Every finding on record at Hallmark Healthcare Center

Based on observation, record review and staff interview, the facility failed to provide sanitary meal service when two kitchen staff failed to don [put on] appropriate facial hair covers for food preparation. This failure had the potential to affect 79 residents receiving dietary services from the facility. Findings include:Review of the facility policy Nutrition Policies and Procedures dated 10/15/25 revealed, POLICY: The Dietary Department employees will adhere to a facility dress code that facilitates safe and sanitary meal production and service .6. Appropriate hair restraints (hair covers or nets, beard restraints) while involved in food production activities . On 04/29/26 from 5:49 AM through approximately 6:20 AM, a brief tour of the kitchen was conducted. Upon entry to the kitchen, [NAME] (DD) and Dietary Aide (FF) were observed preparing breakfast. Both staff had facial hair/beards. They were wearing head covers but had not donned facial hair covers prior to the surveyor donning a hair net and asking staff if facial hair covers were available for them to use to cover their facial hair while preparing food for the residents. Each donned facial hair covers at that time. During an interview with the Dietary Manager (DM), on 05/02/26 at 8:30 AM he confirmed that a facial hair covering was required while preparing food for the residents.

Based on record review and interview, the facility failed to act promptly and to provide documented responses to recurring grievances related to call light response times that were expressed during resident council meetings for 10 of 13 months of meeting minutes reviewed. (June 2025, July 2025, August 2025, September 2025, October 2025, November 2025, December 2025, January 2026, February 2026, and March 2026) Findings include:A review of the undated facility policy titled, Social Services Policies and Procedures, with a revision date of 11/06/23, revealed, Subject: Complaints/Grievances process. Policy: . 2. Facility Leadership acts promptly to understand and resolve complaints and grievances completed in a reasonable expected time frame . Responsibility of Grievance Official: Identifying a Grievance Official who is appointed by the Administrator and who is responsible for: 1. Overseeing the grievance process, receiving, and tracking grievances through to their conclusions . 5. As necessary, taking immediate action to prevent further potential violations . Grievance Reports: . C. The Quality Assurance and Performance Improvement Committee (QAPI) discusses trends and patterns to identify areas of opportunity for resolution and prevention of recurrence . A review of the resident council meeting monthly minutes including April 2025 through April 2026 revealed the topic of resident call light response time complaints each month from June 2025 through March 2026, a total of 10 months without resolution documented on the meeting minutes. An interview with Resident (R)12 on 04/30/26 at 9:00 AM revealed he has had a concern with call light response times for a long time. During the group interview held on 04/30/26 at 2:00 PM, R12 identified a concern related to call light response times and stated, They occasionally take a long time to answer them, and that is usually at night. An interview with the Activities Director (AD) CC on 05/01/26 at 9:00 AM revealed that she documented complaints and/or grievances brought up at the resident council meeting and reported them to social services. Except for December 2025, AD CC did not know why the concerns with call light response times documented on the resident council meeting minutes between June 2025 and March 2026 were not included on the grievance log which is maintained by Social Services (SS) DD who is the grievance coordinator.An interview with SS DD on 05/01/26 at 9:15 AM revealed she is the grievance coordinator. Depending on the complaint, she delegates or refers them to the department most appropriate to handle the complaint. Call light complaints are referred to nursing, specifically the Director of Nursing (DON) for investigation and resolution. She reviewed the resident council minutes and the grievance logs for the last 13 months and confirmed there were two call light grievances which had been documented as resolved on the grievance log, and there were 10 months wherein call light concerns were documented on the resident council minutes. She also confirmed that the call light grievance dated 12/11/25 coincided with the resident council meeting minutes dated the same. She agreed that call light concerns, whether in resident council meeting or as an individual grievance should be responded to in a timely manner. She agreed that 10 months was not in a timely manner. She further stated that she did not know the reason the grievances documented on the resident council meeting minutes were not documented on the grievance and stated that they probably should have been.In an interview with the Director of Nursing (DON) on 05/01/26 at 9:20 AM, she confirmed that she, along with the Administrator, responded to call light grievances reported to them by SS DD. She confirmed that there were two call light grievances which had been documented as resolved on the grievance log, and there were 10 months wherein call light concerns were documented on the resident council minutes. She also confirmed that the call light grievance dated 12/11/25 coincided with the resident council meeting minutes dated the same, and that all call light concerns should be on the grievance log. She agreed that call light concerns should be responded to in a timely manner. She agreed that 10 months was not in a timely manner.

Based on review of facility policy, observation, and interview, the facility failed to maintain equipment in safe operating condition. Specifically, 1 of the 2 washing machines in the laundry room was leaking water and chemicals from the rear of the machine. Findings Include: Review of the facility policy titled, Clinical Equipment Management last revised December 12, 2016, states, Inspections and maintenance will comply with all governing agencies and equipment manufacturer's recommendations in order to maintain safe operating conditions . prior to the use of all machines in the department, it will be the responsibility of the operator or provider of service to be certain that the machine is in good operational condition. During an observation and interview, in the laundry room, on 03/24/25 at 11:10 AM, Washing Machine 1 was observed squirting water from the back of the machine onto the wall and floor surrounding the machine. The Laundry Director (LD) stated, We have a drain back there, and I did not notice the water shooting out of the back of the machine before. I will have to call RYA [Contracted Servicer]. During an interview on 03/24/25 at 11:45 AM, the Facility Administrator (FA) stated she was unaware of the malfunctioning washer and said they would contact RYA to fix it. During a follow-up observation on 03/24/25 at 1:22 PM, approximately three minutes into a wash cycle, Washing Machine 1, was profusely leaking chemicals and water from the back of the machine. A notable amount of soap suds was leaking from the back of Washing Machine 1 and onto the floor.

Based on a review of facility policy, observation, and interview, the facility failed to adhere to infection control guidelines. Specifically, clean linens were improperly stored in the soiled linen room and the laundry room was unclean, increasing the risk of cross-contamination. Findings Include: Review of the facility policy titled, Laundry dated 03/2006, states, All Linens . 1. Linens are to be handled in a safe manner to prevent contamination of the linen, the personnel and the environment . 6. Clean and soiled linen never comes in contact with each other . Housekeeping of Laundry facility: 1. The laundry facilities is to be kept clean and debris free. During an observation and interview on 03/24/25 at 11:15 AM, clean laundry (pillows, containers of clothes and other clean items) were being stored in the soiled room. The Laundry Director (LD) stated there should not be clean items in here and that they have a shed outside that we can keep the extra clean items. During an interview on 03/24/25 at 11:45 AM, the Facility Administrator (FA) stated, There should not be clean laundry in the soiled room . they have to move those items.

Based on review of facility policy, observation and interview, the facility failed to ensure expired and out dated medications and biological's were removed and not in use with residents' current medications and biological's, from 3 of 3 medication carts and 1 of 2 treatment carts. Findings include: Review of the undated facility policy titled, General Guidelines for Storage of Medication and Biological's revealed, 1) Medications and biological's are stored safely, securely and properly following manufacturer's recommendations or those of the supplier . Procedures: . 5. Medications with manufacturer's expiration date expressed in month and year will expire on the last day of the the month. 6. Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines in respect to expiration dates of opened medications . 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the Pharmacy, if replacements are needed. Review of the Sweetgrass Unit Treatment Cart on [DATE] at 8:49 AM, revealed the following: One bottle of Curad Plain Packing Strips with Lot #6051907022, ,d+[DATE] inch x 5 yards, was open and stored on the cart and no longer sterile. One Suture Removal Tray, manufactured by Medline with Lot #(10) 21KBK230 was expired on [DATE]. One package of Maxorb II, Alginate wound dressing with antibacterial silver, manufacture by Medline, 4 x 5 sterile dressing with Lot #(10) 83624057803 was open and stored on the cart and no longer sterile. One package of Tegaderm 3M transparent film dressing, 4 inches x 4 ,d+[DATE] inches, was expired on [DATE]. One package of Maxorb, Alginate wound dressing, manufactured by Medline with Lot #83624068030 was open and stored on the treatment cart and no longer sterile. Two Sofsorb pads, manufactured by De Royal with Ref #,d+[DATE] was expired on [DATE]. During an interview on [DATE] at 9:00 AM, Licensed Practical Nurse (LPN)1 confirmed the expired, outdated biological's, and the opened sterile dressings that were no longer sterile and removed them from the treatment cart. Review on [DATE] at 11:10 AM, of the Palmetto Medication Cart (front) revealed the following: Furosemide 40 milligram (mgs), 7 tablets with Lot #FUB223055G, with RX #1846487 were expired on [DATE]. Albuterol Sulfate 2.5 mgs/3 milliliters (mls), NDC[DATE] with Lot #23B68, 13 vials were expired on ,d+[DATE]. Furosemide 40 mgs, manufactured by Rising with Lot #FUB223008G, 14 tabs were expired on [DATE]. During an interview on [DATE] at 11:20 AM, Registered Nurse (RN)1 confirmed the expired and outdated medications and removed them from storage. Review on [DATE] at 11:55 AM, of the Palmetto Medication Cart (back) revealed the following: Two packages of Nestle, orange Arginaid Powder with Lot #3215T176A[DATE] were expired on [DATE]. Sureprep protective wipes manufactured by Medline with Lot #61220220077, 50 wipes were expired on ,d+[DATE]. During an interview on [DATE] at 12:05 PM, LPN3 confirmed the above expired medication and biological's and removed them from storage.

Based on review of facility policy, observation and interview, the facility failed to ensure Resident (R)57 was clean, dressed, and free from facial hair, for 1 of 1 resident reviewed for respect and dignity. Findings include: Review of the facility policy titled, Activities of Daily Living, Optimal Function, revised on May 5, 2023, documents, The facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming and hygiene . Procedures: 1. Facility staff recognize and assess an inability to perform ADLs, or a risk for decline in any ability to perform ADLs by reviewing the most current or most recent quarterly assessment. 3. Facility staff develop and implement interventions in accordance with the resident's assessed needs, goals for care, preferences and recognized standards of practice that address the identified limitations in ability to perform ADLs. The facility admitted R57 on 09/03/21, with diagnoses including, but not limited to: congestive heart failure, hypertension, generalized anxiety disorder, rash and urinary tract infection. Review of R57's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/25, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated R57 had mild cognitive impairment. Section D was not scored for moods, section E was not coded for behaviors, and Section GG was not coded for functional abilities. Review of a document titled, Point of Care History revealed R57 bath schedule from 02/25/25 through 03/24/25. Further review revealed there were 11 days that a bath was not documented as given. The document indicated R57 did not receive a bath (any type of bath) on the following days: 02/27/25, 02/28/25, 03/02/25, 03/05/25, 03/08/25, 03/09/25, 03/11/25, 03/15/25, 03/17/25, 03/19/25 and 03/22/25. Further review of this document revealed 3 days, 03/10/25, 03/16/25 and 03/21/25, documented that R57 only received partial bed baths and not a full bath. Review of R57's Comprehensive Care Plan revealed a problem area titled ADLs Functional Status/Rehabilitation Potential which documented, Resident requires various levels of assistance with ADLs (bathing, dressing, grooming, oral care and etc.) due to weakness and deconditioning. She is offered choice of a bed bath or shower. The goal indicated the resident will participate with her ADLs as much as she is able as evidenced by Certified Nursing Assistant (CNA) documentation. The interventions directed staff to, Encourage resident to do as much as she is able. Assist with what she cannot do for herself. Allow ample time to complete tasks. Inform nurse and therapy of any decline or unwillingness to participate. Monitor for fatigue and pace care as needed. Licensed nurses, CNAs along with therapy stall will assist with ADLs care (bathing, dressing, grooming, oral care, hygiene, toileting) as needed. ADL care will be provided upon awaking, before and after meals, and before going to bed as needed along with throughout the day. Further review of the Comprehensive Care Plan revealed a problem, Continence Status: Resident is incontinent of both bowel and bladder related to weakness and deconditioning. The interventions directed staff to, provide incontinent care after each incontinent episode. During an observation on 03/23/25 at 11:05 AM, R57 was lying in bed, in a hospital gown, an odor was noted and R57 had facial hair on her chin. During an observation on 03/24/25 at 10:50 AM, R57 was lying in bed, in a hospital gown, with a similar odor and had facial hair on her chin. During an observation and interview on 03/25/25 at 1:25 PM, R57 was still wearing a hospital gown, with a similar odor and the facial hair was still on her chin. R57 stated, I usually have them shave it when I get a bath, I guess they are too busy and have a lot to do. During an interview with Licensed Practical Nurse (LPN)2, who was also the Unit Manager, stated, [R57] does not like to get out of bed so she has to have bed baths. LPN2 offered no explanation as to why R57 was in a hospital gown, with an odor and facial hair for 3 days.

