Every finding on record at Francis Marion Manor Health & Rehabilitation

Based on staff interview and facility document review, the facility staff failed to ensure information provided on the payroll-based journal (PBJ) was accurate. The findings include: The facility staff were including Hospice staff not employed by the facility on the PBJ report. This facility had triggered for one star staff rating and No Registered Nurse (RN) coverage for quarter 3 of 2023 (April, May, June). When reviewing these reports, the surveyor noted the facility staff had included Hospice staff on the report. On 08/14/24 at 9:15 a.m., the surveyor interviewed the staff the facility identified as being responsible for these reports RN #3. This staff stated Hospice personnel were contracted and they were patient care givers. RN #3 confirmed they were not paid by the company, and they would reach out to the email provided on the guidelines for completing the PBJ reports. On 08/14/24 at 10:12 a.m., RN #3 stated they had received a response from their email, and they should not have been including Hospice personnel on their PBJ reports. This staff provided the surveyor with copies of their email and part of a booklet titled, Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual Version 2.6 June 2022. Page 3 of this document read in part, .Reminder .visits to residents billed to Medicare or another payer, hours for service provided by hospice staff and private duty nurses shall not be reported . On 08/14/24 at 1:10 p.m., during a meeting with the Administrator/Chief Executive Officer and Director of Nursing (DON) the issue with Hospice personnel being included on the PBJ report was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, employee record review, and facility document review, the facility staff failed to follow their policy regarding screening of new hires for 2 of 15 employees. New hire #1 and #14. The findings include: The facility staff failed to follow their policy for screening of new employees. The facility staff failed to obtain criminal background checks through the Virginia State Police (VSP) criminal records exchange. The facility administrative staff provided the surveyor with a copy of their policy titled, Background Checks-Human Resources. This policy read in part, The Recruitment Team will initiate the background investigation after a conditional job offer has been made .screenings are done in addition to the required criminal history records obtained through the state of Virginia .candidates for positions to be employed in Virginia who are working in those areas required by the state of Virginia to have a criminal history background check obtained through the Central Criminal Records Exchange, Department of State Police will consent to a full criminal background check . On 08/14/24 at approximately 12:27 p.m., the surveyor completed a review of employee records for the staffing task with Human Resource (HR) personnel #1 and #2. Fifteen employee records were reviewed of these 15 records 2 employee files were identified as not having VSP background checks. New hire #1 was employed as an Occupational Therapist, their hire date was documented as 07/29/24. The employee record did not include a VSP background check through the central records exchange. HR personnel #1 stated this employee worked at a hospital for the same company prior to working at this facility and the hospital staff were not aware a VSP background check needed to be completed. New hire #14 was employed in the dietary department, their hire date was documented as 09/14/23. The employee record did not include a VSP background check through the central records exchange. HR personnel #1 confirmed this was a contract employee and the VSP background check had not been completed. On 08/14/24 at 4:00 p.m., during an end of the day meeting with the Administrator/Chief Executive Officer (CEO) and Director of Nursing (DON) the issue with the missing VSP background checks were reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and facility document review, the facility staff failed to ensure Registered Nurse (RN) coverage for 8 consecutive hours a day 7 days a week for quarter 3 of 2023. The findings include: The facility staff failed to ensure they had RN coverage for 8 consecutive hours a day 7 days a week for quarter 3 of 2023 (April, May, June). There was no facility employed RN on staff on 04/30/23, 05/14/23, 05/27/23, 05/28/23, 06/11/23, and 06/25/23. The facility census was as follows 04/30/23 (40), 05/14/23, 05/27/23, 05/28/23 (39), 06/11/23 (38), and for 06/25/23 (35). Three surveyors entered the facility on 08/12/24 at 6:10 p.m., staffing was as follows 1 RN, 2 Licensed Practical Nurses (LPN's), and 3 Certified Nursing Assistants (C.N.A.'s). The census was 25. This facility had triggered for one star staff rating and No Registered Nurse (RN) coverage for quarter 3 of 2023 (April, May, June). A review of the facility payroll-based journal (PBJ) reports revealed that the facility had no RN coverage on the above named dates. On 08/13/24 at 3:10 p.m., during a meeting with the Administrator/Chief Executive Officer (CEO) and Director of Nursing (DON) the issue regarding RN coverage was reviewed. These staff confirmed they did not have RN coverage on these days as they had a staff person out on medical leave. On 08/14/24 at 10:50 a.m., during an interview with LPN #2 this staff stated they did not recall any issues when they did not have an RN, and this would have been their weekends to work. LPN #2 stated if they had issues, they could have called the house supervisor at the hospital (same company), the DON, or RN #2 as they lived near the facility. LPN #2 stated they weren't accepting admissions at one point due to staffing issues. During interviews with C.N.A. #1, #2, #3, #4, and #5, no staff expressed any concerns regarding nursing coverage and issues with the residents of the facility. On 08/14/24 at 1:10 p.m., the Administrator/CEO and DON stated they did not recall any issues regarding not having an RN on site at the facility for the above dates. On 08/14/24 at 1:35 p.m., during an interview with the Social Worker this staff denied having any complaints from families and/or residents regarding RN coverage. No issues regarding staffing were observed while on site. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for 2 of 14 residents, Resident #19 and #23. The findings include: 1. For Resident #19, the facility staff failed to ensure the residents' order for Digoxin was accurate regarding administering the medication with food. Resident #19's diagnoses included atrial fibrillation and chronic heart failure. Section C (cognitive patterns) of Resident #19's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/08/24 included a brief interview for mental status (BIMS) summary score of 15. Per the MDS manual a score of 15=cognitively intact. The clinical record included an order dated 08/07/24 for Digoxin 62.5 mcg to be given daily at 8:00 a.m. the administration instructions included with this order read as follows, Digoxin should be given one hour before or two hours after eating. On 08/14/24 at 9:03 a.m., during an interview with the Director of Nursing (DON) the DON stated the original order for the Digoxin had a stop date, the physician rounded, and the resident requested it be reordered. Their software pre-populated the documentation regarding mealtimes, and it previously had to hold if the pulse less than 60. The DON stated the nurse putting the order in did not notice that the software had pre-populated the comment regarding meals. On 08/14/24 at 9:45 a.m., during an interview with Medical Director #1, this staff stated the residents Digoxin level was sub-therapeutic and they wanted them off it. Resident #19 has a cardiologist appointment coming up and insisted on the time that it's administered. The part of the order that speaks of it being given with or without food is part of EPIC (software).I did not remove it from the order . On 08/14/24 at 12:18 p.m., during an interview with Registered Nurse (RN) #1 this staff stated the original Digoxin order ended after the dosage on 08/03/24, Resident #19 wanted the medication back, they were seen by the physician, and it was reordered. RN #1 stated breakfast was served around 7 a.m. till 8:30 a.m. and they did not know the order regarding the food and holding the medication was attached to the order, before it was just the heart rate. RN #1 stated the dosage this morning was given by the night shift nurse this at 7:02 a.m. The surveyor was able to verify through the clinical record review that the pulses had been obtained daily. On 08/14/24 at 4:00 p.m., during a meeting with the Administrator/Chief Executive Officer and Director of Nursing (DON) the issue regarding the Digoxin was reviewed. The DON stated a ticket had been put in regarding the food and administration of Digoxin to get it removed from the software. No further information regarding this issue was provided to the survey team prior to the exit conference. 34307 2. For Resident #23 the facility staff failed to accurately complete a Virginia Department of Health Durable Do Not Resuscitate (DDNR) form. Resident #23's clinical record was reviewed and contained a signed DDNR for dated 07/28/22. This form read in part, I, the undersigned, state that I have a [NAME] fide physician/patient relationship with the patient named above. I have certified in the patient's medical record that he/she or a person authorized to consent on the patient's behalf has directed that life-prolonging procedures be withheld or withdrawn in the event of cardiac or respiratory arrest. I further certify (must check 1 or 2): Neither box one nor two was checked. The form continued to read, If you checked 2 above, check A, B, or C below. No boxes were checked in this section. The concern of the incomplete DDNR form was discussed with the administrator and director of nursing on 08/13/24 at 3:30 pm. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to ensure residents were free of significant medication errors for 1 of 21 residents in the survey sample, Resident #27. The findings included: For Resident #27, the facility staff failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #27's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/22/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15 in section C, Cognitive Patterns. Resident #27's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #27's October 2021 MAR (medication administration record) revealed [MEDICATION(S)] was administered in error on 10/05/21 at 9:13 pm for a blood pressure of 160/70. A review of Resident #27's October 2021 MAR and blood pressure summary revealed the following systolic blood pressure readings greater than 160 in which [MEDICATION(S)] was not administered: 10/02/21 8:13 am 183/75, 10/02/21 8:28 pm 161/72, 10/11/21 10:33 am 180/79, 10/24/21 9:09 pm 161/71, and 10/28/21 6:09 am 162/72. On 11/04/21 at 10:06 am, surveyor spoke with the UM (unit manager) who verified the above surveyor findings for Resident #27. Resident #27's current comprehensive person-centered care plan included a focus area stating (Resident #27) is at risk for altered cardiovascular status r/t (related to) CHF (congestive heart failure), [CONDITION(S)], cardiomegaly, hx (history) of hypertension, MI ([CONDITION(S)]), ASCVD ([CONDITION(S)] cardiovascular disease) with an intervention stating check blood pressure every shift, administer meds as indicated. On 11/04/21 at 2:31 pm surveyor met with the administrator, director of nursing, UM, social worker, and the infection preventionist and discussed the concern of Resident #27 not receiving [MEDICATION(S)] as ordered by the physician on six (6) separate occasions. No further information regarding this issue was provided to the survey team prior to the exit conference on 11/04/21.

