Every finding on record at Heartland Health Care Center - Greenville East

Based on observation, interview, and policy review, the facility failed to store, prepare, and serve food under accepted sanitary conditions due to lack of regular cleaning of the food preparation area, placement of non-resident food items in the walk-in cooler and removal of expired items from the food supply. The deficient practice had the potential to affect 119 of 122 residents receiving oral diets.Findings include:Review of the facility policy titled, Sanitization, with a revision date of November 2022, revealed Policy Statement - The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris and protected from rodents and insects.All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair.All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions.Review of the facility policy titled, Policy on Pot Holders [sic] and Oven Mitts with Frays or Holes, revealed Pot holders [sic] and oven mitts used in the dietary department must be maintained in safe, clean and intact condition at all times. Any items showing frays, holes, tears, exposed inner padding, loose stitching, scorch marks, melted areas, thinning fabric and excessive wear shall be immediately removed from service and replaced. Damaged pot holders [sic] or mitts may not provide adequate heat protection and may also trap food residue, moisture, and bacteria, making them unsuitable for continued use in a foodservice environment.Observation and interview with the Dietary Director (DD) during the initial kitchen tour on 06/16/26 at 11:10 AM revealed in the dry food storage area a tub of vanilla frosting opened on 03/03/26 and with a Use By date of 06/06/26 and two large bags of vanilla wafers with a Best By date of 04/13/26. Fallen food crumbs, other debris, and soil were visible on the floor of the dry food storage room along with several dead insects. Other dried substances were observed smeared on the shelving.Further observation of the facility's one walk-in cooler revealed there was no backup thermometer placed inside the cooler and water was pooled on the floor. Three cans of soda belonging to an employee(s) were on a shelf inside the cooler.Observation along with the DD on 06/17/26 at 11:21 AM revealed three torn and soiled potholder gloves being used in the kitchen. The DD stated he had more and would replace them. Further observation of kitchen area revealed buildup of food spillage/grease, soiled saucers stored on bottom shelf of food prep areas. Food debris was also inside the storage drawers of the food preparation tables.

Based on observation, interview, and policy review, the facility failed to maintain the operation of the walk-in freezer in a manner to prevent accumulation of ice buildup along the walls and on the food stored within. The deficient practice had the potential to affect 119 of 122 residents receiving oral diets.Findings include:A review of the 2022 Food Code published by the U.S. Food and Drug Administration found: Chapter 4. Equipment, Utensils, and Linens . 4-501.11 Good Repair and Proper Adjustment. Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures.Observation and interview during the initial tour of the kitchen on 06/17/26 at 11:10 AM with the Dietary Director (DD) revealed the freezer, which was accessed from inside the walk-in cooler, had a buildup of ice and condensation on boxes, walls and surfaces with the ice being inches thick in some places. The DD stated a work order had been put in for repairs to the freezer and it was supposed to have been fixed.Review of a Summary of Work Performed dated 06/3/26 from the freezer service provider revealed the following, After arriving at the customer's location, checked in with [facility staff name]. Here today to service the walk-in freezer customer stated that there was ice buildup inside. There's a lot of ice inside of the box primarily around the fans on further inspection I found a few concerning issues, one being that the fan was damaged and needed to be replaced. The other was that the defrost time had an unusually long period of defrost this can cause excess moisture inside of the box. Defrost times have been reset to 4 times a day for 15 minutes each. One of the employees told me that they have been keeping cooler and freezer doors open for extended periods of time, sometimes exceeding one hour. They thought doing this would help reduce ice buildup in the freezer, however this has the opposite effect. New fan blade was installed. Ice was removed from the fan guards. The unit is running well at this time holding temp [temperature] below 0 degrees SH=20 SC=10 Checked out with [facility staff name [sic].During an observation and interview of the kitchen with the Operations Assistant (OA) on 06/18/26 at 9:25 AM the concern with the accumulation of ice in the freezer was verified. The OA also reported that she had attempted to remove the buildup, but it did not fix the problem.

Based on observation, staff interviews, and policy review, the facility failed to ensure each resident's needs were met by failing to ensure an appropriate usable call light was in reach and available for use for one of one sampled resident who needed a soft touch call light instead of the regular push button call light, Resident (R)13.Findings include:Review of an undated facility policy titled, Signal System Policy, found: Guideline: 1. Be sure the call light is plugged in at all times. 2. Call light shall be placed within the reach of the resident. 3. Any call light not working appropriately will be reported immediately to supervisor. 4. Call lights will be answered as soon as possible. 5. For residents unable to utilize the call light, staff will monitor these residents frequently by making rounds. 6. If call light system becomes inoperable at any time, bells will be distributed to each resident for use to signal staff of needed assistance. For residents unable to utilize the call bell, staff will monitor these residents frequently by making rounds.On 06/16/26 at 12:15 PM, R13's call light was observed on the floor under the bed.On 06/16/26 at 12:40 PM, the Unit Manager for the 600 Unit was in the room with this surveyor. The Unit Manager pulled the call light from underneath the bed, cleaned it with a sani-wipe and placed it on top of the sheets where R13 was in bed. The call light was a standard push button call light which required the resident to push the red button on the end of the cord when assistance was needed. The Unit Manager stated R13 should always have his/her call light in reach. R13 was observed to be wearing bilateral hand splints. The Unit Manager stated R13 wore the splints for eight hours daily. When the Unit Manager was asked if R13 could use the call light while wearing the hand splints, she stated she did not think so. When asked if R13 ever had a different type of call light, the Unit Manager stated that R13 used to have a soft touch pad call light that all he had to do was to bump the pad when assistance was needed. The Unit Manager stated she did not know why R13 no longer had the soft touch pad call light.On 06/17/26 at 10:09 AM, the Director of Nursing (DON) stated during an interview that R13 was able to move his arms and had the capability to use a soft touch pad call light but was not physically able to use a push button call light. The DON stated the facility was in the process of having a new call light system installed and the company had provided call light cords but soft touch call lights were not available, and the facility did not have any in the building. The DON confirmed R13 did not have the ability to pick up and ring a handheld bell. The DON stated the company installing the new call light system had not provided soft touch bells for the new system. The DON stated she had instructed the Operations Assistant (OA) to order some as other residents could possibly benefit from them also. The DON stated she did not know long R13 had been without his soft touch call light, but would be first on the list to get one when the order came through. The DON further stated she would speak to nursing staff and have them make frequent rounds to check on R13 to ensure his needs were being met.On 06/17/26 at 1:00 PM, the OA reported that he had ordered 10 soft touch call lights last week but they had not arrived yet. Later, the OA presented for review a message from the call bell installation company dated 06/17/26 at 1:51 PM, that stated the order would be shipped on 06/18/26. Since the order had not yet shipped, R13 would not have access to a call light that he would be able to use until the order arrived from a remote location.

Based on observations, interviews, and policy review, facility staff failed to implement infection control procedures when delivering a meal tray to a resident on isolation precautions, specifically for Resident (R)3.Findings include:Review of the facility's policy titled, Isolation - Transmission-Based Precautions & Enhanced Barrier Precautions, revised September 2022, revealed, Policy Statement - Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents . 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of CDC [Centers for Disease Control and Prevention] precaution(s), instructions for use of PPE [personal protective equipment], and/or instructions to see a nurse before entering the room period Signs and notifications comply with the resident's right to confidentiality or privacy.Review of the facility's policy titled, Food Delivery for Isolation Rooms, undated, revealed Purpose - To ensure the safe handling, delivery, collection, and disposal of meal trays for residents on isolation precautions while minimizing the risk of infection transmission and maintaining resident dignity and nutritional care. Scope - This policy applies to all dietary, nursing, environmental services, and other staff involved in meal service for residents under isolation precautions. Policy Statement - Residents on isolation precautions shall receive meals in a manner that prevents cross-contamination and complies with infection prevention and control standards. Staff shall follow the required personal protective equipment (PPE) and hand hygiene procedures when delivering and retrieving trays.Review of the clinical record revealed a Physician's Order dated 06/12/26 which placed R3 on contact isolation precautions through 07/24/26. Corresponding signage and equipment were posted outside of the resident's room door.During an observation on 06/16/26 at 12:24 PM, Certified Nursing Assistant (CNA)6 was observed entering the room of R3 to deliver the lunch meal tray without donning any PPE.In an interview on 06/16/26 at 12:40 PM, CNA6 reported that PPE was not required as she was not going to be providing care.In a follow-up interview on 06/16/26 at 12:45 PM, Licensed Practical Nurse (LPN)5, the unit's Nurse Manager, confirmed that PPE was required due to R3 being on contact isolation precautions.In an interview on 06/18/26 at 9:55 AM, the Director of Nursing (DON) acknowledged staff should be donning PPE before entering and doffing PPE before exiting resident rooms for residents on contact isolation precautions. The DON also confirmed that R3's meal tray with the reusable dishware, was placed back onto the cart to be returned to the kitchen and that was also an Infection Control concern.

Based on observation, review of narcotic records, staff interview, and review of facility policy, the facility failed to establish a system of records of disposition of an injectable multi-dose vial of a Schedule III Controlled Drug in sufficient detail to enable an accurate reconciliation when passing responsibility of controlled drugs from one nurse to another. Findings include:Review of an undated facility policy, titled, Narcotics, Controlled Substances, and Preventing Drug Diversion, revealed: All medications are stored in a secure manner, as outline in other policies. Special storage and security procedures will be followed to protect controlled substances (narcotics, etc) and to help prevent drug diversion. Procedure: .2. A Narcotic Count Sheet will be maintained for all narcotic medications. a. When a narcotic is received in the community, it is counted by two staff members and added to the narcotic sheet with the current medication count reflected in the amount on hand. b. Each time a resident receives assistance with self-administration of a narcotic, this is documented and the amount of medication on hand is updated on the Narcotic Count Sheet. c. At the end of each shift, the staff member responsible for medication completing his/her shift, and the staff member responsible for medications who is starting his/her shift, count all narcotic medications and confirm that the amount on hand matches was [sic] it listed on the Narcotic Count Sheet for each medication. Both staff members will sign a Narcotic Reconciliation Sheet confirm the accurate count of narcotics on hand. d. Any discrepancies are immediately reported to the Administrator.On 06/16/26 at 12:25 PM during reconciliation of narcotics on the medication storage cart for the 600 Unit, a bottle of testosterone cypionate Injection 1000 milligrams (mg) per milliliter (ml), (a schedule III narcotic), a 10 ml multidose vial for R1 was maintained in the narcotic lock box. The Narcotic Count Sheet documentation noted the bottle contained seven ml. The bottle was not scored or labeled to indicate how much was in the bottle. The bottle was a made of clear glass with only the manufacturer label and no other markings. The prescription label for the medication was on the box. The medication label on the box containing the multidose vial of testosterone cypionate injection for R1 had instructions to administer 0.75 ml intramuscular (IM) once a week. The narcotic sign out sheet indicated four does had been administered over the past four weeks. Licensed Practical Nurse/Supervisor (LPN/S) 7, who was conducting reconciliation, stated he was unable to tell how much was left in the bottle but when shift counts were conducted, the nurses just went by what was recorded on the narcotic sign out sheet. LPN/S7 stated, since the bottle was not scored or marked in any way, there was no way to determine how much remained in the bottle of testosterone cypionate injection.Review of the medical record, under the Physician's Order tab, for R1 revealed a Physician's Order dated 06/06/25 for testosterone cypionate injectable 1000 mg/ml. Inject 0.75 ml intramuscularly one time a day every seven day(s) for low testosterone.On 06/17/26 at 10:09 AM, during an interview with the Director of Nursing (DON), the medication cart was revisited on the 600 Unit. The clear unscored and unmarked bottle of testosterone cypionate injectable remained in the narcotic box. The DON confirmed the count could not be verified. She said pharmacy would need to be contacted to request a container that the remaining amount could be verified when the reconciliation took place at shift change. The DON stated she could not determine by looking at the bottle how much of the medication remained in the bottle.On 06/17/26 at 10:16 AM LPN/S7 stated he had contacted pharmacy and was told that the clear unscored and unmarked bottle was the only way the medication was packaged. The DON, who remained present, stated she would contact pharmacy to see what the options were so that nurses could complete the narcotic reconciliation accurately.

