Every finding on record at Carlyle Senior Care of Florence

Based on interview and record review, the facility staff failed to report abuse immediately, within two hours, to the administrator for one of six facility-reportable incidents reviewed and failed to report the results of the facility-reportable incident investigations to the State Survey Agency (SA) within five working days of the incident for two of six incidents reviewed. Findings include: Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated 02/05/26, revealed, . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: . c. Include training for new, existing, and contract staff on activities that constitute abuse, neglect . reporting procedures . 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, Ombudsman and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . B. The Administrator will maintain confirmation of notification to appropriate government agencies in the file to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. 1. Review of the facility's investigation documents, resident records, and interviews revealed a facility-reported incident in which Dietary Aide (DA) DD reported verbal and/or mental abuse of Resident (R) 1 by Licensed Practical Nurse (LPN) AA. Review of the 2 hour report submitted to the State Agency (SA) revealed that the Director of Nursing (DON) submitted the report on 06/24/26 at an unknown time. The SA acknowledged receipt via email to the DON on 06/24/26 at 4:53 PM, between five and seven days following the alleged incident.In an interview with DA DD on 07/15/26 at 1:55 PM, When asked when the incident occurred, she replied, It happened on the Wednesday before the Wednesday that I reported it, the seventeenth, in the dining room full of people, which she confirmed by looking at the June 2026 calendar. When asked the reason she waited until 06/24/26 to report the incident, she stated, I kinda (sic) did not want to be biased. I asked [Human Resources Director] about it, and she told me to go ahead and report it. I think that was on the 23rd or 24th. She described the incident and then said, At that moment, I thought she was being abusive. Now, I don't think that situation is abuse. It wasn't that bad. She learned her lesson. I had a talk with her. Review of employee training documentation revealed DA DD had been trained and tested on the Abuse, Neglect, and Exploitation Policy on 02/25/26, 06/08/26, and 06/24/26. An interview with the Human Resources Director on 7/15/26 at 2:00 PM revealed that DA DD reported the allegation to her on 06/24/26 at approximately 4:00 PM. The Human Resources Director then facilitated the reporting of the incident to the Director of Nursing and the Administrator.2. Review of the facility's investigation documents, resident records, and interviews identified a facility reported incident involving an abuse allegation. An anonymous caller reported to the local sheriff's Crime Stoppers hotline that residents were being physically abused and given cold showers. The sheriff's office received the report and notified the facility. The facility learned of the allegation on 06/03/26 at approximately 10:35 AM, when an investigator from the sheriff's office arrived and informed staff about the information received earlier that day.Review of the 5 day report revealed that the Administrator submitted it on 06/11/26 at an unknown time. The SA acknowledged receipt via email on 06/11/26 at 6:32 PM, six business days after the facility became aware of the allegation. 3. Review of the facility's investigation documents, resident records, and interviews revealed that a facility reported resident to resident abuse incident occurred on 05/23/26 at 1:10 PM. Review of the 5 day follow up report submitted to the SA revealed that the Administrator submitted it on 06/01/26 at an unknown time. The SA acknowledged receipt via email on 06/01/26 at 3:13 PM, six business days after the incident.An interview with the Administrator on 07/16/26 at 9:00 AM revealed his expectation of timely reporting of suspected abuse is immediately, adding it must be less than two hours, because we only have two hours to turn it in. An interview with the Regional Nurse Consultant on 07/16/26 at 9:05 AM revealed her expectation of timely reporting of suspected abuse is immediately to the administrator, that the initial report should be submitted to the SA within two hours of the report, and that the 5-day follow-up report should be submitted to the SA within five business days.

Based on record review, observation, and interview, the facility failed to implement an effective Performance Improvement Plan to address facility water temperatures. This had the potential to affect all 78 residents. Findings include: Review of facility document titled 'QAPI' (not dated) revealed, Maintenance-We provide a maintenance program that maintains building safety, conducts repairs as needed, and performs safety inspections in accordance with State and Federal expectations to ensure all aspects of safety are enforced, ensuring the safety and well- being for each resident, visitor, and staff who enters the building. A review of facility QAPI meeting minutes from 2/2025 through 2/2026 showed there was no indication of Performance Improvement Plan in place concerning plumbing problems or water temperatures. Review of Water Temperature Log 2026 revealed water temperatures below 100 degrees during week three the whirlpool (99 degrees), week five room [ROOM NUMBER] (97 degrees), week six room [ROOM NUMBER] (98 degrees), week seven room [ROOM NUMBER] (98 degrees) and the whirlpool (99 degrees), week eight room [ROOM NUMBER] (99 degrees), week ten room [ROOM NUMBER] (99 degrees) and the whirlpool (99 degrees), week 13 the whirlpool (99 degrees). During observations on 3/24/26, 3/25/26, and 3/26/26, water temperatures in the facility were found to be tepid in resident care areas. During observation on 3/24/26 at 1:04 PM with the Maintenance Assistant (MA) OO, the water temperature in room [ROOM NUMBER] was 98.5 degrees, room [ROOM NUMBER] was 97 degrees, room [ROOM NUMBER] was 90 degrees, west hall shower room was 90 degrees. During observation on 3/25/26 at 9:18 AM with MA QQ, the water temperature in room [ROOM NUMBER] was 87 degrees, room [ROOM NUMBER] was 87 degrees, room [ROOM NUMBER] was 94 degrees, and the west hall shower room was 68 degrees. During observation on 3/26/26 at 10:32 AM with MA QQ, the water temperature in room [ROOM NUMBER] was 86 degrees, room [ROOM NUMBER] was 87 degrees, room [ROOM NUMBER] was 70 degrees. During interview on 3/24/26 at 11:43 AM Director of Maintenance, he revealed the water temperatures should be no higher than 120 degrees, but he was not sure of a minimum temperature for hot water. Further stated water temperatures are checked weekly, and adjustments are made to the temperature as needed. During an interview on 3/24/26 at 1:52 PM with MA OO, he revealed that when water temperatures were lower than 100 degrees, he checked the hot water heaters to ensure the temperature at the hot water heater is 120 degrees. During interview on 3/24/26 at 2:01 PM, Certified Nursing Assistant MM revealed the water has been inconsistent in the building for months. Stated some rooms have hot and cold water, but others have just cold or tepid water. Stated, she often must go to other rooms to get hot water because after letting the water run for long periods of time it still does not get warm or hot. During an interview on 3/24/26 at 2:36 PM with the Administrator, he stated he was unaware of the water temperatures being below 100 degrees and the hot water faucet not working in the center employee/visitor restroom. During an interview on 3/25/26 at 11:27 AM, CNA KK revealed she has reported to maintenance the cold-water temperatures in some residents' rooms and the shower room. During an interview on 3/25/26 at 1:17 PM with CNA NN revealed she is aware of the issue with some rooms not having hot water. Stated, she has told the maintenance department about the issues, and they will repair it, but it does not seem to improve much. A group interview was conducted with four cognitively intact residents (R)55, R59, R68, and R69) on 03/25/26 at 11:00AM. The residents were regular participants in the facility Resident Council group. They were asked about their group as well as any other concerns they had with the facility. All four residents stated that they had no hot water in the bathrooms in their rooms. They stated they are cleaned with cold to tepid water routinely. R69 stated that the shower room water is often too cold as well. The group stated they had discussed it with the former Activities Director (AD). During an interview on 3/26/26 at 11:04 AM with Unit Manager (UM) BB revealed the west hall nurses' station and medication room does not have running water. Stated the water has not been working for some time, and this has been reported to maintenance. During an interview on 3/26/26 at 11:11 AM, LPN HH revealed that the water temperatures in several resident rooms, the shower room on the [NAME] Hall and nurses' station are tepid. Also stated staff have to retrieve water from other rooms to bath residents or go into other resident rooms to wash hands where there is hot water. During an interview on 3/26/26 at 12:08 PM with the Administrator, Director of Nursing, and Senior Nurse Consultant related to the Quality Assurance & Performance Improvement (QAPI) revealed they had not put a PIP in place to address the low water temperatures.

Based on record review and interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments were completed no greater than 92 days from the most recent prior quarterly review for 14 of 16 residents' records reviewed and 19 of 19 quarterly assessments reviewed which had the potential to affect all residents living in the facility.Findings include:A review of facility policy titled MDS 3.0 Completion implemented on 10/1/25 without review or revision dates revealed, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: . e. Quarterly Assessment - completed using an ARD no >92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD) .A review of 14 of 16 residents' records for quarterly assessments revealed 19 of 19 assessments were not completed within 92 days of the Annual Review Date (ARD) or the last comprehensive assessment for Residents (R) 17, R7, R27, R33, R42(x2), R48(x2), R52, R55, R60, R63, R73, R74(x2), R9, and R8(x3). A review of the quarterly Minimum Data Set (MDS) found in R17's electronic medical record (EMR) revealed an ARD 11/21/25 and a completion date of the quarterly assessment of 3/25/26 which is 124 days past the ARD. A review of the quarterly MDS found in R7's EMR revealed a quarterly review due date of 11/21/25 and a completion date of 1/12/26 which is 144 after the last quarterly review dated 8/21/25.A review of the quarterly MDS found in R27's EMR revealed an ARD of 11/21/25 had a completion of the quarterly reviewed date of 3/25/26 which is 124 days past the ARD. A review of the quarterly MDS found in R33's EMR revealed a quarterly review due date of 11/7/25 and a completion date of 12/21/25 which is 136 days past the last quarterly review dated 8/7/2025. A review of the quarterly MDS found in R42's EMR revealed a quarterly review due date of 2/19/26 and had a completion date of 3/23/26 which is 124 days past the last quarterly review dated 11/19/25. A review of the quarterly MDS found in R42's EMR revealed a quarterly review due date of 11/19/25 and had a completion date of 1/5/26 which is 139 days past the last quarterly review dated 8/9/25. A review of the quarterly MDS found in R48's EMR revealed a quarterly review due date of 2/21/26 and had a completion date of 3/25/26 which is 124 days past the last quarterly review dated 11/21/25. A review of the quarterly MDS found in R48's EMR revealed a quarterly review due date of 11/21/25 and had a completion date of 1/12/26 which is 143 days past the last quarterly review dated 8/22/25. A review of the quarterly MDS found in R52's EMR revealed a quarterly review due date of 2/14/26 and had a completion date of 3/23/36 which is 129 days past the last quarterly review dated 11/14/25.A review of the quarterly MDS found in R55's EMR revealed an ARD of 11/19/26 had a quarterly review completion date of 3/23/26 which is 124 days past the ARD. A review of the quarterly MDS found in R60's EMR revealed a quarterly review due date of 11/20/25 and had a completion date of 1/5/26 which is 138 days past the last quarterly review dated 8/20/25. A review of the quarterly MDS found in R63's EMR revealed a quarterly review due date of 2/14/26 and had a completion date of 3/23/26 which is 129 days past the last quarterly review dated 11/14/25. A review of the quarterly MDS found in R73's EMR revealed a quarterly review due date of 2/14/26 and had a completion date of 3/19/26 which is 125 days past the last quarterly review dated 11/14/25. A review of the quarterly MDS found in R74's EMR revealed a quarterly review due date of 2/13/26 and had a completion date of 3/19/26 which is 126 days past the last quarterly review dated 11/13/25. A review of the quarterly MDS found in R74's EMR revealed a quarterly review due date of 11/13/25 had a completion date of 12/26/25 which is 135 days past the ARD of 8/13/25. A review of the quarterly MDS found in R9's EMR revealed a quarterly review due date of 1/30/26 and had a completion date of 3/11/26 which is 132 days past the significant change assessment dated [DATE]. A review of the quarterly MDS found in R8's EMR revealed a quarterly review due date of 3/7/26, and it had no completion date as of 3/26/26 which is 111 days past the last quarterly review dated 12/5/25. A review of the quarterly MDS found in R8's EMR revealed a quarterly review due date of 12/5/25 and had a completion date of 1/12/26 which is 129 days past the last quarterly review dated 9/5/25. A review of the quarterly MDS found in R8's EMR revealed a quarterly review due date of 9/5/25 and had a completion date of 9/29/25 which is 111 days past the ARD of 6/6/25. In an interview with Director of Nursing (DON) on 03/25/26 at 3:50 PM, she stated, [Assistant Director of Nursing (ADON)] 'signs off' on the MDS assessments behind LPN AA. DON did not know the assessment or the submission timeframes for due dates. An interview on 03/25/26 with Regional Nurse Consultant (RNC), referring to quarterly assessments, said, Assessments are due by the 92nd day and submissions are due after that. She said that is the expectation for all MDS submissions. When shown a list of 16 residents' assessments, she acknowledged several late assessments.

