopulmonary resuscitationb. Intravenous therapy course relative to the administration of fluids via peripheral and central venous access devices/line that includes both didactic and supervised clinical training with return demonstration. The facility policy reviewed on [DATE] titled Care and maintenance of the Central Line Protocol, listed under Standards of Practice - Central line care is performed by a Registered Nurse and under Documentation - Document the [MEDICATION NAME] Flush/Saline Flush on the Medication Administration Record. Documentation includes: site assessment, resident subjective complaints, and any interventions completed and resident response. On [DATE] at approximately 4:00 PM, in an interview with LPN # 3, she stated that she had administered medication via the PICC line and flushed the line. She stated that she had additional training. Interview with the facility DON revealed that the facility did not have any documentation of the advanced training for any of the LPNs and stated that the facility policy stated that only RNs administer medications via a PICC line. She stated that she had not been aware that any LPNs were administering meds via the PICC line, however confirmed that she was aware that the facility did not always have RN coverage. Review of the facility monthly time schedule revealed that there was no RN coverage on [DATE] and [DATE], which was confirmed by the facility administrator. Review of the facility protocol for the Care and maintenance of the Central Line Protocol, revealed that only a Registered Nurse was to perform care to a central line. In addition, the policy stated that flushes should be documented on the MAR. Interview with the facility Medical Director (and the attending Physician for Resident #11) on [DATE] at approximately 9:30 AM, revealed that he was unaware that LPNs were administering medication/flushing PICC lines and had no knowledge of the expired medication used as an IV flush. Immediate Jeopardy was cited at F281 with a scope and severity of "K" related to failure of nursing staff to clarify orders to flush a PICC line when the original order was discontinued without a physician's orders [REDACTED]. documenting on the MAR when administering medication. On [DATE] at 5:25 PM the survey team met with the Administrator and Director of Nursing to inform them of the determination of Immediate Jeopardy with a start date of [DATE] related to the system failure identified with using expired [MEDICATION NAME] to flush a PICC line; the failure to follow the facility policy for the care and maintenance of a central line and the failure to follow the South Carolina Board of Nursing policy related to the extended role of practice of the LPN. The Immediate Jeopardy was not removed at the time the survey team exited from the facility [DATE] and is ongoing.

On the days of the Recertification and Extended Survey, based on chart reviews, interviews, review of The South Carolina State Board of Nursing Advisory Option # 9 B, and review of the facility policies, the facility failed to provide care and services that met professional standards of practice for one of one sampled resident reviewed with a PICC (Peripheral Inserted Central Catheter) line (Resident # 11). The facility nurses failed to clarify with the Physician a discontinued order related to flushing a PICC line. In addition, LPNs (Licensed Practical Nurses) documented that they administered medications through the PICC line with no documentation of advanced training and there was no RN (Registered Nurse) on site when the LPN administered the medications via the PICC line. The facility nurses failed to document consistently that they were flushing the PICC line and failed to note medications used for the flush were taken from a container of expired [MEDICATION NAME] Lock Flushes with a large number of expired [MEDICATION NAME] syringes. In addition the facility nurses failed to recognize signs and symptoms of infection of a surgical wound in a timely manner for Resident # 11, which delayed treatment. The findings included: The facility originally admitted Resident # 11 on [DATE] and after a brief hospital stay readmitted Resident #11 on [DATE] with diagnoses, which included Aftercare for Reverse Total Shoulder Arthroplasty, Hypertension, [MEDICAL CONDITION] and [MEDICATION NAME] Degeneration. On [DATE], review of the progress notes revealed that on [DATE] at 3:15 PM LPN # 3 documented that the surgical wound had intact staples, and a small amount of serous yellow tinged drainage. On [DATE] at 3:56 PM, LPN # 3 documented that the wound had increased serous yellow tinged drainage and increased pain. On [DATE] at 2:42 PM. LPN # 3 documented that the wound continued to drain a moderate amount of serous yellow drainage that was blood tinged. There was no documentation of the Physician being notified. At 2:35 PM on [DATE] LPN # 3 documented a moderate amount of blood tinged yellow drainage was observed on the dressing when removed. On [DATE] an order for [REDACTED]." Interview on [DATE] with the DON (Director of Nurses) at approximately 12:00 PM, revealed that the nursing staff should document Physician notification in the progress notes. She confirmed that the nursing staff failed to recognize signs and symptoms of the surgical wound being infected even though the nurse had documented possible signs and symptoms on [DATE] and that there was a delay in treatment. On [DATE] the resident was transferred to the hospital at 5:00 AM for Incision and Drainage of the right shoulder surgical wound. Further review of the record revealed that Resident # 11 returned to the facility on [DATE] with a PICC line in the "left upper arm." Review of the Physician orders [REDACTED]. The first dose was to be given at 8:00 PM on [DATE], the evening she was readmitted to the facility. The final dose was to be given [DATE]. In addition the Physician ordered to flush the PICC line with 5 ccs (cubic centimeters) normal saline before and after each use, followed by 3 ccs of [MEDICATION NAME]. On [DATE], observation of the facility's Medication Room revealed a brown cardboard box located on the top shelf of an open cart to the right of the doorway as you entered the room. The box contained ,[DATE] millimeter (ml) [MEDICATION NAME] Lock Flushes. Review of the flushes revealed that 75 of the 79 had expired. The 4 unexpired flushes were located at the bottom of the box. The expiration dates were: ,[DATE] ml. [MEDICATION NAME] Lock Flush syringes expired [DATE]; ,[DATE] ml. [MEDICATION NAME] Lock Flush expired [DATE], ,[DATE] ml. [MEDICATION NAME] Lock Flush syringes expired [DATE]. Interview on [DATE] at 4:00 PM was held with RN #1. The RN confirmed that the [MEDICATION NAME] used to flush Resident #11's PICC line was taken from the box to the right of the medication room door. The box identified by RN #1 contained the [MEDICATION NAME] syringes that were noted by the surveyor and LPN #1 to have 75 of 79 syringes expired. Review of the MAR (Medication Administration Sheets) for November and [DATE], revealed that the IV flush was discontinued on [DATE] on the MAR without an order to discontinue the IV flush. Review of the resident progress notes (interdisciplinary notes used by all disciplines at the facility) revealed documentation that the PICC line had been flushed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] however there was no documentation as to what medication had been used to flush the IV or PICC line. On [DATE] during an interview with the DON she stated that there was no formal system in place to review that orders were entered into the computer system correctly. She stated that the facility pharmacy had discontinued the IV flush in error. The DON confirmed that the staff had documented on the MAR that the IV flushes had been done. Interview with RN # 1 on [DATE] at 4:00 PM, revealed that she had been flushing the PICC line with 5 cs of normal saline before and after administration of the IV antibiotic and following with 3 ccs of [MEDICATION NAME]. When questioned where this would be documented, she initially stated on the MAR. The surveyor shared with her that the IV flush had been discontinued on the MAR beginning [DATE]. She stated that maybe she had documented this in the progress notes. Asked why she had not questioned the IV flush not being on the MAR and calling the Physician, she confirmed that she had not called the MD that she had continued the IV flush of the PICC line because it was a standard of practice. When RN #1 was questioned if the nurses should have been documenting that the IV flushes were done and what medication was to be used per standards of practice, she stated yes. Further review of the MARs for November and [DATE], revealed that on [DATE], [DATE], [DATE] and [DATE] LPNs had initialed in the EMAR (Electronic Medication Administration Record) that they had administered the IV [MEDICATION NAME] via the PICC line. Review of the South Carolina Board of Nursing document related cardiovascular system Licensed Practical Nurse with Specialized Education and Training revealed that any LPN that administered medication via a PICC line must complete an intravenous therapy course relative to the administration of fluids and medications via peripheral and central venous devices. This document also