Based on observations, staff interviews, and facility document review, it was determined the facility staff failed to accurately implement facility policies, procedures, and/or processes relating to DNR (do not resuscitate) status for two (2) of 21 facility residents (Resident #15 and Resident #49). The following information was found in a facility policy titled DO NOT RESUSCIATE ORDERS (DNR) AND DURABLE DO NOT RESUSCITATE (DDNR) ORDERS - VIRGINIA - (medical corporation name omitted) (with an effective date of 10/1/21): To issue a DDNR order, an Authorized Practitioner must: a. Explain to the patient or Legally Authorized Representative the DDNR Order and alternatives available for response in the event of Cardiac or Respiratory Arrest. b. If the option of a DDNR Order is agreed upon, an Authorized Practitioner will: . Complete the state approved DDNR form . The findings include: 1. The facility staff failed to ensure Resident #15's Virginia Department of Health DDNR (durable do not resuscitate) Order form was complete. The facility staff failed to ensure Resident #15's wristband had a 'purple star' on it; the purple start indicated the resident had a DNR (do not resuscitate) order. Resident #15 minimum data set (MDS) assessment, with an assessment reference date (ARD) of 8/27/21, was completed on 8/31/21. Resident #15 was assessed as able to make self understood and as usually able to understand others. Resident #15's BIMS (Brief Interview for Mental Status) summary score was a five (5) out of 15. Resident #15 was assessed as requiring assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #15's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's active plan or care included the following 'focus' area: (Resident #15's name omitted) wishes to be a Do Not Resucitate [sic] in the event of cardiopulmonary arrest. Resident #15's clinical record contained a signed Virginia Department of Health DDNR Order form dated 10/15/21. This form included an area which read in part I further certify (must check 1 or 2); this documented whether or not the resident was 'capable' of making an informed decision. Neither 1 nor 2 was checked. A completed copy of this form, for Resident #15, was provided to the survey team prior to the conclusion of the survey. On 11/3/21 at 5:05 p.m., CNA (certified nurse aide) #21 stated one of the ways to know a resident's DNR status is to check the resident's armband for a purple star. CNA #21 reported a 'purple star' indicates the resident has a DNR order. Review of Resident #15's clinical record revealed a medical provider order for a DNR but Resident #15's armband did not have a 'purple star' on it. On 11/3/21 at 5:09 p.m., the facility's Nurse Manager confirmed that Resident #15's armband did not have a 'purple star' but that it should. The Nurse Manager corrected Resident #15's armband to include a 'purple star'. On 11/4/21 at 8:30 a.m., the facility's Administrator reported the facility's DNR policy did not address the use of a 'purple star' on residents' armband to identify presence of a DNR order for the resident. On 11/4/21 at 2:23 p.m., the facility's Administrator, Director of Nursing, Infection Preventionist, and Unit Manager participated in a survey team meeting. During this meeting the failure of the facility staff to ensure Resident #15 had a completed DDNR from and the failure of the facility staff to ensure Resident #15's armband had the resident's DNR status indicated with a 'purple star' was discussed for a final time. 2. For Resident #49 the facility staff failed to ensure a complete Virginia Department of Health DDNR (durable do not resuscitate) form. Resident #49's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) with an ARD (assessment reference date) of 10/15/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15 in section C, cognitive patterns. This indicates the resident is severely cognitively impaired. Resident #49's clinical record was reviewed on 11/03/21 and contained a signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #49's clinical record contained a Virginia Department of Health DDNR form dated 04/28/21, which read in part I further certify (must check 1 or 2). On this section of the form, 2 was checked. The form also read If you check 2 above, check A, B or C below. In this section, no areas were checked. The incomplete DDNR was discussed with the administrator on 11/03/21 at 5:15 pm. Administrator stated they would correct the DDNR. Administrator provided the surveyor with a copy of a corrected DDNR for on 11/04/21 at 8:50 am. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to demonstrate a review of pharmacy recommendations for one 1 of 21 residents (Resident #41). The findings included: The facility staff failed to follow up on a pharmacy recommendation for the month of August 2021. Resident #41's clinical record included the diagnosis unspecified [CONDITION(S)], dementia, depressive disorder, and anxiety disorder. Section C (cognitive patterns) of Resident #41's quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 10/04/2021 included a (BIMS) brief interview for mental status summary score of 12 out of 15 points. Resident #41's clinical record included a drug regimen review dated 08/20/2021. The reviewing pharmacist had marked the box beside the statement that read, Recommendations made, review Pharmacy Report for recommendations. The surveyor was unable to locate a pharmacy report with the date of 08/20/2021 that referenced a recommendation in Resident #41's clinical record. 11/04/2021 11:16 a.m., the (DON) director of nursing was made aware of the missing pharmacy report. 11/04/2021 2:23 p.m., an end of the day meeting was held with the administrator, DON, infection preventionist, and unit manager. The missing pharmacy review recommendation was reviewed with these staff. 11/04/2021 3:14 p.m., the DON stated they were unable to locate anything in regards to the pharmacy review for the month of August 2021 for Resident #41. No further information regarding the pharmacy review for August 2021 was provided to the survey team prior to the exit conference.

Based on observations, staff interviews and facility document review, and during the course of a COVID-19 focused survey, it was determined the facility staff failed to consistently implement infection control plans/practices designed to attempt to prevent the development and/or transmission of COVID-19. The findings included: The facility staff failed to provide specific PPE (personal protective equipment) signage posted outside of (2) resident's rooms (Resident #1 and Resident #2). On 6/22/2020 at 4:15 pm, the surveyor and administrator conducted a walking tour of the nursing facility. During this tour, the surveyor noted over the door PPE for Resident #1 and #2's rooms. There was no signage to inform the staff of the appropriate PPE to be used while caring for the residents in these rooms. The surveyor asked the administrator if appropriate signage should be on the resident's door alerting the staff the type of isolation the resident was on and what type of PPE was required to be used by the staff caring for the residents. The administrator stated, Yes there should be a sign on both of these rooms. The administrator informed the DON (director of nursing) of the above documented findings. On 7/1/2020, the surveyor reviewed the facility's policy titled Infection Control which read in part .Signage shall be posted at the first point of encounter with instruction to Residents and Team Members to take appropriate control measures . No further information was provided to the surveyor prior to the exit conference on 7/1/2020.

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections as evidenced by a failure of a staff member to cleanse an injection site prior to the administration of a subcutaneous injection for 1 of 20 residents in the survey sample (Resident #40). The findings include: On 2/20/20 at 8:00 a.m., Staff Member (SM) #21 was observed to administer Humolog (insulin) 10 unit via subcutaneous injection to Resident #40. SM #21 did not cleanse the injection site prior to administering the medication. SM #21 confirmed the injection site was not cleansed prior to the injection. SM #21 reported always cleansing an injection site prior to administering an injection and was unsure why he/she did not cleanse the injection during the aforementioned observation. Resident #40's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 1/11/20, had the resident assessed as requiring assistance with eating, hygiene, and dressing. Resident #40's [DIAGNOSES REDACTED]. The following information was found in facility infection control and/or injection procedure documents provided to the survey team by the facility's Director of Nursing on 2/20/20 at 10:25 a.m.: Subcutaneous Injection . 12. Examine the patient's skin to select an appropriate injection site . 15. Clean the intended injection site with an alcohol swab or facility approved antiseptic solution and allow it to air-dry 16. Uncap the needle and administer the injection . Resident #40's care plan included Diabetes Mellitus as a focus area. This focus area had administer diabetes medication as an intervention. During a meeting on 2/20/2020 at 3:20, the failure of SM #21 to cleanse Resident #40's injection site prior to a subcutaneous injection was discussed with the facility's Administrator and Director of Nursing.

Based on clinical record review and staff interview, facility staff failed to ensure that residents receive treatment and care in accordance with the comprehensive person-centered care plan as evidenced by failure to obtain daily weights for 1 of 20 residents in the survey sample, Resident #23. For Resident #23, facility staff failed to obtain daily weights as ordered by the physician. Resident #23's [DIAGNOSES REDACTED]. The most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 11/20/19 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive Patterns. A review of Resident #23's medical record revealed an active physician's orders [REDACTED]. (pounds) in 24 hours or 5 lbs. in one week, give [MEDICATION NAME]. Resident #23's comprehensive care plan included the problem area of (Name omitted) is at risk for fluid imbalance, approaches included, but were not limited to administer medications as ordered, refer to MAR (Medication Administration Record) and weigh and record as ordered, notify physician of significant findings. A review of the TAR (Treatment Administration Record) and the resident's Weights and Vitals Summary Report revealed weights were being obtained weekly. February 2020 weights were obtained on 2/03/20, 2/10/20, and 2/17/20. On 2/20/20 at approximately 10:00am, surveyor notified the DON (director of nursing) of the above findings. The DON did not provide any additional information. On 2/20/20 at approximately 3:30pm, the administrative team consisting of the administrator and the DON were made aware of staff not following the physician's orders [REDACTED].#23. No further information regarding this issue was presented to the survey team prior to the exit conference on 2/21/20.

Based on staff interview and clinical record review, the facility staff failed to ensure 6 of 18 residents were free of an unnecessary [MEDICAL CONDITION] medication (Resident #13, Resident #43, Resident #16, Resident #27, Resident #54, and Resident #61). The findings included: 1. The facility staff failed to monitor the use of [MEDICATION NAME] (an antidepressant) for Resident #13. The clinical record of Resident #13 was reviewed 4/30/19 through 5/3/19. Resident #13 was admitted to the facility 9/5/18 with diagnoses, that included but not limited to end stage [MEDICAL CONDITIONS], volume overload, hypertension, [MEDICAL CONDITION], [MEDICATION NAME], left shoulder arthritis, chronic [MEDICAL CONDITION], type 2 diabetes mellitus, deconditioning, depression, [MEDICAL CONDITION], [MEDICAL CONDITION], and history [MEDICAL CONDITION]. Resident #13's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/15/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. No signs or symptoms of [MEDICAL CONDITIONS], or behaviors that affected others were assessed. Section D Mood was assessed with [REDACTED]. Current comprehensive care plan initiated 5/30/18 and revised on 11/21/18 identified that Resident #13 uses an antidepressant medication to control episodes of depression. His depression is contributed to end stage [MEDICAL CONDITION]. His wife is unable to care for him at home. Interventions: Administer antidepressant medications as ordered by physician, refer to MAR (medication administration record). Observe/document side effects and effectiveness q shift (every shift). Allow him to talk and express his feelings when having s/s (signs/symptoms) of depression. He participates in therapy from a counseling service. Notify physician if current medications are ineffective or if depression worsens. Resident #13's (MONTH) physician orders [REDACTED]. [MEDICAL CONDITION] Order date 10/25/18 Start Date 10/27/18. The surveyor reviewed the Behavior Observation Weekly Summary forms from (MONTH) 2019 through (MONTH) 2019. The behavior observation weekly summaries were not done the week of 3/21/19, 3/28/19, 4/4/19, 4/11/19 and 4/18/19. The surveyor reviewed the (MONTH) 2019 electronic medication administration records (eMAR), the (MONTH) 2019 eMAR, (MONTH) 2019 eMAR and (MONTH) 2019 eMAR and the nurse's progress notes from (MONTH) 2019 through (MONTH) 2019 and found no documentation of behavior monitoring to include effects, side effects, and non- pharmacological interventions. The current comprehensive care plan did not identify targeted behaviors or non-pharmacological interventions prior to the use of the medication. The surveyor informed the administrator and the director of nursing of the above concern with failure to monitor the use of [MEDICATION NAME], identify targeted behaviors and include non-pharmacological interventions on the care plan on 5/3/19 at 3:52 p.m. No further information was provided by the facility prior to the exit conference on 5/3/19. 2. The facility staff failed to monitor the use of [MEDICATION NAME] and [MEDICATION NAME] (used for anxiety) for Resident #43. The clinical record of Resident #43 was reviewed 4/30/19 through 5/3/19. Resident #43 was admitted to the facility 11/28/18 with diagnoses that included but not limited to [MEDICAL CONDITION] ([MEDICAL CONDITION], [MEDICAL CONDITIONS], leukocytosis, peripheral artery disease, CAD ([MEDICAL CONDITION]), obesity, TIA [MEDICAL CONDITIONS], acute [MEDICAL CONDITIONS], constipation, hypertension, and pacemaker. Resident #43's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/25/19 assessed the resident with a BIMS (brief interview for mental status) as 00/15. Resident #43 had no assessed signs or symptoms of [MEDICAL CONDITIONS], or behaviors that affected others. Section D Mood assessed the resident with a total severity score of 9. Resident #43's current comprehensive care plan (undated) identified the focus area that read the resident uses [MEDICAL CONDITION] medications-antipsychotic medication r/t (related to) agitation and anxiety. Interventions: Administer [MEDICAL CONDITION] medications as ordered by physician, observe for side effects and effectiveness, consult with pharmacy, MD (medical doctor) to consider dosage reduction when clinically appropriate at least quarterly, discuss with MD, family re: ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness. Observe prn (as needed) any adverse reactions of [MEDICAL CONDITION] medications. The current comprehensive care plan also identified the issue of mood problem r/t disease process of [MEDICAL CONDITION]. Interventions: Administer medications as ordered, refer to MAR (medication administration record), encourage him to talk about his thoughts and feelings, and observe/record/report to MD prn mood patterns, s/s (signs/symptoms) of depression, anxiety, and sad mood. Resident #43's (MONTH) 2019 physician's orders [REDACTED]. The current comprehensive care plan did not specify targeted behaviors for the use of [MEDICATION NAME] and [MEDICATION NAME], non-pharmacological interventions prior to the administration of each, and weekly monitoring of the [MEDICAL CONDITION] medications per the Behavior Observation Weekly Summary. Only one summary was done from (MONTH) through (MONTH) 2019 and that one was done 3/7/19. The surveyor informed the administrator and the director of nursing of the concern with the lack of behavior monitoring and care plan without targeted behaviors for the use of [MEDICATION NAME] and [MEDICATION NAME] in the end of the day meeting on 5/3/19 at 3:52 p.m. No further information was provided prior to the exit conference on 5/3/19. 3. The facility failed to document accurately on the behavioral monitor sheets for Resident #16. Resident #16 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to [MEDICAL CONDITION], diabetes, stroke, dementia, [MEDICAL CONDITION] disorder, anxiety disorder, depression and [MEDICAL CONDITION]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/18/19 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 4 out of a possible 15. Resident #16 was also coded as requiring extensive assistance of 1-2 staff members for dressing, personal hygiene and coded as being totally dependent on 1 staff member for bathing. During the clinical record review on Resident #16, the surveyor noted the following on the weekly behavioral monitoring sheets: 4/26/19 and 4/12/19 .2. Current MD (medical doctor) order and [DIAGNOSES REDACTED]. The box under this only has Klonopin listed without a diagnosis. 4/5/19 and 3/29/19 .Current MD order and [DIAGNOSES REDACTED]. The box under this only has Klonopin and [MEDICATION NAME] listed. There were no diagnosis listed with these two medications. 3/22/19 .B. Behaviors and Side effects .7. Paranoia (describe below) . was marked by the staff but there was no description of this behavior. 3/15/19 and 3/1/19 .2. Current MD (medical doctor) order and [DIAGNOSES REDACTED]. The box under this only has Klonopin listed without a diagnosis. The surveyor reviewed the MAR (medication administration record) for (MONTH) and (MONTH) 2019. The resident was receiving Klonopin 0.5 mg (milligram) two times a day for dementia/agitation, [MEDICATION NAME] 30 mg two times a day for major [MEDICAL CONDITION] and Quetiapine 25 mg at bedtime for dementia with behavioral disturbance. The surveyor notified the DON (director of nursing) of the above documented findings on 5/2/19 at approximately 11 am. The DON stated, No they didn't put a [DIAGNOSES REDACTED]. The surveyor notified the administrative team of the above documented findings on 5/3/19 at 3:52 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 5/3/19. 4. The facility staff failed to document accurately on the behavioral monitor sheets for Resident #27. Resident #27 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to [MEDICAL CONDITIONS] bladder, diabetes, arthritis, Stage 3 pressure ulcer, high blood pressure and depression. On the quarterly MDS (Minimum Data Set) with an ARD of 3/3/19, the resident's BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #27 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and was totally dependent on 1 staff member for bathing. During the clinical record review on 5/1 to 5/3/19, the surveyor noted the following on the weekly behavioral monitoring sheets: For the dates of 4/23/19, 4/17/19, 4/9/19, 4/1/19, 3/26/19, 3/19/19, 3/12/19 and 3/4/19 .2. Current MD (medical doctor) order and [DIAGNOSES REDACTED]. The box under this only has [MEDICATION NAME] 100 mg (milligram) q (every) day listed without a diagnosis. Also for the above dates, Under Section B. Behaviors and Side Effects Other has been marked but the staff did not describe what Other was. The surveyor reviewed the MAR (medication administration record) for (MONTH) and (MONTH) 2019. The resident was receiving [MEDICATION NAME] 100 mg (milligram) one time a day for depression. The surveyor notified the DON (director of nursing) of the above documented findings on 5/2/19 at approximately 11 am. The DON stated, No they didn't put a [DIAGNOSES REDACTED]. The surveyor notified the administrative team of the above documented findings on 5/3/19 at 3:52 pm in the conference room. 5. The facility staff failed to document accurately on the behavioral monitor sheets for Resident #54. Resident #54 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to dementia, anxiety disorder, depression, [MEDICAL CONDITION] and high blood pressure. On the quarterly MDS (Minimum Data Set) with an ARD of 4/5/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 11 out of a possible score of 15. Resident #54 was also coded as requiring extensive assistance of 2 staff members for dressing, personal hygiene and being totally dependent on 1 staff member for bathing. During the clinical record review on 5/1 to 5/3/19, the surveyor noted the following on the weekly behavioral sheets: For the dates of 4/20/19, 4/13/19, 4/5/19, 3/30/19, 3/23/19, 3/16/19, 3/8/19 and 3/2/19 .2. Current MD (medical doctor) order and [DIAGNOSES REDACTED]. The box under this only has [MEDICATION NAME] 50 mg (milligram) daily and [MEDICATION NAME] 25 mg BID (twice a day) listed without a diagnosis. The surveyor also reviewed the MAR (Medication Administration Record) for the months of (MONTH) and (MONTH) 2019. The physician had ordered the following for Resident #54 to be given: [MEDICATION NAME] 50 mg one time a day for depression [MEDICATION NAME] 25 mg two times a day for [MEDICAL CONDITION] The surveyor notified the DON (director of nursing) of the above documented findings on 5/2/19 at approximately 11 am. The DON stated, No they didn't put a [DIAGNOSES REDACTED]. The surveyor notified the administrative team of the above documented findings on 5/3/19 at 3:52 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 5/3/19. 6. For Resident #61 the facility staff failed to monitor behaviors and side effects related to [MEDICAL CONDITION] medication usage. Resident #61 was admitted to the facility on [DATE]. Diagnoses included but not limited to [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] reflux disease, diabetes mellitus, [MEDICAL CONDITION], arthritis, [MEDICAL CONDITIONS], anxiety and depression. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 04/13/19 coded the Resident as 15 of 15 in section C, cognitive status. This is an annual MDS. Resident #61's CCP (comprehensive care plan) was reviewed and contained a care plan for .uses anti-anxiety medications due to anxiety at times. She is at risk for adverse reaction related to the use of medications. Interventions related to this care plan include Observe/document/report PRN (as needed) any adverse reaction of anti-anxiety medication: unsteady gait, tardive dyskinesia, EPS ((extra-pyramidal symptoms) shuffling gait, rigid muscles, shaking), frequent falls. Refusal to eat, difficulty swallowing, dry mouth, depression, [MEDICAL CONDITION], social isolation, blurred vision, diarrhea, fatigue, [MEDICAL CONDITION], loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Resident #61's clinical record was reviewed on 05/02/19. It contained signed physician's orders [REDACTED]. Resident #61's clinical record was reviewed and contained Behavior Observation Weekly Summary forms. The surveyor could only locate one weekly form for the month of (MONTH) 2014. Surveyor spoke with the DON (director of nursing) regarding the missing behavior observation forms. The DON could not locate the forms. The concern of not monitoring the Resident's behavior or side effects of the medication was discussed with the administrative team during a meeting on 05/02/19 at approximately 1625. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and a medication pass and pour observation the facility staff failed to follow professional standards of practice for 3 of 18 residents (Resident #9, Resident #28 and Resident #54). The findings included: 1. For Resident #9 the facility staff failed to follow professional standards of practice for the administration of medications as evidenced by signing for a medication that was unavailable for administration. Resident #9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/10/19 coded the Resident as 3 of 15 in section C, cognitive patterns. This is a quarterly MDS. Surveyor observed LPN # 1 (licensed practical nurse) on 05/01/19 at approximately 0835 during a medication pass and pour. Surveyor observed LPN #1 prepare and administer the Residents medications. Surveyor reconciled the medications with the clinical record on 05/01/19 at approximately 0930. Resident #9's clinical record contained a signed physician's orders [REDACTED]. This order is listed as active with a start date of 03/28/19. The surveyor did not observe LPN #1 administer [MEDICATION NAME] to the Resident. Resident #9's eMAR (electronic medication record) for the month of (MONTH) 2019 was reviewed. It contained an entry, which read in part [MEDICATION NAME] Tablet 10 mg (Loratidine) Give 1 tablet by mouth one time a day for possible drug reaction. This entry was initialed as administered on 05/01/19 at 0900. Surveyor spoke with LPN #1 on 05/01/19 at approximately 1125. Surveyor asked LPN #1 if he had administered the Resident's [MEDICATION NAME], and he stated, I'm sure I did. He then proceeded to check the medication cart for the Resident's [MEDICATION NAME]. The [MEDICATION NAME] could not be located in the medication cart. Surveyor spoke with the pharmacist on 05/01/19 at approximately 1450 regarding Resident #9's [MEDICATION NAME]. Pharmacist stated the [MEDICATION NAME] had not been sent to the facility since 03/26/19 and they had received a discontinue order for the [MEDICATION NAME] on 03/27/19. Surveyor reviewed the pharmacy manifest for the month of (MONTH) and could not locate any deliveries of [MEDICATION NAME] for Resident #9. Surveyor reviewed the pharmacy manifest for 03/26/19. It contained an entry that read in part, Patient Name: . (Resident #9), Description: Loratidine 10 mg, Quantity: 14, Status: Delivered. Resident #9's eMAR for the month of (MONTH) 2019 was reviewed and contained an entry which read in part [MEDICATION NAME] Tablet 10 mg (Loratidine) Give 1 tablet by mouth one time a day for possible drug reaction -Start date- 03/28/19. This entry had been initialed as being administered for each day of the month. Surveyor spoke with the DON on 05/01/19 at approximately 1600 regarding Resident #9's [MEDICATION NAME]. DON provided the surveyor with a copy of a physician's orders [REDACTED]. DON also provided the surveyor with a copy of a pharmacy recommendation dated 03/27/19, which read in part 2. Resident on BID (twice daily) [MEDICATION NAME], consider reducing to one daily. Surveyor asked the DON how the facility relays orders to the pharmacy, and DON responded, The nurses input the orders in the computer from the handwritten orders in the paper chart. Surveyor informed the DON at this time that the medication, [MEDICATION NAME] was not available in the medication cart to be administered, but the nurses had been signing for it. Surveyor also informed the DON that the medication had not been delivered from the pharmacy since 03/26/19. The surveyor requested a copy of the facility standards of practice for medication administration and the DON informed the surveyor on 05/03/19 that the facility does not have a one. According to Lippincott Procedures Safe Medication Administration Practices, General the nine rights of medication administration are: 1. Right Patient 2. The right medication 3. The right dose 4. The right time 5. The right route of administration 6. The right documentation 7. The right action 8. The right form 9. The right response The concern of not following professional standards of practice was discussed with the administrative team during a meeting on 05/02/19 at approximately 1625. No further information was provided prior to exit. 2. The facility staff failed to document an assessment after Resident #28 returned to facility from ER (emergency room ) visits on 1/18/19 and 2/20/19. Resident #28 was readmitted to the facility on [DATE] with the following diagnoses, but not limited to [MEDICAL CONDITIONS], high blood pressure, [MEDICAL CONDITION], diabetes and arthritis. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/3/19; the resident was code d as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #28 was also coded as only requiring supervision with dressing and limited assistance for personal hygiene and bathing. The surveyor on 4/30 to 5/3 /19 conducted a clinical record review. The surveyor noted that the resident had been sent to theER on ,[DATE] and 2/20/19. There was documentation in the nurses' progress notes dated for 1/18/19 at 1949 (7:49 pm) which read in part, .need to transfer resident r/t (related to) shortness of breathe-lower extremity [MEDICAL CONDITION]. At 2215 (9:15 pm), there was documentation which read, .returned from ____ (name of hospital ER) via (by) stretcher via c-trans (C-transportation) Skin w/d (warm and dry) color good no new orders . On 2/20/19 at 1730 (5:30 pm) the following was documented in the nurses' progress note: This nurse was called to room-resident sitting in w/c (wheelchair) slumped posture-skin pasty gray in color and cyanotic around mouth; eyes glassy; no response to touch or verbal stimuli; pulse 88 respirations 20 O2 (oxygen) sat (saturation) 88% unable to obtain blood pressure; assisted back to bed. There was not an assessment of the resident when she was returned to the facility. The surveyor notified the administrative team of the above documented findings on 5/1/19 at 4:45 pm and again on 5/3/19 at 3:52 pm in the conference room. The surveyor asked the DON (director of nursing) when a resident returns to the facility from being at the ER, would you expect your nurses' to perform an assessment and document in the nurses' progress notes. The DON stated, Yes. The surveyor requested a copy of the facility's standard of practice concerning performing assessments of the resident that returns to the facility from the ER. On 5/3/19 at 4:30 pm, the surveyor notified the DON that the surveyor needed a standard of practice for nurses' performing assessments. The DON stated, We have looked and I don't have one. But I do expect the nurses' to do assessments on the residents when they come back to us from the ER. No further information was provided to the surveyor prior to the exit conference on 5/3/19. 3. The facility staff failed to document a [DIAGNOSES REDACTED].#54. Resident #54 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/5/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 11 out of a possible score of 15. Resident #54 was also coded as requiring extensive assistance from 2 staff members for dressing, personal and is totally dependent on 2 staff members for bathing. The surveyor conducted a review of Resident #54's clinical record and noted that on the dates below, these medications did not have a [DIAGNOSES REDACTED]. 5/1/19 . [MEDICATION NAME] 50 mg (milligram) po (by mouth) qd (every day) . 3/22/19 .Start 800 mg [MEDICATION NAME] BID (twice a day) . The surveyor notified the DON (director of nursing) of the above documented findings in her office on 5/3/19 at 10 am. The surveyor requested a copy of the facility's policy or standard of practice that the facility uses as an expectation of the nursing staff and writing medication orders. At 3:52 pm, the surveyor notified the administrative team of the above documented findings. The surveyor did ask the DON if she had copies of the items documented above. The DON stated, We don't have a standard or policy on how to write a verbal order. The surveyor asked the DON does she expect her staff to include a [DIAGNOSES REDACTED]. The DON stated, Yes, this should be included on the order sheet. No further information was provided to the surveyor prior to the exit conference on 5/3/19.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to offer and provide written information about bed holds when 5 of 18 residents were transferred to the hospital (Resident #9, Resident #73, Resident #6, Resident #29, and Resident #49). The findings included: 1. The facility staff failed to offer and provide written bed hold information when Resident #9 was transferred to the emergency roiagnom on [DATE]. The clinical record of Resident #9 was reviewed 4/30/19 through 5/3/19. Resident #9 was admitted to the facility 7/13/16 with [DIAGNOSES REDACTED]. Resident #9's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/10/19 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #9 was assessed with [REDACTED]. The clinical record progress note dated 2/4/19 at 17:30 (5:30 p.m.) revealed the resident was found in the floor by a certified nursing assistant on 2/4/19 at 5:30 p.m. c/o (complained of) left hip and neck pain. Reported to medical doctor with new order to send to ED (emergency department) for eval (evaluation). Ambulance called for transport (name omitted). 2/4/19 18:30 (6:30 p.m.) Ambulance service here to transport to ED (emergency department) for eval (evaluation) & tx (treatment) re: fall. Report called to ED. The clinical record did not have documentation that bed holds were offered and information about bed holds provided to Resident #9 on 2/4/19. Resident #9's clinical record revealed the resident was found in the floor 4/30/19 at 1945 (7:45 p.m.). The resident was found lying in front of her roommate's bed. Resident was lying in the prone position with her face against the floor and stated she had stood up and was bending over to pick something up from the floor when she lost her balance and fell . The resident stated she did not lose consciousness. Resident was wearing tennis shoes but was not using walker. Call light had not been used for assist. Small amount of blood noted in the floor above resident's head. Resident assessed for back and neck injury and was then assisted to roll on to her back. Resident noted to have a discolored, raised area over her right eye. Small laceration also noted over right eye. Raised discolored area noted to right hand. Resident stated she was hurting all over. Nurse practitioner, on call for MD (medical doctor) contacted and new order was received to send resident to ED (emergency department) at 1948 (7:48 p.m.). TAS (ambulance service) contacted for transport at 1947 (7:47 p.m.) report called to hospital ED at 2003 (8:03 p.m.), resident's brother notified of fall and transport to ED at 2010 (8:10 p.m.). Upon TAS arrival at 2000, (8:00 p.m.) resident was transferred on to backboard for assist from floor to stretcher. Resident stabilized. Paperwork given to ambulance staff. The clinical record did not have documentation that bed holds were offered and information about bed holds provided to Resident #9 on 4/30/19. The surveyor interviewed licensed practical nurse #1 on 5/2/19 at 2:49 p.m. on what information was sent with residents when they are sent to the emergency room . L.P.N. #1 stated face sheet, history and physical, medication administration records (MARs)s, any pertinent labs, ER (emergency room ) order, advanced directives, POA # (power of attorneys), and emergency transfer sheet. [MI]P.N. #1 was asked if the facility sent the comprehensive care plan goals with the resident. [MI]P.N. #1 stated she doesn't send them and didn't know about bed holds. [MI]P.N. #1 stated the business office does the bed holds. The surveyor interviewed the admissions assistant on 5/2/19 at 2:57 p.m. The admissions assistant stated bed hold information was provided on admission but not when the residents were sent to the emergency room . The surveyor informed the administrator and the director of nursing of the above concerns on 5/2/19 at 4:32 p.m. The administrator stated every resident was welcomed back and bed holds were not done. The surveyor requested a copy of the facility policy on bed holds. The facility policy titled I. Title: Bed-Hold and Readmission Policy-Francis Marion Manor read in part VI. Policy: A. Residents or their legal representative will receive two (2) bed-hold notifications that includes information for readmission. B. The first notice is given on admission and the second anytime they are transferred to the hospital or takes therapeutic leave. VII. Procedure: A. On admission the resident or legal representative will receive the first Notice of Bed-Hold. 1. Whenever a resident is transferred to a hospital or takes therapeutic leave, they will receive another Notice of Bed Hold. A. In cases of emergency transfer, notification is provided within twenty-four (24) hours of the transfer. i. This requirement is met if the resident's copy of the notice is sent within other papers to the hospital. No further information was provided to the surveyor prior to the exit conference on 5/3/19. 2. The facility staff failed to offer and provide written bed hold information when Resident #73 was transferred to the emergency roiagnom on [DATE]. The clinical record of Resident #73 was reviewed 4/30/19 through 5/3/19. Resident #73 was admitted to the facility 7/26/15 and readmitted [DATE] with diagnoses, that included but not limited to, wound and [MEDICAL CONDITION] of right leg, [MEDICAL CONDITIONS] stage 3,[MEDICAL CONDITION], falls, [MEDICAL CONDITIONS], depression, [MEDICAL CONDITION] arthritis, hypertension, acute decline, [MEDICAL CONDITION] ([MEDICAL CONDITION], CAD ([MEDICAL CONDITION]) and chronic [MEDICAL CONDITION]. Resident #73's significant change in assessment minimum data set (MDS) with an assessment reference date (ARD) of 4/19/19 assessed the resident with a BIMS (brief interview for mental status) as 5/15 and with no signs or symptoms of [MEDICAL CONDITIONS], or behaviors affecting others. The clinical record progress note dated 2/9/19 at 0035 that the nurse was called to the room by aide-resident sitting on side of bed-c/o (complains of) increase in pain RLE (right lower extremity)-dark purple, raised area to RLE increasing in size-appears to have large hematoma of blood under skin-resident grimaces when area is touched-no other c/o (complaints of)-v/s (vital signs) 97.7, 97%, 72, 221/85. 2/9/19 0037 Nurse practitioner, on call, contacted-new order received to send to ed (emergency department) for eval (evaluation) and tx (treatment). 2/9/19 0041 resident family notified 2/9/19 0045 tas (ambulance service) contacted for transport 2/9/19 0054 report called in to rn (registered nurse) at name of hospital ed. 2/9/19 0058 tas here for transport. 2/9/19 0230 received report from ed-stated pt (patient) was on her way back-stated clot had been removed from hematoma and area has been wrapped. The clinical record did not have documentation of bed hold information. The surveyor interviewed licensed practical nurse #1 on 5/2/19 at 2:49 p.m. on what information was sent with residents when they are sent to the emergency room . L.P.N. #1 stated face sheet, history and physical, medication administration records (MARs)s, any pertinent labs, ER (emergency room ) order, advanced directives, POA # (power of attorneys), and emergency transfer sheet. [MI]P.N. #1 was asked if the facility sent the comprehensive care plan goals with the resident. [MI]P.N. #1 stated she doesn't send them and didn't know about bed holds. [MI]P.N. #1 stated the business office does the bed holds. The surveyor interviewed the admissions assistant on 5/2/19 at 2:57 p.m. The admissions assistant stated bed hold information was provided on admission but not when the residents were sent to the emergency room . The surveyor informed the administrator and the director of nursing of the above concerns on 5/2/19 at 4:32 p.m. The administrator stated every resident was welcomed back and bed holds were not done. The surveyor requested a copy of the facility policy on bed holds. The facility policy titled I. Title: Bed-Hold and Readmission Policy-Francis Marion Manor read in part VI. Policy: A. Residents or their legal representative will receive two (2) bed-hold notifications that includes information for readmission. B. The first notice is given on admission and the second anytime they are transferred to the hospital or takes therapeutic leave. VII. Procedure: A. On admission the resident or legal representative will receive the first Notice of Bed-Hold. 1. Whenever a resident is transferred to a hospital or takes therapeutic leave, they will receive another Notice of Bed Hold. A. In cases of emergency transfer, notification is provided within twenty-four (24) hours of the transfer. i. This requirement is met if the resident's copy of the notice is sent within other papers to the hospital. No further information was provided to the surveyor prior to the exit conference on 5/3/19. 3. The facility staff failed to offer and provide written bed hold information when Resident #6 was transferred to the emergency roiagnom on [DATE]. The clinical record of Resident #6 was reviewed 4/30/19 through 5/3/19. Resident #6 was admitted to the facility 9/1/18 with [DIAGNOSES REDACTED]. Resident #6's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 4/29/19 assessed the resident with a BIMS (brief interview for mental status) as 14/15. Resident #6 was assessed with [REDACTED]. The surveyor interviewed Resident #6 on 5/1/19 at 9:43 a.m. Resident #6 was asked if there had been any recent hospitalization s and the resident responded her right ankle /leg had been broken about seven (7) months ago during a fall. The clinical record revealed Resident #6 had been sent to the emergency roiagnom on [DATE] at 19:10 (7:10 p.m.). There was no documentation of what information was provided to the receiving provider when the resident was sent to the emergency room or when the resident returned. The clinical record did not contain any information about bed holds The surveyor was unable to locate any evidence that bed hold information was offered to the resident on 2/1/19. The surveyor interviewed licensed practical nurse #1 on 5/2/19 at 2:49 p.m. on what information was sent with residents when they are sent to the emergency room . L.P.N. #1 stated face sheet, history and physical, medication administration records (MARs)s, any pertinent labs, ER (emergency room ) order, advanced directives, POA # (power of attorneys), and emergency transfer sheet. [MI]P.N. #1 was asked if the facility sent the comprehensive care plan goals with the resident. [MI]P.N. #1 stated she doesn't send them and didn't know about bed holds. [MI]P.N. #1 stated the business office does the bed holds. The surveyor interviewed the admissions assistant on 5/2/19 at 2:57 p.m. The admissions assistant stated bed hold information was provided on admission but not when the residents were sent to the emergency room . The surveyor informed the administrator and the director of nursing of the above concerns on 5/2/19 at 4:32 p.m. The administrator stated every resident was welcomed back and bed holds were not done. The surveyor requested a copy of the facility policy on bed holds. The facility policy titled I. Title: Bed-Hold and Readmission Policy-Francis Marion Manor read in part VI. Policy: A. Residents or their legal representative will receive two (2) bed-hold notifications that includes information for readmission. B. The first notice is given on admission and the second anytime they are transferred to the hospital or takes therapeutic leave. VII. Procedure: A. On admission the resident or legal representative will receive the first Notice of Bed-Hold. 1. Whenever a resident is transferred to a hospital or takes therapeutic leave, they will receive another Notice of Bed Hold. A. In cases of emergency transfer, notification is provided within twenty-four (24) hours of the transfer. i. This requirement is met if the resident's copy of the notice is sent within other papers to the hospital. No further information was provided to the surveyor prior to the exit conference on 5/3/19. 4. The facility staff failed to offer a bed hold when Resident #29 was admitted to the hospital on [DATE]. Resident #29 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/4/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. During the clinical record review on 5/2/19, the surveyor noted that the resident had been admitted to the hospital on [DATE]. There was no documentation noted in the clinical record that the resident or resident representative had been offered a bed hold. The surveyor notified the administrator of the above documented findings on 5/2/19 at approximately 3:30 pm. The administrator stated, We don't offer a bed hold because we always take them back. The surveyor interviewed the business office staff #1 of when she notified the resident of a bed hold if they were admitted to the hospital. The business office staff #1 stated, I tell them about a bed hold when the resident is first admitted to the facility but I don't tell them this when they are sent out to the hospital. The surveyor notified the administrative team of the above documented findings on 5/3/19 at 3:52 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 5/3/19. 5. For Resident #49 the facility staff failed to offer a bed hold when the Resident was transferred to the hospital. Resident #49 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 04/01/19 coded the Resident as 15 of 15 in section C, cognitive patterns. This is a quarterly MDS. Resident #49's clinical record was reviewed on 05/01/19. It contained a signed physician's orders [REDACTED]. The clinical record also contained a nurse's progress note dated 03/11/19, which read in part 3/11/19 09:24 LAB CALL WITH CRITICAL POTASSIUM (sic) CALL . (name omitted) AND . (name omitted) ORDER PT (Patient) TO GO TO (facility name omitted) ER CALL . (name omitted) AMBULANCE SERVICE TO TRANSPORT PT TO ER, . (name omitted) KNOWS AND UNDERSTANDS, REPORT CALL TO ER AT . (facility name omitted) . (name omitted) HERE PT ON WAS TO (facility name omitted) ER. This note did not contained any information on what type of documentation was sent to hospital with the Resident or that a bed hold had been offered. The surveyor spoke with the admissions assistant on 05/02/19 at approximately 1530 regarding the offering of bed holds. The admissions assistant stated that she only provides information regarding bed holds upon admission. Admissions assistant stated that she does not offer bed hold when Residents are sent to the hospital because we always keep their room for them. The surveyor requested and the administrator provided a copy of a facility policy entitled Bed-Hold and Readmission Policy, which read in part VI. Policy: B. The first notice is given on admission and the second anytime they (the Resident) are transferred to the hospital or takes a therapeutic leave. The concern of not offering the bed hold was discussed with the administrative team during a meeting on 05/02/19 at approximately 1635. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure the clinical record contained documentation of information sent with 6 of 18 residents when transferred from the facility that affected Resident #9, Resident #73, Resident #6, Resident #29, Resident #28, and Resident #49. The findings included: 1. The facility staff failed to ensure the clinical record contained documentation of information sent to the emergency roiagnom on [DATE] for Resident #9. The clinical record of Resident #9 was reviewed 4/30/19 through 5/3/19. Resident #9 was admitted to the facility 7/13/16 with [DIAGNOSES REDACTED]. Resident #9's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/10/19 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #9 was assessed with [REDACTED]. The clinical record progress note dated 2/4/19 at 17:30 (5:30 p.m.) revealed the resident was found in the floor by a certified nursing assistant on 2/4/19 at 5:30 p.m. c/o (complained of) left hip and neck pain. Reported to medical doctor with new order to send to ED (emergency department) for eval (evaluation). Ambulance called for transport (name omitted). 2/4/19 18:30 (6:30 p.m.) Ambulance service here to transport to ED (emergency department) for eval (evaluation) & tx (treatment) re: fall. Report called to ED. The clinical record did not have documentation of information sent to the receiving provider, a completed transfer/discharge form or information about bed holds for resident #9's emergency room visit on 2/4/19. Resident #9's clinical record revealed the resident was found in the floor 4/30/19 at 1945 (7:45 p.m.). The resident was found lying in front of her roommate's bed. Resident was lying in the prone position with her face against the floor and stated she had stood up and was bending over to pick something up from the floor when she lost her balance and fell . The resident stated she did not lose consciousness. Resident was wearing tennis shoes but was not using walker. Call light had not been used for assist. Small amount of blood noted in the floor above resident's head. Resident assessed for back and neck injury and was then assisted to roll on to her back. Resident noted to have a discolored, raised area over her right eye. Small laceration also noted over right eye. Raised discolored area noted to right hand. Resident stated she was hurting all over. Nurse practitioner, on call for MD (medical doctor) contacted and new order was received to send resident to ED (emergency department) at 1948 (7:48 p.m.). TAS (ambulance service) contacted for transport at 1947 (7:47 p.m.) report called to hospital ED at 2003 (8:03 p.m.), resident's brother notified of fall and transport to ED at 2010 (8:10 p.m.). Upon TAS arrival at 2000, (8:00 p.m.) resident was transferred on to backboard for assist from floor to stretcher. Resident stabilized. Paperwork given to ambulance staff. The clinical record did not document what paperwork was sent with the resident, if a bed hold was offered and if a transfer form had been completed for 4/30/19. The surveyor interviewed licensed practical nurse #1 on 5/2/19 at 2:49 p.m. on what information was sent with residents when they are sent to the emergency room . L.P.N. #1 stated face sheet, history and physical, medication administration records (MARs)s, any pertinent labs, ER (emergency room ) order, advanced directives, POA # (power of attorneys), and emergency transfer sheet. [MI]P.N. #1 was asked if the facility sent the comprehensive care plan goals with the resident. [MI]P.N. #1 stated she doesn't send them and didn't know about bed holds. [MI]P.N. #1 stated the business office does the bed holds. The surveyor interviewed the admissions assistant on 5/2/19 at 2:57 p.m. The admissions assistant stated bed hold information was provided on admission but not when the residents were sent to the emergency room . The surveyor informed the director of nursing on 5/2/19 at 2:57 p.m. about the transfer form sent with Resident #9. The DON stated I looked and there was none done. I spoke with the staff responsible for the transfer and the last one completed was 8/25/18. The surveyor requested from the DON the facility policy on transfers/discharges on 5/2/19. The DON did provide the surveyor with paperwork from the emergency room visits on 2/4/19 and 4/30/19; however, the paperwork did not include a transfer form and the documentation in the clinical record did not state what paperwork was sent with the resident. The surveyor informed the administrator and the director of nursing of the above concern about paperwork not provided to the receiving provider when the resident was sent to the emergency department on 2/4/19 and 4/30/19 and lack of documentation of information sent with the resident on 2/4/19 and 4/30/19 in the end of the day meeting on 5/2/19 at 4:34 p.m. No further information was provided to the surveyor prior to the exit conference on 5/3/19. 2. The facility staff failed to ensure the clinical record contained documentation of information sent to the emergency room for Resident #73. The clinical record of Resident #73 was reviewed 4/30/19 through 5/3/19. Resident #73 was admitted to the facility 7/26/15 and readmitted [DATE] with diagnoses, that included but not limited to, wound and [MEDICAL CONDITION] of right leg, [MEDICAL CONDITIONS] stage 3,[MEDICAL CONDITION], falls, [MEDICAL CONDITIONS], depression, [MEDICAL CONDITION] arthritis, hypertension, acute decline, [MEDICAL CONDITION] ([MEDICAL CONDITION], CAD ([MEDICAL CONDITION]) and chronic [MEDICAL CONDITION]. Resident #73's significant change in assessment minimum data set (MDS) with an assessment reference date (ARD) of 4/19/19 assessed the resident with a BIMS (brief interview for mental status) as 5/15 and with no signs or symptoms of [MEDICAL CONDITIONS], or behaviors affecting others. The clinical record progress note dated 2/9/19 at 0035 that the nurse was called to the room by aide-resident sitting on side of bed-c/o (complains of) increase in pain RLE (right lower extremity)-dark purple, raised area to RLE increasing in size-appears to have large hematoma of blood under skin-resident grimaces when area is touched-no other c/o (complaints of)-v/s (vital signs) 97.7, 97%, 72, 221/85. 2/9/19 0037 Nurse practitioner, on call, contacted-new order received to send to ed (emergency department) for eval (evaluation) and tx (treatment). 2/9/19 0041 resident family notified 2/9/19 0045 tas (ambulance service) contacted for transport 2/9/19 0054 report called in to rn (registered nurse) at name of hospital ed. 2/9/19 0058 tas here for transport. 2/9/19 0230 received report from ed-stated pt (patient) was on her way back-stated clot had been removed from hematoma and area has been wrapped. The clinical record did not have documentation of what information was sent with the resident to the emergency department on 2/9/19. The surveyor was unable to locate a transfer/discharge form in the clinical record. The surveyor interviewed licensed practical nurse #1 on 5/2/19 at 2:49 p.m. on what information was sent with residents when they are sent to the emergency room . L.P.N. #1 stated face sheet, history and physical, medication administration records (MARs)s, any pertinent labs, ER (emergency room ) order, advanced directives, POA # (power of attorneys), and emergency transfer sheet. [MI]P.N. #1 was asked if the facility sent the comprehensive care plan goals with the resident. [MI]P.N. #1 stated she doesn't send them and didn't know about bed holds. [MI]P.N. #1 stated the business office does the bed holds. The surveyor interviewed the admissions assistant on 5/2/19 at 2:57 p.m. The admissions assistant stated bed hold information was provided on admission but not when the residents were sent to the emergency room . The surveyor informed the director of nursing on 5/2/19 at 2:57 p.m. about the transfer form sent with Resident #73. The DON stated I looked and there was none done. The surveyor requested from the DON the facility policy on transfers/discharges on 5/2/19. The surveyor informed the administrator and the director of nursing of the above concern about paperwork not provided to the receiving provider when the resident was sent to the emergency department on 2/9/19 in the end of the day meeting on 5/2/19 at 4:34 p.m. No further information was provided to the surveyor prior to the exit conference on 5/3/19. 3. The facility staff failed to provide the receiving provider with information that included Resident #6's comprehensive care plan goals and failed to document what information was sent with the resident when transported to the emergency roiagnom on [DATE]. The clinical record of Resident #6 was reviewed 4/30/19 through 5/3/19. Resident #6 was admitted to the facility 9/1/18 with [DIAGNOSES REDACTED]. Resident #6's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 4/29/19 assessed the resident with a BIMS (brief interview for mental status) as 14/15. Resident #6 was assessed with [REDACTED]. The surveyor interviewed Resident #6 on 5/1/19 at 9:43 a.m. Resident #6 was asked if there had been any recent hospitalization s and the resident responded her right ankle /leg had been broken about seven (7) months ago during a fall. The clinical record revealed Resident #6 had been sent to the emergency roiagnom on [DATE] at 19:10 (7:10 p.m.). There was no documentation of what information was provided to the receiving provider when the resident was sent to the emergency room or when the resident returned. The clinical record did not contain any information about bed holds The clinical record did contain a form titled Emergency Department Referral dated 2/1/19 which included the code status, brief history of present condition, contact information of the practitioner and emergency contact. The clinical record did not have documentation of information sent to the provider. The surveyor interviewed licensed practical nurse #1 on 5/2/19 at 2:49 p.m. on what information was sent with residents when they are sent to the emergency room . L.P.N. #1 stated face sheet, history and physical, medication administration records (MARs)s, any pertinent labs, ER (emergency room ) order, advanced directives, POA # (power of attorneys), and emergency transfer sheet. [MI]P.N. #1 was asked if the facility sent the comprehensive care plan goals with the resident. [MI]P.N. #1 stated she doesn't send them and didn't know about bed holds. [MI]P.N. #1 stated the business office does the bed holds. The surveyor interviewed the admissions assistant on 5/2/19 at 2:57 p.m. The admissions assistant stated bed hold information was provided on admission but not when the residents were sent to the emergency room . The surveyor requested from the DON the facility policy on transfers/discharges on 5/2/19. The surveyor informed the administrator and the director of nursing of the above concern about the comprehensive care plan goals not sent with Resident #6 to the emergency roiagnom on [DATE] and the lack of documentation of the information sent to the ED on 2/1/19 in the end of the day meeting on 5/3/19 at 4:32 p.m. No further information was provided to the surveyor prior to the exit conference on 5/3/19. 4. The facility staff failed to ensure correct information was contained on the transfer form for Resident #29. Resident #29 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/4/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. During the clinical record review on 5/3/19, the surveyor noted there was documentation on the Notice of Transfer or discharge date d for 4/24/19. On this date, the resident had abnormal labs and the physician had ordered for him to go to ER (emergency room ) to be evaluated. In the nursing notes dated 4/24/19 at 17:34 (5:34 pm) the following was documented: Face sheet, Code status sheet, H and P (History and Physical) current physician orders, current progress note from PCP (primary care provider), discharge delivery sheet .faxed to ____ (name of hospital) ER. 4/24/19 at 20:57 (8:57 pm) ER called and patient admitted to room [ROOM NUMBER] . The surveyor reviewed the Notice of Transfer or discharge date d for 4/24/19 and the following items were checked: .7. The safety of individuals in the facility is endangered due to the clinical or behavioral status exhibited by you (the resident) as evidenced by . 7a. This section was marked as NA. .9. You (the resident) have failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the nursing facility . The surveyor notified the administrative team of the above documented findings on 5/3/19 at 3:52 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 5/3/19. 5. The facility staff failed to ensure the correct information was contained on the transfer form for Resident #28. Resident #28 was readmitted to the facility on [DATE] with the following diagnoses, but not limited to [MEDICAL CONDITIONS], high blood pressure, [MEDICAL CONDITION], diabetes and arthritis. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/3/19; the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #28 was also coded as only requiring supervision with dressing and limited assistance for personal hygiene and bathing. During the clinical record review on 5/2 and 5/3/19, the surveyor noted the following marked on the Transfer sheet dated for 1/18/19: .7. The safety of individuals in the facility is endangered due to the clinical or behavioral status exhibited by you (the resident) as evidenced by: . 10. The facility will cease to operate on 1/18/19 . In addition, a transfer summary sheet dated for 2/20/19 was noted to contain the following information with the boxes beside of these were checked: .4. The discharge has been planned in collaboration with you (the resident) and/or your resident representative and represents the choice of such . 7. The safety of individuals in the facility is endangered due to the clinical or behavioral status exhibited by you (the resident) as evidenced by: . 8. The health of the individuals in the facility would otherwise be endangered as evidenced by: . 9. You (the resident) have failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the nursing facility . The surveyor notified the administrative team of the above documented findings on 5/3/19 at 3:52 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 5/3/19. 6. For Resident #49 the facility staff failed to ensure the transfer/discharge form was correct. Resident #49 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 04/01/19 coded the Resident as 15 of 15 in section C, cognitive patterns. This is a quarterly MDS. Resident #49's clinical record was reviewed on 05/01/19. It contained a signed physician's orders [REDACTED]. The clinical record also contained a nurse's progress note dated 03/11/19, which read in part 3/11/19 09:24 LAB CALL WITH CRITICAL POTASSIUM (sic) CALL . (name omitted) AND . (name omitted) ORDER PT (Patient) TO GO TO (facility name omitted) ER CALL . (name omitted) AMBULANCE SERVICE TO TRANSPORT PT TO ER, . (name omitted) KNOWS AND UNDERSTANDS, REPORT CALL TO ER AT . (facility name omitted) . (name omitted) HERE PT ON WAS TO (facility name omitted) ER. This note did not contained any information on what type of documentation was sent to hospital with the Resident. The Resident's clinical record contained a Notice of Transfer or Discharge form, dated 03/11/19. This form contained check boxes of different reasons for transfer/discharge. The boxes reading 6. The transfer or discharge is necessary for your (the Resident's) welfare and your (the Resident's) needs cannot be met in the facility as evidenced by:, 7. The safety of individuals in the facility is endangered due to the clinical or behavioral status exhibited by you (the Resident) as evidenced by:, 8. The health of individual in the facility would otherwise be endangered as evidenced by:, 9. You (the Resident) have failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the nursing facility, 9a. Total amount due to the facility is, 9b. You and/or your representative were previously given notice of payment due on, 10. The facility will cease to operate on and 11. The facility will assist you with a safe and orderly discharge. If discharge does not occur within 30 days, it is the intent of the facility discharge you were all checked as reason for the Resident's discharge. The concern of the incorrect form was discussed with the administrative team during a meeting on 05/02/19 at approximately 1635. The DON (director of nursing) stated all of the boxes should have not been checked. No further information was provided prior to exit.