Based on record review, interview, and observation, the facility failed to ensure resident grievances were documented and resolved related to uncomfortable water temperatures during 1 of 1 resident group interview (Resident (R)55, R59, R68, and R69) and 1 of 19 (R9) resident interviews. Findings include: A group interview was conducted with four cognitively intact residents R55, R59, R68 and R69 on 03/25/26 at 11:00AM. The residents were regular participants in the facility's Resident Council group. They were asked about their group as well as any other concerns they had with the facility. All four residents stated that they had no hot water in the bathrooms in their rooms. They stated they are cleaned with cold to tepid water routinely. R69 stated that the shower room water is often too cold as well. The group stated they had discussed it with the former Activities Director (AD) who passed away December 2025.The current AD provided the resident council notes from December 2025 through March 2026. The review revealed no documented resident council concerns related to the water temperature concerns. The grievance logs were reviewed from March 2025 to March 2026. There were no documented grievances regarding water temperatures.During interview on 3/24/26 at 1:32 PM R9 stated the water in his room is never warm. Stated the staff sometimes bathe him in the cool water, other times they go get water from another room. During an observation on 3/24/26 at 1:04 PM with the Maintenance Assistant (MA) OO, the water temperature in room [ROOM NUMBER] was 98.5 degrees, room [ROOM NUMBER] was 97 degrees, room [ROOM NUMBER] was 90 degrees, west hall shower room was 90 degrees. During an interview on 3/24/26 at 1:52 PM with MA OO, he revealed that when water temperatures were lower than 100 degrees, he checked the hot water heaters to ensure the temperature at the hot water heater is 120 degrees. During an interview with the Director of Nursing (DON) on 03/25/26 at 3:00 PM she was asked if the resident's concerns, discussed in resident group meeting, had been addressed as a formal grievance. She stated she did not have a grievance about cold water, but she had been told that the residents thought the water was too cold for bathing. She stated it had been reported situationally, so it had not been addressed as a formal grievance, and she had not met with the residents regarding a resolution to their complaint. During an interview on 3/26/26 at 12:08 PM with the Administrator, DON, and Senior Nurse Consultant revealed they were not aware of complaints from residents or staff about hot water not being available in various parts of the facility. They stated that the Maintenance Director did not notify them of abnormal temperature findings during weekly temperature checks.

Based on record review and interview, the facility (1) failed to ensure the comprehensive Annual Minimum Data Set (MDS) assessment was completed within 366 days of the Assessment Reference Date (ARD) for eight of eight residents reviewed requiring an Annual MDS assessment (Resident (R) 7, R17, R27, R33, R52, R60, R63, and R73) and (2) failed to ensure the comprehensive admission MDS assessment was completed within 14 days of admission for two of six residents reviewed for admission MDS assessment (R55 and R81).Findings include:1. A review of facility policy titled MDS 3.0 Completion implemented on 10/1/25, without review or revision dates indicated, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan .Policy Explanation and Compliance Guidelines: .c. Annual Assessment- a comprehensive assessment completed using an ARD no > 366 days from the most recent prior comprehensive assessment and no > 92 days from the most recent quarterly assessment (counting ARD to ARD) A review of the admission Minimum Data Set (MDS) found in R17's electronic medical record (EMR) R17's revealed an ARD of 11/21/25 had a completion date of 1/8/26 which is 48 days past the ARD. A review of the admission MDS found in R7's EMR revealed an ARD of 2/21/26 had a completion date of 3/24/26 which is 31 days past the ARD.A review of the admission MDS found in R 27's EMR revealed an ARD of 11/21/25 had a completion date of 1/8/26 which is 48 days past the ARD. R33's EMR revealed an ARD of 2/7/26 had a completion date of 3/18/26 which is 39 days past the ARD. A review of the admission MDS found in R52's EMR revealed an ARD of 11/14/25 had a completion date of 12/5/25 which is 21 days past the ARD. A review of the admission MDS found in R60's EMR revealed an ARD of 2/20/26 had a completion date of 3/25/26 which is 33 days past the ARD. A review of the admission MDS found in R63's EMR revealed an ARD of 11/14/25 had a completion date of 1/5/26 which is 52 days past the ARD. A review of the admission MDS found in R73's EMR revealed an ARD of 11/14/25 had a completion date of 1/5/26 which is 52 days past the ARD. 2. A review of facility policy titled MDS 3.0 Completion implemented on 10/1/25, without review or revision dates indicated, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan .Policy Explanation and Compliance Guidelines: b. admission assessment-complete within 14 days of assessment A review of the admission MDS found in R55's EMR revealed an admission date of 11/10/25 and had a completion date of 1/5/26 which is 57 days past the date of admission. A review of the admission MDS found in R81's EMR revealed an admission date of 1/23/25 and had a completion date of 2/10/26 which is 18 days past the date of admission. An interview on 03/25/26 at 1:35 PM with Licensed Practical Nurse (LPN) AA, referring to admission assessments, revealed, Assessments are due within 14 days of the due date and are required to be submitted within 14 days of completion.In an interview with Director of Nursing (DON) on 03/25/26 at 3:50 PM, she stated, [Assistant Director of Nursing (ADON)] 'signs off' on the MDS assessments behind LPN AA. DON did not know the assessment or the submission timeframes for due dates.

Based on record review, observation, and interview, the facility failed to ensure comfortable water temperatures were maintained throughout resident care areas as identified in 1 of 1 resident council meeting (Resident (R)55, R59, R68, and R69) and 1 of 19 resident (R9) interviews. Findings include: Review of facility policy titled Safe Water Temperatures dated 10/1/25 revealed It is the policy of this facility to maintain appropriate water temperatures in resident care areas. Policy Explanation and Guidelines: 2. Staff will be educated on safe water temperatures upon employment and on a regular basis 4. Staff will report abnormal findings, such as complaints of water too cold or hot, burns, redness, or any problems with water temperatures (ex. water is painful to touch or causes redness) to supervisor and/or maintenance staff. Review of facility policy titled Safe and Homelike Environment dated 8/1/25 revealed Policy: In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing residents to use his/her personal belongings, to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk .11. General Considerations: .f. Report any unresolved environmental concerns to the Administrator. During an observation on 3/24/26 at 9:58 AM, the center hall visitor/employee bathroom was observed with only the cold-water faucet working. During an observation on 3/24/26 at 11:20 AM, the west hall visitor/employee bathroom was observed with only cold water flowing from both the hot and cold-water faucets. The water was allowed to run for five minutes. During an interview on 3/24/26 at 11:43 AM with the Director of Maintenance revealed the water temperatures should be no higher than 120 degrees, but he was not sure of a minimum temperature for hot water. Further stated water temperatures are checked weekly, and adjustments are made to the temperature as needed. During an observation on 3/24/26 at 1:04 PM with the Maintenance Assistant (MA) OO, the water temperature in room [ROOM NUMBER] was 98.5 degrees, room [ROOM NUMBER] was 97 degrees, room [ROOM NUMBER] was 90 degrees, and west hall shower room was 90 degrees. During an interview on 3/24/26 at 1:52 PM with MA OO, he revealed that when water temperatures were lower than 100 degrees, he checked the hot water heaters to ensure the temperature at the hot water heater is 120 degrees. During an interview on 3/24/26 at 2:01 PM, Certified Nursing Assistant MM revealed the water has been inconsistent in the building for months. Stated some rooms have hot and cold water, but others have just cold or tepid water. Stated, she often must go to other rooms to get hot water because after letting the water run for long periods of time, it still does not get warm or hot. During an interview on 3/24/26 at 2:36 PM with the Administrator, he stated he was unaware of the water temperatures being below 100 degrees and the hot water faucet not working in the center employee/visitor restroom. During an observation on 3/25/26 at 9:18 AM with MA QQ, the water temperature in room [ROOM NUMBER] was 87 degrees, room [ROOM NUMBER] was 87 degrees, room [ROOM NUMBER] was 94 degrees, and the west hall shower room was 68 degrees. During an interview on 3/25/26 at 11:27 AM, CNA KK revealed she has reported to maintenance the cold-water temperatures in some residents' rooms and the shower room. During an interview on 3/25/26 at 1:17 PM with CNA NN revealed she is aware of the issue with some rooms not having hot water. Stated, she has told the maintenance department about the issues, and they will repair it, but it does not seem to improve much. A group interview was conducted with four cognitively intact residents (R)55, R59, R68, and R69) on 03/25/26 at 11:00 AM. The residents were regular participants in the facility Resident Council group. They were asked about their group as well as any other concerns they had with the facility. All four residents stated that they had no hot water in the bathrooms in their rooms. They stated they are cleaned with cold to tepid water routinely. R69 stated that the shower room water is often too cold as well. The group stated they had discussed it with the former Activities Director (AD). During observation on 3/26/26 at 10:32 AM with MA QQ, the water temperature in room [ROOM NUMBER] was 86 degrees, room [ROOM NUMBER] was 87 degrees, room [ROOM NUMBER] was 70 degrees. During an interview on 3/26/26 at 11:04 AM with Unit Manager (UM) BB revealed the west hall nurses' station and medication room does not have running water. Stated the water has not been working for some time, and this has been reported to maintenance. During an interview on 3/26/26 at 11:11 AM, LPN HH revealed that the water temperatures in several resident rooms, shower room on the [NAME] Hall and nurses' station are tepid. Also stated staff have to retrieve water from other rooms to bath residents or go into other resident rooms to wash hands where there is hot water. During an interview on 3/26/26 at 12:08 PM with Administrator, Director of Nursing, and Senior Nurse Consultant revealed they were not aware of complaints from residents or staff about hot water not being available in various parts of the facility. They stated that the Maintenance Director did not notify them of abnormal temperature findings during weekly temperature checks. Further, a plumbing company had been to the facility in the past to fix various issues with the water circulation system.

Based on record review and interviews, the facility failed to complete significant change Minimum Data Set (MDS) assessments within 14 days of a significant change for one of one significant change assessment reviewed for timely completion (Resident (R)1).Findings include:A review of facility policy titled MDS 3.0 Completion implemented on 10/1/25 without review or revision dates revealed, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: . d. Significant Change in Status Assessment (SCSA) - a comprehensive assessment completed within 14 days of the identification of a status change that meets the requirements outlined in Chapter 2 of the Version 3.0 RAI Manual.The significant change Minimum Data Set (MDS) assessment for Resident 9 was reviewed and indicated the resident's diagnoses included, but were not limited to: diabetes mellitus requiring insulin, hyperlipidemia, arthritis, anxiety disorder, depression, COPD [chronic obstructive pulmonary disease] and respiratory failure, chronic pain syndrome, weakness, peripheral vascular disease, and psychophysiologic insomnia, pressure and venous/arterial ulcers, and hospice/palliative care. There were 10 Care Area Assessments (CAA) completed on 12/15/2025 for the Significant Change MDS dated [DATE]: Cognitive loss/dementia, ADL functional/rehabilitation potential, Urinary incontinence and indwelling catheter, psychosocial well-being, behavioral symptoms, falls, nutritional status, pressure ulcer, psychotropic drug use, and pain. R9's MDS revealed a significant change dated 10/30/25 and a completion date of 12/15/25 which is 46 days past the significant change dated 10/30/25.An interview on 03/25/26 at 1:35 PM with Licensed Practical Nurse (LPN) AA, referring to significant change assessments, revealed, Assessments are due within 14 days of the due date and are required to be submitted within 14 days of completion.In an interview with Director of Nursing (DON) on 03/25/26 at 3:50 PM, she stated, [Assistant Director of Nursing (ADON)] 'signs off' on the MDS assessments behind LPN AA. DON did not know the assessment or the submission timeframes for due dates.