Based on observations, record review, staff interviews, and review of facility policy, the facility failed to ensure that residents who required oxygen received care in accordance with professional standards of practice and physician orders for two of two residents, Resident (R) 13 and R49, sampled for oxygen therapy. Findings include: Review of an undated facility policy, titled, Oxygen Administration, revealed the policy did not address the administration of oxygen via a tracheostomy mask. The policy addressed the administration of oxygen via an oxygen mask over the nose and mouth, a nasal cannula or a nasal catheter. Review of an undated facility policy, titled, Departmental (Respiratory), noted: Purpose: 1. Review the resident's care plan to assess for any special circumstances or precautions related to the resident. 2. Assemble the equipment and supplies needed. 1. [sic] Check water level of any pre-filled reservoir every day, if ordered. 2. Change pre-filled humidifier bottle, if ordered every seven (7) days, or as needed. 3. Change the oxygen cannula and tubing every seven (7) days, or as needed. 4. Keep the oxygen cannula and tubing used PRN [as needed] in a plastic bag when not in use. 5. Wash external filters from oxygen concentrators with soap and water as needed. Rinse and squeeze dry. The policy did not address oxygen administered via a tracheostomy mask. The policy also did not instruct staff to ensure the oxygen concentrators were on and operating correctly to ensure the resident was receiving the supplemental oxygen ordered by the physician. On 06/16/26 at 12:40 PM, R13 was observed to have a tracheostomy and was wearing an oxygen mask/ tracheal collar over his tracheostomy site. The tracheal collar and the connecting tubing were not dated to the last time they had been changed. A humidified bottle was connected to the oxygen concentrator and the connecting tubing and was dated 06/14/26. The oxygen concentrator was in the off position and R13 was not receiving supplemental oxygen as ordered. The Unit Manager for the 600 Unit was present in the room and confirmed the oxygen concentrator was off and R13 was not receiving any oxygen. The Unit Manager stated the concentrator had been on earlier in the morning when she did rounds. The Unit Manager turned on the concentrator and set the level at five liters per minute. The Unit Manager also confirmed the tracheal collar and connecting tubing were not dated as to when they were last changed. The Unit Manager checked R13's oxygen saturation, and documented it as 93%. Review of Physician's Orders for R13 revealed orders as follows regarding his tracheostomy: 05/05/26 Trach and Ambu bag at bedside 05/05/26 O2 (oxygen) at five liters/minute via tracheal collar continuously every shift. 05/06/26 Suction as needed 2. A review of R49's medical record revealed R49 was admitted to the facility on [DATE]. A record review of R49's Physician's Orders revealed the following: Oxygen @ (at) 3L(liters) per nasal cannula-continuously every shift for hypoxia; change oxygen tubing every night shift every Sunday. A review of Resident #49's diagnoses included acute respiratory failure with hypoxia and obstructive sleep apnea. A review of R49's current Significant Change Minimum Data Set assessment, with an Assessment Reference date of 03/24/26, revealed a Brief Interview for Mental Status score of three, indicating the resident had severely impaired in cognition. In an observation and interview on 06/16/26 at 2:25 PM, R49 was participating in activities in the dining room while utilizing oxygen at 3L per nasal cannula. Registered Nurse (RN) 4 stated the resident's oxygen tubing was dated 06/08/26. RN4 stated per facility policy, oxygen tubing was changed every Sunday. RN4 stated the resident's tubing should have a date of 06/14/26. RN4 confirmed policy and procedure was not followed for changing oxygen tubing. In an interview on 06/18/26 at 10:50 AM, the Director of Nursing (DON) stated oxygen tubing was changed every Sunday night on 3rd shift and as needed.

Based on observation, record review, and staff interviews, the facility failed to ensure a resident who was fed by enteral means, received the appropriate treatment and services to ensure adequate nutrition to prevent complications such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for one of one resident reviewed whoreceived nutrition via a percutaneous endoscopic gastrostomy tube (G-tube), (Resident (R) 13).Findings include:On 06/17/26 at 10:09 AM, during an interview with the Director of Nursing (DON), she stated the facility did not have a policy regarding the labeling of tube feeding formula.On 06/16/26 at 12:40 PM, while touring the room of R13, a container of tube feeding formula was observed on a pole beside the bed. The container had a manufacturer's label that identified it as Jevity 1.5. The formula was connected to a G-tube in the abdomen of R13. The formula was infusing via a feeding pump at 70 milliliters (ml) per hour (hr) with water flushes to infuse at 175 ml every four hours. The label on the front of the formula did not identify who the formula was for (name of resident) and did not have a date or time or infusion rate to on the label. These areas were left blank. Additionally, there was a clear bag also hanging on the pole containing a clear liquid. This bag did not identify the contents of the bag, the name of the resident, date, time, or the rate the liquid was to infuse.A review of Physician's Orders for R13 revealed the following orders:05/05/26-check residual every shift and if >60 ml hold feeding;05/05/26-flush with 175 ml of water every four hours;05/05/26-Jevity 1.5 at 70 ml/hr-start at 6:00 PM and stop at 2:00 PM (20 Hours)A bottle of Jevity 1.5 contains 1000 ml of formula, the feeding was scheduled to infuse at 70 ml/hr for 20 hours a day and R13 should receive a total of 140 ml. Tube feedings are paused occasionally for resident care, repositioning and transfers. Since the bottle and the soft clear bag were not labeled as to date and time it was started, it would not be able to be determined how long the formula had been open and hanging on the pole. Since Resident #13 received more than one (1) 1000ml bottle a day, it was not possible to determine when this bottle of formula was initially put into service or how long it had been open.On 06/17/26 at 10:09 AM during an interview with the DON, she stated that all bottles of tube feeding formula and water should be labeled with the date and time. She further confirmed since tube feedings are often paused for care and repositioning that the start time of each bottle of formula could vary and should have a time written on each bottle and each bag of water flush so that the start time could be determined and it would not be left hanging for an extended period of time.

Based on interview, record review, and review of the facility policy, the facility failed to ensure the facility Code Book was updated to accurately reflect the resident's current code status of Full Code after the physician's order was changed from Do Not Resuscitate (DNR) to Full Code. The Code Book was identified by staff as a primary resource used to determine code status during an emergency. This affected one of 24 sampled residents reviewed (Resident (R) 14).Findings include:Review of the facility's policy titled, Emergency Procedure - Cardiopulmonary Resuscitation and Basic Life Support, dated 2001, noted: Policy Statement [:] Personnel are certified in cardiopulmonary resuscitation (CPR) for healthcare providers and basic life support (BLS), including defibrillation for victims of sudden cardiac arrest. General Guidelines [:] 1. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a staff member who is certified in CPR for healthcare providers/BLS will administer CPR unless: a. it is known that a do not resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual.Preparation for Cardiopulmonary Resuscitation.g. Document advance directives in the resident medical records and educate staff on how to access this information. h. Provide clear instructions for staff regarding how to determine code status during an emergency.Review of R14's Face Sheet indicated that the resident was admitted to the facility on [DATE], and readmitted on [DATE] following a hospitalization, with diagnoses that included vascular dementia.Review of R14's hand-written physician orders, located under the Physician Orders tab, found an order dated [DATE] which read, DNR. Does not have decisional capacity.Review of the facility document titled, Physician's Certification of Decisional Capacity, noted: We hereby certify that we have determined upon physician examination that this resident [R14] is unable to exercise his or her rights in making Health Care Decision because of the following diagnosis.mood disorder[.] Extent and duration of decision making[:] permanent all medical decision, [sic], signed and dated by the Physician on [DATE].Review of R14's Advanced Directives form titled, Resident/Family Consent for Cardiopulmonary Resuscitation, noted: I understand that CPR constitutes an extraordinary measure and SHOULD NOT be done on [R14], [sic] the form noted verbal consent by the resident's representative, and was signed and dated by two witnesses on [DATE]. Review of R14's updated Resident/Family Consent for Cardiopulmonary Resuscitation, noted: I understand that CPR constitutes an extraordinary measure and SHOULD be done on [R14] [sic]. The form noted verbal consent by the resident's representative and was signed and dated by two witnesses on [DATE].During an interview on [DATE] at 1:05 PM, Licensed Practical Nurse (LPN) 1 stated that the staff rely on a Code Book kept at the nursing station to determine a resident's code status if the resident is unresponsive, in an emergency. LPN1 stated, The staff rely on the code book as the most reliable source in an emergency to see if the resident is full code or DNR [sic].During an observation and interview on [DATE] at 1:07 PM, LPN2, the Manager of 500 Unit, retrieved a large red binder titled, Code Book, from the nursing station. LPN2 opened the book and located R14's Advance Directive Sheet, which read, Do Not Resuscitate [DNR]. LPN2 stated that it was Social Service staff's responsibility to update the Code Book with the most accurate code status based on the Advance Directive education provided, a signed consent from the resident/resident representative, and a Physician's Order. LPN2 verified that R14's Physician Order dated [DATE] revealed an active order for a Full Code Status not a DNR status and that the Code Book, LPN2 described as the staff's most reliable resource for determining the resident's code status during an emergency, was not accurate. LPN2 admitted that not performing CPR during an emergency as R14's legal representative requested could have led to imminent harm or death.During an interview on [DATE] at 1:15 PM, Certified Nursing Assistant (CNA) 3 stated, We can log in and see the code status in our POC [Point of Care], but if we want the most accurate information [code status], the [Code] book would probably be it [sic].During an interview on [DATE] at 1:54 PM, the Social Services Director (SSD) confirmed that R14's DNR Code Status in the Code Book was not accurate and that there was an active order for a Full Code Status from [DATE]. The SSD admitted that they were responsible for updating the Code Book on each Unit with any changes. The SSD stated, I didn't update the Code Book, [R14's] paperwork [Full Code Status orders and consent] was buried under a bunch of paperwork on my desk. It just got lost and I didn't do it.During an interview on [DATE] at 2:51 PM, the Director of Nursing (DON) stated that the Code Book was used by staff to confirm a resident's code status in an emergency. The DON stated, It should be done as soon as possible, in a timely manner, when we get the order. The Social Worker is usually the one that updates the Code Book, if she is off, there is always someone covering, usually the Discharge Planner. They would assume that roll. Staff can check on the computer [the resident's medical record] but they are relying on that Code Book to be accurate. The DON admitted that that not performing CPR during an emergency as the R14's legal representative requested, could have led to imminent harm or death.

