Every finding on record at Greenwood Transitional Rehabilitation Unit

Based on record review, interviews, and policy review, the facility failed to ensure one of one resident (Resident (R) 9) reviewed for hospitalization out of a total sample of 11 was given a written notice prior to transfer to the hospital. This failure created the potential for residents or their responsible party to not have the information needed to understand their transfer to the hospital. Findings include: Review of facility policy titled, Right to Notification of Changes, revised 06/18, revealed To provide for notification of changes related to residents as outlined by federal and state regulations. Policy: The unit will immediately inform the resident, consult with the resident's physician, and if known, notify the resident's legal guardian or an interested family member when there is .D. The decision to transfer or discharge the resident from the unit .Procedure .F. All notifications will be documented in the resident's medical record and will include the following components: date, time, details of notification, individual being notified, response of that individual, and follow up care. Review of a facility document titled, ''Discharge/Transfer Notice,'' revised 06/10/19, revealed the following items to be completed by the facility prior to discharge of a resident: ''Date of discharge/transfer: Reason for discharge/transfer: Transfer/discharge is necessary for your welfare because the [name of the facility] cannot meet your needs . Discharge/transfer destination . Special instructions for care (this section is to be completed for transfers only. For discharge, see attached discharge instructions).'' Review of facility provided ''Face Sheet'' revealed that R9 was admitted to the facility on [DATE] and transferred on 04/12/24. Further review the ''Face Sheet'' revealed R9 was readmitted to the facility on [DATE] and transferred on 04/30/24. Review of facility provided ''Admission History and Physical (H&P),'' dated 04/08/24, revealed '' .R9 has a past medical history significant for hypertension, diabetes, gastroesophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), anxiety and cerebrovascular accident (CVA).'' Review of facility provided ''Notes,'' dated 04/12/24, revealed ''[R9] having recurrent brown watery emesis [vomiting] and foul odor . [name of physician] ordered to send [R9] onto emergency care center (ECC) .[R9] and wife in agreement with sending to ECC.'' Further review revealed '' .[R9] is admitted to hospital with bowel obstruction.'' Review of facility provided ''Admission H&P,'' dated 04/27/24, revealed ''[R9] on 04/12/24 was sent to emergency department (ED) secondary to abdominal pain, diarrhea and abdominal distention .taken into surgery and underwent sigmoidoscopy with decompression and rectal tube placement [this is a procedure that uses a sigmoidoscopy to decompress the sigmoid volvulus and place a rectal tube in the sigmoid colon] .recommend to be discharged to rehabilitation facility.'' Review of facility provided ''Notes,'' dated 04/30/24, revealed [R9] complained of lower abdominal pain good bowel movement yesterday, but this morning was only able to pass small amount of loose stool with moderate amount of mucous. [R9] states the pain feels the same as it did last time . [name of physician] ordered to send to [name of hospital] emergence department (ED) for further evaluation to rule out small bowel obstruction (SBO).'' Review of the electronic medical record (EMR) with the Director of Transitional Rehab Unit (DOTRU), located under the tab Clinical Documentation revealed no evidence of a written transfer notice for either the 04/12/24 and/or 04/30/24 hospital transfer. During an interview on 06/05/24 at 11:01 AM, the DOTRU confirmed that R9 did not have a written transfer notice for either hospital transfer on 04/12/24 and 04/30/24. During an interview on 06/05/24 at 12:30 PM, the Administrator stated that the written transfer notices for acute transfers were completed by the nurses and confirmed that R9's paperwork was not done upon either transfer to the hospital.

Based on interview, record review, and policy review, the facility failed to report an allegation of neglect in a timely manner for one of one resident (Resident (R) 61) reviewed for neglect out of a total sample of 11 residents. This failure had the potential to place residents at risk of not receiving appropriate care. Findings include: Review of the Abuse, Assault, Neglect, and Misappropriation of Property - Victims of policy, revised 06/2019 and provided by the facility, revealed, abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishments, with resulting physical harm, pain or mental anguish. This includes staff neglect or indifference to the infliction of injury or intimidation of one resident by another. Neglect is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy indicated the procedure of preventing, identifying, reporting, and investigating abuse. The reporting section contained the requirement of reporting the allegation/incident within two hours if it involved neglect. Review of the Face Sheet (FS), provided by the facility, revealed R61 was admitted on [DATE] and discharged from the facility on 01/23/24. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/03/24 and provided by the facility revealed R61 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R61 was cognitively intact. R61 required set-up for meals and moderate assistance with toileting and bathing. Review of the Initial Report, dated 01/15/24 and provided by the facility, revealed a box labeled Brief Description of Reportable Incident that indicated Resident Family Member (FM)61 had reported that she felt R61 had been neglected. FM61 stated to the facility that she did not understand why R61's pain was not improving and why he had increased confusion. FM61 reported that there had been an unused diaper seen on the floor, R61 had not been able to feed himself and was not given assistance, and R61 had not been bathed or dressed. Review of the Initial Report, dated 01/15/24 and provided by the facility, revealed the facility had taken the report from FM61 and listed the type of reportable incident as neglect. The report indicated the time of the report to be 12:30 PM on 01/15/24. A box labeled 24-Hour Initial was checked under the report type. The fax cover sheet provided with the initial report indicated the report went through to the State on 01/16/24 at 10:07 AM. Review of a printed interdisciplinary email between the Administrator and staff, dated 01/15/24 and provided by the facility, revealed the Administrator was planning to report the incident after finishing the email, to meet the two-hour reporting requirement. However, the time of the incident was at 12:30 PM and the email was sent at 3:17 PM. In an interview on 06/05/24 at 2:15 PM, the Administrator stated she knew the complaint by FM61 warranted the two-hour initial report due to the complaint being of an alleged neglect nature. The Administrator supplied an email that indicated she was aware of the required time frame and intended to comply with the regulation evidenced in the printed conversation. The Administrator stated she did not know why the 24-hour box was checked on the report sent to the State, nor why the report was sent in within the 24-hour time frame and not the two-hour time frame. The Administrator stated the allegation should have been reported by 2:30 PM on 01/15/24 after the allegation was made.