Based on review of facility policy, document review and interview, the facility failed to develop and implement an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. Specifically, they failed to complete systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety related to abuse prevention. This deficient practice has the potential to affect all residents in the facility. Findings include: Review of the facility's policy titled QAPI dated 10/24/22, revealed, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides .The facility conducts at least one distinct performance improvement project (PIP) annually that focuses on high risk or problem prone areas. PIPs shall be designed to achieve and sustain performance improvement over time and to have an expected favorable outcome. The Quality Assessment and Assurance (QAA) shall select additional members to participate in various subcommittees based upon the PIP topic and participant expertise. Upon conclusion of the PIP, the sub-committee shall provide the QAA committee with a report, which contains a summary and analysis of activities and recommendations for improvement. Review of the facility ' s PIP's over the past year and interview on 03/27/25 at 6:52 PM with the Administrator, Director of Nursing (DON), and the Infection Preventionist (IP), the PIP consisted of a one page document that stated the problem to be solved was abuse prevention. This PIP was completed in two days by the Administrator. A form was filled out using F223 for abuse, which is no longer the federal regulation for abuse. The goal was there would be no abuse in the facility. There was no documentation to go along with this PIP. When the Administrator was questioned on the effectiveness of this PIP, he stated Our goal is to have zero abuse. When asked if he feels that this PIP is achievable, he did not reply. The survey team entered the facility with three abuse complaints that were all substantiated. Three weeks prior, the State Agency (SA) investigated several abuse complaints. The PIP did not contain a summary, how this was identified to QAPI, a sub-committee, or a summary and analysis of the process. When the Administrator was asked if he understood the purpose of QAPI and an annual PIP, he stated Yes.

Based on review of the facility policy, record review and interviews, the facility failed to monitor and evaluate antibiotic usage for four of five residents (Resident (R) 24, R81, R55, and R15) reviewed for antibiotic usage out of 28 sample residents. This failure had the potential to affect residents' safety related to antibiotic usage. Findings include: Review of the facility's policy titled, Antibiotic Stewardship Program dated 09/30/24 revealed, It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of this program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness .Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness (process measure) . 1. Review of R24's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed R24 was admitted to the facility on [DATE]. R24 was sent to the emergency room (ER) on 02/18/25 for an indwelling urinary catheter. A urine analysis (UA) was completed, and an antibiotic was started. R24 returned to the facility and completed the antibiotic. A culture was not done by the ER and the Infection Preventionist (IP) did not question the antibiotic. 2. Review of R81's Admission Record located under the Profile tab of the EMR revealed R81 was admitted to the facility on [DATE]. R81 was sent to theER on [DATE] for urinary retention, was catheterized, and came back to the facility on an antibiotic. No UA or culture was completed. 3. Review of R55's Admission Record located under the Profile tab of the EMR revealed R55 was admitted to the facility on [DATE]. R55 was sent on 03/04/25 to the ER for a change in condition and came back to the facility on an antibiotic. A UA was completed by the ER; however, a culture was not ordered to be completed. 4. Review of R15's Admission Record located under the Profile tab of the EMR revealed R15 was admitted to the facility on [DATE]. R15 has a Stage IV pressure ulcer to the sacrum. The Wound Doctor was alerted to an odor coming from the sacrum and ordered an antibiotic (Doxycycline) for 14 days. No culture was order by the provider to determine if antibiotic was needed or appropriate. During an interview on 03/25/25 at 12:43 PM, Licensed Practical Nurse (LPN9) revealed, I noticed a foul odor coming from the sacrum with drainage. I notified the wound doctor, and he came and evaluated the resident. A culture was not completed on the wound. Doxycycline was ordered for 14 days. I informed the IP that an antibiotic was started. During an interview on 03/27/25 at 2:45 PM, the IP stated, I told LPN9 and the wound doctor that a culture should have been done on R15. The wound doctor usually does a culture, but for some reason, did not do one on this resident. I have learned that I must get cultures from the hospital to see if a resident did have a Urinary Tract Infection (UTI) and that they are on the correct antibiotic. If I do not have a culture, I will call the hospital to get one. During an interview on 03/27/25 at 3:43 PM, the wound doctor revealed, I normally do a culture. I am not sure why I did not do one. I understand that a culture should always be completed before an antibiotic is given. During an interview on 03/27/25 at 6:53 PM, the Administrator revealed, My expectation for antibiotic stewardship is to follow the Centers for Medicare and Medicaid Services (CMS) guidelines.

40902 Based on record review, interview, and policy review, the facility failed to thoroughly investigate resident to resident abuse for four of five residents (Resident (R)72, R54, R12, and R52) reviewed for abuse out of 28 sample residents. This had the potential to affect residents in the facility who were at risk for abuse. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation revised 10/24/22 revealed, .an immediate investigation is warranted when suspicion of abuse . or reports of abuse, .occur. Written procedures for investigations include: Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations . 1. Review of R54's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which include but are not limited to: autistic disorder, anxiety disorder, mental disorder, and mood disorder. Review of R54's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/25 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated the resident was severely cognitively impaired. Review of R72's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which include but are not limited to: strange and inexplicable behavior. Review of R72's Quarterly MDS with an ARD of 02/03/25 and located in the resident's EMR under the MDS tab, revealed a BIMS score of 13 out of 15, which indicated the resident was cognitively intact. Review of the Facility's Five Day Follow Up Report dated 02/14/25, revealed the date and time of the incident was 02/10/25 at 11:00 PM. The summary finding indicated the residents did have a physical alteration. Further review did not indicate what occurred or who the aggressor was. There was no interview with [R72] after the incident occurred. It did not indicate what staff member witnessed the incident or an interview with that staff member. There were no interviews with any other residents who may have been in the Television (TV) room or had any knowledge of the incident or residents. During an interview on 03/26/25 at 4:24 PM, the Administrator stated he was the Abuse Coordinator, and it was his responsibility to ensure the completion of the investigation. He said anytime there was a resident-to-resident incident the investigation should include: statements by any staff who witnessed the incident, all residents involved and any staff in the area. He stated staff should have interviewed R72 the night of the incident to ensure he felt safe and had no concerns. He also stated he thought the Certified Nurse Aide (CNA) who witnessed the incident was interviewed. He agreed the CNA should have been identified in the investigation. 2. Review R12's Admission Record found in the EMR under the Profile tab, revealed R12 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of R12's Annual MDS with an ARD of 02/21/25 located in the EMR under the MDS tab indicated both short term and long-term memory problems and R12 rarely/never understood. The MDS also indicated that R12 wanders daily and that R12's wandering significantly intrudes on the privacy of activities of others. Review R52's Admission Record found in the EMR under the Profile tab revealed R52 was readmitted to the facility on [DATE] with a diagnosis of dementia. Review of R52's Quarterly MDS with an ARD of 01/09/25 located in the EMR under the MDS tab with a BIMS score of 10 out of 15, which indicated R52's cognition was moderately impaired. The MDS indicated that R52 had no behaviors. Review of R60's Annual MDS with an ARD of 12/05/24, located in the EMR under the MDS tab with a BIMS score of 15 out of 15 which indicated R60's cognition was intact. Review of R60's Statement from the person alleging abuse or reportable incident dated 02/19/25 indicated, I yelled at [R12] to get out of my room. [R52] got up and tried to make her [R12] get out of the room. [R12] held onto my bed and would not turn it loose. [R12] slapped [R52] and [R52] slapped her [R12] back. Review of the facility's Initial Report dated 02/19/25 indicated, On 02/19/25 at approximately 7:20 PM, residents [R12 and R52] had a physical altercation. Residents were immediately separated by staff and law enforcement notified . Review of R60's statement from the reportable incident dated 02/19/25, indicated, I yelled at [R12] to get out of my room. [R52] got up and tried to make her [R12] get out of the room, [R12] held onto my bed and would not turn it loose. [R12] slapped [R52] and [R52] slapped her [R12] back. Review of R52's statement from the person alleging abuse or reportable incident dated 02/19/25, indicated, [R12] was in our room. We told her [R12] to get out. She [R12] would not leave; I pushed her out of the room, and she [R12] slapped me in my face. I slapped her [R12] back in her face. Review of the facility's investigative documents revealed no evidence of interview with other residents. During an interview on 03/25/25 at 11:37 AM, R52 said R12 came into her room, went into the bathroom, came out and sat down, so R52 opened the bedroom door and told R12 to get out. R52 said that R12 pushed her, so she pushed R12 back. R52 said that the unknown nurse came into the room and removed her from the room and told her not to come back. During an interview on 03/26/25 at 2:15 PM, R12 was alert, but confused and unable to recall the incident. During an interview on 03/26/25 at 5:23 PM, the Administrator confirmed that there were no further residents' interviews. The Administrator stated that this was an isolated incident and that was the reason why only R52 and R60 was interviewed. The Administrator confirmed that R12 has a low BIMS score and was unable to be interviewed. He confirmed that a statement was not written regarding this information about R12.

Based on review of the facility policy, observation and interviews, the facility failed to ensure medical records containing personal health information (PHI) were not accessible to 16 of 16 residents.This failure had the potential to allow inappropriate access to residents' records. Findings include: Review of the facility policy titled HIPAA Security Measures last revised 09/30/24 revealed, it is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and /or records that are in electronic format . During an observation on 03/25/25 at 10:44 AM, the east unit nursing medication cart was in the hallway and the cart was locked but the computer screen was on and revealed six resident names. Four residents and three staff walked past the medication cart and computer screen before Licensed Practical Nurse (LPN)7 returned to the cart. During an interview on 03/25/25 at 10:47AM, LPN7 stated the computer screen was locked. She said she leaves the screen open with the residents' names but there was no medical information on the screen. When asked to click on one of the residents' names, she saw that PHI immediately display on the computer screen. She said she did not know how to lock the screen and would have to close the computer to lock it. During an interview 03/27/25 at 9:52 AM, the Director of Nursing (DON) stated nursing staff were supposed to keep computer records out of sight and that all computer screens should have been locked when nurses were not at the medication cart. She said all medical documentation containing PHI should be kept out of view and secured.

Based on interview and record review, the facility failed to ensure a resident's representative (RP) was informed of the risks and benefits associated with the resident taking psychotropic medications for one of three residents (R) Resident 72) reviewed for unnecessary medication use out of a total sample of 28. This failure had the potential to affect residents receiving psychotropic medications. Findings include: Review of R72's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis which included strange and inexplicable behavior. Review of R72's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/25 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. Review of R72's Certification of Inability to Make Healthcare Decisions located in the electronic medical record (EMR) under the Misc tab and dated 07/27/23 revealed two physicians certified the resident was unable to make healthcare decisions for himself. Review of R72's Informed Consent for psychoactive medication Use located in the electronic medical record (EMR) under the Misc tab and dated 03/20/25 revealed the resident signed the document that indicated the risk and benefits of receiving a psychotropic medication. Further review revealed the nurse completing the form was the Director of Nursing (DON). During an interview 03/27/25 at 9:52 AM the Director of Nursing (DON) said she was unaware that R72 had been deemed incapably of making health care decisions. She agreed the RP should have signed the form and not R72. She said she only looked at the resident's BIMS score. She said she spoke with R72 about the medication. He said okay, so she assumed he understood. But she agreed that if a physician had deemed him incapable it was inappropriate to discuss the risk and benefits of the medications with him and have him sign the document.