stated: see Advisory Opinion # 9 B on the role of LPNs in IV (intravenous) therapy. Review of the South Carolina Department of Labor, Licensing and Regulation State Board of Nursing Advisory Opinion # 9 revealed that the Board of Nursing for South Carolina acknowledges it is within the extended role practice of the selected LPN to perform procedures and to administer ordered treatments via peripheral and central venous access devices and lines according to the following stipulations: 1. The agency has established policy and procedures that are approved by the nursing administrator and applicable medical director. Procedures include: a.criteria for the qualification and selection of the LPN; b. description of the additional education and training necessary for assuming additional rates.c. specific standing orders for the administration, monitoring and discontinuation of peripheral and central venous lines.d. specific standing orders to deal with potential complications or emergency situations and provision for supervision by the RN.2. The selected LPN shall document completion of special education and training to include:a. Cardiopulmonary resuscitationb. Intravenous therapy course relative to the administration of fluids via peripheral and central venous access devices/line that includes both didactic and supervised clinical training with return demonstration. The facility policy reviewed on [DATE] titled Care and maintenance of the Central Line Protocol, listed under Standards of Practice - Central line care is performed by a Registered Nurse and under Documentation - Document the [MEDICATION NAME] Flush/Saline Flush on the Medication Administration Record. Documentation includes: site assessment, resident subjective complaints, and any interventions completed and resident response. On [DATE] at approximately 4:00 PM, in an interview with LPN # 3, she stated that she had administered medication via the PICC line and flushed the line. She stated that she had additional training. Interview with the facility DON revealed that the facility did not have any documentation of the advanced training for any of the LPNs and stated that the facility policy stated that only RNs administer medications via a PICC line. She stated that she had not been aware that any LPNs were administering meds via the PICC line, however confirmed that she was aware that the facility did not always have RN coverage. Review of the facility monthly time schedule revealed that there was no RN coverage on [DATE] and [DATE], which was confirmed by the facility administrator. Review of the facility protocol for the Care and maintenance of the Central Line Protocol, revealed that only a Registered Nurse was to perform care to a central line. In addition, the policy stated that flushes should be documented on the MAR. Interview with the facility Medical Director (and the attending Physician for Resident #11) on [DATE] at approximately 9:30 AM, revealed that he was unaware that LPNs were administering medication/flushing PICC lines and had no knowledge of the expired medication used as an IV flush. Immediate Jeopardy was cited at F281 with a scope and severity of "K" related to failure of nursing staff to clarify orders to flush a PICC line when the original order was discontinued without a physician's orders [REDACTED]. documenting on the MAR when administering medication. On [DATE] at 5:25 PM the survey team met with the Administrator and Director of Nursing to inform them of the determination of Immediate Jeopardy with a start date of [DATE] related to the system failure identified with using expired [MEDICATION NAME] to flush a PICC line; the failure to follow the facility policy for the care and maintenance of a central line and the failure to follow the South Carolina Board of Nursing policy related to the extended role of practice of the LPN. The Immediate Jeopardy was not removed at the time the survey team exited from the facility [DATE] and is ongoing. First Follow-Up Visit During an unannounced onsite visit on [DATE] at 11:30 AM, it was determined based on interviews, observations, review of records, and review of facility policies, that the Allegation of Compliance submitted by the facility on [DATE] with an addendum submitted on [DATE] had been implemented by the facility and was in practice as of [DATE], removing the immediacy of the deficient practice. The citation at F-281 remained at a lowered scope and severity of " E". The facility will be in compliance at F281 when an acceptable Plan of Correction is submitted and a follow up visit, to determine that the facility has implementted their Plan of Correction, is conducted.