Based on record review interviews, and policy review, the facility failed to ensure one of one resident (Resident (R) 9) reviewed for hospitalization out of a total sample of 11 residents was given a written copy of a bed hold notice prior to or within 24-hours of emergency transfer to the hospital. This failure created the potential for resident and responsible party to not have the information needed to safeguard their return to the facility. Findings include: Review of the facility document titled, ''Discharge/Transfer Notice,'' revised 06/10/19, revealed .''Notice of bed hold: Your bed will be held for two midnights following transfer to acute care, in case you become medically stable and appropriate to return to skilled nursing care within the two-midnight period. Review of facility provided ''Face Sheet'' revealed that R9 was admitted to the facility on [DATE] and transferred on 04/12/24. Further review the ''Face Sheet'' revealed R9 was readmitted to the facility on [DATE] and transferred on 04/30/24. Review of facility provided ''Admission History and Physical (H&P),'' dated 04/08/24, revealed '' .R9 has a past medical history significant for hypertension, diabetes, gastroesophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), anxiety and cerebrovascular accident (CVA).'' Review of facility provided ''Notes,'' dated 04/12/24, revealed ''[R9] having recurrent brown watery emesis [vomiting] and foul odor . [name of physician] ordered to send [R9] onto emergency care center (ECC) .[R9] and wife in agreement with sending to ECC.'' Further review revealed '' .[R9] is admitted to hospital with bowel obstruction.'' Review of facility provided ''Admission H&P,'' dated 04/27/24, revealed ''[R9] on 04/12/24 was sent to emergency department (ED) secondary to abdominal pain, diarrhea and abdominal distention .taken into surgery and underwent sigmoidoscopy with decompression and rectal tube placement [this is a procedure that uses a sigmoidoscopy to decompress the sigmoid volvulus and place a rectal tube in the sigmoid colon] .recommend to be discharged to rehabilitation facility.'' Review of facility provided ''Notes,'' dated 04/30/24, revealed [R9] complained of lower abdominal pain good bowel movement yesterday, but this morning was only able to pass small amount of loose stool with moderate amount of mucous. [R9] states the pain feels the same as it did last time . [name of physician] ordered to send to [name of hospital] emergence department (ED) for further evaluation to rule out small bowel obstruction (SBO).'' Review of the electronic medical record (EMR) under the tab Clinical Documentation revealed no evidence of a written bed hold notice for either the 04/12/24 and/or 04/30/24 transfers to the hospital. During an interview on 06/05/24 at 11:01 AM, the Director of Transitional Rehab Unit (DOTRU) stated that the written bed hold notice was at the bottom of the written transfer notice and confirmed that R9 did not get the bed hold notice for either transfer to the hospital. During an interview on 06/05/24 at 12:30 PM, the Administrator stated that the bed hold notices for acute transfers were completed by the nurses and confirmed that R9's written bed hold notice was not completed for either hospital transfer.

Based on observations, interviews, record review and document review, the facility failed to ensure one (Resident(R) 14) of three residents reviewed for respiratory care received services in accordance with professional standards of practice. Specifically, R14's oxygen tubing was not labeled and R14's continuous positive airway pressure ([CONDITION(S)]) was not covered. Findings include: Review of R14's undated Face Sheet provided by the facility, indicated R14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R14's undated Care Plan provided by the facility revealed R14 has an alteration in respiratory function related to [CONDITION(S)], pneumonia risk as evidenced by increased work of breathing, abnormal breath sounds, low oxygenation on room air, shallow respirations, tachypnea, bronchospasms, and bronchoconstriction .interventions included .administer oxygen via in line with [CONDITION(S)] at night per home use. Review of R14's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .and oxygen therapy every shift, oxygen delivery: nasal cannula, 2 liters(L)/minute . Request for care and labeling of resident's nasal cannula and [CONDITION(S)] mask policy was requested from both the Director of Nursing Operations (DNO) and the Administrator. Both indicated that the facility does not have a policy for these items. The DNO later provided a form she called the respiratory therapy protocol, which instructed oxygen tubing/masks should be changed every seven days or as needed and, high flow devices and humidification accessories should be changed per policy (usually 48 to 72 hours). Observations on 05/31/22 at 11:41 AM and 06/01/22 at 8:20 AM of R14's oxygen tubing, attached to the wall revealed the tubing was unlabeled, indicating when it was applied and/or changed. Observations conducted at the same times were made of R14's [CONDITION(S)] face mask which was lying on R14's bedside table, not covered, leaving the mask open to contamination. During an interview conducted with Registered Nurse (RN)1 on 06/01/22 at approximately 8:24 AM, RN1 confirmed the oxygen tubing was not labeled and the [CONDITION(S)] mask was not covered. RN1 stated, the oxygen tubing should be labeled, and the [CONDITION(S)] mask covered. RN1 added it is the responsibility of the respiratory therapist and nursing to ensure this is done. During an interview conducted with Director of the Transitional Rehabilitation Unit (DTRU), on 06/01/22 at 8:28 AM, the DTRU confirmed that R14's oxygen tubing is supposed to be labeled and the [CONDITION(S)] mask has to be covered. During an interview with the DNO on 06/01/22 at 10:05 AM, the DNO stated, oxygen tubing should be labeled for seven days, discard afterwards. The respiratory therapist and/or the admission nurse is responsible for these to be completed. Also, the [CONDITION(S)] mask should have been in a bag.

Based on observation, interview and record review, the facility failed to follow proper sanitation and maintain food safety in 1 of 1 kitchen reviewed. The stove, food slicer and dry storage bins were noted with debris and grease build up. Food was not held at appropriate temperatures. The dish sanitizer in the three-compartment sink did not register per test strip efficiency range. The findings included: Observations during initial tour on 5/6/2019 at approximately 11:15 am revealed debris and a sticky substance noted on the tops of the flour, sugar, and rice bins, the stove was noted with burned grease/food spatter/drippings on the front and the bottom. Observation on 5/7/2019 at 11:00 am of food temperatures revealed food items were not covered on the steam table. Further observation revealed mixed fruit at 57 degrees and cold items for salads (tomatoes, shredded carrots, pimentos shredded cheese, and black olives) registered between 52 and 57 degrees. Further observations at that time revealed the food slicer with grease/debris on the handle/knob, and the water in the dish sanitizer three compartment sink did not register according to test strip efficiency range. Review of the cleaning schedules on 5/7/2019 at approximately 11:45 am revealed the convection oven was to be cleaned on Mondays and Thursdays, the gas ovens on Tuesdays, and Fryers on Wednesdays. Further review revealed the flour, sugar and rice bins were to be cleaned when empty before restocking. Interview with the Administrator on 5/7/2019 at approximately revealed the facility had recently been through several Dietary Managers in past few months. Interview with the Dietary Manager on 5/8/2019 at approximately 10:29 am revealed he/she just created the cleaning schedule. The Dietary Manager further stated there were no cleaning logs to indicate when the kitchen equipment was cleaned last.

