Every finding on record at Chandler Creek Post Acute

Based on observation, interviews and review of facility policy, the facility failed to follow professional food safety practices for preparation and service of resident meals. This deficiency potentially affected all residents receiving meal service from one main kitchen. This was evidenced by an observation of dirty equipment consisting of a counter mounted can opener; meat slicer, and the ice machine.Findings include: The undated facility's procedure titled, Cleaning Instructions: Slicer, read, Slicer will be cleaned and sanitized after each use.The undated facility's procedure titled, Cleaning Instructions: Ice Machine and Equipment, read, Ice machine and equipment will be kept clean and sanitized, according to the manufacturer's procedures (if available), or according to the following guidelines. 3. Wash inside with detergent solution, then rinse with clean, hot water and drain. Sanitize inside with a sanitizing solution and sanitizer cloth. 6. Wipe down exterior with detergent solution.The undated facility's procedure titled, Cleaning Instructions: Can Opener, read, Hand-held, mounted, and electric can openers will be cleaned following each use. 2. Protocol for counter-mounted can openers: Remove can opener shaft from base; wash in sink with soap and water . Wash the base carefully with mild detergent and hot water; be sure to get rid of all food particles from the blade and the basde.During an initial tour of the kitchen with the Certified Dietary Manager (CDM), on 06/30/26 at 10:45 AM, the counter mounted can opener was observed with a large amount of buildup of black, brown, and orange food particles on the blade and base of the can opener. There was an observation made of a meat slicer with a clear plastic cover. The CDM stated, if it's covered, it is clean. The CDM removed the clear plastic cover. An observation was made of food particles on the blade and around the base of the meat slicer. The ice machine was observed to have a dark grey/black substance around the opening and inside the ice machine bin.During an interview on 06/30/26 at 10:55 AM, the CDM stated the meat slicer was covered indicating the equipment was clean. The CDM stated, the ice machine should be cleaned and not have a buildup of a black/grey substance inside the ice machine. The CDM stated the can opener should be washed and not have a buildup of food particles or other substances.During an interview on 06/30/26 at 11:04 AM, the CDM was asked about her expectations for the cleaning of equipment. The CDM stated the staff should do an inspection and/or cleaning of any equipment prior to using the equipment and the equipment coming in contact with any food.

Based on observation, interview, record review, and review of facility policy, the facility failed to implement and maintain an effective infection prevention and control program by failing to ensure Enhanced Barrier Precautions (EBP) were initiated and followed for three of three residents reviewed for EBP who had indwelling medical devices and/or wounds (Residents R135, R91, and R36). Specifically, the facility failed to ensure EBP signage was posted, personal protective equipment was readily available, and staff and contracted hospice personnel used gowns and gloves during high-contact resident care activities, including urinary catheter care, incontinence care, repositioning, transferring, feeding tube-related care, and wound/skin care. These failures had the potential to affect residents on EBP and placed residents at risk for cross-contamination and transmission of infectious organisms.Findings include:Review of the facility's policy titled, Enhanced Barrier Precautions, revised in December 2024, noted: Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Policy Interpretation and Implementation .7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room).8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. providing hygiene or grooming; d. changing briefs or assisting with toileting; e. transferring; f. providing bed mobility; g. changing linens; h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin.; i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and j. wound care (any skin opening requiring a dressing).16. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required.Review of R135's Face Sheet indicated that the resident was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease and chronic kidney disease, Stage 3B and was receiving hospice servicesReview of R135's physician orders, located under the Order Summary Report, found an order dated 06/29/26 for indwelling urinary catheter (Foley Cath) care. There was no order found for EBP.During an observation on 06/30/26 at 11:17 AM, there was no EBP signage on R135's door or in his room. There were no PPE supplies, specifically gowns, seen near or in R135's room. R135 was lying in bed with his eyes open. Registered Nurse (RN) 2, the hospice nurse, was standing on the left side of R135's bed. RN2 was wearing gloves, but no gown, and had a 10-milliliter normal saline (NS) filled syringe in their hand, and with the catheter tubing disconnected from the urinary catheter, was observed flushing the catheter tubing with the NS syringe.During an interview on 06/30/26 at 12:27 PM, RN2 stated that they were not aware that R135 was on EBP due to having an indwelling urinary catheter. RN2 stated, I am not familiar with the facilities process. When asked if RN2 was required to wear a gown and gloves while caring for R135's urinary catheter, the nurse replied, I can't answer that. I don't know.During a follow-up observation on 07/01/26 at 8:55 AM, R135's door had no EBP signage to indicate R135 was on precautions, and there were no gowns visible or available in their room.During an observation and interview on 07/01/26 at 1:10 PM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) verified that R135 had no EBP signage on his door or in his room and no PPE (gowns) readily available to apply before direct care was performed. The ADON/IP stated that R135 should have been on EBP due to having an indwelling urinary catheter.Review of R91's Face Sheet indicated that the resident was admitted to the facility on [DATE] with diagnoses that included a cerebral infarction, aphasia, dysphagia, and a gastrostomy. Further review of R91's Quarterly Minimum Data Set, with an Assessment Reference Date of 05/22/26, revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated that R91 was severely cognitively impaired.Review of R91's physician orders, found an order dated 11/03/25 for a G-tube (gastrostomy tube).An observation of R91's room on 06/30/26 at 12:45 PM, revealed there was no signage on or near the door for EBP use. There was a plastic three-drawer cart along the wall on the right side of the resident's room that had yellow gowns visible in the second drawer. R91 was lying in bed dressed in a hospital-type gown, wearing a pair of adult disposable briefs. Certified Nurse Aide (CNA) 1 was wearing gloves, but no gown and was holding a clean disposable adult brief in her hand. CNA1, without wearing a gown, lifted R91's hospital-type gown up to expose his feeding tube and removed the resident's adult brief, performed incontinence care, and placed a clean brief on the resident. CNA1 removed her gloves, performed hand hygiene, and without donning a gown or another pair of gloves, grabbed R91 by the arm and assisted the resident in sitting up in bed and transferring from the bed to R91's wheelchair. CNA1 assisted R91 with meal setup and then exited the room.During an interview on 06/30/26 at 3:11 PM, CNA1 confirmed that she did not wear a gown during incontinence care, repositioning, or transferring R91 from the bed to the wheelchair. CNA1 stated, Quite frankly, we don't wear gowns when we do care, when asked if gowns and gloves were required to be worn while providing direct care for residents with urinary catheters, wounds, or feeding tubes.During an interview on 07/01/26 at 1:02 PM, the ADON/IP stated that staff were required to wear gowns and gloves when providing direct care for residents with feeding tubes such as R91. The ADON/IP stated they expect staff to wear a mask, gown, and gloves when providing care, linen changes, and incontinence care, for any resident who had a catheter, drainage, foley, wounds, or peripherally or percutaneous inserted central catheters (IVs or PICCs).Review of R36's Face Sheet indicated that the resident was admitted to the facility on [DATE] and readmitted to the facility following a hospitalization on 06/29/26 with diagnoses that included chronic kidney disease, dysphagia, and obstructive and reflux uropathy.Review of R36's physician order dated 06/29/26 revealed an active order for an indwelling urinary catheter.During an observation of R36 in their room on 06/30/26 at 10:50 AM, there was no EBP signage on the resident's door or wall near the door. There were no PPE supplies (specifically gowns), in or near the resident's room. CNA1 and Licensed Practical Nurse (LPN) 4 were observed at R36's bedside. CNA1 was standing on the on the right side of R36's bed holding the resident on his left side while LPN4, stood on the right side of the bed. LPN4 stated that they were performing a head-to-toe skin assessment on R36 who was just readmitted to the facility following a hospitalization. LPN4 and CNA1 were both wearing gloves, but no gowns, while touching the resident, the urinary catheter tubing, and R36's bedding and environmental items. R36's urinary catheter was attached, and the collection bag was secured on the right side of the bed frame. LPN4 had R36's buttocks area exposed during their skin assessment with an open wound visible on observation.During an observation of R36 in his room on 07/01/26 at 10:21 AM, with CNA3, revealed R36 lying in bed awake, in a flat position. CNA3 performed hand hygiene, donned gloves, and without donning a gown, stood on the right side of the resident's bed and performed urinary catheter care. CNA 3 positioned R36 on his right side, with the urinary catheter tubing resting against CNA3's lower legs and thighs. CNA 3 continued to provide urinary catheter and incontinence care without donning a gown. Once the urinary catheter care was completed, CNA3 performed hand hygiene and donned a gown and gloves to assist with positioning while LPN4 performed wound care without donning a gown. At 11:05 AM, LPN4 completed the dressing change. CNA3 removed her gloves, while still wearing her gown, and continued to reposition R36's upper body, adjusting the pillow under his head before removing her gown, performing hand hygiene, and exiting the room.During an interview on 07/01/26 at 11:17 AM, when asked if LPN4 should have worn a gown and gloves during R36's skin assessment observed on 06/30/26, LPN4 stated, I would wear a gown and gloves for dressing changes. If I would have known he had a wound, I would have worn one [a gown]. I should have had a gown and gloves on because the catheter was intact [sic].During an interview on 07/01/26 at 11:21 AM, CNA3 stated, I didn't wear a gown and gloves during [R36's] catheter care and his ADL care and I should have. He's on EBP for the wound. CNA3 admitted that they removed their gloves, while still wearing their gown and continued to reposition R36 after wound care was completed. CNA3 stated, When I took my gloves off, I should have washed my hands and put on a new pair, before continuing to fix him, but I would have to go outside the room to get another pair of gloves.During an observation on 07/01/26 at 12:44 PM, LPN5 performed hand hygiene, entered R36's room and without donning a gown or gloves, lifted the urinary collection bag from the right side of the bed frame and placed the collection bag into a dignity cover before re-securing the bag to the bedframe. LPN5 leaned against the right side of the bed, with her legs touching the bed, catheter tubing, and urine collection bag, and while wearing gloves, but no gown, rolled R36 from his left side onto his back and repositioned R36's bilateral lower extremities forward and placed a pillow under his knees. While repositioning R36 and moving the urinary catheter from under the top sheet covering the resident, LPN5 noted that there was liquid brown stool covering approximately 7-8 inches of the bed under the resident's right side. LPN5 looked down at her pantlegs and stated, Oh, I hope I didn't [checking her pantlegs for stool], no I didn't. LPN5 stated, [R36] had a bowel movement.During an interview on 07/01/26 at 2:41 PM the DON stated that the expectations are that residents who had an indwelling urinary catheter, tracheostomy, ostomy or wound were on EBP. The DON stated that staff should wear gowns along with gloves when providing direct care for residents on EBP, including incontinence care, repositioning, and transferring the resident from the bed to the wheelchair. The DON stated, There should be an EBP sign on the resident's door and a caddy with gloves, gowns and masks inside the room. I expect that anyone providing direct care and any direct contact, wear gown, gloves, and a mask also. Anyone coming in should adhere to the same EBP, including Hospice and Agency. We provide them an email with our policy and expectations to train their staff before coming.

Based on observation, interview and review of facility policy, the facility failed to provide a homelike and odor free environment for four out of 33 sampled residents, Resident (R) 4, 6, 54 and 61. Findings include: A review of the untitled and undated facility environmental policy revealed, It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Policy Explanation and Compliance Guidelines: . 1. Preventive maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. 10. All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue. Observation on 06/30/26 at approximately at 10:45 AM of R54's room revealed the room's windowsill had damaged laminate/wood exposing a deteriorated substrate. The wall beneath the window had unfinished drywall repairs, patched surfaces, and areas not restored to a finished condition. An electrical cord was observed lying across the floor adjacent to the wall. Observation on 07/01/26 at approximately 9:30 AM of R54's room, revealed the room to be in the same condition as observed on 06/30/26. Additionally, a large section of the resident room wall was observed with missing wall covering/paint exposing the underlying wall surface. The baseboard area showed extensive deterioration and unfinished repairs. A third observation of R54's room, conducted on 07/02/26 at approximately 9:45 AM, with the Director of Nurses (DON) found the room remained in the same condition as observed on 06/30/26 and 07/01/26. Observation on 06/30/26 at 11:05 AM of R6's room revealed the room had a foul odor, and the toilet contained feces and urine. The resident bathroom wall adjacent to the sink contained an open wall penetration with unfinished patching and showing deteriorated wall surfaces. The wall surrounding the sink displayed uneven repairs and was not restored to a finished condition. R6 stated that she had been using a cup to pee in because the bathroom toilet had been out of order since approximately the prior week. R6 stated this problem occurs monthly and that no one cares. R6 stated the situation was embarrassing and further stated that bowel movement remained in the toilet because she had no other means to use the bathroom. R6 stated the odor in the room was due to the toilet not working. Observation on 6/30/26 at approximately 11:25 AM of in R4's room found the lower wall corner and baseboard had broken trim, separated molding, chipped drywall, and exposed underlying material. The edge of the overbed had significant laminate damage exposing the underlying wood substrate. The ceiling in R4's room had two large areas of missing textured ceiling material with visible discoloration surrounding the exposed drywall surface. During an interview with R4 on 6/30/26 at 11:25 AM, he revealed that the missing textured ceiling material fell on him one day about 3 or 4 weeks ago. R4 indicated that the Maintenance Director are aware of the issues with the environment in the facility. During an interview with the Maintenance Director (MD) on 06/30/26 approximately 11:40 AM, the MD revealed knowledge of the concerns with resident rooms and indicated that the facility had a plan of correction to fix the issues. A second observation of R4's room on 07/01/26 between the hours of 9:00 AM through 11:00 AM found the room remained the same as 06/30/26. A third observation of R4's room, conducted on 07/02/26 approximately 9:45 AM, with the DON, found the room in the same condition as 06/30/26 and 07/01/26. Observations of R61's room on 07/01/26 at 10:00 AM, found the resident room door frame contained extensive scuffing, gouges, chipped paint, and damaged wood. In the bathroom, the lower wall contained multiple areas of damaged drywall with exposed substrate and deteriorated wall covering. The wall behind the bedroom door had a puncture with missing drywall material exposing the underlying wall surface. A second observation of R61's room, on 07/02/26 approximately 9:20 AM, found the room in the same condition as 07/01/26. During an interview conducted with Maintenance Director, on 07/02/26 at 10:00 AM, he revealed that a plan of correction for the environment was given to the DON. During an interview with the Operational Manager and DON, on 07/02/26 at 11:15 AM, both the Operational Manager and DON indicated that this was an old facility and that the Maintenance Department was working on making repairs. Both indicated that an environmental corrective action plan was developed and discussed in daily morning meetings.

Based on observation, interviews, and review of Resident Council Meeting Minutes and concern/grievance reports, the facility failed to respond to and resolve Resident Council concerns/grievances for four residents who attended Resident Council meetings (R) 4, R17, R61, and R71). The residents reported that concerns regarding cold food, missing meal tray items, small portions, and call light response times were ongoing and had not been addressed by the facility. Findings include:Resident Council Meeting Minutes from 01/2026 through 04/2026 were reviewed. The minutes were provided to the survey team on 07/01/26. Review of the 01/09/26 Resident Council Minutes indicated several concerns regarding the kitchen. Some of the concerns listed indicated that staff did not consistently pass out trays to independent diners before assisting dependent diners on all units, residents were not receiving silverware and napkin sets with their meals, condiments were not always on the trays, there was a lack of base plate warmers with their meals and residents would like breakfast menus to be posted the evening prior to the meal. Review of the Concern/Grievance Report dated 02/04/26 indicated concerns that condiments and complete silverware sets were often missing from trays, the dietary staff was not delivering the meal trays timely, thus letting the food get cold, that the 3rd shift noise level was too high on all units, concerns regarding slow call light response times and staff turning off call lights before meeting residents' needs and there was a consensus that staff did not act with any urgency in regard to residents' needs. Review of the Minutes dated 02/22/26 identified concerns regarding food temperatures, residents' food likes and dislikes, missing condiments, and missing silverware. Review of the Concern/Grievance Report dated 03/18/26 indicated a request for education on where urinals were cleaned and stored. The report also identified concerns regarding 3rd shift noise, loud voices, loud music at the side door, and a request for receipts when paying bills. Review of the Concern/Grievance Report dated 04/15/26 indicated concerns that food portions on the [NAME] unit were small at supper and that the food was cold. The report also indicated that meal tickets were not always correct; for example, residents may have received a lunch ticket at supper instead of a supper ticket. Further review revealed concerns that milk, sandwiches, and other items were not available on the units, and that 2nd shift staff told residents, The kitchen is closed, after supper trays were passed. Residents were not assisted with requests and room [ROOM NUMBER]W was not being cleaned on weekends and the floor stayed dirty. No other Resident Council Meeting Minutes were provided for review. On 07/01/26 at 2:30 PM, the Resident Council President, Resident (R) 4, was interviewed. R4 stated that concerns remained regarding the food always being cold and staff not answering call bells. R4 was informed that the Resident Council Meeting Minutes reviewed did not consistently document concerns about cold food. R4 indicated that he had requested copies of the Resident Council Meeting Minutes for months, but no one had provided copies to him. R4 indicated that cold food was discussed every month and that kitchen staff reported they needed to order plate warmer bases for the bottoms of the plates. R4 stated that if the facility had plate warmer bases, the food might not be as cold. R4 indicated that residents repeatedly called him and reported concerns with food and call lights. R4 indicated that staff were not allowed to reheat residents' food. R4 indicated that these concerns were among the reasons he was being discharged on 07/15/26 due to lack of care. On 07/01/26 at 3:00 PM, an interview was conducted with R61, the incoming Resident Council President. R61 stated that the food at the facility was always cold and that many items were missing, including sweet tea, condiments, and silverware. R61 stated that residents were served unsweet tea and that sometimes they received only a fork. R61 indicated that these concerns had been ongoing for months. R61 confirmed what R4 had reported earlier, stating that food concerns were discussed monthly during Resident Council Meetings. The surveyor confirmed that cold food was a concern that had not been consistently documented or addressed on the Concern/Grievance Reports. On 07/01/26 at 3:25 PM, an interview was conducted with R71. R71 indicated that cold food and small portions were discussed monthly during Resident Council Meetings, but nothing had been done about the concerns. R71 indicated that the food was great during lunch that day; however, R71 believed it was because the state surveyors were present. On 07/02/26 at 10:00 AM, an interview was conducted with R17. R17 stated that the same concerns remained, including weekly cold food and call lights not being answered for more than 30 minutes. R17 indicated that this had been a problem all year. During an interview with an anonymous staff member, the staff member confirmed that the office did not provide all concerns from the Resident Council Meetings and that food had been an issue for many months. The anonymous staff member indicated that the kitchen was aware that plate warmer bases were not available to keep residents' food warm on the halls during tray pass. The anonymous staff member reported that a lot of things here are being swept under the rug. The anonymous staff member further reported that residents' food and care needs should have been provided without ongoing concerns or issues. The staff member requested anonymity due to fear of losing their job.

Based on observations, interviews, record review, and policy review, the facility failed to report an allegation of employee-to-resident abuse for one of three residents reviewed for abuse, Resident (R) 56. Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated August 2022, revealed that all allegations of resident abuse, including staff-to-resident abuse, neglect, exploitation, injuries of unknown origin, or misappropriation of resident property, were to be reported to local, state, and federal agencies as required by current regulations and thoroughly investigated by facility management. The policy further specified that suspected staff-to-resident abuse must be reported immediately to the Administrator, and that all allegations of staff to resident abuse must be reported immediately but no later than 2 hours The policy identified the state licensing/certification agency, the local/state ombudsman, Adult Protective Services, law enforcement officials, the resident's representative, the attending physician, and the facility medical director as persons or agencies to be notified. The policy defined immediately as within two hours of an allegation involving abuse or resulting in serious bodily injury. Review of R56's chart indicated that he was admitted to the facility on [DATE] with medical diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, muscle weakness, anxiety disorder, major depressive disorder, and other seizures. Review of R56's Annual Minimum Data Set (MDS) assessment, dated 03/13/26, revealed that R56 had a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating severe cognitive impairment, and that R56 was difficult to understand when expressing his needs. Review of R56's care plan revealed no identified concerns or behaviors related to interactions with staff or residents. On 06/30/26 at approximately 9:30 AM, during the entrance conference, the Director of Nursing (DON) revealed that the facility had several allegations of abuse and provided a list for review. Review of the facility's list revealed that R56's name was not included on the list of employee-to-resident abuse allegations. During a tour of R56's unit on 06/30/26, beginning at approximately 11:30 AM, no residents on the unit reported allegations of abuse or employee-to-resident abuse. During a second interview with the DON on 06/30/26 at approximately 3:15 PM, the DON revealed no issues related to employee-to-resident abuse; however, stated the facility had investigated a fall for the same resident. On 07/01/26 at 2:00 PM, during an interview and observation with R56, no issues or injuries were observed. R56 had no knowledge of anyone hitting him or mistreating him. R56 was unable to respond to detailed questions. Interviews conducted on 07/01/26 between 9:00 AM and 3:00 PM, with Certified Nursing Assistants (CNAs) on the unit, found they had no knowledge of abuse or neglect of R56 or any other residents on the unit. The CNAs knew whom to report issues and concerns related to abuse to. Interviews were also conducted with Licensed Practical Nurse (LPN) 10 and LPN15 on the unit on 07/01/26 at 2:40 PM, LPN10 and LPN15 indicated they had already completed statements and stated that staff were told R56 had an unwitnessed fall, which resulted in the discoloration on his face and eye. LPN10 indicated no knowledge of mistreatment of R56 or any other residents in the facility. Interview with the Unit Manager on Duty on 07/01/26 at 2:50 PM, was not present on the day of the incident and verbalized knowledge of whom to report abuse to and how to protect residents. The RN indicated no concerns during his/her time at the facility and stated that the facility had zero tolerance for abuse and neglect. Review of the facility's fall investigation for R56 revealed that, on 05/30/26 at 11:29 AM, the weekend supervisor notified the Operational Manager and DON that she had received a call from the day-shift nurse, LPN15, stating R56 had bruising to the left eye. The DON drove to the facility and arrived at 12:40 PM to initiate an investigation. The DON interviewed both day-shift nurses and requested written statements. LPN15 stated that LPN10, who was assigned to R56, discovered that R56 had left eye discoloration and reached out to the night nurse, RN16, to ask what happened. LPN15 stated in response, RN16 had texted her at approximately 10:00 AM and asked her to check R56 and send a picture of the resident's left eye and informed her that R56 had fallen early that morning. LPN15 stated that RN16 added that R56 became upset because RN16 would not give him pain medication and threw a cup at RN16 and began hitting himself. The DON documented she attempted to contact RN16 several times because there was no documentation of a fall or resident behaviors; however, RN16 did not answer. The DON interviewed R56, who was unable to provide a clear explanation for the left-eye discoloration. R56 said, That's sad man!.Pain, pain!.Look! .That's crazy man! Per the report, the DON also interviewed R56's roommate, R35, who had a BIMS of 6. R35 reported that R56 used a racial slur toward RN16 and threw a cup at RN16 but he could not see R56 and RN16 because the curtain was drawn. The DON documented that she also interviewed residents and staff on the unit, and no one reported anything out of the ordinary. The fall investigation revealed that the Operational Manager and DON reached RN16 by telephone at 3:30 PM on 5/30/26, and RN16 stated R56 had an unwitnessed fall early that morning and had aggressive behaviors toward staff and self. RN16 acknowledged that the incident was not documented and later completed late-entry documentation. The facility addressed the matter as a documentation and reporting issue, and RN16 resigned effective immediately after disagreeing with the disciplinary action. During an interview conducted with the DON on 07/01/26 at 5:00 PM, the DON indicated the facility had not reported the incident as abuse because RN16 claimed that R56 had an unwitnessed fall and had discoloration. The surveyor informed the DON that an allegation of employee-to-resident abuse had been received and that the allegation alleged the employee-to-resident abuse had been reported to facility management. She reported no knowledge of employee-to-resident abuse. Further review of the fall investigation found on 05/31/26 at 2:00 PM, the Operational Manager spoke with R56 and asked what happened to his eye and documented, [R56] stated, 'pain, pain, crazy, crazy as hell, man.' I asked him what he meant by crazy, but he kept repeating himself. I then asked him again if he could tell me what happened to his eye and he said the same thing followed with 'boom.' He couldn't explain what boom meant. The Operational Manager also interviewed R56's roommate, R35, on 05/31/26 at 2:00 PM, and documented that R35's bed was perpendicular to R56's bed, and the curtain was drawn halfway. R35 stated that R56 called RN16 a racial slur and threw an empty cup at RN16. R35 stated he could not see R56 and RN16 because the curtain was drawn. R35 denied hearing yelling or noise. Both residents were observed on 07/01/26 at 1:30 PM, no issues identified, and no concerns were reported. On 07/02/26 at approximately 12:45 PM, two anonymous staff reported, on the day of the incident, information was reported to both the DON and the Operational Manager that R56 had been hit by the nurse on duty, RN16. Anonymous staff stated RN16 claimed R56 had an unwitnessed fall after he found out about the eye discoloration. Anonymous staff also indicated that R56 had no fall history and had resided in the facility for years. Anonymous staff reiterated that no fall was reported until after the abuse allegation was reported to the facility. Anonymous staff stated, We do care for our residents, and right is right, and The abuse was swept under the rug just like everything else around here. During an interview with the DON on 07/02/26 at approximately 1:15 PM, the DON stated the facility did not report the incident involving R56 to the state agency as an allegation of employee-to-resident abuse. The DON stated the facility investigated the incident as an unwitnessed fall based on RN 16's report. The DON stated the facility was aware that R56 had discoloration to the left eye, and that there was no documentation of a fall at the time the injury was identified and indicated that statements received described concerns related to the interactions between RN16 and R56. During a follow-up interview with the Operational Manager on 07/02/26 at 11:20 AM, the Operational Manager stated the facility completed an internal investigation related to R56's left-eye discoloration and RN16's failure to document and report the incident. The Operational Manager stated the facility did not submit the incident to the state agency as an abuse allegation because the facility determined the injury was related to an unwitnessed fall. The Operational Manager confirmed RN16 did not document the fall or notify facility management, the physician, or the resident representative at the time of the incident.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles and the manufacturers or pharmacy's expiration and beyond-use dates. The facility allowed expired medications to remain available for use in medication storage areas for one of two medication rooms, Transition Care Unit (TCU), and one of three medication carts observed, Pointsett Unit Cart A. Findings include: Review of the facility policy titled, Storage of Medications, revised date of November 2020 revealed outdated drugs were to be returned to the dispensing pharmacy or destroyed. On 07/01/26 at 11:19 AM, an observation of the TCU Medication Room refrigerator revealed one Lantus Pen for Resident (R) 126 with an open date of 05/11 and an expiration date of 06/09. The Lantus Pen remained in the refrigerator and was available for use beyond the manufacturer's recommended use date. On 07/01/26 at 11:19 AM, an observation of the TCU Medication Room refrigerator revealed one open and half-full bottle of Lido/Diphen/Mi Acid 1:1:1 suspension oral for R93 with a dispensed date of 06/16/26 and an expiration date of 06/16/26. The medication remained in the refrigerator and was available for use beyond the pharmacy's expiration date. On 07/01/26 at 11:57 AM, an observation of [NAME] Unit Medication Cart A revealed one card of Bupropion XL 300 mg (milligrams) with 24 of 30 tablets remaining. The medication had a dispense date of 01/15/26 and an expiration date of 05/31/26. The expired medication remained on the medication cart and was available for use for R13. During an interview on 07/01/26 at 11:52 AM, Licensed Practical Nurse (LPN) 5 stated that once insulin is dated, it should not go back into the refrigerator, and she was unsure why the insulin was in the refrigerator. During an interview on 07/01/26 at 12:05 PM, LPN11 stated expired medications absolutely should not be on a medication cart and stated potential negative outcomes included decreased effectiveness or ineffectiveness of the medication if administered when it was expired or beyond use.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure oxygen equipment was maintained in accordance with facility policy and physician orders for one of one resident reviewed for respiratory/oxygen care (Resident (R) 135). Specifically, the facility failed to ensure R135's nasal cannula tubing was labeled and dated to identify when the tubing had last been changed. This failure had the potential to increase the risk for infection related to oxygen equipment use.Findings include:Review of the facility policy titled, Oxygen Administration, last reviewed October 2010, noted: Purpose. The purpose of this procedure is to provide guidelines for safe oxygen administration.Documentation[:] After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed.5. The reason for p.r.n. [as needed] administration.Review of R135's Face Sheet indicated that the resident was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease, chronic systolic heart failure, chronic obstructive pulmonary disease, and was receiving hospice services.Review of R135's physician orders, located under the Order Summary Report, found orders dated 06/29/26 that read, Change Nasal Cannula [NC] every night shift every Sun [Sunday] [sic] and O2 [oxygen] at 2 liters via NC as needed for SOB [shortness of breath].An observation of R135 in his room on 06/30/26 at 10:41 AM revealed the resident was lying in bed with his eyes open. The resident was wearing a nasal cannula in his nares with the tubing connected to an oxygen concentrator on the floor on the right side of his bed. The flowmeter was set at three liters per minute. The nasal cannula tubing was not labeled or dated.An observation of R135 in his room on 07/01/26 at 8:55 AM revealed the resident was lying in bed with his eyes open. The resident was wearing a nasal cannula in his nares with the tubing connected to an oxygen concentrator on the floor on the right side of his bed. The flowmeter was set at three liters per minute. The nasal cannula tubing was not labeled or dated.An observation and interview on 07/01/26 at 12:58 PM, Licensed Practical Nurse (LPN)5 confirmed that R135's nasal cannula tubing, worn in his nares, was not labeled or dated and that the O2 flowmeter was set at 3LPM. LPN5 stated that the facility's policy was to label and date the oxygen tubing with each tubing change. LPN5 reviewed R135's electronic medical record in the computer and stated that they were unable to verify when the last time R135's nasal cannula tubing had been changed because the resident was just admitted on [DATE] and had the O2 when he was admitted .During an interview on 07/01/26 at 2:41 PM the Director of Nursing (DON) stated that it was the facility's policy to label and date oxygen tubing each time the tubing was changed so that staff will know when the task was completed last. The DON confirmed that changing the oxygen tubing routinely and when soiled, reduced the risk of infection.