On the days of the Recertification and Extended Survey, based on full and/or limited record reviews and interviews, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that were accurately documented. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The findings included: Resident #11 was originally admitted on [DATE] and was readmitted after a hospital stay on [DATE] with [DIAGNOSES REDACTED]. Resident #11 was admitted back to the facility on [DATE] with a PICC line and was ordered by the physician to "Flush PICC with 5cc Normal Saline before and after each use, followed by 3cc [MEDICATION NAME] Once a Day at 8PM, start date [DATE]". On [DATE], review of Resident #11's Medication Record (MAR) revealed 4 dates, [DATE], [DATE], [DATE] and [DATE], which indicated that Licensed Practical Nurses (LPNs) had administered IV antibiotics and IV flushes via a Peripherally Inserted Central Catheter (PICC) Line. During an interview with one of the LPN's that signed off the MAR indicated [REDACTED]'s antibiotic and both saline and [MEDICATION NAME] flushes through the resident's PICC line and that she had advanced training and certification to allow her to administer medications via a PICC Line. On [DATE], during an interview with the facility's Administrator, the Administrator stated that there was a "glitch" in the e-mar (electronic) record keeping system that inserted the wrong nurse's initials onto the MAR. She stated that if the nurse did not log out completely when the shift ended there was no security system that would log them out after a certain time had passed with no activity on the part of the staff member. The Administrator did state the nurses were just not taking the time to log out completely and that when medications were given it would be documented as the wrong nurse having administered the medication. She did state that at times it was not the LPN listed on Resident #11's MAR giving the injection. The Administrator stated she was informed LPN #3 had a certificate in advanced training but did not have any evidence of that training. The Administrator did confirm during the interview that this could impact the documentation on all of the resident's MAR's as it relates to their accuracy. Immediate Jeopardy was cited at F514 with a scope and severity of "J" related to the facility administrator's failure to ensure the facility maintain clinical records on each resident in accordance with accepted professional standards and practices that were accurately documented. The electronic system in place for Medication Administration documentation did not ensure accuracy if not logged out properly by staff. Nursing staff were not taking the final step to log off the system and information documented related to medication administration was faulty. On [DATE] at 5:25 PM the survey team met with the Administrator and Director of Nursing to inform them of the determination of Immediate Jeopardy with a start date of [DATE] related to the system failure identified with using expired [MEDICATION NAME] to flush a PICC line; the failure to follow the facility policy for the care and maintenance of a central line and the failure to follow the South Carolina Board of Nursing policy related to the extended role of practice of the LPN. The Immediate Jeopardy was not removed at the time the survey team exited from the facility [DATE] and is ongoing.

On the days of the Recertification and Extended Survey, the facility failed to ensure that expired medications were not stored with medications readily available for resident use resulting in expired Heparin Lock Flush available for use. Seventy Five of 79-3 millimeter Heparin Lock Flushes, were observed in the medication room with expiration dates prior to the survey, an additional 30 were found 12/13/2010 in the bio-hazard container with an expiration date of 8/1/2010 and 2 used Heparin 3 millimeter syringes were found in the sharps container on 12/13/2010 with expiration dates of 8/1/2010 and 11/1/2010. One of one resident sampled with a Peripherally Inserted Central Catheter (PICC), Resident #11, had a IV flush daily with a Heparin Lock Flush ordered. The findings included: Resident #11 was originally admitted on [DATE] and was readmitted after a hospital stay on 11/16/2010 with [DIAGNOSES REDACTED]. Resident #11 was admitted back to the facility on [DATE] with a PICC line and was ordered by the physician to "Flush PICC with 5cc Normal Saline before and after each use, followed by 3cc Heparin Once a Day at 8PM, start date 11/16/2010". On 12/8/2010, during observation of the facility's medication room, expired supplies were noted to be in the same area as the supplies used for resident care. The medication room contained 14-3 ml. Heparin Lock Flush syringes expired 8/1/2010; 60-3 ml. Heparin Lock Flush expired 11/1/2010 and 1-3 ml. Heparin Lock Flush syringes expired 10/20/2010. The Heparin Lock Flushes were observed to be in an open brown cardboard box, sitting on a cart to the right as you entered the medication room. At 10:45 AM on 12/8/2010, expired items (Heparin Lock Flushes) in the medication room were verified by LPN #1 who then removed them from