Based on record review and interviews, the facility failed to ensure it had systems in place to verify licensure for nursing leadership. The Director of Nursing (DON)'s license was suspended by the State of South Carolina (SC), effective June 18, 2025, yet she continued providing clinical oversight, supervising nursing staff, and direct resident care while unlicensed.On 02/14/26 at 3:50 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations could cause psychosocial harm.On 01/14/26 at 3:50 PM, the survey team provided the Director of Nursing with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 06/18/25. The IJ was related to 42 CFR S483.70 Administration.On 01/15/26 the facility provided an acceptable IJ Removal Plan. On 01/15/26 the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance.Review of a document from the South Carolina Department of LLR dated June 18, 2025, revealed DON1's license to practice nursing in this state is hereby temporarily suspended, effective immediately, until further Order of the Board.Review of a facility document titled Job Description: Director of Nursing signed by DON1 on May 15, 2024, states, The DON is a registered nurse who oversees and supervises the care of all residents. The DON provides direct resident/patient care.Essential Duties: Overall management of the entire nursing department and staffing levels. Responsible for ensuring resident safety, provide direct/hands-on resident/patient care as needed.Supervisory Requirements: The Director of Nursing is responsible for supervising and managing the ADON, and entire nursing staff either directly or indirectly.Qualifications: Education: Must be in good standing with the State Board of Nursing and maintain all required continuing education/licensing requirements at all times.During an interview on 01/14/26 at 11:32 AM, the HR Staff, stated, the DON was terminated from her job on 06/25/25 for conduct and unprofessionalism, she stated that her termination letter states sexual harassment due to the nature of some of the comments made. HR states that they were unaware of DON1s' license suspension and that they were not made aware until sometime after her termination. The DON was a salaried exempt employee and therefore did not clock in and out. HR was unable to state what kind of duties the DON would have performed during the time she was working with her license suspended.Attempted a telephone interview with DON1 on 01/14/26 at 12:04 PM was unsuccessful.During an interview on 01/14/26 at 11:41 AM, DON2 stated the previous DON would have performed typical DON duties and does not believe that she was signed off for any patient care during that time frame. DON2 states she took over as DON on June 25th, 2025, the same day as DON1's termination. She stated that they were not aware of DON1's nursing license suspension until June 30th when conducting an audit of the narcotics due to something DON1 had stated to DON2 after her termination. During the facility internal audit/investigation DON2 and a regional consultant had looked DON1 up and that was when they found out her license was suspended.During a follow up interview on 01/14/26 at 12:46 PM, HR Staff stated that they currently do not have a policy for auditing licenses. However, for the nurses, unless they have a reason they do not check/audit licenses in between their two-year renewal period.The facilities removal plan includes: The facility has taken the following steps related to Tag F835As communicated to the survey team, the former employee at issue was terminated from employment on 06/25/25 for reasons unrelated to her licensure. The employee did not notify the employer/facility that her license was temporarily suspended by the Board of Nursing on 06/18/2025. While the facility performed licensure verification at hire, licensure renewal dates, and annually, a verification was not performed in the seven (7) day period between the Board of Nursing Temporary Suspension Order and the date of termination.The Temporary Suspension Order was not provided by the State or the employee to the employer/facility. While the Board of Nursing has no publicly available timeline for how long an order takes to be posted on its website for verification purposes after it is issued, anecdotally, it can take days to weeks before an order is publicly available. In this case, there were only four (4) business days between execution of the order and the employee's termination. Therefore, even if verification was performed more frequently than annually (no regularity requirement exists under current law) and the verification happened to be run in the seven (7) day period between the suspension and the employee's termination, there is no guarantee that the order would have been publicly posted.Upon notification of the Immediate Jeopardy tag, the facility took the following remediation steps:1. On 01/14/2026, at 4:16pm the Director of Nursing (DON) notified the Medical Director of the Immediate Jeopardy. Any additional required external notifications will be completed, if applicable.2. On 01/14/2026, the Human Resource Director initiated a primary source audit of licensed nursing staff currently employed in the facility to ensure all have an active license and are in good standing with the Board of Nursing. No licensure issues were identified. Verification evidence for all licensed nursing staff was printed or electronically saved and will be placed into appropriate personnel files.3. On 01/14/2026, the DON completed a look-back investigation for all shifts worked by the ex-employee at issue during the license suspension time of 06/18/2025 to 06/25/2025.(the ex employee called out on 06/24/2025 and did not work in the facility and was terminated on 06/25/25). The review found no evidence of resident harm and no resident complaints. With regard to the residents identified in the survey, on 1/14/2026, Resident 4 was interviewed and assessed by the Unit Manager following identification of the concern. R4 reported no complaints and exhibited no negative effects related to the assessment previously completed by the ex-employee. Resident 5 was discharged from the facility on 10/31/2025.4. On 01/14/2026, licensed nursing staff received mandatory re-education on the requirement to immediately notify the Administrator and/or Director of Nursing if their nursing license is under investigation, a licensure-related consent order is entered, or the license becomes suspended, restricted, expires, or changes status for any reason.5. The Human Resource Director will audit nursing license monthly x 3 months and then quarterly x3 quarters to ensure nurses in the facility have an active nursing license. Results of audits will be reported to the QAPI Committee monthly for three(3) months and quarterly for three (3) quarters. The QAPI Committee will re-evaluate the need for further monitoring after these reporting periods. The Human Resource Director will be responsible for monitoring and follow up.6. On 01/14/2026, the Human Resource Director uploaded current, active nursing licenses for all licensed nursing staff into the facility's human resources system to ensure centralized and accessible credential verification.7. On 1/14/2026, the Human Resource Director was re-educated by the Regional [NAME] President and Assistant Regional Director of Clinical Services on the licensure certification and registration of personnel policy (attached). When questioned, the Human Resources Director failed to provide the policy to the surveyors.8. On 01/14/2026, the facility implemented a process for all newly hired employee sign an attestation stating it is their responsibility to inform the Administrator, Director of Nursing, or Human Resource Director of any licensure investigate entry of any licensure-related consent order, or change in licensure status. to report constitutes grounds for disciplinary action up to and including termination.9. On 1/14/2026 the facility initiated an attestation for all currently hired license personnel that it is their responsibility to inform the Administrator, Director of Nursing, or Human Resource Director of any licensure investigation, the entry of an licensure-related consent order, or change in their licensure status. Failure to report constitutes grounds for disciplinary action up to and including termination.10. All attestations for licensed personnel will be completed by 1/15/2026 or employee will not work until attestation is completed.11. A standardized license verification form and central licensure tracking log with verification and expiration dates will be implemented by 1/15/2026.

Based on record review and interviews, the facility failed to ensure that nursing services were provided by a licensed nurse when the Director of Nursing (DON)1 worked while her nursing license was placed on temporary suspension, effective June 18th, 2025. The DON1 continued to work on June 18th, 2025, and June 23rd, 2025, providing nursing leadership oversight without a valid license and provided direct patient care for two residents (R)4 and R5. On 01/14/26 at 3:50 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations could cause psychosocial harm.On 01/14/26 at 3:50 PM, the survey team provided the Director of Nursing with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 06/18/25. The IJ was related to 42 CFR S483.35(c)(3) Nursing Services.On 01/15/26, the facility provided an acceptable IJ Removal Plan. On 01/15/26, the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance.Findings include:Review of a document from the South Carolina Department of Labor Licensing and Regulation (LLR) dated June 18, 2025, revealed DON1's license to practice nursing in this state is hereby temporarily suspended, effective immediately, until further Order of the Board.Review of a facility document titled Job Description: Director of Nursing signed by DON1 on May 15, 2024, stated, The DON is a registered nurse who oversees and supervises the care of all residents. The DON provides direct resident/patient care.Essential Duties: Overall management of the entire nursing department and staffing levels. Responsible for ensuring resident safety, provide direct/hands-on resident/patient care as needed.Supervisory Requirements: The Director of Nursing is responsible for supervising and managing the ADON, and entire nursing staff either directly or indirectly.Qualifications: Education: Must be in good standing with the State Board of Nursing and maintain all required continuing education/licensing requirements at all times.Review of R4's face sheet revealed he was admitted to the facility on [DATE].Review of R4's Electronic Medical Record (eMAR) dated June 2025, revealed the following:06/23/25 10:39 AM [R4] approached [DON1] and said hey look at my chest and see what you think needs to be done about it. He held up his shirt and under his right pec area he has a large erythamatic and ulcerated rash. NP and Dr[ ] were made aware and looked at area. [DON] also called the wound provider and received orders for Mycolog II cream BID for 14 days, Diflucan 100 mg PO QD for 5 days, Keflex 500 mg PO BID for 10 days and to place Interdry to area at least 3 hours after application of Mycolog. [wound provider] also stressed importance of showering daily until rash is resolved. [DON1] did explain this to [R4] and stated he would need to shower prior to the first administration of the cream daily. He is agreeable for the time being.06/23/25 2:33 PM, DON1 entered orders for Diflucan 100 mg, one time a day for erythrasma for 4 days and Cephalexin 500 mg every 12 hours for erythrasma for 10 days.06/23/25 7:12 PM [DON1] spoke with [R4] at around 1045 this morning and told him I would do his wraps on his bilateral lower extremities but he would need to take his shower and be out by 1500. He stated he would do that. At 1225 I reminded resident again to be finished with his shower at by 1500, to which he stated he would. [DON1] also reminded resident at around 1345 at this time [R4] stated he would gather his stuff and get in the shower. At 1519 resident still had not began his shower. [DON1] explained to him of an appointment at 1800 she was required to be present at and writer needs to leave facility by 1715. He stated Ok, ok, I'm getting in the shower now. [DON1] waited on [R4] to be out of the shower until 1730, and he was still in the shower when writer had to leave the facility. [DON1] did check on [R4] multiple times during the shower and reminded him he needed to complete the shower and come out of the shower room so his legs could be dressed. When [DON1] told [R4] she had waited all she could he said that's the problem is no one here wants to do anything to take care of me. It was explained again that [DON1] had reminded him several times he needed to shower so his legs could be treated and he did not even begin his shower until over an hour past the time that had been agreed on.Review of R5's Face sheet revealed she was admitted to the facility on [DATE].Review of R5's eMAR dated June 2025, revealed a weekly summary note written by DON1 dated 06/18/25 and IDT conference assessment signed by DON1.During an interview on 01/14/26 at 11:32 AM, the Human Resources (HR) Staff, stated, [DON1] was terminated from her job on 06/25/25 for conduct and unprofessionalism. She stated that her [DON1's] termination letter states sexual harassment due to the nature of some of the comments made. HR states that they were unaware of DON1's license suspension and that they were not made aware until sometime after her termination. The DON1 was a salaried exempt employee and therefore did not clock in and out. HR was unable to state what kind of duties the DON1 would have performed during the time she was working with her license suspended.Attempted interview with DON1 on 01/14/26 at 12:04 PM via telephone, was unsuccessful.During an interview on 01/14/26 at 11:41 AM, DON2 stated, The previous DON would have performed typical DON duties and does not believe that she was signed off for any patient care during that time frame. DON2 states she took over as DON on June 25th, 2025, the same day as DON1's termination. She stated that they were not aware of DON1's nursing license suspension until June 30th when conducting an audit of the narcotics due to something DON1 had stated to DON2 after her termination. During the facility internal audit/investigation, DON2 and a Regional Consultant had looked DON1 up and that was when they found out her license was suspended.During a follow up interview on 01/14/26 at 12:46 PM, HR stated that they currently do not have a policy for auditing licenses. However, for the nurses, unless they have a reason, they do not check/audit licenses in between their two-year renewal period.The facilities removal plan includes: The facility has taken the following steps related to Tag F727:As communicated to the survey team, the former employee at issue was terminated from employment on 06/25/25 for reasons unrelated to her licensure. The employee did not notify the employer/facility that her license was temporarily suspended by the Board of Nursing on 06/18/2025. While the facility performed licensure verification at hire, licensure renewal dates, and annually, a verification was not performed in the seven (7) day period between the Board of Nursing Temporary Suspension Order and the date of termination.The Temporary Suspension Order was not provided by the State or the employee to the employer/facility. While the Board of Nursing has no publicly available timeline for how long an order takes to be posted on its website for verification purposes after it is issued, anecdotally, it can take days to weeks before an order is publicly available. In this case, there were only four (4) business days between execution of the order and the employee's termination. Therefore, even if verification was performed more frequently than annually (no regularity requirement exists under current law) and the verification happened to be run in the seven (7) day period between the suspension and the employee's termination, there is no guarantee that the order would have been publicly posted.Upon notification of the Immediate Jeopardy tag, the facility took the following remediation steps:1. On 01/14/2026, at 4:16 pm the Director of Nursing (DON) notified the Medical Director of the Immediate Jeopardy. Any additional required external notifications will be completed, if applicable.2. On 01/14/2026, the Human Resource Director initiated a primary source audit of licensed nursing staff currently employed in the facility to ensure all have an active license and are in good standing with the Board of Nursing. No licensure issues were identified. Verification evidence for all licensed nursing staff was printed or electronically saved and will be placed into appropriate personnel files.3. On 01/14/2026, the DON completed a look-back investigation for all shifts worked by the ex-employee at issue during the license suspension time of 06/ 18/2025 to 06/23/25) the ex-employee called out on 06/24/2025 and did not work in the facility and was terminated on 06/25/25). The review found no evidence of resident m and no resident complaints. With regard to the residents identified in the [NAME], on 1/14/2026, Resident 4 was interviewed and assessed by the Unit Manager owing identification of the concern. R4 reported no complaints and exhibited no negative effects related to the assessment previously completed by the ex-employee. Resident 5 was discharged from the facility on 10/31/2025.4. On 01/14/2026, licensed nursing staff received mandatory re-education on the requirement to immediately notify the Administrator and/or Director of Nursing if their nursing license is under investigation, a licensure-related consent order is entered, or the license becomes suspended, restricted, expires, or changes status for any reason.(3) months and quarterly for three (3) quarters. The QAPI Committee will re-evaluate the need for further monitoring after these reporting periods. The Human Resource Director will be responsible for monitoring and follow up.6. On 01/14/2026, the Human Resource Director uploaded current, active nursing licenses for all licensed nursing staff into the facility's human resources system to ensure centralized and accessible credential verification.7. On 1/14/2026, the Human Resource Director was re-educated by the Regional [NAME] President and Assistant Regional Director of Clinical Services on the licensure certification and registration of personnel policy (attached). When questioned, the Human Resources Director failed to provide the policy to the surveyors.8. On 01/14/2026, the facility implemented a process for all newly hired employees to sign an attestation stating it is their responsibility to inform the Administrator, Director of Nursing, or Human Resource Director of any licensure investigation, the entry of any licensure-related consent order, or change in licensure status. Failure to report constitutes grounds for disciplinary action up to and including termination.9. On 1/14/2026, the facility initiated an attestation for all currently hired licensed personnel that it is their responsibility to inform the Administrator, Director of Nursing, or Human Resource Director of any licensure investigation, the entry of any Licensure-related consent order, or change in their licensure status. Failure to report constitutes grounds for disciplinary action up to and including termination.10. All attestations for licensed personnel will be completed by 1/15/2026 or the employee will not work until attestation is completed.11 A standardized license verification form and central licensure tracking log with verification and expiration dates will be implemented by 1/15/2026.

Based on review of the facility policy, observation, and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for 124 out of 124 residents. Findings include: Review of the facility's Food Storage: Dry Goods policy and procedure revised in 02/2023, revealed, 1. All items will be stored on shelves at least 6 inches above the floor. Review of the facility's Food Storage: Cold Foods policy and procedure revised in 02/2023 revealed, 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. During a tour of the kitchen on 04/08/25 at approximately 7:45 AM, a box of cereal and a box of thickened sweet tea were stored on the floor. Dented cans of black-eyed peas and chili were found in the storeroom stored with ready to use cans of food. A plastic container with what appeared to be egg salad was not labeled or dated. In a reach-in refrigerator, a container of pureed fruit was not labeled and had no date. A plastic zip lock bag with a date of 04/02/25, was not labeled. In the walk-in refrigerator, two (2) cases of chocolate milk were observed with expiration dates of 04/02/25. In the same walk-in refrigerator, four (4) plastic containers of various unidentifiable food were observed with no label and no date. Pepperoni was observed partially wrapped in plastic wrap with no date or label and was stored on top of raw beef which also had no date or label and was not in a pan or container. The beef was thawed and in cryovac. The shelving, vent hoods, ceiling vents, and floor throughout the entire kitchen appeared to be dirty. During an interview on 04/08/25 at approximately 8:30 AM, the Account Manager (AM) stated they agreed with observations made and that they were going to throw away every container that was not labeled and dated because they did not know how old the food in the containers was were. During an interview on 04/08/25 at approximately 1:00 PM, the Dietary Manager (DM)1 stated that they just started working at the facility the week before the survey. DM1 stated that they walked into a mess and they were making changes in the kitchen to address the issues. During an interview on 04/11/25 at approximately 10:00 AM, the Administrator stated that they started in December and was told that the person running the kitchen was a Certified Dietary Manager (CDM), but was not a CDM. The Administrator stated that they identified the kitchen as a problem a month into working at the facility. The Administrator stated that it took time replace the company that was running the kitchen and to find a different company.

Based on observation, interview, record review, and review of facility policy and manufacturer's instructions, the facility failed to ensure staff implemented infection control measures during medication pass. Staff failed to sanitize a glucometer before and after use for one (Resident (R) 93) resident during medication administration observation. In addition, staff failed to perform hand hygiene during medication administration. These failures had the potential to create cross contamination and/or spread infection. Findings include: Observation on 05/30/23 at 4:23 PM revealed Registered Nurse (RN)1 took a glucometer from the medication cart. RN1 failed to clean the glucometer and failed to perform hand hygiene before entering R93's room to perform a blood glucose check. RN1 then proceeded to perform a fingerstick blood glucose check without performing hand hygiene or donning gloves. At 4:26 PM, after performing the blood glucose check, RN1 then placed the glucometer back in the medication cart without cleaning the glucometer and without performing hand hygiene. At 4:28 PM, RN1 pulled two insulin pen injections and R93's oral medications from the medication cart and returned to R93's room. At 04:29 PM, RN1 administered R93's oral medications. RN1 then went into R93's bathroom to retrieve a paper towel to clean a spill of medication on R93. RN1 did not perform hand hygiene at this time. At 4:30 PM, RN1 cleaned the injection sites with an alcohol rub and administered both injections to R93 without performing hand hygiene and without donning gloves. RN1 finally performed hand hygiene at 4:31 PM. Interview with RN1 on 05/30/23 at 4:49 PM revealed the glucometer was used on multiple residents who required blood glucose checks. RN1 stated she was aware that the glucometer should be sanitized each time after using it. RN1 confirmed that she had placed the glucometer in the medication cart without first sanitizing the glucometer. When asked how to clean the glucometer, RN1 stated she would use alcohol wipes and proceeded to demonstrate cleaning the glucometer with two alcohol wipes. An interview was conducted with the Director of Nursing (DON) on 05/30/23 at 5:06 PM, as the facility's Infection Preventionist (IP), who worked part-time, was not available. The DON was informed of the observations related to RN1's failure to clean the glucometer, as well as the lack of gloves while performing an injection, and failure to perform hand hygiene when appropriate. The DON confirmed the facility's glucometers were used on multiple residents and that none of the residents in the facility had their own dedicated glucometer. The DON stated it was her expectation that staff sanitize glucometers using the facility's EPA registered cleaning wipes, rather than the alcohol wipe that RN1 demonstrated. The DON also stated that RN1 should have worn gloves to administer injections to the resident and should have performed hand hygiene in between tasks and before entering and exiting the resident's room. Review of the facility policy, Blood Glucose Monitoring, Long-Term Care, revised 11/28/22, revealed The Centers for Disease Control and Prevention recommends refraining from sharing blood glucose meters among residents whenever possible. If one device must be used to monitor several residents, it must be cleaned and disinfected after every use following the manufacturer's instructions to prevent carryover of blood and infectious agents. Single use auto disabling fingerstick devices should also be used to prevent the spread of bloodborne pathogens. Review of the User's Guide for the glucometer (Evencare G3) revealed that, Cleaning and Disinfecting Procedures for the Meter: The Evencare G3 Meter should be cleaned and disinfected between each patient. Further review of the User's Guide for the glucometer revealed it requires an EPA registered disinfectant (which alcohol is not) for cleaning/sanitizing. Review of the facility's policy, titled Hand Hygiene, reviewed 08/19/22, revealed, To protect a patient from health care-associated infection, hand hygiene must be performed routinely and effectively . Using an alcohol-based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, excretions, mucous membranes, non-intact skin, or wound dressings (if hands aren't visibly soiled); after removing gloves; and after contact with inanimate objects in the patient's environment.

Based on interview and record review, the facility failed to ensure that binding arbitration agreements were only entered into by residents who had the cognitive ability to understand the information being presented and make an informed decision about whether to enter the binding arbitration agreement, prior to signing their consent. Two (Resident (R) 207 and 209) of three residents reviewed for binding arbitration agreements had cognitive impairment which limited their ability to understand the information being presented and, in response, make an informed decision as to whether they wished to enter into the agreement. This failure creates the potential for residents to lose legal rights to take action against the facility. Findings include: 1. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/16/23 revealed R207 was admitted to the facility on [DATE] with diagnoses that included sepsis, moderate protein-calorie malnutrition, metabolic encephalopathy, and urinary tract infection. Per the MDS, R207 had a Brief Interview for Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment. Review of an Arbitration Agreement provided by the facility, dated 05/10/23, revealed R207's signature indicating understanding of the arbitration agreement. Further review of the arbitration agreement revealed that there was no signature of a responsible party or guardian. Observation on 05/29/23 at 4:33 PM revealed R207 was sitting in her wheelchair and had been placed at the nurse's station due to her confusion. During an attempted interview with R207, on 05/31/23 at 08:20 AM, R207 was confused and unable to answer any questions. Interview with the Social Services Director (SSD) on 05/30/23 at 12:58 PM revealed she performs a social work initial assessment within 48 hours on all newly admitted residents. The SSD stated part of her initial assessment is to determine whether the resident has decisional capacity. Review of a Social Services Evaluation, dated 05/11/23 and located under the Assessments tab of the electronic medical record (EMR), revealed that the resident was moderately cognitively impaired and had barriers to communication which included receptive/expressive deficits .confusion. Per the section of the Evaluation titled, Decision Making, it stated that R207 did not make her own decisions and R207's husband's name was listed as the person who made decisions for the resident. During an interview with the Administrator on 05/31/23 at 6:00 PM, she confirmed R207 was cognitively impaired, so she could not have understood the arbitration agreement that she signed. 2. Review of the admission MDS with an ARD of 05/28/23 and which was still in progress, revealed R209 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, alcohol dependence with other alcohol-induced disorders, and alcohol abuse with withdrawal delirium. Review of document titled Social Services Evaluation dated 05/25/23 located under the Assessments tab of the EMR revealed under the section Decision Making that R209 was his own decision maker. Review of the section: Communication revealed R209 has the following barriers to communication: receptive/expressive deficits . delayed speech. The assessment further revealed The patient is oriented to person, place and situation, with a BIMS score of 14, with the resident listed as cognitively intact. Review of the Arbitration Agreement provided by the facility dated 05/29/23 revealed R209's signature indicating understanding of the arbitration agreement. Further review of the arbitration agreement revealed that there was no signature of a responsible party or guardian. Observation on 05/29/23 at 12:05 PM revealed R209 hit the call light, and when staff responded in the presence of surveyor, R209 stated he was trying to get a ride home. R209 also stated he thought he was already home. During an interview with R209 on 05/31/23 at 8:17 AM, in the presence of the facility's Administrator, R209 stated he did not know what a binding arbitration was. R209 stated he did not recall signing an arbitration agreement two days earlier. The administrator confirmed R209 neither recalled nor understood what binding arbitration was. During an interview with the Admissions Director (AD1) on 05/30/23 at 2:30 PM, she stated she was responsible for having residents sign binding arbitration agreements. The Admissions Director stated she gives an overview of what arbitration is to the residents before they sign, saying that she explains that it is a legal document, and that if they have an issue with the facility, they would be bound by the arbitration agreement to have an arbitrator appointed to them and would sit down and come to an agreement usually outside of court. When asked how she ensures that each resident understood what they were signing, she stated the resident usually said they understood. When asked how the facility ensures that only residents who are cognitively intact sign the arbitration agreement, she stated whoever signs the admission agreement, signs the arbitration agreement because it is part of the admission agreement. When asked if she explained to residents that they have the right to rescind the agreement within a certain number of days of signing, the AD stated no resident had ever told her they changed their mind, and she did not know how many days the resident was given to rescind the agreement. Review of the verbiage in the arbitration agreement provided by the facility revealed the following statement: This arbitration agreement governs important legal rights. Please read the agreement in its entirety before signing. Each party is waiving the right to trial by jury. Disputes must be resolved exclusively through binding arbitration. I acknowledge that my signature below indicates that this agreement has been explained to me and that I understand it.

Based on observations, record reviews, interviews, and review of facility protocol, the facility failed to investigate the causative factors of the falls, failed to provide interventions as planned and failed to provide effective interventions for the prevention of falls for one (1) of two (2) residents reviewed for falls. (Resident #57) Resident #57 experienced 28 falls since 1/1/21 resulting in two (2) head lacerations requiring sutures or skin glue to treat. Findings include: Review of the facility protocol titled, Falls Practice Guide dated 12/2011 documented the Falls Practice Guide was an approach that used the nursing process framework: assess, plan, implement and evaluate. The comprehensive care plan was developed to include individualized resident interventions that focused on the resident's risk factors. The approaches for fall interventions were clear, specific, and individualized for the resident's needs. Review of Resident #57's clinical record revealed the admitted [DATE]. The diagnoses included: Dementia without Behavioral Disturbance, Cognitive Communication Deficit, Major Depressive Disorder, Disorder of Muscle, and [CONDITION(S)]. Review of the clinical record revealed the resident had 13 falls from admission on 1/7/2020 to 12/31/2020. Review of Resident #57's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score of six (6) with a score of zero to seven (0-7) indicating severe cognitive impairment. The resident displayed inattention and disorganized thinking that fluctuated and did not display behaviors. The MDS documented the resident required supervision with bed mobility, transfers, walking, locomotion and dressing. The resident required limited assistance with toileting. Resident #57 was not steady but able to stabilize without staff assistance with walking and turning around. The resident was not steady and not able to stabilize without staff assistance with moving on and off the toilet, surface with surface transfers and moving from a seated to standing position, Resident #57 utilized a walker and a wheelchair and had one (1) without injury since the previous assessment. The MDS documented the resident did not receive therapy or restorative services. Review of the clinical record revealed Resident #57 had eight (8) falls since the previous assessment completed on 1/3/21 and not the one documented on the MDS dated [DATE]. Review of Resident #57's Care Plan in place on 12/31/2020 listed the fall interventions: encourage to transfer and change positions slowly, have commonly used articles within easy reach assist to transfer and ambulate as needed, anti-roll backs to wheelchair, assist when the resident becomes fatigues, assist with toileting upon rising, at hour of sleep (HS) and before and after meals, encourage and remind him/her to use his/her walker, keep bed at wheelchair height, medication review, offer and assist with toileting, place walker within easy reach, provide and assist with nonskid socks, reinforce need to call for assistance and assist with toileting hygiene, and reinforce wheelchair safety as needed such as locking brakes,. Review of the facility provided Timeline, the Fall Investigations, and the Care Plan listed the following 28 falls with injuries noted and interventions documented since 1/1/21: 1/30/21 at 7:15 a.m. - staff found the resident on the floor in the bathroom, the resident did not have on socks or shoes. 2/1/21 at 11:15 a.m. - staff found the resident on the floor in his/her bathroom. The resident sustained a Small goose egg to back of head. Staff added the intervention to refer to the Nurse Practitioner (NP) for labs and rehab to screen for safety awareness. 2/9/21 at 10:00 a.m. - staff found the resident sitting on the floor between his/her bed and the window. Staff added the intervention to encourage the use of the wheelchair. 2/22/21 at 12:05 a.m. - staff heard a loud noise and crying and found the resident on the floor at the foot of the bed, the resident's head was under the bed. The resident sustained an abrasion to the nose from his/her glasses. 3/2/21 at 6:45 p.m. - staff found the resident sitting on the floor in his/her room. The resident sustained a small hematoma to the right side of the forehead. Staff added the intervention to encourage the resident to allow staff to monitor for safety. 3/17/21 at 12:30 a.m. - staff found the resident on the floor in his/her room. 3/18/21 at 6:43 a.m. - staff found the resident on the floor in his/her room. Staff added the intervention to administer medications per Physician's Orders. 3/26/21 at 5:45 a.m. - staff found the resident on the floor at the foot of the bed. The resident sustained a Crushing skin wound to left forehead. The area was bleeding and staff applied a dry dressing. Staff added the intervention for a night light to brighten the room and rehab to screen for knee weakness. 4/5/21 at 9:30 a.m. - staff found the resident laying on the floor in his/her room. Staff documented that at 9:20 a.m. the resident was sitting on the side of the bed eating breakfast. The resident sustained a laceration to the forehead and was sent to the emergency room (ER). Staff added the intervention for Pharmacy to assist with medication review (which they do monthly). 4/6/21 at 3:00 a.m. - staff found the resident on the floor next to his/her bed. The resident sustained a large hematoma on the right side of [his/her] forehead. 4/6/21 at 7:20 a.m. - staff found the resident on the floor next to his/her bed. Resident sustained a hematoma to the posterior right side of the head. Staff added the intervention for pillows to define borders of the bed. 4/15/21 at 5:10 a.m. - staff found the resident on the floor in his/her room. Staff added the intervention for a medication review for a supplement for increased risk and history of urinary tract infections ([CONDITION(S)]) and refer to therapy plan of treatment for more detail. 4/20/21 at 4:14 a.m. - staff heard the resident yelling and found the resident on the floor in his/her room. Staff added the intervention to check the resident's orthostatic blood pressures to determine irregularities. 4/30/21 at 2:20 a.m. - staff found the resident on the floor between his/her bed and window. 5/3/21 at 2:44 p.m. - staff found the resident on the floor in their room. There was no Nurse's Note or Investigation of this fall, only listed on the Timeline the facility provided. 5/4/21 at 10:30 a.m. - staff found the resident on the floor next to his/her bed. The resident was calling out for help. Staff added the intervention for Physical Therapy (PT) to screen for balance issues. The facility did not provide an investigation of this fall. 5/6/21 at 2:45 a.m. - staff found the resident on the floor next to his/her bed. The resident sustained an abrasion to the forehead. The facility did not provide an investigation of this fall. 5/6/21 at 9:30 a.m. - resident was sitting in his/her locked wheelchair, leaned over to pick up a piece of paper and fell out of his/her wheelchair. Staff added the intervention to elevate the head of bed as tolerated and to encourage use of a scoop chair (low to the ground chair that tilted) as tolerated. The facility did not provide an investigation of this fall. 5/7/21 at 10:30 a.m. - staff found the resident on the floor in his/her room. The resident stated he/she rolled out of bed. Staff added the intervention for the Physician to review the resident's medication and move to a room closer to the Nurses' Station. The facility did not provide an investigation of this fall. Review of the Physician's orders revealed an order dated 5/5/21 for PT and Occupational Therapy (OT) secondary to frequent falls. Review of Resident #57's Rehabilitation Screening dated 5/13/21 documented the resident may benefit from skilled therapy services. Review of the clinical record and therapy provided documentation lacked evidence the resident received the therapy services. 7/2/21 at 3:30 p.m. - staff heard yelling and found the resident on the floor in his/her room. Staff added the intervention to keep the resident within close observation at the Nurses' Station for safety as he/she would allow during waking hours and a low bed. The facility did not provide an investigation of this fall. 7/4/21 at 5:18 a.m. - staff found the resident on the bathroom floor. Staff again added the intervention to toilet the resident upon rising, before and after meals and at HS as he/she will tolerate. The facility did not provide an investigation of this fall. 9/14/21 at 1:30 a.m. - staff heard a loud noise and yelling and found the resident on the floor in his/her room. The resident sustained an open laceration to the left temple area in the hair line. Staff transferred the resident to the Emergency (ER). Staff again added the intervention for the Physician to review the resident's medications. The resident received three (3) sutures. The facility did not provide an investigation of this fall. 9/16/21 at 10:40 p.m. - staff found the resident on the floor in his/her room. The resident stated, This bed is not big enough for my boyfriend and me. Staff added the intervention for lab work related to hallucinations. The facility did not provide an investigation of this fall. 9/20/21 at 5:50 a.m. - staff found the resident on the floor in the bathroom. The facility did not provide an investigation of this fall. 9/24/21 at 5:45 a.m. - staff found the resident lying on the floor at the foot of his/her bed. Staff added the intervention to attempt the use of a hand bell. 10/5/21 at 6:28 a.m. - staff heard a loud noise then yelling and found the resident on the floor next to his/her bed. The resident sustained a five (5) cm laceration to the mid forehead. Staff transferred the resident to the ER. Staff added the intervention to set up a care plan meeting with the provider and Interdisciplinary team (IDT). The ER closed the laceration with skin glue. 10/19/21 at 2:05 p.m. - Housekeeping Manager found the resident on the bathroom floor. The resident stated, [name] was just talking to me . Staff added the intervention for a protective helmet as the resident would allow. 11/11/21 at 6:20 a.m. - staff heard a loud noise and crying and found the resident on the floor at the foot of the bed. Bleeding from crack in scab at top of forehead that [he/she] received from previous fall. Staff added the intervention for therapy to evaluate for knee buckling. Review of the falls lacked consistent investigations of the falls, lacked consistent determination of the causative factor for the falls and lacked interventions based on the causative factors. The Fall Investigations lacked evidence the facility provided the interventions as planned. Observation on 11/30/21 at 11:35 a.m. revealed the resident sat across from the Nurses' Station with an approximate one (1) inch by two (2) inch dark scab on the top/middle section of the forehead. Observation on 12/1/21 at 12:09 p.m. revealed the resident's room door closed. Upon entrance to the room the resident was sitting on the side of bed eating his/her lunch. The resident's rollator was on the other side of the overbed table. No staff were present with the resident. Staff did place the resident at the Nurses' Station for close observation for safety, as added to the care plan on 7/2/21. Observation on 12/2/21 at 10:20 a.m. revealed the resident lying in bed on his/her back. The rollator was at the bedside, but no scoop chair noted in the room, as added to the care plan on 5/6/21. Observation on 12/3/21 at 10:30 a.m. revealed the resident's door opened and upon entering, observation revealed the resident in the bathroom pulling up his/her pants. No staff were with the resident. Interview with Licensed Practical Nurse (LPN) #6 on 11/30/21 at 11:35 revealed the wound/abrasion to the top of the resident's head was due to a fall. Interview with Certified Nursing Assistant (CNA) #16 on 12/2/21 at 10:45 a.m. revealed for the prevention of falls, the staff keep a good eye on the resident. CNA #16 stated the resident was continent and wore pull-ups and was able to do his/her own toileting. CNA #16 was asked about the use of the scoop chair and where it was located. After looking, CNA #16 found the scoop chair in the locked shower room. Interview with LPN #6 on 12/2/21 at 10:46 a.m. revealed, if a fall occurred the nurse completed an assessment of the resident, notified all parties, obtained witness statements, and documented the fall on the 24-hour report. The Fall Team reviewed all the falls. The nurse tried to put an intervention in place right after the fall. LPN #6 stated Resident #57 fell due to confusion, age, was able to ambulate, and the resident felt they could walk. LPN #6 stated the fall interventions included: encourage the resident to use the walker, encourage the resident to call us prior to transferring him/herself, monitor the resident's whereabouts frequently. LPN #6 stated there was no set timeframe for the frequency of monitoring. LPN #6 stated the staff should open the resident's room door to lay eyes on the resident. LPN #6 stated the resident toileted him/herself. Interview with Unit Manager (UM) #17 on 12/2/21 at 11:02 a.m. revealed after a resident fell the nurse working the unit would fill out the Incident Management with a detailed report of what happened, including items like the bed height. The nurse would also get witnessed statements. UM #17 stated if the resident was at risk for falls, we would just monitor them as they have the right to fall. The nurse working can add an intervention to prevent further falls. The facility does not have a real fall program. The facility discussed all falls at the morning meetings which included the Administrator, UMs, Director of Nursing (DON), Therapy, Dietary, maintenance, housekeeping, MDS Coordinator, Social Worker and Discharge Planner. UM #17 stated Resident #57 fell due to being [AGE] years old, demented and wanted to go back to Connecticut. The facility had tried a helmet, but the resident could not wear it due to the wound on his/her head. We have also tried a knee brace, pain gel for his/her knee, a night light and frequent checks. When asked how frequently the staff should check on Resident #57, UM #17 said at least every hour. Interview with the Rehab Director on 12/2/21 at 11:25 a.m. revealed Resident #57's left knee buckled at times. He/she stated therapy had ordered a knee sleeve for the resident, but it had not come in yet. Interview with the DON on 12/2/21 at 1:29 p.m. revealed when a resident fell the nurse on the floor completed an incident report and notified the physician and family. The nurse should put an intervention in place immediately. During the morning meetings the clinical staff discuss all the falls that occurred since the previous meeting. The clinical staff consisted of the DON, UMs, MDS Coordinator, Administrator, Dietitian, Therapy, and Activity staff. During the meeting we would review the fall, including what happened and what cause the fall and the interventions in place. Resident #57 was admitted due to him/her falling at home. The DON stated Resident #57's causes for his/her falls was he/she did not remember things, the resident thought they could do for him/herself and the resident toileted him/herself. For Resident #57's fall interventions we brought in his/her family. The family stated the resident would have UTIs that caused him/her to fall but we checked, and the resident did not have a [CONDITION(S)]. Interview with the Administrator on 12/3/21 at 10:00 a.m., he/she knew the facility had completed the investigations for all of Resident #57's falls but was unable to find them per their protocol to review the circumstances surrounding a resident's fall. Interview with the Rehab Director on 12/3/21 at 10:15 a.m. regarding the 5/13/21 Rehab Screen indicating the resident may benefit from skilled therapy, stated due to the resident's insurance the request for therapy would have been e-mailed to the Business Office to follow up on but those e-mails were automatically deleted after four (4) months. The Rehab Director further stated if the resident was added to the PT schedule, those schedules were deleted after five (5) months. The Rehab Director stated he/she did not know why the resident was not picked up for therapy.

Based on observations record reviews, interviews, and facility protocols, the facility failed to follow the care plan for the prevention of falls for one (1) resident (Resident #57) and for providing showers for one (1) resident (Resident #98). The sample included 25 residents. Resident #57 had 28 falls and the staff did not consistently follow the care plan and the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #98's was care planned to receive two (2) showers a week and the staff did not provide the showers as planned. Findings include: Review of the facility's protocol titled; Interdisciplinary Care Planning dated 3/2018 revealed the resident's care plan was a communication tool that guided members of the interdisciplinary healthcare team in how to meet each individual resident's needs. It also identified the types and methods of care the resident should receive. The care plan should describe the services the facility was to provide. The Care Plan process included the assessment, planning implementation, and evaluation. 1. Review of Resident #57's clinical record revealed the admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score of six (6) with a score of zero to seven (0-7) indicating severe cognitive impairment. The resident displayed inattention and disorganized thinking that fluctuated and did not display behaviors. The MDS documented the resident required supervision with bed mobility, transfers, walking, locomotion, and dressing. The resident required limited assistance with toileting. Resident #57 utilized a walker and a wheelchair and had one (1) fall without injury since the previous assessment. Review of Resident #57's Care Plan in place on 12/31/2020 listed the fall interventions: encourage to transfer and change positions slowly, have commonly used articles within easy reach, assist to transfer and ambulate as needed, anti-roll backs to wheelchair, assist when the resident becomes fatigued, assist with toileting upon rising, at hour of sleep (HS) and before and after meals, encourage and remind him/her to use his/her walker, keep bed at wheelchair height, medication review, offer and assist with toileting, place walker within easy reach, provide and assist with nonskid socks, reinforce need to call for assistance, assist with toileting hygiene, and reinforce wheelchair safety as needed such as locking brakes. Review of the facility provided Timeline, the Fall Investigations, and the Care Plan interventions revealed: 1/30/21 at 7:15 a.m. - staff found the resident on the floor in the bathroom, the resident did not have on socks or shoes on per the care plan. 2/1/21 at 11:15 a.m. - staff found the resident on the floor in his/her bathroom. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff did not assist the resident to the bathroom as care planned. 2/9/21 at 10:00 a.m. - staff found the resident sitting on the floor between his/her bed and the window. Staff did not assist the resident with transfers and ambulation as care planned. 2/22/21 at 12:05 a.m. - staff heard a loud noise and crying and found the resident on the floor at the foot of the bed, the resident's head was under the bed. Staff did not assist the resident with transfers and ambulation as care planned. 3/2/21 at 6:45 p.m. - staff found the resident sitting on the floor in his/her room. Staff did not assist the resident with transfers and ambulation as care planned. 3/17/21 at 12:30 a.m. - staff found the resident on the floor in his/her room. Staff did not assist the resident with transfers and ambulation as care planned. 3/18/21 at 6:43 a.m. - staff found the resident on the floor in his/her room. Staff did not assist the resident with transfers and ambulation as care planned. 3/26/21 at 5:45 a.m. - staff found the resident on the floor at the foot of the bed. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff did not assist the resident with transfers and ambulation as care planned. 4/5/21 at 9:30 a.m. - staff found the resident laying on the floor in his/her room. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . 4/6/21 at 3:00 a.m. - staff found the resident on the floor next to his/her bed. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff did not assist the resident with transfers and ambulation as care planned. 4/6/21 at 7:20 a.m. - staff found the resident on the floor next to his/her bed. resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff did not assist the resident with transfers and ambulation as care planned. 4/15/21 at 5:10 a.m. - staff found the resident on the floor in his/her room. Staff did not assist the resident with transfers and ambulation as care planned. 4/20/21 at 4:14 a.m. - staff heard the resident yelling and found the resident on the floor in his/her room. Staff did not assist the resident with transfers and ambulation as care planned. 4/30/21 at 2:20 a.m. - staff found the resident on the floor between his/her bed and window. Staff did not assist the resident with transfers and ambulation as care planned. 5/3/21 at 2:44 p.m. - staff found the resident on the floor in their room. Staff did not assist the resident with transfers and ambulation as care planned. 5/4/21 at 10:30 a.m. - staff found the resident on the floor next to his/her bed. Staff did not assist the resident with transfers and ambulation as care planned. 5/6/21 at 2:45 a.m. - staff found the resident on the floor next to his/her bed. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff added the intervention for the use of a scoop chair to help with safety. 7/2/21 at 3:30 p.m. - staff heard yelling and found the resident on the floor in his/her room. Staff added the intervention to keep the resident within close observation at the Nurses' Station for safety as he/she would allow during waking hours. Staff did not assist the resident with transfers and ambulation as care planned. 7/4/21 at 5:18 a.m. - staff found the resident on the bathroom floor. Staff did not provide assistance with toileting as planned. 9/14/21 at 1:30 a.m. - staff heard a loud noise and yelling and found the resident on the floor in his/her room. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff transferred the resident to the Emergency (ER). The resident received three (3) sutures. Staff did not assist the resident with transfers and ambulation as care planned. 9/20/21 at 5:50 a.m. - staff found the resident on the floor in the bathroom. The facility did not provide an investigation of this fall. Staff did not assist the resident to the bathroom as care planned. 9/24/21 at 5:45 a.m. - staff found the resident lying on the floor at the foot of his/her bed. Staff did not provide assistance with transfers and ambulation as care planned. 10/5/21 at 6:28 a.m. - staff heard a loud noise then yelling and found the resident on the floor next to his/her bed. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The ER closed the laceration with skin glue. Staff did not provide assistance with transfers and ambulation as care planned. 10/19/21 at 2:05 p.m. - Housekeeping Manager found the resident on the bathroom floor. Staff did not assist the resident with toileting as care planned and did not keep the resident at the Nurses' Station as care planned. 11/11/21 at 6:20 a.m. - staff heard a loud noise and crying and found the resident on the floor at the foot of the bed. Staff did not provide assistance with transfers and ambulation as care planned. The Fall Investigations lacked evidence the facility provided the interventions as planned. Observation on 11/30/21 at 11:35 a.m. revealed the resident sat across from the Nurses' Station with an approximate one (1) inch by two (2) inch dark scab on the top/middle section of the forehead. Observation on 12/1/21 at 12:09 p.m. revealed the resident's room door closed. Upon entrance to the room, the resident was sitting on the side of the bed eating his/her lunch. The resident's rollator was on the other side of the overbed table. No staff was present with the resident. Staff did place the resident at the Nurses' Station for close observation for safety, as added to the care plan on 7/2/21. Observation on 12/2/21 at 10:20 a.m. revealed the resident lying in bed on his/her back. The rollator was at the bedside, but no scoop chair was noted in the room. As added to the care plan on 5/6/21. Observation on 12/3/21 at 10:30 a.m. revealed the resident's door opened and upon entering, observation revealed the resident in the bathroom pulling up his/her pants. No staff was with the resident. 2. Review of Resident #98's clinical record documented the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #98's Care Plan dated 11/2/21 listed the intervention to assist the resident to bathe/shower as needed. Review of Resident #98's Kardex (identified as the Care Guide for the Certified Nursing Assistants (CNAs) dated 12/1/21 listed the intervention for staff to shower/bathe the resident Wednesday and Saturday evenings Review or the Shower Documentation provided by the facility for the period of 10/3/21 to 12/2/21 revealed Resident #98 should have received 17 showers but only received sic (6) showers and one (1) documentation that the resident refused a shower. Interview with CNA #16 on 12/2/21 at 10:45 a.m. revealed the facility provided each resident two (2) showers a week, per the Kardex/Care Guide. Interview with Licensed Practical Nurse (LPN) #6 on 12/2/21 at 10:46 a.m. revealed the facility's protocol was for the staff to bathe the residents two (2) times a week. Interview with Unit Manager (UM) #17 on 12/2/21 at 11:02 a.m. revealed staff should bathe the residents two (2) times a week.

Based on observation, interview, record review and facility policy review, the facility failed to ensure appropriate transmission-based precautions were implemented for one (1) of 25 sampled residents (Resident #160). The facility failed to ensure Resident #160, newly admitted with no record of receipt of COVID-19 vaccination, was placed in isolation and contact/droplet precautions protocol was implemented. There was no signage on the resident's door and staff were observed to enter and exit the resident's room and failed to wear personal equipment (PPE) in accordance with transmission-based precautions protocol. Findings include: Review of facility Practice Guidelines dated 7/2/21 revealed guidelines to address Airborne Precautions that outlined requirements for staff to follow to include keeping a resident's door closed and keeping the resident in the room while on precautions. Staff should wear a N95 fitted disposable mask when entering the room. The Practice Guidelines further outlined procedures to be used for Droplet Precautions. Staff were to wear gloves, mask, and goggles when within six (6) feet of the resident. A resident under droplet precautions should be in a private room or cohort with other residents with same active infection. For COVID-19 and some respiratory illnesses with the potential for aerosolization, it may be appropriate to keep the door closed. Review of a document titled Covid-19 Admission Criteria dated 3/18/21 revealed a flowchart that outlined the paths to follow for all newly admitted residents. The flowchart specified for all new resident admissions who were not 14 days post-completion of full vaccination series (COVID-19) and not (or unknown) tested for COVID, the resident was to be admitted to a private room in transmission-based (airborne-droplet) precautions for 10 days. Conduct COVID-19 testing on the 5th, 6th, or 7th, day. If the resident tests negative and remains asymptomatic they can be removed from isolation on the 8th day. Resident #160 was admitted to the facility on [DATE]. Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed a Nurse's Progress Note dated 11/24/21 that specified Resident #160 was currently in Airborne Respiratory Isolation. Review of a Nurse's Progress Note dated 11/25/21 at 5:18 a.m. revealed Resident #160 was noted to currently be in Airborne Respiratory Isolation. A Nursing Progress Note documented on 11/25/21 at 3:02 p.m. stated the resident was moved from room [ROOM NUMBER]-B to room [ROOM NUMBER]-A due to the heat not working. A Nurse's Progress Note documented on 11/25/21 at 10:56 p.m., after the room change, revealed Resident #160 was not in Airborne Respiratory Isolation. A review of Nurses' Notes documented for 11/26/21, 11/27/21, 11/28/21, 11/29/21, 11/30/21 and 12/1/21, 12/22/21 revealed on each date the nursing staff had documented Resident #160 was not in Airborne Respiratory Isolation. Continued review of progress notes revealed the Nurse Practitioner (NP) had documented on 12/2/21 at 10:49 a.m. Pt. (resident) has no signs/symptoms of COVID and has been tested . It is okay to take Pt. off isolation. Review of the medical record revealed Resident #160 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed no evidence Resident #160 had received a COVID-19 vaccination prior to or after admission. Continued review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #160 on 11/30/21 at approximately 10:33 a.m. revealed the resident was lying on his/her back in bed. The resident appeared to be alert and oriented and responded appropriately to verbal stimuli. The door to the resident's room was open and there was no signage on the resident's door to indicate Resident #160 was under contact precautions. Resident #160 was observed on 12/2/21 at 9:46 a.m. to be lying on his/her back in bed. The resident stated s/he did remember being in a different room before moving into the room s/he currently resided in. The resident stated s/he was not sure if s/he had received a COVID vaccination prior to admission. The door to Resident #160's room was observed to be open and there was no signage on the doorway to indicate the resident was under contact precautions. Interview was conducted on 12/2/21 at 10:00 a.m. with Licensed Practical Nurse (LPN) #4, who was assigned to provide care for Resident #160. LPN #4 stated s/he had noticed the airborne/droplet precautions signage had been added to the resident's doorway the previous afternoon. LPN #4 stated the Director of Nursing (DON) had come through that morning and told the LPN to take down the signage because the doctor had taken Resident #160 off precautions. LPN #4 further stated s/he was aware the resident had tested negative for COVID that morning. LPN #4 stated, however, prior to yesterday (12/1/21) Resident #160 had not been under precautions. The LPN stated staff had been entering the resident's room to provide care without donning/doffing full PPE as required when a resident was under Transmission-based Precautions. Interview was conducted on 12/2/21 at 11:40 a.m. with the Certified Nursing Assistant (CNA) #7 who was assigned to provide care for Resident #160. CNA #7 stated Resident #160 would get in a wheelchair and propel him/herself down the hallway. CNA #7 stated the resident was not on any contact precautions. The CNA stated s/he was not aware of the resident being on precautions since residing on the hallway. Interview was conducted on 12/2/21 at 10:05 a.m. with the DON. The DON stated Resident #160 had tested negative for COVID earlier that morning. The DON had asked the resident about a previous COVID vaccination, but the resident could not remember. The resident's family member was then contacted but reported not knowing the resident's vaccination status. The DON stated s/he did recognize the facility had failed to follow the resident with the signage for airborne/droplet precautions when the resident was moved to his/her current room. The heating unit had quit working in the room Resident #160 was first in. The resident was under precautions prior to being moved, however, after being moved to another room, the facility had failed to identify the need for isolation. The DON acknowledged that due to this failure, staff had entered/exited the room, provided direct care to the resident, without using PPE required to be worn for airborne/droplet precautions. The DON further stated s/he was aware when Resident #160 was first admitted , the physician had ordered the facility to place the resident on a 14 day precaution isolation and the facility had failed to follow the order. Interview was conducted on 12/2/21 at 10:34 a.m. with the Nurse Practitioner (NP). The NP stated s/he had been made aware yesterday (12/1/21) that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP stated s/he had then ordered the facility to obtain a COVID test. The NP had been informed the morning of 12/2/21 that the resident had tested negative for COVID. The NP stated an order had been given this morning for Resident #160 to be taken off precautions after receiving the negative test results. The NP stated the facility should have placed Resident #160 in the physician ordered isolation.

Based on interview, record review and review of facility procedure, it was determined the facility failed to provide the necessary services to maintain good grooming and personal hygiene for one (1) of 25 residents. Residents #98 required staff assistance with bathing/showering and were scheduled to receive the services two times each week. Baths/showers were not provided as scheduled and interviews revealed the resident was not receiving the required assistance. Findings include: Review of a nursing procedure titled Bathing revised 7/2016 revealed the purpose was to cleanse skin and promote circulation. The document indicated there were two (2) types of baths, a bed bath and a shower or tub bath. Procedures included staff verifying with the resident their bath preference and schedule. Procedures for staff to implement when residents required assistance with a tub bath or shower were outlined. Review of Resident #98's clinical record revealed an admitted [DATE] and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #98's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition and displayed no behaviors. Resident #98 required total assistance of one (1) staff with bathing. Review of Resident #98's Care Plan dated 11/2/21 listed the intervention to assist the resident to bathe/shower as needed. Review of Resident #98's Kardex (identified as the Care Guide for the Certified Nursing Assistants (CNAs) dated 12/1/21 listed the intervention for staff to shower/bathe the resident on Wednesday and Saturday evenings. Interview with Resident #98 on 11/30/21 at 9:16 a.m. revealed the staff were not providing him/her with showers two (2) a week. Review of the Shower Documentation provided by the facility for the period of 10/3/21 to 12/2/21 revealed Resident #98 should have received 17 showers but only received six (6) showers. Interview with CNA #16 on 12/2/21 at 10:45 a.m. revealed each resident should receive two (2) showers a week. Interview with Licensed Practical Nurse (LPN) #6 on 12/2/21 at 10:46 a.m. revealed the facility's protocol was for the residents to be bathed two (2) times a week. Resident #98's unit did not have a bathtub, so the staff provided showers. Interview was conducted on 12/3/21 at 10:40 a.m. with CNA #14 who provided services on the unit where Resident #98 resided. The CNA stated residents who were supposed to receive assistance with showers were not always provided a shower. CNA #14 stated residents who were supposed to receive assistance with showers on second shift did not always get a shower. The CNA stated residents should be getting showers just like you and me when scheduled but it wasn't always happening. Interview was conducted on 12/3/21 at 10:50 a.m. with CNA #15 who worked on first shift and provided services on the unit where Resident #98 resided. CNA #15 stated residents scheduled for showers on second shift frequently did not get their showers.

Based on record reviews and interviews, the facility failed to complete accurate Minimum Data Set (MDS) Assessments for two (2) residents (Resident #57 and Resident #68). The sample included 25 residents. Not conducting an accurate assessment can cause the facility to not develop an accurate plan of care for the residents. Findings include: 1. Review of Resident #57's clinical revealed the admitted [DATE] and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's MDS Assessments revealed an Annual MDS completed on 1/3/21. Review of the Quarterly MDS dated [DATE] revealed the resident had one (1) no injury fall since the MDS assessment was completed on 1/3/21. Review of Resident #57's clinical record revealed the resident had eight (8) falls from 1/3/21 to 4/4/21, revealing staff did not complete an accurate MDS assessment on 4/4/21. Interview with the MDS Coordinator on 12/3/21 at 10:26 a.m. revealed when completing the fall section of the MDS, he/she looked in the electronic record to see if the resident had fallen, how many times, and if an injury was sustained. The MDS coordinator stated he/she did not know why the assessment was coded wrong. 2. Review of Resident #68's clinical record revealed an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #68's Admission MDS assessment dated [DATE] documented Resident #68 had no pressure ulcers on admission. Review of the Incident Report - Patient Involved dated 9/9/21 at 4:04 p.m. revealed the staff found an unstageable pressure ulcer to Resident #68's left inner heel. Review of the End of Part A Stay MDS dated [DATE] revealed Resident #68 had two (2) unstageable pressure ulcers, and both were present on admission. Review of the Significant Change MDS dated [DATE] revealed Resident #68 had two (2) unstageable Pressure Ulcers, and both were present on admission. Interview with the MDS Coordinator on 12/2/21 at 11:40 a.m. revealed when he/she completed the MDS Assessment, he/she met and talked with the resident, reviewed the History and Physical, Discharge Summary, and other parts of the clinical record. The MDS Coordinator confirmed Resident #68 did not come in with the pressure ulcers and did not know why he/she documented the resident came to the facility with the two (2) unstageable pressure ulcers.

Based on observation, record review and interview, the facility failed to accommodate Resident (R) #3's food preferences, 1 of 4 sampled residents reviewed for food preferences. The resident was served foods on both days of the survey that were documented as foods the resident did not like. The findings included: The facility admitted the resident with diagnoses including, but not limited to, Heart Failure, Stroke, Depression and Gastrointestinal Bleeding. Observation and interview of R#3, on 9/15/21 at 12:20 PM, revealed the resident sitting up in bed finishing her/his lunch. The resident had eaten approximately half of the meal, but it appeared s/he did not eat any of the peas that were served. R#3 was asked if s/he was enjoying the meal. R#3 stated s/he was served peas and s/he does not like peas. R#3 stated her/his meal ticket says s/he doesn't like peas, but was served peas despite this. R#3 stated s/he was frequently served items that she doesn't like. Review of the meal ticket on the resident's lunch tray indicated the resident's food dislikes included fish, Brussels sprouts, carrots, chocolate, citrus, oatmeal, peas, tomatoes and tomato sauce. Observation and interview of R#3, on 9/16/21 at 12:25 PM, revealed the resident had just finished her/his lunch. R#3 was asked how her/his lunch was today. R#3 stated they gave me carrots and I don't like carrots. The resident's lunch tray was observed and the resident had been served carrots that appeared to have been untouched. The resident's meal ticket was present on the tray and indicated the resident did not like carrots. R#3 was asked if s/he would like anything else to eat and R#3 stated no, her/his family was bringing chicken from outside of the facility. Cook #1 came to the resident's room on 9/16/21 at 12:30 PM and confirmed the resident had been served carrots and carrots were listed under dislikes for the resident. Cook #1 apologized to R#3 and stated that should not have happened. Cook #1 asked the resident if s/he would like anything else to eat and the resident refused. During an interview with the Certified Dietary Manager (CDM), on 9/16/21 at 2:07 PM, the CDM stated the facility had a process for verifying residents meals are free of items residents don't like or have allergies to. The CDM stated a staff person is supposed to review each meal ticket and inform the cook of any dislikes or allergies while meal trays are being prepared. The CDM stated a 2nd staff person is also supposed to review the trays for accuracy before being sent to residents. The CDM stated this was an error by the kitchen staff that would be fixed. Review of the facility's Food Preferences policy revealed any tool may be used to collect patient food preference information while discussing food service with the patient. This information is entered into Dietary eKardex. Dislikes and allergies/sensitivities print on the tray card for reference during meal service. Clarification helps the dietary staff to serve foods as intended to meet the patient's preference.