Based on observation, record review, and interview, the facility failed to follow physician orders [REDACTED]. Resident #114's physician's orders [REDACTED]. The findings included: The facility admitted Resident #114 with a [DIAGNOSES REDACTED]. On 5/6/19 at 12:34 PM, and 5/7/19 at 10:28 AM, observations of Resident #114's oxygen regulator dial revealed the dial was set at 3 liters per minute. On 5/8/19 at 10:15 AM, an observation with Registered Nurse (RN) #2 of Resident #114's oxygen regulator dial revealed the dial was set at 3 liters per minute. On 5/8/19 at 10:20 AM, a record review of Resident #114's medical records revealed a physician order [REDACTED]. On 5/8/19 at approximately 10:25 AM, an interview with RN #2, s/he verified Resident #114's oxygen was set at 3 liters and indicated the oxygen should have be set at 2 liters.

Based on observation, interview, and review of the facility policy titled Medication Dispensing, the facility failed to secure medication in 1 of 1 units reviewed. On the Transitional Care Unit wasted medication was not secured from access. The findings included: On 5/07/19 at approximately 4:40 PM, during an observation of med pass with Registered Nurse (RN) #1, s/he scored (cut in half) a tablet of the medication [MEDICATION NAME] and placed the unused half into a waste can that was labeled WASTE IV BAGS. The waste can contained a variety of approximately 200 pills and was located in the nurses station that did not have a door or lock and was accessible to any passerby. On 5/7/19 at approximately 4:45 PM, during an interview with RN #1 and the Administrator, RN #1 verified the approximate 200 medications in the waste can were not secured. Further investigation and interview with RN #1 and the Administrator revealed there were no wondering residents on the unit at the time and there was a separate secure medication disposal for narcotics, [MEDICATION NAME], and other medications deemed hazardous. The Administrator then removed the can to a secure location. Review of the facility policy entitled, Medication Dispensing states, Medications not administered and not returned to storage shall be wasted by disposal in the proper Pharmaceutical Waste bin in the med room. Pharmaceutical waste bins are labeled with what types of waste they can receive.

Based on observation, interview, and review of facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed and has the potential to affect 5 of 5 residents with ordered diets as evidenced by failing to do the following: Dispose of expired food items, remove dented cans from storage, wear hair restraint, and clean stove top. The findings included: On 5-15-17 at approximately 11:13 AM, an initial tour of the kitchen with the Dietary Manager (DM) revealed: Walk-in refrigerator: 1.) (1) Open bag of whipped topping dated 3/1 with a green/black substance growing in the bag. 2.) (1) 6 pound (lb.) 5 ounce (oz.) container of cranberry sauce with an open date of 7/26 and expiration date of 1/4/17. 3.) (1) Container of 128 oz. Sauerkraut that was opened and undated. 4.) (3) Gallons of 2% milk containers, (2) dated 5/14/17 and (1) dated 5/8/17. 5.) (1) Canister of walnuts in syrup dated 4/13 without an expiration date. 6.) (6) Heads of lettuce that were brown and had a brown liquid in side bag dated 4/18/17. 7.) (1) Bag of salad opened that was brown and contained a brown liquid. Kitchen area: 8.) Stove top had a large build-up of black and brown greasy food debris on and around all burners. Dry Storage: 9.) (1) Bag of granola that was opened and undated. 10.) (2) 6 lb. 10 oz. cans of Mandarin oranges were on the storage rack dented. Walk-in freezer: 11.) (1) Bag of Italian sausage that was opened and undated with freezer burn. Emergency foods supply: 12.) (12) 50 oz. cans of vegetable beef soup with an expiration date of 1/25/17. 13.) (12) 50 oz. cans of chicken noodle soup with an expiration date of 4/12/17. 14.) (12) 50 oz. cans of cream of potato soup with an expiration date of 4/22/17. 15.) (6) 108 oz. cans of beef ravioli in tomato meat sauce with an expiration date of 4/2/17. Following the initial tour observations of the kitchen, the DM verified the above 15 findings. On 5/16/17 at 4:14 PM, during an observation of the dinner line temping the DM did not wear a facial hair restraint in the kitchen or at the steam table during temping. Also, in the kitchen the stove top had a large build-up of black and brown greasy food debris on and around all burners. Following the observation the DM verified s/he did not wear a facial hair restraint and the build-up of debris on the stove. Review of the facility policy Food Safety and Sanitization, states under procedure (D) Dry and Refrigerated Food Storage: (5) Food from broken packages or food with abnormal appearance or odor is destroyed. Dented cans are removed from storage and stored in a specified location for vendor return. Also, (11) states, All dairy products are destroyed on the day of the code date listed on the carton, and (19) states, Food and non-food items shall be clearly labeled and dated and shall be stored in separate areas.

Based on observations, interview, review of the facility policy, the facility failed to follow a procedure to ensure that expired medication were removed from medication storage in 1 of 1 Pixis Med Station 4000s' reviewed. Expired medication was in the Pixis Med Station 4000 after the expiration date. The findings included: On [DATE] at 4:24 PM, an observation of the Transitional Rehabilitation Unit (TRU) Pixis Med Station 4000 with Registered Nurse (RN) #1 and the Pharmacy Director revealed (11) tablets of Diphenoxlate/Atropine 2.5 mg/ .025mg (Lot #R ) with an expiration date of [DATE]. Following the observation RN#1 and the Pharmacy Director verified the Diphenoxlate/Atropine was expired and indicated the medication should have been removed from the Pixis Med Station 4000. Review of the facility policy, Medication Destruction revealed under procedure (A) When a drug has been identified as expired or unstable the medication needs to be placed in a designated expired/unstable medications.