40902 Based on review of facility policy, record review, document review and interviews, the facility failed to protect the residents from physical and verbal abuse by another resident or staff for four of five residents (Resident (R)72, R71, R12, and R52) reviewed for abuse. This had the potential to affect residents in the facility who were at risk for abuse. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation revised 10/24/22 revealed, it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . 1. Review of R54's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which include but are not limited to: autistic disorder, anxiety disorder, mental disorder, and mood disorder. Review of R54's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/25 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated the resident was severely cognitively impaired. Review of R54's Care Plan, dated 12/05/24 and located in the EMR under the Care Plan tab revealed, Disruptive and anxious behaviors, yelling and slamming doors, restlessness, agitation and non-compliance. Interventions put in place were when resident becomes agitated intervene before agitation escalates. Review of R72's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which include but are not limited to: strange and inexplicable behavior. Review of R72's quarterly MDS with an ARD of 02/03/25 and located in the resident's EMR under the MDS tab, revealed a BIMS score of 13 out of 15, which indicated the resident was cognitively intact. Review of R72's Nurse's Note dated 02/11/25 at 3:04 PM and located in the EMR under the Notes tab written by Licensed Practical Nurse (LPN) 2 revealed, This nurse had a conversation with resident about reportable incident from the night before to get his side of the story, this resident told me that he was sitting in the lobby in his usual chair looking at the TV. He stated the accused aggressor started talking loudly and yelling, when this resident asked aggressor what was wrong, aggressor walked up to him and hit me on my right cheek. This resident stated he only hit him 1 time and then walked away. This resident denies hitting aggressor back. Review of the Facility's Five Day Follow Up dated 02/14/25 revealed the date and time of the incident was 02/10/25 at 11:00 PM. Further, the summary indicated the residents did have a physical alteration. During an interview on 03/26/25 at 1:15 PM, R72 stated, on the night of 02/10/25 he was sitting on one couch and R54 was sitting on the other couch across from him. He stated R54 got up and walked over to him and hit him on the side of his face with an open hand. During an interview on 03/26/25 at 1:40 PM, LPN2 stated she spoke with R72 on 02/11/25 who reported on the night of 02/10/25 he was just watching TV when R54 said something to him, but he did not say anything. Then R54 hit him in the face once and walked away. He said staff were notified who separated them. During an interview on 03/26/25 at 3:09 PM, Certified Nurse Aide (CNA)2 stated, on the night of 02/10/25 she was coming down the hall when she saw R54 hit R72. She said they were each sitting on a couch in the TV area when R54 got up and walked over towards R72 and hit him on the side of his face. She said they were arguing about something and that R72 did not do anything. During an interview on 03/26/25 at 4:24 PM, the Facility Administrator (FA) stated they found that the incident did occur and that it was substantiated. 2. Review of R71's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses that include but are not limited to: bipolar disorder, human immunodeficiency virus, and attention deficit. Review of R71's annual MDS with an ARD of 03/18/25, indicated a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. Review of a Facility Related Incident Report (FRI), indicated that R71 was verbally abused by CNA9. Review of the facility investigation revealed that on 02/12/25 at 4:54 AM, CNA9 was charging her cell phone in the day room of the west unit. R71 was up and had gone to his friend's room to get his cell phone charger. R71 was returning to his room when CNA9 accused him of stealing her phone. Review of the facility statement from CNA9 revealed, I was charging my phone on a table in the day room. I saw R71 coming out of another residents room. I looked on the table and my phone was gone. It had to be R71. He was the only one up. I told him that I was not leaving without my phone. He stole it and ditched it in another resident's room. I did not curse at him. During an interview on 03/26/25 at 2:14 PM R71 stated, CNA9 said that I took her phone. I did not take her phone. I went to another room to get a phone charger. CNA9 was outside of another room when she saw me and asked what I was doing. I went back to my room. She then accused me of taking her phone. She is not her anymore. CNA9 said she was calling the police. I told her that I was calling the police. She said she was going to beat my mother f*** a**if I didn't return her phone. During an interview on 03/26/25 at 5:45 PM CNA10 stated, I witnessed CNA9 telling another staff that R71 took her phone. CNA9 stated that he took her [foul word] phone, and he better give it back. She did state that she would beat his a**. R71 was sitting in the corner of the day room and could hear her. During an interview on 03/27/25 at 6:58 PM, the FA stated, [R71] did let staff look for the phone in his room and it was not found. CNA9 was immediately suspended pending investigation and quit. She never returned to the facility. We try to prevent abuse of any kind and protect our residents. 3. Review R12's Admission Record found in the EMR under the Profile tab, revealed R12 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of R12's annual MDS with an ARD of 02/21/25 located in the EMR under the MDS tab indicated short term and long-term memory problems. R12 was rarely/never understood. The MDS indicated that R12 wanders daily and that R12's wandering significantly intrudes on the privacy of activities of others. Review of a Skin Note found in the EMR under the Notes tab dated 02/20/25 revealed, .R12 noted to have red areas around after incident with other resident, no other visible injuries noted. Review R52's Admission Record found in the EMR under the Profile tab revealed R52 was readmitted to the facility on [DATE] with a diagnosis of dementia. Review of R52's quarterly MDS with an ARD of 01/09/25 located in the EMR under the MDS tab with a BIMS score of 10 out of 15, which indicated R52's cognition was moderately impaired. The MDS indicated that R52 had no behaviors. Review of R60's annual MDS with an ARD of 12/05/24, located in the EMR under the MDS tab with a BIMS score of 15 out of 15 which indicated R60's cognition was intact. Review of R60's Statement from the person alleging abuse or reportable incident dated 02/19/25 indicated, I yelled at [R12] to get out of my room. [R52] got up and tried to make her [R12] get out of the room. [R12] held onto my bed and would not turn it loose. [R12] slapped [R52] and [R52] slapped her [R12] back. Review of the Initial Report dated 02/19/25 indicated, On 02/19/25 at approximately 7:20 PM, residents [R12 and R52] had a physical altercation. Residents were immediately separated by staff Further review revealed, a statement from R52 saying, [R12] was in our room. We told her to get out. She would not leave; I pushed her out of the room, and she slapped me in my face. I slapped her back on her face. Review of LPN1's Witness Statement, dated 02/19/25, stated, I heard the two residents arguing. I went to the room and [R12] was standing in [R52's] doorway .I did not see the altercation but heard [R52] yelling. During an interview on 03/25/25 at 11:37 AM, R52 said R12 came into her room, went into the bathroom, came out and sat down, so R52 opened the bedroom door and told R12 to get out. R52 said that R12 pushed her, so she pushed R12 back. R52 said that an unknown nurse came into the room and removed R12 from the room and told R12 not to come back. During an interview on 03/26/25 at 2:15 PM, R12 was alert, but confused and unable to recall the incident. During an interview on 03/26/25 at 2:50 PM, LPN2 said R12 had wandered into R52's room, touching things, and R52 was yelling at R12. Staff immediately went into R52's room and removed R12. During an interview on 03/25/25 at 4:00 PM, LPN1 said R12 was at the doorway of R52's room. LPN1 said the residents were separated and indicated R12 wanders throughout the facility. LPN1 confirmed there were no further incidents. During an interview on 03/26/25 at 5:23 PM, the FA stated, The FA stated both residents should have immediately had a skin assessment after the incident; however, FA confirmed that R12's skin assessment was not completed until 02/20/25. The FA confirmed that this incident was resident to resident abuse. During an interview on 03/26/25 at 6:16 PM, LPN4 said she was giving report to the oncoming shift and had to go down to R52's room because R12 wandered inside. Once there in the room, R52 and R12 were separated. R52 and R60 said that R12 hit first, who had redness to one side of the neck and there was no redness to R52. LPN4 said that there have been no further incidents between these residents. 43050

Based on Resident #76 Nutrition 02/07/24 01:56 PM admitted [DATE] DOB Full Code NKDA DX: Vitamin B 12 deficiency, Dysphagia, Schizophrenia, Bacterial pneumonia, Seizures, Acute Kidney failure, Acute respiratory failure, GERD, Constipation, DM type 2, Hyperlipidemia, Dementia, TIA, Pain, Adult failure to thrive, Encephalopathy, HTN, Bipolar disorder, Dysphagia Depression, Vascular dementia, Gastrostomy, Aphasia, Cough, Covid 19, Fever, Nasal congestion, Overactive bladder, UTI, Hypokalemia, Abnormal posture. Medications: Aspirin 81mg via tube qd Potassium Cl ER 10meq 2 caps via tube qd Linzess 145 mcg 1 cap per tube qd Atorvastatin 80mg via tube qd Docusate sodium 50mg/5mls give 20 mls via tube qd Metoprolol Tartrate 50mg 1 via tube bid Levetiracetam 100mg/ml give 5 mls via tube qd Furosemide 40mg via tube bid Polythylene glycol 3350 powder via tube bid Gentle laxative 10mg 1 per rectum qd Hydralazine 50mg 1 via tube tid Diltiazem 30mg 1 via tube tid Gatorade Zero via peg tube bid Diabetisource at 45cc hr per feeding pump wit 30cc's of H20 qhour. Weights: 7/3/23 175 lbs. 7/18/23 183 lbs. 8/7/23 178 lbs. 9/1/23 177 lbs. 10/5/23 178 lbs. 11/6/22 172 lbs. 12/6/23 168 lbs 1/6/24 164 lbs. 2/6/24 158 lbs. These are in the computer These were provided by [NAME] the DON: Care plan related to nutrition: Resident has a g-tube due to Dysphagia related to Dementia, resident has the potential for alterations in nutrition and hydration related to DX of Dementia, GERD, medication use, failure to thrive, encephalopathy, vitamin B 12 deficiency DM. Goal: Resident will receive adequate nutrition and hydration by way of tube feeding as evidenced by: No signs and symptoms of dehydration and will have no complications through next 90 days. Interventions: Weigh Monthly. Keep HOB elevated as tolerated to a least 30 degrees. Refer to CDM/RD for evaluation of current nutritional status as needed. Check placement of tube before meds, feedings and as ordered. Check for residual and placement as ordered. Observe for tolerance of feeding such as N/V, congestion, coughing, wheezing, diarrhea, constipation, coughing, abdominal distention and or fever and notify the physician as needed. Observe for signs and symptoms of dehydration, change in metal status, n/v, dry, pale mucous membranes, poor skin turgor, decreased output, concentration urine and or increased BUN. Notify physician as needed. Labs as ordered and notify MD of results. During medication administration flush tube with 30cc of H20 before and after meds. 5ccs between each medication. Monitor G tube daily for condition and patency. Provide mouth care every shift and prn. Change gtube PRN for occlusion or resident removal. May crush meds and or open capsules and give meds individually via G tube. Record tube feeding intake. Omeprazole as ordered. Resident may use pillowcase on tube feeding pole related to dignity. Diabetasource as ordered. Gatorade Zero as ordered per Dr. [NAME]. 2/7/2024 3:15 PM Interview with [NAME] RD - she stated that she is not the RD for this facility, that she comes and helps out while DHEC is in the facility. She stated that the Dietician that is responsible for this facility is in another community. She stated that this resident was in the hospital and when she returned the TF was decreased. And she went out to look at the residents. 2/7/2024 4:05 PM [NAME] RD - she stated that when the resident returned from the hospital in October, the facility RD, who is not here at this time, made a recommendation to increase the tube feeding from 20, and (It is now 45 cc/hr) and the recommendation was never acted upon. So this resident lost over 20 lbs. She stated that the weight loss was accurate. Review of the 1:1 activities attendance sheets for December, January and to date in February - No concerns Review of the activities provided in room are music, watching moves, and conversations. Interview with [NAME] activity worker. Care Plan: Resident has the potential for decreased socialization related to amount of assistance needed with all ADLs. Goal: Resident will participate in at least 1 activity weekly Resident will participate in at least 1 activity weekly through next 90 days. Interventions: Provide activities based on resident preferences. Place activity calendar in room. Encourage phone calls, video chats or alternate methods of communication with my family and friends. Staff to provide support and encouragement through 1:1 visits Ensure resident is wearing face mask and practicing social distancing per guidelines if outside of room. Provide in room activities that I may enjoy. No concerns with activities and attendance. 2/9/2024 10:02AM Inter view with [NAME] RN MDS, concerning the interventions on weight loss, and she stated that the weight loss was not significant, and the tube feeding was increased on 2/7/2024, (when I brought it to their attention) I stated that each day this week that the tube feeding was infusing at 45 cc/hr. 2/9/2024 10:13 AM Attempted to call Dr. [NAME], concerning the weight loss. Left a message at [PHONE NUMBER]. 02/07/24 09:06 AM 183 lbs on 07/18/23 178 lbs 08/07/2023 158 lbs on 02/06/2024