Based on review of facility policy, record review, and interview, the facility failed to ensure medication irregularities were identified and reported to the physician for 2 of 5 residents reviewed, Resident (R)28 and R43. Specifically, R28's hydrocodone-acetaminophen (used to treat pain), venlafaxine (an antidepressant) and R43's olanzapine (an antipsychotic) were documented with the incorrect indication of use. Findings Include: Review of the facility policy titled, Medication Management Program last revised 05/05/23, states, The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements . 2. Licensed Independent Practitioners, licensed nurses, consulting pharmacists, and pharmacy service providers collaborate and review medication orders to ensure medical and clinical necessity and appropriateness. The primary mechanism for this validation is an initial and ongoing medication reconciliation process. Review of R28's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including but not limited to: post traumatic stress disorder, major depressive disorder, anxiety disorder, borderline personality disorder, chronic pain, fibromyalgia, and alcohol dependence. Review of R28's Care Plan dated 02/13/25, revealed R28 had a potential for complications related to psychotropic medication use with listed approaches that stated, Pharmacy consultant will review monthly. Review of R28's Physician's Order's revealed the following: 1. Dated 02/10/25 hydrocodone-acetaminophen; 5-325 Milligrams (mg); [DX: Hypothyroidism] Twice A Day (BID); 09:00 AM, 09:00 PM. 2. Dated 02/10/25 venlafaxine 150 mg [Diagnosis] DX: Alcohol dependence Once a Day; 09:00 AM. 3. Dated 03/05/25 venlafaxine 37.5 mg DX: Major depressive disorder Once a Day; 09:00 AM with Special Instructions to give with venlafaxine 150 mg. Review of a document titled [FCOS] Resident Medication Reconciliation Audit revealed the following: 1. Completed by admitting nurse at time of admission, highlighting clinically significant issues identified in the Nurse Comment section below 2. Nurse will attach a copy of the MAR/TAR 3 printed from Matrix, a copy of hospital discharge orders, and a list of medications taken at home. 3. Nurse will sign Resident Medication Reconciliation Audit, noting clinically significant issues communicated to physician in Nurse Comments. 4. Nurse will document the clarification or new orders received from physician under Follow Up and communicate changes to pharmacy by midnight of next calendar day. Further review revealed a boxed checked stating that R28's Patient Drug Regimen Review was completed upon admission and [NO] clinically significant medication issues were identified. Review of R28's Medication Regime Review dated 03/03/25, did not identify any concerns with venlafaxine or hydrocodone-acetaminophen. Review of R43's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including but not limited to: Neurocognitive disorder with Lewy bodies, vascular dementia, psychotic disorder with hallucinations, anxiety, insomnia, restlessness and agitation. Review of R43's Physician Order revealed an order for Zyprexa (olanzapine) tablet; 5 mg; 1/2 tab (2.5mg); [DX: Restlessness and agitation] Once A Day; 10:00 PM with a start dated of 12/19/24. Review of a document titled Physicians Orders Therapeutic Interchange Program dated 12/19/24, noted the following: Attention Nurse: The following order should be checked and transcribed to the [Medication Administration Record] MAR, Olanzapine 2.5mg 1 Tablet (2. 5mg) one time a day. During an interview on 03/25/25 at 9:08 AM, the Director of Nursing (DON) stated, when residents are admitted to the facility, nursing staff will call the Nurse Practitioner (NP) with any orders that need to be verified, unless the NP is in the building. Unit Managers (UMs) usually transcribe and place the order in the medical records, though floor nurses can also do this. The DON confirmed that R28's and R43's medications did not have accurate indications for use and stated that it may have been an error when transcribing the orders to the Medication Administration Record (MAR), but she would have them updated. During an interview on 03/25/25 at 12:10 PM, the NP stated, upon admission to the facility, medications are reviewed for accuracy. The DON will reach out to her regarding any issues with medication orders, and typically, the UMs are the ones who identify discrepancies in the MAR. The NP also mentioned that the psych provider reviews and adjusts medications and will place the order and then verify it for finalization. The NP acknowledged that the medication orders for R28 and R43 were an oversight.

Based on review of facility policy, observation, and interview, the facility failed to ensure placement of a feeding tube (abdominal) for Resident (R)45, before flushing with water and inserting oral medications into the tube, for 1 of 1 residents observed receiving medications via a feeding tube. Findings include: Review of the undated facility policy titled Enteral Feeding - Administering Medications documented, The licensed nurse will administer medications prescribed by the physician to be given by enteral tube, using the appropriate method according to recognized standards of practice. The licensed nurse will verify correct tube placement on those devices that are not inserted directly into the gut, per clinical standards of practice. The facility admitted R45 on 01/03/25, with diagnoses including, but not limited to: stroke with hemiplegia and hemiparesis, protein calorie malnutrition and vascular dementia along with dysphagia and aphasia. Review of R45's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/09/25, revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severe cognitive deficits. Resident is total care with all activities of daily living. Review of R45's Physician Orders dated 07/09/24, revealed, Enteral Feeding: Placement Verification - Check Residual. If residual is 150 milliliters or less reinsert volume into stomach and continue feeding. If greater than 150 milliliters hold feeding and notify physician. Review of R45's Comprehensive Plan of Care dated 07/20/24, revealed a problem, Resident requires a feeding tube related to poor PO (by mouth) intake and weight loss. The goal revealed, Resident will not exhibit signs of complications from feeding tube or enteral feeding solution. The intervention directed staff to, Check placement and patency of feeding tube before each feeding or medication administration. During an observation on 03/24/25 at 7:48 AM, of medication administration via feeding tube for R45 went as follows: Registered Nurse (RN)1 had previously crushed the medications for R45 and was going into his room to give the medications. RN1 knocked on the resident's room door and entered, then explained the procedure to the resident. RN1 used a piston syringe to check residual, none came out into the syringe. RN1 stated there is no residual. The nurse did not check placement and proceeded to administer the medications via the tube, and they did not go down freely via gravity. RN1 milked the tubing and had difficulty getting the medications to go down the tube. Eventually RN1 used the plunger and placed a small amount of pressure to get the medications to go down the tube. RN1 then flushed the tube and restarted the tube feeding. During an interview on 03/24/25 at 8:15 AM, RN1 confirmed that she did not first confirm placement of the tube before administering the medications.

Based on review of facility policy, record review, and interview, the facility failed to refer Resident (R)20 for a Preadmission Screening and Resident Review (PASARR) Level II, after the resident received a new diagnosis of a severe mental illness and/or experienced a significant change in status assessment related to their mental illness, for 1 of 2 residents, (Resident (R)20), reviewed for PASARR. Findings Include: Review of the facility policy titled, PASARR Documentation Policy last revised June 9, 2023, documented under PASARR Care Plan, 6 Any resident with newly evident or possible serious mental disorder, ID or a related condition must be referred, by the facility to the appropriate state-designated mental health or intellectual disability authority for review. Review of R20's PASARR Level I Screening Form, dated 11/21/14, revealed the following diagnoses: sepsis, hypertension, seizures and [UE] extremities. R20 had no diagnoses of mental illness nor a history of psychiatric hospitalization in the past two years and no behavioral indicators. R20 received a recommendation of No further evaluation recommended. Review of R20's Face Sheet revealed R20 was admitted to the facility on [DATE]. R20's current diagnoses included but are not limited to: psychotic disorder (09/19/25), delusional disorders (12/06/24), major depressive disorder (12/06/24), dementia without psychotic disturbance (10/09/24), generalized anxiety disorder (12/06/24) and restlessness and agitation (10/18/24). Review of R20's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/08/25, revealed R20 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderate cognitive impairment. Further review revealed, R20 had, verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) that occurred daily. Review of a Nursing Progress Note dated 02/07/25, noted, Resident was yelling, cursing at roommate and this writer when I attempted to intervene. Resident stated get him out of my blank room I mean it he better get out of my room explained to resident he is sharing a room with another resident stated I don't care told resident we are reporting him to management due to negative behaviors towards roommates will continue to monitor behaviors. Review of a Progress Noted dated 02/25/25, completed by R20's physician noted, Recent increase in behaviors [DATE]-already on scheduled lorazepam . Previously declined for inpatient management by gen psych institution. Review of R20's Electronic Medical Records (EMR) did not reveal a referral for a Level 2 PASARR. During an interview on 03/23/25 at 3:53 PM, the Social Services Director (SSD) stated, R20 has not been screened and there was no referral for screening. The SSD states the reason for R20 not being screened was, he has not had significant behaviors or treatment in the last two years.