Based on observation, interview, record review, and review of facility policy, the facility failed to protect residents' rights to privacy during care for one of two residents reviewed for privacy (Resident (R) 91). Specifically, the facility to provide privacy for R91 during incontinence care when the resident was exposed and visible to his roommate. This privacy violation placed R91 at risk for embarrassment and psychosocial harm.Findings include:Review of the facility's policy titled, Dignity, last revised February 2021, noted: Policy Interpretation and Implementation.11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.Review of R91's Face Sheet indicated that the resident was admitted to the facility on [DATE] with diagnoses that included a cerebral infarction, aphasia, dysphagia, and a gastrostomy.Review of R91's Quarterly Minimum Data Set, with an Assessment Reference Date of 05/22/26, revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated that R91 was severely cognitively impaired. The MDS identified that R91, required substantial to maximal assistance when repositioning from lying to sitting on the side of the bed, and when transferring from the bed to a chair or wheelchair, and that R91 was always incontinent of urine and stool.An observation on 06/30/26 at 12:45 PM, revealed R91's door was closed, but the curtain was pulled open and pushed against the wall between R91 and the resident's roommate. R91's roommate was sitting in his wheelchair between R91's bed and the right side of his bed, with a bedside table in front of him eating his lunchtime meal. R91 was lying in bed dressed in a hospital gown, wearing an adult disposable brief and was fully visible to his roommate. Certified Nursing Aide (CNA) 1 lifted R91's hospital-type gown up to expose their feeding tube and removed the resident's adult brief, performed incontinence care, and placed a clean brief on the resident. R91's privacy curtain between the resident and their roommate remained open and the resident remained in full view of their roommate while CNA1 performed incontinence care for R91. After performing care, CNA1 grabbed R91 by the arm and assisted the resident with sitting up in bed and transferring from the bed to R91's wheelchair. CNA1 then assisted R91 with his meal setup and exited the room.During an interview on 06/30/26 at 3:11 PM, CNA1 confirmed that they did not pull the privacy curtain closed between R91 and his roommate before providing personal hygiene/incontinence care to R91 and that the resident remained in full view of the resident's roommate while the resident sat eating his lunch. CNA1 admitted that by leaving the privacy curtain open during personal care with R91 in view of his roommate, R91 was not provided with dignity or the right to privacy during such intimate care.During an interview on 07/01/26 at 2:41 PM, the Director of Nursing (DON) confirmed that R91's privacy curtain should have been pulled closed to provide privacy for R91, from view of his roommate or any other bystanders while CNA1 was performing incontinence care. The DON stated that they expected the staff to treat the resident with dignity and protect the resident's right to privacy while being undressed or exposed during activities of daily living including incontinence care.

Based on observation, interview, and record reviews, the facility failed to ensure a reasonable accommodation of need for an accessible and usable call bell, and toileting availability, for two of 33 sampled residents (Resident (R) 36 and R6). R36, who had upper extremity limitations, had a push-button style call bell, which was positioned out of reach behind his back while R36 was lying on their left side, crying out in pain, requesting repositioning, and stating they could not reach the call light. R6 was not provided with an alternative toileting solution when the toilet in the resident's bathroom was not working. These failures resulted in psychosocial harm for both R36, who had to yell and plead for help and stated they felt, belittled, and R6 who stated she had to urinate in a cup for several days, and felt embarrassed. Findings include:During an interview on 7/1/26 at 2:45 PM, with the Director of Nursing (DON), the DON stated the facility did not have 'a policy that focused on call bell style and use.1. Review of R36's Face Sheet indicated that the resident was admitted to the facility on [DATE] and readmitted to the facility following a hospitalization on 6/29/26 with diagnoses that included chronic kidney disease, dysphagia, and obstructive and reflux uropathy.Review of R36's 5-day Minimum Data Set, with an Assessment Reference Date (ARD) of 06/20/26, revealed a Brief Interview for Mental Status (BIMS) score of 06, which indicated that R36 was severely cognitively impaired. The MDS further identified that R36 had a one-sided upper extremity impairment.Observations on 07/01/26 revealed the following: At 12:01 PM, R36 was crying out in pain, audible from the doorway into the resident hallway. Upon entry into the resident's room, R36 was lying on his left side in bed with his heel protector boots intact and a pillow propped between his knees. R36's head faced the left wall with his forehead against the raised left upper bed rail. The head of the bed was elevated at approximately 20 degrees. R36's push button call bell cord was draped over the right side of the bed, with the push button resting against R36's lower back, behind the resident. When asked if the resident was in pain and if he could rate his pain on a 1-10 numeric pain scale, R36 stated, it's a 9 out of 10. At 12:03 PM, Licensed Practical Nurse (LPN) 5, the direct care nurse for R36, entered R36's doorway and asked the resident if everything was okay. R36 stated he was in pain, requested to be repositioned, and could not reach the call light. LPN5 stated they were going to lunch but would let someone know.At 12:05 PM, with no response from staff, R36 stated he could not reach the call bell and complained, my legs and feet hurt. I'm all cramped up in bed. I'm 6 [feet] 4 [inches] and have neuropathy. The bed is too small. R36 continued to yell out, Help, please. Ow, it hurts, approximately three to four more times.At 12:08 PM, Certified Nurse Aide (CNA) 3 entered R36's room briefly, and without speaking to the resident or assisting him with repositioning, left the room.At 12:09 PM, Speech Language Pathologist (SLP) 6, entered R36's room, and R36 informed SLP6 that he was in severe pain in his legs, and the bed was too short. SLP6 requested that R36 reposition himself from his left side and lay back in bed with his head forward so SLP6 could raise the head of the bed to complete the swallowing evaluation. R36 informed SLP6 he could not reposition himself and asked for help due to his limited mobility and current pain. R36 was still unable to reach call bell located on his right side, behind his back.At 12:44 PM, LPN5 entered R36's room and began repositioning R36.During an interview on 07/01/26 at 12:45 PM, LPN5 stated, I didn't ask [LPN7] to give [R36] any pain medicine, earlier when I was going to lunch, I was just thinking about getting him repositioned and getting a bigger bed. Sometimes he says things out of context with his pain. Regarding the call light, I don't even know if he could use the call light if it was right in front of him, he wouldn't be able to push it.During an observation and interview with R36 on 07/01/26 at 2:17 PM in his room, R36 was positioned with his knees propped on a pillow, heel boots intact, laying in semi-Fowlers position and resting quietly with his eyes closed. On approach, R36 opened his eyes. When asked if he was aware of how long it took staff to help him with re-positioning and to address his pain earlier, R36 stated, yes, it took them a long time. When asked if his pain was better now, R36 stated, Yes, it's better and R36 rated the pain level a 2-3 on a 1-10 numeric pain scale. When asked to describe how R36 felt when crying out for help and wasn't able to reach his call light or have his pain or request for repositioning addressed during interactions with multiple staff, R36 stated, I felt belittled, belittled. R36 declined to answer any further questions and wanted to rest.During an interview on 07/01/26 at 2:41 PM the Director of Nursing (DON) stated that the expectation for residents is that the resident's call bell is always within reach. The DON stated, Before staff leave the room, they should always make sure the resident's call bell is within reach and that the resident is able to use the call bell. For R36, if staff were aware that he could not push the call bell button then they should have informed the supervisor, we have pad sensors available. The resident should never be expected to just have to yell for help. The fact that R36 remained uncomfortable for so long.and felt belittled, can have a psychosocial effect on him. It's unacceptable. I will have social worker check in on him to see where he is at mentally.2. During a tour observation on 06/30/26 from 11:00 AM, through 1:00 PM, R6's room was observed to have a foul odor which extended into the hallway. During an interview on 06/30/26 approximately 11:05 AM, R6 stated she had been using a cup to pee in because the bathroom toilet had been out of order since approximately the prior week. R6 stated the problem occurred monthly and that no one cares. R6 stated the situation was embarrassing and further stated that her bowel movements remained in the toilet because she had no other means to use the bathroom. R6 stated the odor in the room was due to the toilet not working. During an interview on 06/30/26 11:20 AM, R4, who resided in the room next to R6, stated the facility was aware that R6's bathroom toilet was out of order. R4 stated staff had used R4's bathroom to empty urine from R6's room and that R6 had to go to another resident's room for toileting needs. R4 stated he was provided with a bedside commode. R4 stated the concern had been reported to nursing staff and that staff were aware of the ongoing problem. During an interview on 06/30/26 at approximately 11:30 AM., the Maintenance Director (MD) stated he was aware that R6's toilet was out of order and stated, we are working on this concern. During an interview on 06/30/26 at approximately 11:40 AM, Unit Manager (UM) 12 stated she was aware that R6's toilet was out of order but was not aware R6 had been using a cup to urinate. UM12 did not provide evidence that a toileting alternative was provided to R6 while the toilet was out of order. During an interview with the Director of Nursing (DON) on 07/01/26 at approximately 2:30 PM, the DON stated she was not aware that R6's toilet was not working. The DON stated she would follow up with the Maintenance Director regarding the concern. During the interview, the surveyor asked the DON about using a bedside commode until R6's bathroom toilet was repaired. DON did not say a word. During an interview with the Administrator and DON on 07/02/26 at approximately 11:10 AM, the surveyor discussed the facility's expectation to meet residents' reasonable accommodation needs. The DON indicated she had spoken with staff and that no one was aware R6 had been using a cup to urinate. The Operational Manager and DON both indicated that all residents needs should be met.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure residents were treated with dignity and respect during care for two of 33 sampled residents (Resident (R) 36 and R6). Specifically, the facility failed to treat R36 in a dignified manner by failing to respond for 43 minutes to R36's repeated verbalized requests for repositioning and pain relief, leaving R36 lying in pain in his own feces. The facility failed to treat Resident #6 with respect and dignity by failing to ensure the resident had a functioning toilet or an appropriate, dignified alternative for toileting, when the toilet in the resident's bathroom was not working. This failure resulted in actual psychosocial harm for R36, who stated they felt belittled, and R6 who stated she had to urinate in a cup for several days and felt embarrassed.Findings include:Review of the facility's policy titled, Dignity, last revised February 2021, noted: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation. 1. Residents are treated with dignity and respect at all times.12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered; b. promptly responding to a resident's request for toileting assistance.13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example; a. addressing the underlying motives or root causes for behavior; and b. not challenging or contradicting the resident's beliefs or statements.1. Review of R36's Face Sheet indicated that the resident was admitted to the facility on [DATE] and readmitted to the facility following a hospitalization on 06/29/26 with diagnoses that included chronic kidney disease, dysphagia, and obstructive and reflux uropathy. Review of R36's 5-day Minimum Data Set with an Assessment Reference Date (ARD) of 06/20/26 revealed a Brief Interview for Mental Status (BIMS) score of 06, which indicated that R36 was severely cognitively impaired.During an observation on 07/01/26 at 12:01 PM, R36 was crying out in pain, audible from the doorway into the resident hallway. Upon entry into the resident's room, R36 was observed lying on his left side in bed with his heel protector boots intact and a pillow propped between his knees. R36's head faced the left wall with his forehead against the raised left upper bed rail. R36's push button call bell cord was draped over the bed, with the push button resting against R36's lower back, behind the resident. When asked if the resident was in pain and if they could rate their pain on a 1-10 numeric pain scale, R36 stated, it's a 9 out of 10. At 12:03 PM, Licensed Practical Nurse (LPN) 5, the direct care nurse for R36, entered R36's doorway and asked the resident if everything was okay. R36 stated they were in pain, requested to be repositioned, and couldn't reach the call light. LPN5 informed R36 that LPN5 was going to lunch but would let someone know.At 12:05 PM, with no response from staff, R36 stated he could not reach the call bell and complained, my legs and feet hurt. I'm all cramped up in bed. I'm 6 [feet] 4 [inches] and have neuropathy. The bed is too small. R36 continued to yell out, Help, please. Ow, it hurts, approximately three to four more times.At 12:08 PM, Certified Nurse Aide (CNA) 3 entered R36's room briefly, and without speaking to the resident or assisting him with repositioning, left the room. CNA3 walked down the resident hallway and opened the meal tray cart to start delivering trays to residents.At 12:09 PM, Speech Language Pathologist (SLP) 6, entered R36's room, and R36 informed SLP6 that he was in severe pain in his legs, and the bed was too short. R36 began groaning in pain while SLP6 informed R36 they were there to complete a swallowing evaluation. SLP6 requested that R36 reposition himself from his left side and lay back in bed with his head forward so SLP6 could raise the head of the bed to complete the swallowing evaluation. R36 informed SLP6 he could not reposition himself and asked for help due to his limited mobility and current pain.At 12:15 PM, SLP6 approached the nurse's station and informed Registered Nurse (RN) 7 that R36 was in pain and asked to be repositioned. SLP6 asked what time LPN5 would return from lunch.At 12:16 PM, SLP6 re-entered R36's room as R36 continued to yell out in pain, please! SLP6 asked the resident if he wanted to, set up a bit and have a sip of water. R36 intermittently yelled, Ow, ow, when SLP6 began raising the head of the bed while R36 was still lying on his left side SLP6 left the room briefly and re-entered the room at 12:20 PM with a Styrofoam cup containing ice chips and stated, I'm evaluating for swallowing safely. Alright I'm about to sit you up now. SLP6 raised the head of the bed higher and folded the residents' pillow in half and propped it under his head. R36 was now lying in bed with his head and nose pointed toward the ceiling with his body remaining positioned on his left side. R36 reached out for the ice chip container with his right hand and took some ice chips in his mouth.At 12:24 PM, LPN5 wheeled the medication cart down the resident hallway, parked the cart across the hall from R36's room, and began to type on the computer's keyboard while SLP6 remained in R36's room.During an interview on 07/01/26 at 12:25 PM, when asked if LPN5 notified anyone that the resident was in pain and needed to be repositioned when they were informed by R36 at 12:03 PM, LPN5 stated, I told CNA3 when I went on break. I also notified the Unit Manager about getting him a longer bed, I think they told the Director of Nursing (DON). [LPN 7] watches the unit along with the Unit Manager, when I'm on break, but I didn't ask [LPN 7] to give any meds [medications]. I thought [R36] was all set [sic].On 07/01/26 at 12:27 PM, SLP6 exited R36's room and informed LPN5 that R36 was complaining of pain throughout the swallowing assessment and that SLP6 would have to come back the next day to try and complete the evaluation again.During an interview on 07/01/26 at 12:29 PM, SLP6 stated that they didn't want to 'overstep' regarding repositioning R36 due to pain and wanted to complete the swallowing evaluation so that they could advance the resident's diet as soon as possible.During an observation on 07/01/26 at 12:44 PM, LPN5 entered R36's room and rolled R36 from his left side onto his back and repositioned R36's bilateral lower extremities into the center of the bed and propped a pillow under his knees. While repositioning R36 and moving the urinary catheter from under the top sheet covering the resident, there was liquid brown stool covering approximately seven to eight inches of the bed under the resident's right side. LPN5 looked down at their pantlegs and stated, Oh, I hope I didn't [checking their pantlegs for stool], no I didn't. LPN5 stated, [R36] had a bowel movement. LPN5 informed R36 that he had received pain medication in the morning, but that he could receive Tylenol if he wanted.During a follow up interview on 07/01/26 at 12:45 PM, LPN5 stated, I didn't ask [LPN7] to give [R36] any pain medicine, earlier when I was going to lunch, I was just thinking about getting him repositioned and getting a bigger bed. I didn't know he had stool all over the place until I just went in and helped him [sic].During an interview on 07/01/26 at 1:01 PM, CNA3 stated that they did not have enough help to take care of the residents at the time R36 was yelling for help. CNA3 stated, When [R36] was yelling for help, I was helping three other residents and then I had to pass [meal] trays. I thought we weren't supposed to do incontinence care while we are doing tray pass.During an observation and interview with R36 on 07/01/26 at 2:17 PM in his room, R36 was positioned with his knees propped on a pillow, heel boots intact, laying in semi-Fowlers position and resting quietly with his eyes closed. When asked to describe how R36 felt when crying out for help and wasn't able to reach his call light, or have his pain or request for repositioning addressed during interactions with multiple staff, R36 stated, I felt belittled, belittled. R36 declined to answer any further questions and wanted to rest.During an interview on 07/01/26 at 2:41 PM, the DON stated the resident should never be expected to just have to yell for help. When asked what the expectation was for resident's who were identified as having pain or discomfort, the DON replied, The resident's pain should have been addressed before it ever reached a 9 out of 10. Staff had several opportunities to address the pain. I expect any staff to respond to the resident's request for help and let someone know. I expect the staff to respond immediately. The resident never should had been left that long without being repositioned and in pain. And, he had stooled, too. The resident's comfort and pain level is priority with wound care. The fact that [R36] remained uncomfortable for so long both times, and felt belittled, can have a psychosocial effect on him. It's unacceptable. I will have social work check in on him to see where he is at mentally.2. During a tour observation on 06/30/26 between 11:00 AM and 1:00 PM, R6's room was observed to have a foul odor which extended into the hallway During an interview on 06/30/26 at 11:05 AM, R6 stated that she had been using a cup to pee in because the bathroom toilet had been out of order since approximately the prior week. R6 stated this problem occurs monthly and that no one cares. R6 stated the situation was embarrassing and further stated that bowel movements remained in the toilet because she had no other means to use the bathroom. R6 stated the odor in the room was due to the toilet not working. During an interview on 06/30/26 at 11:20 AM, R4, who resided in the room next to R6, stated the facility was aware that R6's bathroom toilet was out of order. R4 stated staff had used R4's bathroom to empty urine from R6's room and that R6 had to go to another resident's room for toileting needs. R4 stated he used a bedside commode. R4 stated the odor was related to the nonfunctioning toilet and R6 using a cup to urinate. R4 stated the concern had been reported to nursing staff and that staff were aware of the ongoing problem. During an interview on 06/30/26 at approximately 11:30 AM, the Maintenance Director stated he was aware that R6's toilet was out of order and stated, we are working on this concern. The Maintenance Director stated he did not work on the weekend and stated he would provide the work order related to the toilet concern. During an interview on 06/30/26 approximately 12:10 PM, Unit Manager (UM) 12 stated she was aware that R6's toilet was out of order but was not aware R6 had been using a cup to urinate. UM12 stated R6 often would not allow staff into the room, nor would R6 come out of her room, and stated that staff entered the room in pairs due to prior allegations of mistreatment. UM12 did not provide evidence that a timely, dignified toileting alternative was attempted or provided while the toilet was out of order. During an interview with the Director of Nursing (DON), on 07/01/26 at approximately 2:30 PM, the DON stated she was not aware that R6's toilet was not working. The DON stated she would follow up with the Maintenance Director regarding the concern. Review of Work Orders for R6's bathroom found repair requests on 04/13/26 for a clogged toilet, 05/01/26 for a clogged toilet, and 06/30/26 for bathroom not working. During an interview with the Administrator and DON on 07/02/26 at approximately 11:10 AM, the surveyor informed the Administrator and DON of the concern that R6 had been using a cup to urinate because the toilet in R6's bathroom was out of order. The Adminstratorr expressed he was unaware this was occurring.

Based on review of facility policy, resident records, hospital records, and interviews, the facility failed to protect Resident (R)2 from a significant medication error for 1 of 2 residents reviewed. Specifically, on 12/04/25, Licensed Practical Nurse (LPN)1 administered medications prescribed for R3 to R2, including Oxycodone thirty milligrams (mg) (a pain medication), Amlodipine 5 mg (a blood pressure medication), Losartan 50 mg (a blood pressure and heart medication), Dofetilide 250 micrograms (mcg) (a heart rhythm medication), Gabapentin 600 mg (a nerve pain medication), and Metoprolol 50 mg (a heart rate and blood pressure medication). This failure resulted in R2 being sent out to the hospital.On 02/23/26 at 3:06 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.On 02/23/26 at 3:06 PM, the survey team provided the Director of Nursing with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 12/04/25. The IJ was related to 42 CFR S483.45(f)(2) Pharmacy Services.On 02/23/26, the facility provided an acceptable IJ Removal Plan. On 02/23/26 the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F760 at a lower scope and severity of D.An extended survey was conducted in conjunction with the Complaint Survey, for non-compliance at F760, constituting substandard quality of care.Findings Include: Review of the facility policy titled Administering Medications last revised in April 2019, states, Policy Statement: Medications are administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation: . 4. Medications are administered in accordance with prescriber orders, including any required time frame. 9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. Checking identification band; b. Checking photograph attached to medical record; and c. If necessary, verifying resident identification with other facility personnel. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 26. Medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nursing Services.Review of R2's admission Record revealed the facility admitted R2 on 08/23/25, with diagnoses including but not limited to: cognitive communication deficit, dementia with mild anxiety, atrial fibrillation, dysphagia and major depressive disorder.Review of R3's admission Record revealed the facility admitted R3 on 03/17/25, with diagnoses including but not limited to: heart failure, high blood pressure, chronic pain syndrome and lumbar spondylosis. Review of a witness statement dated 12/04/25 and written by LPN1 revealed, 0800 nurse labeled med cup with a [sic] residents name- then I poured meds into med cup I mixed whole pills in pudding to help resident swallow pills. I administered pills to room [ROOM NUMBER]D [R2]. Then I proceeded to look for room [ROOM NUMBER]w [R3] meds and instead found [R2's] med cup that's when I realized my error.Review of a witness statement dated 12/04/25 and written by Unit Manager (UM)1 revealed, I received a call from nurse [LPN1] at 8:14 AM. She stated she did a Med error on [R2] and gave her the following meds that weren't hers. Gabapentin 600 mg, Dofletilide 250 [sic] mg, Metoprolol ER 50 mg, Cozarr 50 mg and oxycodone 30 mg. She stated pt was stable. ADON and NP called right away. BP to be checked [every thirty minutes] Q30 min and Midodrine 10 ordered. Patient monitored closely. At 2:00 PM pressures were dropping and wouldn't go up even with midodrine and ordered fluids. EMS called.Review of a witness statement dated 12/04/25 and written by the Assistant Director of Nursing (ADON) revealed, [R2's] Medication Error: This nurse was informed by Unit Manager that nurse [LPN1] had a medication error. Resident [R2] was given another resident's medication. Medication given was Oxycodone 30mg, Amlodipine 5mg, Losartan 50mg, Dofetilide 520mcg, Gabapentin 600mg, Metoprolol 50mg, Metoprolol 50mg. This nurse contacted NP who went to see resident and ordered STAT Midodrine 5mg to be given and BP & Pulse to be checked every 30mins. Orders were placed by this nurse. [Nurse Practitioner] NP checked on resident throughout the day. Vitals were still low, and orders to send residents to ER were given.Review of R3's Active Physician Orders for the month of December 2025, revealed the following orders: Oxycodone 30 mg - Give 1 tablet by mouth three times daily, Amlodipine 5 mg - Give 2 tablets by mouth once daily, Losartan 50 mg - Give 1 tablet by mouth twice daily, Dofetilide 250 mcg - Give 1 capsule by mouth twice daily, Gabapentin 600 mg - Give 1 tablet by mouth four times daily, Metoprolol 50 mg - Give 1 tablet by mouth once daily.Review of R2's Active Physician Orders dated December 2025, revealed no documented physician orders for the medications administered on 12/04/25.Review of R2's Progress Notes revealed the following:12/4/2025 11:58 Nurse's Note: Note Text: contacted NP and [Resident Representative] RR regarding recent med error incident. Esident [sic] stable in bed RR next to bedside.12/4/2025 15:10 Nurse's Note : Note Text: was checking [Blood Pressure] BP every 30 mints as ordered Blood pressure continues to be lower inspite [sic] of ordered midrodine 10mg one time. resdient [sic] drank about 4 [ounces] oz of fluids, residetn [sic] alert and responsive at time of transfer, BP 74/48 pulse 44 [Respirations] resp 8 [dangerously slow breathing] 02 sats [Oxygen Level] at 96% with02 on via nonrebreather mask. notified RR of NP transfer to [Local Hospital] for furter [sic] Evaluation.Review of R2's Weights and Vitals Summary dated 12/04/25, revealed the following: 12:59 BP 77/48, HR 4711:50 BP 72/42 HR 5111:37 BP 86/44 HR 4511:09 HR 4110:47 BP 83/59 HR 63Review of a document titled Discharge Summary-Hospital Medicine dated 12/10/25, revealed, Chief Complaint: Patient presents with Medication Problem- Med error. [History of Present Illness] HPI obtained from admission [History and Physical] H&P: [R2] is an 82 y.o. with multiple chronic medical problems who presents with somnolence [excessive sleepiness], hypotension [critically low blood pressure], bradycardia [critically slow heart rate], and hypoxia [critically low oxygen levels] after medications incorrectly administered this morning while at her rehab facility. Per report, the staff at [NAME] Creek gave patient incorrect medications at about 8AM today: Oxycodone 30mg, Amlodipine 5mg, Losartan 50 mg, Dofetilide 250 mcg, Gabapentin 600mg, Metoprolol 50mg. BP 79/44, [Heart Rate] HR 44, 02 96% on 15 [Liters] L. Per EMS/ER triage note: Original 74% on [Room Air] RA, BP 60/palp [blood pressure critically low, measured by feeling the pulse only], [Blood Sugar] BGL 108. Given 700 NS [Normal Saline-a sterile saltwater solution given through an IV to provide fluids], 1mg Narcan [used to reverse overdoses of pain medications], 1mg atropine [used to treat low blood pressures]. BP increased to 100/60, Pulse 90. Hospital Course by Problem: Hypotension due to drugs/Bradycardia [slow heart rate]/Drug overdose: Initially admitted following unintentional receipt of multiple antihypertensives, antiarrhythmic, and opioid medications intended for another resident of her long-term care facility. Received atropine, naloxone in ED prior to admission at the recommendation of toxicology. Required initiation of vasoactive medications [given to support critically low blood pressure] due to persistent hypotension which persisted for several days. Acute Respiratory Failure with Hypoxia/Sepsis/[Pneumonia] PNA: Noted to have hypotension requiring vasopressor therapy for multiple days following hospital admission.Review of an After Visit Summary dated 12/10/25 revealed, Summary of Your Hospitalization: your primary diagnosis was: Hypotension Due to Drugs 12/04/25-12/10/25. Your diagnoses also included: Drug overdose, accidental or unintentional, confusion caused by a drug, bradycardia, respiratory insufficiency, sepsis with acute hypoxic respiratory failure without septic shock, and pneumonia. During an interview on 02/23/25 at 12:38, LPN2 stated the process for administering medications starts with asking the resident their name and looking at medication card to confirm. LPN2 then stated she would ask the resident for their name and date of birth and if they are unable to communicate this information, they have pictures on the Medication Administration Record (MAR) the nurse can see. Some residents also wear bracelets with their information on it.During an interview on 02/23/25 at 1:00 PM, LPN1 stated, I made an error. LPN1 reports that during the morning medication pass, she pre-pulled medications for more than one resident at a time. She had already prepared R2's medications and R3's medications. While she was about to give R2's medications, that's when R3 asked for pain medication. She then retrieved R3's Oxycodone and then went to give R2 her medications first but got distracted. She then administered medications to R2. Afterward, when she went to give R3's medications, she realized that R2's medications were still in the cup on the cart and that R2 had received R3's medications by mistake. LPN1 immediately reported the error to her supervisor. She stated that at the time, R2 was arousable, but her breathing was slowing. LPN1 further stated, I was a little distressed and concerned that she wouldn't make it. The family was notified, and the resident was sent to the hospital. The NP administered Midodrine. Despite receiving medications and fluids, R2's blood pressure never improved. She had previously received training for medication administration, which included following the five or six rights, checking vitals, washing hands, and using sanitizer. Staff are aware that interruptions can happen, but they are instructed not to interrupt nurses during medication passes.During an interview on 02/23/25 at 1:36 PM, the ADON states that LPN1 notified her immediately after administering the medication. She stated that she initially assumed LPN1 had pre-pulled the medications and then realized the wrong resident had received the dose. The ADON notified the NP, who ordered Midodrine to raise the resident's blood pressure and instructed staff to check vital signs every 30 minutes. The resident was transferred to the emergency room a few hours after the error. The ADON recalled that the only medication she specifically remembered was Oxycodone 30 mg due to the high dosage. She explained that facility expectations are: only one resident's medications should be pulled at a time, nurses must verify the resident at least three times, and the five rights of medication administration must be followed. Medications should never be pre-pulled before administration. The ADON was unsure if the administrator was notified of the incident. She stated that after pre-pouring medications, the nurse was pulled into the office and disciplined.During an interview on 02/23/25 at 1:50 PM, the NP stated, I was made aware right after the medication error occurred. LPN1 called me on my cell phone. Upon notification, I came and assessed the resident, took her vitals, listened to her heart and lungs, and at this moment there was no acute distress noted. Within the hour of the medications being given, the resident started to become symptomatic. During the initial assessment, I ordered vital signs to be taken every 30 minutes. Midodrine was ordered and given to try to keep her blood pressure up, but it was not effective. The Medical Director was notified. It was less than four hours between the medication error and the resident being sent out. R2 was still alert and oriented, but her blood pressure was low.On 02/23/26, the facility provided an acceptable IJ Removal Plan, which included the following:The facility has taken the following steps to ensure the safety of our residents regarding significant medication error.1. On 2/23/2026, the Administrator notified the Medical Director of the Immediate Jeopardy.2. On 12/4/2025, [R2] was assessed by the Nurse Practitioner, and new orders were written for vital signs Q30 minutes and Midodrine stat.3. On 12/4/2025, [R2] was sent to the emergency department for a higher level of care.4. On 12/4/2025, the Assistant Director of Nursing began the investigation into the medication error.5. On 12/4/2025, the Assistant Director of Nursing counseled [LPN1] related to the medication error and failure to follow the five rights of medication pass, prepulling medication that resulted in medication error. The licensed nurse was placed on a process improvement plan on 2/23/2026.6. On 12/4/2025, the Assistant Director of Nursing provided 1:1 education with the licensed nurse [LPN1] related to types of medication errors, causes, and prevention.7. On 12/5/2025, the Assistant Director of Nursing began a medication pass in-service related to the 5 rights of medication administration.8. On 2/19/2026, the Assistant Director of Nursing or designee began education with the licensed nurses on the 5 rights of medication pass and medication administration to be completed by 2/24/2026.9. On 2/23/2026, the Assistant Director of Nursing or designee began education on the medication administration policy to include how to verify the medications are correct. This will be completed by 2/24/2026 for all licensed nurses on or before the licensed nurses' next scheduled shift.10. On 2/23/2026, the Assistant Director of Nursing or designee began competency checks on medication pass on all licensed nurses. This will be completed by 2/24/2026 or before the licensed nurses' next scheduled shift.11. On 2/23/2026, the Administrator, the Director of Nursing, and the Assistant Director were re-educated on Medication Pass, including medication errors, by the Regional Assistant Director of Clinical Services.12. On 2/23/2026, the Director of Nursing completed a review of hospitalizations since 12/1/2025 to determine if any were related to medication error.13. On 2/23/2026, the Director of Nursing completed a 6-month medication error review to ensure proper documentation, appropriate corrective action, and reporting compliance.14. On 2/23/2026, nurse management will begin to randomly select each nurse daily to observe medication passes x 7 days, then weekly x 4 weeks, then monthly x 2 months.15. The nurse involved in the deficiency will have completed medication pass competency daily x 7 days, weekly x 4 weeks, monthly x 2 months, and quarterly x 2.DATE OF COMPLIANCE: 2/24/2026