Based on Resident #76 Nutrition 02/07/24 01:56 PM admitted [DATE] DOB Full Code NKDA DX: Vitamin B 12 deficiency, Dysphagia, Schizophrenia, Bacterial pneumonia, Seizures, Acute Kidney failure, Acute respiratory failure, GERD, Constipation, DM type 2, Hyperlipidemia, Dementia, TIA, Pain, Adult failure to thrive, Encephalopathy, HTN, Bipolar disorder, Dysphagia Depression, Vascular dementia, Gastrostomy, Aphasia, Cough, Covid 19, Fever, Nasal congestion, Overactive bladder, UTI, Hypokalemia, Abnormal posture. Medications: Aspirin 81mg via tube qd Potassium Cl ER 10meq 2 caps via tube qd Linzess 145 mcg 1 cap per tube qd Atorvastatin 80mg via tube qd Docusate sodium 50mg/5mls give 20 mls via tube qd Metoprolol Tartrate 50mg 1 via tube bid Levetiracetam 100mg/ml give 5 mls via tube qd Furosemide 40mg via tube bid Polythylene glycol 3350 powder via tube bid Gentle laxative 10mg 1 per rectum qd Hydralazine 50mg 1 via tube tid Diltiazem 30mg 1 via tube tid Gatorade Zero via peg tube bid Diabetisource at 45cc hr per feeding pump wit 30cc's of H20 qhour. Weights: 7/3/23 175 lbs. 7/18/23 183 lbs. 8/7/23 178 lbs. 9/1/23 177 lbs. 10/5/23 178 lbs. 11/6/22 172 lbs. 12/6/23 168 lbs 1/6/24 164 lbs. 2/6/24 158 lbs. These are in the computer These were provided by [NAME] the DON: Care plan related to nutrition: Resident has a g-tube due to Dysphagia related to Dementia, resident has the potential for alterations in nutrition and hydration related to DX of Dementia, GERD, medication use, failure to thrive, encephalopathy, vitamin B 12 deficiency DM. Goal: Resident will receive adequate nutrition and hydration by way of tube feeding as evidenced by: No signs and symptoms of dehydration and will have no complications through next 90 days. Interventions: Weigh Monthly. Keep HOB elevated as tolerated to a least 30 degrees. Refer to CDM/RD for evaluation of current nutritional status as needed. Check placement of tube before meds, feedings and as ordered. Check for residual and placement as ordered. Observe for tolerance of feeding such as N/V, congestion, coughing, wheezing, diarrhea, constipation, coughing, abdominal distention and or fever and notify the physician as needed. Observe for signs and symptoms of dehydration, change in metal status, n/v, dry, pale mucous membranes, poor skin turgor, decreased output, concentration urine and or increased BUN. Notify physician as needed. Labs as ordered and notify MD of results. During medication administration flush tube with 30cc of H20 before and after meds. 5ccs between each medication. Monitor G tube daily for condition and patency. Provide mouth care every shift and prn. Change gtube PRN for occlusion or resident removal. May crush meds and or open capsules and give meds individually via G tube. Record tube feeding intake. Omeprazole as ordered. Resident may use pillowcase on tube feeding pole related to dignity. Diabetasource as ordered. Gatorade Zero as ordered per Dr. [NAME]. 2/7/2024 3:15 PM Interview with [NAME] RD - she stated that she is not the RD for this facility, that she comes and helps out while DHEC is in the facility. She stated that the Dietician that is responsible for this facility is in another community. She stated that this resident was in the hospital and when she returned the TF was decreased. And she went out to look at the residents. 2/7/2024 4:05 PM [NAME] RD - she stated that when the resident returned from the hospital in October, the facility RD, who is not here at this time, made a recommendation to increase the tube feeding from 20, and (It is now 45 cc/hr) and the recommendation was never acted upon. So this resident lost over 20 lbs. She stated that the weight loss was accurate. Review of the 1:1 activities attendance sheets for December, January and to date in February - No concerns Review of the activities provided in room are music, watching moves, and conversations. Interview with [NAME] activity worker. Care Plan: Resident has the potential for decreased socialization related to amount of assistance needed with all ADLs. Goal: Resident will participate in at least 1 activity weekly Resident will participate in at least 1 activity weekly through next 90 days. Interventions: Provide activities based on resident preferences. Place activity calendar in room. Encourage phone calls, video chats or alternate methods of communication with my family and friends. Staff to provide support and encouragement through 1:1 visits Ensure resident is wearing face mask and practicing social distancing per guidelines if outside of room. Provide in room activities that I may enjoy. No concerns with activities and attendance. 2/9/2024 10:02AM Inter view with [NAME] RN MDS, concerning the interventions on weight loss, and she stated that the weight loss was not significant, and the tube feeding was increased on 2/7/2024, (when I brought it to their attention) I stated that each day this week that the tube feeding was infusing at 45 cc/hr. 2/9/2024 10:13 AM Attempted to call Dr. [NAME], concerning the weight loss. Left a message at [PHONE NUMBER]. 02/07/24 09:06 AM 183 lbs on 07/18/23 178 lbs 08/07/2023 158 lbs on 02/06/2024

Based on observations, interviews, and facility policy review, the facility failed to employ a qualified Certified Dietary Manager (CDM). Findings include: Review of CMS Manual System Publication ,d+[DATE] State Operations Provider Certification from the Department of Health and Human Services (DHHS) Centers for Medicare and Medicaid Services (CMS) dated [DATE], revealed, If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services. The director of food and nutrition services must at a minimum meet the following qualifications, has an associate's degree or higher in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or has two (2) or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than [DATE], that includes topics integral to managing dietary operations including, but not limited to , foodborne illness, sanitation procedures, and food purchasing/receiving. Review of the facility's CDM credentials revealed an expiration date of [DATE] and serv-safe expiration date of [DATE]. On [DATE] at 10:44 AM, the former CDM stated they were aware their credentials were expired and had completed the course to obtain new credentials. However, they had not taken/passed the exam yet. On [DATE] at 1:01 PM, the Regional Dietary Manager (RDM) stated the facility did not have a Certified Dietary Manager. The former CDM had not successfully passed the course/test to renew their CDM credentials, which had expired [DATE]. On [DATE] at 11:54 AM, the Administrator stated they were aware the facility did not have a CDM. The former CDM whose credentials had expired, was scheduled to take the exam after survey, although an exact date was not known.

Based on observations and interviews, the facility failed to properly label, store and discard expired foods. Findings include: On [DATE] at 10:11 AM, an initial kitchen walkthrough with Cook #1 revealed the following: 1 (one) bag of uncooked rice, opened, undated, and unlabeled 1 (one) bag of flour, opened, undated, and unlabeled 1 (one) bag of fruit loop cereal, opened, undated, and unlabeled 1 (one) bag of cornflakes cereal, opened, undated, and unlabeled 1 (one) bag of cooked rice, opened, undated, and unlabeled 1 (one) cup of grapes, undated and unlabeled 1 (one) opened bag of whipped topping, expired on [DATE] 1 (one) plastic tray of turkey bacon, opened and uncovered, undated and unlabeled 1 (one) jar of chicken base, opened, undated and unlabeled 1 (one) jar of beef base, opened, undated and unlabeled 1 (one) jar of cherry halves, expired on [DATE] 1 (one) cup of hard-boiled eggs, undated and unlabeled 1 (one) bag of deli ham, opened, undated and unlabeled 1 (one) bowl of gravy, expired on [DATE] 1 (one) prepackaged frozen cooked meat lasagna, expired [DATE] 1 (one) container of potato salad, expired [DATE] 1 (one) block of velveeta cheese, opened, undated and unlabeled 1 (one) Styrofoam to go plate with a garden salad, undated and unlabeled During an interview on [DATE] at 10:22 AM, the former Certified Dietary Manager (CDM) stated the food truck delivery comes every Monday and Thursday. When the inventory is received, the items are labeled with the date. Staff are to label food items opened, pulled for use, or thawed, with the date and time. Leftover food that would be used again, is to be labeled with what the items were, the date, time and use by date. The former CDM stated that staff were aware of how to properly label and store food items because there was a chart posted in both the dry storage and refrigeration area of the kitchen.

Based on Resident #10 Dignity Review of resident #10's Face Sheet indicated the facility admitted the resident on 07/23/2023, with a diagnosis of but not limited to, contracture, right hand, contracture, left hand, functional quadriplegia, muscle weakness (generalized), limitation of activities due to disability, Acute kidney failure with tubular necrosis, Unspecified severe protein-calorie malnutrition, (RTP) Age-related physical debility, Epilepsy, unspecified, not intractable, without status epilepticus, Vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dysuria, history of falling, Hydronephrosis with ureteral stricture, not elsewhere classified, and depression, unspecified, depression. Review of Resident #10's Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #10 was dependent on staff for toileting, showering/bathing, upper and lower body dressing but independent rolling left and right. Resident #10 was always incontinent of bowel. Review of resident #10's care plan dated 01/05/2024 revealed, resident had difficulty making decisions related to diagnosis of Dementia. Resident #10's goal would be to participate in decision making regarding food, clothing and activities #10's interventions included providing opportunities for resident to make simple choices with Activities of Daily Living (ADL), Praise resident when any decision was made. Review of Physician's Orders revealed, Alprazolam 0.5 MG tablet: 1/2 tablet by mouth daily, Senna Plus 8.6 MG tablet 2 tablets by mouth daily, Lacosamide 200 MG tablets, 1 tablet by mouth twice a day, Buspirone HCL 10 MG tablets , 1 tablet by mouth three times a day, Hydrocodone-Acetamin 5-325 MG tablets, 1 tablet by mouth every four hours as needed for pain, Escitalopram 10 MG tablet, 1 tablet by mouth daily, Mirtazapine 15 MG tablet, 1 tablet by mouth daily Progress Notes: 02/01/2024 at 01:26 AM Weekly Body Audit and Nurses Note: Resting in bed with eyes closed at this time. Alert and verbally responsive. Resp even and unlabored. Skin w/d No behavior issues this shift. Requires assistance x 1 staff member for bathing, dressing and bed mobility. Feeds self meals. Takes meds whole with thin liquids. Incontinent of b&b with incontinent care provided routinely and as needed. ABT administered for old J/P drain site on rt flank. Yellow to lt green drainage noted from site. Dressing changed this shift due to wet dressing. No adverse reactions noted to ABT. Dressing to site dry and intact at this time. Body audit complete. No new areas of concern noted. Receives PRN pain medication as needed. No distress noted. VS: BP 131/81 P93 R 19 T 97.7 O2 SATS 94% 01/31/2024 09:00 PM Resident continues on ABT for right flank abscess,old J/P drain site. No adverse reaction noted. No heat, redness or swelling noted with a small amt of thick, yellow drainage. Resident c/o pain eariler. Received pain med with relief. Incont of B&B, incont care provided. No distress noted. Role: NUR, Category: Nurses Notes Signed by: [NAME], LPN On 02/06/2024 at 11:15 AM observed resident lying in bed, alert and oriented, completing a crossword puzzle. The room is well lit neat and clean with no odors. The ceiling water damage over the bed A. The resident stated that she has a problem with Certified Nursing Assistant (CNA) [NAME]. The CNA [NAME] talks down to resident, is very rude and speaks in a condescending tone. Resident stated CNA has an attitude, and mean to me every time they have to care for me. CNA always tells resident I'm in charge you will do what I say. CNA treats resident like a child. Resident stated I have told Registered Nurse [NAME] about the CNA again this morning and . Resident has addressed concerns about CNA and feels as if the CNA's attitude toward her is because of it. On 02/06/2024 at 3:54 PM, the Administrator stated that they were unaware of the manner in which CNA [NAME] had been speaking to resident #10. It had been brought to their attention, however more in a poor customer service way. The CNA was questioned and re-trained on customer service. The Administrator stated that the CNA would be interviewed again and the matter would be investigated. On 02/07/2024 at 12:55 PM, left message for Licensed Practical Nurse (LPN) [NAME] to return my call regarding the verbal abuse allegation between CNA [NAME] and resident #10 On 02/07/2024 at 1:09 PM, the Administrator stated that they had spoken with CNA [NAME] regarding the verbal abuse of resident #10 at that time CNA [NAME] was suspended on 02/06/2024 until the facility's investigation is complete. Administrator had not spoken to resident #10. The Social Worker Carylon interviewed the resident. On 02/07/2024 at 2:56 PM, the Social Worker (SW) stated they spoke with resident #10 regarding the alleged verbal abuse with R #10 and CNA [NAME]. SW stated that R#10 stated that CNA [NAME] addressing them in a condescending tone. CNA [NAME] has told R#10 I do it my way and I am in control of this. I feel like CNA is aggressive in the way I am handled by them. SW stated that after they had explained the protocols and procedures the staff had to follow R# 10 appeared to settle down about the matter. To my knowledge the CNA had not had any issues with any other residents or with staff and R#10 had not as well. On 02/07/2024 at 3:45 PM, left message for Certified Nursing Assistant [NAME] to return my call in reference to the verbal abuse allegation between the CNA and resident #10 On 02/08/2024 at 8:44 AM, Resident #10 stated that the Social Worker had spoken with her about the incident on 02/06/2024, but the resident feels that the CNA would continue with that behavior because the resident had asked the CNA to not speak or treat them in that way before. The SW explained to the resident the procedures/protocol for patient care informing them of how CNA's were trained . Resident #10 stated that they explained to the SW that they were also aware of those procedures but that did not justify her rude, condensing, and aggressive behavior told them. Resident #10 stated they had not seen the CNA since they reported the incident and that they preferred it if that CNA no longer provided their care. On 02/08/24 at 9:11 AM, left message for Certified Nursing Assistant [NAME] to return my call in reference to the verbal abuse allegation between the CNA and resident #10. This is second attempt. On 02/08/24 at 09:12 AM , left message for Licensed Practical Nurse (LPN) [NAME] to return my call regarding the verbal abuse allegation between CNA [NAME] and resident #10. This is second attempt. On 02/08/2024 at 01:00 PM, during a telephone interview with Licensed Practical Nurse (LPN) [NAME], LPN stated that Resident #10 had spoken with them about the incident but R#10 r had not said that CNA said anything rude, or spoken in a nasty way. LPN stated that Resident #10 had complained about the way CNA had provided patient care (changing adult diaper) stated that the CNA was aggressive. LPN stated she informed R#10 that staff have procedures that they must follow and they are trained the right way to perform patient care. Resident #10 stated to LPN, CNA is the only one that does it like that. LPN stated that at times R#10 could be hard to deal with because of attention seeking. LPN stated they had not seen or heard CNA being rude, or aggressive with any other residents. Review of Certified Nursing Assistant (CNA) [NAME]'s personnel file revealed, in-service training on abuse was completed January 2023, August 2023 and January 2024. There were no disciplinary write ups noted.