Based on review of facility policy, record review, and interview, the facility failed to ensure Resident (R)1, while having an acute neurological change, was free from continued falls and injuries, for 1 of 3 residents reviewed. Findings include: Review of the facility policy, dated May 5, 2023, titled, Fall Management revealed under policy, qualified staff evaluates resident and determines contributing causes, addresses risk factors for the fall such as the residents medical condition and determines interventions to prevent future falls. Review of R1's Face Sheet revealed the facility admitted R1 on 07/25/23 with diagnoses including but not limited to: Schizoaffective Disorder, heart disease, metabolic encephalopathy, unsteadiness of feet, dementia, history of falling, type 2 diabetes, hypertension, and essential hypertension. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/31/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating R1 had moderately impaired cognition. Review of R1's Quarterly MDS with an ARD of 04/30/24, revealed R1's BIMS score was documented, acute onset mental change, behavior continuously. There was no score as it could not be ascertained. Review of R1's Care Plan with a start date of 11/14/23, revealed, [R1] is at risk for falls r/t incontinence episodes and other medical diagnoses listed in the H&P No absolute prevention from falls Actual falls: 4/8/24, 4/13/24, 4/16/24, 4/17/24 (5), 4/19/24. The goal for this Care Plan documented, [R1] will have no serious injuries from falls . Review of R1's Electronic Medical Record (EMR) and Situation Background Assessment Recommendation (SBAR) Communication Form revealed R1 suffered a fall on the following days: On 04/13/2024 at 1:30 PM, R1 was found on the floor by the therapist beside her bed. Her blood pressure (B/P) was 90/48, indicating it was low. It further recorded a change in mental status and increased confusion. She was sent to the hospital and was diagnosed with a new hematoma to front and back of right scalp area. Imaging at the hospital revealed new left rib fractures. On 04/16/24 at 1:30 PM, R1 was observed on the floor near the door of her room. Change in mental status was recorded. On 04/17/24 at 11:30 AM, R1's blood pressure recorded as 91/42, indicating it was low. She was described as confused, disoriented with change in mental status. On 04/17/24 at 1:35 PM, R1 was found on the floor in her room, without vital signs recorded. She was described as having increased confusion. No injury recorded. On 04/17/24 at 1:50 PM, R1 was found on the floor in her room, no vital signs were recorded. A change in mental status was recorded. No injury recorded. On 04/17/24 at 2:15 PM, R1 was found on the floor in her room, her pulse was 113, normal is 60-100 beats per minute. Her B/P was recorded 98/54, indicating a low B/P. No injury recorded. On 04/17/24 at 2:30 PM, R1 was found on the floor in her room, her pulse was 113 and her B/P was 98/54, same as previous vital signs. On 04/17/24 at 10:15 PM, R1 was found on the floor with no apparent injury. On 04/19/24 at 2:20 PM, R1 was found on the floor. She complained of pain on her bottom. No injury was recorded. On 04/21/24 at an unspecified time, R1 became hypotensive with B/P 73/45, not verbally responsive and she was sent to the hospital. On same date, facility called for an update and was informed R1 was diagnosed with subdural hemtoma. She returned from the hospital on 04/25/24. During an interview on 06/10/24 at 3:35 PM, Licensed Practical Nurse (LPN)1 revealed, for a low blood pressure (B/P), we would notify the Nurse Practitioner (NP), she was in the building the day she [R1] fell all those times. During an interview on 06/10/24 at 5:14 PM, the Director of Nurses (DON) stated, for each of [R1's] falls, the NP was notified, I cannot say if she was notified specifically on the low B/P's. During an interview on 06/12/24 at 12:12 PM, the LPN Unit Manager stated, I help my nurses when they need it, that day [R1] had a lot of falls. In April, her B/P was running a lot lower. I helped with the incident reports, but I may not have had the vitals and the nurse will put them in. The low B/P could have contributed to [R1's] falls. Some nurses will tell me if the B/P's are low, but others will tell the NP. I like to recheck them. In April, [R1] was a different person, more confused, easily agitated and more impulsive. During an interview on 06/12/24 at 1:40 PM, the Nurse Practitioner (NP) stated, They were monitoring her neuro checks. I was not aware of the low B/P's or I would have sent [R1] to the emergency room , or I would have tried some things, and held her B/P medication. She may have had the subdural hematoma, but it didn't show on imaging until 04/21/24, when she was hospitalized .

Based on observations, interviews, and review of the facility policy, the facility failed to ensure foods that are stored in the freezer, dry storage, emergency storage and resident dietary rooms were properly labeled and discarded after the manufacturer's expiration date. Findings Include: Review of the facility's policy titled, Food Safety in Receiving and Storage, dated [DATE], revealed, Food will be received and stored by methods to minimize contamination and bacterial growth. Receiving Guidelines .6. Check expiration dates and use-by dates to assure the dates are within acceptable parameters. Dry Storage Guidelines .3. Containers holding food or food ingredients that are removed from their original packages such as cooking oils, flour, sugar, herbs and spices are identified with he common name of the food. Refrigerated Storage Guidelines .12. Refrigerated, ready to eat Time/Temperature Control for Safety Foods (TCS) are properly covered, labeled, dated with use-by date, and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. During an observation on [DATE] at 11:14 AM of the kitchen, walk-in refrigerator, dry food storage area, walk-in freezer, and emergency storage room revealed the following: Kitchen: A large bin of powder like substance that was not labeled or dated. The substance was confirmed to be flour by the Kitchen Manager (KM). Walk-in Refrigerator: A box of Idaho potatoes, contained one potato that had a mold-like substance on the skin. Dry Food Storage Area: Three packs of 6' Flour Tortillas with an expiration date of [DATE] and a received date of ,d+[DATE]. Walk-in freezer: A clear container labeled as corn and tomatoes, had a use by date of [DATE]. A large square clear container containing a red substance was not labeled or dated; the KM stated that was spaghetti sauce. The emergency storage room contained a large box of Zesta box crackers with an expiration date of ,d+[DATE]. All items identified above were removed by the KM. During an observation on [DATE] at 2:03 PM of the 200-hall resident dietary room, revealed a large clear plastic Ziplock bag that contained 22 individually wrapped Kellogg Honey Graham crackers and two Zesta Saltines, which were not dated. During an interview on [DATE] at 11:20 AM, with the KM, revealed that all items should be labeled with the date the product was opened and a use by or expiration date. The items are checked about every other day, to keep an accurate record of what can be used or what needs to be thrown out. She includes they must do a better job looking at the dates when they receive the items because some of them are already expired when they get them from the food provider. The KM includes she is fairly new and her expectation is for all staff to follow policies to ensure that there aren't any deficiencies in the kitchen. During an interview on [DATE] at approximately 12:00 PM with the Administrator, revealed they had just cleaned out their emergency supply room and that box must have been overlooked. The maintenance director removed the box from the room. During a follow up interview on [DATE] at 2:10 PM the KM, revealed that they usually write down the day they bring the snacks down to the dietary rooms and the date is placed on the Ziploc bag. They typically replace the snacks every three days, and they provide them to the halls as requested by the nurses.

Based on record review, interviews, and facility policy review, the facility failed to implement procedures and safeguards to reduce the potential growth and spread of Legionella. This failure had the potential to affect all resident in the facility. Findings include: A review of the facility's policy titled, Water Systems, Safety and Management, with a complete revision date of May 15,2023, revealed, Facility will implement procedures and safeguards to reduce the potential of growth and spread of Legionella and other opportunistic pathogens in building water systems. 1. A. Using this policy and the Centers for Disease Prevention and Control's Facility Leadership will assess water systems. B. Facility Leadership in conjunction with the Safety Committee and Infection Preventionist will comprise the Water Management Team. This team is overseen and facilitated by the Administrator to ensure adequate resources and Program Implementation. During an interview with the Maintenance Director (MD) on 06/23/23 at 1:52 PM, revealed that no water management program to prevent the growth of Legionella was established and that the Commissioners of Public Works (CPW) came and tested the water, but they informed him that he needed to contact a private company to come out and test the water for Legionella. The MD stated that they have not had any cases in the building, and he recognizes the symptoms of the disease include nausea and vomiting. The MD further stated that the facility does not have any water fountains, they use five-gallon water bottles to provide water to the residents. During an interview with the Infection Preventionist (IP) on 06/23/23 at 2:06 PM, the IP stated that maintenance was over the water management program and that was, beyond her duties.

Based on review of the facility policy, observation, record review, and interview, the facility failed to ensure that 1 (Resident (R)17) of 5 residents observed for resident rights was provided bathing preferences. Findings include: Review of the facility's policy titled, Social Services Policies and Procedures with a complete revision date of 10/01/20, revealed, The Facility provides care for each resident in a manner that promotes, maintains, or enhances quality of life, recognizing each resident's individuality. Review of R17's Admission Record revealed R17 was admitted to the facility on [DATE], with diagnoses including but not limited to; Parkinson's disease, multiple sclerosis, type 2 diabetes mellitus without complications, and major depressive disorder. Review of R17's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/18/23, revealed R17 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R17 was moderately cognitively impaired. Further review of the MDS revealed, it is somewhat important for R17 to have a shower over a bed bath. Review of the Shower Records revealed that R17 was scheduled for showers on Mondays and Thursdays, on second shift. A complete review of the shower sheets revealed no evidence that R17 had received a shower over the period of 02/26/23 to 06/21/23. During an observation on 06/20/23 at approximately 12:37 PM, R17 was observed in her room, in the bed which was in an elevated position. R17's hair was greasy and unwashed and she was wearing a night grown. During an interview with R17 on 06/20/23 at approximately 12:39 PM, she stated that she prefers showers, her shower days are Monday and Thursday. R17 further stated, she has not had a shower since February 2023. R17 stated staff will say she refuses showers, but she does not refuse. During an interview on 06/23/23 at approximately 1:11 PM with Certified Nursing Assistant (CNA)1, revealed that CNA1 provides Activities of Daily (ADL) services to R17. CNA1 revealed she usually provides R17 with complete bed baths or partial bed baths. CNA1 stated that R17's shower days are Mondays and Thursdays. CNA1 concluded that R17 has not requested showers. During an interview with the Activity Director (AD), on 06/23/2023 at 11:12 AM, the AD revealed that residents are provided with an activity calendar and activity staff go to the resident rooms and ask if residents would like to attend activities. The AD stated participation is very low at this facility, some of it's due to residents not wanting to participate and some is due to staff not getting residents out of bed. R17 has expressed to the AD that she would like to come to activities and has stated that staff will not get her up for showers or activities.

Based on review of facility policy, record reviews, and interviews the facility failed to provide a notice of transfer for hospitalization and the reasons for the transfer in writing or as soon as practicable to Resident (R)59 and R26, the Resident Representative and Ombudsman for 2 out of 2 residents. Findings include: Review of the facility's policy titled, Social Services Policies and Procedures Discharge Notification with a complete revision date of 10/01/20 documented under section Discharge Notification. The Social Services Staff/or designee is charged with ensuring that systems are in place to provide written notification to the patient/resident and if known, a family member or legal representative prior to the patient's/resident's transfer and the LTC ombudsman. The notifications must be documented in the resident's medical record. The transfer/discharge notice must comply with federal and state regulations and must contain the following information. The facility policy further reveals #6. Notice before transfer (a) Before a facility transfer or discharges a resident, the facility must (1) notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. (2) The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman and documentation to reflect in the resident's medical record. (3) Document the reasons for the transfer or discharge in the resident's medical record as noted above in Page 7 (3) A 2. 1. Review of R59's Face Sheet revealed R59 was admitted to the facility on [DATE]. Review of R59's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 04/30/23 revealed a Brief Interview of Mental Status (BIMS) score of 0 out of 15, indicating R59 was severely cognitively impaired. Review of R59's Progress Note dated 03/21/23 at 2:29 PM (recorded as late entry on 03/21/2023 at 5:56 PM) revealed, .PER wound care NP resident to be transferred to [local hospital] for eval and TX. Review of R59's Progress Note dated 04/17/23 at an unspecified time revealed, Resident returned at 4pm via stretcher . An interview with the Administrator on 06/22/23 at 3:37 PM, revealed the facility doesn't have documentation in writing of notification of the reason for the transfer/discharge, to the hospital, in a language they understand, nor a copy of the notice sent to the Ombudsman office. A follow up interview with the Administrator on 06/22/23 at 3:53 PM, revealed the Administrator presented the surveyor with the Admission Handbook, which included the Behold Policy basic per diem rate of $194.50. The Administrator stated, this is presented to residents at admission and reviewed during admission meeting with the bed hold rate. The Administrator stated this is not provided at the time of transfer/discharge. The Administrator further stated, they mail the names of residents who were transferred or discharged to the Ombudsman Office. An interview with the Ombudsman's Office on 06/23/23 at 9:16 AM revealed, the Ombudsman didn't receive any discharge information regarding R59. The Ombudsman stated normally the facility will notify the office through email or fax. An interview with Social Services (SS) on 06/23/23 at 2:02 PM revealed, SS stated for residents discharged and/or transferred she completes the forms and place the forms in Matrix. The SS stated she is unsure of what the policy is. She stated she will notify the Ombudsman by email. The SS stated she does not document this process anywhere, except to place the documents on Matrix. 2. Review of R26's Face Sheet revealed R26 was admitted to the facility on [DATE], with the latest return on 11/21/22. R26 was admitted with diagnoses including, but not limited to; osteomyelitis of vertebra, sacral and sacrococcygeal region, acute tracheitis, peripheral vascular disease, type 2 diabetes mellitus, and pressure ulcer of sacral region, stage 4. Review of R26's Progress Note dated 03/27/23 at 6:51 PM, revealed, 635p alerted by daughter feeding was coming out at connection of peg tube, requested by daughter to have her sent out via 911 to [local hospital]. RN at [hospice] made aware. DON also informed. Review of R26's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/19/23 revealed R26 did not have a Brief Interview for Mental Status (BIMS) conducted, as the resident is severely cognitively impaired. Review of R26's electronic medical record, revealed that R26 was discharged to the hospital on 03/27/23 and no documentation detailed that there had been any correspondence to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move, verbally or in writing, in a language and manner they understand. An interview on 06/23/23 at 10:29 AM with the Director of Nursing (DON), revealed that R26 had issues with her feeding tube, and it kept coming out, the facility put it back in, but the daughter of R26 wanted it reevaluated to make sure they had completed the procedure correctly, so they sent her to the emergency room (ER). The DON revealed that each time she goes out she is provided with discharge and bed hold information, that is usually provided by the business office and social worker, but she was not able to present documentation that was provided to R26 at this time. 47257