Based on interviews and record reviews, it was determined the facility failed to provide CPR (cardiopulmonary resuscitation) for one (Resident #1) of three sampled residents who expired in the facility within the last six months with a Full Code status. Resident #1 was found unresponsive with no vital signs, and the facility failed to perform CPR in an effort to prevent death for this resident who was a Full Code. Fifty-two residents in the facility had a status of Full Code. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Immediate Jeopardy was related to State Operations Manual, Appendix PP, 483.24 (basic life support and CPR) at a scope and severity of J Past Non-Compliance. On [DATE] at 3:45 PM, the Administrator and Director of Nursing were informed of the Immediate Jeopardy. The Immediate Jeopardy existed [DATE] to [DATE]. Staff interviews, record review, policy review and review of trainings were completed during the survey to verify the immediate corrective actions taken by the facility. There was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the survey. Therefore, this deficient practice was cited as Past Noncompliance. The findings included: Resident #1 had [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS), dated [DATE], indicated s/he had been admitted to the facility from an acute care hospital, on [DATE], for rehabilitation services and was expected to be discharged to the community. Resident #1's Brief Interview for Mental Status was 15, indicating s/he was cognitively intact with decision making. A physician's progress note, dated [DATE], documented the resident had been admitted to the facility for rehabilitation after a hospital stay, from [DATE] to [DATE], for a debility secondary to [MEDICAL CONDITION] and heart failure. The progress note documented the resident's code status as Full. Full Code indicates a resident is to be resuscitated (provide CPR) in the event of respiratory or [MEDICAL CONDITION]. A social services progress note, dated [DATE], indicated the resident was a Full Code. A care plan, dated [DATE], indicated the resident desired to be a Full Code. The goal listed in the care plan was, Code status will be honored during stay. Interventions included, In the event of [MEDICAL CONDITION] initiate CPR. A Nurse Practitioner's progress note, dated [DATE] at 6:15 PM, indicated the resident's wishes regarding advanced directives were discussed at length from 6:15 PM to 6:31 PM. The note indicated the benefits and risks of CPR were explained to the resident. The resident verbalized understanding, and she wished to be a Full Code. A physician's progress note, dated [DATE], indicated the resident was experiencing increased anasarca (swelling throughout the body) related to heart failure, [MEDICAL CONDITION], and kidney disease. The note indicated the resident was experiencing poor participation in therapy and that palliative care or hospice would be appropriate. The note indicated labs and a chest x-ray were ordered for [DATE], and the doses for two of her diuretic (water pills to remove fluid from the body) medications had been increased. A nursing progress note, dated [DATE] at 1:45 AM, by Registered Nurse (RN) #1 documented, Resident deceased . No apical pulse, no palpable pulse, or BP (blood pressure). No respirations. Pale skin with mottled hands and feet. O2 NC (oxygen by nasal cannula) removed from nares. Resident status is DNR (Do not resuscitate) per report. A nursing progress note, dated [DATE] at 2:24 AM, by Licensed Practical Nurse (LPN) #1 indicated the resident had been found unresponsive by Certified Nurse Assistant (CNA) #3 and reported to this nurse. The note indicated LPN #1 observed the resident to be unresponsive, partially cyanotic (bluish or purple discoloration), and with no respirations or chest movement indicating breathing. The report indicated the resident's pulses could not be detected after one minute of listening. The report indicated the time of death was 1:45 AM, and the family was notified at 2:00 AM. A physician's telephone order, dated [DATE] at 2:00 AM, indicated the physician had been notified, and the body could be released to the funeral home. An initial incident report, dated [DATE] at 3:30 AM, indicated a reportable event involving Resident #1. The report indicated a licensed nurse had failed to provide CPR to Resident #1, who had been found unresponsive with no pulse and no respirations. The report indicated a full investigation had been started. A five-day incident report, dated [DATE], indicated the resident had last been observed, on [DATE] at 11:15 PM, in a stable condition and then was found unresponsive, about two hours later, on [DATE] at 1:15 AM. The report indicated both nurses in the room observed the resident unresponsive with no pulses, no respirations, and mottled (spots or patches of color) arms and dark purple hands. The report indicated the physician was notified at 2:15 AM, and the family was also notified. The report documented LPN #1 was suspended and an investigation was started. A statement of the incident from the facility's investigation by LPN #2, dated [DATE], indicated the resident kept removing her [MEDICAL CONDITION] (Continuous Positive Airway Pressure) machine from her face on the 3 PM to 11 PM shift, and this had been reported to the oncoming nurse, LPN #1. A statement of the incident from the facility's investigation provided by LPN #1, dated [DATE], indicated at 11:20 PM, the resident was easy to awaken by touch and calling her/him name, and s/he went back to sleep after waking. However, the report indicated during the next round at 1:30 AM, the resident was found unresponsive, her/his mouth was open, her facial skin was cyanotic, her/his skin was mottled, her extremities were cold, and a pulse could not be found. The report indicated while CNA #3 stayed with the resident, LPN #1 referred to the resident's chart to determine the resident's code status. LPN #1 found a DNR (Do Not Resuscitate) form at the front of the resident's chart in a plastic sleeve. The statement documented, no CPR performed as DNR status. The time of death was 1:45 AM. After the family arrived at the facility at approximately 2:30 AM, they informed LPN #1 the resident was a Full Code. The report indicated LPN #1 notified the Administrator of the event at that time. A statement of the incident from the facility's investigation provided by RN #1, indicated s/he was called by CNA #2 to come to the 400 unit real quick. When s/he arrived at the resident's room, CNA #3 was in the room trying to obtain vital signs, was unsuccessful, and stated the resident was gone. S/he asked LPN #1 if the resident was a DNR, and s/he said, Yes. S/he tried to obtain a carotid pulse, an apical pulse, and respirations for over one minute, and there were none. The resident had mottled (bluish/purple covered) arms and both hands were purple. S/he returned to his unit, but at approximately 3:00 AM, LPN #1 called him stating the resident had been a Full Code. S/he stated the nurse from the prior shift had told herhim the resident was a Full Code. A statement from the facility's investigation provided by CNA #2, indicated she was at the nurses' station when CNA #3 reported to LPN #1 the resident was not breathing. CNA #2 retrieved the resident's hard chart and sat it on top of the desk, anticipating LPN #1 would need it. LPN #1 asked her/him to tell RN #1 to come assist. The statement indicated CNA #2 asked LPN #1 if the resident was a Code, and s/he was told the resident was a DNR. A statement from the facility's investigation provided by CNA #3, indicated s/he began making her rounds of the unit at 11:10 PM, and the resident was breathing, and her/his chest was moving. At 1:15 AM, the resident was discovered pale, her fingertips were blue, and s/he did not respond when her name was called. S/he reported this to LPN #1, and LPN #1 was unable to get a pulse reading from the resident or an oxygen saturation rate. CPR was not started because LPN #1 thought the resident was a DNR. The statement further indicated staff did not realize, until learning from the family later, that the resident had a Full Code status. On [DATE] at 8:58 AM, Resident #1's family member was asked the code status of the resident. The family member stated the resident desired to be a Full Code. On [DATE] at 11:46 AM, the Administrator was asked if Resident #1 had a DNR status. S/he stated the resident had a status of Full Code. S/he stated after the incident, the resident's chart was reviewed and a blank DNR form was found in the chart. S/he stated the DNR form found in the resident's chart had not been filled out or signed. S/he stated the facility had been in the process of changing to an electronic medical record (eMR) system, and the first day that system had been fully utilized was on [DATE]. S/he stated under the old process, with records kept in a hard (paper) chart, when Medical Records Staff prepared a hard chart to admit a resident, the blank DNR forms were included in the chart, in case they were needed. With the change to the eMR, staff had been instructed to look in the computer for a resident's code status. She stated all staff, including LPN #1, had been trained on how to use the new eMR system, including where to find the resident's code status. S/he stated LPN #1 should not have referred to the paper chart to find the resident's code status. S/he provided documentation of staff training and the implementation process of the new system. S/he stated LPN #1 had completed orientation to the new eMR system, on [DATE], and should have looked in the computer for the code status, and s/he provided documentation of this training. S/he stated she thought LPN #1 just panicked. S/he stated immediately upon learning of the event, a complete investigation was started. S/he stated the following interventions were started immediately and completed on [DATE]: 1. LPN #1 was re-educated on Emergency Procedures, where to find code status and reporting of changes in a resident's condition. She stated LPN #1 was an agency nurse, was suspended from work, and had not been back to work in the facility. 2. All staff in the building were educated on Emergency Procedures, where to find code status and reporting of changes in a resident's condition. 3. No staff could start a shift until educated on Emergency Procedures, where to find code status and reporting of changes in a resident's condition. 4. All resident paper charts were reviewed and any blank DNR forms were removed from the charts. 5. All resident's code statuses were reviewed to be correct. Documentation of these interventions was provided. S/he stated a related Performance Improvement Project (PIP) was started on [DATE] with a target end date of [DATE]. Documentation of the PIP was provided, and the summary of the root cause documented, Resident's advanced directive for a full code status was not followed and CPR was not implemented, and patient expired. A nurse stated a blank DNR form for patient was on chart. The form indicated the PIP had been successful. On [DATE] at 12:20 PM, the resident's Nurse Practitioner was asked if CPR should have been provided for a resident with a status of Full Code who was found unresponsive, with no pulse or respirations, even if the resident had blue areas on their fingers and toes. S/he stated CPR should have been started on Resident #1 and cyanosis should not play a part in the decision to start CPR at all. On [DATE] at 1:21 PM, CNA #2 was asked why CPR had not been started for Resident #1. S/he stated she asked the nurse if the resident was a Full Code, but LPN #1 stated the resident was a DNR, and so CPR was not started. On [DATE] at 1:26 PM, the Respiratory Therapist, who taught CPR at the facility, was asked if CPR should have been provided for a resident with a status of Full Code who was found unresponsive, with no pulse or respirations, even if the resident had blue areas on their fingers and toes. S/he stated CPR should have been started and a code called for anyone found unresponsive and blue, with no pulse or respirations. On [DATE] at 1:38 PM, LPN #2 stated he took care of Resident #1 on the 3 PM to 11 PM shift on [DATE]. S/he stated the resident would take off her [MEDICAL CONDITION], but that was usual behavior for the resident, and s/he reported it to the oncoming nurse. He stated the resident had been declining slowly ever since she had arrived at the facility. S/he was asked if the resident had experienced a change of condition since the doctor had seen her/him that afternoon, and he said, No. S/he was asked what the code status was for the resident, and s/he stated s/he had been a Full Code. On [DATE] at 2:02 PM, LPN #1 was asked why Resident #1 did not receive CPR. S/he stated the nurse from the prior shift had told her the resident was a DNR during the nursing report given to her at shift change. S/he stated when CNA #3 told her/him the resident was not breathing, s/he checked the resident's chart and saw a DNR form. S/he stated she thought the resident's status was DNR, so s/he did not start CPR. S/he indicated s/he could not find the orders in the paper chart. S/he stated it was only after the family told her Resident #1 was a Full Code that s/he rechecked the DNR form in the chart, and saw it was blank and not filled out. S/he stated s/he was a relatively new nurse, and this was the first time s/he had ever had a patient expire on her/his shift. On [DATE] at 2:15 PM, CNA #3 was asked why CPR had not been provided to the resident. S/he stated s/he asked the nurse if s/he should start CPR, but LPN #1 told her/him the resident was a DNR. S/he stated LPN #1 looked in the book (hard chart) and said it had a DNR form. CNA #3 said, Come to find out, nobody had signed that form. S/he (LPN #1) honestly thought the resident was DNR. CNA #3 stated LPN #1 was very upset to learn the resident was a Full Code. The facility's Plan of Correction documented: This Plan of Correction serves as Heartland Health Care Center of Greenville East's response to the Immediate Jeopardy notification that the center received [DATE] at 15:45 regarding tag F678. The center does not admit nor concede the citations cited in the Notification. However, to the extent that any legitimate deficiencies exist at the Center, the Center is taking appropriate actions to correct any deficiencies that may be present at the center including, that actions listed in the Plan of Correction. The facility took immediate action to resolve the alleged of the facility to provide appropriate care, specifically not ensuring CPR was provided to a resident in an effort to prevent death. - On [DATE], (name redacted), Director of Nursing, reeducated LPN on location of code status in patient's electronic medical record. - On [DATE], (name redacted), Administrator held an ad-hoc QAPI meeting to discuss incident review and immediate corrective action. In addition, the facility took the following actions: Like Residents - All resident charts were audited by social services to validate code status was readily available and correct on [DATE]. Systemic Changes - All resident charts were audited by Medical Records to remove blank EMS DNR and advance directives order form for current charts (if full code) and blank admission packets moving forward, completed on [DATE]. - Administrator reeducated social services on advance directives process to include the complete execution of all appropriate paperwork, signatures and order execution, completed on [DATE]. - Administrator audited 5 random pre-made new admission charts weekly x 4 weeks; initiated on [DATE] completed on [DATE]. - Director of Nursing reeducated all licensed nursing staff and current agency licensed staff, beginning on [DATE] on advanced directives, including code status identification and proper execution of CPR processes and completed all licensed nurses on [DATE]. - Licensed nurses to receive education upon hire, as part of orientation, and annually on advanced directives, including code status identification and proper execution of CPR processes. - Agency staff will receive orientation for education on emergency management, including code status identification and proper execution of CPR processes, prior to receiving initial assignment, beginning on [DATE]. Monitoring - Code status to be reviewed daily in clinical meeting by IDT on all new admits. - Social worker initiated new admission audits on [DATE] to verify code status guidelines are being followed x 3 weeks, completed on [DATE]. - Agency orientation checklist to be reviewed with HR and/or designee, prior to staff working on floor. This plan was reviewed on [DATE]. The facility's corrective actions were reviewed during the survey for validation. Records were reviewed for twelve agency nurses who currently worked in the facility, and they all had received the required training. Records were reviewed for five staff nurses and three CNAs and they all had received the required training. Interviews were conducted with six nurses (RNs/LPNs) and five CNAs. All staff members confirmed ongoing education related to emergency procedures, CPR, and code status determination. Random hard (paper) charts were sampled throughout the facility, and no chart was found to contain a blank DNR form. Resident's code status for five residents was reviewed in the eMR and found to be correct. On [DATE] at 1:30 PM, the Administrator was asked, if a resident has a physician's orders [REDACTED]. S/he said, Yes. A facility policy titled, Cardiopulmonary Resuscitation: Adult, documented: when [MEDICAL CONDITION] occurred CPR was to be initiated unless a valid DNR (Do Not Resuscitate) was in place, initiating CPR could cause injury or peril to the rescuer, or obvious signs of clinical death were present including rigor mortis, decapitation, transection, or decomposition. The policy documented, In all other instances, CPR is to be administered. A facility policy titled, Emergency Management, included Emergency Response Guidelines. These guidelines indicated the first licensed nurse to arrive on the scene would evaluate the resident and direct additional nursing staff to review the chart for living will or DNR documentation, physician orders [REDACTED]. As documentation provided and interviews conducted confirmed all elements of the plan had been implemented, this deficiency was cited as Past Noncompliance.