Based on Resident #10 Abuse Review of resident #10's Face Sheet indicated the facility admitted the resident on 07/23/2023, with a diagnosis of but not limited to, contracture, right hand, contracture, left hand, functional quadriplegia, muscle weakness (generalized), limitation of activities due to disability, Acute kidney failure with tubular necrosis, Unspecified severe protein-calorie malnutrition, (RTP) Age-related physical debility, Epilepsy, unspecified, not intractable, without status epilepticus, Vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dysuria, history of falling, Hydronephrosis with ureteral stricture, not elsewhere classified, and depression, unspecified. Review of Resident #10's Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #10 was dependent on staff for toileting, showering/bathing, upper and lower body dressing but independent rolling left and right. Resident #10 was always incontinent of bowel. Review of resident #10's care plan dated 01/05/2024 revealed, resident had difficulty making decisions related to diagnosis of Dementia. Resident #10's goal would be to participate in decision making regarding food, clothing and activities #10's interventions included providing opportunities for resident to make simple choices with Activities of Daily Living (ADL), Praise resident when any decision was made, Review of Physician's Orders revealed, Alprazolam 0.5 MG tablet: 1/2 tablet by mouth daily, Senna Plus 8.6 MG tablet 2 tablets by mouth daily, Lacosamide 200 MG tablets, 1 tablet by mouth twice a day, Buspirone HCL 10 MG tablets , 1 tablet by mouth three times a day, Hydrocodone-Acetamin 5-325 MG tablets, 1 tablet by mouth every four hours as needed for pain Progress Notes: Nurse Note: 01/15/2024 at 5:41 PM, Resident alert and verbal. Assisted with Activities of Daily Living (ADLs). Incontinent care provided as needed. Able to voice needs. Resident had refused all three meals on today. Stating that her stomach just don't feel right. Resident drank 100 percent of Boost Supplement. 02/01/2024 at 01:26 AM Weekly Body Audit and Nurses Note: Resting in bed with eyes closed at this time. Alert and verbally responsive. Resp even and unlabored. Skin w/d No behavior issus this shift. Requires assistance x 1 staff member for bathing, dressing and bed mobility. Feeds self meals. Takes meds whole with thin liquids. Incontinent of b&b with incontinent care provided routinely and as needed. ABT administered for old J/P drain site on rt flank. Yellow to lt green drainage noted from site. Dressing changed this shift due to wet dressing. No adverse reactions noted to ABT. Dressing to site dry and intact at this time. Body audit complete. No new areas of concern noted. Receives PRN pain medication as needed. No distress noted. VS: BP 131/81 P93 R 19 T 97.7 O2 SATS 94% On 02/06/2024 at 11:15 AM observed resident lying in bed, alert and oriented, completing a crossword puzzle. The room is well lit neat and clean with no odors. The ceiling water damage over the bed A. The resident stated that she has a problem with Certified Nursing Assistant (CNA) [NAME]. The CNA [NAME] talks down to resident, is very rude and speaks in a condescending tone. Resident stated CNA has an attitude, and mean to me every time they have to care for me. CNA always tells resident I'm in charge you will do what I say. CNA treats resident like a child. Resident stated I have told Registered Nurse [NAME] about the CNA again this morning and . Resident has addressed concerns about CNA and feels as if the CNA's attitude toward her is because of it. On 02/06/2024 at 3:54 PM, the Administrator stated that they were unaware of the manner in which CNA [NAME] had been speaking to resident #10. It had been brought to their attention, however more in a poor customer service way. The CNA was questioned and re-trained on customer service. The Administrator stated that the CNA would be interviewed again and the matter would be investigated. On 02/07/2024 at 12:55 PM, left message for Licensed Practical Nurse (LPN) [NAME] to return my call regarding the verbal abuse allegation between CNA [NAME] and resident #10 On 02/07/2024 at 1:09 PM, the Administrator stated that they had spoken with CNA [NAME] regarding the verbal abuse of resident #10 at that time CNA [NAME] was suspended on 02/06/2024 until the facility's investigation is complete. Administrator had not spoken to resident #10. The Social Worker Carylon interviewed the resident. On 02/07/2024 at 2:56 PM, the Social Worker (SW) stated they spoke with resident #10 regarding the alleged verbal abuse with R #10 and CNA [NAME]. SW stated that R#10 stated that CNA [NAME] addressing them in a condescending tone. CNA [NAME] has told R#10 I do it my way and I am in control of this. I feel like CNA is aggressive in the way I am handled by them. SW stated that after they had explained the protocols and procedures the staff had to follow R# 10 appeared to settle down about the matter. To my knowledge the CNA had not had any issues with any other residents or with staff and R#10 had not as well. On 02/07/2024 at 3:45 PM, left message for Certified Nursing Assistant [NAME] to return my call in reference to the verbal abuse allegation between the CNA and resident #10 On 02/08/2024 at 8:44 AM, Resident #10 stated that the Social Worker (Carylon [NAME]) had spoken with her about the incident on 02/06/2024, but the resident feels that the CNA would continue with that behavior because the resident had asked the CNA to not speak or treat them in that way before. The SW explained to the resident the procedures/protocol for patient care informing them of how CNA's were trained . Resident #10 stated that they explained to the SW that they were also aware of those procedures but that did not justify her rude, condensing, and aggressive behavior told them. Resident #10 stated they had not seen the CNA since they reported the incident and that they preferred it if that CNA no longer provided their care. On 02/08/24 at 9:11 AM, left message for Certified Nursing Assistant [NAME] to return my call in reference to the verbal abuse allegation between the CNA and resident #10. This was second attempt. On 02/08/24 at 09:12 AM , left message for Licensed Practical Nurse (LPN) [NAME] to return my call regarding the verbal abuse allegation between CNA [NAME] and resident #10. This was second attempt. On 02/08/2024 at 01:00 PM, during a telephone interview with Licensed Practical Nurse (LPN) [NAME], LPN stated that Resident #10 had spoken with them about the incident but R#10 r had not said that CNA said anything rude, or spoken in a nasty way. LPN stated that Resident #10 had complained about the way CNA had provided patient care (changing adult diaper) stated that the CNA was aggressive. LPN stated she informed R#10 that staff have procedures that they must follow and they are trained the right way to perform patient care. Resident #10 stated to LPN, CNA is the only one that does it like that. LPN stated that at times R#10 could be hard to deal with because of attention seeking. LPN stated they had not seen or heard CNA being rude, or aggressive with any other residents. On 02/09/2024 at 9:16 AM, left message for Certified Nursing Assistant [NAME] to return my call in reference to the verbal abuse allegation between the CNA and resident #10, this was third attempt. Review of Certified Nursing Assistant (CNA) [NAME]'s personnel file revealed, in-service training on abuse was completed January 2023, August 2023 and January 2024. There were no disciplinary write ups noted. Neglect Nurse Note: 11/12/2023 at 2:37 PM, Resident had continuously been on call light and calling out numerous things this shift. Explained that she did not have to do both, using the call light and calling out at the same time. We would answer the call light. Resident stated understanding. Signed by: [NAME], LPN Nurse Note: 11/12/2023 at 6:43 PM, Resident has continually been on call light and calling out for numerous things this shift. Told resident that she did have to yell for staff because her light would be answered. Resident stated that she would not yell for staff again. Signed by [NAME], LPN Nurse Note: 11/18/2023 at 2:12 PM, Resident pushing call light and yelling for help. Went to room and resident stated that she needed her bed changed because something had spilt on it. Explained that I was only one on the floor at this time due to the CNA's being in a short meeting with the supervisor and that I had be available due t being the only one and also answering the door. Told resident that I would send her CNA as soon as the meeting was over. Resident continued to yell out. Signed by: [NAME], LPN Nurse Note: 11/18/2023 at 2:17 PM, CNA out of meeting and sent to residents room. Signed by [NAME], LPN Nurse Note: 01/06/2024 at 1:13 PM, Resident constantly on the call light and yelling for staff members. Talked with resident that when she use the call light that a staff member would get to her as soon as they could and that she did not have to start yelling out. Resident stated that she would use the call light only. Signed by: [NAME], LPN On 02/06/2024 at 11:15 AM observed resident lying in bed, alert and oriented, completing a crossword puzzle. The room is well lit neat and clean with no odors. The ceiling has water damage over bed A. Resident #10 stated that staff are neglectful. It takes staff a long time to answer the call lights if they do at all. The staff will come to the room, turn the call light off, ask what resident needs, leave and not come back. On 02/07/2024 at 9:02 AM, observed resident's call light on. Resident stated that they needed to be changed but that staff never answers the call lights when breakfast was being served. Resident stated staff would wait until breakfast was over because of cross contamination or because staff was busy. Resident's call light had been on for more than 35 minutes while the surveyor interviewed the resident. Surveyor observed feces protruding from resident's adult diaper. On 02/07/2024 at 9:31 AM, CNA Cherese [NAME] stated that call lights are answered when staff sees them. If the call light goes off during meal pass ( breakfast, lunch, or dinner) staff would check to see what the resident needs. If the resident requires any kind of patient care the resident would have to wait until the meal is over and trays picked up. CNA [NAME] stated they knew what resident #10 needed and had informed the resident that they would be taken care of after breakfast. On 02/07/2024 at 9:31 AM, observed CNA [NAME] enter resident #10's room and turned off the call light. Resident told CNA [NAME] she needed to be changed because she was uncomfortable and that her call light had been on for over 35 minutes. CNA told resident they would assist her with patient care after all the breakfast trays had been picked up. On 02/07/2024, the Director of Nursing stated call lights are to be answered in a timely manner and as we can. Staff usually would not answer the call lights during meal time.