Based on review of facility policy, record review, and interviews, the facility failed to provide 2 out of 2 residents a copy of the bed hold policy in order to ensure that Resident (R)59 and R26 were aware of the bed hold policy and basic per diem rate. Findings include: Review of the facility's policy titled, Facility's Policy and State Requirements for a Temporary Leave Bed-Hold dated (Admissions Handbook) revised 03/2023 documented, the resident and/or his/her representative will be given a copy of the Facility's bed-hold policy before the resident actually leaves for his/her temporary leave or hospitalization , the bed hold policy may accompany the resident to the hospital or will be given to the resident or his/her legal representative within twenty-four hours of the resident's hospitalization . Review of R59's Face Sheet revealed R59 was admitted to the facility on [DATE]. Review of R59's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/23 revealed, R59 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating R59 had severe cognitive impairment. Review of R59's Progress Note dated 03/21/23 at 2:29 PM (recorded as late entry on 03/21/2023 at 5:56PM) revealed, . PER wound care NP resident to be transferred to [Local hospital] for eval and TX. Review of R59's Progress Note dated 04/17/23 revealed, Resident returned at 4pm via stretcher. In an interview with the Administrator on 06/22/23 at 3:37 PM, revealed the facility doesn't have documentation in writing of notification of the reason for the transfer/discharge to the hospital in a language they understand nor a copy of the notice sent to the Ombudsman office. In a follow up interview with the Administrator on 06/22/23 at 3:53 PM revealed, she presented the surveyor with the Admission Handbook with the Behold Policy basic per diem rate of $194.50. The Administrator stated this is presented to the resident at admission and reviewed during admission meeting with the bed hold rate. She stated this is not provided at the time of transfer/discharge. She further stated they mail the names of residents transferred or discharged to the Ombudsman Office. In an interview with the Ombudsman Office on 06/23/23 at 9:16 AM, revealed the Ombudsman did not receive any discharge information for R59 for the month of March 2023. She stated normally the facility will notify the office through email or fax. In an interview with Social Services (SS) on 06/23/23 at 2:02 PM, revealed for residents discharged and/or transferred SS would complete the forms and place the forms in Matrix. She stated she is unsure of what the policy is. She stated she will notify the Ombudsman by email. She stated she does not document this process anywhere, except to place the documents on Matrix. 2. Review of R26's Face Sheet revealed she was admitted to the facility on [DATE], with the latest return on 11/21/22. Review of R26's Progress Note dated 03/27/23 at 6:51 PM, revealed 635p alerted by daughter feeding was coming out at connection of peg tube, requested by daughter to have her sent out via 911 to [local hospital]. RN at [Hospice] made aware. DON also informed. Review of R26's Quarterly MDS with an ARD of 05/19/23, revealed R26 did not have a BIMS assessment conducted, as the resident is severely cognitively impaired. Review of R26's Electronic Medical Record (EMR), revealed that she was discharged to the hospital on 03/27/23. Further review of the EMR, revealed no documentation that any correspondence to notify the resident and the resident's representative(s) of the bed hold policy, as it is required that facilities provide written information about the policies prior to and upon transfer for such absences. The notice must be provided to the resident, and if applicable the resident's representative, at the time of transfer and include the reserve bed payment policy. An interview on 06/23/23 at 10:29 AM with the Director of Nursing (DON), revealed that R26 had issues with her feeding tube, and it kept coming out, the facility put it back in, but the daughter of R26 wanted it reevaluated to make sure they had completed the procedure correctly, so they sent her to the emergency room (ER). The DON revealed that each time she [R26] goes out she is provided with discharge and bed hold information, that is usually provided by the business office and social worker, but she was not able to present documentation showing that was provided to R26 or R26's representative at this time. 47257

Based on observations, interviews, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan for 1 (Resident (R)60) of 5 residents whose comprehensive care plans were reviewed. Specifically, the facility failed to develop a comprehensive care plan for R60 to be on isolation precautions for the diagnosis of sabies. Findings include: Review of the facility policy titled, Care Plan Process, Person-Centered Care with an effective date of 05/05/23, revealed .the baseline person-centered care plan will include the minimum healthcare information necessary to properly care for the resident including, but not limited to initial goals based on admission orders, resident goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendation, if applicable. Review of R60's Resident Face Sheet indicated the facility admitted (R)60 on 03/10/23 with diagnoses that included but was not limited to; Parkinson's disease, psoriasis, dementia, anxiety disorder, and psychotic disorder with delusions due to known physiological condition. Review of R60's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/23, revealed (R)60 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had moderately impaired cognitive skills for daily decision making and had short and long-term memory problems. The MDS indicated the resident did not have any skin condition but was receiving applications of ointments. The MDS indicated the resident was independent with transfers, eating, toileting, personal hygiene and bed mobility. Review of a Care Plan(s), Review of a Care Plan, with a problem start date of 06/20/2023, revealed Resident #60 had a rash on the residents back.The facility developed interventions that included to administer medications as ordered, discourage resident from scratching area to reduce tissue damage, monitor and record complaints of pain/itching/discomfort, and to conduct a systematic skin inspection per doctor's orders. Care plan did not identify scabies prior to 6/20/23. Review of History and Physical indicated the date of service was 03/14/2023 and the resident had a past medical history of psoriasis. Review of Focused Observation, completed on 03/17/2023 at 7:16 PM indicated the resident had warm, dry skin with normal color and turgor with no alterations in skin. Review of Focused Observation, completed on 06/09/2023 at 11:46 AM indicated the resident had cool, extremely dry skin with normal skin turgor. The observation also included an additional comment of psoriasis. Review of Focused Observation, completed on 06/16/2023 at 12:42 AM indicated the resident had warm, dry skin of normal color and normal skin turgor. The observation included the resident had alterations in skin that included redness to arms, legs, trunk and face and the resident had creams ordered for treatment. Review of Resident Progress Notes revealed on 06/14/2023 at 12:58 PM, Licensed Practical Nurse (LPN)6 documented R60 received a new physician's order for Permethrin cream and Ivermectin treatment due to a new diagnosis of scabies. The resident was reminded to stay in their room and use the call bell for assistance and contact precautions were in place. Review of Order History was reviewed from 05/21/2023 through 06/21/2023 and revealed on 06/14/2023, there was a one-time physician's order for permethrin 5% topical cream to be applied to the resident's entire body and to leave on for eight to 12 hours and wash off. The same order was repeated on 06/20/2023. There was no physician's order listed for the resident to be on contact isolation. During a concurrent observation and interview on 06/20/2023 at 1:33 PM, Resident #60 walked down the hallway of Zone 3, past the nurse's station and entered the Day Room to speak to the surveyor using an interpreter on an iPad. The interpreter had a difficult time understanding the resident, but the resident indicated the she had itching but did not specify where. She indicated to the interpreter that the facility had applied a cream but that did not help with the itching. During the interview, the resident was observed scratching both arms. During an observation on 06/20/2023 at 3:51 PM, R60 was observed walking down the hall designated as Zone 3 using their walker for assistance. At 3:54 PM, the resident was observed walking back down the hallway. During an observation on 06/20/2023 at 4:09 PM, R60 was sitting on their rolling walker in the hallway of Zone 3. During an interview on 06/23/2023 at 11:40 am, the MDS Coordinator stated she was responsible for updating care plans. She stated if a resident is on contact isolation, there should be a care plan addressing it. While reviewing R60's care plan, the MDS Coordinator indicated the care plan should have been updated on 06/14, but she is running behind due to staffing shortages. During an interview on 06/23/2023 at 11:59 AM, the Director of Nursing (DON) reported the MDS Coordinator is responsible for care plan updates. She stated if a resident is on any type of tranmission based precautions, their care plan should be updated. During an interview on 06/23/2023 at 12:05 PM, the Corporate Clinical Director stated she was made aware that R60 did not have an accurate care plan and her expectations was that staff would update the care plan accurately.

Based on review of facility policy, observation, record review, and interview, the facility failed to ensure that 1 (Resident (R)17) of 5 residents reviewed for activities received activities that meet the intent and needs of each resident. Findings include: Review of the facility's policy titled, Activity Policies and Procedures with a complete revision date of 09/01/20, revealed, The Activity/Recreational Director and staff will schedule programs and events at times available to patients and resident interests, hobbies, and cultural preferences. Review of R17's Admission Record revealed R17 was admitted to the facility on [DATE], with diagnoses including but not limited to, Parkinson's disease, multiple sclerosis, type 2 diabetes mellitus without complications, and major depressive disorder. Review of R17's annual Minimum Data Set (MDS), located in the Electronic Medical Record (EMR) under the MDS tab, with an Assessment Reference Date (ARD) of 02/18/23, revealed R17 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R17 was moderately cognitively impaired. Further review of the MDS revealed it is somewhat important for R17 to have their favorite activities. During an observation on 06/20/23 at approximately 12:37 PM, R17 was observed in her room, in the bed with the head of bed in an elevated position. An interview with R17 on 06/20/23 at approximately 12:39 PM, revealed R17 is interested in attending activities and she never gets to attend any activities. R17 stated that staff come around informing her of activities, but staff never take her to any of the activities and she does not refuse to attend activities. An interview with the Activity Director (AD) on 06/23/2023 at 11:12 AM, revealed residents are provided with an activity calendar and activity staff go to the resident rooms and ask if residents would like to attend activities. The AD stated resident participation is very low at this facility, some of it's due to residents not wanting to participate and some is due to staff not getting residents out of bed. R17 has expressed to the AD that she would like to come to activities and has stated that staff will not get her up for activities. During an interview on 06/23/23 at approximately 12:37 PM with the Director of Nursing (DON), she revealed we ensure staff are available to assist with activities in and out of the facility. The DON stated she was not aware that R17 wanted to attend activities.