Based on review of facility policy, record review and interview, the facility failed to report a significant medication error that resulted in serious bodily injury to the Administrator and the State Agency within 2 hours, for 1 of 2 residents reviewed, Resident (R)2. Specifically, on 12/04/25, Licensed Practical Nurse (LPN)1 administered medications prescribed for R3, to R2. Following the medication error, R2 was hospitalized . Findings Include: Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating last revised in September 2022, states, Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation: Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/ licensing the facility . 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. Review of R2's admission Record revealed the facility admitted R2 on 08/23/25, with diagnoses including but not limited to: cognitive communication deficit, dementia with mild anxiety, atrial fibrillation, dysphagia and major depressive disorder.Review of R2's Progress Notes revealed the following:12/4/2025 11:58 Nurse's Note: Note Text: contacted [Nurse Practitioner] NP and [Resident Representative] RR regarding recent med error incident. Esident [sic] stable in bed RR next to bedside.12/4/2025 15:10 Nurse's Note : Note Text: was checking [Blood Pressure] BP every 30 mints as ordered Blood pressure continues to be lower inspite [sic] of ordered midrodine 10mg one time. resdient [sic] drank about 4 [ounces] oz of fluids, residetn [sic] alert and responsive at time of transfer, BP 74/48 pulse 44 [Respirations] resp 8 [dangerously slow breathing] 02 sats [Oxygen Level] at 96% with 02 on via nonrebreather mask. notified RR of NP transfer to [Local Hospital] for furter [sic] Evaluation.Review of a witness statement dated 12/04/25 and written by LPN1 revealed, 0800 nurse labeled med cup with a [sic] residents name- then I poured meds into med cup I mixed whole pills in pudding to help resident swallow pills. I administered pills to room [ROOM NUMBER]D [R2]. Then I proceeded to look for room [ROOM NUMBER]w [R3] meds and instead found [R2's] med cup that's when I realized my error.Review of a witness statement dated 12/04/25 and written by Unit Manager (UM)1 revealed, I received a call from nurse [LPN1] at 8:14 AM. She stated she did a Med error on [R2] and gave her the following meds that weren't hers. Gabapentin 600 mg, Dofletilide 250 [sic] mg, Metoprolol ER 50 mg, Cozarr 50 mg and oxycodone 30 mg. She stated pt was stable. ADON and NP called right away. BP to be checked [every thirty minutes] Q30 min and Midodrine 10 ordered. Patient monitored closely. At 2:00 PM pressures were dropping and wouldn't go up even with midodrine and ordered fluids. EMS called.Review of a witness statement dated 12/04/25 and written by the Assistant Director of Nursing (ADON) revealed, [R2's] Medication Error: This nurse was informed by Unit Manager that nurse [LPN1] had a medication error. Resident [R2] was given another resident's medication. Medication given was Oxycodone 30mg, Amlodipine 5mg, Losartan 50mg, Dofetilide 520mcg, Gabapentin 600mg, Metoprolol 50mg, Metoprolol 50mg. This nurse contacted NP who went to see resident and ordered STAT Midodrine 5mg to be given and BP & Pulse to be checked every 30mins. Orders were placed by this nurse. [Nurse Practitioner] NP checked on resident throughout the day. Vitals were still low, and orders to send residents to ER were given.Review of the facility-provided reportable incident log for the past three months did not include the medication error involving R2 on 12/04/25. During an interview on 02/23/26 at 1:00 PM, LPN1 stated, I made an error. LPN1 reports that on the day of the incident during the morning medication pass, she pre-pulled medications for more than one resident at a time. She had already prepared R2's medications and R3's medications. While she was about to give R2's medications that's when R3 asked for pain medication. She then retrieved R3's Oxycodone and then went to give R2 her medications first but got distracted. She then administered medications to R2. Afterward, when she went to give R3's medications, she realized that R2's medications were still in the cup on the cart and that R2 had received R3's medications by mistake. LPN1 immediately reported the error to her supervisor.During an interview on 02/23/26 at 1:25 PM, the Director of Nursing (DON) stated that when a medication error occurs, the resident's condition should be assessed, vital signs checked, the Nurse Practitioner notified, and the incident reported to the State Agency. The DON stated she was on maternity leave at the time of the incident and confirmed that a report was not submitted. She stated that the ADON was unaware that the incident needed to be reported.During the same interview, the DON was asked if the facility had submitted a report since discovering the incident. She stated, Well I thought since y'all were here we didn't have to now. The surveyor informed the DON that the facility had a duty to self-report because this was a complaint received by the State Agency. The DON stated she would submit the report immediately.During interview on 02/23/26 at 1:36 PM, the ADON states that LPN1 notified her immediately after administering the medication. the ADON further stated she was unsure if the Administrator was notified of the incident. The ADON also noted that she was unaware she was required to report the incident to the State Agency.During an interview on 02/23/26 at 2:43 PM, the Facility Administrator (FA) stated that he was only made aware of the medication error recently, when he spoke with [R1]. The FA confirmed that a report was not sent to the State Agency. He also stated that the ADON discovered the incident and that he was not informed of it at the time.

Based on observation, interview, and review of the facility policy, the facility failed to ensure proper food safety practices related to the maintenance and documentation of refrigerator and freezer temperatures, these failures had the potential to affect all residents who eat from the kitchen. Findings include: Review of the facility policy titled, Food and Nutritional Services Manual documented, 10. Food Receiving and Storage-All food and supplies received at [NAME] Creek Post Acute must be from approved sources and stored under conditions that prevent spoilage and contamination. Dry storage areas are clean, ventilated, and items are stored [greater than or equal to] 6 inches off the floor. Refrigerators maintain [less than or equal to] 41 deg F; freezers maintain a frozen state at 0 deg F or below. Thermometers are placed in all refrigeration units and temperatures are recorded daily. 17. Refrigerators and Freezers-Refrigeration and freezer units are maintained at safe temperatures to prevent spoilage and foodborne illness. Refrigerator temps are maintained at or below 41 deg F; freezers at 0 deg F or below. Internal thermometers are present in all cold storage units and checked daily. Logs are maintained and reviewed weekly by the food service manager. 25. Daily/Weekly/Monthly Log Templates-Documentation tools are maintained to support compliance, monitoring, and quality improvement. Logs include but are not limited to: Refrigerator/Freezer Temp Logs, Dish Machine Temperature/PPM Logs, Substitution Logs, Daily Assigned Cleaning Checklist. During an observation and interview during the initial brief kitchen tour on 05/18/25 at 10:48 AM, revealed there was no internal temperature gauge in the freezer. Further observation revealed the external thermometers for the refrigerator and freezer were not working properly. Additional observation revealed, there were incomplete temperature logs for the refrigerator and freezer. During the initial brief kitchen tour on 05/18/25 at 10:48 AM, a request was made for temperature logs for the refrigerator and freezer, the Kitchen Manager stated that he had not started the temperature logs for the month of May 2025. Subsequently, temperature logs were only provided for April 2025. During an interview on 05/19/25 at approximately 2:00 PM, the Kitchen Manager was asked to provide any additional refrigerator and freezer temperature logs. The Kitchen Manager provided temperature logs for November 2024 to March 2025 and May 1, 2025 to May 19, 2025. When the Kitchen Manager was asked how the temperatures were acquired for May 2025, the Kitchen Manager admitted to falsifying the temperatures for May 1st to May 18th, 2025.

Based on observation, interview, and review of facility policy, the facility failed to provide regular dishware during meal service, in order to promote a homelike environment for all residents in the facility. Findings include: Review of the undated facility policy titled, Food and Nutrition Services Manual revealed, 5. Disposable Dishware and Utensils-Disposable items shall be used only under circumstances where reuse of standard dishware is not feasible or safe. Single-use items (plates, cups, utensils) are permitted during: Dish machine malfunction, Infection Control isolation, and Resident-specific dietary restrictions or requests . During a dining observation on 05/18/25 at 12:43 PM, Certified Nursing Assistants (CNA)s were observed applying hand sanitizers to their hands and shortly thereafter removing lunch trays from a tall, silver bin in the hallway. Some meal trays were being served using regular dishware, while some meal trays were being served using styrofoam containers. During an interview on 05/19/25 at 10:00 AM, with the Resident Council, R60 stated that no condiments are received with meals, and they are served in styrofoam boxes that cause soup to spill and make their sandwiches soggy. R13, who is the Resident Council President, stated that food is their number one problem, sometimes we will be given plates with no dividers. Last night we had stale bread with one slice of cheese, and tomato soup in a container. R13 proceeded to show a picture of the soup and a sandwich meal he was provided a styrofoam container. R46 stated, We get plastic utensils. During an interview on 05/19/25 at 1:47 PM, the Registered Dietician (RD) stated that he is only here once a week and unsure of the reasoning for the use of styrofoam containers. While speaking with the RD, a loud crash was heard coming from the dishwasher area of the kitchen. In response to the loud noise, the RD stated, As you can hear we are constantly breaking dishware. The RD further explained that he is mainly responsible for assessing the nutritional needs of residents and therefore has a very limited role on the service side of the kitchen. During an interview on 05/19/25 at 2:02 PM, the Kitchen Manager (KM) stated that styrofoam containers and disposable eating utensils are used due to a lack of regular dishware supplies. He further stated, Dishes often get broken, and silverware gets missing. We are constantly having to purchase replacement dishware. During an observation and interview on 05/20/25 at 7:19 AM, the Lead [NAME] stated that there were no current issues with the dishwasher and that they have continued to use styrofoam containers and plastic utensils because they keep breaking plates.

Based on observation, interview, and review of the facility policy, the facility failed to provide privacy during Resident Council meeting for 5 residents who attended, Resident (R)13, R46, R20, R60, R21. Findings include: Review of the facility policy titled Resident Council dated September 2018, revealed that the policy does not address privacy during resident council meetings. On 05/19/25 at 10:00 AM, a Resident Council Meeting was held in the Veterans room located outside of the dining room of the facility. In the Veterans room were 2 (two) doors, that led to staff offices. In attendance was 2 (two) surveyors conducting the meeting and 1 (one) surveyor observing. The current Resident Council President was in attendance, with four (4) other residents in attendance. The door to the Veterans room was closed with a sign posted on the outside of the door indicating Resident Council Meeting including the date and time. Observations during the meeting revealed staff coming and going through the Veterans' room during the Resident Council meeting. During observation of the Resident Council meeting held on 05/19/25 at 10:00 AM, the meeting was interrupted multiple times by staff entering the Veterans room where the meeting was being held. During interviews on 05/19/25 at 10:00 AM, R13, R20, and R60, all stated that staff always come in out of the room during the Resident Council Meetings. During an interview on 05/19/25 at approximately 10:15 AM, R60 stated, The Resident Council Meetings are normally held in the main dining room which there are continuous staff interruptions and lots or noise coming from the kitchen staff, and the meetings are never private. During an interview on 05/20/25 at 10:14 AM, the Activity Director stated, Resident Council meetings are held in the main dining room. Privacy is ensured by closing the door to the dining room. The staff know not to interrupt during the meetings. There is a sign that gets posted on the dining room door indicating the Resident Council meeting is in process. During an interview on 05/20/25 at 10:29 AM, R13 (resident council president) stated, The resident council meetings are not private. The meetings are held in the dining room. The staff are constantly coming and going in and out of the room during the meeting. There is no signage on the door indicating the Resident Council meeting is in progress. The Activity Director leads the meeting. The Administrator has been present at the meetings he has attended. The residents are in fear of retaliation, so they are intimidated to speak during the meeting because they are too busy watching the staff coming and going during the Resident Council meetings. During an interview on 05/20/25 at 10:55 AM, the Administrator stated he attended 3 Resident Council meetings. The Administrator further stated his expectation of the Resident Council meetings is for privacy during the meetings and no interruptions. Meetings are always held in the main dining room. When there is a Resident Council meeting it is announced in the morning staff meetings for the staff to know. The signage of the Resident Council meeting has not been posted, far as he has seen.

Based on review of facility policy, observation and interview, the facility failed to ensure medications were free of expiration, failed to ensure narcotic boxes were permanently affixed, failed to discard medication after discontinuation of medication, failed to ensure treatment carts were locked when unattended, and failed to sign narcotics out from narcotics sheet for 2 of 3 unit medication rooms and 2 of 3 medication carts. Findings include: Review of the undated facility policy titled, Storage of Medications states in the policy heading, The facility stores all drugs and Biologicals in a safe, secure . manner. The policy also states, #4. discontinued drugs or biologicals are returned to the dispensing pharmacy . #6. Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. #8. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Review of the facility policy dated 2001, titled, Administering Medication states in the policy, #12. The expiration date on the medication label is checked prior to administering. During an observation on [DATE] at 10:55 AM, revealed an unlocked treatment cart on the unit by the nurses station and unattended. There were no nurses at the nursing station. During an observation on [DATE] at 9:10 AM, revealed an unlocked treatment cart by the nurses station. All nurses were passing medication. No nurses were in the vincity of the unlocked cart. During an observation on [DATE] at 1:20 PM, revealed an unlocked treatment cart by the nurses station. There were no nurses at the nurse station. Upon opening the treatment cart, the following contents were observed: Metronidazole Gel USP 0.75%, Apply gel topically twice daily for 14 days, dated [DATE]. An open tube of triple antibiotic ointment, missing a cap was also in the cart. The Assistant Director of Nurses (ADON) was walking past the unit, and walked over when called. She stated, it should have a cap on it, I will discard it. During an interview on [DATE] at 1:25 PM, the Assistant Director of Nursing (ADON) stated the treatment cart should not be unlocked unless they are using it. The ADON confirmed the date on the Metronidazole Gel USP 0.75 % was [DATE]. The ADON stated the Metronidazole is finished as of [DATE]. It should not be in the treatment cart. During an observation and interview on [DATE] at 9:00 AM, of the [NAME] Medication (Med) Room with Licensed Practical Nurse (LPN)2, revealed the narcotic lock box was kept in the refrigerator and was locked. The narcotic lock box was not permanently affixed. The narcotic lock box contained 3 vials of Ativan. LPN2 stated, we've not had the narcotic box attached to the refrigerator. During an observation on [DATE] at 9:15 AM, of the TCU Med Room with LPN5 Unit Manager, revealed the narcotic lock box was kept in the refrigerator and was locked. The narcotic lock box was not permanently affixed. The narcotic lock box contained 10 vials of Ativan. LPN5 confirmed the narcotic lock box was not permananetly attached to the refrigerator. On [DATE] at 9:30 AM an interview with the Director of Nurses (DON). She said she ordered clear narcotic boxes for all the nurses, and said we will superglue them to the refrigerator. On [DATE] at 10:57 AM an observation of A Medication Cart [NAME] Unit with LPN 7. An open bottle of Acidophilus was in the stock drawer. The label states to store in refrigerator after opening. LPN 7 said we leave the acidophilus on the med cart and she confirmed it was open. She stated, I did not know it was supposed to be refrigerated. A bottle of Geri Care Vitamin E 160 milligram (mg) (400 international unit (IU) with best by dated ,d+[DATE]. LPN 7 confirmed it was expired. 2 bottles of Refresh tears were observed without open dates, but confirmed by LPN 7 to be open, as well as 4 Nasacort Allergy spray bottles, without an open date but confirmed to be open. LPN 7 confirmed they are good for 60 days after opening. On [DATE] at 11:25 AM an interview with LPN 2, Unit Manager. She said the eye drops and Nasacort need to be dated. We can't confirm when they were open to follow the expiration date after opening. On [DATE] at 11:28 AM an observation of TCU Unit Medication Cart B with LPN 8. During a narcotic count of medication, 2 cards of narcotic medication did not match what was on hand on the cards. One narcotic sheet recorded Oxycodone 5 mg tablet, 15 remaining. The matching Narcotic card had 14 tablets of Oxycodone 5 mg tablet remaining. Additionally, the second narcotic sheet recorded 26 tablets of Tramadol 50 mg, however the card of Tramadol had 25 tablets on hand. On [DATE] at 11:30 AM LPN 8 and LPN 5, Unit Manager confirmed the narcotic cards and narcotic medication records do not match. LPN 5, UM stated, The narcotics should match. On [DATE] at 12:01 PM an interview with the Director of Nurses (DON). She stated, If any meds are expired or discontinued or changed, I expect them to remove them from the cart to avoid potential errors. Unit Managers (UM) are to check the Med Room daily, checking the cart for loose pills, everything labeled, with an expiration date, and resident names on the meds. For a narcotic cart, one nurse checks the cart, the other the sheet, both visualize the med card and count sheet together. If there is a discrepancy, they let me or the Assistant DON know. Then we will investigate. The med sheets are to match the narcotic count sheet. The narcotic boxes are counted with the off going and oncoming nurse together. The med cart and treatment cart should be locked when not attended. Medications are never left at bedside. I expect the nurse to watch that the medication is taken when they are giving it.

Based on review of facility policy, observation, interview, and record review, the facility failed to ensure the call light was within reach for Resident (R)107, for 1 of 1 resident reviewed. Findings include: A review of the facility policy titled Signal System Policy with no revision date, revealed the following: 1. Be sure the call light is always plugged in. 2. The call light shall be placed within the reach of the resident. 3. Any call light not working appropriately will be reported immediately to the supervisor. 4. Call lights will be answered as soon as possible. 5. For residents unable to utilize the call light, staff will monitor these residents frequently by making rounds. 6. If the call light system becomes inoperable at any time, bells will be distributed to each resident for use to signal staff of needed assistance. Review of R107's Face Sheet revealed an admitted [DATE], with diagnoses including but not limited to: Alzheimer's disease, cognitive communication deficit, other lack of coordination, and Parkinson's disease without dyskinesia. Review of R107's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/08/25, revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the resident was severely cognitively impaired. Further review of the MDS revealed R107 required substantial/maximal assistance for transfers and toileting. Review of R107's Care Plan revealed, ADL/Mobility [R107] has actual ADL/mobility decline and requires assistance related to fluctuating ADLs, recent hospitalization , weakness, abnormalities of gait and mobility Date Initiated: 05/02/2025 Revision on: 05/15/2025. Intervention: Encourage to use call light for assistance . Falls: [R107] is at risk for falls with or without injury related to decreased muscular coordination, seizure disorder, poor safety awareness. Date Initiated: 05/15/2025. Intervention: Educate/remind resident to call for assistance with all transfers. During an observation and interview on 05/18/25 at 11:44 AM, revealed no call light cord observed on R107's side of the room. R107 stated he didn't have one. During an observation and interview on 05/18/25 at 12:00 PM, revealed no call light cord observed on R107's side of the room. R107's roommate revealed, R107 has had no call light for a few days and the roommate would push his call light if R107 needed help. R107's roommate stated if he leaves his room, R107 would have to wait for assistance until he gets back or wait for a staff member to come in and check on him. During an observation on 05/19/25 at 8:58 AM and 10:37 AM, revealed no call light cord on R107's side of the room. During an interview with Certified Nursing Assistant (CNA)1 on 05/19/25 at 1:40 PM, CNA1 confirmed being R107's aide. CNA1 states from the time she clocks in she receives report from the previous shift aides and check on the residents to ensure they have their morning ADL care, and ensure they have their call lights on them or within reach. CNA1 states call lights are also supposed to be checked during rounds, which is every 2 hours or as needed. CNA1 then confirmed R107 had no call light cord on his side of the room, and stated she didn't realize he didn't have one. CNA1 stated that in the case of emergency, he wouldn't be able to voice his needs. During an observation and interview with License Practical Nurse (LPN)5 on 05/19/25 at 1:47 PM, LPN5 confirmed R107 didn't have a call light cord in his room, and he should have had one. LPN5 stated they were unsure why or how long R107 didn't have one. During an interview with the Maintenance Director (MD) on 05/19/25 at 1:50 PM, revealed the MD utilizes an electronic system called TELS (work order system for repairs). The MD stated all department heads have access to place a work order if something needs repair or as simple as an extra call light cord. The MD explains CNAs are to communicate to their nurse, and their nurse is to place a work order in, once received, he follows up on it. The MD further stated there has been no work order requesting an extra call light cord. During an interview with the Director of Nursing (DON), in the presence of the Facility Administrator, on 05/19/25 at 2:07 PM, revealed they were unaware of R107 not having a call light. Both the DON and Facility Administrator agreed call light cords should be accessible, and everyone should have a cord. Both agreed that their expectation is to check it while doing rounds.

Based on review of facility policy, observation, interview and record review, the facility failed to ensure a clean, sanitary homelike environment was provided for Resident (R)30, for 1 of 1 residents reviewed for homelike environment. Findings include: Review of the facility policy dated 2001, titled, Homelike Environment revealed in the policy statement, Residents are provided with a safe, clean, comfortable and homelike environment . The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a clean, sanitary and orderly environment; pleasant, neutral scents. Review of R30's Face Sheet revealed he was admitted to the facility on [DATE], with diagnosis including, but not limited to: personal history of transient ischemic attacks, type 2 diabetes mellitus, epilepsy and atherosclerotic heart disease. Review of R30's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/05/25, revealed he had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating he was cognitively intact. Review of R30's Care Plan, revealed a problem area of refusing showers and refuses to request assistance, however there was no care plan addressing the foul odor in the room or interventions to minimize the odor/cleanliness of the room or of R30's person. Review of the Wheelchair Washing Schedule revealed, 11p-7a CNA's are responsible for washing wheelchairs (W/C). Review of the Wheelchair Washing Sign-Off Log dated May 2025 recorded 2 days that R30's room was scheduled and signed as the wheelchair being washed. During an observation on 05/18/25 at approximately 2:10 PM, a foul odor was noted in R30's room and the hallway leading up to the room. During an observation on 05/19/25 at 9:19 AM, the same foul odor was noted near R30's. Licensed Practical Nurse (LPN)6, who was at her medication cart a room away, confirmed it was from R30 and stated, It always smells like that. During an observation on 05/19/25 at 9:20 AM, R30's room still had the same foul odor, which resemble the odor of a bowel movement. R30 was lying in bed with his eyes closed and the blanket pulled up covering his head. An attempt to speak to him, but was unsuccessful. An observation of a pair of slippers located on the cushion seat of his wheelchair (W/C), appeared to have dried bowel movement, embedded inside both slippers. The W/C was beside R30's bed. When standing closer to the W/C with the slippers, the same foul odor was even stronger and permeated throughout the room, and was the same odor noted during previous observations. An observation of 2 plastic water pitchers at R30's bedside, the plastic clear straws had black debris on each straw. Inside one water pitcher the liquid was pink, in the other water pitcher the liquid was dark brown, both were full. There was debris along the baseboard of the room, dried substance on the wall by the air conditioner and heavy coating of dust on belongings on the resident's table and on a radio. On 05/19/25 at 2:03 PM, an interview with the Maintenance and Environmental Director revealed R30 smears BM (bowel movement) on the walls. He can't help it, it's his disease. Upon walking towards the room, the foul odor was noted before entering room. Upon entering the room they confirmed the black debris on the residents 2 water pitcher straws. They confirmed how dirty the residents things were on his bedside table and the radio on the floor covered in dust, debris on the wall by the air conditioning unit and around the baseboards. They confirmed the dried substance in the residents slippers that were located in his W/C seat. They said my housekeepers go in to clean, but he refuses for them to touch his things. On 05/19/25 at 2:35 PM, an interview with Certified Nurse Assistant (CNA)8, confirmed she was R30's CNA and stated, R30 doesn't ask for help. His room always smells foul. We do an ice round in the mornings or afternoon. CNA8 confirmed the 2 water pitchers at his bedside, she said those have probably been there a while. One had brown liquid the other had pink liquid. CNA8 confirmed the straws each had a black substance on both of them at the tip. She said if it's their own personal cup, we will clean it ourselves, rinse it out with soap and hot water. She said someone will take care of that, possibly throw them away and get him clean ones as she walked away. On 05/19/25 at 2:40 PM, an interview with Licensed Practical Nurse (LPN)6, confirmed there was bowel movement in R30's slippers and also confirmed the foul odor in the room. LPN6 stated, We wash them multiple times, its a daily thing. She also confirmed the black substance on the tip of both straws. On 05/20/25 at 10:47 AM, an observation revealed dried bowel movement on R30's W/C seat cushion. Also, his slippers, located on his W/C seat appeared to have dried bowel movement embedded in them with a strong odor emanating from them. Additionally, the 2 water pitchers at bedside with black debris on both straws was observed, it appeared to be the same drink as the previous day, a pink drink and a dark brown drink. R30's room still had a foul odor of bowel movement. On 05/20/25 at 10:51 AM, an interview with LPN7 revealed, The straws in [R30's] drink pitchers in the room are dirty, BM is on his seat, and I could smell BM stronger when you stand over his slippers. His W/C is soiled all the time. On 05/20/25 at 12:50 PM, an interview with the Director of Nurses (DON) revealed the CNA's should go in the room every 2 hours, ensure residents have fresh water available. The DON stated, I interact with [R30] often, he always had that odor on him. I'm not aware his slippers may have BM in them. The W/C's are cleaned on night shift. If the straws have deposit on it, they should have been thrown out. [R30] is care planned for refusal and non compliance. I'm not aware of anyone going in and speaking to him about his hygiene and odor, but I will. On 05/20/25 at 1:15 PM, an interview with the Administrator revealed they deep clean rooms, I'm not sure of the frequency. I feel staff come in with the mentality that I'll do the least amount of work if they know a resident refuses, I feel they may take advantage and not clean like they should. The Administrator confirmed he was not aware of the odors from R30's room. On 05/20/25 at 2:56 PM, a follow up interview with the Maintenance/Environmental Director and the Administrator. The Maintenance/Environmental Director stated R30 refuses, they just have to work around that. He stated, If he doesn't want them to touch his items, they clean around it. Nothing you can do with baseboard. I don't have records that I can show you for deep cleaning. It takes about 2 weeks before you get back to deep cleaning the same room again.