the medication room. LPN #1 stated all nurses were responsible for ensuring any expired meds were removed from the medication room, but there was no system in place to determine when it should be checked or how often it was to be done. During an interview with the Pharmacist on 12/8/2010 at 3:55 PM, he stated that it was the responsibility of the facility's Pharmacy Consultant to ensure that all expired medications and supplies were removed from the facility. The Pharmacist also stated that the pharmacy had not sent Heparin Flushes to the facility in over a year. During the interview with the facility's Pharmacist the surveyors requested the invoices for Heparin delivered to the facility. The Pharmacist stated that he was unable to locate any. When asked how he tracked the lot numbers of the Heparin, he stated that they did not charge for it so they did not track the lot numbers. When asked by the surveyors whose responsibility it was to monitor the facility's medications he stated that the Pharmacy contracted with a consultant who was responsible for that. During an interview with Registered Nurse #1 on 12/8/2010 at 4:00 PM, she stated that the Heparin Flushes she used currently were located on a cart to the right of the door as you walked into the medication room. The container identified by RN #1 was the one noted to hold the expired Heparin Lock Flushes. During an interview with the Nursing Home Administrator on 12/8/2010 at 4:15 PM, the Administrator stated that the Pharmacy Consultant was responsible for monitoring the medication room and medication carts for expired medications. She also stated that the consultant had been to the facility for review on 11/17/2010, and that she had no idea where the expired Heparin in the facility came from. The NHA verified that the Pharmacy had not sent Heparin to the facility in over a year at 5:25 PM on 12/8/2010. On 12/13/2010, an additional box of 30-3 ml. Heparin Lock Flush expired 11/1/2010 was observed in the bio-hazard box by a surveyor and 1 used-3 ml. Heparin Lock Flush syringe expired 8/1/2010 and 1 used 3-ml Heparin Flush syringe expired 11/1/2010 was retrieved by that surveyor from the sharps container located on the medication cart. In an interview with the Interim Director of Nursing (DON) on 12/13/2010, The DON stated that the bio-hazard material had been picked up on 12/1/2010 and provided documentation of that pick-up. She also stated that the medication cart sharps container was emptied approximately every 3 weeks because the facility did not use many sharps. On 12/13/2010 during an interview with the Pharmacy Consultant, the Consultant confirmed she was responsible for ensuring expired medications were removed from the medication room. She stated she was in the facility monthly for medication review and checked the medication room and carts at that time. She stated she was unaware the Heparin was in the building. On 12/13/2010 at 4:15 PM, during an interview with the facility's Pharmacist, he stated that he did not have lot numbers of Heparin Flushes received prior to September 16, 2010. When asked how he would recall medications from facility's when the Federal Drug Administration recalled medications by lot number, he stated that he would recall the medication by name, not lot number. When asked if his process would include medication lot numbers not included in the recall he stated that it would. Immediate Jeopardy was cited at F425 with a scope and severity of "J" related to expired Heparin Lock Flushes (75 of 79) stored in an area readily available for resident use. The Immediate Jeopardy existed when a resident (Resident #11) was admitted and was using the IV flushes daily per physician order [REDACTED]. In addition 2 used syringes of the IV Heparin Lock Flush were found in a sharps container and noted to have dates that were expired. On 12/8/2010 at 5:25 PM the survey team met with the Administrator and Director of Nursing to inform them of the determination of Immediate Jeopardy with a start date of 11/16/2010 related to the system failure identified with using expired Heparin to flush a PICC line; the failure to follow the facility policy for the care and maintenance of a central line and the failure to follow the South Carolina Board of Nursing policy related to the extended role of practice of the LPN. The Immediate Jeopardy was not removed at the time the survey team exited from the facility 12/13/2010 and is ongoing. First Follow-Up Visit During an unannounced onsite visit on 12/29/2010 at 11:30 AM, it was determined based on interviews, observations, review of records, and review of facility policies, that the Allegation of Compliance submitted by the facility on 12/13/2010 with an addendum submitted on 12/23/2010 had been implemented by the facility and was in practice as of 12/18/2010, removing the immediacy of the deficient practice. The citation at F-425 remained at a lowered scope and severity of " D". The facility will be in compliance at F-425 when an acceptable Plan of Correction is submitted and a follow up visit is conducted, to determine that the facility has implemented their Plan of Correction as stated.

On the days of the Recertification and Extended Survey, based on full and/or limited record reviews and interviews, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that were accurately documented. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The findings included: Resident #11 was originally admitted on [DATE] and was readmitted after a hospital stay on [DATE] with [DIAGNOSES REDACTED]. Resident #11 was admitted back to the facility on [DATE] with a PICC line and was ordered by the physician to "Flush PICC with 5cc Normal Saline before and after each use, followed by 3cc [MEDICATION NAME] Once a Day at 8PM, start date [DATE]". On [DATE], review of Resident #11's Medication Record (MAR) revealed 4 dates, [DATE], [DATE], [DATE] and [DATE], which indicated that Licensed Practical Nurses (LPNs) had administered IV antibiotics and IV flushes via a Peripherally Inserted Central Catheter (PICC) Line. During an interview with one of the LPN's that signed off the MAR indicated [REDACTED]'s antibiotic and both saline and [MEDICATION NAME] flushes through the resident's PICC line and that she had advanced training and certification to allow her to administer medications via a PICC Line. On [DATE], during an interview with the facility's Administrator, the Administrator stated that there was a "glitch" in the e-mar (electronic) record keeping system that inserted the wrong nurse's initials onto the MAR. She stated that if the nurse did not log out completely when the shift ended there was no security system that would log them out after a certain time had passed with no activity on the part of the staff member. The Administrator did state the nurses were just not taking the time to log out completely and that when medications were given it would be documented as the wrong nurse having administered the medication. She did state that at times it was not the LPN listed on Resident #11's MAR giving the injection. The Administrator stated she was informed LPN #3 had a certificate in advanced training but did not have any evidence of that training. The Administrator did confirm during the interview that this could impact the documentation on all of the resident's MAR's as it relates to their accuracy. Immediate Jeopardy was cited at F514 with a scope and severity of "J" related to the facility administrator's failure to ensure the facility maintain clinical records on each resident in accordance with accepted professional standards and practices that were accurately documented. The electronic system in place for Medication Administration documentation did not ensure accuracy if not logged out properly by staff. Nursing staff were not taking the final step to log off the system and information documented related to medication administration was faulty. On [DATE] at 5:25 PM the survey team met with the Administrator and Director of Nursing to inform them of the determination of Immediate Jeopardy with a start date of [DATE] related to the system failure identified with using expired [MEDICATION NAME] to flush a PICC line; the failure to follow the facility policy for the care and maintenance of a central line and the failure to follow the South Carolina Board of Nursing policy related to the extended role of practice of the LPN. The Immediate Jeopardy was not removed at the time the survey team exited from the facility [DATE] and is ongoing. First Follow-Up Visit During an unannounced onsite visit on [DATE] at 11:30 AM, it was determined based on interviews, observations, review of records, and review of facility policies, that the Allegation of Compliance submitted by the facility on [DATE] with an addendum submitted on [DATE] had been implemented by the facility and was in practice as of [DATE], removing the immediacy of the deficient practice. The citation at F-514 remained at a lowered scope and severity of " D". The facility will be in compliance at -514 when an acceptable Plan of Correction is submitted and a follow up visit, to determine that the facility has implementted their Plan of Correction, is conducted.

On the days of the Recertification and Extended Survey, based on record review and interview, the facility failed to notify the attending Physician of the signs and symptoms of an infected surgical wound for one of one resident reviewed with an infected surgical wound. (Resident # 11) The findings included: The facility admitted Resident # 11 on 11/1/2010 with diagnoses, which included aftercare for Reverse Total Shoulder Arthroplasty, Hypertension, [MEDICAL CONDITION] and [MEDICATION NAME] Degeneration. Resident #11 was re-admitted [DATE] after a hospital stay. On 12/8/2010, review of the progress notes (nurses notes) revealed that on 11/4/2010 at 3:15 PM LPN # 3 documented that the surgical wound had intact staples, and a small amount of serous yellow tinged drainage. On 11/5/2010 at 3:56 PM, LPN # 3 documented that the wound had increased serous yellow tinged drainage and increased pain. On 11/6/2010 at 2:42 PM. LPN # 3 documented that the wound continued to drain a moderate amount of serous yellow drainage that was blood tinged. There was no documentation of the Physician being notified. At 2:35 PM on 11/8/2010 LPN # 3 documented a moderate amount of blood tinged yellow drainage was observed on the dressing when removed. On 11/8/2010 an order for [REDACTED]." Interview with the DON (Director of Nurses) at approximately 12:00 PM, revealed that the nursing staff should document Physician notification in the progress notes. She confirmed that the nursing staff failed to recognize signs and symptoms of the surgical wound being infected even though the nurse had documented possible signs and symptoms on 11/5/2010 and that the resident's MD (in addition to the resident' attending physician this was also the facility's Medical Director) had not been notified of the change of condition of the wound until 11/8/2010 which resulted in a delay in treatment. On 11/12/2010 the resident was transferred to the hospital at 5:00 AM for Incision and Drainage of the right shoulder surgical wound. Cross refers this tag to F-281 as it relates to the facility's nursing staffs failure to provide care and services that met professional standards of practice.