Based on review of facility policy, observation, record review, and interview, the facility failed to ensure Resident (R)55 was free from significant medication errors related to blood pressure (BP) medication administration for 1 of 5 residents reviewed for medication administration. Findings include: Review of the facility's policy titled, Medication Management Program with a complete revision date of 05/05/23 revealed, Prior to administering medications, the nurse is responsible for A. Obtaining and recording any necessary vital signs. A review of R55's electronic medical record (EMR) revealed R55 was admitted to the facility with diagnoses that included but was not limited to; Wernicke's encephalopathy, major depressive disorder, bradycardia, and hypertension. Review of R55's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/03/23, revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident was severely cognitively impaired. A review of R55's care plan, revised on 02/23/2022, revealed the following: has cardiac disease with diagnoses of Hypertension, Bradycardia, Iron-deficiency anemia, and is being treated as ordered. Interventions include to administer meds as ordered per physician's orders, check Medication Administration Records (MARs) for current dose/time, Monitor for cardiac distress and update physician as needed. Also, monitor ordered labs, vital signs. Administer diet as per physician orders and monitor for weight gain, shortness of breath, edema and update physician with any changes. Monitor for cardiac BP variances, sudden weakness or pallor, shortness of breath, distress, (i.e.) chest pain, dizziness, changes in vital signs and update MD as needed. Monitor/document/report as needed abnormal laboratory values (e.g., white blood cell count and differential, serum protein, serum albumin, and cultures). A review of R55's June 2023 physician's orders revealed an order for Chlorthalidone tablet 25 milligrams (mg)- one half tablet with special instructions to hold if the systolic blood pressure was less than 100. During an observation and interview on 06/23/23 at 9:23 AM, Licensed Practical Nurse (LPN)1 was observed completing the morning administration of medication to residents. LPN1 stated that R55 had an order for Chlorthalidone tablet 25 mg, one half tablet, Loratadine 10 mg 1 tablet, and Thiamine mononitrate (vitamin B1)- 1 tablet. R55 was observed lying in bed with the head of bed elevated. LPN1 administered the Chlorthalidone 25 mg, one half tablet to the resident without checking R55's blood pressure. During an observation on 06/23/23 at 10:10 AM, LPN1 checked R55's blood pressure. The first BP was 98/61 with R55 lying down. The second check was 81/64 in the left arm. The third check, manually was 114/65. LPN1 then asked R55 how he felt and he stated he felt tired. During an interview with LPN1 on 06/23/23 at 10:20 AM, she stated she administered the medication based on R55's BP from the previous day. She revealed that she should have taken a fresh BP. She added that by administering the medication without checking the BP, there could have been adverse reactions to R55. During an interview with the Director of Nursing (DON) on 06/23/23 at 11:59 AM, she stated her expectation was for staff to follow the parameters of the orders. If the medication was to be held, it should have been. She stated that vital signs should not be used from the previous day to administer medications.

Based on review of facility policy, record review, and interviews, the facility failed to ensure one Resident (R)1 out of 5 reviewed, received medications per physician orders. Specifically, the facility failed to assure that procedures were implemented so that all medication orders were processed consistently and accurately through the stages of ordering, receiving, and administering medications. Findings include: Review of the facility policy titled, Medication Management Program revealed Policy: The facility implements a medication management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. 2. Licensed nurses will evaluate, assess, monitor, document, and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life. Review of the facility's face sheet revealed R1 was admitted to the facility from a local hospital on 04/29/22 with diagnoses including but not limited to, systemic lupus, pneumonia due to coronavirus disease, chronic obstructive pulmonary disease ([CONDITION(S)]), long term use of anticoagulants, personal history of venous [CONDITION(S)] and embolism, obstructive sleep apnea, gastroesophageal reflux disease, pain in leg, and nausea. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/04/22 revealed R1 had a Brief Interview of Mental Status score of 15, indicating she is cognitively intact. Review of R1's Hospital Discharge Summary dated 04/29/22 revealed she was discharged from the hospital with the following physician orders: 1. [MEDICATION(S)] ([MEDICATION(S)]) 25mg- 25 mg oral (by mouth) daily 2. [MEDICATION(S)] ([MEDICATION(S)]) 5mg- 5mg oral daily by mouth Wed 3. [MEDICATION(S)] ([MEDICATION(S)]) 5mg- 7.5mg oral daily Instructions: Except Wed 4. [MEDICATION(S)] [MEDICATION(S)] XL 50mg- 50mg oral daily 5. [MEDICATION(S)] 200mg- 400mg oral at bedtime 6. [MEDICATION(S)] 10mg- 10mg oral daily 7. [MEDICATION(S)] 300mg- 300mg oral in am 8. [MEDICATION(S)] 100mg- 100mg oral Noon 9. [MEDICATION(S)] 600mg- 600 mg oral at bedtime 10. Vitamin D3 1,000 units- 5,000 units oral daily 11. [MEDICATION(S)] 25mg- 25mg oral twice daily as needed for Dizziness 12. Omeprazole 40mg- 40mg oral daily 13. [MEDICATION(S)] 250mg-250mg oral daily 14. [MEDICATION(S)] 5mg- 10mg oral at bedtime Review of the facility's Medication/Treatment Error Investigation Worksheet dated 05/03/22 at 3:00 PM revealed on 04/29/22 at 5:45 PM, under the section titled Medication Error revealed R1 missed meds (medications) during admission process. Under the section titled Reasons for Error the following boxes were checked: Failure to Follow Procedure and Misread Order/Dose. Under the section titled Describe error revealed during admission process (patient arrived at 5:45 PM on Friday, 4/29/22) a portion of medications were missed and not put into matrix. Patient is alert and oriented and made staff aware of missing medications. Meds were resolved Monday 5/2 but doses were missed Saturday 4/30 and Sunday 5/1. See attached paper for missing medications. Under the section titled Findings and Analysis revealed during admission on Friday evening agency nurse missed a portion of medications when inputting orders. MDS Licensed Practical Nurse (LPN) discovered missing meds Monday 5/2. No phone calls were made to on call phone during weekend. MDS LPN assessed patient, meds were put into matrix and pulled for administration. Pharmacy called, meds sent Monday night, MD assessed patient 5/3. There were no adverse reactions to missed doses. Further review of the Investigations Findings revealed a list of the following medications that were not administered: 1. [MEDICATION(S)] ([MEDICATION(S)]) 25mg- 25 mg oral (by mouth) daily 2. [MEDICATION(S)] ([MEDICATION(S)]) 5mg- 5mg oral daily Wed 3. [MEDICATION(S)] ([MEDICATION(S)]) 5mg- 7.5 mg oral daily Instructions: except Wed 4. [MEDICATION(S)] [MEDICATION(S)] XL 50mg- 50mg oral daily 5. [MEDICATION(S)] 200mg- 400mg oral at bedtime 6. [MEDICATION(S)] 10mg- 10mg oral daily 7. [MEDICATION(S)] 300mg- 300mg oral in am 8. [MEDICATION(S)] 100mg- 100mg oral Noon 9. [MEDICATION(S)] 600mg- 600 mg oral at bedtime 10. Vitamin D3 1,000 units- 5,000 units oral daily 11. [MEDICATION(S)] 25mg- 25mg oral twice daily as needed for Dizziness 12. Omeprazole 40mg- 40mg oral daily 13. [MEDICATION(S)] 250mg-250mg oral daily 14. [MEDICATION(S)] 5mg- 10mg oral at bedtime A telephone interview with R1 on 06/22/22 at 10:50 AM revealed on 04/29/22 she was admitted to the facility from the hospital. R1 stated she was admitted late on a Friday afternoon and remembers her admitting nurse was a male. R1 stated she asked the nurse (during the evening) for her inhaler and the nurse politely explained to her, he could not find the medication. R1 revealed to the surveyor that she became concerned and began to take notes in the journal of her stay at the facility. R1 stated she documented notes all weekend and did not receive any of the medications she was discharged from the hospital with. R1 stated she remembers a nurse came and told her that the medications would arrive late Friday evening or early Saturday morning, however, she still did not receive any medications over the weekend. R1 stated she was approached by the new Administrator on 05/02/22 and filed a grievance. R1 revealed she reported to the Administrator that she had not received any medications over the weekend and the Administrator notified the physician. R1 revealed she was assessed by a nurse and physician and was given orders for medications. R1 stated that she did not have any pain or symptoms for not receiving her medication but was disappointed that none of the staff knew what to do. A telephone interview with LPN1 on 06/22/22 at 1:13 PM revealed he was R1's admitting nursing on 04/29/22. LPN1 stated he did not remember if he put R1's medications into the system or if they were done by someone else. LPN1 stated he did not administer R1 any medications on 04/29/22 and revealed he only worked the 3-7 PM shift. LPN1 revealed he did not work on 04/30/22 or 05/01/22, so he was unsure if R1 received any medications during the weekend. LPN1 further stated when residents are admitted to the facility late in the afternoon, medications aren't usually delivered until the next morning. LPN1 stated he could not confirm if R1 medications arrived to the facility on [DATE]. An interview with the Director of Nursing (DON) on 06/22/22 at 2:15 PM revealed her expectations of staff are to verify resident medications on admission. The DON stated she conducted in-service with all staff on how to verify medications and ensure prescriptions are sent to the pharmacy in a timely manner. The DON further stated that the facility has designated two unit managers (one for each unit) that will process all new admissions and ensure this situation does not happen again. During an interview with the Administrator on 06/22/22 at 2:45 PM, the Administrator stated, The facility rarely admits residents after 2 PM on Fridays and the weekends. The Administrator stated her expectation of staff is to verify the resident's medications upon admission. The Administrator stated the facility has designated managers on duty who will be responsible for processing all new admissions. A telephone interview with R1's Physician on 06/28/22 at 8:45 AM revealed her expectation of staff is to call the on-call physician if they have questions or concerns with resident medications. The physician stated she was aware of the situation and spoke to R1 on 05/02/22 about not receiving medications. The Physician stated R1 was alert and did not display any adverse reactions to not receiving medications.