Based on observation, interview, record review, and review of the facility policy, the facility failed to identify and assess Resident (R)43's skin wounds located on the bilateral lower extremities, for 1 of 2 resident reviewed. Findings include: Review of the undated facility policy titled, Skin Assessment documents, Skin Assessment-Inspect the skin on a daily basis when performing or assisting with personal care or ADLs . Monitoring-1. Evaluate, report, and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. Review of R43's Progress Note dated 05/16/25 with a timestamp of 10:29 AM, confirmed no indication of any skin wounds. Specifically, no information was provided under Section C (Skin). Items 1C (Current Skin Condition), 2C (Progress), and 3C (Comments) were all blank. Review of R43's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/02/25, revealed under Section M-Skin Conditions, no wounds, no injuries, nor any ulcers were documented. During an observation and interview on 05/18/25 at 11:19 AM, the son of R43 reported bilateral bruises on the front of his mother's shins. R43's son proceeded to ask his mother's permission to expose her leg bruises. Upon observation and after being granted permission, the bruises appeared to be in the healing process with a thick crusted scab on top of a slightly reddened area approximately a nickel size in diameter on the front shin of both of her legs. R43's son stated that the staff was unable to verify how the wounds came about. He further commented that no further information nor any updates have since been provided. During an interview on 05/19/25 at 3:44 PM, the Floor Unit Nurse Manager, Licensed Practical Nurse (LPN)4, was unable to verify how R43 acquired her bilateral shin wounds. When advised that there was no record and/or documentation of a skin wound charted, LPN4 provided no further response. During an interview on 05/19/25 at approximately 2:00 PM, an unspecified Certified Nursing Assistant (CNA) stated that the wounds had been there for an extended period (at least a couple of months) and had been reported previously. During an interview on 05/19/25 at 4:54 PM, with the facility's former Wound Care Nurse and current Assistant Director of Nursing (ADON), LPN3. The ADON stated that the bilateral leg wounds on R43 was brought to her attention today 05/19/25. The ADON further stated that once inspected, she believed upon her observation that the wounds were most closely associated with what appeared to be venous stasis ulcers. Additionally, LPN3 stated that the wounds, in her opinion, were associated with an initial unknown impact that caused bruising and was not associated with any superficial scratches. LPN3 stated, Venous ulcers start as open lesions that open up quick and when treated will get smaller. The ADON stated that skin assessments are done every week and believed the wounds formed 3-4 days ago.

Based on review of facility policy, record review, observation, and interview, the facility failed to assess Resident (R)26 and R270 for self administration of medication, for 2 of 3 residents reviewed. Findings include: Review of the facility policy titled, Self-Administration of Medications with a revised date of February 2021, documented, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident . 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan . 4. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications . 1. Review of R26's Face Sheet revealed R26 was admitted to the facility on [DATE], with diagnoses including but not limited to: encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dyshagia, bipolar disorder, contracture of right shoulder and right hand, manic episode, sever with psychotic symptoms, and seizures. Review of R26's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/25, revealed R26 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated R26 had severe cognitive impairment. Review of R26's Care Plan revealed the following problem areas: Self Care Deficit R/T impaired mobility, including oral care, debility, weakness, hx. of CVA with hemiparesis, contracture right hand, DM, incontinent of B&B, copd, neuropathy d/t pvd, onchomycosis, hx tia, convulsions, VITAMIN D DEF., VITAMIN B DEF. RESIDNT WITH RIGHT HAND SPLINT Date Initiated: 07/29/2016 and ALTERATION IN THOUGHT PROCESS-AEB SHORT TERM MEMORY LOSS, LONG TERM MEMORY LOSS, PROBLEMS WITH RECALL AND IMPAIRED DECISION MAKING R/T CVA, Encephalopathy Date Initiated: 03/12/2024 Revision on: 03/12/2024. Further review of the Care Plan did not revealed a Care Plan related to self administration of medications. Review of R26's Physician Orders, did not reveal an order for self administration of medication. Review of R26's Electronic Medical Record (EMR) did not reveal documentation that R26 was assessed for self administration of medication. During an observation and interview on 05/18/25 at 11:36 AM, R26 was laying in bed, with the bed side table over his midsection. Observation of the bed side table revealed a pill cup containing 1 white oblong pill labeled G12 and another triangle shaped pill labeled UU. R26 stated he does not know what the pills are. R26 further stated he takes his own medications everyday, they (nurse) drop it off and he takes it when he wants. During an observation on 05/20/25 at 9:26 AM, R26 was eating breakfast, with the breakfast tray on the bed side table over the resident midsection. Further observation revealed a pill cup on the breakfast tray, the pill cup contained multiple pills and 1 oblong pill was directly on the breakfast tray. As this surveyor asked R26 about the pill cup, R26 grabbed the pill cup, and loose pill, off the breakfast tray and wrapped both hands around the cup, in order to hide the contents from this surveyor. R26 began shaking his head. This surveyor exited the room in order to prevent R26 from becoming agitated. During an interview on 05/20/25 at 9:29 AM, Licensed Practical Nurse (LPN)1 stated, He is able to self administer, he used to be a pharmacist and he is adamant about taking his own meds. I tried to stay in there and watch him take it. When I tried to take them away he grabbed the pills. I explained that he needed to take the meds because DHEC was here. During an interview on 05/20/25 at 9:50 AM, LPN2 who is also the Unit Manager, stated, He should not be self administering. He can be difficult sometimes with taking his meds. When we try to take it away he'll snatch them. We should not be leaving the meds in his room for him to self administer. During an interview on 05/20/25 at 10:00 AM, the Director of Nursing (DON) revealed medications should be administered while the nurse is in there. The DON concluded the resident should swallow the meds before the nurse leaves. During an interview on 05/20/25 at 10:00 AM, the Administrator stated even if he was able to self administer the medications, the nurse should have watched. Surveyor: [NAME], [NAME] 2. Review of R270's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to hypertension, Type 2 diabetes mellitus with diabetic polyneuropathy (nerve damage), major depressive disorder and foot drop. Review of R270's Baseline Care Plan did not revealed a Care Plan addressing R270's self administration of medication. During an observation on 05/18/25 at 10:13 AM, medication was observed on the over bed table in R270's room, 2 pills were observed, each in an individual med cup. R270 was not in the room. During an interview on 05/18/25 at 10:14 AM, Registered Nurse (RN)1 confirmed the medications were on R270's overbed table. RN1 stated the medications should not be in the room at bedside. RN1 stated he handed the med's to R270 and he was getting ready to go to therapy. RN1 concluded R270 must have sat them down and forgot to take them. Review of R270's Assessments revealed there was no assessment for self administration of medication. Review of R270's Physician Order did not revealed an order for R270 to self administer medication. During an interview on 05/19/25 at 1:12 PM, R270 confirmed the nurse did give him 2 medications yesterday. R270 stated, Therapy came in and took me from the room before he had a chance to take them. R270 concluded he was going to take them when he came back. During an interview on 05/20/25 at 12:01 PM, the DON stated, Medications are never left at bedside. I expect the nurse to watch that the medication is taken when they are giving it. 48835

Based on observation, staff interview, resident interview, and review of the facility policy, the facility failed to maintain safe hot water temperatures within non-hazardous ranges for 12 of 121 (R) residents (R31, R272, R52, R75, R22, R9, R74, R55, R93, R103, R81, R100). The assistance of the facility's Maintenance Director was requested and on 02/28/22 at 8:28 PM, water temperatures were measured by the Maintenance Director, utilizing the facility's Raytek noncontact thermometer. Temperatures above 120 degrees Fahrenheit (F) were discovered for the following resident conjoined bathrooms: 131-133 degrees F in rooms 6 and 7, 131 degrees F in rooms 9 and 10 (where steam was observed rising from the sink), 132 degrees F in rooms 11 and 13, and 132 degrees F in rooms 12 and 14 (steam was observed rising from the sink). The Maintenance Director stated he had been using the thermometer, which was provided by the facility, for a year. He said he calibrates it every month and records the water temperatures for each unit. The Maintenance Director further stated he documents the temperatures in the facility system called The Equipment Lifecycle System (TELS). He also stated that there were nine water heater units for the whole facility, with two water heaters on the Transitional Care Unit (TCU) unit. On 02/28/22 at 11:20 PM, the Administrator and the Director of Nursing (DON) were notified that the facility neglected to provide the residents with safe water temperatures. The temperatures from the bathroom sink for the conjoined rooms 6 and 7(occupied by R9, R74, & R100), 9 and 10 (occupied by R75, R22, & R81) , 11 and 13 (occupied by R31, R55, & R93), and 12 and 14 (occupied by R272, R152, & R103), and one of three shower rooms were above 120 degrees Fahrenheit. The facility's failure to provide safe water temperatures to the above rooms had the potential for serious injury, serious harm, serious impairment, or death. The IJ existed on 02/28/22. On 03/01/22 at 4:57 PM, the facility presented an allegation of compliance indicating the removal of the immediacy. The survey team validated the allegation of the compliance plan and the facility remained out of compliance with an F689 at a lower scope and severity of E (pattern with potential for minimal harm) following the removal of the IJ. Findings include: Review of the facility's policy titled Water Temperatures, Safety of, dated December 2009 reads the following: .water heaters that service resident room, bathrooms, common area, and tub/shower areas shall be set to temperatures of no more than 120 degrees F. (Fahrenheit) or the maximum allowable temperature per state regulation. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. During the initial tour on 02/28/22 at 6:15 PM, hot water temperatures were checked in residents' rooms to determine if there were any extreme hot water temperatures. The water was initially tested by touching, but after detecting uncomfortable temperatures, thermometers were used for testing. The assistance of the facility's Maintenance Director was requested and on 02/28/22 at 8:28 PM, water temperatures were measured by the Maintenance Director, utilizing the facility's Raytek noncontact thermometer. Temperatures above 120 degrees Fahrenheit (F) were discovered for the following resident conjoined bathrooms: 131-133 degrees F in rooms 6 and 7, 131 degrees F in rooms 9 and 10 (where steam was observed rising from the sink), 132 degrees F in rooms 11 and 13, and 132 degrees F in rooms 12 and 14 (steam was observed rising from the sink). The Maintenance Director stated he had been using the thermometer, which was provided by the facility, for a year. He said he calibrates it every month and records the water temperatures for each unit. The Maintenance Director further stated he documents the temperatures in the facility system called The Equipment Lifecycle System (TELS). He also stated that there were nine water heater units for the whole facility, with two water heaters on the Transitional Care Unit (TCU) unit. According to TELS Logbook Documentation, the water temperature measured 100 to 115 degrees F. on the dates of 8/2/21- 8/6/21, 8/30/21-9/3/21, 9/27/21-10/1/21, 11/8/21-11/12/21, 11/15/21-11/19/21, 12/6/21-12/10/21, and 12/27/21-12/31/21 for the front offices, [NAME] unit, TCU unit, and [NAME] unit. According to TELS Logbook Documentation, the water temperature measured 100 to 120 degrees F. on the dates of 1/3/22-1/7/22, 1/10/22-1/14/22, 1/17/22-1/21/22, and 1/24/22-1/28/22 for the front offices, [NAME] unit, Trans unit, and [NAME] unit. According to the TELS Logbook Documentation, the water temperature measured 100 to 115 degrees F. on the dates of 2/21/22-2/25/22 for the front offices, [NAME] unit, Trans unit, and [NAME] unit. On 02/28/22 at 9:16 PM, during a telephone interview with the Maintenance Director, he stated that there had been no concerns from the residents or staff members regarding the hot water. He confirmed there was no outside company that would come in to adjust the temperature on the water heaters. The Maintenance Director stated he did it himself. He stated that the two heaters on the TCU unit were about two or three years old. He can boost up the water heater where the gauge is between 100 to 160 degrees F. He states TCU unit is set to 115 degrees F. He stated that the right temperature for the residents is between 100 to 120 degrees F. He said it would alarm him if the hot water temperatures measured 130 degrees F or above. On 02/28/22 at 10:00 PM, the surveyors walked with the Maintenance Director to test the water temperatures in the following areas: [NAME] Unit shower room: 99 degrees F; [NAME] Unit shower room: 99 degrees F. The Maintenance Director did a video call with the surveyors while he went to the COVID unit. Hot water temperatures for the TCU shower room measured 140-141 degrees F, Room 16 - 157 degrees F, Room 19 - 110 degrees F, and Room 22 -120 degrees F. On 02/28/22 10:48 PM, the surveyor asked the Maintenance Director to explain the difference between the temperature degrees from the TELS Logbook Documentation for the date of 02/25/22 being between the temperatures of 100-115 degrees F. to on the date of survey 2/28/22 with temperatures being at or higher than 130 degrees F. The Maintenance Director stated that he was not sure how the changes occurred over the three days. On 03/01/22 the following water temperatures were observed as the corporate Maintenance Director measured the readings: 1:25 AM, conjoined rooms 11 and 13 measured at 97.2 degrees F 1:27 AM, conjoined rooms 12 and 14 measured at 98.5 degrees F 1:32 AM, conjoined rooms 9 and 10 measured at 99.5 degrees F 1:35 AM, conjoined rooms 6 and 7 measured at 99.0 degrees F 1:40 AM, COVID-19 shower room was measured at 94-95 degrees F 1:43 AM, private room 16 was measured at 94-95 degrees F

Based on record review and interviews, the facility failed to provide adequate supervision to 1 of 3 residents reviewed for injuries. Resident #3 had repeated falls with injuries and did not receive adequate supervision to prevent falls/injuries. The findings included: Resident #3 sustained falls on: 2/28/17- No injury. 3/17/17- Laceration over left eye. 3/29/17- fell on right knee, bruise resulted to left forearm. 4/11/17- Fall with redness to right shoulder, lower back and ribs. 3:00 PM, 2nd fall of day- neurochecks. 4/16/17- Fall with laceration of left eye, resulted in sutures. physician progress notes [REDACTED]. Precautions included 101 (one on one) may be necessary. Staff was not with resident when fell on [DATE] and sustained laceration which required sutures. The facility admitted resident #3 with [DIAGNOSES REDACTED]. Review of the medial record revealed an Annual Minimum Data Set (MDS) of 12/22/2016. The resident was noted to have a Brief Interview for mental status (BIMS) score of nine (9). The resident had cognitive deficits. S/he was coded extensive assist with all Activities of Daily Living (ADL's) except supervision was required with eating. S/he was coded to have had one (1) fall with no injury. Review of the Quarterly MDS of 3/24/17 revealed BIMS score remained at 9. Moderately impaired cognition. No behaviors listed. The resident was non-ambulatory. S/He was unsteady with transfers. The resident was coded to have had two (2) falls with no injury and 2 falls with injury. S/he was coded to have had antipsychotics and antidepressants for 6 days of the look back period. S/He was coded to have received 7 days of antianxiety meds. Further review of the medical record revealed Physicians Progress Notes: 2/20/2017: S/he has difficulty communicating due to physical and cognitive impairments. S/he has been given Klonopin scheduled twice a day and Ativan when necessary which s/he reportedly tolerates very well and works well for the patient. S/he has required Ativan as needed several times over the past month but does not typically need it on a daily basis .The psychiatry team have also been involved in helping to manage the patient .Apparently the patient also had an elopement and there were adjustments made the psychiatry team to augment treatment including changes to Depakote and Ativan We will continue to follow the patient very closely and monitor for any signs or symptoms of adverse reactions or underlying complications . 2/28/17: Agitated belligerent behavior with recurrent falls. This patient has episodes of agitated behavior. S/he has no judgement about what s/he does and often will escape any fall precautions that we implemented. We need to monitor her/him closely. S/He's been more agitated. The patient is a high risk for falls. Precautions including 101 may be necessary. 3/23/17: Has very hostile behaviors at times. Psychiatry added Depakote sprinkles. S/He continues to have significant agitation . 4/13/13: S/he repeatedly gets up from wheelchair. S/he is not safe. S/he has to be watched constantly. Nurses say Ativan does not help. At times s/he is extremely hyperactive. The patient has had multiple falls and they say that Haldol did work on one occasion when it was ordered. S/He has sutures over her/his left eyebrow. They are clean and dry. Plan: Worsening behaviors and branches off of associated with a decline in function and increased likelihood of death. S/he remains at high risk for falls. 4/17/17: S/He is not safe. S/He has to be watched constantly. The patient continues to have falls. The care plan team does not appear to be able to put together a successful care plan for preventing them. The best one so far is one to one which I suggested they consider last week. Uncertain of the number of falls . I think we need to seek care at another environment until s/he can be managed better . We will refer him to administration to decide about 1 on 1. ADDENDUM: The resident went to the emergency room as a result of a fall. The resident had a facial laceration and sutures Review of the Nurses Progress Notes revealed: 2/26/17: Resident extremely agitated, constantly attempting to get up without assistance. Becomes combative when staff tries to redirect. 2/28/17: No complaints from recent fall. 3/7/17: Increased agitation noted. Sitting in wheelchair getting up and down repeatedly. Will continue to monitor. 3/8/17: Continues to attempt to stand without assist no injuries noted related to recent fall. 4:34 PM sitting at nurses desk in wheel chair. Noted to be calm and cooperative. 3/15/17: Resident increased anxiety, as needed medication (PRN) administered. 3/17/17: Resident sitting in wheelchair at the nursing station. Attempted to stand without assistance, and fell forward onto the floor, nurses heard alarm sounding and attempted to prevent fall. Nursing assessment complete. Laceration above the left eye. Area cleaned with normal saline. Triple antibiotic ointment (TAO) applied and covered with a dry dressing. Wound measurement 2.5 x 0.5 centimeters. 3/20/17 new order for physical therapy (PT) to evaluate related to recent fall. PT determined no intervention through them is necessary at this time. RP notified. No adverse effects r/t recent fall. Continues with neuro checks. 3/29/17: Resident was attempting to get out of wheelchair and ended up on his right knee. Assisted back into w/c ROM normal, Nurse Practitioner (NP) in facility and notified. Son notified. 3/30/17: Discolored area to left forearm from recent fall. 4/6/17: Resident continues to have increased anxiety and attempting to rise from wheelchair unassisted. This nurse has provided 1:1 care to maintain safety. 4/10/17: Resident continues to have increased anxiety with hitting staff and trying to bite this nurse's arm. Continuing to monitor. This nurse providing 1:1 care for pt safety. 4/11/17: 13:18 speaking with family member regarding care, alarm sounding in dining room and family member yelled ___ fell This nurse and Medical Doctor (MD) ran into dining room and noted resident lying on his back with head near another chair. Resident moving lower extremities without grimacing. Redness noted to right shoulder, lower back and rib. Assisted back to chair, RP and NP notified. 3:11 PM, Resident noted on floor on back in TV room. ROM within normal, PEARL assisted back into chair. Neurochecks started, Resident escorted back to room. NP and son notified. 4/12/17: No complaints from recent fall. Resident has been extra restless today, trying to stand. Was toileted and given food and drink and tried to redirect without effects. PRN was administered without effects. Had to have 1:1 all day. 4/13/17: continued to need 1:1 constantly trying to get up unassisted, 9:18 PM Continues to have increased agitation and attempting to hit staff. This nurse spoke with son. RP stated he would come and try to sit with resident but was unavailable tonight and asked this nurse to go ahead and administer the PRN Haldol. Haldol administered in L deltoid. 4/16/17: Resident sitting in front of nursing station, alert and confused. Wheelchair alarm went off, nurse and CNA discovered resident on floor. Laceration above left eye, area cleaned, pressure applied. MD notified orders to send to ER. Dr. in facility to evaluate. Spoke with son regarding sending to Hospital for psych evaluation. RP stated he would have to digest that first. 4/17/17: Psychosocial: Sent referral to Hospital Geri-Psych. Resident not a candidate for services related to larynx. Notified Dr. to follow up on next visit. 4/17/17: Son refused physical therapy. Gave resident a false sense of security. Continued neurochecks and one on one. 4/18/17: Continued neurocheck and 1:1. 4/19/17 no concerns. 4/20/17: No concerns. Licensed Practical Nurse (LPN) #1 was interviewed by the surveyor on 8/17/17 at approximately 9:04 AM. The nurse stated the resident had interventions in place and had been sitting in front of the nurse's station. The nurse stated s/he was sitting at the table in the day area and had the resident in sight. Her/his alarm went off. I saw her/him leaning forward. I could not get to her/him in time. S/he has had a sitter off and on. Three Certified Nursing Assistants (CNAs) on the unit second shift, on weekend. It was after 3:00 PM. S/he needed a sitter 24 hours a day . There was only three CNA's on duty on the unit. The facility stopped the sitter. Two CNA's were interviewed by the surveyor on 8/17/17. The two CNAs stated they did not witness the fall. CNA #1 stated s/he was assigned to the resident on the day s/he fell . The CNA stated s/he had taken the resident to the nurse's station while s/he went to lay other residents down. The CNA stated the resident was left with the nurse. CNA #2 stated s/he was picking up trays and heard the alarm. Did not witness fall. Heard alarm and observed resident on floor with nurse standing near her/him.

Based on record review and interview, the facility failed to provide sufficient nursing staff to prevent accidents with injuries for 1 of 3 residents reviewed for accidents/injuries. Resident #3 sustained numerous falls with injury. The findings included: Cross refer to F323: Accidents/Incidents/ Supervision The facility admitted resident #3 with [DIAGNOSES REDACTED]. Review of the medical record revealed Nurses' Notes of April 2017: 4/12/17:No complaints from recent fall. Resident has been extra restless today, trying to stand. Was toileted and given food and drink and tried to redirect without effects. PRN was administered without effects. Had to have 1:1 all day. 4/13/17: continued to need 1:1 constantly trying to get up unassisted, 21:18 Continues to have increased agitation and attempting to hit staff. This nurse spoke with son. RP stated he would come and try to sit with him but was unavailable tonight and asked this nurse to go ahead and administer the PRN [MEDICATION NAME]. [MEDICATION NAME] administered in L deltoid. 4/16/17: Resident sitting in front of nursing station, alert and confused. Wheelchair alarm went off, nurse and CNA discovered resident on floor. Laceration above left eye, area cleaned . Resident #3 sustained falls on 2/28/17- No injury. 3/17/17- Laceration over left eye. 3/29/17- fell on right knee, bruise resulted to left forearm. 4/11/17- Fall with redness to right shoulder, lower back and ribs. 3:00 PM, 2nd fall of day- neurochecks. 4/16/17- Fall with laceration of left eye resulted in sutures. physician progress notes [REDACTED]. Precautions included 101 (one on one) may be necessary. Staff was not with resident when fell on [DATE] and sustained laceration which required sutures. Licensed Practical Nurse (LPN) #1 was interviewed by the surveyor on 8/17/17 at approximately 9:04 AM. The nurse stated the resident had interventions in place and had been sitting in front of the nurse's station. The nurse stated s/he was sitting at the table in the day area and had the resident in sight. Her/his alarm went off. I saw her/him leaning forward. I could not get to her/him in time. S/he has had a sitter off and on. Three Certified Nursing Assistants (CNAs) on the unit second shift, on weekend. It was after 3:00 PM. S/he needed a sitter 24 hours a day . There was only three CNA's on duty on the unit. The facility stopped the sitter. Review of the facility Daily Staffing Posting revealed on 2/17/17, the facility census was 126. The 11-7 Shift had five (5) Certified Nursing Assistants on the 11-7 shift for the care of 126 residents. Each CNA would have been responsible for the care of at least 25 residents. On 5/13/17 the facility had a census of 130 with 14 CNAs on duty on the 7-3 shift. The CNAs would care for over 9 residents on the day shift. Eight (8) CNAs on the 3-11 shift. Each CNA would be responsible for 16 plus residents. Three (3) CNAs were scheduled for the 11-7 shift. Each CNA would have been responsible for at least 41 residents each. On 5/14/17 the facility census was 130 with 11 CNAs on the day shift. Each CNA would have been responsible for 11 or 12 residents on the day shift. Seven (7) CNA's were on the 3-11 shift. Each CNA would have been responsible for at least 18 residents. On the 11-7 shift four (4) CAN's were on duty. Each CNA would have been responsible for at least 32 residents.

Based on record review and interview the facility failed to provide adequate supervision to prevent accidents for Resident #2 with a known history of falls. Resident #2 fell from his/her wheelchair and was placed back in the wheelchair with no new interventions to prevent falls. S/he fell out of the wheelchair a second time and was sent to the hospital due to injuries sustained due to the fall. Review of facility files revealed Resident #4 was injured during a transfer from the wheelchair to the bed. The Certified Nurse Aide (CNA) failed to follow the resident's care plan, failed to report and act upon the incident of neglect in a timely manner (2 of 3 resident reviewed for falls). The findings included: Resident #2 admitted to the facility with [DIAGNOSES REDACTED]. His/her discharge summary from another facility, dated 08/06/2015 stated, .Hopefully as his/her delirium clears s/he will be able to be tapered off of some of his/her quetiapine. His/her delirium was found to be secondary to multiple etiologies [DIAGNOSES REDACTED]with rapid ventricular response, dehydration and pain, anticolinergice use, Paxil use. There was also some suspected major neurocognitive disorder going on, possibly secondary to Alzheimer's dementia, clouded by current delirium . Review of the Nurse's Notes from 08/06-08/07/2015 documented that Resident #2 was admitted to the facility with a history of falls and that a bed alarm was placed on the bed at admission to alert the staff when the resident attempted to get out of bed unassisted. On 08/07/2015 at 2:00 PM a secure care was placed related to the resident's wandering behavior. The Nurse's Notes for 08/07/2015 at 4:00 PM stated, Resident up in w/c (wheelchair) uncooperative constantly attempting to get out of chair - Rept (reporter) reminding him/her to not get up - because s/he would fall. 4:30 PM Resident got out of w/c and attempted to ambulate in hallway, but fell in floor - assisted up to w/c no injury noted. 5:00 PM Resident got out of w/c again and fell in floor - received small laceration to left side of forehead - area cleaned and dressed - pupils not reacting to light, MD notified of resident condition order received to send to hospital . Review of the Physician's Telephone Orders dated 08/07/2015 at 5:45 PM stated, Send resident to hosp (hospital) for evaluation from fall. Review of the initial care plan dated 08/06/2015 identified a risk for injury (falls) related to an unsteady gait. The interventions included .bed alarm . Review of the Resident #2's fall risk assessment dated [DATE] indicated s/he scored 13 representing a high risk for falls. In a telephone interview with the surveyor on 12/01/2015 at approximately 9:55 AM LPN #2 stated that s/he was assigned to Resident #2 the night of the falls. When asked by the surveyor what interventions were put in place after Resident #2 fell out of the wheelchair the first time s/he stated, I told him/her not to get up. The CNA's knew s/he fell . When asked by the surveyor if Resident #2 was alert and oriented s/he stated, Alert but not oriented, s/he couldn't follow directions. When asked by the surveyor if s/he asked the CNA's to watch the resident s/he stated, It's been a long time ago, not sure. In an interview with the surveyor on 11/18/2015 at approximately 1:45 PM the Assistant Director of Nursing (ADON) when asked if interventions were put in place after the first fall s/he stated, He was put in a wheelchair and brought to the common area. When asked by the surveyor about the outcome of the facility investigation s/he stated that LPN #2 was terminated due to her/his delayed response to Resident #2's condition. Review of the facility Five-Day Follow-up Report to the State Agency dated 10/19/2015 stated that Resident #4 was injured while being transferred from the wheelchair to the bed when s/he hit her ankle causing a fracture (as evident by the x-ray result). Review of Resident #4's care plan dated 01/04/2013 indicated a risk for injury from falls with interventions that included the .use of mechanical lift for transfers Review of the resident's Nurse Aide's Information Sheet/Care guide revealed s/he required the use of a sling lift with the assistance of 2 people for transfer. Review of the facility obtained statements revealed an undated statement written by Licensed Practical Nurse (LPN) #1 that stated, This nurse went into room to give resident medicine. CNA (#1) walked in room behind me. Res'd (resident) and CNA said - res'd hit foot on metal bed rail when s/he was put to bed at 5 PM after going to beauty shop. Res'd said it hurt (left ankle) like a toothache. This nurse examined foot no swelling/redness/bruising noted. Res'd said left ankle hurt like a toothache. S/he was increased pain when touching the foot . The nurse practitioner was notified and ordered an x-ray of the left ankle. In an interview with the surveyor on 11/17/2015 at 3:50 PM LPN #1 confirmed s/he wrote the facility obtained statement. LPN #1 stated that CNA #1 did not tell her/him about the incident with Resident #4 until sometime around 9:30 PM. S/he told me the resident was complaining about pain. When the CNA and I went in the room s/he and the resident told me about the injury earlier, after s/he came back from the beauty shop. Review of a mobile x-ray of Resident #4's left ankle dated 10/14/2015 stated, .acute fracture involving the distal tibial diaphysis . There is soft tissue swelling . A x-ray of Resident #4's left ankle obtained on 10/16/2015 at an orthopedist appointment stated, .shows osteopenic bone quality, can appreciate a cortical irregularity through the distal tibial and fibula and old fracture seen there. No other fractures seen or significant soft tissue swelling . The orthopedist placed Resident #4's leg in a posterior-leg splint for immobilization and protection; pain medication was prescribed with a follow-up appointment in 10 days. In a facility obtained statement dated 10/14/2015 CNA #1 stated, As I was assisting (Resident #4) to bed her foot got caught under the bed. I checked out because s/he said it felt broken. But as I looked I didn't notice any changes in her/his left foot. In an interview with the surveyor on 11/17/2015 at 4:15 PM Resident #4 stated that the CNA dropped her/him on the floor. S/he stated s/he did not know the CNA. I had been to the beauty shop, s/he put her/his hands under my arms and dropped me. S/he confirmed that the staff used the lift to transfer her/him from the wheelchair to the bed prior to the incident.

Based on record review and interview the facility failed to prevent mistreatment and neglect of residents. Resident #2 fell from his/her wheelchair and was placed back in the wheelchair with no new interventions to prevent falls. S/he fell out of the wheelchair a second time and was sent to the hospital due to injuries sustained due to the fall. Review of facility files revealed Resident #4 was injured during a transfer from the wheelchair to the bed. The Certified Nurse Aide (CNA) failed to follow the resident's care plan, failed to report and act upon the incident of neglect in a timely manner (2 of 3 resident reviewed for falls). The findings included: Resident #2 admitted to the facility with [DIAGNOSES REDACTED]. His/her discharge summary from another facility, dated 08/06/2015 stated, .Hopefully as his/her [MEDICAL CONDITION] clears s/he will be able to be tapered off of some of his/her quetiapine. His/her [MEDICAL CONDITION] was found to be secondary to multiple etiologies [MEDICAL CONDITION] with rapid ventricular response, dehydration and pain, anticolinergice use, [MEDICATION NAME] use. There was also some suspected major neurocognitive disorder going on, possibly secondary to Alzheimer's dementia, clouded by current [MEDICAL CONDITION] . Review of the Nurse's Notes from 08/06-08/07/2015 documented that Resident #2 was admitted to the facility with a history of falls and that a bed alarm was placed on the bed at admission to alert the staff when the resident attempted to get out of bed unassisted. On 08/07/2015 at 2:00 PM a secure care was placed related to the resident's wandering behavior. The Nurse's Notes for 08/07/2015 at 4:00 PM stated, Resident up in w/c (wheelchair) uncooperative constantly attempting to get out of chair - Rept (reporter) reminding him/her to not get up - because s/he would fall. 4:30 PM Resident got out of w/c and attempted to ambulate in hallway, but fell in floor - assisted up to w/c no injury noted. 5:00 PM Resident got out of w/c again and fell in floor - received small laceration to left side of forehead - area cleaned and dressed - pupils not reacting to light, MD notified of resident condition order received to send to hospital . Review of the Physician's Telephone Orders dated 08/07/2015 at 5:45 PM stated, Send resident to hosp (hospital) for evaluation from fall. Review of the initial care plan dated 08/06/2015 identified a risk for injury (falls) related to an unsteady gait. The interventions included .bed alarm . Review of the Resident #2's fall risk assessment dated [DATE] indicated s/he scored 13 representing a high risk for falls. In a telephone interview with the surveyor on 12/01/2015 at approximately 9:55 AM LPN #2 stated that s/he was assigned to Resident #2 the night of the falls. When asked by the surveyor what interventions were put in place after Resident #2 fell out of the wheelchair the first time s/he stated, I told him/her not to get up. The CNA's knew s/he fell . When asked by the surveyor if Resident #2 was alert and oriented s/he stated, Alert but not oriented, s/he couldn't follow directions. When asked by the surveyor if s/he asked the CNA's to watch the resident s/he stated, It's been a long time ago, not sure. In an interview with the surveyor on 11/18/2015 at approximately 1:45 PM the Assistant Director of Nursing (ADON) when asked if interventions were put in place after the first fall s/he stated, He was put in a wheelchair and brought to the common area. When asked by the surveyor about the outcome of the facility investigation s/he stated that LPN #2 was terminated due to her/his delayed response to Resident #2's condition. Review of the facility Five-Day Follow-up Report to the State Agency dated 10/19/2015 stated that Resident #4 was injured while being transferred from the wheelchair to the bed when s/he hit her ankle causing a fracture (as evident by the x-ray result). Review of Resident #4's care plan dated 01/04/2013 indicated a risk for injury from falls with interventions that included the .use of mechanical lift for transfers Review of the resident's Nurse Aide's Information Sheet/Care guide revealed s/he required the use of a sling lift with the assistance of 2 people for transfer. Review of the facility obtained statements revealed an undated statement written by Licensed Practical Nurse (LPN) #1 that stated, This nurse went into room to give resident medicine. CNA (#1) walked in room behind me. Res'd (resident) and CNA said - res'd hit foot on metal bed rail when s/he was put to bed at 5 PM after going to beauty shop. Res'd said it hurt (left ankle) like a toothache. This nurse examined foot no swelling/redness/bruising noted. Res'd said left ankle hurt like a toothache. S/he was increased pain when touching the foot . The nurse practitioner was notified and ordered an x-ray of the left ankle. In an interview with the surveyor on 11/17/2015 at 3:50 PM LPN #1 confirmed s/he wrote the facility obtained statement. LPN #1 stated that CNA #1 did not tell her/him about the incident with Resident #4 until sometime around 9:30 PM. S/he told me the resident was complaining about pain. When the CNA and I went in the room s/he and the resident told me about the injury earlier, after s/he came back from the beauty shop. Review of a mobile x-ray of Resident #4's left ankle dated 10/14/2015 stated, .acute fracture involving the distal tibial diaphysis . There is soft tissue swelling . A x-ray of Resident #4's left ankle obtained on 10/16/2015 at an orthopedist appointment stated, .shows osteopenic bone quality, can appreciate a cortical irregularity through the distal tibial and fibula and old fracture seen there. No other fractures seen or significant soft tissue swelling . The orthopedist placed Resident #4's leg in a posterior-leg splint for immobilization and protection; pain medication was prescribed with a follow-up appointment in 10 days. In a facility obtained statement dated 10/14/2015 CNA #1 stated, As I was assisting (Resident #4) to bed her foot got caught under the bed. I checked out because s/he said it felt broken. But as I looked I didn't notice any changes in her/his left foot.

Based on record review and interview the facility failed to follow Resident #4's care plan for transfers. Resident #4 was injured during a transfer from the wheelchair to the bed. The Certified Nurse Aide (CNA) failed to follow the resident's care plan (1 of 3 resident reviewed for injuries). The findings included: Review of the facility Five-Day Follow-up Report to the State Agency dated 10/19/2015 stated that Resident #4 was injured while being transferred from the wheelchair to the bed when s/he hit her ankle causing a fracture (as evident by the x-ray result). Review of Resident #4's care plan dated 01/04/2013 indicated a risk for injury from falls with interventions that included the .use of mechanical lift for transfers Review of the resident's Nurse Aide's Information Sheet/Care guide revealed s/he required the use of a sling lift with the assistance of 2 people for transfer. Review of the facility obtained statements revealed an undated statement written by Licensed Practical Nurse (LPN) #1 that stated, This nurse went into room to give resident medicine. CNA (#1) walked in room behind me. Res'd (resident) and CNA said - res'd hit foot on metal bed rail when s/he was put to bed at 5 PM after going to beauty shop. Res'd said it hurt (left ankle) like a toothache. This nurse examined foot no swelling/redness/bruising noted. Res'd said left ankle hurt like a toothache. S/he was increased pain when touching the foot . The nurse practitioner was notified and ordered an x-ray of the left ankle. In an interview with the surveyor on 11/17/2015 at 3:50 PM LPN #1 confirmed s/he wrote the facility obtained statement. LPN #1 stated that CNA #1 did not tell her/him about the incident with Resident #4 until sometime around 9:30 PM. S/he told me the resident was complaining about pain. When the CNA and I went in the room s/he and the resident told me about the injury earlier, after s/he came back from the beauty shop. In a facility obtained statement dated 10/14/2015 CNA #1 stated, As I was assisting (Resident #4) to bed her foot got caught under the bed. I checked out because s/he said it felt broken. But as I looked I didn't notice any changes in her/his left foot. In an interview with the surveyor on 11/17/2015 at 4:15 PM Resident #4 stated that the CNA dropped her/him on the floor. S/he stated s/he did not know the CNA. I had been to the beauty shop, s/he put her/his hands under my arms and dropped me. S/he confirmed that the staff used the lift to transfer her/him from the wheelchair to the bed prior to the incident.

On the days of the survey, based on record review, interview, and policy review of Reporting of Alleged Abuse to Facility Management, the facility failed to ensure freedom of neglect for 1 of 7 residents reviewed for abuse. Resident #95 was transferred incorrectly by staff resulting in a fracture that required surgery. The findings included: On 3/18/13 at 2:18 PM interview with Resident #95 for question "Have you ever been treated roughly by staff?" revealed that a Certified Nursing Assistant (CNA) transferred him/her without the required assistance. Resident #95 stated his/her "foot got caught at the railing" and when he/she told the CNA, he/she "yanked her foot loose and broke his/her ankle." On 3/19/13 at approximately 3:00 PM review of Resident #95's medical record revealed a [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) of 15 on the 12/10/12 Comprehensive Assessment (MDS) indicated the resident was cognitively intact. The assessment documented the resident "Expects to be discharged to the community" on the 9/1/13 MDS (Minimum Data Set) , and "Expects to remain in this facility." on the 11/19/12 MDS. Record review of Radiology report dated 09/09/2012 revealed "Examination: Ankle Comp, Min 3V, Left. Results: There is regional soft tissue [MEDICAL CONDITION]. [MEDICATION NAME], minimally displaced distal fibula and tibia fractures a the level of the plafond are present with slight lateral talar subluxation. Conclusion: Fracture as described". On 3/19/13 3:20 PM interview with the resident revealed "I probably would have gone somewhere. That is why I am here permanently now. The way I got hurt my children are not able to take me and take care of me. I will be here the rest of my life" On 3/19/13 at 4:30 PM record review of Departmental Notes E-NURSE (electronic charting) dated 9/9/2012 at 9:30 PM revealed "Resident informed this nurse at 7:30 p.m. that his/her ankle was hurting. This nurse examined the resident's left ankle. Swelling and bruising was noted. Resident informed this nurse that "it happened during transfer from wheel chair to bed around supper time". Mobile X Ray ordered per P.O. (Telephone Order) Dr. (doctor) xx." Departmental Notes ENURSE dated 9/10/2012 at 1:22 PM revealed "Resident returned from doctor's appt. (appointment) with no new order for L (left) ankle. MD (medical doctor) in facility notified. New order to send to ER for Tx (treatment) and evaluation. Family notified." On 3/19/13 at 10:40 AM record review of Investigation of Incident / Accident revealed Section D: Mobility: Does resident ambulate on own? "NO"; Is assistance required for transfer/ambulation? "Yes"; Does resident wheel him/herself around in W/C (wheelchair)? "No". Section E: Is abuse or neglect suspected or alleged? "No". Record review of Incident Report revealed CNA #1 as the CNA involved in the incident on 9/9/12. Incident Witness Account by CNA #1 revealed "Around 5:00 PM resident #95 needed to go to the restroom, however the toilet was mess up. (sic) I told resident #95 I put him/her in the bed instead. As I proceed to transfer him/her, I ask him/her if he/she can stand, he/she said with assisted.(sic) As I proceed to transfer him/her to the bed, his/her feet got stuck under the bed rail. I slowly untwist his/her foot." Describe anything unusual that may have contributed to the incident? "I have transfer Resident #95 several times one person assist, he/she always perform well in helping with transfers. Resident #95 is two person assist. I felt comfortable transfer him/her." On 3/20/13 at 9:15 AM record review or the resident Care Plan revealed "Problem Onset: 8/25/13" for "I am at risk for falls related to debility and weakness". "Problem Onset: 8/25/13" for "I have impaired mobility related to debility and weakness" with "Approaches" "Transfer me with appropriate amount of staff/equipment". Record review of consults revealed Report of Consultation 9/17/12 Recommendations: "Short leg cast - NWB. (non weight bearing) Return to office in 2 weeks for repeat x-ray - may need surgery if positioning changes of fracture." Consult dated 10/2/12; Outpatient Surgery Pre-Operative Instructions: Date of Surgery "10-4-12" On 3/21/13 at 8:15 AM record review of faxed Orthopaedic Associates PA 10/1/12 Office Visit with Plan "I am concerned that his/her ankle looks actually worse now than it did previously, given the increased shift. I think he/she certainly is at risk for having pain in the ankle and a possible non union which would lead to him/her being completely bed bound. He/she was very active and was walking without assist before his/her pelvic fracture. I spent a very long time discussing this with his/her and her daughter and they would like to go ahead and proceed with surgery." Operative Report for surgery dated 10/4/12 revealed "Operation: 1. Deltoid ligament repair. 2. Open reduction internal fixation of fibula." On 3/20/13 at 9:00 AM record review of Physical Therapy Plan of Care Initial Assessment electronically signed on 8/27/12 reveals resident #95's current level of functional deficits for "Transfers, Bed/Chair" to be "Max Assistance x 2 (76-99% assist with 2 people)". "Rehab Potential: Good due to: Independence in prior ambulation ability. Stable medical condition. Strong social support at home." PT(Physical Therapy)- Therapist Progress Report electronically signed 9/3/12 reveals Current Level of Function "The patient is able to safely complete bed <-> wheelchair transfers requiring moderate assistance x 2 (26-75% with 2 people) with sliding board and tactile and verbal instructions/cues." On 3/20/13 at 9:30 AM record review of Discharge Plan Review and Updates revealed "8/27/12 Pt (patient) here for short term rehab and is expected to return home p (after) reaching max potential." "9/28/12 Pt dc (discharge) plan is now LT (long term) placement." "10/10/12: PT continues c (with) treatment @ (at) this time. He/she plans to d/c to an ALF (Assisted living facility) once he/she reaches appropriate level of care." "11/5/12 Res. (resident) moved to LTC (long term care) unit on this day, as he/she requires skilled nursing." On 3/22/13 at 1:15 PM record review of Initial Nursing Summary revealed Physical Function and Structural Problems; Mobility; Mode of Locomotion; Assisted Ambulation "2", Bed Mobility "2", and Assisted Transfers "2". Lower Extremities: "Limited Rt Fx Pelvis" dated 8/25/12. Written statements by the CNA and the Director of Nuring in the facility investigative report revealled both were aware the resident was to be transferred with assistance of two and was not. On 3/25/13 at 2:39 PM policy review of Reporting of Alleged Abuse to Facility Management revealed "the following definitions of abuse are provided by the State Operations Manual Appendix PP Guidance to Surveyors:" "f. "Neglect" is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

On the days of the survey, based on record review and interview, the facility failed to comprehensively assess 2 of 3 residents for wounds. Resident #267 was not assessed at risk for pressure ulcers and acquired pressure ulcers while in the facility. Resident #277 had conflicting information related to wound assessment date for their first admission and no wound assessment completed on second admission. The findings included: On 3/20/13 at 2:15 PM record review revealed Resident #267 to have [DIAGNOSES REDACTED]. . Record review of admission Care Plan revealed problem of "I am resistant to daily care." On 3/21/13 at 1:35 PM record review of Initial Nursing Summery completed on 3/1/13 documented the resident was admitted with "generalized [MEDICAL CONDITION]". On admission the resident was documented as having no pressure areas , no stasis ulcers but the presence of "bruises" was noted. Under Nursing Interventions / Initial Care Plan "1. Pressure reduction device needed? "No"; "Bed "Yes"; "Chair "Yes". The Anatomical Figure Body Assessment revealed a "Skin Tear" to right forearm and a "Skin Tear" to right calf. "4. Wound care protocol implemented? "Yes". The Resident Risk Assessment Profile (RAP) for Skin Conditions was left blank. Pressure Ulcer RAP Item "Any of the items listed below that are checked on your Resident Risk Assessment Profile indicate either an existing pressure ulcer or risk for pressure ulcer. Care plan for treatment/prevention" left blank. A record review of the residents Care Plan prior to 3/14/13 did not address any concerns for pressure ulcers risk. On 3/21/13 at 10:30 AM record review of Wound Assessment Report dated 3/14/13 revealed three stage III (3) pressure ulcers on Resident #267's back. Review of the physician Telephone Orders revealed new orders on 3/14/13 (without a time) for "D/C (discontinue) Pressure Reducing device to bed. Air mattress to bed. Check function + Placement Q shift." and "Cleanse top mid back and bottom mid back c (with) wound cleaner. Apply Santyl cover c border gauze change Q (every) day + PRN (as needed) wound + middle mid back." On 3/21/13 at 3:00 PM record review of Daily / Weekly / Monthly Body Audit and Hydration Report revealed an assessment on 3/7/13 with Comment "Skin is warm + (and) dry to touch. Skin tears currently under TX. No new areas of Concern." Assessment on 3/14/13 with Comment "Skin is warm + dry to touch. Skin tears currently under TX. No redness or breakdown noted. No new area of concern." On 3/22/13 at 8:20 AM interview with the Wound Care Nurse revealed that he/she did not know how the Daily / Weekly / Monthly Body Audit and Hydration Report would have missed the resident's new areas, because later in the evening when she treated the resident's skin tears the resident told her to check his back and that was when the pressure ulcers were identified. Resident # 277 was admitted to the facility on [DATE] and discharged on [DATE]. The resident was again admitted on [DATE] and discharged on [DATE]. Record review on 3/21/13 revealed a skin assessment for Resident # 277 was dated as completed on 2/6/13 and electronically signed on 2/7/13. However, the nurse completing the assessment dated [DATE] was not on duty when then the resident arrived in the facility. The resident arrived at 5:30pm per the admission nursing note and this staff member time card documented s/he left the facility at 5:23pm. The resident had multiple areas that were addressed on the wound assessment report. However, a "reddened area" over the resident's buttocks noted on the body diagram was not measured or assessed on the wound reports. During an interview with Licensed Practical Nurse (LPN) # 4 on 3/21/13, s/he verified the resident had a reddened area but no assessment was documented because s/he felt it was "yeasty" and not a pressure area. When asked how the surveyor would know that it was not a Stage I pressure area, s/he replied " I guess you wouldn't". A treatment was noted for a yeast infection under the breast that was not addressed in the assessments. There was no treatment for [REDACTED]. On the resident's second admission of 2/14/13, there was no documentation that a skin assessment was completed despite being readmitted following a dehisced left hip wound. The Initial Nursing Summary (on page 7) Skin Condition was not completed, page 8 indicated the resident had a "bruise" with no further documentation. A body diagram to be used to document wounds and other skin alterations was left blank. A resident Risk Assessment profile listed a " 2" next to red or mottled or [MEDICAL CONDITION], and a " 2" under the skin column. The assessment scored the resident as a 33 or at low risk for skin concerns. . There was no documentation or measurement of the left hip wound (other than a wound vac order) , a venous stasis ulcer of the left inner shin that measured 4 x 6 x .10 cm on 2/6/13; a venous stasis ulcer of the left lateral shin that measured 1.6 x .80 x. 10 on 2/6/13; or a venous stasis ulcer of the left ankle that had measured 4 x 4 x .10 on 2/16/13. A note in the previous admission record from Dietary had noted the stasis areas were previously "weeping". There was no documentation of skin tears noted on 2/6/13 to the left and right knee that had measured 2 x 4 cm; left lower shoulder skin tear that measured 2 x 1 cm; and a right upper arm skin tear that measured 3 x 2 cm. During an interview with the admission nurse on 3/21/13, LPN # 4 verified no skin assessments had been completed on admission of 2/14/13 or during the three days the resident resided in the facility. On 3/21/13, Medical Records, the Nurse Consultant and LPN # 4 verified after reviewing and looking for additional information there was no additional information available.

On the days of the survey, based on record review and interview, the facility failed to promote a facility free of hazards/accidents for 1 of 4 residents reviewed for accidents. Resident #95 was transferred inappropriately resulting in a fracture that required surgery. The findings included: On 3/18/13 at 2:18PM interview with resident #95 revealed that a certified nursing assistant (CNA) transferred him/her without the required assistance. Resident #95 stated his/her "foot got caught at the railing" and when he/she told the CNA he/she "yanked his/her foot loose and broke his/her ankle." On 3/19/13 at 4:30PM record review of Departmental Notes ENURSE dated 9/9/2012 at 9:30PM revealed "Resident informed this nurse at 7:30 p.m. that his/her ankle was hurting. This nurse examined the resident's left ankle. Swelling and bruising was noted. Resident informed this nurse that "it happened during transfer from wheel chair to bed around supper time". Mobile X Ray ordered per T.O. (Telephone Order) Dr. (doctor) Tadd Venn." Departmental Notes ENURSE dated 9/10/2012 at 1:22PM revealed "Resident returned from doctor's appt. (appointment) with no new order for L (left) ankle. MD (medical doctor) in facility notified. New order to send to ER for Tx and evaluation. Family notified." On 3/19/13 at approximately 3:00PM record review of Resident #95 revealed [DIAGNOSES REDACTED]. Record review of Radiology report dated 09/09/2012 revealed "Examination: Ankle Comp, Min 3V, Left. Results: There is regional soft tissue edema. Transverse, minimally displaced distal fibula and tibia fractures a the level of the plafond are present with slight lateral talar subluxation. Conclusion: Fracture as described". On 3/19/13 at 10:40AM record review of Incident Report revealed CNA #1 as the CNA involved in the incident on 9/9/12. Incident Witness Account by CNA #1 revealed "Around 5:00PM resident #95 needed to go to the restroom, however the toilet was mess up. I told resident #95 I put him/her in the bed instead. As I proceed to transfer him/her, I ask him/her if he/she can stand, he/she said with assisted. As I proceed to transfer him/her to the bed, his/her feet got stuck under the bed rail. I slowly untwist his/her foot." Describe anything unusual that may have contributed to the incident? "I have transfer Resident #95 several times one person assist, he/she always perform well in helping with transfers. Resident #95 is two person assist. I felt comfortable transfer him/her." Also documented was the Director of Nurses awareness of the inappropriate two person transfer and that s/he had counselled the CNA following the incident. On 3/20/13 at 9:15AM record review or the resident Care Plan revealed "Problem Onset: 8/25/13" for "I am at risk for falls related to debility and weakness". "Problem Onset: 8/25/13" for "I have impaired mobility related to debility and weakness" with "Approaches" "Transfer me with appropriate amount of staff/equipment". Record review of consults revealed Report of Consultation 9/17/12 Recommendations: "Short leg cast - NWB. Return to office in 2 weeks for repeat x-ray - may need surgery if positioning changes of fracture." Consult dated 10/2/12; Outpatient Surgery Pre-Operative Instructions: Date of Surgery "10-4-12" On 3/21/13 at 11:17AM interview the Staff Development Coordinator (SDC) revealed that CNA certification training teaches transfers and unless there is an issue they we do not do inservice or training. On 3/21/13 at 12:36PM Physical Therapy (PT) inservces for Resident #95, delivered by the Interim Rehab Director after request for all PT training for Resident #95, revealed an Inservice Attendance sheet for "Slide Board Transfer Training" dated 10/24/12. The only employees signed in attendance were two CNAs and the PT instructor. Inservice completed after incident. On 3/22/13 at 9:15AM interview with the Administrator revealed CNA Clinical Skills Checklist was missing for on the job training orientation for CNA #1. Blank CNA Clinical Skills Checklist received that revealed skills checks for "Transferring the resident using the pivot technique" and "Transferring the dependent resident".

On the days of the survey, based on record review and interview, the facility failed to assess and implement interventions to prevent pressure ulcer development for 1 of 2 sampled residents reviewed for pressure ulcers. Resident #267, was not identified at risk for skin alterations and acquired three Stage III (3) pressure ulcers within 14 days of admission. The findings included: On 3/20/13 at 2:15 PM record review revealed Resident #267 to have [DIAGNOSES REDACTED]. On 3/21/13 at 1:35 PM record review of the Initial (admission) Nursing Summary completed on 3/1/13 revealed the resident was admitted with generalized [MEDICAL CONDITION]" and "bruises". There were no pressure ulcers or stasis ulcers noted on admission. Under Nursing Interventions / Initial Care Plan "1. Pressure reduction device needed? "No"; "Bed "Yes"; "Chair "Yes". The Anatomical Figure Body Assessment revealed a "Skin Tear" to right forearm and a "Skin Tear" to right calf. A Resident Risk Assessment Profile (RAP) for Skin Conditions was left blank. The Pressure Ulcer RAP Item "Any of the items listed below that are checked on your Resident Risk Assessment Profile indicate either an existing pressure ulcer or risk for pressure ulcer. The "Care plan for treatment/prevention" was left blank. Record review of the resident's Care Plan prior to 3/14/13 did not address any active pressure ulcer concerns or identify the resident at risk for pressure ulcers. Nurses Notes documented on 3/13/13 12:15 PM "Res. (resident) c/o (complaint of) pain. PRN (as needed) pain med. admin at 12 PM. No further wants or needs voiced at this time. Dressings to skin tears were also changed at this time" The resident's skin condition was not documented again until 3/16/13 at 7 PM when the "Resident stated "I was using the urinal + I rubbed it on my skin" [MEDICAL CONDITION] skin tear to R thigh." There was no notation of pressure ulcers in the Nurses Notes from identification on 3/14/13 through 3/20/13. A Wound Assessment Report dated 3/14/13 (14 days after the resident was admitted to the facility) identified three Stage III (3) pressure ulcers on Resident #267's back. The documentation identified the areas "New Wound (s)" and stated they were not present on admission. On 3/21/13 at approximately 3:00 PM record review of Telephone Orders revealed new orders on 3/14/13 without a time for "D/C Pressure Reducing device to bed. Air mattress to bed. Check function + Placement Q shift." and "Cleanse top mid back and bottom mid back c (with) wound cleaner. Apply Santyl cover c border gauze change Q day + PRN (as needed) wound + middle mid back." On 3/21/13 at 3:00 PM record review of Daily / Weekly / Monthly Body Audit and Hydration Report revealed an assessment on 3/7/13 with Comment "Skin is warm + (and) dry to touch. Skin tears currently under TX. No new areas of Concern." The next Assessment completed on 3/14/13 stated "Skin is warm + dry to touch. Skin tears currently under TX. No redness or breakdown noted. No new area of concern." On 3/22/13 at 8:20 AM interview with the Wound Care Nurse revealed that he/she did not know how the Daily / Weekly / Monthly Body Audit and Hydration Report would have missed the resident's new areas, because later in the evening when s/he treated the resident's skin tears, the resident told her to check his/her back and that was when the pressure ulcers were identified.

On the days of the Recertification, Extended and Complaint Survey, based on record reviews and interviews, the facility failed to develop a comprehensive care plan for Resident #13 and #25 as determined by the resident's needs, including routine and emergent [MEDICAL CONDITION] care. Resident #6 did not have an interim care plan for [MEDICAL CONDITION] Care Resident #8 and #13's care plans were not periodically reviewed and revised. Resident #8 did not have a care plan updated related to suicidal ideation. Resident #2 and #12, identified as interview-able residents were not afforded the right to participate in their care plan meetings. Additionally, 5 of 6 interview-able residents attending group meeting also stated they were not invited to care plan meetings. The findings included: The facility admitted Resident #6 on 2/10/12 with [DIAGNOSES REDACTED]. On 2/12/12 at 2:50 PM, during review of the medical chart for Resident #6, no interim (admission) care plan was noted to be on the chart. There was no care plan available to provide guidance to routine or emergent care for a [MEDICAL CONDITION] resident. In an interview with Registered Nurse #1 at 3:10 PM on 2/12/12, she verified that there was no care plan available. She stated that they do not do interim care plans for nursing issues. She also stated that it was important for nursing to have a care plan for nursing to refer to for care of all residents. The facility admitted Resident #25 on 1/23/2012 with [DIAGNOSES REDACTED]. On 2/12/2012 at 4:30 PM, review of Resident #25's medical chart, revealed that he had had a [MEDICAL CONDITION] placed on 1/4/12. Review of the resident's care plan indicated the [MEDICAL CONDITION] was noted on his ADL (activities of daily living) care plan with interventions which included: "Assist resident as needed to have his needs met; Encourage resident to participate in ADLs; Praise all efforts; Allow time for resident to complete task. The resident had a care plan for "At risk for respiratory distress " with interventions listed as: " Observe for s/s (signs and symptoms) of respiratory distress (restlessness, wheezing, shortness of breath, diaphoresis, [MEDICAL CONDITION]; O2 (oxygen) as ordered; Clean O2 filter per facility protocol; Change O2 tubing per facility protocol; Notify MD (Medical Doctor) PRN (as needed) and Meds (medications) as ordered. A care plan stating the "Resident has a [MEDICAL CONDITION] r/t (related to) Cancer" contained interventions of : "Tx (treatment) as ordered, Suction as ordered; notify MD PRN; Observe for complications (change in color of sputum, copious drainage, odor, bloody sputum, shortness of breath)." The care plan did not address the specific care the resident required related to the new [MEDICAL CONDITION] or what steps would need to be taken in an emergency. No other care plans were noted to be in the resident's chart. On 2/13/2012 at 8:30 AM, during an interview with Registered Nurse #1, she verified that there was no care plan specific to [MEDICAL CONDITION] care and that the resident should have had a care plan specific to the new [MEDICAL CONDITION] care and emergency care. During an interview on 2/14/12 at 3:15 PM, the Director of Nurses (DON) confirmed the care plan(s) were not updated and did not reflect each resident's current status. She confirmed no interventions were put in place related toResident #13's decannulations. The facility admitted Resident #13 on 12/13/11 with [DIAGNOSES REDACTED]. Resident #13's care plan was not updated to address emergency management of a [MEDICAL CONDITIONS] on 1/7/12, and the discontinuation of the [MEDICAL CONDITION]. Review on 2/13/12 of Nurse's Notes from the resident's admission to present revealed a note dated 1/9/12 at 9:35 PM which stated: "Answered Residents call light. While entering the Room noticed [MEDICAL CONDITION] his hand. When asked Resident stated "I coughed hard and it came out". Immediately contacted on call Physician Dr. ---. Order received to either [MEDICAL CONDITION] send out to Hospital if this nurse was not comfortable reinserting Trach. Transferred Resident to (Hospital). Family & Administration notified". During an interview on 2/14/12 at approximately 4:40 PM, Registered Nurse (RN) #7 verified she was the nurse taking care of Resident #13 the night of 1/9/12 when [MEDICAL CONDITION] out. She stated at the time she sent the resident out to the hospital, she thought his "whole trach" had come out, but found out later when the resident was returning from the hospital that only the inner cannula had been coughed out. She stated she didn't have a stethoscope and couldn't listen to his breath sounds at the time of the incident. She stated she called and spoke with the doctor while another nurse stayed with the resident. The doctor asked her how the resident was doing, and she told her that he was not in distress. According to RN #7, the doctor wanted her to put [MEDICAL CONDITION] in, but she did not feel comfortable doing this. She stated that she had some training in school but no recent formal training [MEDICAL CONDITION] or emergency care for a trach. When asked if she knew how to put [MEDICAL CONDITION] in, she stated she would lay the resident flat; remove any pillows; take the trach, turn it to the side, and stick it back in. She stated there was no emergency equipment at the bedside at the time that she knew of. When asked what an obturator was, she stated she couldn't think what that was. When asked why she did not call 911, she stated that since the resident was not in distress, she could send him out to have [MEDICAL CONDITION]. She stated if the resident did have trouble breathing or turned blue, she would have tried to put [MEDICAL CONDITION] in. Record review on 2/13/12 at 3:25 PM revealed a Physician's Telephone Order dated 1/7/12 at 1:00 PM which stated, "Sent to (Hospital) ER (emergency room ) r/t (related to )[MEDICAL CONDITION] out". During a phone interview on 2/21/12 at 5:47 PM, RN #2 verified she had worked on 1/7/12 and had sent the resident out to the hospital. She stated she was passing medications and went into the residents room to give him his medication. When she could not see the resident'[MEDICAL CONDITION] on his neck, she reached up and pulled the resident's shirt away from his neck and saw that the whole [MEDICAL CONDITION], outer and inner cannula along with [MEDICAL CONDITION] lying on the resident's chest. She stated that the resident was able to talk and had no respiratory distress. She stated she tried to reinsert the trach, but met resistance and stopped. She stated she picked up the whole [MEDICAL CONDITION] (outer and inner cannula still attached), and tried to put [MEDICAL CONDITION] in. She stated she felt comfortable trying to reinsert the trach, but it would only go approximately 1/4 inch into the skin before she met resistance and stopped. When asked if she knew what an obturator was prior to her recent inservice, she stated she did not know what an obturator was at the time of the incident, and also stated there was not one hanging over the resident's bed or at the bedside. She stated she was not aware of any emergency equipment at the bedside. She could not recall if a suction machine was present at the bedside but didn't think so. She stated there was no [MEDICAL CONDITION] or [MEDICAL CONDITION] kit at the bedside. She stated after attempting to reinsert the trach, she went out to call the doctor. When asked, she stated that no one else was in the room with the resident when she went to call the doctor. She stated the resident was fine, no distress and skin color was pink. She stated the resident was not wheezing and while she had not checked his O2 sat (oxygen saturation) at the time [MEDICAL CONDITION], his O2 sat on room air had previously been 94%-97%. When asked if she had taken the resident's Vital Signs or assessed his lung sounds, she stated she had not since he wasn't in distress. She stated if he was in distress, she would have taken his Vital Signs, listened to his lungs and called 911. The nurse stated she would also put him on O2 if needed. When questioned as to what type of training she had received related [MEDICAL CONDITION] and emergency management of a trach, she stated she had some training a long time ago in school. She stated that before she took the job at the facility in November 2011, she did go on- line and [MEDICAL CONDITION]. Review of the current care plan dated 12/29/11 revealed an entry dated 12/13/11 for "Medical Device: [MEDICAL CONDITION]- Potential for complications associated with [MEDICAL CONDITION]". The goal was that the resident "Will remain free of infection or there complications related to presence of [MEDICAL CONDITION] x 92 days" and that he "Will have clean, intact skin at [MEDICAL CONDITION] site daily x 92 days". The goal date was listed as 3/13/12. Approaches included "Staff Note: Resident has [MEDICAL CONDITIONS] care as ordered..., Suction as ordered ..., Administer Oxygen as ordered, Encourage resident to cough, deep breathe, and turn regularly, Assess/record/report to MD (medical doctor) prn (as needed) s/sx (sign and symptoms) of [MEDICAL CONDITION] complications: Aspiration, Respiratory Infection..., [MEDICAL CONDITION] site infection... Communication difficulties". The care plan had not been updated to include information to address the emergency management of [MEDICAL CONDITION] that [MEDICAL CONDITION] become dislodged on 1/7/12. Review on 2/13/12 of Physician's Telephone Orders dated 1/27/12 revealed a clarification order for 1/24/12 to "D/C (Discontinue)[MEDICAL CONDITION] qd (daily), D/C cleanse inner cannula, D/C suction [MEDICAL CONDITION] orders". Another Telephone Order dated 1/27/12 stated "...Cleanse neck (with) wound [MEDICAL CONDITION]". Review of "Medicare Nursing Notes dated 1/23/12 revealed an entry that [MEDICAL CONDITION] been removed. Review of the Medication Record revealed [MEDICAL CONDITION] been removed in January 2011. The current care plan did not include information that [MEDICAL CONDITION] been discontinued. During an interview on 2/14/12 at 12:00 Noon, RN #5 verified she was responsible for updating care plans. She stated she did not normally update the care plan with any emergency measures related to the [MEDICAL CONDITION]. She stated she didn't have any guidelines related to emergency care of [MEDICAL CONDITION] that nursing staff would need to "go where they should" to get that information. She stated that she had included to the approach to observe the resident for complications and that nursing staff should implement as appropriate. When asked why the care plan had not been updated related to the inner cannula becoming dislodged (1/9/12), she stated that she had never updated a care plan for dislodgement before. She verified the current care plan had not been updated relative to the discontinuation of the trach. Resident #13's care plan also had not been updated related to interventions to prevent falls or injury from falls. Review on 2/13/12 at 3:00 PM of the Admission Minimum Data Set (MDS) Assessment for Resident #13 revealed an ARD (Assessment Reference Date) of 12/20/11 and a BIMS (Brief Interview for Mental Status) score of 15. According to this MDS Assessment, the resident had one fall without injury since admission. Record review on 2/13/12 at 3:30 PM revealed the following Nurses Notes dated 12/19/11 through 2/12/12 which documented the resident being found sitting on the floor. -12/19/11 at 10:00 AM - "Walked in to give res'd (resident) AM meds and observed res'd sitting on floor by the bed. When asked what happened res'd stated, "I was trying to go to the bathroom and lost my balance." Observed res'd (right) arm wedged between mattress + siderail. Gently removed resd's arm- (no) C/O (complaints of) pain noted, redness to (right) shoulder observed. Notified Mobilex for xray to (right) shoulder...". -1/6/12 at 1:20 AM - "Resident found on knees beside bed. ROM (Range of Motion) WNLs (Within Normal Limits), (No) bumps, bruises or skin tears noted. (No) C/O pain voiced...". -1/11/12 at 5:50 AM - "Resident found sitting on floor beside bed...Asked Resident what occurred & he stated he was trying to get to the Restroom. (no) bumps, bruises, or skin tear noted. (No) C/O pain voiced by Resident. Taught Resident the importance of using the call light and asking for assistance when transferring...". -2/12/12 at 10:30 PM - "Resident states he tripped on edge of bed. Observed sitting up on floor, at the bottom of bed. Denies hitting his head.....Small skin tear to left ankle...". When the facility was asked for Incident Reports related to the resident being found on the floor, two Incident Reports were provided for the "Fall(s)" on 1/6/12 and 1/11/12. According to both reports the resident was found on the floor, his mental status was 'Alert and Oriented', and the resident stated he was trying to get to the restroom. Both reports checked that "No" medical devices were involved. The report 1/11/12 documented that "No" safety devices were in place; and the report 1/6/12 had neither "Yes" or "No" marked for "Safety devices in place". Review of the "Resident Risk Assessment- Master" dated 2/14/12 revealed a "Fall Risk Score of "Medium" for Resident #13. Review of the Care Plan dated 12/29/11 revealed an entry dated 12/13/11 that Resident #13 was "...at risk for falls and injury r/t (related to) mobility impairment, hx (history) of recent fall and medication regimen". The goal listed stated "Resident will maintain safety in his environment through the next assessment period" and included a goal date of 3/12/11. Approaches listed included "Ensure room is adequately lit and clutter free, Ensure call light is working ...and encourage him to summon assistance for any activity that may compromise his safety, Should resident become restless, agitated, or anxious, observe for any unmet needs (ie hunger, comfort, toileting) and assist him to have these needs met". Handwritten underneath the Approaches were the notations "1/6/12- Staff to assist resident prn (as needed) for safety" and "1/11/12- Encourage resident to use call light and staff to answer promptly, call light promptly". The Care Plan did not include updated information that the resident had been found on the floor 12/19/11 or 2/12/12 and had not been updated related to any new interventions to prevent falls or prevent injury from falls. During an interview on 2/14/12 at 12:00 Noon, Registered Nurse (RN) #5 verified there were no safety devices ordered or in use for the resident presently or in the past. She stated that Fall Risk Assessments were done on Admission and quarterly. She stated if a resident falls, the resident is discussed in the morning meeting and measures are put into place if decided upon. She stated that Resident #13 does have weakness, but is alert and oriented. She stated the team met and discussed his care after the falls and those measures were added to the Care Plan (ie handwritten information 1/6/12 and 1/11/12). Review of the policy provided by the facility entitled "Falls Potential and Risk Reduction Protocol" on 2/14/12 revealed "It is the policy of this facility to assess residents for the potential for falls and to identify factors that might contribute to falls. The facility will address those factors identified in order to reduce the risk for falls". Under "Procedure" was listed "...2. The care plan will address special needs and/or risk factors identified on the Resident Risk Assessment Profile....3. If the resident has fallen in the past month, the resident will be considered at high risk regardless of their risk score....4. The care plan should be updated after a fall to address the most recent cause of the fall". The facility admitted Resident #8 on 4/17/06 and readmitted her on 11/16/11 with [DIAGNOSES REDACTED]. The Care Plan was not updated related to interventions to prevent falls or injury from falls. Review of Nurse's Notes dated on 2/14/12 at 10:56 AM revealed the following entries related to falls: -11/17/11 at 10:05 AM- "Resident found lying on floor in front of nurses station beside wheelchair. When asked Resident what happened, she stated that she was trying to get into another chair and she fell ...". -12/14/11 at 4:00 PM- "Resident found lying on (right) side in bathroom. Bed alarm sounding. Soiled brief in bed. Res(ident) stated, "I fell when I got off toilet, I hit my head."...Reminded to use call light for help. Alert (with) confusion....". -12/26/11 at 2:30 PM- "This nurse was informed that res(ident) was on the floor in her room while nurse was on break. Nurse on cart assessed res(ident)...". -1/6/12 at 4:00 PM- "Order obtained for neurochecks R/T (Related To) fall per ---NP (Nurse Practitioner). Able to move all extremities...". Review of the Incident Report related to the fall on 11/17/11 revealed the resident was found lying on the floor in the hall. The resident did not say what had happened, but a wheelchair was involved and there were no safety devices in place. According to the Incident Report from the fall 12/14/11, the resident was found lying on her side in the bathroom of her room and had stated "I fell when getting off the toilet". According to the report, a wheelchair was involved and a bed alarm was sounding. Review of the Incident Report dated 12/26/11 revealed the resident was found sitting on the floor of her room. She stated "I was trying to go to the bathroom. According to the report, there were no medical devices involved or safety devices in place. Review of the Care Plan dated 12/2/11 revealed an entry dated 11/16/11 that Resident #8 was "At risk for injury from falls r/t cognitive deficits, mobility impairment, and medication regimen. The goal was to "...maintain safety in her environment through the next assessment period" and included a goal date of 2/16/12. Approaches listed included "Therapy as ordered, Maintain resident environment free of clutter..., Place items frequently used by resident within easy reach..., Provide....adequate lighting, Call light within reach in room". Handwritten below the Approaches was documented "12/17/11 Neurochecks as ordered, 12/26/11 Assess for toileting program, 1/6/12 Should resident become restless, agitated, or anxious, observe for any unmet needs (ie hunger, thirst, comfort, toileting) and assist her to have her needs met". There was no indication from the Care Plan that any safety devices were in use for Resident #8. The resident's Admission Risk Assessment was reviewed with Licensed Practical Nurse (LPN) #2 on 2/14/12 at 11:45 AM. When asked what the resident's fall risk score was on admission, the nurse said it was "Moderate". Review of the Risk Assessment Totals dated 2/10/12 revealed Resident #8 presently had a Fall Risk Score that was "High". Review of the Medication Record for November 2011 revealed a Tab alert was added to the resident's bed on 11/17/11 and placement and function checked every shift. Further review of the Medication Record for November revealed a chair alarm was added to the wheelchair on 11/18/11 with placement and function checked every shift. The interventions for the chair and bed alarm were not included in the resident's current Care Plan, and there was no documentation found of any additional safety measures put into place for Resident 8 after the the falls on 12/14/11, 12/26/11, or 1/6/12. During an interview on 2/14/12 at 11:42 AM, LPN #2 verified the chair and bed alarms were placed after the fall on 11/17/11. After reviewing the Nurse's Notes and Care Plan for falls, she was asked if any other safety measures had been implemented and could find none. During an interview on 2/14/12 at 11:50 AM, RN #5 was asked about the resident's falls. She stated that fall interventions are discussed by the team (DON, ADON, MDS Coordinator, Unit Managers, Wound Nurse, and sometimes the Administrator) in morning meeting. She stated that together, they decide on what interventions to put into place when a resident falls. She stated she was responsible for updating the Care Plan for any interventions related to falls. When asked, she verified the handwritten Care Plan updates. She stated the resident gets confused and restless and does not call for help. She verified no safety interventions like fall mats or protective equipment had been added. When asked who was responsible for assessing the resident for a toileting program (intervention for 12/26/11), she stated the ADON or LPN #2 was responsible. During an interview on 2/14/12 at 12:15 PM, LPN #2 stated the previous ADON was responsible for doing the Voiding Assessment for Resident #8, however, this had not been done. Resident #8's Care Plan was not updated in regards to her Suicidal Ideation. Record review on 2/14/12 at 10:42 AM revealed a Physician's Telephone Order dated 12/2/11 for "1. Suicide Precautions Q (every) 15 min(utes) for 24 hrs (hours), 2. [MEDICATION NAME] 50 mg (milligrams) QID (Four times daily) + BID (Twice daily) PRN (As Needed) PO (By Mouth) r/t (related to) pain". Review of "Resident Social Progress Notes" dated 12/3/11 revealed "Yesterday while receiving care, Res(ident) stated, "it hurts so bad I want to kill myself" r/t (related to) skin rash to buttocks. When speaking (with) Res(ident) she denied any desire to harm self. Pt (Patient) put on 24 hr suicide watch per protocol. SS to document". Review of Nurse's Notes revealed a note dated 12/2/11 at 5:45 PM which stated "While being assisted to bed and provided incont(inent) care, resident stated "It hurts so bad I want to kill myself." Resident (with) raw yeasty skin rash to buttocks, groin, peri-area. [MEDICATION NAME] ordered 12/1/11 for qd (daily) x 7 d(ays). On call provider paged". The next note was dated 12/2/11 at 5:50 PM. It stated "Resident resting in bed-denies pain @ present. When asked about harming self stated she would never harm "me" (referring to self) and had no plan. Awaiting return call". A note 12/2/11 at 6:30 PM stated "Dr. --- returned page, notified him of matter at hand. Ordered Suicide Precautions Q 15 min(utes) for 24 hrs, [MEDICATION NAME] 50 mg QID + BID PRN. Notified POA (Power of Attorney), will continue to monitor". Continued review of Nurse's Notes revealed an entry dated 12/23/11 which stated "...Alert, tearful, sli(ght) depression noted...". Another note dated 1/3/12 stated "Order obtained for [MEDICATION NAME] 10 mg (milligrams) PO (By Mouth) depression...". Review of the Care Plan dated 12/2/11 revealed no mention that the resident was put on "Suicide Precautions" in December 2011 related to suicidal ideation; or that the resident had any issues related to her mood and was started on antidepressant medication. During an interview on 2/14/12 at 11:27 AM, the SSD (Social Services Director) stated she was responsible for updating the Care Plan related to the resident's mood and suicidal ideation. She verified that this had not been done. The facility admitted Resident #12 on 11/30/11 with [DIAGNOSES REDACTED]. Record Review on 2/12/12 at approximately 1:55 PM revealed an Admission MDS (Minimum Data Set) that indicated Resident #12 had a BIMS (Brief Interview for Mental Status) of 15 which indicated the resident was cognitively intact. The facility indicated Resident #12 was alert, oriented and interview-able. During an individual interview on 2/12/12 at approximately 2:45 PM, the resident stated he was not invited to participate in care plan meeting. Resident #12 further stated he would have liked to participate in a meeting regarding his care. An interview on 2/12/12 at approximately 3 PM with the SSD (Social Services Director revealed residents are invited to care plan meeting with a written notice. The SSD stated she could not find the written notice to indicate Resident #12 was invited to participate in his care plan meeting. The facility admitted Resident # 2 on 12/31/11 with [DIAGNOSES REDACTED]. Record review on 2/12/12 revealed the resident to have a BIMS score of 15 noting the resident to be alert, oriented, and able to make his own decisions. Occupational Therapy noted the resident to be a recently retired Attorney. The facility had also deemed him to be an interviewable resident. During an individual interview with the resident on 2/13/12, it was ascertained that the resident had not been invited to a care plan meeting to discuss his care. He stated, "I would certainly would have wanted to attend, if I had been invited." This resident was very involved in his care, especially with the treatments of his Stage IV Decubitus Ulcer. He further stated, " None of the staff have informed me of any meeting about my care needs." On 2/13/12 at 10:30 AM, an interview was conducted with the Director of Social Services. She stated their policy was to take a letter to the resident and/or family member to notify them when the meeting was to be held, and to place a copy of the letter in the resident's chart. Review of the medical record showed no letter from the Social Service Director; however, she did have a copy in her book. On the CARE PLAN ATTENDANCE RECORD in the medical record there was a a notation that the resident declined invitation to care plan meeting. Also noted was that the Care Plan Meeting Invitation made verbally not via Mail as usual. The Resident again stated, "No one asked or invited me to a Care Plan Meeting." During group interview on 2/13/12 at approximately 10:35 AM, 5 of 6 group members stated they had not been invited to participate in their care plan meeting. Three of 5 group members stated they would have liked to be involved with their plan of care. On 2/14/2012 at 5:45 PM, the Administrator, Director Of Nursing and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-280, F-281, F-328, F-490 and F-501 at a scope and severity of "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 1/7/2012 when a resident's trach, both inner and outer cannula, came out and could not be reinserted by staff and no emergency supplies were available at bedside The Allegation of Compliance submitted by the facility on 2/15/12 was implemented by the facility and observed to be in practice, removing the immediacy of the deficient practice. All licensed facility nursing staff currently at work were interviewed, had been educated and were knowledgeable of [MEDICAL CONDITION] care and emergent care of residents with tracheostomies. The Administrator was informed of this on 2/15/12 at 11:30 AM. The citations of F-280, F-281, F-328, F-490 and F-501 remained at a lower scope and severity of "E". The facility will be in compliance with F-280, F-281, F-328, F-490 and F-501 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction. Cross Refer to F-280, F-281, F-328, F-490 and F-501 as it relates to the failure of the facility to ensure that residents with tracheostomies received adequate care. The facility failed to ensure staff are adequately trained to provide appropriate care to residents with tracheostomies and that emergency supplies were available for those residents.