Based on record review, interview, and review of the facility's policy entitled Interdisciplinary Wound Prevention Assessment and Treatment, the facility failed to appropriately assess a pressure ulcer to include measurements for Resident #93, 1 of 1 resident reviewed for pressure ulcers. The findings included: The facility admitted Resident #93 with [DIAGNOSES REDACTED]. At 3:47 PM on 05/16/2017, review of the Nursing Admission Assessment revealed the resident had a dried blister present on left heel on admission and was staged as a SDTI (Suspected Deep Tissue Injury). At 4:04 PM on 05/16/2017, review of the Wound Documentation revealed the wound was assessed on 4/29/17 and 5/3/17 but was not measured. On 5/10/17 the wound was assessed and measured 4 x 2 cm (Centimeters) with eschar. No measurements were found since admission until 5/10/17. During an interview on 05/17/2017 9:18:09 AM, RN #2 Kayla, confirmed there were no measurements when the wound was assessed on 4/29/17 or 5/3/17. When asked if s/he knew what the standard of practice was for assessing wounds, RN #2 stated I don't know what you mean. Review of the facility's policy on 05/17/2017 at 10:29 AM, revealed G. Any wound that is identified as Stage II or greater, or full thickness will have an in depth assessment with the first dressing change and weekly, including but not limited to, Wound measurement should be in cm with the following dimensions: length (head to toe), width (side to side), and depth. Photograph the wound. In addition, the policy stated Photo documentation must be completed on 1st (first) dressing change after admission and weekly and recorded within the medical record.

Based on observation, record review, interview, and review of the facility's policy entitled Food Safety and Sanitation, the facility failed to ensure dietary staff was knowledgeable regarding calibrating a thermometer, holding temperatures, and dish machine temperatures in 1 of 1 kitchen. The findings included: On 08/08/2016 at 11:20:06 AM, when temping the tray line, the fried fish was noted to be at 98 degrees holding temperature. The mixed fruit was noted to be at 58 degrees holding temperature. These temperatures were confirmed by Cook #1. During the process, Cook #1 asked a dietary aide to serve a visitor from the tray line. The visitor did not request the fried fish. The fried fish nor the mixed fruit were removed from the tray line until the surveyor verified the temperatures with the Cook again and then questioned the cook if the foods could be served. The Nursing Home Administrator (NHA) was also present while the temperatures were being checked. At approximately 11:40 AM, the Nursing Home Administrator indicated that 1 person had been served fish but had not started eating yet. The NHA stated that resident's tray was removed and a new tray delivered. The NHA also confirmed the fish had been discarded and new fish fried. On 08/08/2016 at 11:46:44 AM, the Dietetic Technician Lisa Davis stated the thermometer was not accurate when s/he checked after the tray line was temped and foods found not at acceptable temperatures. When asked if the Cook had calibrated the thermometer prior to temping the tray line, the technician stated s/he would have to ask the Cook. The Dietetic Technician had no explanation why the thermometer would have been accurate before temping and inaccurate afterward. No further information was provided by the facility. On 08/09/2016 11:21:00 AM, Cook #1 confirmed s/he did not calibrate the thermometer before temping the tray line on 8/8/16 and stated I just learned how to do it yesterday. On 08/09/2016 at approximately 2:25 PM, observation of the dish machine revealed the wash temperature to be 156 degrees and the rinse temperature reached 180 degrees as the rack was coming out of the machine. The Certified Dietary Manager (CDM) confirmed these finding and stated the machine had not been used for at least a half an hour. A second rack was run through the machine to check the temperatures a second time. The wash temperature was 150 degrees. The rinse temperature was 180-196 degrees. The CDM confirmed the findings and stated the wash actually went down. Review of the Dish Machine Temperature Log for August, 2016 revealed the was temperature was also below 160 degrees at 152 degrees at breakfast on 08/09/2016, and 159 degrees at lunch on 08/02/2016. At the bottom of the form was a notation stating the Standard for the wash was 160 degrees and for the rinse 180 degrees. Review of the facility policy, Food Safety and Sanitation dated 08/13, page 4 revealed 5. Thermometers are properly calibrated at least once daily or if dropped. 6. Cold temperature calibration involves inserting the thermometer's probe into an equal mixture of crushed ice and water until the indicator stabilizes and then turning the calibration nut so the indicator reads 32 (degrees) F (Fahrenheit). In addition, Section J. Dishwashing using Dishwashing Machine stated 8. If dishes are sanitized by hot water method; the wash, rinse and final rinse temperatures are documented and recorded at each meal.10. If, for any reason, the dish machine temperature is not maintained, action is taken, a record of such action and downtime are recorded and maintained by the department.

Based on personnel record review, interview, review of South Carolina Code of Law Title 44, Chapter 7, Article 23 Section 44-7-2910, and review of facility provided policy entitled "Abuse, Assault, Neglect, and Misappropriation of Property, Victims of," the facility failed to clarify and implement facility policy for screening employees that prohibited mistreatment, neglect, and abuse of residents. The policy did not define how screens were to be conducted for new employees and did not include conducting criminal background checks. The facility failed to perform SC SLED (South Carolina State Law Enforcement Division) background checks for 5 of 5 new employees hired in the last 4 months. In addition the facility failed to report an allegation of abuse timely to the state survey agency per facility policy. The findings included: On 4/14/15 at 9:50 AM, review of personnel records for 5 new employees as part of the Abuse Prohibition Review revealed 2 Certified Nursing Assistants (CNA) had no background check in their records. Review also revealed 1 other CNA and 2 Registered Nurses (RN) had background checks conducted by a third party entity but did not include SC SLED checks as required by South Carolina Code of Law Title 44, Chapter 7, Article 23 Section 44-7-2910. Review of the third party checks revealed a Federal Criminal - National check was listed but was not conducted by finger prints and review of the Jurisdictions Searched for South Carolina revealed SLED was not listed as a resource. RN #1 - 7 year search completed in Greenwood County, SC; RN #2 - 7 year search in Durham County, NC and in Greenwood County, SC; CNA #1 - 7 year search in Abbeville County, SC; CNA #2 - No Background Check; CNA #3 - No Background Check During an interview on 4/14/15 at 11:50 AM, the Administrative Assistant and Nursing Home Administrator confirmed there was no documentation that the background checks were conducted via SC SLED and that SLED was not listed as a source of information for the State or Federal background checks. Review of the facility's policy, "Abuse, Assault, Neglect, and Misappropriation of Property, Victims of," page 2, "III PROCEDURE A. Post Job Offer Screen" revealed "4. Screens are defined by Human Resource Policy." There were no written procedures for conducting the screens or ensuring the screens were conducted in accordance with the State law. On 4/13/15 at 4:00 PM, review of one of two reportable incidents revealed that an allegation of neglect was reported to facility staff by the resident on 02/8/15, but was not reported to the State Survey and Certification Agency until 02/10/15, two days later. In addition, the Five-Day Follow-Up Report with the summary of findings was reported to the State Survey and Certification agency on 2/16/15 and not within 5 business days of the incident, which would have been 2/13/15, as required. Review of the facility's report revealed the resident "requested assistance from the staff on the unit. (The resident) was upset per staff and (s/he) had an incontinent episode". The report further stated that after not receiving assistance timely, the resident "informed them of what had happened." The findings were confirmed by the Nursing Home Administrator at approximately 5:15 PM on 4/13/14. The administrator stated that s/he was informed of the incident on the 10th and reported it to the state agency on that date. The administrator further confirmed that other staff members were aware of the incident on the day of the occurrence, 2/8/15. Review of the policy entitled "Abuse, Assault, Neglect, and Misappropriation of Property, Victims of" on page 3 Section E. Reporting stated "6. Agencies to whom to report, time frames for reporting, and the various events to be reported are given in the following table and subsections:" Included in "Types of Accidents/Incidents to report" to Certification included "Neglect" and the "Reporting Timeframes" stated "Immediately (in accordance with Omnibus Adult Protection Act), but not to exceed 24 hours after discovery of the incident." Further, Section E, further "5. Persons required to report abuse, neglect, or exploitation of an adult" listed "a) A physician, nurse dentist, optometrist, medical examiner, coroner, other medical, mental health or allied health professional, counselor, psychologist, mental health or intellectual disability specialist, social or public assistance worker, caregiver, staff or volunteer of a facility, or law enforcement officer having reason to believe that a vulnerable adult has been or is likely to be abused, neglected, or exploited."