Based on observations, interviews, record reviews, and review of the facility's policies, the facility failed to prevent the potential transmission of COVID-19 between facility residents after staff provided care to a newly admitted resident with an unknown COVID-19 status (Resident #18). The facility admitted the resident from the hospital to their quarantine unit and under droplet isolation precautions; however, observations on 08/26/20 revealed staff were providing care without wearing the facility required personal protective equipment (PPE). The facility's failure had the potential to affect all residents of the facility who did not reside on the facility's COVID-19 positive unit. The facility Administrator was notified on 08/26/20 at 9:15 PM that the Immediate Jeopardy existed on 08/25/20. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 08/27/20 and the Immediate Jeopardy at F880 was removed with an effective completion date of 08/28/20 at 2:45 PM and lowered to the scope and severity of E. Findings include: Review of the facility's policy titled, Infection Prevention and Control Policies and Procedures, revised 04/15/20, revealed, Admission Infection Prevention Issues .5. For admission of any patient/resident with another diagnosed communicable disease .B. Appropriate Precaution are instituted. C. The facility accepting the patient/resident has appropriate placement and protective equipment and supplies available . Review of the facility's policy titled, Infection Prevention and Control Policies and Procedures, Subject: Quarantine Units, dated 08/12/20, revealed, The facility will establish designated units/halls/or sections of the facility for a quarantine unit to safeguard those residents who are new admissions, left the facility for appointments, and/or have an unknown status of COVID-19. The facility will provide full PPE to include gown, gloves, facemask, goggles, or face shields to the staff who is assigned to the quarantine unit to ensure safe interactions with resident of unknown status . Review of the facility's untitled and undated color-coded floor plan, provided by the facility upon entrance, revealed the facility designated resident rooms 106 through 123 as the COVID-19 positive unit. Continued review of the floor plan revealed resident rooms 209 through 212 were designated by the facility as their Quarantined Unit. Further review of the floor plan revealed the resident rooms 101 through 105 and 201 through 208 were resident rooms who were considered negative for COVID-19. Review of Resident #18's undated Face Sheet, located in the resident's Electronic Medical Record (EMR) under the face sheet tab, revealed the resident was admitted to the facility on [DATE]. Review of Resident #18's COVID test results, located in the resident's EMR under the documents tab revealed the resident was tested on [DATE] for COVID-19 with the results dated 08/16/20 of Negative. Continued review of the resident's EMR revealed no other COVID testing results. Observation on 08/26/20 at 5:15 PM on the facility's designated Quarantine Unit, revealed Certified Nursing Assistant (CNA) #1 entered room [ROOM NUMBER], which had a white sign on the door which indicated droplet precautions. Continued observation revealed the CNA only had PPE of gloves and a mask on. Observation on 08/26/20 at 5:16 PM on the facility's designated Quarantine Unit, revealed Licenses Practical Nurse (LPN) #2 entered room [ROOM NUMBER], carrying medication cup in his/her hand, wearing PPE of a mask and gloves. Observation on 08/26/20 at 5:17 PM, on the facility's designated Quarantine Unit, revealed CNA #3 delivered a meal tray to resident room [ROOM NUMBER] wearing PPE of a mask. Continued observation revealed the CNA assisted the resident with setup of his/her meal including adjusting his/her bedside table. Review of the facility's assignment sheets for the dates of 08/25/20 and 08/26/20 revealed LPN #2 was assigned the front and back halls of the Rainbow Unit. Interview on 08/26/20 at 5:25 PM with LPN #2 revealed his/her assigned rooms for 08/25/20 and 08/26/20 were rooms 101-105 and rooms 201-212; however, room [ROOM NUMBER] did not have a resident occupying the room. Interview on 08/26/20 at 5:20 PM with CNA #1 revealed he/she entered room [ROOM NUMBER] to assist Resident #18 with using the urinal. The CNA confirmed he/she only had on PPE of a mask and gloves. Continued interview with the CNA revealed that the signage (droplet precautions) on the resident's door indicated the resident was just admitted today from the hospital. CNA #1 stated she was not responsible for this room, but just answering his/her call light. The CNA also stated he/she had provided care to the resident not long after his/her admission. Further interview with CNA #1 revealed he/she had delivered meal trays to other residents' room after providing care to the Resident #18. Interview on 08/26/20 at 5:25 PM LPN #2 confirmed he/she did go into room [ROOM NUMBER] and administered Resident #18 medications with only a mask and gloves on. During continued interview, LPN #2 stated the signage was on the resident's door because the resident was just admitted from the hospital. LPN #2 stated there was no PPE bin on the resident's door, so he/she only had to wear a mask and gloves when he/she was in the resident's room providing care. The LPN also stated he/she had not worn gowns or shields when he/she had gone into rooms [ROOM NUMBER] (all in the quarantine unit) today or yesterday (08/25/20). Further interview revealed for the past two days, she had entered into 13 other residents' rooms to administer medication and provide care after providing care to residents in the three rooms on the quarantine unit. LPN #2 stated he/she had not seen any gowns on the unit. Interview on 08/26/20 at 5:28 PM with the Director of Nursing (DON) revealed when asked what PPE was to be worn when going into the PUI/Quarantine rooms, the DON stated, Full PPE, it's on the sign on the door. Interview on 08/26/20 at 5:31 PM with Unit Manager (UM) #4 revealed Resident #18 was a new admission and was quarantined on droplet precautions. Continued interview revealed when asked what was to be worn when going into Resident #18's room, the UM #4 stated staff who were providing care were to only wear a mask and gloves despite the signage stating full PPE was required. Continued interview on 08/26/20 at 6:02 PM with the DON revealed it was his/her expectation staff would have worn full PPE (mask, gown, face shield, and gloves) when entering into Resident #18's room. The DON stated he/she the facility had quarantine guidelines from their cooperate leadership; however, there were no written policies regarding accepting new admissions during the COVID pandemic. The DON also stated he/she informed all staff that had been here at the facility that full PPE was required (on the quarantine unit) and this was nothing new. Further interview revealed there had been PPE at the nurses' station; however, there was not any now, but plenty in his/her office. The DON stated, He/She can lead them (staff) to water and encourage them to drink. Interview on 08/27/20 at 1:50 PM with the Medical Director revealed it was his/her expectation for newly admitted residents who were placed in quarantine, the facility would have followed CDC guidelines related to transmission-based precautions and isolation.

Based on interviews, record reviews, and review of facility policy, the facility failed to initiate cardiopulmonary resuscitation (CPR) without delay for a resident who had an advance directive of full code status, including CPR, for one of one resident reviewed for code status (Resident #19). On [DATE], Resident #19 was found unresponsive and was assessed for respirations by a facility nurse who delayed for approximately four minutes before initiating compressions. The facility's deficient practice had the potential to negatively affect all 31 residents who the facility identified to have advance directives and/or a full code status. The facility Administrator was notified on [DATE] at 5:15 PM that the Immediate Jeopardy existed on [DATE] at 8:45 AM. The facility provided an Immediate Jeopardy Removal Plan that was accepted on [DATE] and the Immediate Jeopardy at F678 was removed with an effective completion date of [DATE] at 2:245 PM and lowered to the scope and severity of D. Findings include: Review of the facility's policy titled, Nursing Policies and Procedures Cardiopulmonary Resuscitation, Emergency Code Blue, revised [DATE] revealed The Facility implements policies and procedures for the provision of cardiopulmonary resuscitation (CPR) by staff, safely and according to current Basic Life Support guidance. 1. Code Blue will be announced to notify the appropriate team members to participate in a systematic, organized procedure during a potential life-threatening situation. 2. This policy only applies to residents who are full code .4. The facility ensures CPR certified healthcare providers are available immediately, 24-hours per day to provide basic life support, including CPR to residents requiring emergency care prior to the arrival of emergency medical personnel, and subject to accepted professional guidelines, the resident's advance directive and physician orders. 5. The Facility ensures provision of basic life support and CPR for residents who do not show obvious clinical signs of irreversible death and; 1) who have requested CPR in their advance directives .Procedures: 1. Determine the safety needs and consideration for the area in which CPR will be performed .3. For persons with known respiratory droplet or airborne pathogens (such as [MEDICAL CONDITION], [DIAGNOSES REDACTED], MERs, COVID-19), respirations should be provided with an ambu bag with filter ensuring a tight seal around the resident's face (bag mask). If the facility does not have an ambu bag and is concerned with the resident's status, place a mask on the resident and continue with hands only CPR .4. Follow practice guidelines for CPR by initiating Resuscitation with and without Automatic External Defibrillator (AED), as appropriate, etc. in accordance with patient/resident Advance Directives. 5. Page overhead Code Blue (room and unit) . 6. Call 911 for emergency transfer to an acute care center, unless the patient/resident is coding, and staff has determined that the patient/resident is a DNR .12. Document in the appropriate area of the medical record . Review of the facility's Advance Directives and Code Status Report, undated, provided by the facility, revealed the facility identified 31 residents to have a directive of Full Code. Review of the Emergency Medical Service (EMS) Patient Care Report, dated [DATE] revealed Narrative. Medic 2 dispatched emergently via 911 dispatch to the above location for an unconscious person. Responded with lights and sirens to find nursing home staff outside directing EMS to the covid (sic) wing of facility. Inside, patient was found supine in bed with a hard board under back, unresponsive with CPR in progress by staff member. Assessment revealed patient to be apneic, pulseless via carotid, with a warm core but cool extremities. Pupils were fixed at approximately 5mm. Initially facility was unable to determine patient's last normal time (time alive at baseline). Staff attempted to awaken patient for breakfast when they noticed (he/she) was not breathing .Records from staff indicated that patient was last checked on at 0745 (7:45 AM), just over one hour prior to contacting 911, with notable vital signs of a blood pressure approximately ,[DATE]. Staff stated they did not notice patient to be awake this morning yet as they passed by the room, unknown level of consciousness at 0745 (7:45 AM) with vital signs check. Staff did not know last time patient was seen awake or alert . Review of Licensed Practical Nurse (LPN) #5's American Heart Association (AHA) Basic Life Support (BLS), certification card dated [DATE] revealed the LPN's CPR certification was current and did not expire until ,[DATE]. Review of Resident #19's undated Face Sheet, located in the resident's electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] and expired on [DATE]. Continued review of the resident's face sheet revealed the resident was a Full Code. Review of Resident #19's Physician Order, dated [DATE], located in the resident's EMR, under the orders tab, revealed Code Status: Full. Review of Resident #19's Advance Directives and Notification Worksheet, dated [DATE], located in the resident's EMR under the documents tab, revealed the worksheet was completed and signed by the resident's responsible party/legal representative. The worksheet had marked for selection Advance Directive and also marked selected I do want CPR: Attempt Cardiopulmonary Resuscitation. Choosing CPR means that all medical treatments will be done to prolong life when the heart stops or breathing stops. Code. Review of Resident #19's Progress Note, dated [DATE], located in the resident's EMR, under the progress notes tab, completed by LPN #5 revealed Resident observed with no pulse at 0845, EMS and CPR initiated, previous contact with resident at 0745 by CNA who observed she was awake and communicative. EMS arrived at 0848, at 0857 EMS (EMS name) discontinued CPR and (corner name), coroner was notified and issued BRT # 2. Family was contacted and advised of death at 0915. Family confirmed that Simplicity was performing the cremation, so coroner was advised and confirmed pick-up. Resident left with funeral services at approximately 1100. During a confidential interview on [DATE] at 12:10 PM, where the person who provided the information requested anonymity, stated on [DATE] Resident #19 had passed away. The interviewee stated, the police was here (at the facility) and they believed Resident #19 was a full code and were not sure if CPR was performed on Resident #19. The interviewee also stated there was no crash cart located on the COVID unit and that the Director of Nursing (DON), who was present in the building at the time, took the facility crash cart to the COVID unit by going out the front door and around to the outside entrance for the COVID unit. Interview on [DATE] at 1:00 PM with Unit Manager (UM) #6 revealed he/she was the Unit Manager for the COVID positive unit. Continued interview with UM #6 revealed there was only one crash cart for the entire building. Interview on [DATE] at 1:07 PM with LPN #5 revealed he/she was Resident #19's nurse on [DATE]. Continued interview revealed on [DATE] at approximately 8:45 AM, Certified Nursing Assistant (CNA) #5 reported to him/her that he/she had discovered Resident #19 unresponsive. LPN #5 stated at that time he/she went to Resident #19's room, looked at the resident (checked breathing), and then ran to the nurses' station to call 911. The LPN also stated LPN #15 called for the crash cart and within two minutes the crashed cart arrived. LPN #5 stated when the crash cart arrived, the resident was placed on the board and CPR was resumed until EMS arrived and took over. When asked how much time had lapsed from when he/she looked at the resident until he/she arrived back in the resident's room to initiate CPR, LPN #5 stated, three to four minutes. Interview on [DATE] at 1:20 PM with the DON revealed on [DATE] he/she was in the building when the code blue was called. Continued interview revealed the crash cart was on the non-COVID area of the building, and where the COVID positive unit was separated from the rest of the facility with a barrier, he/she pushed the crash cart out the front door of the building around to the side to the entrance of the COVID unit. The DON stated it was his/her expectation LPN #5 would have immediately initiated CPR and called for additional help. The DON also stated LPN #5 should have started CPR right then because the resident was a full code. Interview on [DATE] at 10:56 AM with EMS revealed on [DATE] he/she was dispatched to the facility for an unresponsive resident. Continued interview revealed when he/she arrived at the facility, a facility nurse was performing CPR on Resident #19. The EMS stated no one was able to initially tell him/her when the last time the resident was seen alive, but then it was determined the by the facility staff the resident was seen alive at approximately 7:45 AM and the residents blood pressure was in the 50's and 80's per the facility staff. The EMS also stated the resident's pupils were fixed and not reactive to light, resident was not responsive, the resident's cardiac rhythm was in asystole, the resident's extremities were cool, and the resident's core was warm. Interview [DATE] 12:35 PM with LPN #5 revealed he/she did not know the resident was a full code until after EMS arrived and he/she printed Resident #19's face sheet for EMS. Continued interview revealed when he/she came out of Resident #19's room, LPN #15 was located on the unit's long hall passing medication and Resident #19's room was around the corner on the short hall. LPN #5 stated when he/she arrived at the nurses' station to call EMS, he/she yelled and motioned for LPN #15 to come to the nurses' station and told him/her the resident was not breathing. Further interview revealed LPN #15 called a code blue. When asked how long he/she was on the telephone with EMS, the LPN stated approximately two minutes. When asked if there was an ambu bag (manual resuscitator) on the COVID unit on [DATE], LPN #5 stated, no, it was on the crash cart (on the non-COVID positive unit). LPN #5 also stated he/she started compressions when he/she got back to the resident's room but did not give breaths due to not having an ambu bag. Interview on [DATE] at 1:50 PM with the Medical Director revealed it would be his/her expectation the staff would find out what the resident's code status was and if full code, then they would immediately start CPR.

