Every finding on record at Dr Ronald E McNair Nursing & Rehabilitation Center

Based on observation, interview, record review, facility policy review, and manufacturer guidelines review, the facility failed to ensure the medication administration error rate was less than 5 percent (%). The facility had 3 medication errors out of 27 opportunities, affecting 3 Residents, (R)44, R66, and R5, of 5 residents reviewed during the medication administration task, resulting in a medication error rate of 11.11%.Review of the facility's undated policy titled, Medication Handling and Administration Procedure, revealed, 1. Review E-MAR [Electronic Medication Administration Record]/MAR [Medication Administration Record]. 2. Check the E-Medication Administration Record (EMAR)/MAR for the medication due to be given. 3. Review the medication labels within the medication drawer for the appropriate medication. Verify the resident and medication information, as to the name of drug, strength, dose, route, and time of administration within the E-MAR/MAR. 4. Remove medication from the packaging over the medication cup so that the medication falls into the cup. 5. Should a dose be offered and subsequently refused or not given for any reason, discard the medication and document this on the E-MAR/MAR. 6. After the drug has been given and swallowing is observed, document administration on the E-MAR/MAR. Review of the facility's undated policy titled, Injections, Subcutaneous, revealed, 14. Expel air from syringe by priming with at least 2units [sic] of insulin to remove air. An Instructions for use Novolog (insulin aspart) injection, for subcutaneous or intravenous use 3 mL [milliliter] FlexPen prefilled pen, instruction manual, revised in 03/2023, revealed, Before each injection small amounts of air may be collected in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units [instructions refer to diagram]. F. Hold your Novolog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge [instructions refer to diagram]. G. Keep the needle pointing upwards, press the push-button all the way in [instructions refer to diagram]. The dose selector returns to 0. A drop of insulin should appear at the needle tip. The manufacturer instructions continued, Check and make sure that the dose selector is set at 0. H. Turn the dose selector to the number of units you need to inject. 1.Review of R44's Resident Face Sheet revealed the facility admitted R44 on 12/13/22. According to the Resident Face Sheet, the resident had a past medical history that included diagnosis of type 2 diabetes mellitus. Review of R44's Physician Order Report, dated from 12/14/25 to 01/14/26, contained an order, dated 09/17/24, for metformin tablet 500 milligrams (mg); amount: 1,000 mg, by mouth twice a day for type 2 diabetes mellitus. During an observation of medication administration on 01/14/26 at 8:08 AM, Registered Nurse (RN) 3 prepared R44's medications, to include two tablets of metformin 1,000 mg. RN 3 handed R44 the cup of medications. While the resident was still holding the cup of medications, the surveyor requested RN 3 to review the medications. RN 3 took the cup of medications from R44 and exited the room. RN #3 reviewed R44's electronic medication administration record, physician order, and the resident's metformin medication card. RN 3 stated R44's physician order for metformin was to administer 1,000 mg and she had prepared two 1,000 mg tablets. During an interview on 01/14/26 at 8:18 AM, RN 3 stated she was confused by R44's metformin order because the order was to administer 500 mg tablets for a total of 1,000 mg, so she removed 2 tablets, not aware that she pulled two 1,000 mg tablets of the medication. 2. Review of R66's Resident Face Sheet revealed the facility admitted R66 on 08/16/24. According to the Resident Face Sheet, the resident had a past medical history that included diagnosis of constipation. Review of R66's Physician Order Report, dated from 12/14/25 to 01/14/26, contained an order, dated 09/16/25, for sennosides-docusate sodium 8.6 mg-50 mg, one tablet by mouth twice a day for constipation.During an observation of medication administration on 01/14/2026 at 9:01 AM, RN 1 performed hand hygiene and prepared R66's medications to include one tablet of 8.6 mg sennoside. RN 1 gathered the resident's medications, entered the resident's room, and administered the medications to the resident. During an interview on 01/14/26 at 9:19 AM, RN 1 reviewed the medications she removed from the cart for administration to R66 and confirmed that she administered sennosides 8.6 mg instead of sennosides-docusate sodium 8.6 mg-50 mg. RN 1 observed R66's physician orders and confirmed that she administered the incorrect medication to R66. Review of R5's Resident Face Sheet revealed the facility admitted R5 on 02/03/23. According to the Resident Face Sheet, the resident had a past medical history that included diagnosis of type 1 diabetes mellitus. Review of R5's Physician Order Report, dated from 12/15/25 to 01/15/26, contained an order, dated 11/23/25, for Novolog FlexPen (insulin aspart), amount 3 units subcutaneously, three times a day with breakfast, lunch, and dinner, for type 1 diabetes mellitus. During an observation of medication administration on 01/14/26 at 12:27 PM, Licensed Practical Nurse (LPN) 4 removed R5's insulin aspart insulin pen, a needle, and an alcohol pad from the medication cart. LPN 4 applied a needle to the tip of the insulin aspart pen and dialed the selector to 3 units. LPN 4 did not prime the insulin pen needle with 2 units of insulin prior to dialing the 3-unit dose. LPN 4 performed hand hygiene, donned clean gloves, cleansed R5's right lower abdomen with alcohol, and administered the insulin. During an interview on 01/14/26 at 12:39 PM, LPN 4 stated that she normally primed the insulin needle with 2 units of insulin prior to selecting the dose and administering it to the resident. LPN 4 stated that she forgot to prime the insulin pen needle prior to administering the insulin to R5. During an interview on 01/16/26 at 12:33 PM, the Director of Nursing (DON) stated nursing staff were to read the resident's medication order, verify the order on the medication card, and make sure the medication matched with the physician's order. The DON stated nursing staff should verify the right resident, right route, right time, right medication, right dose, and right date when administering medications to residents. The DON stated if that process were not followed, it could result in a medication error. The DON said she expected nursing staff to prime the needle of the insulin pen with 2 units of insulin before selecting the dose and observe the insulin come out of the needle before administering it to the resident. During an interview on 01/16/26 at 12:42 PM, the Administrator stated that she expected nursing staff to follow the DON's expectations related to medication administration.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure nail care was provided for 2 (Resident #7 and Resident #73) of 4 sampled residents reviewed for activities of daily living (ADLs). Review of the facility's undated policy titled ADL Policy indicated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, promote as much independent functionality as possible. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care. The policy continued, 2. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene.1.Review of R7's Resident Face Sheet revealed the facility admitted R7 on 07/01/23. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of Parkinson's, type 2 diabetes mellitus, and neurocognitive disorder. Review of R7's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/25, revealed R7 had moderate impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a staff assessment of mental status (SAMS). The MDS indicated the resident was dependent on staff with all ADLs, including personal hygiene. Review of R7's Individual Service Plan included a problem statement dated 05/27/25 that indicated the resident required total assistance with ADL care. Interventions directed staff to provide and record assistance routinely and to notify a nurse of any decline noted, every shift. The Individual Service Plan also included a problem statement that indicated the resident had a decline in functional ability related to the diagnosis of Parkinson's disease. Interventions directed staff to assist the resident with activities of daily living as needed. During an observation on 01/12/26 at 9:33 AM, R7 was observed in their bed. The resident's fingernails on both hands were long. During an observation on 01/13/26 at 9:00 AM, R7 was observed in their bed. The resident's fingernails on both hands remained long and curved inward toward the resident's palms. During an observation on 01/14/26 at 10:20 AM, R7's fingernails on both hands remained long and were curved inward toward the resident's palms. During an observation on 01/14/26 at 2:00 PM, R7's fingernails on both hands remained long. During an interview on 01/14/26 at 2:08 PM, Registered Nurse (RN) #1 stated that when a resident received their baths/showers, that included trimming their fingernails. During an interview on 01/14/26 at 2:16 PM, Certified Nursing Assistant (CNA) #2 stated that trimming a resident's fingernails was part of daily ADL care provided to the resident. CNA #2 stated if the resident were diabetic then the nurses were responsible for trimming the resident's nails. CNA #2 stated she had not offered to trim Resident #7's fingernails, but she should have, because the resident was dependent on staff to assist them with their ADL care. During a concurrent interview and observation on 01/14/26 at 2:22 PM, CNA #2 confirmed R7's fingernails were too long and there was potential for the resident's fingernails to cause injury and infection if they continued to grow towards the palm of the resident's hands. During a concurrent observation and interview of R7's fingernails on 01/14/26 at 2:30 PM, RN #1 stated R7's fingernails had not been trimmed in a long time, and the fingernails were curved inward towards the resident's palms. RN #1 stated R7 was a diabetic, and a nurse should have trimmed their fingernails as part of their daily ADL care. During a concurrent observation and interview on 01/14/26 at 2:55 PM, the Administrator (ADM) observed R7's fingernails and stated that the resident's fingernails needed to be trimmed. The ADM said R7's fingernails were very long and if the resident's fingernails were not maintained/trimmed, there was potential for their fingernails to become embedded into the palms of their hands.2. A Resident Face Sheet indicated the facility admitted Resident #73 on 12/20/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of seizures, muscle spasm, and unspecified pain. Review of R73's annual MDS, with an ARD of 11/24/25, revealed R73 had moderate impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a staff assessment of mental status (SAMS). The MDS indicated that the resident required substantial/maximal assistance from staff for personal hygiene. Review of R73's Individual Service Plan included a problem statement dated 12/10/24 that indicated the resident required assistance with activities of daily living (ADL) Care. Interventions directed staff to provide and record assistance routinely and to notify a nurse of any decline noted, every shift. During an observation on 01/12/26 at 9:24 AM, R73 was lying in their bed. The resident's fingernails on both hands were long and dirty. Resident #73's fingernails were uneven and with what appeared to be dried food under the resident's fingernails. During an observation on 01/13/26 at 9:56 AM, R73 was sitting in their medical recliner. The resident's fingernails on both hands remained long and dirty. During an observation on 01/14/26 at 10:30 AM, R73 was sitting in their medical recliner. The resident's fingernails on both hands remained long, extending past the end of the resident's fingertip. During an interview on 01/14/26 at 2:08 PM, RN #1 stated that when residents received their baths/showers, that included trimming their fingernails. RN #1 stated that diabetic residents were trimmed as needed by the nurses. During an interview on 01/14/26 at 2:17 PM, CNA #2 stated R73 did not refuse ADL care and was dependent on staff to trim their fingernails. CNA #2 stated R73 was non-verbal and unable to ask staff for ADL assistance, and she should have offered to trim the resident's fingernails. During a concurrent observation and interview on 01/14/26 at 2:20 PM, CNA #2 confirmed R73's fingernails were too long and needed to be trimmed. During a concurrent observation and interview on 01/14/26 at 2:35 PM, RN #1 observed R73's fingernails and stated that the resident's fingernails needed to be trimmed. During a concurrent observation and interview on 01/14/26 at 2:55 PM, the ADM stated R73 was dependent on staff for ADL care including nail care. The ADM stated R73's fingernails needed to be trimmed. During an interview on 01/15/26 at 10:32 AM, the Director of Nursing (DON) said she expected staff to trim the residents' fingernails. The DON stated that the nurses were responsible for trimming the fingernails of the diabetics. The DON stated her staff knew trimming fingernails was part of their daily ADL duties. During an interview on 01/15/26 at 11:05 AM, the ADM stated she expected the staff to offer to trim the residents' fingernails. The ADM stated the CNAs could trim non-diabetic residents' fingernails, but the nurses were responsible for trimming diabetic residents' fingernails.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were secured in 1 of 3 medication carts when not attended by staff and failed to ensure proper disposal of medications during 2 of 5 observations during the medication administration task. Review of the facility's policy titled, Medications - Discarding and Destroying Medications, revised on 09/08/25, revealed, 9. Medications should be discarded in the sharps container by Nurses during medication pass as indicated. Review of the facility's undated policy titled, Medication Storage, revealed, a. All drugs and biologicals will be stored in locked compartments (i.e. [id est, that is], medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. The policy continued, c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. During an observation of medication administration on 01/14/26 at 8:08 AM, Registered Nurse (RN) 3 prepared medications for R44, gathered the medications, and entered the resident's room with the medications. RN 3 left the medication cart unlocked in the hallway. No other staff members were observed in the unit hallway at the time of the observation. RN 3 then exited the room with the cup of medications, at the surveyor's request, to review and discuss the medications. RN 3 reviewed R44's electronic medication administration record, physician order, and the resident's medication card for metformin. RN 3 stated R44's physician order for metformin was to administer 1,000 milligrams (mg) and she had prepared two 1,000 mg tablets. RN 3 removed the additional tablet of metformin 1,000 mg from the medication cup and disposed of it in the medication cart trash can. During a concurrent interview and observation on 01/14/26 at 8:18 AM, RN 3 stated she normally locked the medication cart whenever she walked away from the cart during medication administration and stated she forgot to lock the medication cart. RN 3 stated that if medications needed to be wasted, they would normally be disposed of in the sharps container on the medication cart. RN 3 stated that she disposed of the extra metformin 1,000 mg pill in the medication cart trash can. A cup of 10 medication pills was also observed in the medication cart trash can. RN 3 removed the cup of 10 medication pills from the medication cart trash can and stated that a resident refused their medications earlier that morning and she had disposed of those medications in the medication cart trash can. RN 3 identified the 10 medications in the cup as one tablet of montelukast 10 mg, two tablets of divalproex sodium 125 mg, two tablets of metoprolol tartrate 5 mg, one tablet of donepezil 10 mg, one tablet of trazodone 100 mg, two tablets of memantine 5 mg, and one tablet of simvastatin 20 mg. RN #3 stated that the medications should have been disposed of in the sharps container. During an observation of medication administration on 01/14/26 at 9:01 AM, while preparing medications, RN 1 dropped an omeprazole 20 mg tablet and missed the medication cup. RN 1 picked the tablet up and disposed of it in the medication cart trash can. During an interview on 01/14/26 at 9:19 AM, RN 1 stated that she disposed of the wasted omeprazole 20 mg in the medication cart trash can. RN 1 stated that the wasted medication should have been disposed of in the sharps container on the medication cart. During an interview on 01/16/26 at 12:37 PM, the Director of Nursing (DON) said she expected nursing staff to dispose of wasted medications in the sharps container because nobody could access the medication. The DON stated it was not acceptable for nursing staff to dispose of medications in the medication cart trash can unless it was a cream or an ointment. The DON stated that if the medication cart was out of the nurse's eyesight, she expected the medication cart to be locked. During an interview on 01/16/26 at 12:41 PM, the Administrator (ADM) stated that she expected nursing staff to follow the facility policies and procedures related to medication storage and disposal. The ADM stated she expected nursing staff to ensure medications were kept in a secure and locked location.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain infection control practices by failing to ensure the proper implementation of Enhanced Barrier Precautions (EBP) for 1 Resident (R)7 of 5 residents observed during the medication administration task. Review of the facility's undated policy titled, Enhanced Barrier Precautions, revealed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms. The policy revealed, b. We implement enhanced barrier precautions as indicated for residents with any of the following: i. Wounds (e.g. [exempli gratia, for example], chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wound, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC [peripherally inserted central catheter] lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO [multidrug-resistant organism]. Review of R7's Resident Face Sheet revealed the facility admitted R7 on 06/25/19. According to the Resident Face Sheet, the resident had a past medical history that included diagnosis of gastrostomy status. Review of R 7's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/25, revealed R7 had moderate impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a staff assessment of mental status (SAMS). The MDS revealed the resident received nutrition through a feeding tube during the last seven days of the assessment look-back period. R7's Individual Service Plan included a problem statement, dated 05/27/25, that indicated the resident was on EBP related to the increased risk for infection due to gastric feeding tube, chronic diagnoses that increase risk, and frequent antibiotic use related to aspiration pneumonia and urinary tract infection. Interventions directed staff to use EBP when performing high-contact resident care activities and for residents who met criteria for the use of EBP (initiated 05/27/25). During an observation of medication administration on 01/14/26 at 9:36 AM, Registered Nurse (RN) 1 removed nine medications from the medication cart, crushed the medications as needed, and placed each medication in a separate cup for administration to R7. A sign was observed on R7's door, which indicated that the resident was under EBP. The signage directed staff to wear gloves and a gown for high-contact resident care activities. RN 1 performed hand hygiene, donned clean gloves, and entered the resident's room. RN 1 did not don a gown prior to the procedure. RN 1 administered the medications to R7through the resident's gastrostomy tube. During an interview on 01/14/26 at 10:18 AM, RN 1 stated R7 was on EBP, and she should have donned a gown prior to administering the resident's medication. RN 1 stated that EBP was implemented for any residents who had an open area, such as a wound, gastrostomy tube, or urinary catheter. During an interview on 01/16/26 at 12:29 PM, the Director of Nursing (DON) stated that EBP was used as a protective measure due to the resident having an external device, such as a tracheostomy, gastrostomy tube, or urinary catheter. The DON stated that when facility staff provided care for residents on EBP, they should don the equipment that was listed on the signage posted on the resident's door. The DON stated she expected nursing staff to don the appropriate personal protective equipment when administering medications through a gastrostomy tube. During an interview on 01/16/26 at 12:43 PM, The Administrator stated that she expected nursing staff to follow the expectations of the DON regarding EBP.

Based on observation, interviews, and review of the facility policy, the facility failed to ensure that food items were correctly labeled and dated in the freezer and dry storage areas. This deficiency has the potential to increase the risk of foodborne illnesses. Findings include: Review of the facility policy titled, Labeling and Dating Foods (Date Marking), dated 2020 reveals, All foods stored will be labeled according to the following guidelines. Guidelines outlined include but are not limited to the following. 1. Date marking for dry storage food items. The exception to dating individual dry storage food items includes individually packaged food items stored in bulk containers such as packets of hot chocolate, tea bags, saltine crackers, packets of sugar, packets of individual cookies, etc. The Dining Services Manager is to ensure that these bulk items are rotated with old items used first. New product is never to be placed on top of old product. Expiration dates on commercially prepared, dry storage food items will be followed. Additionally, the policy guidelines for dating marking freezer storage food items reveal the following, Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe storage guidelines or by the manufacturer's expiration date. Based on initial observation of facility walk in freezer on [DATE] at 10:16 AM with [NAME] 1 (C1) revealed: 1.) 2 Ziplog bags of precooked item which was not labeled with its contents, preparation date, or expiration date. 2.) 1 Box of Stampede Boneless Beef Ribeye Steak (5 Count) - Expired [DATE] 3.) 1 Box of Hormel Deli Bread Ready Premium Buffet Ham (12 lbs) - Expired [DATE] Based on initial observation of facility dry storage on [DATE] at 10:50 AM, observations revealed: 1.) 7 Bottles of [NAME] Creek Chocolate Flavored Syrup 24 ounces (oz) - No labeled expiration date. 2.) 6 cans of 66.5 oz Skipjack Chunk Light Tuna - No labeled expiration date. 3.) 10 Cans of 16oz [NAME] Mushroom Pieces and stems - No labeled expiration date. During an interview with C1 at approximately [DATE] at 10:30 AM, C1 revealed that The kitchen manager (KM) and dietary staff try and check the refrigerators and freezers routinely throughout the week in order to ensure expired food items are thrown away. C1 also revealed, If a food item is cooked and is to be frozen for future consumption, the facility expects the team to label what the food item is, the date it was prepared, and the date it expires. C1 was unaware of and did not realize that there was an unlabeled precooked food item in the freezer and was unaware of the expired food items in the freezer. During an interview with Dietary Aide, (DA)1 on [DATE] at 10:59 AM, he revealed the following; The kitchen manager is typically the one responsible for the intake of food delivery. DA1 also stated, Without the expiration date of food items in the dry storage room, they could not indicate surely whether or not food items were safe to serve to residents. DA1 could not identify expiration dates on the tuna cans and mushroom cans. During an interview with KM1 on [DATE] at 09:50 AM revealed she is primarily responsible for the inventory, intake, and of inventory of food items. KM1 stated that she typically do not label dry storage items with a receive by date or an expiration date when receiving delivered dried goods prior to survey. KM1 revealed that typically kitchen staff will call her if they have any issues with dates regarding food items. KM1 revealed she understands how their current way of labeling dry storage items can lead to potential issues for residents and she is also responsible for completing an inventory of the facility refrigerator and freezer to ensure that expired items are discarded. She stated that she does this at least 3 times a day. KM1 also stated, Cooked food that needed to be frozen or refrigerated needs to be labeled with what it is, when it was made, and an expiration date. KM1 confirmed that food items were not labeled based on facility expectations. KM1 was unaware of the expired food items in the freezer and unlabeled items in the dry storage room. During an interview with Certified Dietary Manager (CDM)1 on [DATE] at 10:00 AM, she stated that it is her expectation of her dietary/kitchen staff to discard of expired food items in the facility and that all food items are to be labeled with an expiration date. CDM1 revealed that she was unaware of the expired food items in the freezer. CDM1 revealed that they will work on immediate interventions and conduct full inventories of all food items to ensure food items are properly labeled and dated. During an interview with the Administrator on [DATE] at 10:30 AM, she reveals that when it comes to food storage and labeling practices it is her expectation that the dietary team follow the facility policy. She stated it is her expectation of the KM to do daily audits of storage areas checking for expired food items. If expired food items are found, it is her expectation that kitchen staff discard expired food items. The Administrator also revealed that any food item that must be re-refrigerated or re-frozen needs to be labeled with what the food item is and to date food items with the date it was prepared and the date it needs to be discarded.

Based on the facility policy, observations and interviews, the facility failed to ensure an excessive amount of lint was removed from the top of the lint basket and around the wiring in 1 of 3 clothes dryers. Findings include: Review of the facility policy titled, Lint Removal in Laundry, states, The facility removes lint from Dryers to prevent transmission of pathogens and hazards. 4. Laundry equipment will be used and maintained. 5. Lint trap is checked frequently and cleaned by Laundry Staff at least hourly while the machine is in use. The logs reviewed did not contain any documentation to ensure the lint had been removed since the start of the shift. An observation on 11/26/2024 at 07:51 AM revealed an excessive amount of lint in 1 of 3 clothes dryers. The lint was noted above the lint basket and hanging in a mass from the wiring where it was difficult to see the wiring for the lint. During an interview on 11/26/2024 at 08:05 AM with Maintenance he confirmed the excessive amount of lint. Maintenance did not provide logs to ensure he or the laundry workers were removing the lint after each load.

Based on interviews, review of staff daily postings, registered nurse (RN) time sheets reviews, and the Payroll Based Journal (PBJ), the facility failed to ensure an RN was scheduled for 8 hours on weekends as reported on the PBJ for 3 out of 4 weekends reviewed. Findings include: Review of facility daily postings for May 2024 revealed the following: May 12th - (1) RN coverage 8AM- 5PM May 26th - (1) RN coverage 8am -5PM May 31st - (2) RN coverage 8AM- 5PM Review of facility daily postings for June 2024 revealed the following: June 9th - (1) RN coverage 8AM-5PM Review of RN Time sheets for May 2024 revealed there was no RN coverage on the following dates: 11th, 12th, 19th, 25th, 26th, 27th, 30th. Review of RN Time sheets for June 2024 revealed there was no RN coverage on the following dates: 2nd, 8th and 9th. During an interview on 11/24/24 at approximately 10:00 AM, Licensed Practical Nurse (LPN)5 revealed the facility did not have a charge nurse on weekends, but the facility has a nurse on call. LPN5 stated the facility does not have RNs on weekends. During an interview on 11/26/24 at approximately 10:00 AM, the Director of Nursing (DON) revealed the following, Management looks at staffing patterns daily, and what is going on with the residents. The DON stated, Staffing sheets are done daily and staff requirements and assignments are made according to residents' needs and diagnoses to ensure the facility has staff to meet resident needs. The DON also stated, We have 12-hour Licensed Practical Nurses (LPNs) in the building every day and at least 8-hour RN coverage. The DON stated, The facility staffs coverage according to resident census with a nurse on each unit and RN coverage may be a 12-hour coverage. When asked about call-ins, DON stated, Management will make calls to replace staff by calling other regular staff or on-call nurses who will cover the shift. During an interview on 11/26/24 at approximately 10:16 A, the Administrator stated, There is no temporary or contract staffing used in facility. The facility cannot afford contract staffing. However, the facility has a group of nurses that take incentives and work overtime.

Based on observations, record keeping, interviews, facility policy, manufacturer and pharmacy labeling, the facility failed to ensure that out-of-date medications were removed from active stock and medications were properly stored in 2 of 2 medication rooms and 3 of 6 medication carts. Findings Include: Review of the facility policy related to Medication Storage copyright 2024 states: 'It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer' recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. and Refrigerated Products: .Temperatures are maintained within 36-40 degrees F (Fahrenheit). On 11/24/24 at approximately 10:16 AM inspection of the Hall 200 Medication Room revealed one Equate Therapeutic Shampoo 6 oz. (ounce) 7/2024 and one T/Gel Therapeutic Shampoo 8.5 oz. expired 8/2024 both located on a metal storage shelf. The refrigerator thermometer read 28 degrees F at 10:18 AM. On 11/24/24 at approximately 10:19 AM, Licensed Practical Nurse (LPN)1 inspected and acknowledged the expired medications. On 11/24/24 at approximately 10:56 AM, the Surveyor rechecked the refrigerator thermometer with both the Surveyor's calibrated thermometer and both thermometers read 30 degrees F. On 11/24/24 at approximately 10:58 AM, LPN1 confirmed the 30 degrees F reading on both thermometers and was asked to contact the Maintenance Director to bring the facility thermometer to recheck the refrigerator's temperature. On 11/24/24 at approximately 11:16 AM, the Maintenance Director inspected the Hall 200 Medication Room refrigerator and read 30 degrees F on the refrigerator thermometer, but did not have a facility thermometer available to check the temperature. On 11/24/24 at approximately 10:46 AM, inspection of the Hall 100 Medication Room revealed the following: one bottle of Hydrogen Peroxide 32 oz. with expiration of 01/22 located on a metal storage shelf and two urine specimen containers with dark yellow liquid, inside biohazard bags, were stored in the medication room refrigerator alongside medications. One urine specimen container was labeled as having been collected 11/07. On 11/24/24 at approximately 10:53 AM, LPN2 acknowledged these findings stating those should not be in there. On 11/25/24 at approximately 1:41 PM, inspection of 200 Hall Treatment Cart revealed one opened, in use tube of MediHoney 1.5 fl oz (fluid ounce) by Derma Science labeled Tube sterility guaranteed in unopened, undamaged package Single Use Only and one bottle of Hydrogen Peroxide 16 oz. by CVS Health expired 9/2024. On 11/25/24 at approximately 1:49 PM, inspection of 200 Hall Medication Cart 2 revealed one Breyna 160 mcg/4.5 mcg Inhaler by [NAME] opened, in use, not dated. The inhaler had been labeled by the manufacturer Discard the inhaler when labeled # (number) of inhalations have been used or within 3 months of opening the foil pouch and Pharmacy had applied a label leaving space for opened date which had not been filled in. On 11/25/24 at approximately 1:54 PM, LPN3 confirmed the findings for both the treatment cart and the medication cart after reading manufacturer labeling. On 11/25/24 at approximately 2:04 PM, inspection of the Hall 100 Treatment Cart revealed two opened, in use tubes of MediHoney 1.5 fl oz by Derma Science labeled Tube sterility guaranteed in unopened, undamaged package Single Use Only. On 11/25/24 at approximately 2:09 PM, LPN4 read the manufacturer labeling and confirmed the finding.

Based on review of the facility policy and resident rights, record reviews, and interviews, the facility failed to ensure Resident (R)47 and R58 were afforded the right to participate in the planning process of their care and to ensure each resident was invited to the care plan conferences for 2 of 2 residents that expressed their desire to be included in the care planning process. Findings include: Review of the facility policy titled, Care Pan Invitations, states the, MDS (Minimum Data Set) assessment nurse notified the Resident and/or Resident Representative of scheduled Care Plan dated and adjusts dates as indicated. The purpose is, To provide a means of communicating scheduled care plan meeting and reviews. The procedure is as follows: 1. The MDS Nurse schedules Care Plan meetings and notifies Resident and/or Resident Representative as indicated. 2. The MDS Nurse documents Resident/Resident Representative Notifications as indicated. 3. The Care Plan is reviewed with Resident/Representative with input and updates as indicated. 4. The MDS Nurse electronically documents attendance in care plan meeting. Review of the, Resident's [NAME] Of Rights, states, As a resident of this facility, You have or legal guardian has, the right to; 7a. Participate in planning treatment: Resident shall have the right to participate in the planning of their health care. This right includes the opportunity to discuss treatment and alternatives with individual caregivers, the opportunity to request and participate in formal care conferences, and the right to include a family member or other chosen representative. In the event that the resident cannot be present, a family member or other representative chosen by the resident may be included in such conferences. The facility admitted R47 on 01/23/2023 and readmitted her on 05/01/2024. The admitting diagnoses include viral pneumonia, neurogenic shock, major depressive disorder, anxiety disorder and chronic osteomyelitis. Review of the quarterly MDS assessment dated [DATE], revealed the Brief Interview for Mental Status (BIMS) score of 14 out of 15. The score of 14 indicated that R47 has no cognitive deficits and is able to be understood and to understand others. Section D of the MDS for mood is scored a (0) as having no mood disorders and Section E for behavior is scored a (0) as having no behaviors. During an interview on 11//24/2024 with R47, she voiced her wishes to be included in the care planning process for her care. Review on 11/25/2024 of a Care Conference Report revealed R47 attended one care plan conference on 01/12/2024. No documentation could be found to ensure R47 has been invited to any other care planning conference. Review on 11/25/2024 of a progress note dated 10/20/2024 at 02:45 AM states, the resident's responsible party was made aware of the upcoming care plan meeting. The RP will attend in person. Under Notes: Resident will attend care plan meeting. R47 again stated that she had not been invited to care plan conferences would would like to be included. The facility admitted R58 on 08/06/2024 with diagnoses including but not limited to, polyneuropathy, pain, chronic vial hepatitis, respiratory failure with hypoxia, and congestive heart failure. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15 indicating mild cognitive deficits. R58 is coded in section B as understood and understands. R58 is coded (0) for section D and E as having no mood disturbance or behaviors. During an interview on 11/24/2024 with R58, he voiced his concern of not being included in the care planning process for his care. During an interview on 11/25/2024 with the MDS Coordinator, she provided a Care Conference Report, dated 03/11/2024, 03/29/2024, 06/28/2024 and 09/26/2024. R58 was not listed as attending the care plan conferences. Review on 11/25/2024 of a progress note provided by the MDS Coordinator dated 09/01/2024 at 09:07 AM that states, The resident's responsible party was made aware of the upcoming care plan meeting, and the responsible party will attend via a telephone conference. There was not documentation to ensure R58 was also invited or included in the care planning process for his care.

Based on resident observation, interview and record review, the facility failed to promote dignity related to facial hair for Resident (R)1, for 1 of 1 resident(s) reviewed for dignity. Findings include: Review of the facility undated policy titled, Dignity Policy indicated, Compliance Guidelines: 1. Staff members involved in providing care to residents to promote and maintain resident dignity. 3. Groom and dress residents according to resident preference. Review of the facility undated policy titled, ADL Policy indicated, Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, promote as much independent functionality as possible. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care Policy Explanation and Compliance Guidelines: 2. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of a Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to; anxiety disorder due to known physiological condition, dementia with other behavioral disturbance, and Schizoaffective disorder, bipolar type. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 10/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15, indicating R1's cognition is severely impaired. Review of section E- Behavior of R1's Quarterly Minimum Data Set (MDS) revealed the following: E0200 Behavioral Symptoms- Presence and Frequency A-C code -0- Behavior not exhibited. E0800- Rejection of Care - Presence and Frequency code -0- Behavior not exhibited. Review of section GG- Functional Abilities of R1's Quarterly MDS revealed the following: GG0130 Self-Care: C. Toileting hygiene- code 04 I. Personal hygiene- code 04 Code 04 indicates: R1 requires supervision or touching assistance- Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. Review of R1's Care Plan with a start date of 02/09/24 revealed requires limited assistance with bathing, dressing. Extensive assistance needed for incontinent care, feeds self with tray set up. Medications taken whole. Review of R1's Activity of Daily Living-Point of Care History dated 10/28/24- 11/25/24 with no specific resident care documented. An observation on 11/25/24 at approximately 9:00 AM revealed R1 sitting in the day room, fully dressed, with her hair combed. R1 presented with facial hair on the chin area and above lip. During an additional interview on 11/25/24 at approximately 9:35 AM, R1 stated, She does not like the hair being on her face. R1 reported she used to shave her facial hairs in the past. During an interview on 11/25/24 AM at approximately 9:39 AM, Licensed Practical Nurse (LPN)6 stated, R1 is just a setup for ADLs. LPN6 reported, Sometimes when staff attempts to shave or remove R1's facial hair, R1 sometimes refuses. LPN6 stated, R1 has certain CNAs she will let shave her. R1 has a diagnosis of schizophrenia, and can be very vocal. LPN6 stated she would offer R1 to have facial hair removed today and see if she agrees. An observation and interview on 11/25/24 at approximately 2:48 PM revealed R1 lying on bed in her room. When asked if she preferred facial hair, R1 stated she would like to have the facial hair removed. During an interview on 11/25/24 at 2:50 PM, CNA1 stated, R1 sometimes will only let certain staff remove facial hair and sometimes she is non-compliant. CNA1 reported R1's mood varies. At this time, the surveyor and CNA1 observed R1 sitting on the edge of her bed. CNA1 asked R1 who she preferred to remove her facial hair, pointing at CNA1 and then another CNA. R1 stated she wanted and pointed at CNA1 to remove the facial hair. An observation on 11/25/24 at approximately 3:27 PM revealed R1 sitting in activities. R1stated, Her face felt much better now that facial hairs were removed. R1 stated she preferred Certified Nursing Assistant (CNA)1 to remove the facial hairs.

Based on interview, record review, and policy review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 2 residents (Resident (R)23 and R1) of 19 residents reviewed for MDS. The facility failed to ensure significant weight loss was accurately documented for R23 and to ensure R1's diagnoses were accurate. These failures placed the residents at risk for unmet care needs. Findings include: Review of the RAI Manual 3.0, dated 10/19, revealed, . If an MDS assessment is found to have errors that incorrectly reflect the resident's status, then that assessment must be corrected . Review of the facility policy titled MDS Assessment, dated 01/01/22, revealed Residents are assessed using a comprehensive assessment process in order to identify care needs and to develop an interdisciplinary care plan . Quarterly Assessment- completed using an ARD no >92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD). Significant Change in Status Assessment (SCSA)- a comprehensive assessment completed within 14 days of the identification of a status change that meets the requirements outlined in Chapter 2 of the 3.0 Version RAI Manual. A significant change is a major decline or improvement in a resident's status that: (l) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical intervention (is not self-limiting, if a decline); (2) impacts more than one area of the president's health status, and (3) requires interdisciplinary review and/or revision of the care plan . 1. Review of the Admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R23 was admitted to the facility on [DATE]. A review of the most recent quarterly MDS, located under the RAI (Resident Assessment Instrument) tab of the EMR, with an Assessment Reference Date (ARD) of 08/18/22 failed to reveal documentation of R23's significant weight loss of over 10% in the previous 180 days. Review of R23's weights for the previous 180 days located under the Vitals tab of the EMR revealed as follows: 09/28/2022 - 107 lbs 09/14/2022 - 102 lbs 09/13/2022 - 109 lbs 08/29/2022 - 107 lbs 08/15/2022 - 106 lbs 08/07/2022 - 110 lbs 08/01/2022 - 110 lbs 07/18/2022 - 114 lbs 07/08/2022 - 118 lbs 07/04/2022 - 118 lbs 06/08/2022 - 122 lbs 05/10/2022 - 129 lbs 04/19/2022 - 128 lbs Review of the Progress Notes, located in the Progress Notes tab of the EMR, revealed a note on 08/19/22 by the RD (Registered Dietician) that R23 had a BMI (Body Mass Index) of 18.8 and was underweight. RD noted the following weights: 08/07/22 - 110# (pounds) 08/01/22 - 110# 07/2022 - 114# 05/2022 - 129# 02/2022 - 130# The RD noted that the weights indicated a 19% weight loss in 180 days. Interview with the MDS (Minimum Data Set Coordinator - MDSC) on 10/11/22 at 10:10 AM revealed the MDSC was the one who entered the data in the MDS and would review and correct the entry. In an interview on 10/12/22 at 12:03 PM, the Administrator stated the MDS entry was incorrect and would be corrected. 2. Review of R1's undated Face Sheet, located in R1's EMR under the Face Sheet tab, indicated R1 was admitted to the facility on [DATE], with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the R1's quarterly MDS with an Assessment Reference Date (ARD) of 07/01/22, located in R1's EMR under MDS tab, revealed a Brief Interview of Mental Status (BIMS) score of five out of 15, indicating R1's cognitive status was severely impaired. Further review of R1's MDS revealed the resident's active diagnoses included schizophrenia but not dementia. During an interview conducted on 10/13/22 at 1:17 PM, the MDSC was asked to review R1's quarterly MDS for behavioral diagnoses. The MDSC stated, the resident has a diagnosis of schizophrenia. When asked how R1 received the diagnosis of schizophrenia and where to find the documentation for the diagnosis, the MDSC stated it must have been put there from the previous MDS coordinator and that I just copied and pasted what she had done, but I take full responsibility of not double checking my work. During an interview conducted on 10/13/22 at 10:00 AM, after reviewing R1's MDS and Face Sheet, the Administrator confirmed the discrepancy between the two documents.

Based on review of facility policy, record review, and interview, the facility failed to develop and implement a person-centered comprehensive plan of care for 2 residents (Resident (R) 23 and R1). Findings include: A review of the policy titled, Care Plans,' dated 01/01/22, revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of R23's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, documented the resident was admitted to the facility on [DATE] with diagnoses including eating disorder, abnormal weight loss, nausea with vomiting, iron deficiency anemia, other specified nutritional deficiencies, and bipolar disorder. Review of R23's weights for the previous 180 days located under the Vitals,' tab of the EMR revealed as follows: 09/28/2022 - 107 lbs 09/14/2022 - 102 lbs 09/13/2022 - 109 lbs 08/29/2022 - 107 lbs 08/15/2022 - 106 lbs 08/07/2022 - 110 lbs 08/01/2022 - 110 lbs 07/18/2022 - 114 lbs 07/08/2022 - 118 lbs 07/04/2022 - 118 lbs 06/08/2022 - 122 lbs 05/10/2022 - 129 lbs 04/19/2022 - 128 lbs Review of these weights revealed R23 had lost weight as follows: On 04/19/22, the resident weighed 128 lbs. On 09/28/22, the resident weighed 107 pounds which is a -16.41 % loss. Review of the Progress Notes, located in the Progress Notes tab of the EMR revealed a note on 08/19/22 by the RD (Registered Dietician) that R23 had a BMI (Body Mass Index) of 18.8 and was underweight. Further review revealed the RD noted a significant weight loss in 180 days and stated nutritional diagnoses of involuntary weight loss and inadequate energy intake. Review of the Care Plan, located under the Care Plan tab in the EMR, failed to reveal a care plan developed with interventions for significant weight loss of more than 10% in 180 days. A review of the most recent quarterly Minimum Data Set (MDS), located under the RAI (Resident Assessment Instrument) tab of the EMR, with an Assessment Reference Date (ARD) of 08/18/22 failed to reveal documentation of R23's significant weight loss of over 19% in the previous 180 days. In an interview on 10/11/22 at 10:32 AM, the Director of Nursing (DON) confirmed the weights for R23 were correct as recorded in the EMR and that the care plan needed to be written to reflect the resident's significant weight loss. In an interview with the Administrator on 10/12/22 at 12:03 PM, the Administrator verified the Care Plan for weight loss had not been developed but that interventions had been implemented to address R23's weight loss. 2. Review of R1's undated Face Sheet, located in R1's electronic medical record (EMR) under the Face Sheet tab, indicated R1 was admitted to the facility on [DATE], with diagnoses including dementia with behavioral disturbance, hallucinations, and psychotic disturbances. Review of R1's quarterly MDS with an ARD of 07/12/22, located in R1's EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 indicating R1's cognition was severely impaired. Further review of R1's MDS did not indicate R1 had been assessed as having dementia. Review of R1's Care Plan, reviewed and revised 07/21/22, located in R1's EMR under the MDS tab, revealed there was no care plan developed for R1's diagnoses of dementia. During an interview on 10/12/22 at 1:14 PM, the MDS Coordinator (MDSC) responded that she does the care planning and the social worker reviews and signs off on the care plan. The MDSC verified there was no care plan for R1's diagnoses of dementia and stated, I must have overlooked it, because I mis-coded the MDS with diagnoses of schizophrenia and not [R1's] diagnoses of dementia.

Amended [DATE] Based on interviews, record reviews, and review of the facility's policy titled, Residents Rights Regarding Treatment and Advance Directives, and Medical Emergency Response, and Communication of Code Status, the facility failed to ensure that care and services were provided for 1 of 1 sampled resident reviewed for death in the facility. Resident #53 was designated a full code status but did not receive Cardiopulmonary Resuscitation (CPR) as ordered. On [DATE] at approximately 11:45 AM, the Administrator was notified that Immediate Jeopardy (IJ) existed at F678 with a scope and severity level of J with an effective date of [DATE], related to the failure to provide Cardio-Pulmonary Resuscitation to a Resident with a Advance Directive status of Full Code. The Administrator was provided the IJ Template on [DATE] at 11:45 AM. The facility provided an acceptable IJ Removal Plan on [DATE] at approximately 5:30 PM. Upon verification of the IJ removal plan, to include the review of staff trainings related to providing CPR and review of audits completed related to code status of residents residing in the facility, the IJ at F-678 was removed with an effective completion date of [DATE] and lowered to the scope and severity of D. The findings included: Resident #53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], Resident #53 had a change in condition. CPR was not initiated by staff and the resident expired. Review of the medical record for Resident #53 on [DATE] at approximately 3:30 PM and [DATE] at approximately 9:00 AM of the monthly cumulative physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was not documentation to ensure CPR was initiated as ordered by the physician and as requested by Resident #53 and his/her responsible party. During an interview on [DATE] at approximately 4:39 PM with Registered Nurse (RN) #1 stated, during shift change with Licensed Practical Nurse (LPN) #2, an agency nurse and also a new nurse, the narcotics were counted. LPN #2 physically picked up each package to verify the count and then signed off as being correct. A full round was completed, and a complete explanation of the crash cart usage was explained. We reviewed the crash cart book, where to find the physician's numbers was pointed out and LPN #2 had no questions. An inventory of items located in the crash cart was also available. The RN also stated that he/she did not give Resident #53 any medications due to nausea. At 8:30 PM at change of shift with LPN #3 reported that a dose of [MEDICATION(S)] was given to Resident #53 around 7:30 PM due to nausea. At no time was [MEDICATION(S)] administered, Resident #53 does not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on [DATE] at approximately 4:50 PM with the Director of Nursing (DON) confirmed that LPN #2 was disgruntled. The DON went on to say that LPN #2 did not give any of the residents on the unit medications from 3:00 AM to 6:00 AM. LPN #2 was instructed by RN #1 to give the medications before leaving the facility. LPN #2 did not give the medications. When asked by RN #1, LPN #2 stated s/he was too tired, due to the fact s/he had been busy all night due to the death of Resident #53. During an interview on [DATE] at approximately 11:10 AM with Certified Nursing Assistant (CNA) #1, s/he stated, I was working on that unit, but I did not take care of that resident. I heard CNA #2 state that something is wrong with this resident, and I heard him/her say, he/she is not breathing. I dropped what I was was doing and went into the resident's room. CNA #2 and the agency nurse were in the room already, but they were not doing CPR so I went and called 911. When I got back to the room LPN #1 was doing CPR, I then helped LPN #1 with CPR. This surveyor asked CNA #1, How do you know if a resident is a full code or a no code. CNA #1 stated, There is a sticker on the resident's room door by their name, the yellow sticker is a full code and the black sticker is a DNR. During an interview on [DATE] at approximately 11:30 AM with LPN #1 s/he stated that s/he was working on the other Unit, and received a call from the CNA to come and help out with an emergency. I got there and asked what was wrong and the CNA stated, Resident #53 has no pulse and no respirations. I asked the agency nurse (LPN #2) why s/he was out in the hallway and not doing CPR. The agency nurse (LPN #2) stated, She is dead, why do I have to do CPR? LPN #1 went on to say that the code status is on the resident's room door by their name, in the computer and in a book on each unit that clearly states the code status of each resident. LPN#1 also stated s/he went into Resident #53's room with LPN #2, the agency nurse, and stated, s/he did not know how to do CPR. LPN #1 stated, I am still upset over the entire episode. During an interview on [DATE] at approximately 12:40 AM with CNA #2, s/he stated, I got report from the CNA leaving as I was coming on. I went into Resident #53's room to check on her because I received report that s/he had been vomiting and did not feel well. I sat with her for a while. I went back later to check on her and noticed she was not responsive and I stated out loud, she is not breathing. I immediately called the nurse and she went in the room, and we called the nurse from the other unit and she came and started CPR. The LPN taking care of Resident #53 did not start CPR. CNA #2 stated she did not start CPR but is trained, but his/her certification had expired. During an interview on [DATE] at approximately 2:45 PM with LPN #2, s/he stated that s/he had not gotten a full report on the residents. S/he also stated that s/he did not make rounds on the residents after getting report from the nurse going off duty. This surveyor asked if s/he had basic life support and s/he stated, yes. LPN #2 went on to say that the facility does not have enough staff, and there are no supplies in the crash cart. This surveyor asked what supplies s/he needed to do CPR and LPN #2 did not know the answer. LPN #2 stated, When EMS arrived they did say that the resident (#53) had been dead for a good long while. During an interview on [DATE] at approximately 3:30 PM with the Medical Director, s/he revealed they were not aware that Resident #53 had died without receiving CPR after found with no pulse and no respirations. The Medical Director stated that LPN #1 had called to let him/her aware that Resident #53 had passed away and not the agency nurse caring for the resident. The Medical Director stated, s/he would expect the nurse that found the resident and or caring for the resident to initiate CPR if the resident had signed a full code status. Review on [DATE] at approximately 3:40 PM of the facility policy titled, Medical Emergency Response, under Policy: states, It is the policy of this facility to respond to medical emergencies for residents, staff and visitors. The Policy Explanation and Compliance Guidelines states under 1.The employee who first witnesses or is first on sit of a medical emergency, that are trained, will initiate immediate action including, CPR as appropriate, basic first aid and summon for assistance. Number 8 states, If the resident experiences [CONDITION(S)], the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services and: a. In accordance with the resident's advance directives, or b. In absence of advance directives or a Do Not Resuscitate order, and c. If the resident does not show obvious signs of clinical death. The Immediate Jeopardy Removal Plan included the following: Deficiency: F-678 failure to initiate CPR for Resident #53 admitted to the facility on [DATE]. Corrective Action: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. Completion Dare: [DATE]. * Facility Medical Director was notified of the incident on [DATE]. * The MDS Coordinator completed a chart audit on every resident and compared the advance directives to the resident room door for accuracy. Inaccuracies were not identified. * The licensed nurse who did not perform CPR on the full code status resident was reported to the Agency who employed him/her immediately on [DATE] and licensed nurse that did not initiate CPR has also been reported to SC LLR. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. Completion Date: [DATE] * Disciplinary action was taken with licensed nurse who did not initiate CPR on the full code resident. The licensed nurse who did not initiate CPR on the full code status resident was reported to the Agency who employed him/her immediately on [DATE] and the licensed nurse was also reported to the SC LLR. * The DON or designee educated all nursing staff on the facility's policy and procedure for initiating CPR and location of code status for each resident. The nursing staff is not permitted to work a shift until education is completed. Nursing staff on leave will receive education prior to their next scheduled shift. * Shift Supervisor given new responsibility to direct/assign staff roles during code/initiation of code. * A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented. The DON to monitor for code status compliance by interviewing nursing staff about facility CPR policy and procedure, as well as requesting return demonstration of the CPR process. Mock code evaluations will be completed weekly on various shifts. Findings will be reported at monthly QAA Committee meeting. * The DON or designee will audit new admissions to compare the resident's advance directives to the resident room door for accuracy and EMR banner. Findings will be reviewed monthly at the QAA Committee meeting. * A Code Yellow drill will be performed with licensed and non-licensed nursing staff on all shifts until all nursing staff have participated at lease once. Code Yellow drills will continue to be held 2 times a months for 3 months. Findings will be reviewed at the monthly QAA Committee meeting. Completion Date [DATE].

Amended 12/6/21 Based on record reviews, interviews and review of the facility policy titled, Medication Administration, and Medication and Treatment Orders. the facility failed to ensure 17 residents received medications as ordered by the attending physician during the month of August 2021. The residents that did not received their ordered medications include: Resident #8, #10, #11, #12, #15, #22, #23, #24, #26, #31, #40, #42, #44, #48, #50 and Resident A and B. The findings included: Resident 8 Based on the review of R8's quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 07/25/21, the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 01/20/21, was written for Vitamin D2, 50,000 unit, once a day on Wednesday for alcohol dependence with alcohol-induced persisting dementia. In a review of R8's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 03/22/21, was written for [MEDICATION(S)] HCL, 100 mg, once in the morning for alcohol dependence with alcohol-induced persisting dementia. In a review of R8's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. A Physician's Order, dated 03/22/21, was written for [MEDICATION(S)], HFA aerosol inhaler, 80-4.5 microgram (mcg)/actuation, 2 puffs, twice a day for acute and chronic [CONDITION(S)] with hypercapnia. In a review of R8's MAR, dated 08/01/21 to 08/31/21 revealed the medication was not administered on 08/25/21 A Physician's Order, dated 03/22/21, was written for [MEDICATION(S)], 20 milliequivalent (mEq), once in the morning for [CONDITION(S)]. In a review of R8's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. A Physician's Order, dated 03/22/21, was written for [MEDICATION(S)], 20 milligram (mg), once in the morning for acute and chronic [CONDITION(S)] with hypercapnia. In a review of R8's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. A Physician's Order, dated 08/04/21, was written for [MEDICATION(S)], 10 mg, twice a day for unspecified dementia with behavioral disturbances. In a review of R8's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. A Physician's Order, dated 08/10/21, was written for [MEDICATION(S)], 10 mg, once a day for hypertension. In a review of R8's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. A Physician's Order, dated 03/22/21, was written for [MEDICATION(S)], 400 mg, once in the morning for alcohol dependence with alcohol-induced persisting dementia. In a review of R8's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. A Physician's Order, dated 08/07/21, was written for [MEDICATION(S)] [MEDICATION(S)], 50 mcg, twice a day for allergic rhinitis, unspecified. In a review of R8's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/13/21, afternoon administration, and 08/25/21, morning administration. A Physician's Order, dated 03/22/21, was written for [MEDICATION(S)], 1 mg, twice a day for alcohol dependence with alcohol-induced persisting dementia. In a review of R8's MAR, dated 08/01/21 to 08/31/21, revealed the medication was a not administered on 08/25/21, morning administration. Resident 10 Based on the review of R26's quarterly MDS with an ARD of 08/04/21, the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order dated 08/07/21, was written for [MEDICATION(S)], 100 mg, twice a day for chronic pain. In a review of R10's MAR, dated 08/01/21 to 08/31/21 revealed R10 did not receive the medication on 08/25/21, morning administration. A Physician's Order, dated 02/15/21, was written for [MEDICATION(S)] capsules, 400 mg, twice a day for calorie malnutrition. In a review of R10's MAR, dated 08/01/21 to 08/31/21 revealed R10 did not received the medication on 08/25/21, morning administration. A Physician's Order, dated 04/16/21, was written for [MEDICATION(S)] extended release 24 hr, 500 mg, in the morning. In a review of R10's MAR, dated 08/01/21 to 08/31/21 revealed R10 did not receive the medication on 08/25/21. A Physician's Order, dated 04/09/20, was written for [MEDICATION(S)], 25 mg, three times a day for hypertension. In a review of R10's MAR, dated 08/01/21 to 08/31/21 revealed R10 did not receive the medication on 08/25/21, morning administration. A Physician's Order, dated 09/05/20, was written for [MEDICATION(S)], 25 mg, once a day for congestive heart failure. In a review of R10's MAR, dated 08/01/21 to 08/31/21 revealed R10 did not receive the medication on 08/25/21. A Physician's Order, dated 02/15/21, was written for [MEDICATION(S)] HCL tablet, 100 mg, once a day for calorie malnutrition. In a review of R10's MAR, dated 08/01/21 to 08/31/21 revealed R10 did not receive the medication on 08/25/21. A Physician's Order, 06/23/21, was written for [MEDICATION(S)], 25 mg once a day for adjustment disorder with depressed mood. In a review of R10's MAR, dated 08/10/21 to 08/31/21 revealed R10 did not receive the medication on 08/25/21. Resident 11 Based on review of R11's quarterly MDS with an ARD of 08/05/21, the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 08/05/21, was written for [MEDICATION(S)], 50 mg, every 12 hours for pain. In a review of R11's MAR, dated 08/10/21 to 08/31/21 revealed R11 did not receive the medication on 08/08/21, morning administration. A Physician's Order, dated 01/07/19, was written for Thera M Plus, 9 mg iron- 400 mcg, once a day for vitamin deficiency. In a review of R11's MAR, dated 08/10/21 to 08/31/21 revealed R11 did not receive the medication on 08/24/21. Resident 12 Based on review of R12's quarterly MDS with an ARD of 08/05/21, the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 04/28/21, was written for FSBS, twice a day for type 2 diabetes mellitus. A review of R12's MAR, dated 08/01/21 to 08/31/21, revealed the order was not completed for 08/24/21, evening task. Resident 15 Based on review of R15's quarterly MDS with an ARD of 08/11/21, the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 11/29/20, was written for Tums with Calcium, 1177 mg, three times a day for gastro-[CONDITION(S)] reflux disease without esophagitis. A review of R15's MAR, dated 08/01/21 to 08/31/21, revealed the medication as not administered on 08/22/21, evening administration. A Physician's Order, dated 02/20/19, was written for Finger Stick Blood Sugar (FSBS) in the morning for diabetes mellitus. A review of R15's MAR, dated 08/01/21 to 08/31/21, revealed the order was not completed for 08/25/21. Resident 22 Based on review of R22's quarterly MDS with an ARD of 08/17/21, the resident was on 02/12/19 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 01/02/21, was written for [MEDICATION(S)], 2.5 mg, once a morning for hypertension. A review of R22's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. A Physician's Order, dated 01/03/21, was written for [MEDICATION(S)], 200mg, twice a day for [CONDITION(S)]. A review of R22's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 01/03/21, was written for [MEDICATION(S)], 10 mc, once a day for allergic rhinitis. A review of R22's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. Resident 23 Based on review of R23's quarterly MDS with an ARD of 08/22/21, the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 10/07/20, was written for [MEDICATION(S)], 10 mg, once a day for hypertension. A review of R23's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administer on 08/25/21. A Physician's Order, dated 06/01/21, was written for [MEDICATION(S)], 10 mg, give ½ tablet once a day for other specified depressive episodes. A review of R23's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administer on 08/25/21. A Physician's Order, dated 09/30/21, was written for [MEDICATION(S)], 100 mg, twice a day for constipation. A review of R23's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administer on 08/25/21, morning administration. A Physician's Order, dated 09/30/20, was written for [MEDICATION(S)], 2.5 mg, twice a day for acute embolism of [CONDITION(S)] of unspecified femoral vein. A review of R23's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administer on 08/25/21, morning administration. A Physician's Order, dated 11/02/20, was written for Finger Stick Blood Sugar (FSBS), once a day on Wednesday for type 2 diabetes mellitus. A review of R15's MAR, dated 08/01/21 to 08/31/21, revealed order was not completed for 08/25/21. A Physician's Order, dated 01/20/21, was written for [MEDICATION(S)], 25 mg, three times a day for essential hypertension. A review of R23's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administer on 08/25/21, morning administration. A Physician's Order, dated 01/20/21, was written for [MEDICATION(S)], 40 mg, once a day for hypertension. A review of R23's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administer on 08/25/21, morning administration. A Physician's Order, dated 04/26/20, was written for [MEDICATION(S)], 500 mg, twice a day for type 2 diabetes mellitus without complication. A review of R23's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administer on 08/25/21, morning administration. A Physician's Order, dated 05/21/21, was written for Requip ([MEDICATION(S)]), .25 mg, administer .50 mg once a day for disorder of the skin and subcutaneous tissue. A review of R23's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administer on 08/25/21. Resident 24 Based on the review of R24's quarterly MDS with an ARD of 08/24/21, the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 07/07/21, was written for [MEDICATION(S)], 75 mg, twice a day for unspecified joint pain. A review of R24's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 05/21/19, was written for [MEDICATION(S)], 500 mg, twice a day for unspecified convulsions. A review of R24's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. Resident 26 Based on the review of R26's quarterly MDS with an ARD of 08/25/21, the resident was admitted on [DATE]. According to the assessment, the resident was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order dated 06/17/21, was written for [MEDICATION(S)], 250 milligrams (mg), twice a day for [CONDITION(S)]. A review of R26's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 06/17/21, was written for [MEDICATION(S)], .5 mg, twice a day for [CONDITION(S)]. A review of R26's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. Resident 31 Based on the review of R30's quarterly MDS with an ARD of 06/08/21, the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A Physician's Order, dated 07/09/21, was written for [MEDICATION(S)] drops, .3%, three times a day for age-related nuclear cataract. A review of the R31's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. x Resident 40 Based on the review of R40's quarterly MDS with an ARD of 06/21/21, the resident was admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 11/05/19, was written for [MEDICATION(S)], 40 mg, once a day for hypertension. A review of R40's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administer on 08/25/21. A Physician's Order, dated 11/05/19, was written for [MEDICATION(S)], .6mg, once a day for gout. A review of R40's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. A Physician's Order, dated 11/16/21, was written for enteral feedings, record tube feeding intake Q shift, twice a day for [CONDITION(S)]. A review of R40's MAR, dated 08/01/21 to 08/31/21, revealed the order was not followed on 08/25/21, morning administration. A Physician's Order, dated 11/05/19, was written for [MEDICATION(S)], 20 mg, twice a day for gastro-[CONDITION(S)] reflux disease with esophagitis. A review of R40's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administer on 08/25/21, morning administration. A Physician's Order, dated 07/09/21, was written for [MEDICATION(S)], 40 mg, twice a day for [CONDITION(S)] and [CONDITION(S)], following cerebral infarction affecting unspecified side. A review of R40's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 12/21/21, was written for [MEDICATION(S)], 100 mg/mL, administer 7.5 ML twice a day for [CONDITION(S)], unspecified intractable, without [CONDITION(S)]. A review of R40's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 11/05/19, was written for [MEDICATION(S)], 400 mg, twice a day for urinary tract infection. A review of R40's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 11/05/21, was written for [MEDICATION(S)], 50 mg, twice a day for hypertension. A review of R40's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 12/12/19, was written for [MEDICATION(S)], 20 mg, once a day for unspecified [CONDITION(S)]. A review of R40's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. A Physician's Order, dated 01/01/21, was written for [MEDICATION(S)], 5 mg, once a day for hypertension. A review of R40's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. Resident 42 Based on the review of R42's quarterly MDS with ARD of 06/23/21, the resident was admitted on [DATE]. According to the assessment, the resident was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 09/25/21, was written for [MEDICATION(S)], 300 mg, three times a day for pain. A review of R42's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered 08/25/21. Resident 44 Based on the review of R44's discharge MDS with ARD of 08/25/21, the resident was admitted on [DATE]. According to the assessment, the resident was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 08/10/21, was written for continuous O2 @ 2 liters/min. via NC, every shift for acute respiratory disease. A review of R44's MAR, dated 08/01/21 to 08/31/21, revealed the order was not completed on 08/25/21, day shift. A Physician's Order, dated 07/08/21, was written for [MEDICATION(S)], 5 mg, twice a day for alcohol dependence with alcohol-induced anxiety disorder. A review of R44's MAR, date 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 6/22/21, was written for [MEDICATION(S)], 20 mg, twice a day for gastro-[CONDITION(S)] reflux disease without esophagitis. A review of R44's MAR, date 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 06/22/21, was written for [MEDICATION(S)], 100 mg, three times a day for polyneuropathy unspecified. A review of R44's MAR, date 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 08/09/21, was written for [MEDICATION(S)] ([MEDICATION(S)]-[MEDICATION(S)]), 324 mg, once a day for iron deficiency [CONDITION(S)], unspecified. A review of R44's MAR, date 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. A Physician's Order, dated 06/22/21, was written for [MEDICATION(S)], 20 mg, once a day for left ventricular failure. A review of R44's MAR, date 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21 A Physician's Order, dated 08/02/21, was written for [MEDICATION(S)], 400 mg, twice a day for [CONDITION(S)]. A review of R44's MAR, date 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 08/09/21, was written for [MEDICATION(S)] [MEDICATION(S)], 25 mg, once a day for left ventricular failure. A review of R44's MAR, date 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. A Physician's Order, dated 06/22/21, was written for [MEDICATION(S)] ([MEDICATION(S)] hcl), 10 mg, once a day for metabolic [CONDITION(S)]. A review of R44's MAR, date 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. A Physician's Order, dated 06/22/21, was written for [MEDICATION(S)] HCL, 100 mg, once a day for alcohol dependence. A review of R44's MAR, date 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21 A Physician's Order, dated 08/02/21, was written for [MEDICATION(S)], 20 mg, once a day for cerebral infarction due to [CONDITION(S)] of left anterior cerebral A review of R44's MAR, date 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. Resident 48 Based on the review of R48's quarterly MDS with an ARD of 07/08/21, the resident was admitted on [DATE]. According to the assessment, the resident was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 07/07/20, was written for [MEDICATION(S)], 600 mg, three times a day for idiopathic progressive [CONDITION(S)]. A review of R48's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 09/05/20, was written for [MEDICATION(S)], 50 mg, twice a day for hypertension. A review of R48's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. Resident 50 Based on the review of R50's quarterly MDS with an ARD of 07/08/21, the resident was admitted on [DATE]. According to the assessment, the resident was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 06/18/21, was written for tamsulosin, .4mg, twice a day for retention of urine. A review of R50's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 06/18/21, was written for [MEDICATION(S)] HCL, 5 mg, three times a day for gastro-[CONDITION(S)] reflux disease without esophagitis. A review of R50's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 06/18/21, was written for [MEDICATION(S)], 25 mg, twice a day for hypertension. A review of R50's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 06/18/21, was written for [MEDICATION(S)] acid, 500 mg, once a day for pressure-induced deep tissue damage of other site. A review of R50's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. A Physician's Order dated, 06/18/21, was written for [MEDICATION(S)] chloride, 25 mg, twice a day for retention of urine. A review of R50's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 06/18/21, was written for [MEDICATION(S)], 100 mg, once a day for constipation. A review of R50's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. A Physician's Order, dated 06/18/21, was written for [MEDICATION(S)], 20 mg, once a day for gastro-[CONDITION(S)] reflux disease without esophagitis. A review of R50's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. A Physician's Order, dated 06/18/21, was written for [MEDICATION(S)] sulfate, 300 mg (60 mg iron)/5 mL, twice a day for iron deficiency. A review of R50's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, morning administration. A Physician's Order, dated 06/18/21, was written for FSBS once a day for diabetes mellitus. A review of R50's MAR, dated 08/01/21 to 08/31/21, revealed the this order was not administered on 08/25/21. A Physician's Order, dated 06/18/21, was written for [MEDICATION(S)], 20 mg, once a day for hypertension. A review of R50's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. Resident A Based on the review of RA's admission MDS with an ARD of 08/12/21, the resident was admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 08/06/21, was written for [MEDICATION(S)] Solostart U-100 Insulin, 100 unit/milliliter (mL) at bedtime revealed the medication was not administered on 08/24/21. A Physician's Order, dated 08/06/21, was written for [MEDICATION(S)] HCL, 60 mg, four times a day for hypertensive heart and chronic kidney disease. A review of RA's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21, 3:00 AM to 6:00 AM administration. Resident B Based on the review of RB's admission MDS with an ARD of 08/12/21, the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, dated 08/05/21, was written for [MEDICATION(S)], 125 mcg, once a day for [CONDITION(S)]. A review of RB's MAR, dated 08/01/21 to 08/31/21, revealed the medication was not administered on 08/25/21. During an interview on 9/22/2021 at approximately 5:00 PM with the Director of Nursing (DON) stated he/she was aware of the residents that did not receive their medications and had notified the attending physician, and went on to say that he/she was not happy that the residents had not received their ordered medications. Review on 9/23/2021 at approximately 4:10 PM of the facility policy titled, Medication Administration, states, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review on 9/23/2021 at approximately 4:20 PM of the facility policy titled, Medication and Treatment Orders, states under Policy Interpretation and Implementation, number 1. Medications shall be administered only upon the written order .

Based on observation, interviews and review of facility's policy on Chemical Hand Dishwashing procedures, the facility failed to provide the proper amount of chemical hand sanitizing solution required in the 3-compartment hand dishwashing sink to ensure that foods are stored, prepared and served in sanitary conditions, 1 of 1 kitchen observed for proper sanitization levels. Findings include: On 7/27/21 at 2:15 pm, the Dietary Supervisor (DS) was observed performing the procedure of testing hand sanitizing solution in the 3-compartment chemical hand dishwashing sink. The DS dipped the chemical test strip into the third sink of the compartment for 30 seconds. The Dietary Manager compared the color of the test strip to the colors on the chart to verify a 200 ppm solution. The strip registered 0 ppm solution. The Dietary Manager proceeded to attempt the test again with a new test strip and compared the color of the test strip to the colors on the chart to verify a 200 ppm solution. The strip registered 0 ppm. The Dietary Manager then pushed the button on the dispenser to allow more solution into the water. S/he proceeded to attempt the test again with a new test strip and compared the color of the test strip to the colors on the chart to verify a 200 ppm solution. The strip registered 0 ppm. The Dietary Manager removed the container with the chemical solution which was connected to the sink and discovered it was empty. It was observed that no chemical solution was in the container. S/he confirmed. During an interview with the Administrator on 7/27/21 at 3:13 pm, s/he stated that there was a small amount of solution in the container.

Based on observation, interview, record review, review of facility policy and procedure, and manufacturer's guidelines, the facility failed to ensure three (Residents (R) 17, 36, and 43) of three residents with wander prevention devices were checked daily per manufacturer's guidelines for wander prevention usage and two (R) 1 and 17) of three residents reviewed for falls were provided fall risk identification armbands per physician orders. The findings include: Review of manufacturer's guidelines for the wander prevention device titled, Secure Care Transmitter User Guide, dated 03/31/20, revealed, .Section 3 Strap Instructions, A documented test of each transmitter at the facility must be made each day. This testing should also include those transmitters not currently in use. The procedure involves using the #A 900 transmitter Tester and/or the Exit Panel on the wall by the exit, and documenting the performance of the transmitter . 1. Wander Prevention Devices A. Review of R 17's Electronic Medical Record (EMR) Face Sheet dated 03/23/21 revealed R17 was admitted to the facility with the following diagnoses undifferentiated [CONDITION(S)], adjustment disorder with mixed disturbance of emotions and conduct, unspecified dementia with behavior disturbances, and acute pain due to trauma. Review of R-17's EMR Physician Orders revealed orders dated June 2020 to current Monitor wander guard placement q (every) shift .Wander guard alarm checks weekly on Monday . Review of R-17's EMR Care Plan dated 05/11/21 revealed, Hx (history) of wandering with the potential for elopement .Wander guard checks as ordered . Review of R-17's admission Minimum Data Set (MDS) dated [DATE] revealed under Section E Behavior, R-17 exhibited wandering behavior that occurred daily. Review of R-17's EMR revealed no documentation of the wander prevention device checks for function as required per the manufacturer's guidelines. B. Review of R 36's EMR Face Sheet dated 02/25/19 revealed R36 was admitted to the facility with the following diagnoses essential primary hypertension, vascular dementia with behavior disturbances, major depressive disorder, and mood disorder due to known physiological conditions. Review of R36's EMR Physician Orders revealed orders dated 06/24/20 to current to Monitor wander guard placement q (every) shift .Wander guard alarm checks weekly on Monday . Review of R36's Care Plan dated 07/01/20 revealed R36 Exhibits wandering with the potential for elopement . Review of R36's MDS dated [DATE] revealed under Section E Behavior that R36 has not exhibited wandering behavior. Review of R 36's EMR revealed no documentation of the wander prevention device alarm checks. C. Review of R 43's EMR Face Sheet dated 04/01/21 revealed R43 was admitted to the facility with the following diagnoses [CONDITION(S)], sensorineural hearing loss bilateral, disorganized [CONDITION(S)], and unspecified dementia with behavior disturbance. Review of R 43's EMR Physician Orders revealed orders dated 06/24/2020 to current Monitor wander guard placement q (every) shift .Wander guard alarm checks weekly on Monday . Review of R 43's EMR Care Plan dated 04/08/21 revealed R43 Wear wander guard due to high elopement risk . Review of R 43's MDS dated [DATE] revealed under Section E Behavior that R 43 has not exhibited wandering behavior. On 7/28/21 at 11:50 AM an interview with the Administrator, she stated the wander guards are usually checked by one of the lead CNA's. They are probably not documenting it (alarm checks) . On 07/28/21 at 12:25 PM an interview with Lead CNA 1 revealed he/she stated that he/she checks the wander guards. We had a handheld, but we sent it back for repair and we haven't gotten it back since last year. So, we check the bracelet at the front and back doors. We do it once a week. We take the patient to the doors and check. I usually let the QA (Quality Assurance) nurse and the resident's nurse know if it doesn't work. 2. Fall Prevention Intervention Review of the facility's policy titled, Falls-Clinical Protocol dated 09/2012 revealed no documentation for placement of a green armband as a part of the falls protocol. Review of R17's EMR Face Sheet dated 03/23/21 revealed R17 was admitted to the facility with the following diagnoses undifferentiated [CONDITION(S)], adjustment disorder with mixed disturbance of emotions and conduct, unspecified dementia with behavior disturbances, and acute pain due to trauma. Review of R17's EMR Physician Orders from 02/11/20 to current revealed Falling Star: Check green armband every shift. Special instructions: At risk for fall. Every shift; 07:00 AM-11:00 AM, 07:00 PM-11:00 PM . Review of R17's EMR 14 Day Administration History dated 07/15/21 to 07/28/21 revealed nursing documentation indicating the green armband was intact twice daily. An observation of R17 on 07/26/21 at 4:47 PM revealed R17 was observed in his/her room with no green arm band on. An observation of R17 on 07/27/21 at 9:00 am revealed R17 was observed in his/her room with no green armband on. An observation of R17 on 07/27/21 at 12:23 PM revealed R17 was observed in the dining room eating with no green armband on. An observation of R17 on 07/27/21 at 2:05 PM revealed R17 was observed in the dayroom on hallway with a green armband on. On 07/27/21 at 1:25 PM an interview with the Minimum Data Set Coordinator, he/she revealed that, Initially when interventions are put into place, I inform the floor nurse, family, and information is put into the computer. The nurse will check off if something is completed. Information should be documented on the EMR. We removed the green armbands and placed it under the physicians' orders because it was too much on the task list for the nurses to complete. Some residents refuse to wear the bands. Those who refuse are alert and oriented and we tend to learn their preferences and be mindful to them that we work in their homes. On 07/28/21 at 10:47 am an interview with the Licensed Practical Nurse (LPN) 3 revealed he/she stated The green armband identifies that the resident needs a wander guard. The physician will document the resident needing one and then we (nurses) document whether or not it's on and this is done two times a day, AM and PM. The area to document automatically appears for the nurse to document in it. Wander guards are located on the ankles or the wrists of the residents.

Based on interview, registered nurse time card report, review of nursing staff resident census sheets, and review of facility policy and procedure, the facility failed to ensure a registered nurse was staffed for at least eight consecutive hours a day, seven days a week. This failure had the potential to affect provision of registered nursing assessments and services to all 55 residents in the facility. The findings include: Review of the facility undated policy titled, Staffing revealed, 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services . Review of registered nursing timecard reports revealed the following days of no registered nurse on staff for at least eight consecutive hours with the resident census each day: 6/5/21 -56 (census) 6/6/21-56 (census) 6/12/21-54 (census) 6/13/21-54 (census) 6/19/21-56 (census) 6/20/21-56 (census) 6/23/21-56 (census) 6/25/21-58 (census) 6/26/21-57 (census) 6/27/21-56 (census) 6/29/21-56 (census) 6/30/21-56 (census) 7/3/21-57 (census) 7/5/21-56 (census) 7/6/21-56 (census) 7/7/21-57 (census) 7/8/21-57 (census) 7/9/21-57 (census) 7/10/21-57(census) 7/11/21-57(census) 7/12/21-57 (census) 7/16/21-56 (census) 7/19/21-56 (census) 7/21/21-56 (census) On 07/27/21 at 1:10 PM, in an interview with the Director of Nursing, he/she revealed that, We are short staffed due to Covid-19 and we were using Agency nurses and if they call out then that left me short. It's very difficult to get an RN (registered nurse) to come here. The agency we use they were not very reliable and unfortunately there was no repercussions for them calling out. I was aware that we were short for the month of June. I don't count in the census so if myself or the Administrator is gone or on vacation then we didn't have any coverage. The staffing agency we use is the only one in the area. Our RN's take call more than they want to. They take call every three weeks. They work what we need them to do. We've been to job fairs to try and recruit there. This is not an area where nurses flourish. Our Emergency Staffing Plan is myself or my Administrator will cover. On 07/27/21 at 1:16 PM, in an interview with the Administrator, he/she revealed that, We have two (Agency) contracts that we utilize. We have even advertised. There are no repercussions for call outs from Agency staff. Our Emergency staffing plan is to go to the management team. They (nurses) come in on off shifts when the agency (nurse) isn't here. They (nurses) may split shifts to get through it. CNA's (certified nursing assistants) are automatically posted for over time. The nurses may do any extra 12 hour shifts a day to help with the nursing shortages. At some point we talked about it (staffing shortage) in our QA meeting. No documentation was provided by the facility related to staffing in the QA minutes.

Based on observations, interviews, and record review, the facility failed to safely store medications in 2 of 2 medication storage rooms and 2 of 4 medication carts. Expired medication was found in the medication storage rooms and in the medication carts. The findings Included: Observation of the medication storage room on Unit 100 ([NAME] Wing), on 07/26/2021 at 3:48 PM, revealed the storage room contained 2 bottles of Nutricia [CONDITION(S)]-Stat 30 fl oz which had an expiration date of 07/15/2021. Observation of the medication storage room on Unit 200 (Challenger Wing), on 07/27/2021 at 11:50 AM, revealed the following medication and/or supplies expired: 1 bottle Nutricia Pro-Stat wild Cherry Punch - 07/15/2021, 4 bottles GeriCare Bisacodyle - 06/2021, 1 box (containing 1 blister pack of 20 tablets) [MEDICATION(S)] - 06/2021, 2 [MEDICATION(S)] Blood Collection/Infusion Set - 07/2020, 3 BD Vacutainer C&S Transfer Straw Kit - 04/2021, 1 Kangaroo Epump ENPlus Spike with Flush Bag - Open and not sealed (per Manufacture Instructions: Do not use if package is opened or damaged.) Tubing and bag sitting in drawer not packed with other bags that were packaged and sealed. 1 Humidifier Elbow Connector with 10in tubing - 07/15/2020 (not sealed) Observation of 2 medication carts located on the Challenger Wing on 07/27/2021 at 11:50 AM, revealed the following medications expired: Medication cart 1 of 2: 1 Bottle of Nutricia [CONDITION(S)]-Stat Cranberry - 07/22/2021, 1 Vial of [MEDICATION(S)] Eye Drops - 03/21/2021. Medication cart 2 of 2: 1 Bottle of Nutricia Pro-State Wild Cherry Punch - 07/15/2021. Interview with LPN1 on 07/26/2021 at 4:15 PM and LPN2 on 07/27/2021 at 12:45 PM confirmed the expired medications which were then removed. Review of the Narcotics Control Count sheet on 07/27/2021 revealed no issues or concerns. Review of the facility's policy and procedure for medication storage on 07/27/2021 at 1:30 PM, revealed the facility should ensure that medications and biologicals have not been retained longer than recommended by manufacturer or supplier guidelines. Review of the Pharmacy Medications Storage Audit dated 06/16/2021, 05/26/2021 and 04/27/2021, revealed issues with expired medication in the storage units.

Based on record reviews and interviews, the facility failed to ensure Resident #38 received bolus tube feedings as ordered to ensure little or no weight loss for 1 of 1 residents reviewed for Nutrition. The facility further failed to provide documentation to ensure the bolus feedings were administered for a meal intake of less than 50%. The findings included: The facility admitted Resident #38 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 7/26/2021 at 3:22 PM of the medical record for Resident #38 revealed a gradual weight loss from 3/5/2021 of 87 pounds until 6/8/2021 a weight of 79 pounds. A feeding tube was placed on approximately 6/16/2021 followed by an order to administer a bolus of [MEDICATION(S)] 1.5 240 milliliters via the feeding tube if Resident #38 ate less than 50% of meals and to flush the tube with 210 milliliters of water. Further review on 7/26/2021 at 3:30 PM of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation could be found to ensure the percentage of lunch was recorded and no documentation to ensure Resident #38 required or received any bolus feeding of [MEDICATION(S)] from 6/24/2021 through 7/15/2021. On 7/23/2021 the lunch intake was recorded as less that 50%, but no documentation could be found in the medical record for Resident #38 to ensure she received the bolus feeding as ordered by the physician for a meal intake of less than 50%, and again on 7/23/2021. An interview on 7/28/2021 at 3:51 PM with Registered Nurse #1 confirmed that there was no documentation to ensure Resident #38 received the bolus feeding of [MEDICATION(S)] when he/she consumed less than 50% of meals. During an interview on 7/28/2021 at 3:56 PM with the Administrator, provided the same documentation and stated the bolus tube feedings are given because the order was written by the physician, but there is no documentation to ensure Resident #38 was receiving the bolus feedings as ordered by the physician for a meal intake of less than 50%.

Based on observations, interviews and review of the facility policy titled, Dignity, the facility failed to ensure staff knocked on resident room doors before entering during observations on 1 of 2 units. The facility further failed to ensure residents were asked if they would like to have a clothing protector applied before applying them during 1 of 2 dining observations. The findings included: An observation on 7/26/2021 at 12:30 PM revealed multiple staff placing clothing protectors on residents without first asking if they would like to have one applied. Interviews on 7/27/2021 at 12:45 PM with random staff, confirmed the findings and agreed they should first ask residents before applying clothing protectors. Review on 7/29/2021 at 8:50 AM of the facility policy titled, Dignity, states, Each resident shall be care for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation, states under number 1. Residents shall be treated with dignity and respect at all times. Number 8 states, Procedures shall be explained before they are performed. Number 10. states, Staff shall promote, maintain and protect resident privacy. Findings include: Review of the facility Face Sheet revealed Resident 1 (R)1 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 06/30/21, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated R1 was moderately cognitively impaired. Observations conducted of R1 on 07/26/21 at 11:33 AM, 07/26/21 at 12:33 PM, 07/26/21 at 3:17 PM, and 07/27/21 at 10:00 AM revealed Certified Nursing Assistant (CNA) #1 and Licensed Practical Nurse (LPN) #1 entered R1's room without knocking and waiting for permission to enter. During an interview with CNA #1 and LPN #1 on 07/27/21 at 1:13 PM, CNA #1 stated that if a resident was alert and verbal, then staff were supposed to knock and wait for permission to enter from the resident. LPN #1 stated the only time staff could enter a resident's room without waiting for permission was in the event of an emergency. During an interview with eight resident council members on 07/27/21 at 3:15 PM, six out of eight members stated staff usually do not knock and wait for permission before entering their rooms. During an interview with the Director of Nursing (DON) on 07/28/21 at 10:55 AM, the DON stated staff were supposed to knock, state their name, and wait for permission from the resident before entering a resident room. The DON stated that staff who had been at the facility for a while probably did not knock before entering resident rooms because they knew which resident were verbal and non-verbal. The DON also stated that it was a constant battle to get staff to follow the facility policy on residents' rights, but staff should still follow the policy unless in an emergency. Review of the facility policy titled, Resident's Bill of Rights, revealed, (16). Personal Privacy- Facility staff shall respect the privacy of a resident's room by knocking on the door and seeking consent before entering, except in an emergency or where clearly inadvisable.

Based on interviews and record review, the facility failed to ensure residents were free from accidents hazards by failing to lower the bed height to help prevent injuries from falls. As a result, Resident 5 fell from the bed and sustained a right orbital floor fracture. This deficient practice affected 1 (Resident 5) of 4 sampled residents reviewed for accidents. The findings included: Resident 5 was admitted with [DIAGNOSES REDACTED]. The resident was wheelchair bound. A review of a Minimum Data Set (MDS) assessment, dated 10/7/19, indicated the resident had short term memory problems, and moderately impaired cognitive skills for daily decision making. Resident 5 was totally dependent with most activities of daily living, including bed mobility, transfers, dressing, toileting, personal hygiene and bathing. She had not walked in the room or corridor. She was always incontinent of bowel and bladder. There was no history of falls noted on the MDS. No restraints or bed alarms were coded as having been used. A review of Resident 5's care plan indicated the resident was at risk for falls due to poor safety awareness and immobility. Interventions included a green arm band, anticipating needs, ensuring call light was in reach, floor mats to floor, check green arm band every shift, incontinence care routinely and as needed, keep all personal items within reach, therapy as ordered, and routine comprehensive medication review by the pharmacist to assess for polypharmacy and medications that increase the fall risk. Review of the fall risk assessment revealed that Resident 5 had poor safety awareness and immobility. She was high risk for falls. A review of the facility 5-day report, indicated, on 12/06/19 at approximately 8:45 PM, Licensed Practical Nurse (LPN) 3 was summoned to Resident 5's room by housekeeping staff. Upon arrival, the resident was lying on the floor face down. Examination noted a laceration (cut) approximately two cm (centimeters) in size above the right eyebrow, approximately one cm open area to outer corner of right eye, swelling & bruising to lower right eye and right eye partially closed. Swelling noted to corner of right forehead & reddened abrasion to right cheek. Resident was sent to the ER (emergency room ) for further examination and X-ray. X-ray revealed that resident sustained [REDACTED]. A review of Housekeeping Staff 4's witness statement, dated 12/06/19, indicated, at 8:45 PM, while preparing supplies and equipment for the floor stripping, I noted while standing in the hallway that (Resident 5) was not in (his/her) bed as I noted earlier. I knocked and entered. (Resident 5) was on the floor mat faced downward. I immediately called for help. Bed was in the high position. A review of LPN 3's witness statement, dated 12/06/19, indicated, I was summoned to (Resident 5)'s bedroom by a maintenance staff member. Upon arrival Resident 5 was noted to be lying on the floor face down. Upon examination (Resident 5) was noted with a laceration approximately 2 cm in size above the right eyebrow, 1 cm opened area to outer corner of right eye, swelling & bruising to lower right eye and right partially closed. Swelling noted to corner of right cheek. Resident was sent to ER for further examination and x-ray. A nursing note, dated 12/06/19 at 9:55 PM, indicated (Resident 5)'s legal representative was made aware of fall, injuries and physician's orders [REDACTED]. Transported at 10:10 PM. Report was called to ER nurse. A nursing date, dated 12/06/19 at 11:40 PM, indicated, report called from (provider name) nurse stating that (Resident 5) was returning to facility. CT (computed tomography) scan was done of face with results of right occipital fracture, cannot be repaired. Dermabond to laceration above right eyebrow & band aid to remain in place for one week. Vital signs remained stable in the ER. A nursing date, dated 12/06/19 at 11:55 PM, indicated, (Resident 5) returned to facility per transport per stretcher, remains alert and verbally responsive, band aid remained intact to laceration above right eye, dressing intact to opened area outer right eye, swelling with slight discoloration to corner of right forehead, swelling with bluish bruising below right eye. A review of Certified Nursing Assistant (CNA) 6's witness statement dated 12/06/19, indicated, I was with (Resident 5) and provided pm care and placed (Resident 5) into bed. I did not have the bed to the lowest position-but did have it locked. Attempted to interview Resident 5 during the survey, but the resident was not interviewable. During an interview on 09/14/20 at approximately 12:45 PM, the Administrator stated the CNA admitted that she did not lower Resident 5's bed into the lowest position when the resident was put to bed. The Administrator indicated the staff member did not intend to harm the resident, however the staff member was disciplined and retrained on how important it was to lower the bed for the safety reasons.

Based on record review and interview, the facility failed to follow its policy related to reporting and investigating allegations for 5 of 6 residents reviewed for abuse (Residents #12, #118, #46, #56, and #40), 1 of 1 resident reviewed for neglect (Resident #117), and 1 of 4 resident reviewed for accidents (Resident #119). The findings included: The facility admitted Resident #12 to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/19/19 at 11:28 AM, review of the Nursing Progress Notes revealed a noted dated and timed 08/06/2019 at 06:34 PM stating at 6:18 Resident #12 was ambulating on the unit and was observed with a half dollar sized hematoma to the right temporal area. The note further stated there was no reported fall. The Reportable file for an Injury of Unknown Source was requested from the Director of Nursing (DON). On 08/21/19 at 11:18 AM, review of a reportable for the incident revealed it was reported to the Ombudsman and to the Bureau of Health Facilities Licensing. There was no documentation the injury was reported to the Bureau of Certification/State Agency. The facility admitted Resident #117 to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/19/19 at approximately 03:30 PM, review of the facility's Initial 2/24-Hour Report revealed the incident actually occurred on 10/07/18. The resident's son/daughter reported the alleged neglect to the Ombudsman and the Ombudsman reported it to the facility on [DATE]. There is no confirmation when the report was submitted to the State Agency; however, the report was dated 10/16/18. The facility admitted Resident #118 on 04/28/03 with [DIAGNOSES REDACTED]. Review of the reportable file revealed no 2/24-Hour Report was submitted to the State Agency. Review of the facility's Five-Day Follow-Up Report dated 02/15/19 indicated the incident occurred on 02/07/19. The report did not indicate if the facility substantiated neglect. The report was submitted to the State Agency on 02/15/19, which was 6 business days after the incident and not timely. Further review of the file revealed no statements from the staff on duty or a statement from the resident's roommate. There was no statement from the nurse indicating the assignment had been changed or why. During an interview on 08/20/19 at the DON confirmed the report was submitted on 02/15/19 and was not timely. The DON also confirmed there were no staff statements obtained by the facility. Review of the facility's policy at 11:43 AM on 08/21/19 revealed a policy statement that all reports of resident abuse, neglect exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations and thoroughly investigated by facility management. The policy further stated an alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The policy also defined an Injury of unknown source: as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident and b. The injury is suspicious because of the injury (e.g. (for example), (1) the extent of the injury; or (2) the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma); or (3) the number of injuries observed at one particular point in time; or (4) the incidence of injuries over time. In addition, the policy stated with the help of the staff and management, the investigator will compile a list of all personnel, including consultants, contract employees, visitors, family members, etc (etcetera) who have had contact with the resident during the past 48 hours. The Policy also indicated the role of the Investigator included interviews with the person reporting the incident, any witnesses to the incident, the resident (as appropriate), the resident's roommate, family members, and visitors, any staff members (on all shifts) that have had contact with the resident during the time of the alleged incident, and any other residents to whom the accused employee provides care. During an interview on 11:18 AM on 08/21/19, when the reportable was provided, the DON stated there were no statements obtained. At 11:41 AM, the DON also confirmed the incident was not reported to the State Agency. At 12:14 PM, the DON confirmed the policy was not followed related to reporting or investigating all alleged incidents. During an interview on 08/21/19 at approximately 01:00 PM, the DON confirmed the policy was not followed related to reporting an allegation of neglect for Resident #118 and failed to follow the policy related to reporting an allegation of neglect and to thoroughly investigate the allegation for Resident #117 and failed to report an injury of unknown origin for Resident #12. The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Review of the medical record on 8/22/19 at 8:49 AM revealed a Physician's Progress Note dated 8/11/18 at 2:15 PM stating Resident #40 was wincing in pain secondary to being kicked in the left tibia-fibula area by an on duty Certified Nursing Assistant. Review of the reportable file on 8/22/19 revealed the incident was not reported to the State Agency within two hours of the incident and a five day investigation was not sent until 10/31/18. No explanation was given during the survey process as to why the reportable incident was not reported in the required time frames. Review of the medical record on 8/22/19 at 8:49 AM revealed a nurse's note dated 4/24/19 at 1:13 PM which indicated Resident #40's left hand was bluish in color on the interior thumb, some [MEDICAL CONDITION] was noted and an anterior portion of hand noted with redness. Resident #40 did not complain of any pain. On 4/24/19 at 10:58 PM, an x-ray result revealed an acute oblique fourth metacarpal shaft fracture. The injury of unknown origin was not reported to the State Agency until 4/25/19 at 5:24 PM and the 5-day was received on 5/2/19. No explanation was given as to why the reportable incident was not reported in the required time frames. Further medical record review on 8/22/19 of the nurse's notes revealed for Resident #40 on 1/7/19 at 11:00 AM a large hematoma was observed on the resident's left arm; on 3/9/19 10:07 AM bruising continues to left temple, around entire right eye and to right cheek area; and 5/15/19 bruise on resident's right side of face under right eye near nose. Nurse's notes dated 7/17/19 revealed Resident #40 had a resident to resident altercation. There was no indication these injuries of unknown origin or resident to resident altercation were reported to the State Agency. The facility admitted Resident #46 with [DIAGNOSES REDACTED]. Record review on 08/20/19 at approximately 8:46 AM revealed a Facility Reported Incident (FRI) related to an allegation of sexual abuse between Residents #41 and #46, which occurred on 03/23/19 at approximately 10:45 PM. Resident #41 was observed with his/her hands in Resident #46's brief and the residents were separated. Neither resident was interviewable. Resident #41 stated Resident #46 was his/her son/daughter. A 2-hour report of alleged abuse to the State Agency was not found in the facility investigative file. In an interview on 08/20/19 at approximately 02:08 PM, the DON confirmed that no 2-hour report was completed as per the Abuse/Neglect Policy. The facility admitted Resident #56 with [DIAGNOSES REDACTED]. In an interview during initial pool on 08/18/19, Resident #56 stated s/he had fallen and sustained a dislocated shoulder. In a follow-up interview, the DON stated x-rays were ordered for Resident #56 due to complaints of pain in all of his/her joints and the dislocated shoulder was discovered. The DON confirmed the facility did not implement the facility policy related to injuries of unknown origin by not reporting and investigating the injury and its cause. Review of the facility policy entitled Abuse Prevention Program revealed the facility will: 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect or mistreatment of [REDACTED]. Investigate and report any allegations of abuse within timeframes as required by federal requirements.

Based on record review and interview, the facility failed to prevent an abusive (physical) incident for 1 of 6 residents reviewed for abuse (Resident #40). The findings included: The facility admitted Resident #40 with [DIAGNOSES REDACTED]. During a family interview on 8/19/19 at 3:17 PM, the family member stated a Certified Nursing Assistant (CNA) had kicked his/her family member and Resident #40 had developed [MEDICAL CONDITION]. Review of the physician progress notes [REDACTED]. Per the physician's note, the family had been notified by the physician and the proper authorities had been alerted. During an interview with the Administrator on 8/19/19 at approximately 4:30 PM, s/he confirmed the CNA kicked Resident #40.

Not Corrected Based on record review, observation and interviews during the followup inspection the facility failed to complete wound care for Resident #3 as ordered by the physician (1of 2 residents observed for dressing changes), and by review of the South Carolina Board of Nursing (LLR), Advisory Opinion #46, dated September 2003 and reviewed July 2007, the facility failed to ensure that pressure ulcers were evaluated and staged by a Registered Nurse in accordance with the State Law. The findings included: The facility admitted Resident #3 with a [DIAGNOSES REDACTED]. A review of Resident #3's medical record on 9/15/14 at 12:25 PM revealed that a quarterly minimum data set (MDS) performed on 7/23/14 coded him/her as having a brief interview of mental status (BIMS) of 6 and as needing extensive assistance with activities of daily living (ADLs) except eating. During a wound dressing observation on 9/15/14 at approximately 12:25 PM Resident #3 had a dressing on his/her right ankle dated 9/9/14. When the Wound Nurse was questioned about the frequency of the dressing change s/he replied that the dressing was ordered to be changed every 3 days, but that Resident #3 refused to have the dressing changed on 9/12/14 and on 9/14/14, s/he stated that it was documented. A review of the Treatment Administration Record (TAR) on 9/15/14 revealed that there was documentation on the back of the TAR stating that Resident #3 refused to let the staff change his/her dressing on 9/12/14 and 9/14/12. A review of the physician's wound care orders dated 9/3/14 for Resident #3 indicated to clean the right outer ankle with normal saline-pat dry-apply collagen-cover with foam dressing and wrap with kerlix every 3 days and as needed. The facility hired a full time Wound Nurse on 8/14/14, upon review of his/her record on 9/15/14 at 11:30 AM, it was noted that the Wound Nurse was a Licensed Practical Nurse (LPN). A review of the file revealed there was no additional training related to wound care in the employee file. An interview with the Wound Nurse on 9/15/14 at 12 PM revealed that s/he was not certified in wound care, s/he attended a wound care workshop. S/he stated that wounds are measured weekly and recorded on the wound record and in each chart. Currently the Wound Nurse is the only person to measure the wounds for the facility, but sometimes the unit managers will do it, if the Wound Nurse is not available. The Wound Nurse stated that s/he's the only person providing the wound care for the facility. A second interview was conducted with the Wound Nurse at 2:05 PM, in which s/he stated that no one from the facility has measured and signed behind her/him since s/he started. An interview with the Director of Nursing (DON) on 9/15/14 at 2 PM, revealed that the facility previously allowed the LPN's to measure the wounds and a registered nurse (RN) would sign off on them. We switched the forms we use and our old forms had a place for the RN to sign, but the new forms do not. I haven't been signing behind the Wound Nurse since s/he has been hired full time, but there are 2-3 other RN's here that can measure and sign behind her. A review of the "Weekly Pressure Wound Report" provided by the Wound Nurse on 9/15/14 revealed that there were measurements for the facility residents, but there were no signatures from an RN indicating that they were in agreement with the documented measurements provided by the Wound Nurse.

Based on record reviews, interviews, and observations the facility failed to ensure that 2 of 3 sampled residents reviewed for care plans (Residents #1 and #3) had inaccurate revisions related to pressure ulcers. Cross Refers to F-314 related to pressure ulcer treatment. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 7/15/14 revealed the resident was readmitted to the nursing facility on 4/7/14 after a hospitalization . The resident's quarterly Minimum Data Set Assessment with an Assessment Reference Date of 5/6/14 revealed Resident #1 had short and long term memory problems. The resident was coded as totally dependent on staff with the physical assistance of 2 for bed mobility and transfers; impairments in range of motion on both sides of the upper and lower extremities; always incontinent of bowel and bladder; and at risk for pressure ulcers, but having none. Body audits dated 5/9/14, 5/17/14, and 5/23/14 documented discolored and/or dark areas to the bilateral feet with no breakdown. A 5/30/14 body audit documented an open area to the left lateral foot with bloody drainage; documentation dated 6/13/14 revealed "...blackish discoloration(s) cont(inue) to both feet." Body audits dated 6/20/14 and 6/27/14 documented only left lateral foot discolorations. Record review indicated that an unstageable pressure ulcer was noted to the right inner foot on 6/30/14 measuring 3 cm x 3 cm. According to documentation, the center of the wound contained black eschar with pink edges. A review of Resident #1's Comprehensive Care Plan on 7/15/14 revealed an entry for potential skin breakdown due to incontinence dated 6/5/14. Approaches listed included to keep the resident as clean and dry as possible and for preventive skin treatment prn (as needed). There were approaches listed that included turning the resident every 2 hours and prn, treatment as ordered, and labs per physician order. Another care plan entry dated 6/5/14 included information that the resident had current skin breakdown to areas on the buttocks, sacrum, and lower extremities; and the resident would not develop any further breakdown through the next review on 9/12/14. Approaches included Treatment as ordered, notify the MD of worsening, Monitor pain, and Air Mattress. However, a review of the record revealed that on 6/5/14, there was no documentation that the resident had breakdown to the buttocks or sacrum at that time. An interview with RN #1 on 7/15/14 at 11:00 AM revealed the specialty air mattress had been put into place on 6/30/14 after s/he had written orders for treatment for [REDACTED]. RN #1 verified the placement of the air mattress had not been documented in the record. The Comprehensive Care Plan for Resident #1 did not include interventions to elevate the resident's feet on pillows or for the use of heel protectors. During an interview on 7/15/14 at 10:55 AM, Certified Nurse Aide (CNA) #1 provided the CNA care plan for Resident #1. The care plan included documentation of the resident's wounds and that s/he had an air mattress (undated). Heel protectors were also documented on the CNA care plan. When asked about the documentation related to the heel protectors, CNA #1 stated that this information had just been added to the care plan a few minutes ago and had not been included on the care plan previously. CNA #1 stated this information had been added because the nurse was going to get heel boots for the resident. A review of the record including the Medication and Treatment records revealed information had not been care planned or documented related to the use of any heel boots for skin protection. During an interview on 7/15/14 at 11:05 AM the Director of Nursing (DON) verified the body audits indicated dark areas to the bilateral feet prior to the development of the wounds with no documented preventive measures for the feet (except Vaseline for dry skin). The DON verified the inaccurate date noted on the comprehensive care plan that indicated the wounds to the buttock and sacrum was present on 6/5/14. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Resident #3 had been discharged and the care for the resident was reviewed as part of a closed record review. A review of the Admission Minimum Data Set Assessment with an Assessment Reference Date of 1/16/14 revealed Resident #3 was coded as having short and long term memory problems. S/he had been coded as having been totally dependent on staff for bed mobility with the physical assistance of 1. The assessment coded the resident as always incontinent of bowel and bladder. The Braden Scale for Predicting Pressure Sore Risk (on admission) was scored at a 12- high risk. A review of a Braden Scale assessment dated [DATE] revealed a score of 13-moderate risk. According to the Braden Assessments, the resident was chair fast and could not bear his/her own weight. The assessments indicated the resident was either completely immobile or had very limited mobility (ability to change and control body position). The Admission nursing assessment dated [DATE] documented 4 areas of concern on a body diagram. Area #1 was a 3 cm x 1 cm red area with necrotic tissue in the center located on the sacrum. Documentation indicated there was no discharge, pain or odor with a treatment of [REDACTED]. Area #2 was documented on the right buttock measuring 2 cm x 2.5 cm. Area #3 was on the left buttock measuring 0.2 cm x 0.8 cm. Area #4 was documented on the back left (upper thigh/leg) measuring 2.7 cm x 2.2 cm (difficult to make out the measurements or the actual area). Review of the Nurse's Notes from 1/9/14 thru 1/31/14 indicated a change in the sacral wound on 1/23/14. The physician was called regarding a foul smell, necrosis and slough was noted to the wound bed. New wound orders were given and pain medication was obtained for the resident. A review of the Care Plan dated 1/9/14 revealed an entry for an unstageable wound. The care plan had not been updated relative to other wounds to the buttocks that had been noted on 1/23/14.

Based on record reviews, interviews, and a review of the policy provided by the facility entitled "Pressure Ulcer Treatment", the facility failed to ensure that 3 of 3 sampled residents reviewed with pressure ulcers, Residents #1, #2, and #3, received the appropriate treatment and services to promote healing, prevent infection, and prevent new sores from developing. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Resident #3 had been discharged and the care for the resident was reviewed as part of a closed record review. A review of the Admission Minimum Data Set Assessment with an Assessment Reference Date of 1/16/14 revealed Resident #3 was coded as having short and long term memory problems. S/he had been coded as having been totally dependent on staff for bed mobility with the physical assistance of 1. The assessment coded the resident as always incontinent of bowel and bladder. The Braden Scale for Predicting Pressure Sore Risk (on admission) was scored at a 12- high risk. A review of a Braden Scale assessment dated [DATE] revealed a score of 13-moderate risk. According to the Braden Assessments, the resident was chairfast and could not bear his/her own weight. The assessments indicated the resident was either completely immobile or had very limited mobility (ability to change and control body position). The Admission nursing assessment dated [DATE] documented 4 areas of concern on a body diagram. Area #1 was a 3 cm x 1 cm red area with necrotic tissue in the center located on the sacrum. Documentation indicated there was no discharge, pain or odor with a treatment of [REDACTED]. Area #2 was documented on the right buttock measuring 2 cm x 2.5 cm. Area #3 was on the left buttock measuring 0.2 cm x 0.8 cm. Area #4 was documented on the back left (upper thigh/leg) measuring 2.7 cm x 2.2 cm (difficult to make out the measurements or the actual area). The Admission body audit included only measurements for skin areas #2, #3, and #4 and did not include a description or information as to why these areas had been noted on the body audit. The body audit also noted a red area to the resident's groin area and documented a treatment of [REDACTED]. A note below the body diagram stated to "refer to wound tracking sheet for mid sacrum specifics". A review of the weekly body audit documentation done by the nurses revealed a body audit done 1/10/14 by LPN #3 that documented the same 4 areas of skin concern as the admission body audit along with barrier cream to the groin area. According to the documented description, there was "scant ss/bloody drainage, slight odor per sacrum area, s/s of pain..." the RP (Responsible Party) and Physician had been notified. A body audit dated 1/16/14 did not include any documented area of skin concern on the body diagram but the description stated, "Wound remain(s) consistent (with) admission findings. Refer to wound tracking sheet. Skin W/D to touch." There were no body audits documented for 1/23/14 or 1/30/14 while the resident was still present in the facility. The facility was unable to find this documentation prior to the surveyor's exit on 7/15/14. A review of the record on 7/14/14 revealed no documentation related to wound tracking or measurements for the four identified skin areas on the resident's sacrum, right/left buttocks and back left upper thigh/leg. A review of Physician order [REDACTED]. There were no orders for treatments to the right and left buttock or the back left upper thigh/leg upon admission (1/9/14) to the facility. During a phone interview on 7/14/14 at 3:40 PM, LPN #3 (identified by the DON as the treatment nurse at the time) who documented the admission body audit was asked about the skin areas documented on admission to the facility. During this interview s/he did not have access to the record and believed that wound treatments would have included treatments to both buttocks and the sacrum. S/he was unsure why the wound documentation could not be found. When informed that no treatments to the buttocks had been documented as administered on admission, LPN #1 thought that the skin had been intact with no [MEDICAL CONDITION] or redness and that possibly protective barrier cream had been all that was needed for the areas on the buttocks. When informed there had been no protective barrier cream implemented for the buttocks, s/he was unsure why an order had not been written. During a face to face interview on 7/15/14 at 12:50 PM in which the DON was present, LPN #3 reviewed the admission body audit and stated that skin areas #2 (right buttock) and #3 (left buttock) had been "unresolved areas" with the skin intact. The nurse stated that area #4 (left leg/thigh area) had been scabbed over but had intact skin. The DON questioned LPN #3 as to whether the area had been scabbed over or discolored to which LPN #3 answered that the area (#4) had been discolored. According to LPN #3, they wouldn't typically have started barrier cream (to the buttocks) based on the admission body audit findings. A Nurse's Note dated 1/23/14 at 4:00 PM revealed "Dr.-- notified of wound to sacrum + buttock status. Wound has foul smell + some necrosis noted to wound bed, slough tissue also noted. (No) granulation tissue noted, smooth yellowish red tissue. MD gave new wound care orders. Tylenol #3...prn pain..Also will merge wounds 1 + 2 = 5 (and) 3 + 4 = 6, see wound sheets." 5:00 PM "RP notified of the wound status and new orders for the pain med (ication)..." 1/24/14 "...14 day assessment completed. Wound care documentation describes (4) unstageable wounds (with) necrotic tissue, (no) pain reported during dressing change...". 1/26/14 at 5:00 PM which stated, "Sacral area cont(inues) (with) slough + eschar (with) yellow drainage + foul odor, superficial open areas surrounding tissue. Txment as ordered. Res T+R (Turned and Repositioned) q (every) 2 (hours) from side to side but will scoot back on his/her back. Positioned (with) pillows...". 1/29/14 at 3:30 PM documented, "...Kept off back as much as possible but resident will turn on back (after) being positioned on side...". 1/30/14 at 10:30 AM documented, "...Resident cont(inues) to maneuver self to get onto back....". 9:00 PM documented that the dressing to the sacral wound had been changed with a foul odor noted during and after the dressing change. The resident received Tylenol #3 for pain and an elevated temperature (101.4) with positive effect (Temp. 97.2 at 10:00 PM). Nurse's note documented the resident's [MEDICATION NAME] had been started; that the Promote with Juven was infusing, and the foley catheter was in place and draining. 1/31/14 at 6:00 AM documented a blood sugar of 506 with the doctor notified and orders obtained for a 1 x dose of Insulin to cover the elevated blood sugar along with an order to get a CBC (Complete Blood Count). A Nurse's note entry dated 1/31/14 at 8:00 AM documented the resident had been noted with a change in level of consciousness and an elevated temperature. An order was received to send the resident to the emergency room for evaluation and treatment. A Physician's Telephone Order dated 1/23/14 revealed a change in treatment to the sacral wound along with new treatment orders for the right and left buttock. The sacrum and left buttock were to be cleansed with wound cleanser with the application of 2 x 2 gauze soaked in 1/4 strength Dakins solution and Santyl to the wound, with the wound covered with 4 x 4s and a foam/border gauze dressing daily. The right buttock was to be cleansed with wound cleanser with the application of hydrogel to the wound and then covered with a foam/border gauze dressing daily 1/30/14 an order was written to change the tube feeding to Promote at 65 ml/hr with a flush of 600 ml of water with 2 packs of Juven to infuse at 25 ml/hr continuous via peg tube daily; insert a foley catheter and to start [MEDICATION NAME] 875 mg twice daily for 7 days for the treatment of [REDACTED]. During an interview on 7/14/14 at 4:20 PM, the DON who documented the 1/23/14 note stated she notified the Physician of the changes to the wound. According to the DON, the smell was from the necrotic/slough tissue with no signs of infection. The DON stated the Physician changed the treatment to Dakins to help take care of the smell. S/he stated, if the resident had been febrile the Physician may have ordered an antibiotic; but the resident was afebrile at the time. A review of the Admission Care Plan dated 1/9/14 revealed an entry for an unstageable wound. The care plan had not been updated relative to other wounds to the buttocks that had been noted on 1/23/14. A review of a Nutritional assessment dated [DATE] and signed by the RD (Registered Dietician) on 1/13/14 revealed the resident weighed 135 pounds and his/her ideal body weight was listed as between 174 and 191 pounds. His/Her height had been documented as 73 inches with a BMI of 18. The assessment noted a stage II to the mid sacrum measuring 3 cm x 1 cm. The tube feeding formula of Glucerna 1.2 at 50 cc/hr was increased to 65 cc/hr. There were no labs documented on the assessment, and according to staff interview; there had been no labs drawn in reference to nutritional status and none sent from the hospital upon admission to the facility. Resident #3 had a wound to the sacrum on admission (1/9/14) that worsened with noted yellow drainage and foul odor. The physician was not notified of this timely in order to determine if a change in treatment was needed. The resident also developed open areas to both buttocks and the back left upper leg/thigh while in the facility. According to interview, these 3 areas had intact skin on admission. Areas of skin concern to the buttocks and leg area were not thoroughly documented on admission in that it did not include descriptions of the areas of concern (only measurements). Nursing documentation later indicated the wounds were unstageable (1/24/14). The care plan did not address the resident's behavior of refusing to stay off his/her back and/or interventions for this behavior. There was no documentation of weekly wound measurements and tracking information included in the record related to the wounds. Body audit information was missing or not documented for 2 weeks (to be done weekly). There was no documented interventions in the record for the areas of skin concerns noted on admission (to both buttocks and back left upper leg/thigh) until wound treatments were ordered when the skin opened up. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 7/15/14 revealed the resident was readmitted to the nursing facility on 4/7/14 after a hospitalization . The resident's quarterly Minimum Data Set Assessment with an Assessment Reference Date of 5/6/14 revealed Resident #1 had short and long term memory problems. The resident was coded as totally dependent on staff with the physical assistance of 2 for bed mobility and transfers; impairments in range of motion on both sides of the upper and lower extremities; always incontinent of bowel and bladder; and at risk for pressure ulcers, but having none. A 4/7/14 body audit done on readmission to the facility after hospitalization documented a red area to the left foot. The assessment included a notation that the resident's skin had been intact and within normal limits. Body audit documentation dated 4/11/14, 4/18/14, 4/25/14, and 5/2/14 documented intact skin with no concerns related to the feet. Body audits dated 5/9/14, 5/17/14, and 5/23/14 documented discolored and/or dark areas to the bilateral feet with no breakdown. A 5/30/14 body audit documented an open area to the left lateral foot with bloody drainage; documentation dated 6/13/14 revealed "...blackish discoloration(s) cont(inue) to both feet." Body audits dated 6/20/14 and 6/27/14 documented only left lateral foot discolorations. A review of the nursing documentation revealed the resident was being turned and repositioned during this time frame. Interview revealed the resident had a regular pressure reduction mattress. There was nothing documented in the record to indicate the facility nursing staff had implemented any additional measures to prevent skin breakdown to the feet after the discolorations to the resident's feet had been identified on 5/9/14. A review of Weekly Wound/Skin Assessment Tracking Forms for Resident #1 revealed documentation of an acquired stage III pressure ulcer to the left lateral foot on 5/30/14 that measured 1.5 cm (centimeters) x 1.5 cm. The wound documentation revealed the following measurements: 6/2/14 1.9 cm x 1.0 cm, 6/9/14 1.9 cm x 1.0 cm, 6/19/14 1.8 cm x 1.0 cm, 6/23/14 1.8 cm x 1.0 cm, 6/30/14 1.5 cm x 1.0 cm. An undated wound measurement (presumed done in July) measured 1.2 x 1.0 cm. Observation of wound care on 7/15/14 at approximately 10:20 AM revealed LPN #1 removed the old dressing to the left foot. The old dressing did not contain a date or time of the previous dressing change which was verified by LPN #1. According to LPN #1, the left lateral foot wound measured 1.0 cm x 1.9 cm. Record review indicated that an unstageable pressure ulcer was noted to the right inner foot on 6/30/14 measuring 3 cm x 3 cm. According to documentation, the center of the wound contained black eschar with pink edges. On 7/9/14 the wound was documented as measuring 2.5 cm x 2 cm with eschar to wound bed and slight odor noted. The tracking form documented the physician had been notified of this with new orders given. Observation of wound care on 7/15/14 at approximately 10:35 AM revealed LPN #1 removed the old dressing to the right foot (which had not been dated or timed for the previous dressing change). This was verified by LPN #1. The wound measured 3.4 cm x 3.0 cm as per LPN #1. The wound was macerated around the edges. A review of Physician order [REDACTED]. On 7/9/14 the treatment had been changed to clean the wound and then apply 1/4 strength Dakins and cover with gauze/kerlix daily. On 7/15/14 the treatment was changed to 1/2 strength Dakins after cleaning the wound daily. A review of the policy provided by the facility on 7/15/14 entitled "Pressure Ulcer Treatment" revealed the protocol for a Stage III pressure ulcer included the use of an air mattress. According to an interview with RN #1, this (air mattress) was not provided until 6/30/14. Resident #1 had been identified with a stage III pressure ulcer to the left foot on 5/30/14. An arterial study of the lower extremities was ordered on [DATE]. The results of the exam dated 6/5/14 revealed difficulty with the exam since the resident was contracted and in a fetal position. The indication for the study was a non-healing ulcer on the left foot. The sonographer commented that the resident's bilateral PTA's were not imaged due to the contracted state. The bilateral ABI and TBI valves were normal. The Impression was that the findings indicated a normal study with no significant ischemia at rest and with the toe pressures normal bilaterally. Further review of Weekly Wound/Skin Assessment Tracking Forms revealed Resident #1 developed wounds to his/her sacral area, left buttock, and right inner foot towards the end of June 2014. A review of the May and June 2014 Treatment Sheets revealed documentation of barrier cream to the left buttock and sacrum for the resident as ordered. A Stage II pressure ulcer to the sacrum was noted on 6/28/14 that measured 4.5 cm x 1.5 cm x 0.1 cm. On 7/3/14 the wound measured 4.5 x 1.5 cm and contained granulation tissue. Wound notes dated 7/10/14 revealed documentation of pink granulation tissue with some slough and wound measurements of 4.2 cm x 1.5 cm. Wound care observation on 7/15/14 at approximately 10:15 AM revealed a small open area (not measured) to the sacrum. A review of Physician order [REDACTED]. On 6/30/14 the treatment was changed to duoderm (after wound cleansing) every 3-5 days and as needed. A Stage II pressure ulcer to the left buttock was noted on 6/30/14 that measured 7 cm x 3 cm; 7/4/14 the wound measured 7 cm x 2.5 cm; 7/9/14 the wound measured 7 cm x 2 cm. During wound care observation on 7/15/14 at approximately 10:15 AM the wound was measured 5.3 cm x 4.4 cm (as per LPN #1) and was noted beefy red. A review of Physician order [REDACTED]. During an interview immediately after the wound care observation on 7/15/14 at approximately 10:45 AM, LPN #1 stated s/he would call the physician to notify him/her of the changes to the wounds and also to inform the doctor about the addition of heel boots for the resident. When asked about the addition of heel boots for the resident, LPN #1 stated that s/he planned to add the heel boots to the resident's care because the pillow the resident's feet had been elevated on during the wound care observation "wasn't fluffy enough". LPN #1 stated this would provide additional protection to the wounds on the feet. (Observation during the wound care revealed the resident's contracted legs/feet had been elevated on a pillow). The resident was also observed with a specialty air mattress. LPN #1 was unsure when the air mattress had been implemented but stated this information could be noted on the care plan. LPN #1 verified this information was not included on the treatment record. A review of Resident #1's Comprehensive Care Plan on 7/15/14 revealed an entry for potential skin breakdown due to incontinence dated 6/5/14. Approaches listed included to keep the resident as clean and dry as possible and for preventive skin treatment prn (as needed). There were approaches listed that included to turn the resident every 2 hours and prn, treatment as ordered, and labs per physician order. Another care plan entry dated 6/5/14 included information that the resident had current skin breakdown to areas on the buttocks, sacrum, and lower extremities; and the resident would not develop any further breakdown through the next review on 9/12/14. Approaches included Treatment as ordered, Notify the MD of worsening, Monitor pain, and Air Mattress. However, a review of the record revealed that on 6/5/14, there was no documentation that the resident had breakdown to the buttocks or sacrum at that time. An interview with RN #1 on 7/15/14 at 11:00 AM revealed the specialty air mattress had been put into place on 6/30/14 after s/he had written orders for treatment for [REDACTED]. RN #1 verified the placement of the air mattress had not been documented in the record. The Comprehensive Care Plan for Resident #1 did not include interventions to elevate the resident's feet on pillows or for the use of heel protectors. During an interview on 7/15/14 at 10:55 AM, CNA #1 provided the CNA care plan for Resident #1. The care plan included documentation of the resident's wounds and that s/he had an air mattress (undated). Heel protectors were also documented on the CNA care plan. When asked about the documentation related to the heel protectors, CNA #1 stated that this information had just been added to the care plan a few minutes ago and had not been included on the care plan previously. CNA #1 stated this information had been added because the nurse was going to get heel boots for the resident. A review of the record including the Medication and Treatment records revealed information had not been care planned or documented related to the use of any heel boots for skin protection. A review of dietary notes revealed a note dated 5/8/14. The note documented a weight of 115 pounds for Resident #1 with intact skin. The ordered diet was for an enteral feeding of Glucerna at 45 cc/hr. There were no new labs documented with the plan to continue the current regimen. 6/12/14 documented a weight of 115 pounds with glucerna at 45 cc/hr. There were no new labs. Information included a breakdown of the amount of calories and protein this diet provided. The note documented a wound to the left lateral foot and recommended an increase in the tube feeding to 55 cc/hr for weight changes. This recommendation was implemented on 6/13/14. 7/5/14 an order was written and implemented for SF Prostat 30 ml twice daily related to wounds. 7/10/14 documented a weight of 113-115 pounds with new wounds to the sacrum and right inner foot. There were no new labs and recommendations were made to continue the Glucerna tube feeding at 55 cc/hr and continue the Prostat. During an interview on 7/15/14 at 11:05 AM the DON (Director of Nursing) verified the body audits indicated dark areas to the bilateral feet prior to the development of the wounds with no documented preventive measures for the feet (except Vaseline for dry skin). The DON verified the inaccurate date noted on the comprehensive care plan that indicated the wounds to the buttock and sacrum were present on 6/5/14. Resident #1 acquired 4 pressure ulcers in the facility. The resident developed one stage 3 pressure ulcer to the left foot and one unstageable pressure ulcer to the right foot. There was no documentation of preventive measures for the feet after dark areas to the feet were identified during body audits. The resident was not care planned for any foot protection prior to or after the pressure sores developed on his/her feet. At interview it was revealed that the air mattress was not placed until 6/30/14, a month after the stage III pressure ulcer to the left foot had been identified. The resident developed a stage II pressure ulcer to the sacrum and to the left ischium. An entry on the comprehensive care plan inaccurately indicated the use of a speciality air mattress and that wounds to the buttock and sacrum were present on 6/5/14. The facility admitted Resident #2 on 6/27/14 with [DIAGNOSES REDACTED]. A review of the Admission nursing evaluation dated 6/27/14 revealed the resident had left sided weakness secondary to [MEDICAL CONDITION] was unable to stand. The Admission assessment noted old scars to the lower extremities with no skin breakdown noted. A review of the Admission Minimum Data Set Assessment with an Assessment Reference Date of 7/4/14 revealed a Brief Interview for Mental Status score of 10 indicating moderate cognitive impairment at the time of the assessment. The resident was coded as requiring the extensive assistance of 1 with bed mobility and the extensive assistance of 3 with transfers. The resident was coded as having (1) stage II pressure ulcer. A review of the Braden Scale for predicting pressure sore risk revealed a score of 16 on 6/27/14 (day of admission) which corresponded to mild risk. On 7/4/14, 7/10/14, and 7/15/14, the Braden Scale documented a score of 14 which corresponded to a moderate risk for pressure sores. A review of the resident's Admission/Interim Care Plan revealed an entry that the resident developed a pressure ulcer to the sacrum on 6/30/14. Approaches included wound treatment as ordered and to turn and reposition the resident routinely and as needed. A review of the resident's Weekly Wound/Skin Assessment Tracking Form revealed an acquired stage II pressure ulcer on 6/30/14 measuring 2 cm x 1.5 cm. An order was obtained 6/30/14 for treatment to apply duoderm every 3-5 days or as needed. On 7/2/14 the wound was unchanged, and on 7/14/14 the wound measured 2 cm x 1 cm. Observation on 7/15/14 at 11:40 AM revealed a small pink open area to the sacrum. LPN #1 measured the wound at 1.0 cm x 0.9 cm. A review of Dietary notes revealed a nutritional assessment done 6/27/14 and signed by the RD on 7/3/14. The assessment indicated a current weight of 121 pounds with and ideal body weight between 140 and 169 pounds. The resident's BMI was documented as 18. The assessment documented a 50% intake of breakfast, and 75% intake of lunch and dinner. Under lab results on the assessment it was noted that a hemoglobin/hematocrit level had been noted. According to the assessment, the resident had old scars noted to both legs and a bedtime snack should be offered. The nutrient calculations did not account for a stage 2 pressure ulcer that was present on 7/3/14 when the assessment had been signed as completed. During an interview on 7/15/14 at 12:05 PM, the DON was unsure why the sacral wound had not been included in the nutritional assessment. Resident #2 acquired a stage II pressure ulcer to the sacrum while in the facility on 6/30/14. The nutritional assessment signed by the Registered Dietician (RD) on 7/3/14 did not take into account information that the resident had the sacral wound.

On the days of the survey, based on record review and interview the facility failed to provide laboratory (lab) services to meet the needs of 1 of 13 residents reviewed for labs. Resident # 5 with an order for [REDACTED]. The findings included: The facility admitted Resident # 5 on 6-23-08 with the following Diagnoses: [REDACTED]. Review of the medical record revealed labs drawn for [MEDICAL CONDITION]-Stimulating Hormone (TSH) on 5-25-10 with a level of 1.09 and again on 6-4-10 with a level of .78. The most recent TSH lab in the chart was dated 12-8-10 with a level of 13.025 H (high) which had the instructions listed of "Repeat (lab) 1-9-11 and 100 mcg every day." There was no evidence provided indicating the lab result was obtained as ordered to determine if the levels remained elevated and a medication dosage change might be indicated. After the inquiry from the surveyor, the TSH was drawn on 4-26-11, and the lab value was 23.231 H(igh) with the recommended lab value parameter being .350-4.500 as noted on the lab report.

On the days of the survey, based on observation, record review and interview, the facility failed to ensure that 1 of 13 residents reviewed for medications remained free from significant medication errors. Resident # 5 failed to receive [MEDICATION NAME] 100 mcg (microgram)as prescribed which resulted in the resident having abnormal lab values. The findings included: The facility admitted Resident # 5 on 6-23-08 with the following Diagnoses: [REDACTED]. On 2-3-11 Resident # 5 was sent to the hospital and returned to the facility on [DATE]. She was out of the facility at the hospital again from 2-28-11 till 3-2-11. Review of the medical record revealed a lab tests for a [MEDICAL CONDITION]-Stimulating Hormone (TSH) level were done on 5-25-10 with a level of 1.09 and again on 6-4-10 with a level of .78. The acceptable parameter range was noted as .350-4.5) The most recent TSH lab in the chart was dated 12-8-10 with a level of 13.025 H (high) which had the instructions listed of "Repeat (lab) 1-9-11 and 100 mcg every day." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The medication was signed as administered on March 24-29. During a conversation with the Director of Nursing (DON), on 4-26-11, at approximately 1:15 PM, this surveyor asked if additional MAR's could be located for Resident # 5. On 4-27-11 at approximately 9:30 AM, two additional MAR's for February and March were noted to be in the chart. [MEDICATION NAME] 100 mcg was documented as being given on February 2nd, 3rd and from February 11th -28th. A second March MAR indicated [REDACTED]. The April 2011 MAR indicated [REDACTED]. There were a total of 69 days that the medication was signed as administered. During an interview with the Pharmacy Consultant on 4-27-11 at approximately 10:00 AM, she stated that the pharmacy last supplied this medication on 1-27-11 and had sent only 30 pills to the facility at that time which would have depleted the medication on 2-15-11. On 4-27-11 at approximately 10:05 AM, Licensed Practical Nurse # 1 confirmed that there was no [MEDICATION NAME] 100 mcg in either of the medication carts on Hall 100. On 4-27-11 at approximately 10:45 AM, during an interview with the DON, she stated she did not know of any source of medication except the pharmacy, and did not know why the medication was documented as given, when there was not any available. A TSH level obtained on 4/26/11 returned with an abnormal result of 23.231 (high) resulting in the physician increasing the resident's medication and ordering the lab to be repeated in one month.

On the days of the survey, based on observation, record review and interview, the facility failed to ensure that 1 of 13 residents reviewed for falls received adequate supervision and assistive devices to prevent accidents. Resident # 5 was left unattended and unrestrained in the day room, after repeated incidents of attempting to ambulate the previous 2 days. The resident fell and sustained a fractured hip. Also the following concerns; after an X-ray on 3-28-11 determined that Resident # 5 had a left hip fracture, Resident # 5 was observed sitting in a wheel chair, not in a Geri-chair with a lap tray as per the physician's orders [REDACTED]. The findings included: The facility admitted Resident # 5 on 6-23-08 with the following Diagnoses: [REDACTED]. On 2-3-11 Resident # 5 was sent to the hospital for a Right Hip Fracture, which was sustained in the facility. She returned to the facility on [DATE]. She was again at the hospital from 2-28-11 till 3-2-11. Nurse's Notes dated 3-26-11 at 12:45 PM indicated the following: "Resident up in w/c (wheel chair) c (with) w/c alarm in place.....Resident observed attempting to stand several times so far this shift." On 3-27-11 at 5:00 PM the following Nurse's Note was recorded: "Resident attempting x (times) 4 to ambulate independently. Alarm in place.... Order for soft belt x 24 hours and resident to be eval(uated) on 3-28-11 due to unsteady gait. Soft belt applied for safety, will be released Q (every) 2 hours for 15 min(utes)." Review of the physician's orders [REDACTED]." During an interview with the Certified Nursing Assistant (CNA) # 2, on 4-25-11 at 4:55pm, she stated that on 3-28-11 she was assigned to Resident # 5. She further stated that during report that day, she had been instructed by the Unit Manager not to place any restraints on Resident # 5 because the 24 hour order for the soft belt restraint was over. After completing morning care, CNA #2 put Resident # 5 in a wheel chair, placed her into the day room, and left her there unattended, while going back to the change the linen in Resident # 5's room. On 3/28/11, Resident # 5 while left unattended, fell which resulted in a fracture to the left hip. During an interview with the Unit Manager, Registered Nurse (RN) # 1, on 4-25-11 at approximately 4:20 PM, RN #1 verified that she met with the Certified Nursing Assistants (CNA's) on 3-28-11 and informed them that the 24 hour period was over for the soft belt restraint for Resident # 5. She informed them that Physical Therapy would have to evaluate Resident # 5 and make recommendations before another restraint could be placed on the resident. She further stated that she was in the morning meeting and had not been able to talk to Physical Therapy when she was notified that Resident # 5 had fallen. She went to assess the resident and the resident did not show any signs of pain or discomfort. During an interview with Licensed Practical Nurse (LPN) # 2 on 4-25-11 at approximately 4:10 PM, LPN #2 stated that she was the medication nurse on 3-28-11, and at approximately 10:45 AM, she was working at her medication cart which was parked near the day room on the 100 Unit. LPN # 2 further stated that she saw Resident # 5 stand, she yelled out and before she could get into the day room, Resident # 5 had fallen. She stated she did not hear a chair alarm sound. After an assessment of the resident was made, she continued to sit with Resident # 5 and assisted her with lunch. LPN #2 further stated that she gave Resident # 5 two Aleve for pain at 12:25 PM, even though she did not complain of pain. Review of the medical record revealed that on 3-28-11, the resident was sent to the ER (emergency room ) for an X-Ray related to the fall, which revealed a Left Hip Fracture. The X-Ray report from the Hospital dated 3-28-11at 14:07 (2:07 PM) stated: " Concerning the left hip, there appears to be a nondisplaced somewhat subtle subcapital fracture with minimal impaction. This was discussed with Dr. _____ ( Resident # 5's primary physician, who was also the Medical Director of the facility.)" Further review of the hospital records revealed Resident # 5 was not admitted to the hospital for surgery until 3-29-11 at 14:49 (2:49 PM). Surgery notes from the hospital revealed the following statement: "We hoped we could fix the fractured femoral neck with percutaneous pins, but (illegible) it became obvious there was a completely displaced femoral neck fracture and only hemiarthroplasty would suffice." On 4-25-11, review of the physician's orders [REDACTED]. " Review of the Care Plan with run date of 4-19-11 listed problem # 12 as: "Resident requires geri-chair w/lap tray while oob (out of bed). Approaches listed were 1. Geri-chair w/lap tray while oob.. 2. Release every 2 hours for 10 minutes. Provide exercise: PROM (Passive Range of Motion). 3. Monitor resident's response to device." There were no Approach Start Dates listed. On 4-25-11 after the survey team entered the building an updated care plan was placed on the chart. On 4/25/11, observation of Resident # 5's room at 2:15 PM revealed a lap tray in the room. Resident # 5 was observed to be in the day room, sitting in a wheelchair ( not in a geri-chair) at that time. On 4-26-11 at approximately 8:55 AM, the Resident was observed to be sitting in the day area with other residents. The brakes on her wheel chair were not in a locked position. This was confirmed with RN # who stated she was unaware who had moved Resident # 5 into the day area after breakfast. None of unit 100 staff stated that they had moved the Resident. RN #1 then stated that a new order had been written on 4-25-11 for Resident # 5 to be up in a wheel chair with a pommel cushion and a lap buddy to prevent falls.

On the days of the survey, based on record review, interview, and review of the professional resource of Perry-Potter Clinical Nursing Skills & Techniques 7th Edition, the facility failed to maintain professional standards related to medication administration for one of ten sampled residents reviewed for professional standards. The facility nursing staff repeatedly documented that [MEDICATION NAME] (a [MEDICAL CONDITION] medication) was administered as ordered to Resident # 5. However, the medication was not available for administration. The findings included: The facility admitted Resident # 5 on 6-23-08 with the following Diagnoses: [REDACTED]. Review of the medical record revealed labs drawn for [MEDICAL CONDITION]-Stimulating Hormone (TSH) done in 5-25-10 with a level of 1.09 and again on 6-4-10 with a level of .78. The most recent TSH lab in the chart was dated 12-8-10 with a level of 13.025 H (high) which had the instructions listed of "Repeat (lab) 1-9-11 and 100 mcg every day." The Medication Administration Records (MAR), documented that [MEDICATION NAME] was administered for 69 doses from February to April 2011. During an interview with the Pharmacy Consultant on 4-27-11 at approximately 10:00 AM, she stated that the pharmacy last supplied this medication on 1-27-11 and had sent only 30 pills to the facility at that time which would have depleted the medication on 2-15-11. On 4-27-11 at approximately 10:05 AM, Licensed Practical Nurse # 1 confirmed that there was no [MEDICATION NAME] 100 mcg in either of the medication carts on Hall 100. On 4-27-11 at approximately 11:00 AM, during an interview with the DON, she stated she did not know of any source of medication except through the pharmacy and did not know why the medication was documented as administered when the medication was not available. Perry-Potter Clinical Nursing Skills & Techniques 7th Edition, page 515- 518 states: "Standards are those actions that ensure safe nursing practice. To ensure safe medication, nurses follow the nursing standard called the six rights of medication administration every time they administer medications. The process includes assuring the right medication, the right dose, the right patient, the right route, the right time and the right documentation....When preparing medications, compare the label of the medication to the MAR indicated [REDACTED].