Based on record reviews and interviews the facility was found to be using incorrect liability notices for 3 of 3 residents reviewed for liability notices. The findings include: On 4/13/15 at approximately 5:30 PM and on 4/14/15 at approximately 10:30 AM, review of residents who changed pay source revealed that the facility was using CMS-R-193 (hospital) instead of CMS 3 NOMNC (Notice of Medicare Provider Non-Coverage) for the following residents who were discharged home after more than 20 days with days remaining: -Resident 8 who was admitted [DATE] and discharged [DATE] -Resident A who was admitted [DATE] and discharged [DATE] -Resident B who was admitted [DATE] and discharged [DATE] The facility's Controller and Administrator confirmed in an interview on 4/14/15 at approximately 11:05 AM that the CMS-R-193 form was being used instead of the CMS NOMNC.

Based on record review, interview and the facility's policy entitled "Abuse, Assault, Neglect, and Misappropriation of Property, Victims of," the facility failed to ensure that License verification was obtained prior to the date of hire for 1 of 2 Registered Nurses (RN) reviewed. The findings included: On 4/14/15 at approximately 9:50 AM, review of employee files for background checks, registry checks and license checks, revealed that the License verification was completed after the hire date for 1 of 2 RNs. RN #2 was hired on 1/14/15 and the License verification was dated 2/19/15. During an interview on 4/14/15 at approximately 11:50 AM, the Nursing Home Administrator and Administrative Assistant confirmed the date of hire and date of the License verification and that the verification had been completed late. The Administrative Assistant stated that the Regional Human Resources (HR) person had probably conducted an audit after the last HR Manager left, found that a verification had not been done and obtained one at that time . Review of the facility's policy entitled "Abuse, Assault, Neglect, and Misappropriation of Property, Victims of" page 2 "III PROCEDURE" revealed "A. Post Job Offer Screen (prior to resident care assignment) 1. Employment is based on screening results 2. Staff are screened prior to resident care assignments 3. Negative results may exclude staff from hire/starting with the facility 4. Screens are defined by Human Resource Policy." Section C "Prevention of Abuse/Neglect" stated "2. Staff ...c. Verification of licensure or certification occurs with each expiration." There were no written procedures for obtaining License verifications prior to the date of hire.

Based on record review, interview and the facility's policy entitled "Abuse, Assault, Neglect, and Misappropriation of Property, Victims of," the facility failed to ensure that verification was obtained from the Certified Nursing Assistant Registry prior to the date of hire for 1 of 3 Certified Nursing Assistants (CNA) reviewed. The findings included: On 4/14/15 at approximately 9:50 AM, review of employee files for background checks, registry checks and license checks, revealed that the CNA Registry verification was completed after the date of hire for 1 of 3 CNA reviewed. CNA #3 was hired on 12/27/14 and the CNA Registry verification was dated 3/5/15. During an interview on 4/14/15 at approximately 11:50 AM, the Nursing Home Administrator and Administrative Assistant confirmed the date of hire and the date of the registry check and that the verification had been completed late. The Administrative Assistant stated that the Regional Human Resources (HR) person had probably conducted an audit after the last HR Manager left, found that a verification had not been done and obtained one at that time . Review of the facility's policy entitled "Abuse, Assault, Neglect, and Misappropriation of Property, Victims of" page 2 "III PROCEDURE" revealed "A. Post Job Offer Screen (prior to resident care assignment) 1. Employment is based on screening results 2. Staff are screened prior to resident care assignments 3. Negative results may exclude staff from hire/starting with the facility 4. Screens are defined by Human Resource Policy." Section C "Prevention of Abuse/Neglect" stated "2. Staff ...c. Verification of licensure or certification occurs with each expiration." There were no written procedures for obtaining Registry verifications prior to the date of hire.

On the days of the survey, based on observations, interview, and review of the facility policy " Medication Administration " the facility failed to follow a procedure to ensure that expired medications were removed from medication storage in 1 of 1 medication storage stations. The findings included: On 6/9/14 at 2:30 PM, observation of the Transitional Rehabilitation Unit (TRU) " Pyxis System Medication Station 3500 " with the Pharmacist present revealed (8) vials of Promethazine HCL 25 milligram (mg)/1 milliliter (ml) (Lot Number # 2). All vials had an expiration date of 5/2014. Following the observation the Pharmacist verified the (8) vials of Promethazine were expired and verbalized the medication should have been removed. Review of the facility policy entitled " Medication Administration, " revealed in section G.) Medication Storage 2.) Medication storage areas throughout the hospital will be inspected at least monthly by the pharmacy.