Based upon observations, interview, record review, and review of facility policy, the facility failed to ensure that one (1) of one sampled residents reviewed for physical restraints (Resident #1) was free of physical restraint use implemented for staff convenience. Resident #1 was physically restrained by Certified Nursing Assistant (CNA) #1 on 7/18/2020 causing harm to Resident #1. Resident #1 was restrained in bed to prevent her/him from moving; a sheet was tied tightly across the resident's body with the four corners of the sheet affixed to the bed frame. When the resident was found by a nurse, s/he had experienced psychosocial and physical harm including indentations in her legs from the pressure of the sheet. Findings include: Review of Resident #1's Face Sheet dated 7/27/2020 reflected [DIAGNOSES REDACTED]. During an observation of Resident #1 in her room on 7/27/2020 at 3:50 p.m. the resident was agitated and was asking for assistance. Resident #1 was covered by a sheet and did not appear to be wearing any bedclothes. Resident #1 was not interviewable. Review of Resident #1's Annual Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of five (5) indicating severe cognitive deficit. The MDS reflected the requirement for extensive assistance with activities of daily living (ADLs) and that Resident #1 was incontinent of bowel and bladder. The MDS reflected that Resident #1 exhibited mood and behavior issues during the reporting review period. Resident #1''s Personal Health Questionnaire-9 (PHQ-9) reflected a score of twelve (12) indicating moderate depression as evidenced by almost daily symptoms of depression, sleep disturbance, difficulty concentrating, and fatigue. Review of Resident #1's current [MEDICAL CONDITION] medication orders reflected Memantine [MEDICATION NAME] Extended Release (dementia medication) 28 mg once a day for dementia, [MEDICATION NAME] (anti-anxiety medication) 10 mg twice a day for depression, [MEDICATION NAME] (anti-[MEDICAL CONDITION] and benzodiazepine) 1 mg each morning and 2 mg each night for anxiety, Nudexta (medication for pseudobulbar) at unknown dosage twice a day for pseudobulbar affect, and Donepezil (dementia medication) 10 mg each night for dementia. Review of Resident #1's care plan dated 7/7/2020 reflected plans for behavior, [MEDICAL CONDITIONS], mood, depression, falls, communication, impaired skin integrity, bowel and bladder incontinence, pain, anxiety, and ADLs with interventions including anticipating and meeting the resident's needs in a timely manner, maintaining a calm and supportive environment, medication per physician's orders [REDACTED]. Review of Resident #1's care plan dated 7/28/2020 reflected that the care plan had not been updated following the incident of 7/18/2020. Review of the facility's 5-Day Follow Up Report dated 7/23/2020 reflected that Licensed Professional Nurse (LPN) #1 found Resident #1 restrained in his/her bed with a bed sheet on 7/18/2020 at 5:40 p.m. Resident #1 had a bed sheet tied tightly across his/her body from just below the breast area to just above the knees. The four (4) corners of the bed sheet were knotted to the bed frame, and Resident #1 was unable to move in his/her bed. LPN #1 took immediate action to release Resident #1 and performed an assessment of Resident #1 that documented indentations in the resident's lower extremities with noted [MEDICAL CONDITION] and no other injuries. The report of alleged abuse was filed with the State of South Carolina DHEC by phone within two (2) hours according to the report notes, and by fax on 7/20/2020. The investigation was instituted by the facility and completed on 7/23/2020 with a finding of substantiated physical abuse by CNA #1. Review of the Nursing Notes reflected no psychosocial assessments following the incident on 7/18/20. Review of the Social Services notes reflected that the SW had facilitated a Facetime visit between Resident #1 and the RP but had no other entries of psychosocial assessment. The facility had statements from LPN #1 and LPN #2 that CNA #1 had told them that s/he had tied Resident #1 down with a bed sheet because Resident #1 had removed his/her brief three (3) times that day and that CNA #1 didn't want to have to keep changing Resident #1's brief, and the sheet would keep Resident#1 from being able to remove his/her brief. Review of the facility Abuse, Neglect, Exploitation, or Mistreatment Policies and Procedures dated 11/1/2017 reflected that the facility prohibited use of a physical and/or chemical restraint not required to treat a medical condition. The policy defined physical restraint use (not required to treat a medical condition) as physical assault/abuse. The policy further reflected that mistreatment meant inappropriate treatment of [REDACTED]. During an interview on 7/27/2020 at 4:30 p.m. the Administrator stated CNA #1 was provided to the facility by a staffing agency. The Administrator stated it was the facility's responsibility to ensure that residents were free of physical restraints. The Administrator stated the Director of Nursing (DON) conducted and completed the investigation of the incident of 7/18/2020 involving physical restraint of Resident #1. During an interview on 7/28/2020 at 8:00 a.m. Resident #1's Responsible Party (RP) RP stated that s/he was aware of the incident on 7/18/2020. The RP stated that the incident was particularly unfortunate because Resident #1 had suffered significant spousal physical and emotional abuse which was the cause of her/his [MEDICAL CONDITION], and that an incident of this type could cause increased anxiety for Resident #1. During an interview on 7/28/2020 at 2:49 p.m. the Social Worker stated s/he normally followed up on this type of incident by interviewing residents for safety concerns but did not do so in this case because the Administrator and DON conducted the investigation. S/he stated that s/he checked on Resident #1 after the incident and had arranged for a Peacetime visit between Resident #1 and the RP on 7/23/2020. Review of Resident Progress Notes dated 7/23/2020 at 12:02 p.m., recorded by the SW, reflected that a face time call had been held with Resident #1 and the RP with the assistance of the facility Activity Staff. During an interview on 7/28/2020 at 2:24 p.m. the Physician's Assistant (PA) PA stated that s/he was told about the incident on 7/19/2020 in the morning when s/he came in to do rounds. S/he stated that s/he examined Resident #1 on 7/19/2020 and found no trauma but noted that Resident #1 continued to exhibit significant anxiety. S/he stated that s/he did not document the examination of 7/19/2020. S/he said his/her focus on Resident #1 was on the resident's anxiety and that s/he had been trying to medically manage the anxiety and had increased anti-anxiety medications ([MEDICATION NAME]) from 0.5 mg twice a day to 1.0 mg twice a day on 7/20/2020 due to increased anxiety with elevated blood pressure. S/he stated that s/he was planning to place a referral for a repeat psychiatric evaluation of Resident #1 due to Resident #1's anxiety but had not done so yet. During an interview on 7/28/2020 at 3:51 p.m. LPN #1 stated that s/he was the nurse who discovered Resident #1 restrained in bed. LPN #1 said Resident #1 was not on her assignment that evening but the staff CNA came to her for help because s/he was the only non-agency nurse on duty. LPN #1 stated the nurse who was taking care of the resident was LPN #2 who was either agency or PRN (as-needed staff) and that LPN #2 didn't know what had happened when the incident was discovered. LPN #1 stated that one (1) of the staff CNAs frantically asked her to come see Resident #1. LPN #1 said s/he found Resident #1 in her room with no clothes on and tied to the bed with a sheet pulled across her body from below the breasts to the above her knees. All four corners of the sheet were tied with knots to the bed frame. LPN #1 said s/he calmly removed the sheet because s/he knew that the Resident #1 had anxiety and s/he didn't want to upset the resident more. LPN #1 said s/he did a full physical assessment of the resident and noted no trauma other than indentations in the resident's legs with noted [MEDICAL CONDITION] where the sheet had been tied down. LPN #1 said s/he helped clean, settle, and feed Resident #1 with the assistance of LPN #2. LPN #1 said that s/he and LPN #2 then addressed the situation with CNA #1 who stated that s/he had tied Resident #1 down with the sheet because Resident #1 had taken off her briefs and clothing multiple times already that day. CNA #1 said that s/he didn't want to have to keep cleaning Resident #1 and became angry when advised that this was abuse. LPN #1 stated that CNA #1 was immediately removed from the facility. LPN #1 said that LPN #2 helped confront CNA #1 but had offered no other information about Resident #1. LPN #1 stated that to her/his knowledge LPN #2 had not worked at the facility since the incident. Review of the employee list dated 7/28/2020 reflected that LPN #2 was a staff LPN, not an agency staff member. Review of the facility investigation of the incident of 7/18/2020 reflected that the DON had taken a statement from LPN #2 on 7/23/2020 by phone. LPN #2 did not return two calls for interview from the surveyor. During an interview with CNA #2 and CNA #3 at 3:55 p.m. the CNAs stated that they had worked with Resident #1 in the past and that Resident #1 required a lot of care and that Resident #1 was always tapping on the bedside table. Both CNAs said that they had been trained on abuse and neglect and knew that physical restraints were not allowed by facility policy. During an interview on 7/27/2020 at 4:00 p.m. LPN #3 stated that s/he worked a lot with Resident #2 and was aware of the incident on 7/18/2020. LPN #3 stated that Resident #1 required a lot of care and that s/he was often very anxious. LPN #3 stated that s/he was not working the day of the incident but when s/he came back to work s/he noticed Resident #1 had not been eating as much, so s/he had been concerned. LPN # 3 stated that s/he had been trained on abuse and neglect and knew that physical restraints were not allowed. During an interview on 7/27/2020 at 4:15 p.m. and on 7/28/2020 at 10:30 a.m. the DON stated it was the facility's responsibility to ensure that residents were free of physical restraints. The DON stated that all employees including agency staff received education about the facility policies and procedures prohibiting abuse, neglect, exploitation, and mistreatment of [REDACTED]. Review of the facility New Employee Orientation During COVID 19 updated April 3, 2020 reflected that new employees received training including on Systems Overview: Restraints, Creating a Restraint Free Environment, Managing Challenging Behaviors, Understanding [MEDICAL CONDITION] and Dementia, Preventing, Recognizing, and Reporting Abuse, and Abuse Policy and Procedures. Review of the facility's Contract/Vendor Orientation dated 2019 reflected that orientation included a section on restraints that referred the contract/vendor to the local, state, and federal regulations defining physical and chemical restraints. The orientation document also addressed abuse prevention including the prohibition of any form of abuse of residents. The orientation document addressed Behavior and Dementia Management. The orientation documentation specifically addressed the facility's prohibition of use of a physical restraint not required to treat a medical condition. The orientation document reviewed the definitions of abuse as defined by CMS section 483.5. The orientation document also noted the training that all employees including volunteers were to receive. The training included the required components for abuse prevention training: requirement for adequate supervision of staff in order to identify and prevent inappropriate behaviors including rough handling, ignoring the residents' needs requests, etc., and residents requiring excessive nursing care or staff attention. The orientation document noted the required component of Identification and noted that physical restraints (not required to treat a medical condition) constitute physical abuse. The orientation document included a Resident's Bill of Rights (South Carolina Code of Laws, Section 44-81-20 et. seq.) that defined the resident's right to be free from physical abuse and physical restraints (unless ordered by the doctor).