On the days of the Recertification, Extended and Complaint survey, based on observations, record reviews, interviews and review of the facility's policy's entitled [MEDICAL CONDITION] (trach) Management, Physician Orders, In-Service Attendance records and the South Carolina Nursing Standard of Practice SECTION 40-33-110, the South Carolina Nurse Practice Act Laws and Policies, Chapter 33 Section 40-33-20, the Nursing Code of Ethics Provision 4.3, and the South Carolina Labor Licensing Regulations (LLR) Advisory Opinion #37, the facility failed to provide or arrange services that met professional standards of quality. The identified concerns included: A facility staff member mistakenly removed a resident's outer cannula during [MEDICAL CONDITION] care. (Resident # 6) The nurse verbally indicated she was cleaning the inner cannula. However, she had actually discarded the inner cannula and was cleaning the outer cannula. A facility nurse nurse did not recognize the potential for emergency care for Resident #13 [MEDICAL CONDITION] observed loosened and decannulation. The LPN for Resident #25 did not provide emergency care when the resident was observed decannulation. Resident #1's clarification order for eye drops was not written on admission. Resident A's medication order was not transcribed correctly to the current Medication Administration Record. Resident #8's order for suicide precautions were not followed Resident #2, #4, #10, #13 and #14, (5 of 8 residents reviewed for sliding scale insulin), were noted to have either blanks on their Medication Administration Records (MARs) or incorrect doses of insulin administered. The facility did not have a Standing Order for the Sliding Scale Insulin in use/or in the facility for the residents which had been approved by the Medical Director. The findings included: The facility admitted Resident #6 on 2/10/12 with [DIAGNOSES REDACTED]. On 2/12/12, review of the unsigned physician's orders [REDACTED].#6 on admission. The hospital transfer orders stated only "trach care and collar Q (every) 2-4 hr (hour) suctioning. There was no documentation in the nurse's notes date 2/10/12 on admission to indicate that the nurses had called the physician to to verify the type and size of [MEDICAL CONDITION] for Resident #6 or to obtain care and emergency orders. The hand written Medication Order (MAR) form begun on 2/10/12 stated "trach care daily and suction prn" (as needed). There was no documentation on the MAR that this had been provided since the resident's date of admission. Review of the facility provided policy entitled Physician order [REDACTED]...3. Physician orders [REDACTED]. Special medical procedures required for the safety and well-being of the residents...7. Medications, diets, therapy or any treatment may not be administered to the resident without a written order from the attending physician..." An interview was conducted with the attending physician on 2/13/12 at 10:40 AM. The physician stated [MEDICAL CONDITION] should be done at least every 12 hours then stated it "depends on the resident". He also stated that he had not seen the resident but would expect every 12 hour care. The attending physician stated that he had reviewed the resident's paper work with a nurse and he was not aware of the every 2-4 hour suctioning order from the hospital. On 2/13/12, during an interview with LPN #3, prior to [MEDICAL CONDITION], she stated that she had not been trained [MEDICAL CONDITION] at the facility but had "done in it for years" at a hospital where she previously had worked. On 2/13/12 at 2:45 PM, during observation [MEDICAL CONDITION] for Resident #6 by LPN #3, the LPN removed the resident'[MEDICAL CONDITION] (oxygen) and placed it on his chest. LPN #3 did not hyper-oxygenate the resident prior to removing the collar or suction the resident prior to the treatment. After removing the stoma dressing, she removed the inner cannula and placed it in the trash, the resident began coughing forcefully. After pouring the saline into a tray she removed [MEDICAL CONDITION] and removed the outer cannula and began cleaning it with saline soaked 2 X 2 gauze. The surveyor asked why she had removed that cannula. LPN #3 stated, while cleaning the outer cannula, the policy "said to clean the inner cannula with saline" and pointed to papers she had lying on the bed side table. The surveyor then asked LPN #3 if she could put the cannula back as it was the outer cannula, not the inner. At that time LPN #4 placed [MEDICAL CONDITION] on the right side of the resident's chest and left the room to get the Assistant Director of Nursing (ADON) as the surveyor had requested her to do. LPN #3 replaced the outer cannula without using the obturator. She then continued the procedure by cleaning the area around the stoma with cotton tipped swabs dipped in saline and replaced the stoma dressing. LPN #4 and the ADON entered the room. LPN #4 had brought a pulse oximeter to check the resident's oxygen level. Resident #6 had an oxygen level of 82 percent after the procedure. During the procedure the resident had copious amounts of secretions and a forceful cough resulting in secretions being coughed to the bottom of the bed while LPN #3 was cleaning the outer cannula. Physician # 2 also entered the room to assess the resident and replaced the inner cannula. The resident's oxygen level had increased to 99 percent at that time. On 2/13/2012 at 7:05 PM, in an interview with Physician # 2, he stated that he was not sure what size inner cannula was used for Resident #6's trach. He stated that after the resident'[MEDICAL CONDITION] the nurse had brought him a #4 Shiley and he had used it. Another surveyor had entered the room with the physician and verified the outer cannula was a 5 millimeter. On 2/13/12, [MEDICAL CONDITION] was observed by the surveyor, Registered Nurse (RN) #1 was noted to write a telephone order which stated "trach care daily & prn (as needed), suction prn for secretions" RN #1 dated the telephone order for 2/12/12. Further record review revealed a Physician's Progress note handwritten on 2/13/12 which stated: "Asked by nursing to assess this resident who is new to me today. Of note, this assessment is performed urgently prior to my full H & P (History and Physical)...." The note continues to state " Nursing was in the room with the resident [MEDICAL CONDITION]. Per report [MEDICAL CONDITION] strap was loosened. The patient coughed and the entire [MEDICAL CONDITION], a non-cuffed (unreadable) Shiley placed sometime prior to 9/30/2011.....popped out. One of the LPN's performing the care simply "popped" the outer cannula back. The pt's (patient's) respirations were restored immediately and they came to get me."Old [MEDICAL CONDITION] s/p (status [REDACTED]." The physicians note inaccurately reflects the circumstances in which [MEDICAL CONDITION] removed and fails to reflect the resident O2 saturation level of 82%. The facility admitted Resident #25 on 1/23/12 with [DIAGNOSES REDACTED]. Review of the medical chart for resident #25 on 2/12/12 revealed that the resident had a physicians telephone order dated 2/09/12 at 4 PM which indicated "Send to ER (emergency room ) r/t (related to)[MEDICAL CONDITION]. Review of the Nurses' Notes indicated that there was no documentation in the nurses note for that time. The previous notes stated that on 2/9/12 at 6:00 AM the resident had "broken" [MEDICAL CONDITION] and at 2:50 PM his vital signs were taken. The next entry in the Nurses' Notes stated that at 7:00 PM the resident had returned from the ER with [MEDICAL CONDITION] place. On 2/13/12 at 7:40 PM, an interview was conducted with the Registered Nurse (RN) #3, who had signed the 2/9/12 notes at 7:00 PM. RN #3 stated that she had worked the 7:00 AM to 7:00 PM shift on 2/9/12. She stated that she had assessed the resident's respiratory status because he was having difficulty and that his sats (oxygen saturation) "was high" 80% (percent)." RN #3 stated that the resident refused oxygen and suctioning at that time. RN #3 indicated that around 4:30 PM, she entered Resident #25's room and that [MEDICAL CONDITION] out. She also stated that she left the resident's room to find the Wound Nurse, asked her to come into the room, called to notify the Assistant Director Of Nursing (ADON) and called the Family Nurse Practitioner (FNP) who told her to get an obturator to re-insert the resident's trach. She stated she had tried to find an obturator but could not find one. When asked if she would have tried to re-insert [MEDICAL CONDITION] she had found an obturator, she stated that she would have tried. When asked if anyone tried to re-insert [MEDICAL CONDITION] said no, that the ADON paged the FNP. When asked if the resident was in distress she stated no, his oxygen level was 83% and they had called 911 at that time. When asked how long it was from the time the resident was found with [MEDICAL CONDITION] until 911 was called, she said 10-15 minutes. The surveyor then asked if she had taken the emergency cart to the room or administered oxygen, the RN stated no but his oxygen level remained at 83%. The RN was asked if she had had emergency training related to [MEDICAL CONDITION] care and she stated "no". In an interview on 2/14/12 at 2:10 PM with LPN #15 she stated that she was not in the facility when Resident #25 was sent to the emergency room . She stated that she had been trained at another facility in 2011. She stated that she would insert an obturator but not attempt to insert a trach. When asked if the resident would get oxygen through an obturator, the LPN stated no. When asked why she would insert the obturator without the trach, she stated that she did not know. The facility admitted Resident #13 on 12/13/11 with [DIAGNOSES REDACTED]. There was no evidence found that facility Nursing Staff were aware of how to manage Resident #13's [MEDICAL CONDITION] appropriately when he coughed out the inner cannula on 1/9/12 and when [MEDICAL CONDITION] dislodged on 1/7/12. Facility nursing staff also failed to appropriately manage the placement and monitoring of Resident #13's oxygen. Record review on 2/13/12 at 3:25 PM revealed a Physician's Telephone Orders dated 1/7/12 which stated "Sent to (Hospital) ER (emergency room ) r/t (related to)[MEDICAL CONDITION] out". Another Physician's Telephone Order dated 1/9/12 stated to "Transfer to (Hospital)". Review of Physician's Progress Notes dated 1/11/12 revealed "... (Resident #13) is doing well...His [MEDICAL CONDITION] was fully capped when I visited with him today and he was not even using the passing air valve. He did have an episode the other day where the [MEDICAL CONDITION] fell out and had to be placed back by the hospital folk. I do anticipate that he will be able to have that removed completely...". Review of Nurse's Notes from admission to present revealed a note dated 1/9/12 at 9:35 PM which stated "Answered Residents call light. While entering the Room noticed [MEDICAL CONDITION] his hand. When asked, Resident stated "I coughed hard and it came out". Immediately contacted on call Physician Dr. ---. Order Received to either [MEDICAL CONDITION] send out to hospital if this nurse was not comfortable reinserting trach. Transferred Resident to (Hospital). Family & Administration notified". The facility provided a copy of the ER note dated 1/9/12 at the surveyor's request on 2/14/12. According to the note, "65 yo (year old) in rehab states he coughed and [MEDICAL CONDITION] out, it was actually inner cannula that came out and not trach, ...he states he did not want to come to ER, dw (discussed with) nurse at (facility), she [MEDICAL CONDITION] out, and she was not comfortable putting it back in". According to the note, the resident's "Trach in place, inner cannula out, yellow sputum at trach...", and resident with normal O2 sat and Vital Signs. During an interview on 2/14/12 at approximately 4:40 PM, Registered Nurse (RN) #7 verified she was the nurse taking care of Resident #13 the night of 1/9/12 when [MEDICAL CONDITION] out. She stated the resident had pushed his call light and she answered it. She found the resident with [MEDICAL CONDITION] his hand. She stated the resident was scared and she made sure that he wasn't in any respiratory distress. At the time she thought the resident's [MEDICAL CONDITION] come out. She stated a CNA (Certified Nursing Assistant) walked in shortly after she found the resident (since she had not shut off the call light). She stated she assessed the resident by counting his respirations (they were even and not labored) and watching for his chest to rise and fall (normal). She stated she didn't have a stethoscope and couldn't listen to his breath sounds at the time. She stated the CNA stayed with the resident while she went to get another nurse (She was unable to recall who the nurse was). She stated that the other nurse came to stay with the resident, the CNA left, and she went to call the doctor. She stated she spoke with the doctor and told her that the resident'[MEDICAL CONDITION] out. The doctor asked her how the resident was doing, and she told her that he was not in distress. According to RN #7, the doctor wanted her to put [MEDICAL CONDITION] in, but she did not feel comfortable doing this. She stated that she had some training in school but no recent formal training [MEDICAL CONDITION] or emergency care for a trach. She stated the most important and only thing going through her mind at the time was that she was worried that the [MEDICAL CONDITION] would close up. When asked if she knew how to put [MEDICAL CONDITION] in, she stated she would lay the resident flat; remove any pillows; take the trach, turn it to the side, and stick it back in. Sh e stated there was no emergency equipment at the bedside at the time that she knew of. When asked what an obturator was, she stated she couldn't think what that was. When asked why she did not call 911, she stated that since the resident was not in distress, she could send him out to have [MEDICAL CONDITION]. She stated if the resident did have trouble breathing or turned blue, she would have tried to put [MEDICAL CONDITION] in. When asked if she checked the resident's oxygen saturation level, she stated she did. She said the CNA went to get the machine and recalled his O2 saturation was in the upper 90's. When asked how [MEDICAL CONDITION] secured, RN #7 stated she believed there was a velcro strap around [MEDICAL CONDITION] she believed was tight. She stated she believed it was still secured around the resident's neck at the time he coughed [MEDICAL CONDITION]. She stated that she talked to the ER Physician prior to transfer and the Physician called her back when the resident was returning to the facility. He told RN #7 that the [MEDICAL CONDITION] not come out, only the inner cannula. She stated the inner cannula the resident returned with that evening snapped in place and was secure. She stated the inner cannula the resident had prior to the one he returned with wouldn't stay in. She said she had noticed that at times it hung out more than it should. She stated it wasn't the snap type and believed it may have screwed or twisted into place. She stated it wouldn't hang out all the way, but she didn't mind pushing it back in. Review of facility training and inservices for RN #7 on 2/14/12 at 3:27 PM revealed no training related [MEDICAL CONDITION]/emergency management of a [MEDICAL CONDITION]. During a phone interview on 2/21/12 at 5:47 PM, RN #2 verified she had worked on 1/7/12 and had sent the resident out to the hospital. She stated she was passing medications and went into the residents room to give him his medication. When she could not see the resident'[MEDICAL CONDITION] on his neck, she reached up and pulled the resident's shirt away from his neck and saw that the whole [MEDICAL CONDITION], outer and inner cannula along with [MEDICAL CONDITION] lying on the resident's chest. She stated that the resident was able to talk and had no respiratory distress. She stated she then told the resident, it looks like [MEDICAL CONDITION] out and asked him if it had come out. She stated she tried to reinsert the trach, but met resistance and stopped. She stated she had picked up the whole [MEDICAL CONDITION] (outer and inner cannula still attached), and tried to put [MEDICAL CONDITION] in. She stated she felt comfortable trying to reinsert the trach, but it would only go approximately 1/4 inch into the skin before she met resistance and stopped. When asked if she knew what an obturator was prior to her recent inservice, she stated she did not know what an obturator was at the time of the incident, and also stated there was not one hanging over the resident's bed or at the bedside. She stated she was not aware of any emergency equipment at the bedside. She could not recall if a suction machine was present at the bedside but didn't think so. She stated there was no [MEDICAL CONDITION] or [MEDICAL CONDITION] kit at the bedside. She stated that when she had to [MEDICAL CONDITION], she would get a [MEDICAL CONDITION] kit and bring it to the resident's bedside. She stated after attempting to reinsert the trach, she went out to call the doctor. When asked, she stated that no one else was in the room with the resident when she went to call the doctor. She stated the resident was fine, no distress and skin color was pink. She stated the resident was not wheezing and while she had not checked his O2 sat at the time [MEDICAL CONDITION], his O2 sat on room air had previously been 94%-97%. When asked if she had taken the resident's Vital Signs or assessed his lung sounds, she stated she had not since he wasn't in distress. She stated if he was in distress, she would have taken his Vital Signs, listened to his lungs and called 911. She stated she would also put him on O2 if needed. When asked if she knew how [MEDICAL CONDITION] dislodged, she stated she had checked the velcro straps earlier and they were fine. When asked if she thought the velcro strap may have been uncomfortable for the resident causing the resident to do something to the strap she stated she did not think so, that she tried to make sure the straps weren't too tight. When asked what type of training she had received related [MEDICAL CONDITION] and emergency management of a trach, she stated she had some training a long time ago in school. She stated that before she took the job at the facility in November 2011, she did go on - line and [MEDICAL CONDITION]. When asked if she had documented [MEDICAL CONDITION] occurrence anywhere, she stated she was unsure if she had or not. When asked if she had informed Administration or someone over her of the occurrence; she stated if a resident is sent out, nursing staff are supposed to let Administration know, but she was unsure if she had or not. During the interview, RN #2 stated that she had been told on Friday morning (1/6/12), that the resident'[MEDICAL CONDITION] also come out after Resident #13 had fallen the day before. She stated the night shift nurse told her that the resident was found on the floor with his [MEDICAL CONDITION] out. (Review of Nurse's Notes dated 1/6/12 at 1:20 AM revealed the resident was found on his knees beside the bed, however, there was no documentation of [MEDICAL CONDITION]). When asked if the resident had been sent out at the time, she thought she had been told the nurse had put [MEDICAL CONDITION] in. RN #2 was unsure which nurse had given her this information. Review on 2/14/12 of Nurse's Notes from admission to present revealed no mention of [MEDICAL CONDITION] on 1/6/12 or 1/7/12. Review of (Hospital) Discharge Instructions dated 1/7/12 revealed Resident #13 was seen related to "[MEDICAL CONDITION] dislodgement" and that [MEDICAL CONDITION] been replaced. Resident #13 had inappropriate management related to the placement and monitoring of his Oxygen Therapy. Record review on 2/13/12 at 3:34 PM revealed Medicare Nursing Notes dated 12/15/11 at 8:30 PM which stated "Res(ident) (with) SOB (Shortness of Breath), HOB (Head of Bed) (elevated) O2 (Oxygen) on (with) anxiety, BBS (Bilateral Breath Sounds) clear. Trach(eostomy) care given, noted thick yellow mucus. Suction res(ident) white phlegm, Resident tolerated well. O2 sat(uration) (decreased) 86%, pulse 125 (at the beginning). O2 sat(saturation) increased 95% on O2". Continued review of December 2011 Nursing Notes revealed entries dated 12/16/11 at 6:30 PM, 12/17/11 at 3:00 AM, 12/17/11 at 8:05, 12/19/11 at 2:00 AM, and 12/19/11 at 5:00 PM which noted that Resident #13 continued to receive oxygen via trach. The notes did not include the rate of Oxygen. The only notes that contained information related to the resident's O2 saturation were on 12/15/11, 12/16/11 and 12/19/11. Some of the notes indicated the oxygen was in place per Physician order. Review of Physician order [REDACTED].c. (nasal cannula). Under "Special Instructions" was listed "a. Obtain resident vital signs, pulse oxygen level, note any [MEDICAL CONDITION], have recent and prior weights available, and then notify MD (Physician). b. If RN (Registered Nurse) available, assess cardiac and lung sounds prior to contacting MD". There was no documentation found that the Physician was notified that Oxygen was in use per protocol. The protocol did not include information as to what procedure to use for a resident with a [MEDICAL CONDITION], and this was not clarified with the Physician by the nursing staff. Review of the 12/14/11 Initial History and Physical for Resident #13 along with physician progress notes [REDACTED]. Review of physician progress notes [REDACTED]. The note stated "...Breathing is comfortable,[MEDICAL CONDITION] comfortable...Saturation is 93% [MEDICAL CONDITION]". A Physician's Telephone Order dated 12/21/11 stated "...2. D/C O2". Review of Nursing Notes dated 12/20/11 and 12/21/11 revealed no mention of Oxygen in use or that Oxygen had been discontinued. Review of December 2011 Medication/Treatment Records revealed no mention that Oxygen had been started or was in use 12/15/11-12/21/11 or that O2 sats were being checked consistently during this time period. Review of the "T.P.R. Chart" for Resident #13 revealed O2 sats had been documented during the above time period for 12/17/11-93%, and 12/21/11- 94%. This information did not include a time nor if the resident was on O2 at the time of the checks. Review on 2/14/12 of the policy provided by the facility entitled "Medication Orders, Standing Orders (Optional)" revealed that standing orders are used for certain self limited conditions amenable to treatment using good nursing judgment. It stated "To facilitate prompt treatment of [REDACTED]. Under "Procedures" the policy stated "...5. The order is written following the procedure for verbal prescriber orders...In indicating the source of the order, the abbreviation "s.o." is used to indicate a standing order. 6. Documentation of the situation requiring the use of the standing order is placed in the nursing notes section of the resident's medical record prior to initiation of the order. 7. The authorized prescriber countersigns all standing orders...". During an interview on 2/14/12 at 2:55 PM, RN # 6 verified there was no Telephone Order written for the Oxygen, nor documentation in the Medication/Treatment Records that Oxygen was being administered or that O2 saturations were being checked. She verified the TPR Chart listed O2 sats for 2 days, but agreed the log did not specify a time, or if O2 was infusing at the time. She verified the Nursing Notes documentation related to Oxygen administration was sparse and did not contain complete information related to the rate of Oxygen or that the resident's O2 saturations were being checked consistently. On 2/13/2012, during an interview with the Clinical Consultant, she stated that prior to [MEDICAL CONDITION] they had reviewed the procedure with LPN #3 and she had told them that she had done it for years. The Consultant stated she was not aware that the nurses did not know how to [MEDICAL CONDITION] or perform emergency care for a [MEDICAL CONDITION] resident. On 2/13/12 inteview with the Director of Nursing revealed no resident with a Tracheosotomy had an Ambu bag at bedside. The Ambu bag was stored in a locked cart. The key to the cart was on the back of the cart. However, the attached backboard had to first be removed to obtain the key to unlock the cart. Therefore, staff would have to leave the resident, go to the cart, remove the backboard, unlock the cart, obtain the Ambu bag and return to the resident. Review of the facility's Inservice Attendance log revealed that LPN #3, LPN #15 and RN #3 were not inserviced prior to the care or incidents related to the resident's trachs. It also revealed that LPN #4 had attended the inservice. Review of the facility's policy entitled [MEDICAL CONDITION] Management revealed "Policy: ...Only a physician or qualified respiratory therapist may change the outer cannula...Procedure...5. Using sterile technique, suction the entire length of the [MEDICAL CONDITION] to clear the airway of any secretions that may hinder oxygenation...Special Considerations:...2. Staff needs to be knowledgeable regarding emergency measures in case a tube is expelled or the outer cannula becomes blocked...4. [MEDICAL CONDITION] outer cannulas need only be changed based upon the resident's condition and then, only by the physician in an appropriate setting..." The facility admitted Resident #10 on 12/6/2011 with [DIAGNOSES REDACTED]. Review of Resident #10's Medication Administration Records (MARs) on 2/13/2012 at 7:50 AM revealed that on the following dates there had been no documentation on the MARs indicating that on 12/8/12 at 6:30 AM and 11:30 AM that the Finger Stick Blood Sugar (FSBS) had been done per physician's orders [REDACTED]. On 12/19, 12/26, and 12/28/11 the MAR had been initialed and circled. No explanation for the circled dates had been documented. On the January 2012 MAR, 1/4/12 at 6:30 AM, the FSBS was documented as 200 with no coverage given. The Sliding Scale in use by the facility indicated that Resident #10 should have received 2 units of Regular Insulin. On 1/10 and 1/12 at 6:30 AM, the MAR had been initialed and circled, indicating the FSBS was not done, no explanation was documented. Again on 1/24 and 1/25 the FSBS was noted to be 200 on each day at 6:30 AM with no indication that the appropriate coverage had been administered. In the amount given area on the MAR, 0 (zero) had been written in. On 1/27/12 the 6:30 AM FSBS was circled with no explanation. On 1/12/, 1/26 and 1/31/12 at 11:30 AM the FSBS was initialed as taken with no results or insulin administration documented. The FSBS for 1/6/12 at 4:30 PM had been initialed and circled with LOA (leave of absence) to [MEDICAL TREATMENT] documented for that time on the back of the MAR. In February 2012, the 2nd, 7th, 8th and 9th were initialed by a nurse with a circled R in the result area at 6:30 AM. On 2/13/12 at 10:00 AM, during an interview with Licensed Practical Nurse #2, she verified the blanks on the MARs, that a circled R ment that the resident refused the FSBS and the incorrect doses that were given. When asked by the surveyor if the physician should have been notified of the residents refusals, she stated that on the third consecutive day the physician should have been called. She stated that there was no documentation of the physician being notified in the physician's notification book and that it would not be documented any other place. On 2/13/12 during 2 interviews with Registered Nurse (RN) #1, Admitting Nurse, she was asked for a copy of the Standing Orders for Sliding Scale Insulin. She stated to the surveyor that there wasn't one. When asked where it is documented, she stated that it wasn't and that she "just knew it". When the surveyor asked how she knew, RN #1 replied that she was told there was a standing order about 3 years ago but she had never seen it. She stated that when a resident is admitted with Sliding Scale she calls the physician to verify if they want to use the current Sliding Scale. The surveyor then asked how do the other nurses know what to use as a Sliding Scale for Insulin if she (RN #1) is not in the facility for an admission. RN #1 stated that they would have to look at another resident's chart. The facility admitted Resident #4 on 10/20/06 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed blanks on the December DMR (Diabetes Monitoring Record) related to FSBS results and amounts of insulin given on 12/02/11, 12/07/11, 12/08/11 and 12/14/11. An interview on 2/13/12 at approximately 3:05 PM LPN (Licensed Practical Nurse) #1 confirmed the findings that the December DMR had blanks related to FSBS and amounts of insulin given. The facility admitted Resident # 2 on 12/31/11 with [DIAGNOSES REDACTED].[REDACTED].) A copy of the standing orders to be used for this resident and signed by the physician did not include orders for standing sliding scale insulin. Review of the monthly PHYSICIAN ORDERS [REDACTED].<200=0 units SQ ( subcutaneous); 200-249=4 units SQ; 250-299=4 units SQ; 300-349==6 units SQ; 350-399=8 units SQ; 400-449=10 units SQ; 450-499=12 units SQ; >499=14 units SQ; notify MD (Physician) with FSBS <55 or >500. There was no telephone order in the medical record for the sliding scale insulin recorded on the physician monthly orders. The facility admitted Resident # 14 on 1/27/12 with [DIAGNOSES REDACTED]. Record review on 2/12/12 revealed an order on the Monthly physician's orders [REDACTED]. Review of the MAR (Medication Administration Record ) for January showed no concerns. On 2/13/12 the Medication Nurse, LPN # 4 (Licensed Practical Nurse), was asked to review the results of the FSBS's for February. The nurse turned to the Resident's MAR and went through each sheet. There was no documentation that any FSBS's had been done for the month of February. The nurse stated, " There were supposed to be blood sugars done on this resident. I don't know what happened." The Unit Manager stated, "The nurse who reviewed the monthly orders did not carry the order over on the MAR. Both nurses confirmed that no FSBS had been done for 13 days of the month of February. A blood sugar was done at 11:30 AM on 2/13/12 and the result was 140. The facility admitted Resident#13 on 12/13/11 with [DIAGNOSES REDACTED]. Sliding Scale Insulin Coverage was transcribed incorrectly onto the December 2011 Medication Administration Record resulting in omission of Insulin coverage for one dose. A Sliding Scale Insulin Coverage policy was in use without the current Physician or Medical Director's

On the days of the Recertification, Extended and Complaint Survey, based on interviews, observations, record reviews and review of the facility's policy entitled [MEDICAL CONDITION] Management, In-service attendance records related [MEDICAL CONDITION] care and suctioning, the facility failed to ensure that three of three residents with tracheostomies received proper care and treatment. (#6, #13 and #25 Resident #6 was decannulated by the Licensed Practical Nurse (LPN). The Nurse for Resident #13 did not recognize the potential emergency of a decannulated trach. Resident #25 did not receive timely emergency care for a decannulated trach. Facility staff were not adequately trained and appropriate emergency supplies were not maintained at the bedside. The findings included: The facility admitted Resident #13 on 12/13/11 with [DIAGNOSES REDACTED]. Resident #13 received inappropriate management of his [MEDICAL CONDITION] on 1/9/12 when his inner cannula was coughed out, and on 1/7/12 when the [MEDICAL CONDITION] became dislodged. Review of the (Hospital) Discharge Summary on 2/13/12 revealed Resident #13 was admitted to the hospital on [DATE] with Acute [MEDICAL CONDITION] secondary to Pneumonia. "...He was intubated and found to have a right complicated pleural effusion...". According to the report, "...He was difficult to wean off the ventilator; ultimately underwent a trach...At present time patient is showing significant improvement and will be safe to be discharged to (Nursing Facility). Review of Physician's Telephone Orders on 2/13/12 at 3:25 PM revealed a Physician's Telephone Order dated 1/9/12 which stated "Transfer to (Hospital)". Review of Physician's Progress Notes dated 1/11/12 revealed "... (Resident #13's) [MEDICAL CONDITION] was fully capped when I visited with him today and he was not even using the passing air valve. He did have an episode the other day where the [MEDICAL CONDITION] fell out and had to be placed back by the hospital folk...". Review on 2/13/12 of Nurse's Notes from admission to present revealed a note dated 1/9/12 at 9:35 PM which stated "Answered Residents call light. While entering the Room noticed [MEDICAL CONDITION] his hand. When asked Resident stated "I coughed hard and it came out". Immediately contacted on call Physician Dr. ---. Order Received to either [MEDICAL CONDITION] send out to Hospital if this nurse was not comfortable Reinserting Trach. Transferred Resident to (Hospital). Family & Administration notified". The facility provided a copy of the ER note dated 1/9/12 at the surveyor's request on 2/14/12. According to the note, "65 yo (year old) in rehab states he coughed and [MEDICAL CONDITION] out, it was actually inner cannula that came out and not trach, ...he states he did not want to come to er, dw (discussed with) nurse at (facility), she [MEDICAL CONDITION] out, and she was not comfortable putting it back in". According to the emergency room note, the "Trach in place, inner cannula out, yellow sputum at trach...", and resident with normal O2 sat and Vital Signs. During an interview on 2/14/12 at approximately 4:40 PM, Registered Nurse (RN) #7 verified she was the nurse taking care of Resident #13 the night of 1/9/12 when [MEDICAL CONDITION] out. She stated the resident had pushed his call light and she answered it. She found the resident with [MEDICAL CONDITION] his hand. She stated the resident was scared and she made sure that he wasn't in any respiratory distress. At the time, she thought the resident's [MEDICAL CONDITION] come out. She stated a CNA (Certified Nursing Assistant) walked in shortly after she found the resident (since she had not shut off the call light). She stated she assessed the resident by counting his respirations (they were even and not labored) and watching for his chest to rise and fall (normal). She stated she didn't have a stethoscope and couldn't listen to his breath sounds at the time. She stated the CNA stayed with the resident while she went to get another nurse (couldn't remember who it was). She stated that the other nurse came to stay with the resident, the CNA left, and she went to call the doctor. She stated she spoke with the doctor and told her that the resident'[MEDICAL CONDITION] out. The doctor asked her how the resident was doing, and she told her that he was not in distress. According to RN #7, the doctor wanted her to put [MEDICAL CONDITION] in, but she did not feel comfortable doing this. She stated that she had some training in school but no recent formal training [MEDICAL CONDITION] or emergency care for a trach. She stated the most important and only thing going through her mind at the time was that she was worried that the [MEDICAL CONDITION] would close up. When asked if she knew how to put [MEDICAL CONDITION] in, she stated she would lay the resident flat; remove any pillows; take the trach, turn it to the side, and stick it back in. She stated there was no emergency equipment at the bedside at the time that she knew of. When asked what an obturator was, she stated she couldn't think what that was. When asked why she did not call 911, she stated that since the resident was not in distress, she could send him out to have [MEDICAL CONDITION]. She stated if the resident did have trouble breathing or turned blue, she would have tried to put [MEDICAL CONDITION] in. When asked if she checked the resident's Oxygen saturation, she stated she did; that the CNA went to get the machine and recalled his O2 saturation was in the upper 90's. When asked how [MEDICAL CONDITION] secured, RN #7 stated she believed there was a velcro strap around [MEDICAL CONDITION] she believed was tight. She stated she believed it was still secured around the resident's neck at the time he coughed [MEDICAL CONDITION]. She stated that she talked to the ER Physician prior to transfer and the Physician called her back when the resident was returning to the facility. He told RN #7 that the [MEDICAL CONDITION] not come out, only the inner cannula. She stated the inner cannula the resident returned with that evening snapped in place and was secure. She stated the inner cannula the resident had prior to the one he returned with wouldn't stay in. She said she had noticed that at times it hung out more than it should. She stated it wasn't the snap type and believed it may have screwed or twisted into place. She stated it wouldn't hang out all the way, but she didn't mind pushing it back in. Review of facility training and inservices for RN #7 on 2/14/12 at 3:27 PM revealed no training related [MEDICAL CONDITION]/emergency management of a [MEDICAL CONDITION]. Record review on 2/13/12 at 3:25 PM revealed an additional Physician's Telephone Order dated 1/7/12 at 1:00 PM which stated "Sent to (Hospital) ER (emergency room ) r/t (related to )[MEDICAL CONDITION] out". During a phone interview on 2/21/12 at 5:47 PM, RN #2 verified she had worked on 1/7/12 and had sent the resident out to the hospital. She stated she was passing medications and went into the residents room to give him his medication. When she could not see the resident'[MEDICAL CONDITION] on his neck, she reached up and pulled the resident's shirt away from his neck and saw that the whole [MEDICAL CONDITION], outer and inner cannula along with [MEDICAL CONDITION] lying on the resident's chest. She stated that the resident was able to talk and had no respiratory distress. She stated she then told the resident, it looks like [MEDICAL CONDITION] out and asked him if it had come out. She stated she tried to reinsert the trach, but met resistance and stopped. She stated she picked up the whole [MEDICAL CONDITION] (outer and inner cannula still attached), and tried to put [MEDICAL CONDITION] in. She stated she felt comfortable trying to reinsert the trach, but it would only go approximately 1/4 inch into the skin before she met resistance and stopped. When asked if she knew what an obturator was prior to her recent inservice, she stated she did not know what an obturator was at the time of the incident, and also stated there was not one hanging over the resident's bed or at the bedside. She stated she was not aware of any emergency equipment at the bedside. She could not recall if a suction machine was present at the bedside but didn't think so. She stated there was no [MEDICAL CONDITION] or [MEDICAL CONDITION] kit at the bedside. She stated that when she had to [MEDICAL CONDITION], she would get a [MEDICAL CONDITION] kit and bring it to the resident's bedside. She stated after attempting to reinsert the trach, she went out to call the doctor. When asked, she stated that no one else was in the room with the resident when she went to call the doctor. She stated the resident was fine, no distress and skin color was pink. She stated the resident was not wheezing and while she had not checked his O2 sat at the time [MEDICAL CONDITION], his O2 sats on room air had previously been 94%-97%. When asked if she had taken the resident's Vital Signs or assessed his lung sounds, she stated she had not since he wasn't in distress. She stated if he was in distress, she would have taken his Vital Signs, listened to his lungs and called 911. She stated she would also put him on O2 if needed. When asked if she knew how [MEDICAL CONDITION] dislodged, she stated she had checked the velcro straps earlier and they were fine. When asked if she thought the velcro strap may have been uncomfortable for the resident causing the resident to do something to the strap she stated she did not think so, that she tried to make sure the straps weren't too tight. When asked what type of training she had received related [MEDICAL CONDITION] and emergency management of a trach, she stated she had some training a long time ago in school. She stated that before she took the job at the facility in November 2011, she did go on line and [MEDICAL CONDITION]. When asked if she had documented [MEDICAL CONDITION] occurrence anywhere, she stated she was unsure if she had or not. When asked if she had informed Administration or someone over her of the occurrence; she stated if a resident is sent out, nursing staff are supposed to let Administration know, but she was unsure if she had or not. During the interview, RN #2 stated that she had been told on Friday morning (1/6/12), that the resident'[MEDICAL CONDITION] also come out after Resident #13 had fallen the day before. She stated the night shift nurse told her that the resident was found on the floor with his [MEDICAL CONDITION] out. (Review of Nurse's Notes dated 1/6/12 at 1:20 AM revealed the resident was found on his knees beside the bed, however, there was no documentation of [MEDICAL CONDITION]). When asked if the resident had been sent out at the time, she thought she had been told the nurse had put [MEDICAL CONDITION] in. RN #2 was unsure which nurse had given her this information. Review on 2/14/12 of Nurse's Notes from admission to present revealed no mention of [MEDICAL CONDITION] on 1/6/12 or 1/7/12. Review of (Hospital) Discharge Instructions dated 1/7/12 revealed Resident #13 was seen related to "[MEDICAL CONDITION] dislodgement" and that [MEDICAL CONDITION] been replaced. During an interview on 2/14/12 at 7:25 PM, Licensed Practical Nurse (LPN) #4 was asked "Which cannula do you remove when [MEDICAL CONDITION]?" She stated she would remove the outer cannula. When asked what she would do if the [MEDICAL CONDITION] came out, she stated she would use the obturator to put the inner cannula back in. During an interview on 2/14/12 at 7:30 PM, LPN #14 was asked what she would do if the [MEDICAL CONDITION] came out. She stated she would put the inner cannula back in. When asked if she would use anything to put the cannula back in, she said she wouldn't use anything else. Additionally, Resident #13 had inappropriate management related to placement and monitoring of Oxygen Therapy. Record review on 2/13/12 at 3:34 PM revealed Medicare Nursing Notes dated 12/15/11 at 8:30 PM which stated "Res(ident) (with) SOB (Shortness of Breath), HOB (Head of Bed) (elevated) O2 (Oxygen) on (with) anxiety, BBS (Bilateral Breath Sounds) clear. Trach(eostomy) care given, noted thick yellow mucus. Suction res(ident) white phlegm, Resident tolerated well. O2 sat(uration) (decreased) 86%, pulse 125 (at the beginning). O2 sat(saturation) increased 95% on O2". Continued review of December 2011 Nursing Notes revealed entries dated 12/16/11 at 6:30 PM, 12/17/11 at 3:00 AM, 12/17/11 at 8:05, 12/19/11 at 2:00 AM, and 12/19/11 at 5:00 PM which noted that Resident #13 continued to receive oxygen via trach. The notes did not include the rate of Oxygen. The only notes that contained information related to the resident's O2 saturation were on 12/15/11, 12/16/11 and 12/19/11. Some of the notes indicated the oxygen was in place per Physician order. Review of Physician order [REDACTED].c. (nasal cannula). Under "Special Instructions" was listed "a. Obtain resident vital signs, pulse oxygen level, note any [MEDICAL CONDITION], have recent and prior weights available, and then notify MD (Physician). b. If RN (Registered Nurse) available, assess cardiac and lung sounds prior to contacting MD". There was no documentation found that the Physician was notified that Oxygen was in use per protocol. The protocol did not include information as to what procedure to use for a resident with a [MEDICAL CONDITION]. Review of the 12/14/11 Initial History and Physical for Resident #13 along with physician progress notes [REDACTED]. Review of physician progress notes [REDACTED]. The note stated "...Breathing is comfortable,[MEDICAL CONDITION] comfortable...Saturation is 93% [MEDICAL CONDITION]". A Physician's Telephone Order dated 12/21/11 stated "...2. D/C O2". Review of Nursing Notes dated 12/20/11 and 12/21/11 revealed no mention of Oxygen in use or that Oxygen had been discontinued. Review of December 2011 Medication/Treatment Records revealed no mention that Oxygen had been started or was in use 12/15/11-12/21/11 or that O2 sats were being checked consistently during this time period. Review of the "T.P.R. Chart" for Resident #13 revealed O2 sats had been documented during the above time period for 12/17/11-93%, and 12/21/11- 94%. This information did not include a time nor if the resident was on O2 at the time of the checks. Review on 2/14/12 of the policy provided by the facility entitled "Medication Orders, Standing Orders (Optional)" revealed that standing orders are used for certain self limited conditions amenable to treatment using good nursing judgment. It stated "To facilitate prompt treatment of [REDACTED]. Under "Procedures" the policy stated "...5. The order is written following the procedure for verbal prescriber orders...In indicating the source of the order, the abbreviation "s.o." is used to indicate a standing order. 6. Documentation of the situation requiring the use of the standing order is placed in the nursing notes section of the resident's medical record prior to initiation of the order. 7. The authorized prescriber countersigns all standing orders...". During an interview on 2/14/12 at 2:55 PM, RN # 6 verified there was no Telephone Order written for the Oxygen, nor documentation in the Medication/Treatment Records that Oxygen was being administered or that O2 saturations were being checked. She verified the TPR Chart listed O2 sats for 2 days, but agreed the log did not specify a time, or if O2 was infusing at the time. She verified the Nursing Notes documentation related to Oxygen administration was sparse and did not contain complete information related to the rate of Oxygen or that the resident's O2 saturations were being checked consistently. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 2/13/12 at 2:45 PM, during observation of [MEDICAL CONDITION] care for Resident #6 by LPN #3, the LPN removed the resident'[MEDICAL CONDITION] collar and placed it on his chest. LPN #3 did not hyper-oxygenate the resident prior to removing the collar or suction the resident. After removing the stoma dressing, she removed the inner cannula and placed it in the trash. The resident began coughing forcefully. She opened [MEDICAL CONDITION], sanitized her hands, put on sterile gloves, placed the barrier on the resident's chest extending to the bottom of the flange. She then opened the sterile saline and poured it into the tray. After pouring the saline, she removed [MEDICAL CONDITION] and removed the outer cannula and began cleaning it with saline soaked 2 X 2 gauze. The surveyor immediately questioned why she had removed the outer cannula. LPN #3 stated, while continuing to cleaning the outer cannula, that the policy said to clean the inner cannula with saline and pointed to papers (facility policy) she had lying on the bed side table. The surveyor then requested LPN #3 to put the cannula back as it was the outer cannula, not the inner. At that time LPN #4 placed [MEDICAL CONDITION] on the right side of the resident's chest and left the room to get the Assistant Director of Nursing (ADON) per this surveyors request. LPN #3 replaced the outer cannula without using an obturator. She then cleaned the area around the stoma with cotton tipped swabs dipped in saline and replaced the stoma dressing. LPN #4 and the ADON then entered the room. LPN #4 had brought a pulse oximeter to check the resident's oxygen level. Resident #6 had an oxygen level of 82 percent after the procedure. During the procedure the resident had copious amounts of secretions and a forceful cough resulting in secretions being coughed to the bottom of the bed while LPN #3 was cleaning the outer cannula. A physician also entered the room to assess the resident and replaced the inner cannula. The resident's oxygen level had increased to 99 percent at that time. On 2/13/12, during an interview with LPN #3, prior to [MEDICAL CONDITION], she stated that she had not been trained [MEDICAL CONDITION] at the facility but had done in it for years at a hospital where she had worked. On 2/13/2012, during an interview with the Clinical Consultant, she stated that prior to [MEDICAL CONDITION] they had reviewed the procedure with LPN #3, and she had told them that she had done it for years. The Consultant stated she was not aware that LPN #3 did not know how to [MEDICAL CONDITION]. Review of the facility's In-service Attendance log revealed that LPN #3 was not in-serviced prior to the care. Review of the facility's policy entitled [MEDICAL CONDITION] Management revealed "Policy: ...Only a physician or qualified respiratory therapist may change the outer cannula...Procedure...5. Using sterile technique, suction the entire length of the [MEDICAL CONDITION] to clear the airway of any secretions that may hinder oxygenation...Special Considerations:...2. Staff needs to be knowledgeable regarding emergency measures in care a tube is expelled or the outer cannula becomes blocked...4. [MEDICAL CONDITION] outer cannulas need only be changed based upon the resident's condition and then, only by the physician in an appropriate setting..." The facility admitted Resident #25 on 1/23/12 with [DIAGNOSES REDACTED]. Review of the medical chart for Resident #25 on 2/12/12 revealed that the resident had a physicians telephone order dated 2/09/12 at 4 PM which stated: "Send to ER (emergency room ) r/t (related to)[MEDICAL CONDITION]." Review of the Nurses' Notes for that date revealed there was no documentation related to the need to transfer the resident to the emergency room . A previous note stated that on 2/9/12 at 6:00 AM the resident had "broken" [MEDICAL CONDITION] and at 2:50 PM his vital signs were taken. The next entry in the Nurses' Notes stated that at 7:00 PM the resident had returned from the ER with [MEDICAL CONDITION] place. On 2/13/12 at 7:40 PM, an interview was conducted with the Registered Nurse (RN) # 3, who had signed the 2/9/12 notes at 7:00 PM. RN #3 stated that she had worked the 7:00 AM to 7:00 PM shift on 2/9/12. She stated that she had assessed the resident's respiratory status because he was having difficulty and that his sats (oxygen saturation) "was high, 80% (percent)." RN #3 stated that the resident refused oxygen and suctioning at that time. RN #3 stated that around 4:30 PM, she entered Resident #25's room and that [MEDICAL CONDITION] out. She also stated that she left the resident's room to find the Wound Nurse,. She asked her to come into the room, call the Assistant Director Of Nursing (ADON) and call the Family Nurse Practitioner (FNP). The FNP told her to get an obturator to reinsert the resident's trach. She stated she had tried to find an obturator but could not find one. The surveyor asked if she would have tried to re-insert [MEDICAL CONDITION] she had found an obturator. RN # 3e stated that she would have tried. When asked if anyone tried to re-insert [MEDICAL CONDITION] said no, that the ADON paged the FNP. When asked if the resident was in distress, she stated no, his oxygen level was 83% and they had called 911 at that time. When asked how long it was from the time the resident was found with [MEDICAL CONDITION] until 911 was called, she said 10-15 minutes. The surveyor then asked if she had taken the emergency cart to the room or administered oxygen, the RN stated " No, but his oxygen level remained at 83%." The RN was asked if she had had emergency training in [MEDICAL CONDITION] care and she stated "No". In an interview on 2/14/12 at 2:10 PM with LPN #15 she stated that she was not in the facility when Resident #25 was sent to the emergency room . She stated that she had been trained in [MEDICAL CONDITION] care at another facility in 2011. She stated that she would insert an obturator but not attempt to insert a trach. When asked if the resident would get oxygen through an obturator, the LPN stated "No." When asked why she would insert the obturator without the trach, she stated that she did not know. On 2/13/2012, during an interview with the Clinical Consultant, she stated that prior to [MEDICAL CONDITION] they had reviewed the procedure with LPN #3 and she had told them that she had done it for years. The Consultant stated she was not aware that the nurses did not know how to [MEDICAL CONDITION] or perform emergency care for a [MEDICAL CONDITION] resident. Review of the facility's Inservice Attendance log revealed that LPN #3, LPN #15 and RN #3 were not inserviced prior to the care or incidents related to the resident's trachs. It also revealed that LPN #4 had attended the inservice. Review of the facility's policy entitled [MEDICAL CONDITION] Management revealed "Policy: ...Only a physician or qualified respiratory therapist may change the outer cannula...Procedure...5. Using sterile technique, suction the entire length of the [MEDICAL CONDITION] to clear the airway of any secretions that may hinder oxygenation...Special Considerations:...2. Staff needs to be knowledgeable regarding emergency measures in case a tube is expelled or the outer cannula becomes blocked...4. [MEDICAL CONDITION] outer cannulas need only be changed based upon the resident's condition and then, only by the physician in an appropriate setting..." On 2/14/12 at 7:35 PM, Licensed Practical Nurse (LPN) #10 was interviewed on the Transitions Unit, related to [MEDICAL CONDITION] care to include emergency [MEDICAL CONDITION] care. Inquired of LPN #10, "which cannula do you remove to provide [MEDICAL CONDITION] cleaning care?" She answered, "the inner cannula." LPN #10 was asked, "If the resident's [MEDICAL CONDITION] is completely out, would you place the cannula back in?" This LPN was unsure if she should place the cannula back in. Further emergency questions to this LPN, "where is emergency [MEDICAL CONDITION] equipment located?" LPN #10 was not able to provide location of emergency equipment to include the location of the Ambu bag to provide oxygen to a resident in an emergency situation. LPN #10 stated, "I would have another nurse come to the room to help me." On 2/13/2012, during an interview with the Clinical Consultant, she stated that prior to [MEDICAL CONDITION] they had reviewed the procedure with LPN #3 and she had told them that she had done it for years. The Consultant stated she was not aware that the nurses did not know how to [MEDICAL CONDITION] or perform emergency care for a [MEDICAL CONDITION] resident. Review of the facility's Inservice Attendance log revealed that LPN #3, LPN #15 and RN #3 were not inserviced prior to the care or incidents related to the resident's trachs. It also revealed that LPN #4 had attended the inservice. Review of the facility's policy entitled [MEDICAL CONDITION] Management revealed "Policy: ...Only a physician or qualified respiratory therapist may change the outer cannula...Procedure...5. Using sterile technique, suction the entire length of the [MEDICAL CONDITION] to clear the airway of any secretions that may hinder oxygenation...Special Considerations:...2. Staff needs to be knowledgeable regarding emergency measures in case a tube is expelled or the outer cannula becomes blocked...4. [MEDICAL CONDITION] outer cannulas need only be changed based upon the resident's condition and then, only by the physician in an appropriate setting..." On 2/13/12 inteview with the Director of Nursing revealed no resident with a Tracheosotomy had an Ambu bag at bedside. The Ambu bag was stored in a locked cart. The key to the cart was on the back of the cart. However, the attached backboard had to first be removed to obtain the key to unlock the cart. Therefore, staff would have to leave the resident, go to the cart, remove the backboard, unlock the cart, obtain the Ambu bag and return to the resident. On 2/14/2010 at 5:45 PM, the Administrator, Director Of Nursing and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified a F-280, F-281, F-328, F-490 and F-501 at a scope and severity of "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 1/7/2012 when a resident's trach, both inner and outer cannula, came out and could not be reinserted by staff and no emergency supplies were available at bedside. Follow up interviews with the facility nursing staff occurred on 2/15/12. At 10:25 AM on this date. Examples of the interviews conducted were as follows: Registered Nurse (RN) #6 -, "What is the process to clean the [MEDICAL CONDITION] while doing [MEDICAL CONDITION] care?" She answered, "use the [MEDICAL CONDITION] cleaning kit, proper handwashing technique and use of gloves, place pulse ox on patient, if the inner cannula is not disposable clean using sterile water, brush and Q-tips in the kit." This RN further responded, "check the velcro or ties on [MEDICAL CONDITION] to be sure it is securing [MEDICAL CONDITION]." RN #6 was asked, "what do you do if the whole [MEDICAL CONDITION] appliance comes out to include the type of emergency equipment needed and where is the Ambu bag located?" She responded appropriately, stating, "the emergency kit is at bedside, the Ambu bag is on the crash cart and we are going to have an Ambu bag in each resident's room that has a [MEDICAL CONDITION], provide oxygen and call for help and even 911 if necessary." RN #6 continued with, "use the obturator, have suction ready, lay the patient flat and insert outer appliance followed with the inner cannula after removing the obturator." On 2/15/12 at 10:45 AM, LPN #4 was interviewed related to [MEDICAL CONDITION] care to include emergency [MEDICAL CONDITION] care. LPN #4 was asked, "what is the process to clean the [MEDICAL CONDITION] while doing [MEDICAL CONDITION] care?" She responded, "use [MEDICAL CONDITION] kit, put the pulse ox on the patient, and have the emergency kit available at bedside." LPN #4 was able to verbalize the equipment in the [MEDICAL CONDITION] kits and the correct steps/procedure to clean the [MEDICAL CONDITION]. LPN #4 was then asked, "what do you do if the whole [MEDICAL CONDITION] appliance comes out and include the type of emergency equipment needed and the location of the Ambu bag?" She responded, "pull the call light for help, lay the patient flat, use the obturator from the [MEDICAL CONDITION] and replace the appliance, give oxygen and call the doctor. LPN #4 verbalized the Ambu bag is located on the crash cart. LPN # 8 was interviewed on 2/15/12 at 11:05 AM. The first question asked was, "what is the process to clean the [MEDICAL CONDITION] while doing [MEDICAL CONDITION] care?" Her response, "use [MEDICAL CONDITION] kit, use the normal saline, gauze, peroxide to clean the inner cannula. Also use suction unit if needed, give oxygen and check the ties on [MEDICAL CONDITION]." Following question to LPN #8 was, "what do you do if the whole [MEDICAL CONDITION] appliance comes out and include the type of emergency equipment needed and the location of the Ambu bag?" Her response to this question, "the Ambu bag is on the crash cart at the end of the hall; if [MEDICAL CONDITION] comes all the way out, call for help, use the obturator to guide the outer cannula back in, remove the obturator, put in inner cannula, give oxygen, use suction unit if needed, check O2 sats and call 911 if needed." Every nurse on duty at that time was interviewed prior to the survey team exiting the facility and no concerns were identified. Interviews revealed the Allegation of Compliance submitted by the facility on 2/15/12 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of [MEDICAL CONDITION] care and emergent care of resident with tracheostomies. The Administrator was informed of this on 2/15/12 at 11:30 AM. The citations of F-280, F-281, F-328, F-490 and F-501 remained at a lower scope and severity of "E". The facility will be in compliance with F-280, F-281, F-328, F-490 and F-501 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction. Cross Refer to F-280, F-281, F-328, F-490 and F-501 as it relates to the failure of the facility to ensure that residents receive adequate care. In addition failure of the facility to ensure staff are adequately trained to provide appropriate care to residents with tracheostomies.

On the days of the Recertification, Extended and Complaint Survey, based on interviews, the facility failed to provide services in compliance with all Federal, State and local laws, regulations and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Facility Administration failed to ensure Resident #6, #13, and #25 received the necessary care and services to prevent potential harm from occurring. The Administrator failed to assure that policies established as documented in [MEDICAL CONDITION] Management were followed, the licensed staff possessed the knowledge and skills required to safely care for, recognize components of a [MEDICAL CONDITION] and recognize and act upon emergency situations with residents with tracheostomies. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. The facility staff neglected to obtain orders for routine care, suctioning and emergent care of Resident #6's [MEDICAL CONDITION] on admission to the facility. LPN #3 neglected to provide appropriate knowledge and care of the resident'[MEDICAL CONDITION] in the nurse decannulating the resident [MEDICAL CONDITION] resulting in his oxygen level decreasing to 83%. Resident #6 was not adequately care planned for tracheostomies to include routine and emergency care. The facility admitted Resident #13 on 12/13/11 with [DIAGNOSES REDACTED]. Resident #13 had inappropriate management of his [MEDICAL CONDITION] on 1/9/12 when his inner cannula was coughed out, and on 1/7/12 when the [MEDICAL CONDITION] became dislodged. The facility admitted Resident #25 on 1/23/12 with [DIAGNOSES REDACTED]. The facility staff neglected to obtain orders for routine care, suctioning and emergent care of Resident #25's [MEDICAL CONDITION] on admission to the facility. The facility neglected to provide emergency care for Resident #25 when he was left decannulated for 15 minutes resulting in his oxygen level decreasing to 82% prior to 911 being called. Resident #25 was not adequately care planned for tracheostomies to include routine and emergency care. On 2/13/2012, during an interview with the Clinical Consultant, she stated that prior to [MEDICAL CONDITION] they had reviewed the procedure with LPN #3 and she had told them that she had done it for years. The Consultant and the Administrator stated they were not aware that staff did not know how to [MEDICAL CONDITION] or provide emergency care for resident's with trachs. Review of the facility's Inservice Attendance log revealed that LPN #3 and RN #3 had not been in-serviced [MEDICAL CONDITION]. On 2/13/12 inteview with the Director of Nursing revealed no resident with a Tracheosotomy had an Ambu bag at bedside. The Ambu bag was stored in a locked cart. The key to the cart was on the back of the cart. However, the attached backboard had to first be removed to obtain the key to unlock the cart. Therefore, staff would have to leave the resident, go to the cart, remove the backboard, unlock the cart, obtain the Ambu bag and return to the resident. Review of the facility policy on [MEDICAL CONDITION] Management included the following: ...Only a physician or qualified respiratory therapist may change the outer cannula. *For emergency [MEDICAL CONDITION] replacement...#2 Sterile obturator that fits the [MEDICAL CONDITION] in use. #3 Extra sterile [MEDICAL CONDITION] and obturator in appropriate size. #4 Suction equipment and supplies. *Special Considerations....#2 Staff needs to be knowledgeable regarding emergency measures in case a tube is expelled or the outer cannula becomes blocked...#4 [MEDICAL CONDITION] outer cannulas need only be changed based upon the resident's condition and then, only by the physician in an appropriate setting...*Points to remember....Extra [MEDICAL CONDITION] and other essential supplies should always be available: a resuscitation bag should also be kept at the bedside. On 2/14/2010 at 5:45 PM, the Administrator, Director Of Nursing and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified a F-280, F-281, F-328, F-490 and F-501 at a scope and severity of "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 1/7/2012 when a resident's trach, both inner and outer cannula, came out and could not be reinserted by staff and no emergency supplies were available at bedside and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Allegation of Compliance submitted by the facility on 2/15/12 was implemented by the facility and observed by the survey agency to be in practice, removing the immediacy of the deficient practice. All licensed facility nursing staff currently at work were interviewed, had been educated and were knowledgeable of [MEDICAL CONDITION] care and emergent care of residents with tracheostomies. The Administrator was informed of this on 2/15/12 at 11:30 AM. The citations of F-280, F-281, F-328, F-490 and F-501 remained at a lower scope and severity of "E". The facility will be in compliance with F-280, F-281, F-328, F-490 and F-501 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction. Cross Refer to F-280, F-281, F-328, F-490 and F-501 as it relates to the failure of the facility to ensure that residents receive adequate care. In addition failure of the facility to ensure staff are adequately trained to provide appropriate care to residents with tracheostomies.

On the days of the Recertification, Extended and Complaint Survey, based on interviews, observations, review of the facility's policy [MEDICAL CONDITION] Management, South Carolina LLR Advisory Opinion #37, and record reviews, the facility Medical Director failed to ensure the facility's policies and procedures were implemented to ensure licensed staff were knowledgeable and competent to provide routine and emergency care for residents with a [MEDICAL CONDITION] (trach), (Residents #6, #13, & #25) and the facility failed to have established policies to address sliding scale insulin The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. The facility staff neglected to obtain orders for routine care, suctioning and emergent care of Resident #6's [MEDICAL CONDITION] on admission to the facility. LPN #3 neglected to provide appropriate knowledge and care of the resident'[MEDICAL CONDITION] in the nurse decannulating the resident [MEDICAL CONDITION] resulting in Resident #6's oxygen level decreasing to 83%. Resident #6 was not adequately care planned for tracheostomies to include routine and emergency care. The facility admitted Resident #13 on 12/13/11 with [DIAGNOSES REDACTED]. Resident #13 had inappropriate management of his [MEDICAL CONDITION] on 1/9/12 when his inner cannula was coughed out, and on 1/7/12 when the [MEDICAL CONDITION] became dislodged. The facility admitted Resident #25 on 1/23/12 with [DIAGNOSES REDACTED]. The facility staff neglected to obtain orders for routine care, suctioning and emergent care of Resident #25's [MEDICAL CONDITION] on admission to the facility. The facility neglected to provide emergency care for Resident #25 when he was left decannulated for 15 minutes resulting in his oxygen level decreasing to 82% prior to 911 being called. Resident #25 was not adequately care planned for tracheostomies to include routine and emergency care. On 2/13/2012, during an interview with the Clinical Consultant, she stated that prior to [MEDICAL CONDITION] they had reviewed the procedure with LPN #3 and she had told them that she had done it for years. The Consultant and the Administrator stated they were not aware that staff did not know how to [MEDICAL CONDITION] or provide emergency care for resident's with trachs. An interview was conducted with the facility's Medical Director. He stated he would expect the nurses to keep [MEDICAL CONDITION] dry and clean. He also stated that he was not an expert on trachs. When asked if he would expect discharge orders from the hospital to be stated prn (as needed). He then stated he did not remember routine orders, he had never seen one and he would expect it to be based on the individual as to how often it was suctioned and cleaned. When asked if it should be a sterile procedure, he stated " no, it's not a sterile environment". The surveyor asked him what he would expect for emergency treatment if a resident had been decannulated. He replied it depends on the situation. If it comes out he assumes the nurse would re-insert it and if unable to do so would contact the provider. He was asked what he expected the staff should do if the resident experiences respiratory distress? He stated call 911, if stable, call the provider and that some facilities have Respiratory Therapist. The surveyor asked what training would he expect the nurses to have prior to caring for a resident with a trach? He stated " I would not expect them to exceed their comfort level and that if they had seen it done, had training or experience". He then added, "there's a hole there and you put the thing back in. It's not rocket science". He was then asked what emergency supplies he would expect to be kept at the bedside? He stated he had never thought about it, there were no items necessary to keep at the bedside and would not expect the facility to keep an obturator, [MEDICAL CONDITION] Ambu bag at the bedside. Review of South Carolina LLR Advisory Opinion #37 stated, "... The Board of Nursing for South Carolina acknowledges that it is within the role and scope of practice of a RN (registered nurse) and LPN to temporarily remove, reposition or reinsert [MEDICAL CONDITION] in children and adults with well established stomas in the home or school setting providing the environment is supportive to emergency medical care. This responsibility is an expanded role for the RN and LPN. Appropriate written policies and procedures should be developed which specify required special education and training. This special education and training should include documented safety practices and other didactic material as well as clinical skill competency components. The agency policies and procedures should address how the agency will assure a physician or Advanced Practice Registered Nurse (APRN) authorizes removal, repositioning or reinsertion of [MEDICAL CONDITION]. This can be defined in the written policies, procedures, and protocols. Annual updates/reviews need to be documented." Review of the facility policy on [MEDICAL CONDITION] Management included the following: ...Only a physician or qualified respiratory therapist may change the outer cannula. *For emergency [MEDICAL CONDITION] replacement...#2 Sterile obturator that fits the [MEDICAL CONDITION] in use. #3 Extra sterile [MEDICAL CONDITION] and obturator in appropriate size. #4 Suction equipment and supplies. *Special Considerations....#2 Staff needs to be knowledgeable regarding emergency measures in case a tube is expelled or the outer cannula becomes blocked...#4 [MEDICAL CONDITION] outer cannulas need only be changed based upon the resident's condition and then, only by the physician in an appropriate setting...*Points to remember....Extra [MEDICAL CONDITION] and other essential supplies should always be available: a resuscitation bag should also be kept at the bedside. In addition to concerns with [MEDICAL CONDITION] residents, the facility failed to have a Standing Order for the Sliding Scale Insulin in use/or in the facility that had been approved by the Medical Director. According to the DON, the policy supplied was being used at the direction of the former Medical Director. When asked, she stated the pharmacy had sent this policy to the facility since the policy could not be found in the building. When asked, she stated that staff did not have access to this policy. She stated the current Medical Director and Physician had not previously signed a copy of the policy, but that Physician # 1 had signed a copy of the policy that morning (2/14/12). On 2/13/2010 at 5:45 PM, the Administrator, Director Of Nursing and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-280, F-281, F-328, F-490 and F-501 at a scope and severity of "K". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 1/7/2012 when a resident's trach, both inner and outer cannula, came out and could not be reinserted by staff and no emergency supplies were available at bedside. The Allegation of Compliance submitted by the facility on 2/15/12 was implemented by the facility and observed to be in practice, removing the immediacy of the deficient practice. All licensed facility nursing staff currently at work were interviewed, had been educated and were knowledgeable of [MEDICAL CONDITION] care and emergent care of residents with tracheostomies. The Administrator was informed of this on 2/15/12 at 11:30 AM. The citations of F-280, F-281, F-328, F-490 and F-501 remained at a lower scope and severity of "E". The facility will be in compliance with F-280, F-281, F-328, F-490 and F-501 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction. Cross Refer to F-280, F-281, F-328, F-490 and F-501 as it relates to the failure of the facility to ensure that residents receive adequate care. In addition failure of the facility to ensure staff are adequately trained to provide appropriate care to residents with tracheostomies.