On the days of the survey, based on observations and interviews, the facility failed to provide an appropriate pressure ulcer treatment to promote healing and prevent the spread of infection for 1 of 1 residents reviewed for pressure ulcers. (Resident #97) During an observation of wound care, a facility nurse failed to wash his/her hands between glove changes. The findings included: A pressure ulcer treatment was observed for Resident #97 on 6/10/2014 at approximately 1:23 PM. LPN #1 donned gloves and removed the soiled dressing from the wound on the left heel. He/she then removed the soiled gloves and immediately donned a clean pair of gloves; not washing his/her hands at this time. He/she then applied [MEDICATION NAME] using a cotton applicator, removed his/her gloves and donned another pair of gloves, without washing/sanitizing his/her hands. LPN #1 then applied an [MEDICATION NAME] dressing to Resident #97's left heel. After removing his/her gloves and washing his/her hands, he/she bagged the trash, carried the trash to the soiled utility room and placed it in a biohazard receptacle. He/she then washed his/her hands and left the soiled utility room and charted the procedure. During an interview on 6/10/2014 at approximately 1:37 PM with LPN #1, he/she was asked if he/she was aware that he/she had not washed or sanitized his/her hands after removing the soiled dressing and/or between glove changes? He/she stated, "I thought that was OK, I did not touch anything." An interview with the Director of Nurses on 6/11/2014 at approximately 10:00 AM, he/she was asked, "When would you expect a nurse to wash/sanitize his/her hands during a pressure ulcer treatment?" He/she stated, " Each time he/she removes his/her gloves."

On the days of the survey based on observation, review of cleaning assignments and interview, the facility failed to prepare, distribute and serve food under sanitary conditions as evidenced by incorrect parts per millions (ppm) of sanitizer in the 3 compartment sink, multiple dusty ceiling vents in the food preparation area, and a soiled can opener. The findings included: During observation of the kitchen on 5/7/13 at approximately 10:50 AM the surveyor observed a can opener with a build up of metal shavings in it. Further observation of the kitchen on 5/7/13 at 11:00 AM the surveyor observed the 3 compartment sink sanitizer. The facility used a quaternary sanitizer for which recommended concentration is 150-200 ppm. The Dietary aide tested the sanitizer with the designated test strip, and the sanitizer concentration registered at 500 ppm. While touring the kitchen, the surveyor also observed 2 ceiling vents with a build up of dust and 2 more ceiling vents in the tray line area with a build up of dust on them. Review of the Daily Cleaning Assignments, it revealed no documentation related to the cleaning of vents. On 5/7/13 while conducting the kitchen tour the Food Service Supervisor confirmed the surveyors' findings.

On the day of the survey, based on record review and interviews, the facility failed to implement interventions to promote healing of the facility acquired stage 2 pressure ulcer for 1 of 1 resident reviewed for pressure ulcer. Resident #2 did not receive interventions to heal the facility acquired stage 2 pressure ulcer. The findings included: The facility admitted Resident #2 with diagnoses, but not limited to Fracture Dislocation of Right Shoulder and Diabetes Mellitus. On 05/07/2013 at 1:00 PM, record review of the "Wound note" dated 5/1/2013 revealed the facility identified the resident as having an facility acquired unstageable pressure ulcer to the R (Right) mid-ischial location. The documentation stated the resident would be placed on an appropriate turn schedule, limit seated time, the dietician was to assess nutritional status in relation to optimal wound healing. The wound measurements were : L (Length) 1.0 x W(Width) 2.1 x D (Diameter) unknown at this time..."Current Treatment: Exuderm, pressure reduction devices, nutritional support, and turn schedule while in bed". Review of the Registered Dietician's (RD) noted the RD had educated the resident on nutrition needs for wound healing..."Patient is eating well and requests Boost regularly...Labs noted (5/1) Ca (Calcium) 8.3, Hematocrit/Hemoglobin 11.3/34.3...Continue plan of care". The "Wound Addendum/Weekly Update" form dated 5/6/2013, revealed "Staging (Pressure Ulcers): II...Open Wound Surface Area...L x 2.5 X W 0.5 x D 0.2cm... The pressure ulcer is now a stage 2 with an increase in length." Review of the "Daily Flowsheet Treatment Record" dated 5/1/2013-5/6//2013 revealed Resident #2 was eating inconsistently during breakfast and lunch, ranging between 25 and 100% and that there were no documentation of percentage eaten for dinner. During an interview with Resident #2 on 5/07/2013 at 4:45PM , s/he verified that s/he does drink Boost "someday's" but "not everyday". During an interview with the Director of Nursing (DON) on 5/07/13 at 4:48 PM, s/he reviewed and verified the documentation of Resident #2's intake of meals. S/he stated the resident routinely refuses dinner. S/he reviewed and verified that there was no physician's order for the routine provision of Boost and no documentation regarding the amount of Boost consumed. S/he also verified that Resident #2 only received Boost upon the resident's request (which was not daily). The DON also reviewed and verified that there were no labs such as pre [MEDICATION NAME] and [MEDICATION NAME] level drawn, and that there were no documentation relating to a turning schedule.

On the day of the survey, based on record review and interview, the facility failed to immediately inform the resident's legal representative or interested family member of an acquired pressure ulcer and treatment.(1 of 1 resident reviewed for notification related to an acquired pressure ulcer). Resident #2's legal representative/ interested family member was not notified of an acquired pressure ulcer and treatment. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the "Wound notes" dated 05/01/2013 revealed "Notified by nurse on duty that resident appears to have an area of tissue degradation on his/her buttocks...there is a defined area of ulcerative development to the R mid-ischial location...Area appears to be a now-deflated blood blister unstageable, dense to touch with defined edges, and a fine line of deepening purple to the adjoining periwound...Have notified physician and nurse practitioner...Area cleansed, and applied 4 x 4 Exuderm with good seal..." Further record review revealed that there were no documentation indicating notification to Resident #2's legal representative or interested family member of the acquired pressure ulcer and treatment. During an interview with the Director of Nursing (DON) on 05/07/2013 at 4:45 PM, he/she reviewed and verified that there were no documentation of notification to the legal representative or interested person of an acquired pressure ulcer and treatment.