Based on observations, interviews, clinical record reviews and facility policy review, the facility failed to ensure three (3) of four (4) residents (Residents #22, #46, and #[AGE]) reviewed for catheter care received care and services for indwelling Foley catheters in a manner to prevent urinary tract infections. The facility failed to have current treatment orders for the Foley catheter and the catheter was not anchored, Resident #22 suffered blood in his urine and had three (3) bacterial infections that were not identified prior to surveyor intervention. This failure led to Resident #22 experiencing actual harm. 1. Resident #22's Foley catheter was not anchored to prevent pulling, had no current physician's orders [REDACTED]. The resident's catheter was not anchored to prevent pulling or injury. The facility staff was unaware of the red colored urine with sediment in the resident's drainage bag until pointed out by the surveyor. Therefore this standard is cited at harm level. 2. Resident #46's Foley catheter was not anchored or maintained in a dignity bag. 3. Resident #[AGE]'s Foley catheter was not anchored or maintained in a dignity bag. Findings included: Review of the policy titled, Catheter-Urinary Catheter, Cleaning and Maintenance dated 7/1/16 revealed the policy lacked documentation regarding the anchoring of the catheter tubing to the resident to prevent pulling on the urethra. 1. Review of Resident #22's face sheet dated 1/13/2020 revealed he/she was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #22's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident sometimes understood others and was sometimes understood. Resident #22 had severely impaired cognition. The MDS noted Resident #22 had an indwelling urinary catheter. Review of Resident #22's comprehensive care plan updated 11/14/19 revealed he/she used a Foley catheter due to [MEDICAL CONDITION] bladder. Interventions included to change Foley/bag as ordered by the physician. There were no instructions on the care plan as to the size of the catheter required, to irrigate the catheter, or to anchor the catheter to prevent trauma. There were no interventions instructing the nurse to notify the physician when there was sediment or blood in the urine. Review of Resident#22's January 2020 physician orders [REDACTED]. Foley catheter care orders had been discontinued [DATE]20 and not reordered when the Foley catheter was reinserted on 1/11/20. No Foley catheter care orders were in Resident #22's clinical record as of 1/14/2020. The facility was unable to provide documentation of the resident's voiding trial after the catheter was discontinued on [DATE]. Observation of Resident #22 on 1/14/2020 2:03 PM revealed Resident #22 had Foley catheter tubing draining into a collection bag. There was red fluid and sediment in the tubing. The catheter collection bag was half full of red fluid, with darker red fluid at the bottom of the bag. Observation and interview with Certified Nursing Assistant (CNA) #3, at this time, revealed the aide confirmed Resident #22 had a catheter and adjusted Resident #22's brief. The catheter tubing was under the closure of his brief and was not anchored to his leg. Registered Nurse (RN) #5 came into the room at that time and stated she had reinserted the Foley catheter on 1/11/20 after the voiding trial, in which he did not void. She said she had not seen Resident #22's catheter since she reinserted it on 1/11/20 and was not aware of the red fluid in the collection bag. CNA #3 said she did not remember the catheter bag being full of red fluid that morning when she cared for him/her. In an interview on 1/14/2020 at 2:30 PM, the Director of Nursing stated the orders for the resident's catheter were discontinued the previous week because there was a voiding trial, and since he/she was voiding, they did not want to reinsert the catheter. She said Resident #22 had voided 500 milliliters of fluid that weekend. She said Resident #22 had a history of [REDACTED]. She said they had run urine analysis tests and there were no current catheter orders written from the physician. Review of Resident #22's laboratory tests dated 1/11/2020 revealed a urine analysis was performed on that date. Review of Resident #22's nursing notes dated 1/14/20 revealed RN #5 called the Nurse Practitioner after the observation of Resident #22's urine with surveyor and nursing staff was instructed to wait for the urine analysis culture and sensitivity. Review of Resident #22's clinical record revealed there was no culture and sensitivity test found for the urine analysis done 1/11/2020. Observation on 1/16/2020 at 10:35 AM revealed Resident #22's catheter collection bag had red urine in it. In an interview on 1/16/2020 at 10:41 AM, the DON said she would call the laboratory to check the status of the urine culture and sensitivity at surveyor request. In an interview on 1/16/2020 at 5:30 PM, the DON said she received Resident #22's urine culture and sensitivity that day. She said the laboratory was going to rerun the culture because there were different bacteria found. Review of Resident #22's urine culture and sensitivity dated 1/16/2020 revealed there were three (3) bacterium identified in the urine- [CONDITION], [CONDITION], and [CONDITION]. Based on observations, interviews and record reviews, the facility failed to have current treatment orders for the Foley catheter and the catheter was not anchored, Resident #22 suffered blood in his urine and had three (3) bacterial infections that were not identified prior to surveyor intervention. This failure led to Resident #22 experiencing actual harm. 2. Review of the clinical record for Resident #46 revealed an admission date of [DATE] and the [DIAGNOSES REDACTED]. Review of Resident #46's Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BI[CONDITION]) score of 14 (indicating intact cognition). The resident required total assistance of two (2) people with bed mobility and toilet use and required total assistance of one (1) staff for eating, personal hygiene and bathing. The resident had a catheter and was always incontinent of bowels. Review of Resident #46's care plan revised 12/12/19, listed the interventions: provide Foley care per physician's orders [REDACTED]. Review of Resident #46's Physician order [REDACTED]. Review of the clinical record revealed the resident was transferred to the hospital in the last three (3) months with the [DIAGNOSES REDACTED]. Observation on 1/13/2020 at 2:48 PM revealed Resident #46 had dark yellow urine in the catheter bag and the bag was not covered by a dignity bag. Observation on 1/15/2020 at 8:47 AM and 10:40 AM revealed the resident way lying in bed and the catheter bag was not covered with a dignity bag. Observation on 1/15/2020 at 11:47 AM with Registered Nurse (RN) #2 and Unit Manager (UM) #1 during pressure ulcer care revealed the catheter was not anchored to the resident. Observation on 1/16/2020 at 9:44 AM revealed Resident #46's catheter bag was not in a dignity bag. Interview with Unit Manager (UM) #1 on 1/15/2020 at approximately 12:00 PM, revealed the staff should anchor the catheter tubing to the resident and the CNAs are aware of that. Interview with the Assistant Director of Nursing (ADON) on 1/16/20 at 11:57 AM revealed there should be an order for [REDACTED]. The facility failed to anchor the catheter tubing to the resident and failed to maintain the catheter bag in a dignity bag. 3. Review of Resident #[AGE]'s clinical record revealed an admission date of [DATE] and the [DIAGNOSES REDACTED]. Review of the Significant Change MDS for Resident #[AGE] dated 1/12/2020 revealed the Brief Interview for Mental Status (BI[CONDITION]) score of 12, indicating moderately impaired cognition. The resident required extensive assistance of one (1) staff with toileting, had the presence of an indwelling catheter and was always incontinent of bowels. Review of the Care Area Assessment (CAA) for Indwelling Catheter dated 1/14/2020 revealed the resident triggered this CAA secondary to requiring extensive assist with toileting and having a Foley catheter. Review of Resident #[AGE]'s care plan, revised 1/14/2020, listed the interventions for indwelling catheter: monitor for and notify physician of signs/symptoms of UTI and staff to encourage resident to drink all fluids on each meal tray. Review of Resident #[AGE]'s Physician order [REDACTED]. Observation of Resident #[AGE] on 1/13/2020 at 3:06 PM revealed the resident had dark brown urine in the catheter bag and the bag was not in a dignity bag. Observation on 1/15/2020 at 9:23 AM revealed the catheter tubing to dependent drainage and the catheter bag not in a dignity bag. Observation on 1/15/2020 at 9:26 AM revealed Registered Nurse (RN) #2 and Certified Nurse Aide (CNA) #1 provided a position change for the resident. Further observation revealed the catheter tubing was not anchored to the resident. Interview with the staff at that time revealed upon asking if the catheter tubing needed to be anchored to the resident, CNA #1 said it did not need to be anchored to the resident and RN #2 did not answer or correct the CNA. Observation on 1/16/2020 at 10:25 AM revealed the catheter bag not in a dignity bag. Interview with Unit Manager (UM) #1 on 1/15/2020 at approximately 12:00 PM revealed the staff should anchor the catheter tubing to the resident and the CNAs are aware of that. Interview with the Assistant Director of Nursing (ADON) on 1/16/20 at 11:57 AM revealed there should be an order for [REDACTED]. The facility failed to anchor the catheter tubing to the resident and failed to maintain the catheter bag in a dignity bag.

On the days of the complaint inspection, based on record reviews, observations, and interviews, the facility failed to ensure residents were provided adequate assistance to prevent accidents for 1 of 1 resident reviewed who fell from bed while being assisted with personal care by a Certified Nursing Assistant (CNA) (#1). The findings included: Resident #1 with [DIAGNOSES REDACTED]. Review of the resident's annual Resident Assessment Instrument with an assessment reference date of 3/15/12 revealed the resident had a short term memory problem. She understood communication but only sometimes could make herself understood. The resident required extensive assistance of one person for bed mobility and transfer. No falls were noted on the assessment. Review of the medical record revealed physical therapy notes beginning on 3/9/12 related to the resident's positioning deficits and increased skin tears and bruising on her right arm and her legs over the past several months. After the assessment, the resident was provided with a right side arm bolster and leg rest for her wheelchair. Her left side bed rail was discontinued due to the resident being unable to use it, and the right side bed rail was replaced with a turning cane. On 3/13/12, the resident expressed concern about falling out of bed due to a lack of boundary. A perimeter mattress was placed on the bed on 3/14/12. On 3/16/12, the resident reported she still felt that she was falling out of bed on the left side even with the perimeter mattress. A medium bolster was added to the left side of the bed. The resident stated she felt she no longer needed the bolster on 3/19/12. She was discharged from physical therapy on 3/22/12. Review of the Nurse's Notes showed an entry on 4/9/12 at 11:50 PM saying the nurse was called to the resident's room by the CNA. The resident was noted on the floor, on her right side, on the left side of her bed. She had a large hematoma to the right side of her forehead. The physician was notified and the resident was sent to the hospital for evaluation and treatment. Hospital records showed the resident had "Subdural hematoma with cerebral contusion secondary to fall plus Plavix therapy." Review of the facility's investigation revealed that at the time of her fall, the resident's bed was in an elevated position for the CNA to provide personal care. Staff statements revealed the resident liked her bed in a high position, and she was not capable of turning to her left side by herself. The CNA attending the resident on 4/9/12 reported that she asked the resident to turn to her left side. As the resident turned, the CNA turned to the side to get wipes. The resident was "rolling over by the time I went to reach for her Ms. (NAME REDACTED) rolled over and fell off the bed. ..." The CNA was terminated for failing to use appropriate technique with the resident. The resident was re-evaluated by physical therapy after her fall. The left side bolster was put in place once again and the staff was directed to use the assist of two people in assisting the resident with bed mobility.