Based on review of facility policy, interviews, and record review, the facility failed to provide a notice of transfer for hospitalization and the reasons for the transfer in writing, or as soon as practicable to the Ombudsman for 1 out of 1 resident reviewed for transfer, discharge notification Resident (R) 87. Findings include: Review of facility's policy titled, Discharge and Transfer (Including AMA)-Policy effective date 11/23/16 indicated, 6(d) A copy of the notice shall be provided to a representative of the Office of the State Long Term Care Ombudsman. Review of R87's Face Sheet revealed R87 was admitted to the facility on [DATE] with diagnoses including but not limited to; diabetes; hypertension, major depressive disorder, chronic pain and tachycardia. Review of R87's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 02/09/24 revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating R87 has severe cognitive impairment. Review of R87's Transfer Discharge Notice to Resident/Resident Representative and Ombudsman dated 9/14/23 and 11/22/23 revealed discharge from facility to the hospital. During an interview on 02/09/24, Social Services stated the Ombudsman office is notified via email about transfer and discharge. She stated she didn't have the notification where Ombudsman was notified but would look in previous Social Services worker documents to see if she could find the documentation. At the time of exit, this information was not provided by Social Services.

Based on observations, resident and staff interviews, record review, facility policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to protect the 53 residents that were negative for COVID-19 out of a total census of 79 resident from the spread of COVID-19 within the facility by: 1. failing to isolate residents who tested positive for COVID-19 from their roommates that tested negative for COVID-19 on the 01/24/22 facility wide COVID-19 testing but instead cohorted in the same room the COVID-19 positive residents with the COVID-19 negative residents; 2. failing to educate all staff on the COVID-19 status of the residents for whom the staff was providing care as staff was providing care to both positive and negative residents during their work shift; and 3. failing to make hand sanitizing supplies and Personal Protective Equipment (PPE) easily accessible for staff use. On 01/26/22 at 11:00 PM, the Administrator was notified an Immediate Jeopardy (IJ) was identified at F880-K Infection Prevention and Control. The IJ began on 01/24/22 when the facility failed to isolate seven residents who tested positive for COVID-19 but instead continued to cohort the COVID-19 positive residents with roommates that tested negative. The facility provided an acceptable plan for removal of the IJ on 01/27/22 at 7:00 PM. Staff interviews, record reviews, policy and procedure reviews and review of the training and education were completed during the survey to verify the immediate corrective actions were implemented by the facility as defined in the accepted plan of removal. The survey team validated the immediacy was removed on 01/27/22. The noncompliance at F880 remained at a lower scope and severity of E (pattern of no actual harm with the potential for more than minimal harm that was not immediate jeopardy). Findings include: Review of CDC guidelines, Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 10, 2021, revealed .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection: The Infection Prevention and Control (ICP) recommendations described below also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for Transmission-Based Precautions (quarantine) based on close contact with someone with [CONDITION(S)]-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed [CONDITION(S)]-CoV-2 infection unless they are confirmed to have [CONDITION(S)]-CoV-2 infection through testing . Place a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom. Facilities could consider designating entire units within the facility, with dedicated HCP [Healthcare Professional], to care for patients with [CONDITION(S)]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shifts . HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) . Review of the facility's policy titled, Novel Coronavirus Prevention and Response, revised 11/2021, revealed 6 . f.) Educate staff on proper use of PPE and application of standard, contact, droplet and airborne precautions. g.) Promote easy and correct use of PPE by: i.) posting signs on the door or wall outside of the resident room that clearly describes the type of precautions needed and required PPE . ii.) Make PPE including face masks, eye protection, gowns and gloves available immediately outside of the resident's rooms . iii) Position a trash can near the exit of the room to make it easy to discard PPE . Review of the facility's policy titled, Hand Hygiene, date implemented 11/17/17, revealed that all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. During an interview on 01/27/22 at 2:00 PM, the Administrator and Director of Nursing (DON) provided the following information: The census at the time of the survey was 79 with all but two residents fully vaccinated. There were seven rooms identified as having a COVID negative resident cohorting with a newly identified COVID-19 positive resident. The positive tests were a result of facility wide testing of residents and staff on 01/24/22. The facility had been in outbreak status since 01/01/22. The week of 01/01/22 six staff and two residents tested positive. This constituted an outbreak status for the facility and staff and residents were being tested twice weekly regardless of vaccination status due to the outbreak and due to a high/RED county transmission rate per the Centers for Disease Control Data Tracking site for County transmission rates. An observation in Unit 1 (East Unit) outside the room of R1 and R49 on 01/25/22 at 9:15 AM revealed two signs on the door stating Droplet Precautions: Stop. Everyone must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Transmission-based precautions: Stop. Everyone must: 1. Clean hands before entering and leaving the room by using and alcohol-based hand rub or Washing with soap and water 2. Wear Personal Protective Equipment: Gloves, N95 respirator or facemask if not fitted, isolation gown, face shield or goggles These precautions are required upon ALL room entries, regardless of anticipated patient contact. Further observation of the two signs revealed no identification to indicate if one or both residents in the room were COVID positive. During the observation on 01/25/22 at 9:15 AM, Registered Nurse (RN) 1 was asked by the surveyor if the residents in that room were positive for COVID-19. RN1 stated, one of them is. RN1 indicated that R1 was COVID-19 positive and the roommate, R49, was negative for COVID-19. When asked why the two residents were housed in the same room, RN1 stated she did not know, but that since R49 had already been exposed he had not been moved from the room. No PPE was observed to be available to don (put on) prior to entering the room. When asked where the PPE was kept for entry into the room, RN1 stated that there was a PPE cart down the hallway. RN1 proceeded to a small PPE cart down the hallway that was found to be empty. RN1 then stated that there should be an isolation cart (infection control carts that stores and organizes supplies required to mitigate the risk of transmitting infection) on one of the other hallways. No PPE cart was found in the current hallway. The Assistant Director of Nursing (ADON) interjected during the interview on 01/25/22 at 9:20 AM with RN1 and stated that there was an isolation cart nearby. ADON then led the surveyor down the hallway out of Unit 1 and around the corner toward another unit. The surveyor ceased to follow ADON as no isolation cart was located on Unit 1. On 01/25/22 at 12:14 PM, CNA2 was observed entering R22's room (private room, Unit 1). CNA2 was wearing a KN95 mask and face shield, but no gown or gloves. There were two signs on R22's door stating Droplet Precautions: Stop. Everyone must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Transmission-based precautions: Stop. Everyone must: 1. Clean hands before entering and leaving the room by using and alcohol-based hand rub or Washing with soap and water 2. Wear Personal Protective Equipment: Gloves, N95 respirator or facemask if not fitted, isolation gown, face shield or goggles These precautions are required upon ALL room entries, regardless of anticipated patient contact. Continued observation on 01/25/22 at 12:14 PM revealed no PPE was available outside R22's room. When asked if this was a COVID-19 positive room, CNA2 stated she did not know. CNA2 then asked Licensed Practical Nurse (LPN)1 if R22 had COVID-19. LPN1 stated, yes. CNA 2 then proceeded to find an isolation gown. Observation of CNA1 on 01/26/22 at 5:50 PM revealed CNA1 was in R1 and R49's room. Observation of R1 and R49's room revealed two signs on the door stating Droplet Precautions: Stop. Everyone must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Transmission-based precautions: Stop. Everyone must: 1. Clean hands before entering and leaving the room by using and alcohol-based hand rub or Washing with soap and water 2. Wear Personal Protective Equipment: Gloves, N95 respirator or facemask if not fitted, isolation gown, face shield or goggles These precautions are required upon ALL room entries, regardless of anticipated patient contact. Further observations of the signage on the door revealed no indication if one or both residents in the room were COVID positive. Review of the EMR Lab Results tab revealed R1 tested positive for COVID-19 on 01/24/22. Review of the EMR Lab Results tab revealed R49 tested negative for COVID-19 on 01/24/22. Continued observation on 01/26/22 at 5:50 PM revealed CNA1 was wearing an isolation gown, a KN95 mask, and a face shield and was carrying a clipboard upon entering R1 and R49's room. The privacy curtain between the two residents was drawn. R1's bed was closest to the door. CNA1 placed the clipboard on the R1's (who was COVID positive) side table and donned a pair of gloves. CNA1 pulled out a thermometer, pulse oximeter, and wrist blood pressure cuff from his pocket and took R1's vital signs. CNA1 wrote on the clipboard on R1's bedside table. CNA1 moved onto R49, drew back the privacy curtain without changing any of his PPE, including his gloves, or sanitizing the thermometer, pulse oximeter, or wrist blood pressure cuff and took R49's (who was COVID negative) vital signs with the same instruments he had just used on R1. CNA1 returned to R1's bedside table to write on the clipboard he had placed there. CNA1 began to remove his gown and gloves, stopped halfway, and returned behind the privacy curtain to say a few words to R49. CNA1 returned to the door and finished removing the gown and gloves and placed them in a trash receptacle near the room door. CNA1 performed hand hygiene with the alcohol hand rub dispenser in the room before exiting room. In an interview on 01/26/22 at 6:31 PM, CNA1 stated that he was aware that R1 was COVID-19 positive. CNA1 further stated that he believed R49 was also COVID-19 positive, since the residents were in the same room. When asked how he knew that R49 was also COVID-19 positive, CNA1 stated, why else would they be in the same room? Observation on 01/25/22 at 10:00 AM revealed no isolation signs on the door of R225 and R31. Further observations on 01/26/22 at 6:30 PM revealed an isolation kit on the door of R225 and R31. Review of the EMR Lab Results tab revealed R225 tested positive for COVID-19 on 01/24/22. Review of the EMR Lab Results tab revealed R31 tested negative for COVID-19 on 01/24/22. In an interview with the Director of Nursing (DON) on 01/26/2022 at 8:18 PM, the DON confirmed that R225 had tested positive for COVID-19 on 1/24/22 but the facility failed to initiate isolation precautions including posting signage on the R225 and R31's door to indicate R225's COVID positive status, until 01/26/22, to alert staff and visitors of the necessity for precautions. During further interview on 01/26/22 at 8:18 PM, when asked what the facility's practice was when a resident tested positive, the DON stated that the resident would be placed on isolation. A sign would be placed on the door and an isolation cart would be placed in the hallway. When told that there was no sign on R225 and R31's door when surveyors entered the building on 01/25/22, the DON stated that it was easier to just leave the residents where they were because the COVID-19 unit was full. When told there were no isolation carts and signage on R225's door until 01/26/22, two days after he tested positive, the DON offered no further explanations. On 01/27/22 at 1:10 PM, CNA5 was observed to entered R18 and R41's room. CNA5 was wearing a KN95 mask and a face shield, but no gown or gloves. An isolation kit containing necessary PPE was mounted on the door and two signs on the door stating Droplet Precautions: Stop. Everyone must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Transmission-based precautions: Stop. Everyone must: 1. Clean hands before entering and leaving the room by using and alcohol-based hand rub or Washing with soap and water 2. Wear Personal Protective Equipment: Gloves, N95 respirator or facemask if not fitted, isolation gown, face shield or goggles These precautions are required upon ALL room entries, regardless of anticipated patient contact. CNA5 was observed to set down a food tray for R18 on the bedside table and did not perform hand hygiene before entering the room or after exiting the room. Review of the EMR Lab Results tab revealed R18 tested positive for COVID-19 on 01/24/22. Review of the EMR Lab Results tab revealed R41 tested negative for COVID-19 on 01/24/22. Continued observation on 01/27/22 at 1:10 PM revealed CNA5 picked up a food tray and entered R4 and R11's room. Review of the EMR Lab Results tabs revealed R4 and R11 both tested negative for COVID-19 on 01/24/22. CNA5 did not perform hand hygiene between serving residents positive with COVID-19 and residents negative for COVID-19. Continued observations on 01/27/22 at 1:15 PM revealed CNA6 entered into R225's (who was COVID positive) room wearing a KN95 mask and face shield but no gown or gloves and delivered a food tray to R225. There was an isolation kit with PPE on door. CNA6 did not perform hand hygiene before entry, or after exiting R225's room. CNA6 proceeded to the food cart and picked up another tray. CNA6 then served a tray to R27 who per review of the EMR Lab Results tab was COVID-19 negative. CNA6 did not perform hand hygiene between serving R225 and R27. CNA6 performed hand hygiene in the hallway after exiting R27's room. In an interview with the Director of Nursing (DON) on 01/26/22 at 10:15 AM regarding the availability of PPE supplies for staff, the DON stated the facility had ample PPE stored in an outside storage area and staff were to bring supplies into the building as needed. A surveyor accompanied the DON to the storage area outside the COVID unit and confirmed there was adequate quantities of PPE, but it was not easily accessible for staff use resident rooms that required all PPE. The DON stated that they had closed their COVID unit a few months ago because things [COVID-19 transmission] seemed to even out, but the facility had to reopen a COVID unit after the number of residents with positive tests went up following the holidays. During an interview on 01/25/22 at 1:10 PM, when asked about cohorting negative and positive residents in the same room during an interview on 01/25/22 at 1:10 PM, the facility Administrator said that the facility was following guidance provided by the South Carolina Department of Health and the facility Medical Director. The Administrator stated . once we [the facility] got above just a few positives we were instructed to leave the residents where they were, or to essentially shelter in place. The Administrator and DON stated they had been in frequent contact with a named DHEC staff member since their COVID positive numbers started to increase after the holidays. The DON stated that after the COVID unit was reopened and the positives continued to come in they were told by the Medical Director and DHEC that the negative residents in the rooms with the residents that tested positive on 01/24/22 had close proximity exposures and transferring the residents within the facility added to the spread of the infection. During a phone interview on 01/26/22 at 7:10 PM, the Medical Director stated that the residents shed the virus prior to testing positive and the negative roommate had already been exposed and would most likely test positive in about three days. The Medical Director stated, If there are rooms available or a specific unit with COVID positive beds, then the facility can move residents to cohort; but once the number of positives is above four or five residents then it is an outbreak, and moving residents just drags the virus through-out the facility. The Medical Director confirmed the facility was currently in outbreak status and further stated that unless N95s are provided to all residents the exposure risk is elevated regardless of room changes. The MD stated the facility was communicating with DHEC staff and continuing to do their best to prevent the spread, but that moving residents and/or shared equipment does not achieve that goal. In response to the IJ survey citation for Tag F-880-K in which [NAME] Senior Care of [NAME] failed to segregate COVID positive residents and failed to follow Centers for Disease Control (CDC) quarantine guidelines to prevent the spread of COVID-19 infections, [NAME] Senior Care agrees to complete the following corrective actions to ensure compliance with this standard is met: [NAME] Senior Care will continue facility wide outbreak testing for all residents and staff. Effective immediately, a dedicated COVID unit has been reopened to allow segregation of positive residents from noninfected residents. The facility will perform enhanced terminal cleaning of all resident rooms, clinical and non-clinical areas, and non-public spaces. All residents that test positive for COVID-19 will be moved to a unit with dedicated COVID positive rooms, equipment, and staff with increased Transmission Based Precautions (TBPs) on that hall/unit. When space is no longer available on the dedicated COVID unit, residents that test positive for COVID will be cohorted in a room designated as a COVID positive room. The door to the quarantined/COVID positive room will remain closed, and TBPs will be implemented for both/all residents in that room. Personal Protective Equipment will be easily accessible for staff entering the room to provide care. New trash receptacles will be placed at the doorways so staff can doff and discard contaminated PPE prior to exiting the room to contain the spread. Infection Control Preventionist (ICP), the Director of Nursing (DON), and the Administrator will round on the nursing units to ensure staff and residents are following transmission-based precautions, practicing good hand hygiene, and utilizing appropriate PPE to ensure care team members follow the CDC recommended guidelines for TBPs and identification and isolation of positive residents. Any issues with the segregation of the COVID positive residents from non-COVID residents will be addressed by the Administrator and DON in real time and will be used as opportunities for re-education. The Nursing Home Administrator and Director of Nursing are responsible for the corrective actions outlined to be completed by January 27, 2022, and for ongoing monitoring to ensure compliance with this plan to prevent the spread of COVID-19 infection. The IJ removal was confirmed through resident and staff interviews about PPE and identifying residents on quarantine. Observations confirmed terminal room cleans were performed prior to transfers and new room assignments were made for the seven newly identified COVID positive residents; placement of new Personal Protective Equipment (PPE) carts and door bins increased availability of PPE in the rooms of COVID positive residents and in the hallway for staff entering COVID positive rooms. New trash receptacles were placed at the door of the COVID positive rooms so that PPE could be appropriately doffed before exiting the positive room. Staff interviews confirmed requirements in the removal plan that the staff had been reeducated by the facility prior to the start of their shifts and/or during their shift on 01/27/22 regarding proper donning/doffing of PPE, hand hygiene, and how to identify positive and negative rooms/residents while providing cares. The staff were reeducated specifically to include Centers for Disease Control (CDC) recommendations for cohorting residents and PPE/TBPs. The staff sign-in sheets and staff education records were reviewed. The facility policy related to COVID-19 was updated to include the CDC recommendations per Nurse Consultant (NC) 1.

Based on record review and interviews, the facility failed to notify the physician regarding a decline in Resident #1's condition. Resident #1's physician was not notified when the resident experienced an increase temperature and a decline in his/her wound (1 of 3 residents reviewed for notification). The findings included: Cross refers to F-314 as it relates to Resident #1 decline in his/her pressure sore without adequate treatment and physician involvement The facility admitted Resident #1 with a [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) was conducted on 11/21/14 coding the resident as having a Brief Interview of Mental Status (BIMS) of 15. S/he was also coded as requiring extensive assistance for his/her Activity of Daily Living (ADLs) and had a foley catheter with occasional bowel incontinence. A review of the Medical Record on 3/10/15 at approximately 10:47 AM, revealed that the resident was admitted with two stage II pressure ulcers and one unstagable Deep Tissue Injury (DTI), left heel. A review of the wound measurements/documentation on 3/10/15 revealed that Resident #1 was admitted with several wounds, as the wounds continued to increase in size there is no documentation other than an admission progress note by the physician. Further review of the Nurse's Notes for 12/24/14 at 4:30 PM, revealed that Resident #1 had an elevated temperature of 102.2 and was given Tylenol 500 milligrams. His/Her temperature was rechecked and recorded at 100.2. On 12/27/14 at 6 PM Resident #1 again experienced an elevated temperature of 101.6, the nurse gave the resident Tylenol 500 mg and rechecked his/her temperature again at 7 PM and recorded the temperature as 101 degrees. The nurse documented that s/he will monitor and report the elevated temperature to the on coming nurse. There is no documentation that the physician was notified of either elevated temperature. Resident #1 was sent to the hospital on [DATE] for evaluation and treatment of [REDACTED]. An interview was conducted with the Director of Nursing (DON) on 3/10/15 at approximately 5:24 PM, revealed that h/she would expect the nurse to notify the physician for an elevated temperature of 101.6. The DON attempted to locate documentation within the chart that the physician had been notified of the elevated temperatures, but could not produce documentation of physician notification. However, the DON did provide the surveyor with "Employee Disciplinary Action Reports" for both nurses regarding not notifying the physician related to the elevated temperatures that Resident #1 experienced. The report documented that the physician was to be notified for temperatures greater than 100.4.

Based on record review, observations and interviews, the facility failed to ensure residents who enter the facility receive the necessary treatment to promote healing and prevent new pressure sores from developing. Resident #1's wounds deteriorated while a resident at the facility; the physician was not aware of the resident wound deterioration and s/he experienced elevated temperatures and was admitted to the hospital with [REDACTED].#3 noted on observation without a dressing on her/his pressure sore (2 of 3 resident's reviewed with pressure sores). The findings included: The facility admitted Resident #1 with a [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) was conducted on 11/21/14 coding the resident as having a Brief Interview of Mental Status (BIMS) of 15. S/he was coded as requiring extensive assistance for his/her Activity of Daily Living (ADLs) and had a foley catheter with occasional bowel incontinence. A review of the Medical Record on 3/10/15 at approximately 10:47 AM, revealed that the resident was admitted with two stage II pressure ulcers and one unstagable Deep Tissue Injury (DTI), left heel. A review of the PUSH TOOL (pressure ulcer scale healing) from 11/21 - 12/23/2014 revealed: Left Heel 11/25 length 3.5 centimeters (cm) x width 3.2 cm 12/02 length 3.0 cm x width 2.4 cm 12/09 length 3.5 cm x width 3.5 cm 12/16 length 3 cm x 2.2 cm 12/23 length 4 cm x 2.8 cm Mid Upper Back 12/16 length 1 cm x width 1 cm 12/23 length 1 cm x width 1.2 cm Left Buttock 11/21 length 1 cm x width 1cm 11/25 length 3 cm x width 2 cm 12/02 length 3 cm x width 2 cm 12/09 connected to sacrum now 1 big area Lower Sacrum 11/21 length 1cm x width 1.3 cm (no date) combined with other Upper Sacrum 11/21 length .8 cm x width .8 cm 11/25 length 5.8 cm x width 3 cm 12/02 length 1 cm x width 8 cm 12/09 length 9 cm x width 5 cm 12/16 length 10 cm x width 6 cm 12/23 length 10 cm x width 6.8 cm As the wounds continued to increase in size there was no documentation other than an admission progress note by the physician that s/he was aware of the deterioration of the wounds. Further review of the Nurse's Notes for 12/24/14 at 4:30 PM, revealed that Resident #1 had an elevated temperature of 102.2 and was given Tylenol 500 milligrams (mg). His/Her temperature was rechecked and recorded at 100.2. On 12/27/14 at 6 PM Resident #1 again experienced an elevated temperature of 101.6, the nurse gave the resident Tylenol 500 mg and rechecked his/her temperature again at 7 PM, the temperature was 101 degrees. The nurse documented that s/he would monitor and report the elevated temperature to the on coming nurse. There is no documentation that the physician was notified of either elevated temperature. Resident #1 was sent to the hospital on [DATE] for evaluation and treatment of [REDACTED]. After Resident #1 received debridment of the wound its measurements were 15 cm x 18 cm x 3 cm. In an interview with the surveyor on 3/10/15 at 3:50 PM, the Unit Manager (UM)for the West Unit, stated s/he did do the treatments for Resident #1 during his/her first admission, but did not call the physician with regards to the increase in wound size. The UM stated that the "Wound Team" would make the suggestions for treatment changes and they would put them in place and see how they worked for several days. They would fax over the "PUSH" wound sheet every week for the physician to see, but did not specifically call the physician about the wound. An interview was conducted on 3/10/15 with the Minimum Data Set (MDS) Coordinator who was a member of the "Wound Team" in December 2014, during Resident #1's first admission. S/he stated that the team would make rounds usually on Tuesdays for all residents with wounds so that they could have the information for the Wednesday meetings. The previous DON, previous Treatment Nurse (Registered Nurse) and Unit Manager for the West Unit would do the measuring and treatments for the facility. The MDS Coordinator stated that s/he did not know if the physician was called to look at the wounds after s/he wrote the admission progress note on 11/22/14. The treatment changes came from the DON or RN based off of their assessments/findings. In an interview conducted with the surveyor on 3/10/15 at approximately 4 PM with Resident #1 stated that s/he is now getting great care. An observation was made of the sacral dressing, which was dry and intact with today's date. S/he stated they change it every morning and his/her brother watches. S/he stated that when s/he was here before s/he was in a different area and s/he kept telling them that his/her bottom was getting sore, but they thought s/he was talking about his/her back from the arm sling. S/he stated no one changed his/her dressing for weeks and no one would listen to him/her about his/her bottom hurting. It just got worse and worse until I finally told them I could not do it (therapy) anymore, it hurt. My family had to get them to send me to the hospital. The facility admitted resident #3 with a [DIAGNOSES REDACTED]. An Admission MDS was conducted on 2/16/15 coding the resident as having a BIMS of 1. Resident #3 was also coded as requiring total assistance for all ADLs. During the observation of resident #3's wound dressing on 3/10/15 at approximately 1:35 PM, revealed that as the staff member untapped the resident's brief, there was no dressing noted on the resident's sacral wound. The staff stated that they had changed her just a short time ago and the nurse had not replaced the dressing yet. The wound on the sacrum was clean, beefy red and without odor or drainage. At 1:45 PM the Unit Manager confirmed what the staff had stated earlier about the dressing not being applied due to a recent brief change, but stated the dressing had now been applied.