On the days of the survey, based on observation, interview, and review of the the facility provided policy for Abuse, facility administration failed to assure facility polices and procedures were implemented for the prevention of blood borne pathogens related to cleaning and disinfecting multi-resident use glucometer's between each resident receiving Finger Stick Blood Sugars (FSBS). Additionally, administration failed to fully develop and implement policies related to Abuse. The findings included: On 6/11/12 Patient Care Technician/Certified Nursing Assistant (PCT/CNA) #1 was observed and verbally verified she had failed to clean a multi-resident use glucometer between use with residents. She stated the wipes required to clean/sanitize were "locked up". In an interview on 6/11/12 with the NHA (Nursing Home Administrator) and DNO (Director of Nursing Operations), both stated they were not sure why the sanitizing wipes were kept in a locked cabinet. Cross refer to F 441 as it relates to the failure to clean multi-resident use glucometer's between resident use. 483.75 Administration F-490 was identified at Immediate Jeopardy at a scope and severity level of "L". The facility Administration failed to assure that appropriate polices and procedures in place were implemented related to the cleaning of the Glucometer used for multiple residents. The systemic failure of the facility to effectively clean the Glucometers placed the residents at risk at for serious harm. exist on 6/11/12 at 5:30 PM . The Allegation of Compliance was submitted by the facility on 6/12/11. The actions listed in the Allegation of Compliance included the following: The purpose of this document is to provide detailed information regarding immediate actions taken in response to the finding of a glucometer not being cleaned properly following resident treatment, thus increasing the potential spread of infection. Two (2) residents were found to have been affected by the deficient practice. The following actions were taken for not only those two residents, but for the other residents who have the potential to be affected. Patients who are on orders for finger stick blood sugars are the group of residents potentially affected by this deficient practice. Immediate Actions (Completed as of 6/12/12 0800) 1. Education- Responsibility: Infection Control, DON,NHA Development and delivery of detailed educational program by infection control practitioner with formal education classes driven by the TRU Clinical Leadership team regarding: Strategies to minimize possibility of transmitting infection and maintaining a clean environment utilizing proper cleaning products. Proper hand hygrine and gloving technique during patient care. Proper cleaning/disinfecting of equipment used for multiple patients, including the glucometer. Provision of written materials related to education provided to staff. Availability and location of products needed for proper cleaning. 2. Competency Assessment-Responsibility: Infection Control, DNO, NHA Evaluation of the understanding of the education provided through: Return demonstration of key areas of education related to hand hygiene and equipment cleaning by staff. Documentation of competency for specific focus area(s) Ongoing Actions (To Be Completed as Indicated Below) 3. Monitoring and Outcome Measurement-Responsibility: Infection Control, DNO, NHA, Trained RNs (Registered Nurses) Initiation of monitoring of continued competency assessment and interventions through weekly random visual observations (for each item listed below) of staff will occur for as least 30 days. This will be done by a nurse (i.e. DNO, Nurse Manager, Infection Control Nurse, Wound Care Nurse). Proper cleaning/disinfecting of equipment and surfaces Hand Hygiene Random sampling of technique (minimum of at least 20 visual observations per quarter) by Infection Control Nurse with results reported to Quality Council, Medical Executive Committee and Governing Body for at least two quarters or until technique os 100%. After completion of the 30 day period, in the event that the competency cannot be confirmed, further direct proctoring will occur. Failure to meet competency after the second proctoring period will initiate disciplinary action. 4. Criteria for ongoing Personnel Compliance If any personnel are not available for education/proctoring during the intermediate term, then this individual will receive education prior to provision of patient care and services. The education and competency assessment methods will be initiated with all newly hired staff through departmental orientation. Additionally, facility administration failed to develop and implement polices related to abuse, neglect and mistreatment. Following the observation and reporting of the neglectful actions of Patient Care Technician/Certified Nursing Assistant (PCT/CNA) #1, the facility administration failed to identify neglect. Patient Care Technician/Certified Nursing Assistant (PCT/CNA) #1 was observed to fail to clean multi-resident use glucometer's between resident use, placing residents at risk for the transmission of blood borne pathogenic disease. The facility provided policy for neglect stated: "Neglect is consider (sic) a form of abuse and is defined as the failure to provide good and services necessary to avoid physical harm,,," Cross refer to F 224 as it relates to the failure of the facility to identify neglect. In review of the facility provided policy for Abuse, Neglect and Mistreatment, the policy did not include all required components including but not limited to addressing injuries of unknown origin, reporting time frames and reporting to designated state agencies. Review of the facility's policy entitled "Abuse, Assault, Neglect, and Misappropriation of Property-Victims of " revealed: "Neglect is consider (sic) a form of abuse and is defined as the failure to provide good and services necessary to avoid physical harm,,," 1. Any allegations of abuse or neglect must be investigated thoroughly. 2. No person that reports a possible abuse or neglect will be retaliated against. Residents will be immediately protected from any abuse during the investigative process. 3. Continuous observation of any interaction between the resident and subject is required. At no time will b) Family/Visitors/Other Residents will be asked to not visit or interaction (sic) with the resident during the investigation time. a) Immediate removal of the suspect from resident care areas or placed on administrative leave will occur b) If the findings prove to not be founded, the staff will be reinstated with paid time off c) If the findings prove to be founded, disciplinary actions including and up to termination will occur with reporting to state licensing agencies for action. 1. The staff will contact the Case Manager to assist with appropriate referral and investigation 2. The Case Manager will gather information and consult with the attending physician, the resident, and, when indicated, members of the treatment team and facility administration/risk management 3. The complaint/grievance process will be put into place with any allegation. If a report of abuse is alleged by the resident and/or family against any staff of the facility, notification of the state license agency will be performed. 4. As indicated by the findings, referral will be made to the proper authorities for abuse, neglect or exploitation of children, the elderly, or people with disabilities. South Carolina Department of Social Services 1118 Phoenix Street Greenwood, SC, [PHONE NUMBER] 5. The staff and/or Case Manager will complete a facility incident report. 6. The investigation will began immediately upon report of the abuse and will involve all necessary department managers, interviews, physical assessment, and other means of data collection will be performed. 7. If staff is involved, a report to the state facility licensing agency will be performed. Information will be provided as requested to agency personnel in their investigation." Additionally, the facility failed to identify/recognize and or act on the neglectful action of the CNA. The appropriate state agencies were not notified within 24 hours of the incident nor was a five day report received. There was no evidence provided of a thorough investigation and the PCT/CNA continued to work. Cross refer to F 226 related to the administrative failure to develop complete and accurate policies related to abuse. Interviews, and review of policy education and signature sheets on 6/12/2012 revealed the Allegation of Compliance submitted by the facility on 6/12/2012 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of the new policy requiring staff to use germicidal wipes to disinfect glucometer's prior to and after checking FSBS for each resident requiring FSBS checks. The Administrator was informed of this on 6/12/2012 at 2:30 PM. The F-490 remained at a lower scope and severity of "F". The facility will be in compliance with F490 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction. :