Based on observation, facility document review, and clinical record review, the facility staff failed to follow established infection control procedures for 3 of 18 residents (Resident #53, Resident #27, and Resident #45). The findings included: 1. The facility staff failed to follow infection control procedures for Resident #53. The surveyor observed staff members removing gloves and then not performing hand washing or hand hygiene. The clinical record of Resident #53 was reviewed 4/30/19-5/3/19. Resident #53 was admitted to the facility 5/22/18 with diagnoses, that included but not limited [MEDICAL CONDITION], pneumonia, chronic back pain, dementia, high cholesterol,[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease), anxiety, hypertension, depression, fatigue, and tiredness. Resident #53's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 4/5/19 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #53 was not assessed with [REDACTED]. Resident #53 required extensive assistance of one person for toilet use. Resident #53 was assessed to be frequently incontinent of bladder and bowel. Current comprehensive care plan was undated but identified a focus area that the resident had ADL (activities of daily living) self-care performance deficit r/t (related to) dementia, impaired balance, fatigue-has chronic intractable pain as well. Interventions: She requires extensive by 1 staff for toileting. A second focus area for incontinence was also undated and read that the resident has incontinence of bladder- dementia, impaired mobility. She has risk for UTI (urinary tract infection) and dx (diagnosis) of [MEDICAL CONDITION]. Interventions: Clean peri-area with each incontinence episode. If in bed, offer bedpan or BSC (bedside commode), or toilet. She uses disposable diapers. Change prn (as needed). Wash perineum front to back. The surveyor observed incontinence care with certified nursing assistant #1 on 5/2/19 at 7:01 a.m. C.N.A. #1 entered the resident's room without knocking on the door. When the surveyor knocked on the door, C.N.A. #1 turned around and stated to the surveyor she forgot to knock and then apologized. C.N.A. #1 closed the door and donned a pair of gloves. No handwashing observed prior to glove use. The privacy curtain was pulled on both sides of the bed to about mid-bed. When C.N.A. #1 removed the brief, the surveyor observed the resident had been incontinent of urine. C.N.A. #1 removed the brief and placed a clean brief on Resident #53. C.N.A. #1 did not change gloves after removing the soiled brief and failed to provide incontinence care to the resident. C.N.A. #1 then covered the resident up with a blanket and raised the head of the bed. C.N.A. #1 had not changed or removed gloves after changing Resident #53's brief. C.N.A. #1 put the soiled brief in the trashcan and removed the trashcan bag, tied it up, and replaced the liner with a clean one. She removed her gloves, walked down the hall to the soiled utility room, and threw away the trash bag. No handwashing or hand hygiene was observed when C.N.A. #1 left the resident's room. C.N.A. #1 then went into the clean utility, placed her pager in the charger, and then rolled the COW (computer on wheels) to the day room. C.N.A. #1 then went to the break room, got her lunch bag and clocked out. The surveyor informed the administrator at 8:00 a.m. of the above observation. The surveyor observed certified nursing assistant #2 in Resident #53's room on 5/2/19 at 9:36 a.m. CNA #2 was starting to provide incontinent care. C.N.A. #2 had donned gloves on and removed the brief, which was soiled and placed in trashcan. C.N.A. #2 put a clean pull-up on the resident. No incontinence care was provided. Certified nursing assistant #3 came to assist C.N.A. #2. C.N.A. #3 applied gloves. No hand washing or hand hygiene observed prior to donning gloves. C.N.A. #3 assisted with the pull-up, pants, socks and shoes. The surveyor observed a pad and a towel in Resident #53's wheelchair. A gait belt was placed around the resident, then assisted to the side of the bed by both c.n.a.s, and then transferred to the wheelchair. Resident #53's top was changed. C.N.A. #2 took the trash out to the buggy and removed her gloves. The surveyor did not observe handwashing or hand hygiene after C.N.A. #2's gloves were removed. C.N.A. #3 removed her gloves and then combed the resident's hair and then washed her hands after combing hair and left the room. C.N.A. #2 pushed the resident to the hallway. Mouth care not provided. No hand washing after care. C.N.A. #2 then went to the roommate and was observed touching the over the bed table and conversing with the resident. Before C.N.A. #2 exited the room, hands were washed. The surveyor interviewed certified nursing assistant #2 on 5/2/19 at 10:00 a.m. about the care provided and observations made by the surveyor. C.N.A. #2 stated, I forgot. The surveyor informed the administrator and the director of nursing (DON) of the above concern on 5/2/19 at 4:34 p.m. and requested information on perineal/incontinence care. The DON was asked if the staff should wash their hands after removing the soiled gloves. The DON stated yes. The surveyor requested the policy on handwashing and perineal care. The surveyor reviewed the Perineal Care skill sheet on 5/3/19. The skill sheet read Overview: Perineal care involves a thorough cleansing of the patient's external genitalia and surrounding skin. Gloves must be worn during perineal care because of the risk of contracting an infection. Patients who are incontinent of urine or stool require more frequent perineal care. Perineal cleansing is performed with soap and water. Female Perineal Care 1. Perform hand hygiene and don gloves. 2. Introduce yourself to the patient. 10. b. Using a clean washcloth or perineal wipe, wipe from the perineum to the rectum (front to back). Repeat this process on the opposite side, using a new washcloth or perineal wipe. C. Rinse and dry the area thoroughly. 18. Discard supplies, remove gloves and perform hand hygiene. The facility policy titled Hand Hygiene was reviewed 5/3/19. The policy read in part: 2. Hands must be washed with soap and water or alcohol hand gel used a. before and after having direct contact with patients or their surroundings (i.e., before entering the patient's room and upon leaving the patient's room) d. after contact with a patient's skin (i.e., when taking a pulse, blood pressure, lifting a patient) e. after having contact with body fluids or excretions, mucous membranes, non-intact skin or wound dressings), f. after removing gloves g. when moving from a contaminated site to a clean body site h. after contact with inanimate objects (i.e., medical equipment) 4. Glove usage b. Remove gloves after caring for the patient c. Gloves should be changed when moving from a contaminated body site to a clean body site d. Do not wear the same pair of gloves between patients No further information was provided prior to the exit conference on 5/3/19. 2a. The facility staff failed to keep the Foley catheter tubing off the floor for Resident #27. Resident #27 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD of 3/3/19, the resident's BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #27 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and was totally dependent on 1 staff member for bathing. During the initial tour of the resident's room on 4/30/19 at 10:30 am, the surveyor noted the Foley catheter tubing was lying on the floor. RN (registered nurse) #1 was asked to come to the resident's room by the surveyor. RN #1 went to the side of the bed and found the Foley catheter tubing lying the floor. She proceeded to hang the Foley catheter bag on the side of the bed so that the tubing was not in the floor. RN #1 stated, The Foley catheter tubing shouldn't had been in the floor. The surveyor notified the administrative team of the above documented findings on 5/1/19 at 4:45 pm and again on 5/3/19 at 3:52 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 5/3/19. 2b. The facility staff failed to follow infection control guidelines during a dressing change observation on Resident #27. Resident #27 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD of 3/3/19, the resident's BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #27 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and was totally dependent on 1 staff member for bathing. During the wound dressing change observation on 5/2/19 at 10:25 am, the surveyor observed the wound care nurse cleaning the wound with a clean 4 x 4. She proceeded to wipe the wound from side to side. The same 4 X 4 was not discarded and she used the same one all over the resident's wound. The surveyor notified the administrative team of the above documented findings on 5/2/19 at approximately 4 pm in the conference room. The administrator and wound care nurse came back to the conference room and the surveyor notified the wound care nurse of the infection control issue that was observed by the surveyor. The wound care nurse stated, I just got so nervous. No further information was provided to the surveyor prior to the exit conference on 5/3/19. 3. The facility staff failed to follow infection control guidelines in regards to the storage of the nebulizer mask when it was not in use for Resident #45. Resident #45 was admitted to the facility on [DATE] with the following diagnoses, but not limited to [MEDICAL CONDITION], high blood pressure, diabetes, dementia and anxiety disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/19/19 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 12 out of a possible score of 15. Resident #45 was also coded as requiring extensive assistance of 1 staff member for dressing, personal hygiene and is totally dependent on 1 staff member for bathing. During the initial tour of the resident's room on 4/30/19 at approximately 11 am, the surveyor noted that the resident's nebulizer mask was lying on the bedside table. The mask was out in the open and not stored in a plastic bag. On 5/1/19 at 3 pm, the surveyor requested and received a copy of the facility's policy on the storage of a nebulizer mask when not in use. The policy titled .Disposable Nebulizers . which read in part, .Rinse all parts thoroughly with water and air dry or hand dry with a lint free cloth. Reassemble and store in clean equipment bag . The surveyor notified the administrative team of the above documented finding on 5/3/19 at 3:52 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 5/3/19.

Based on observation and staff interview, the facility staff failed to label and date opened food items in the facility kitchen. The findings included: The facility staff failed to ensure food items in the kitchen that were opened included a date when opened and a label of the package contents. The surveyor toured the kitchen on [DATE] at 9:45 a.m. with the food services director (FSD). The following was noted to be opened but not labeled with an expiration or use by date: 18 ounces of Ground Cinnamon, Black Pepper, Garlic Powder and Lemon Pepper. Upon return to the kitchen at 10:45 am, the FSD stated, The manager has called the company and this code at the bottom of the container can be converted to a date. He is getting it sent to him from the company. The surveyor asked if that they go by the code on the container then what is the expiration date or use by date. FSD stated, I didn't know what this code was used for. At 11:30 am, FSD returned to surveyor with a page of codes that corresponds with the month the spices would be expired. The surveyor informed the administrative staff of the kitchen concerns during the end of the day meeting on [DATE] at 4:45 p.m. and again on [DATE] at 3:52 p.m. No further information was provided to the surveyor prior to the exit conference on [DATE].

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to treat 1 of 18 residents with dignity and respect (Resident #53). The findings included: 1. The facility staff failed to knock on the door or announce themselves before entering Resident #53's room. The clinical record of Resident #53 was reviewed 4/30/19-5/3/19. Resident #53 was admitted to the facility 5/22/18 with diagnoses, that included but not limited [MEDICAL CONDITION], pneumonia, chronic back pain, dementia, high cholesterol,[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease), anxiety, hypertension, depression, fatigue, and tiredness. Resident #53's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 4/5/19 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #53 was not assessed with [REDACTED]. Current comprehensive care plan was undated but identified a focus area that the resident had impaired cognitive function r/t (related to) Alzheimer's. Interventions: Communication: Identify yourself at each interaction. The surveyor observed incontinence care with certified nursing assistant #1 on 5/2/19 at 7:01 a.m. C.N.A. #1 entered the resident's room without knocking on the door. When the surveyor knocked on the door, C.N.A. #1 turned around and stated to the surveyor she forgot to knock and then apologized. The surveyor informed the administrator and the director of nursing of the above concern on 5/2/19 at 4:34 p.m. Both stated they would expect staff to knock on the door before entering. The surveyor requested a copy of Resident Rights. The facility's Resident Rights & Responsibilities found in the admission packet was reviewed 5/3/19. Resident Rights included 1. Considerate and respectful treatment including being fully informed in advance about care and treatment and of any changes in that care or treatment that may affect your well-being. 15. Personal freedom and dignity and 19. Privacy. No further information was provided prior to the exit conference on 5/3/19.

Based on staff interview and clinical record review the facility staff failed to notify the physician of a change in condition for 1 of 18 residents in the survey sample (Resident #45). The findings included: The facility failed to notify the physician of Resident #45's suicidal thoughts that were verbally expressed to the facility staff on 2/26/19. Resident #45 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD of 3/27/19 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 12 out of a possible score of 15. Resident #45 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and was totally dependent on 1 staff member for bathing. The surveyor reviewed the clinical record of Resident #45 on 5/1/19. In the Care Focus documentation dated for 2/27/19, the surveyor noted under the area of Review area(s) of Concern, it read in part: .02/26 nurse called to res (resident) room by CNA (certified nursing assistance), CNA stated that the res told her she wanted to kill herself (by grabbing) her own throat) when she had asked her to pull herself up in bed but when nurse walked in res was sitting on the toilet and noted to be crying . The Care Focus sign in sheet had the following signatures that were in attendance: assistant director of nursing, dietitian, wound care nurse #1, director of nursing, activities coordinator and MDS (minimum data set) nurse #1. Under the section Interdisciplinary Recommendation of the Care Focus documentation, the following recommendation/interventions were suggested: .freq (frequent visual checks made . The surveyor also noted the following documentation dated for 2/26/19 at 2130 (9 pm) which reads, .Called to res room by CNA, CNA stated that res had told her she wanted to kill herself (by grabbing her own throat) when she had asked her to pull herself up in bed but when this nurse walked in res was sitting on toilet and noted to be crying upon questioning res res stated she didn't know why she was crying but states, I just want to go home encouraged res to keep doing her therapy and she would be able to go home soon .No suicidal actions were noted for the few minutes I was in the room .(sic) Resident #45's care plan did not reflect a focus area or interventions to be utilized by the staff. On 3/6/19, the surveyor noted a physician order [REDACTED].Episodes of screaming out crying/anxious . There was no documentation in the clinical record that the physician had been notified of the above documented findings. The surveyor notified the administrative team of the above documented findings on 5/1/19 at 4:45 pm. The surveyor asked if the staff notified the physician of Resident #45's suicidal thoughts. The administrator stated, When the staff went back to talk to the resident, the resident said she didn't know why she did that. This is why the physician was not notified. The surveyor was given a copy of a progress note that the social worker had documented for 5/1/19 at 2056 (8:56 pm). It read as follows: SW (social worker) on first floor and interviewed ______ (name of resident). She remembers me. SW explains that in the past she had stated she wanted to die and she put her hands around her neck. She remembers that and states yes and I think I said that one time in the hospital too. SW asked if she would really harmed herself when she stated this. She stated no SW asked if she felt like harming herself at this time. She also no and stated she likes having a room by herself. SW asked how she likes the first floor and she stated she liked it. SW to monitor. The surveyor was also given a copy of a physician order [REDACTED]. No further information was provided to the surveyor prior to the exit conference on 5/3/19.

Based on observation and staff interview, the facility staff failed to provide privacy during care for 1 of 18 residents (Resident #73) and failed to ensure a private location for the resident council to meet. Volunteers interrupted the resident council meeting for five minutes on 5/1/19. The findings included: 1. The facility staff failed to provide privacy during a wound care observation on Resident #73. The clinical record of Resident #73 was reviewed 4/30/19 through 5/3/19. Resident #73 was admitted to the facility 7/26/15 and readmitted [DATE] with diagnoses, that included but not limited to, wound and [MEDICAL CONDITION] of right leg, [MEDICAL CONDITIONS] stage 3,[MEDICAL CONDITION], falls, [MEDICAL CONDITIONS], depression, [MEDICAL CONDITION] arthritis, hypertension, acute decline, [MEDICAL CONDITION] ([MEDICAL CONDITION], CAD ([MEDICAL CONDITION]) and chronic [MEDICAL CONDITION]. Resident #73's significant change in assessment minimum data set (MDS) with an assessment reference date (ARD) of 4/19/19 assessed the resident with a BIMS (brief interview for mental status) as 5/15 and with no signs or symptoms of [MEDICAL CONDITIONS], or behaviors affecting others. The surveyor observed wound care 5/3/19 beginning at 9:52 a.m. with registered nurse #1 and registered nurse #2. The surveyor asked Resident #73 if care could be observed and the resident stated yes. Both registered nurses took part in wound care; however, registered nurse #1 was the primary caregiver. Registered nurse #1 and R.N. #2 both entered the resident's room after knocking. The privacy curtain was not pulled, the door was not closed, and the blinds were not closed. R.N. #1 and R.N. #2 entered and exited the resident's room on five different occasions without closing the door or pulling the privacy curtain with each exit and re-entry. The surveyor interviewed registered nurse #1 on 5/3/19 at 10:29 a.m. R.N. #1 was informed of the surveyor's observation and agreed that the door had not been closed, the privacy curtain not pulled and the blinds not closed. The surveyor informed the administrator and the director of nursing of the above observation during wound care on 5/3/19 at 3:52 p.m. The surveyor reviewed the admission packet and the Resident Rights & Responsibilities found there. The Resident Rights read 1. Considerate and respectful treatment including being fully informed in advance about care and treatment and of any changes in that care or treatment that may affect your well-being. 15. Personal freedom and dignity and 19. Privacy. No further information was provided prior to the exit conference on 5/3/19. 2. The facility staff failed to ensure the resident council had a private place to meet. The resident council meeting was interrupted when two volunteers entered the meeting and stayed for approximately five minutes. The surveyor conducted a resident council meeting on 5/1/19 beginning at 1:30 p.m. with seven (7) resident council members. The council requested that the activity director stay in the meeting. During the meeting, two volunteers entered the resident council meeting without knocking. One volunteer asked, Are you all still coloring?'' The volunteers walked to the activity director's (AD) desk, one of the volunteers chatted with the AD, and the second volunteer sat down in a chair for approximately five minutes before leaving. The surveyor stopped the group meeting until both volunteers left approximately 5 minutes later. The surveyor interviewed the activity director on 5/1/19 after the meeting. The activities director stated she had not put a sign on the doors prior to the meeting. The AD stated one of the volunteer's works at the state hospital and should know better than to enter the meeting. The surveyor informed the administrator and the director of nursing of the resident council concern during the end of the survey meeting on 5/3/19 at 3:52 p.m. No further information was provided prior to the e exit conference on 5/3/19.

Based on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure a clean and comfortable homelike environment in 1 of 18 resident rooms (Resident #53) and on 1 of 2 day/activity rooms. The findings included: The facility staff failed to ensure Resident #53's room was clean and failed to ensure the 1st floor day room was clean. The surveyor and the housekeeping supervisor other #2 toured the first floor on 5/2/19 at 10:12 a.m. During the tour on 5/2/19 of the 1st floor day room, dust was observed on the wall across from the long windows. The dust was hanging near the wall and had what appeared to be a spider's web attached with a dead spider. The housekeeping supervisor confirmed the presence of the dust and stated the housekeepers should have removed the dust/spider web. The housekeeping supervisor stated high dusting was a challenge. The surveyor observed approximately 8-12 inches above the chair railing, dark black marks on the wall behind a row of chairs which resembled black shoe marks. The housekeeping supervisor stated that was part of maintenance's upkeep to do painting. The housekeeping supervisor stated the black markings were from the higher chairs hitting the wall. A large picture on the wall behind the row of chairs was covered with dust on the top. The picture was loose and removed by the surveyor and the housekeeping supervisor and taken to the 1st floor unit manager's office for safety. The housekeeping supervisor stated the picture was wobbly and difficult to clean. The housekeeping supervisor stated, That's one of our biggest challenges in housekeeping. The surveyor and the housekeeping supervisor checked Resident #53's room for cleanliness. In the corner of the resident's room near the hospital bed, a collection of dust was observed behind the chair and a folding chair in the room. The housekeeping supervisor confirmed and stated housekeeping should have gotten the dust. The housekeeping supervisor stated when the residents are in the room, the staff can't move the chairs and therefore some of the corners don't get cleaned. The housekeeping supervisor stated five (5) room inspections were completed each week. Resident #53's most recent room inspection was 4/24/19 and scored 16/18-unsatisfactory in lights and high dusting and vents. The housekeeping supervisor stated the issue was corrected the next day and stated the resident may have been in the room when the housekeeper cleaned the room. The housekeeping supervisor stated there were seven (7) staff members in the building-one in laundry, one supervisor, and five employees that were on the floor. The housekeeping supervisor stated one employee takes care of projects and stated there were four (4) wing cleaners and the staff alternate weekends. The housekeeping supervisor stated at least one (1) day a week, there were only three (3) housekeepers to clean the units and the resident rooms due to projects and days off. The housekeeping supervisor stated projects included stripping floors in the lobby, rehab unit, activities and 27 resident rooms thus far. Resident #53's room was scheduled for stripping and waxing of the floors on 8/14/19 per the QAPI (Quality Assurance Performance Improvement) Plan. The issue/concern was resident rooms stripped and waxed on a scheduled basis. The surveyor requested the job description for housekeepers and a daily schedule of tasks done from the housekeeping supervisor on 5/2/19. The Environmental Services Department Duty List for 1st floor East Wing read 7:00 a.m. Sign in EVS 7:05 a.m. Assemble cart 7:15 a.m. High profile cleaning, dayroom and break room 7:45 a.m. Clean/Eye Wash Rm (room) 7:55 a.m. Supply Room 8:05 a.m. Soiled Utility Room 8:15 a.m. Rm 165 Wound Care 8:45 a.m. High Profile Cleaning-110, 111, and 167 9:15 a.m. Break 9:30 a.m. EVS daily meeting 9:45 a.m. High Profile Cleaning-166, 164, 163, 162, 161, and 160 High profile cleaning-showers/trash 12:00 p.m. lunch 12:30 p.m. High Profile Cleaning 159, 158, 157, 156, 155, 154, 153, 152 Daily Focus Monday-High dust/trash cans Tuesday-Sinks, commodes, stainless steel Wednesday-Corners, edges, door, walls Thursday-Window glass, drinking fountains Friday-Disinfect furniture Sunday-Terminal clean nurse's station from 9:30-10:30 a.m. High profile cleaning read 1. Knock, enter room & cheerfully greet patients, using names. 2. (T) Empty waste can/trash. 3. (D) High dust. 4. (DIS) Disinfect Horizontal Surfaces. 5. (DIS) Disinfect Vertical Surfaces. 6. (RR) Disinfect bathroom. 7. (V) Dust mop. 8. Inspect your work. 9. (D) Damp mop. 10. Thank you and say Goodbye. The surveyor informed the administrator and the director of nursing of the observation during the tour with the housekeeping supervisor on 5/2/19 in the end of the day meeting on 5/2/19 at 4:34 p.m. The clinical record of Resident #53 was reviewed 4/30/19-5/3/19. Resident #53 was admitted to the facility 5/22/18 with diagnoses, that included but not limited [MEDICAL CONDITION], pneumonia, chronic back pain, dementia, high cholesterol,[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease), anxiety, hypertension, depression, fatigue, and tiredness. Resident #53's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 4/5/19 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #53 was not assessed with [REDACTED]. No further information was provided prior to the exit conference on 5/3/19. This is a complaint deficiency.