On the days of the survey, based on observations, interviews and review of the policies provided by the facility entitled "Standard Precautions" the facility failed to ensure a sanitary environment to prevent the development and transmission of disease and infection. A PCT/CNA (Patient Care Technician.Certified Nursing Assistant) failed to clean a multi-resident use glucometer in between resident use. The findings included: The facility admitted Resident #2 on 5/30/12 with [DIAGNOSES REDACTED]. On 6/11/12 at 4:45 PM, Patient Care Technician (PCT/CNA) #1 was observed completing a FSBS for a Resident #2. The PCT/CNA was observed to place the glucometer into its case with out sanitizing the device after testing the resident's blood sample. The facility admitted Resident #7 on 8/9/10 with [DIAGNOSES REDACTED]. PCT/CNA # 1 entered Resident #7's room, explained the procedure, washed her hands and identified the resident. PCT/CNA #1 cleaned the resident's finger with a alcohol wipe, placed a strip into the glucometer and removed a lancet from the case. The PCT/CNA removed the safety tip from the lancet, took the resident's finger in her left hand and placed the lancet next to the resident's finger. At that time, the surveyor asked the PCT not to proceed and to exit the room. The surveyor had not observed the PCT/CNA sanitizing the glucometer after checking another Resident # 2 and prior to attempting to perform a FSBS for Resident #7. The PCT/CNA stated that she forgot to clean the machine because the wipes were kept in a locked cabinet and not available for use. The surveyor asked to see the wipes. Registered Nurse (RN) #1 was called to the area to unlock the cabinet. PCT/CNA #1 stated she had cleaned the glucometer prior to starting the evening blood sugars and had checked 2 other residents prior to Resident #7. When asked by the surveyor if she had checked the first resident and then checked the second without cleansing the glucometer? PCT/CNA # 1 stated she had not cleaned the glucometer before checking the second resident and had not cleaned before attempting to check the third. In an interview on 6/11/12 with the NHA and DNO, (Nursing Home Administrator and Director of Nursing Operations) both stated they would expect the PCT/CNA's and nurses to sanitize the glucometer before and after each resident tested for FSBS (Finger Stick Blood Sugar). They also stated they were not sure why the sanitizing wipes were kept in a locked cabinet. On 6/12/12 at 9:40 AM, during an interview with the facility's Medical Director, he stated that he would expect the staff to follow the standard protocols of the hospital. When asked if he would expect the staff to clean glucometers between resident use he stated "I would definitely hope so" and would expect them to clean everything between patient use. Review of the facility's policy entitled Standard Precautions indicated "...E. Patient Care Equipment...5. Reusable equipment will not be used for the care of another patient until it has been appropriately cleaned and processed..." Immediate Jeopardy was determined to exist on 6/11/12 at 5:30 PM after staff were identified as not using an approved germicidal wipe and/or not cleansing the glucometer between resident FSBS, placing residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. The facility presented a Credible Allegation of Compliance (AOC) on 6/12/12 and it was accepted at 12:07 PM, that included the following: "The purpose of this document is to provide detailed information regarding immediate actions taken in response to the finding of a glucometer not being cleaned properly following resident treatment, thus increasing the potential spread of infection. Two (2) residents were found to have been affected by the deficient practice. The following actions were taken for not only those two residents, but for the other residents who have the potential to be affected. Patients who are on orders for finger stick blood sugars are the group of residents potentially affected by this deficient practice. Immediate Actions (Completed as of 6/12/12 0800) 1. Education- Responsibility: Infection Control, DON,NHA Development and delivery of detailed educational program by infection control practitioner with formal education classes driven by the TRU Clinical Leadership team regarding: Strategies to minimize possibility of transmitting infection and maintaining a clean environment utilizing proper cleaning products. Proper hand hygrine and gloving technique during patient care. Proper cleaning/disinfecting of equipment used for multiple patients, including the glucometer. Provision of written materials related to education provided to staff. Availability and location of products needed for proper cleaning. 2. Competency Assessment-Responsibility: Infection Control, DNO, NHA Evaluation of the understanding of the education provided through: Return demonstration of key areas of education related to hand hygiene and equipment cleaning by staff. Documentation of competency for specific focus area(s) Ongoing Actions (To Be Completed as Indicated Below) 3. Monitoring and Outcome Measurement-Responsibility: Infection Control, DNO, NHA, Trained RNs (Registered Nurses) Initiation of monitoring of continued competency assessment and interventions through weekly random visual observations (for each item listed below) of staff will occur for as least 30 days. This will be done by a nurse (i.e. DNO, Nurse Manager, Infection Control Nurse, Wound Care Nurse). Proper cleaning/disinfecting of equipment and surfaces Hand Hygiene Random sampling of technique (minimum of at least 20 visual observations per quarter) by Infection Control Nurse with results reported to Quality Council, Medical Executive Committee and Governing Body for at least two quarters or until technique os 100%. After completion of the 30 day period, in the event that the competency cannot be confirmed, further direct proctoring will occur. Failure to meet competency after the second proctoring period will initiate disciplinary action. 4. Criteria for ongoing Personnel Compliance If any personnel are not available for education/proctoring during the intermediate term, then this individual will receive education prior to provision of patient care and services. The education and competency assessment methods will be initiated with all newly hired staff through departmental orientation." Interviews, and review of policy education and signature sheets on 6/12/2012 revealed the Allegation of Compliance submitted by the facility on 6/12/2012 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. Facility nursing staff, including PCT #1, had been educated and were knowledgeable of the new policy requiring staff to use germicidal wipes to disinfect glucometers prior to and after checking FSBS for each resident requiring FSBS checks. The Administrator was informed of this on 6/12/2012 at 2:30 PM. The citation at F-441, remained at a lower scope and severity of "D". The facility will be in compliance with F441 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction.