Every finding on record at Inman Healthcare

Based on review of facility policy, observation, and interview, the facility failed to ensure that the dishwashing machine properly sanitized the dishes for 1 of 1 dishwasher reviewed.On 07/22/26 at 12:35 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.On 07/22/26 at 12:45 PM, the Survey Team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 07/22/26. The IJ was related to 42 CFR 483.90 - Physical Environment.On 07/22/26 at approximately 4:30 PM, the facility provided an acceptable IJ Removal Plan. On 07/22/26, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F908 at a lower scope and severity of F. Findings include Review of the facility policy titled, Infection Prevention and Control Program, last reviewed 02/15/24, revealed, The facility has established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per national standards. During an observation on 07/22/26 at 11:50 AM, revealed that the sanitizer test strip did not reach between 50 ppm (parts per million) during the dishwashers' final rinse cycle. During an interview with the Certified Dietary Manager (CDM) on 07/22/26 at 12:00 PM, it was revealed that the plates that lunch was served on today were washed in the dishwasher. The CDM stated that when the ppm was off in the past, they would use the 3-compartment sink. However, it was not used today. The CDM was not aware that the dishwasher was not reaching the 50 ppm until the observation made at 11:50 AM. During an interview with the Ecolab representative on 07/22/26 at 12:40 PM, it was revealed that there was a small crack in the sanitizer supply line from the bottle to the dishwasher, which prevented sanitizer from entering the machine. He replaced a valve, restoring proper function. The crack appeared to be at least one day old, as indicated by the small amount of crust buildup. During an interview with the Administrator on 07/22/26 at 4:15 PM, it was stated that the dishwasher should be consistently maintained and functioning properly to ensure effective sanitation. It is the expectation for sanitizer levels to be adequate for safe to prevent breaks in infection control. Review of the facility's removal plan included the following: Identification of Residents Affected of Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 7/22/26) The dish machine was taken out of service on 7/22/26 upon notification that the low temperature dish machine was below the required 50 PPM. The facility physician and RD was notified of the alleged deficient practice. Orders were received to monitor for signs and symptoms of GI issues for 72 hours. RR/residents were notified of the new orders. The Ecolab technician was dispatched to the facility and arrived at approximately 12:34 pm. The Ecolab technician was able to repair and put the machine in working order by 12:45 pm. The dish machine was tested to ensure that the proper temperature was reached and the required PPM was obtained. All dishes previously sanitized in the dish machine, were re-sanitized on 7/22/26. An audit of all resident rooms was completed on 7/22/26 to remove any dishes/utensils. Those dishes/utensils were sanitized via the dish machine. Actions to Prevent Occurrence/Recurrence: Current staff working in the kitchen received re-education on 7/22/26 on ensuring that the dish machine reaches proper PPM range by comparing the immersed chlorine test paper to the color chart on the chlorine test paper container, prior to utilizing the dish machine. All other staff will be re-educated prior to their next shift on ensuring that the dish machine reaches proper PPM range by comparing the immersed chlorine test paper to the color chart on the chlorine test paper container, prior to utilizing the dish machine. The Administrator or designee will complete audits on the dish machine to ensure that the required PPM range is obtained daily for two (2) weeks, weekly for four (4) weeks, and monthly for two (2) months. The Administrator will be responsible for monitoring and compliance. Audit records will be reviewed by the QAPI Committee until a pattern of compliance has been achieved as determined by the QAPI Committee. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 7/23/26

Based on review of facility policy, observation, and interview, the facility failed to ensure that the refrigerator was free of grime and food build-up. Additionally, the facility failed to ensure that two employees with facial hair wore beard guards, in 1 of 1 kitchen reviewed.Findings include:Review of the facility policy titled, Infection Prevention and Control Program, last reviewed 02/15/24, revealed The facility has established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per national standards.Review of the facility policy titled, Routine Cleaning and Disinfection, implemented 01/06/25, revealed, It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.Review of the facility policy titled, Dietary Employee Personal Hygiene, implemented 01/07/25, revealed, All dietary staff must wear hair restraints to prevent hair from contacting food.During an observation on 07/20/26 at 11:00 AM, revealed that the double-doored refrigerator in the kitchen contained food and drink build-up on the top rack, and black and brown grime and dirt build up in the front and back corners.During an interview on 07/22/26 at 2:15 PM, the Certified Dietary Manager (CDM) stated, it was revealed that refrigerators should be cleaned every week and as needed using soap and hot water, and it is the responsibility of the kitchen staff to share responsibility for maintaining refrigerator cleanliness. While the CDM was not aware of the uncleanliness observed, the expectation is that the fridge always remains clean. Although occasional spills may occur, like when staff are rushing or when nurses quickly take items and accidentally spill, they should be cleaned immediately to maintain proper sanitation standards.During an interview with the Administrator on 07/22/26 at 4:15 PM, the Administrator revealed that the expectation for the cleanliness and sanitation of dietary refrigerators is that any spill, regardless of its size, is wiped down properly and immediately. Maintaining this level of upkeep helps ensure a clean, safe environment for food storage and supports overall infection control standards within the department.During an observation on 07/20/26 at 11:00 AM, revealed two male staff, with beards, in the kitchen area with no beard guards.During an observation on 07/22/26 at 11:45 AM, revealed one male staff, with beard stubble, in the kitchen with no beard guard.During an interview on 07/22/26 at 2:15 PM, the CDM revealed that the expectation for employees working in food preparation or service areas is that any facial hair must be properly covered, and beard guards are required for all facial hair, including short beards or stubble. Although a previous CDM noted that facial hair under two inches may be acceptable, the current practice is to require coverage regardless of length. Staff are educated about beard guard requirements through in services and during the hiring process. If an employee is observed without a required beard guard, they should be instructed immediately to put one on to ensure compliance with sanitation standards.During an interview with the Administrator on 07/22/26 at 4:15 PM, it was revealed that the expectation for dietary staff with facial hair is that all facial hair, including short beards or even stubble, must be fully covered with a beard guard. This requirement applies to everyone and is in place to ensure proper infection control within food preparation areas.

Based on review of facility policy, observation, record review, and interview, the facility failed to ensure the residents' environment was homelike, clean, and sanitary. Specifically, the floors, walls and showers were not clean and stained throughout the building, observations of live and dead roaches, unsealed window seals around the air conditioning vent, noise levels and odors throughout the building.Findings include: Review of the facility policy titled, Pest Control Program, implemented on 01/06/25, revealed, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Review of the facility policy titled, Routine Cleaning and Disinfection, implemented on 01/06/25, revealed, It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Review of the facility policy titled, Infection Prevention and Control Program, last reviewed on 02/15/24, revealed, The facility has established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per national standards. During observation on 07/20/26, the following was observed: room [ROOM NUMBER]: 1) Walls are dirty, scuffed, and in need of repair and paint. 2) Floors are dirty with debris and wax over dirt in corners. 3) The bathroom has rust in the sink, and walls are in need of repair. 4) There was a soiled brief thrown in the shower. 5) The shower had a black substance around the inner edges where the walls of the shower meet the floor of the shower. 5) There is an odor of urine in the room. 6) There is a piece of masking tap covering the light fixture on the left side. room [ROOM NUMBER]: 1) Walls are dirty and in need of repair. 2) The bedside tables are scuffed and scratched. 3) The baseboards are dirty and in need of repair and paint. 4) There was rust in the bathroom sink. 5) The shower, shower chair, and the commode are dirty. 6) The bathroom floor and room floor was dirty. 7) The bathroom light fixture was broken. 8) There was a dirty wash basin in the bathroom, uncovered, sitting on the floor. room [ROOM NUMBER]: 1) There was rust in the bathroom sink. 2) Walls, floors, and baseboards in need of repair, paint and cleaning. room [ROOM NUMBER]: 1) Food was spilled over a large portion of the floor. 2) There were odors in the room. 3) Walls, floors, and furniture were in need of repair. 4) The window unit air conditioner had tape around the edges to close up the gaps to the outside. An observation of the large fire door between the 2 halls, was scuffed, and had deep areas dug into the wood, in need of paint and repair. During an observation on 07/20/26 at 12:30 PM, a crawling roach was observed in room [ROOM NUMBER]. Another crawling roach was observed on 07/21/26 at 2:45 PM, in the middle of the hallway. Another crawling roach was observed on 07/22/26 at 9:15 AM in the therapy room. During an observation on 07/20/26 at 11:00 AM, an unclean light switch, toilet containing feces, and overflowing waste receptacle was observed in room [ROOM NUMBER]. During a walkthrough and interview on 07/22/2026 at 4:40 PM, the Maintenance Director confirmed the findings and stated that he had a plan to start fixing the issues, but it was going to take time.

Based on review of facility policy, observation, record review, interview, and the Manufacturer's Specifications for administering insulin via a pen, the facility failed to ensure there were no significant medication errors while administering medication to Resident (R)5 and R26. Specifically, Licensed Practical Nurse (LPN)1 failed to prime an insulin pen per the manufacture's specifications ensuring R5 received the correct dose. Furthermore, LPN2 failed to ensure R26 was instructed to and was provided water to rinse her mouth after administering an inhaler with the physician ordered directions on the inhaler.Findings include: Review of the facility policy titled, Medication Administration, implemented on 12/04/2025, states, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of facility policy titled, Medication Errors, implemented on 06/16/2026, states, Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services. #4. The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: a. Medication administered not in accordance with the prescriber's order. Examples include, but not limited to: i. Incorrect dose, route of administration, dosage form, time of administration; ii. Medication omission; iii. Incorrect medication. b. Medication administered not in accordance with the manufacturer's specifications regarding the preparation and administration of the medications or biological. Examples include, but not limited to: iii. Administering medications without adequate fluids, without food or antacids. c. Medications administered not in accordance with professional standards and principles. Review of the Manufacturer's Specifications and recommendations, step by step guide on priming an insulin pen for Lantus states, This quick how to guide has been designed to help you more easily learn how to inject the right amount of insulin every time, avoiding getting too little or too much insulin, which can affect your blood sugar levels. Step I - Remove the pen cap with clean hands. Step 2 - Wipe the pen tip (rubber seal) with an alcohol swab and apply the needle. Step 3 - Dial a test dose of 2 units. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that the insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. Step 4 - Dial up the dose of insulin required by the results from the blood sugar. Step 5 - Clean the site with an alcohol swab. Keep the pen straight, and insert the needle into the skin. Use your thumb to press the injection button all the way down and hold for 10 seconds. This will ensure you get the correct dose of insulin. Review of R5's Face Sheet revealed the facility admitted R5 with a diagnosis including but not limited to Diabetes Mellitus Type 2. During an observation on 07/21/2026 at 7:30 AM, Licensed Practical Nurse (LPN)1 removed the cap from the Lantus insulin pen, she wiped the hub and placed the needle. LPN1 then left the needle cap on and held the insulin pen horizontal and dialed up the 2 units to prime the pen and then pressed the injection button. LPN1 had not removed the needle cap and held the pen vertical not horizontal and could not ensure R5 received the correct dose of insulin. During an interview on 07/21/2026 at 07:34 AM LPN1 verified that she had primed the pen with the needle cap on the pen, and had not held the pen vertical to insure no air bubbles and to ensure R5 received the correct dose of insulin per the physician's order. Review of R26's Face Sheet revealed the facility admitted R26 with diagnosis including but not limited to, chronic obstructive pulmonary disease. During an observation on 07/21/2026 at 8:40 AM, LPN2 was preparing to administer a physician ordered inhaler. The inhaler container stated, After the inhalation rinse and do not swallow. LPN2 administered the inhaler, but she did not provide water for R26 to rinse her mouth out. During an interview on 07/21/2026 at 8:42 AM, LPN2 verified that she had not provided the water for R26 to rinse her mouth after using the inhaler, per the physician's order.

Based on review of facility policy, record review, and interview, the facility failed to ensure Resident (R)8 and R28 were afforded the right to formulate an Advance Directive, to include their wishes for medical or surgical treatment, for 2 of 3 residents reviewed for Advance Directives. Findings include: Review of the facility policy titled, Residents' Rights Regarding, Treatment and Advance Directives, implemented on 01/06/2026 states, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive . Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State Law (whether statutory or as recognized by the courts of the state), relating to the provision of health care when the individual is incapacitated . Policy Explanation and Compliance Guidelines: On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive . The facility will provide the resident or the resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate and advance directive. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff . Should the resident refuse treatment of any kind, the facility will document the following in the resident's chart: a. What the resident refused. b. The reason for the refusal. c. How the resident was educated regarding the consequences of refusal. d. The offering of alternative treatments, e. The continuation of provided all other services. Review of facility's Electronic Health Record (EHR) revealed R28 was admitted to the facility on [DATE], with a diagnoses including but not limited to, dementia, unspecified severity, with agitation, convulsions, and anxiety disorder due to known physiological condition. Review of R28's EHR revealed no evidence that the resident was informed and/or provided written information regarding their right to formulate an advance directive or their right to accept or refuse medical and/or surgical treatment. During an interview on 07/21/2026 at an unspecified time, the Administrator revealed that R28 did not have an Advance Directive acknowledgement. The Administrator further revealed that the previous admissions coordinator did not complete the form. Review of R8's EHR revealed the facility admitted R8 on 05/24/2024, with diagnoses including but not limited to, dementia, adult failure to thrive, reduced mobility, weakness, and lack of physical exercise. Further review of the EHR revealed R8 is receiving hospice care and services. Review of R8's Plan of Care dated 07/13/2025, revealed a focus area, resident is at the end state of life and is utilizing hospice care and services. Review of a document titled, Advance Directives Policy and Acknowledgement, found in the admission packet for R8, revealed the document was not signed or acknowledged by R8's personal representative, as having been informed of the following, It is the policy of this Center that every competent adult has the right to make decisions concerning his or her health, including the right to choose or refuse medical treatment, in accordance with the law. The Center acknowledges the right of a competent adult to make an advance directive instructing his or her physician to provide, withhold, or withdraw life prolonging procedures: to designate another individual to make treatment decisions if the person becomes unable to make his or her own decisions; and/or to indicate the desire to make an anatomical donation after death. I acknowledge the Center provided its policy above on advance directives and a written description of South Carolina's state law regarding advance directives as prepared by DHEC or some other substantially similar document. Further review of this form revealed it was not signed or acknowledged by R8's personal representative therefore R8 and/or her responsible party were not afforded the right to formulate an advance directive. During an interview on 07/22/2026, the Social Worker could not provide the, Advance Directives Policy and the Acknowledgement signed by the resident's responsible party, to ensure R8's wishes would be carried out.

Based on review of the facility policy, record review, and interview, the facility failed to timely submit an allegation of resident to resident abuse to the State Agency (SA). Specifically, an incident occurred on 06/13/26 at approximately 11:30 AM, but was not reported to the SA until 06/14/26. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation with a reviewed/revised date of 02/15/24 indicated, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.VII. Reporting/Response A. The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or . Review of the facility's reportable indicated, 06/14/26, reported to Admin that Resident [(R)11] grabbed [R9's] arm while they were in the day room for an activity. Two residents were immediately separated, local police department, resident representative and Medical Director were notified. Further review of the reportable indicated the incident occurred on 06/13/26 prior to lunch and was witnessed by various staff members. During a telephone interview with Certified Nursing Assistant (CNA)1 on 07/21/26 at 2:23 PM, she confirmed an incident occurred, both residents were immediately separated and assessed and management was notified. During a telephone interview on 07/21/26 at 2:31 PM, the Activities Director (AD) confirmed the residents were immediately separated, and she took R9 to the Nurses' station to be assessed. She stated that at this time, she alerted the nurse of the incident. When asked what the process was for reporting, the AD stated, The process is to immediately separate the residents and then alert the abuse coordinator, who is the Administrator. During a telephone interview with CNA2 on 07/21/26 at 2:35 PM, she stated when the incident occurred, the AD immediately separated the residents and took R9 to the Nurse and told the Nurse on duty. CNA2 stated since this incident, staff has been in-serviced on ensuring incidents are immediately reported to the abuse coordinator and to the state agency, but this is done by the Administrator. During an interview with the Administrator on 07/22/26 at 11:15 AM, she confirmed the reportable was sent in to the SA late.

Based on observation, interview and record review, the facility failed to provide proper discharge planning for Resident (R)43, for 1 of 3 residents reviewed for discharge planning. Findings include: Review of facility undated undated policy, titled Discharge Planning Process, revealed Procedure: . 5. If discharge to the community is a goal, an active discharge care plan will be implemented and will involve the interdisciplinary team, including the resident and /or resident representative. The plan shall be documented on (list facility-specific form, comprehensive care plan etc.)Review of R43's Baseline Care Plan revealed, Initial goals/discharge plans: Discharge plan LTC, and hand written note: Resident discharged on 07/20/2026 prior to scheduled 72 hour meeting with family/resident review. On 07/20/2026 at an unspecified time, R43 was observed standing outside of his assigned room door on his cell phone, R43 was overheard informing the person on the phone that he was signing paperwork and after the paperwork was signed he was seen being walked out of the door using a walker by the Director of Social Services (DSS).Review of R43's Electronic Health Record (EHR) revealed that there was no discharge notice presented to the resident, no physician order for the resident to be discharged , and there was no documentation of an IDT meeting.During an interview on 07/20/2024 at an unspecified time, the Director of Social Services (DSS) revealed that the resident was being discharged due to issues with his payor source. The DSS stated that they discovered the issue earlier this morning and that they informed the resident at that time that they needed to discharge him. During an interview on 07/21/2026 at 1:30 PM, the Executive Director (ED) revealed that the business office staff generally verify resident's payor source prior to them being admitted . The ED explained that they were informed by the resident and his family that he was receiving disability, and that they provided paperwork to support what they stated. The ED continued to state that they were unable to verify that the resident was receiving disability and that they called the family immediately, provided the resident with their private pay rate and she was told that the family just showed up the pick the resident up.During an interview on 07/21/2026 at 3:49 PM, R43's Resident Representative (RR) revealed that she was informed that the facility needed financial verification for R43 and that he was being discharged until they could verify he was receiving disability. The RR stated that she was unsure of the paperwork that the facility had the resident to sign.During an interview on 07/21/2026 at 3:52 PM, R43 revealed that he was admitted to the facility after having a stroke and being in the hospital. R43 states that he was informed on the morning of 07/20/2026 that he needed to be discharged because they needed to get his paperwork straight. R43 continued to explain that he was given a paper to sign, however, he did not understand the language of it.

Based on interview and record review, the facility failed to ensure that the MDS (Minimum Data Set) was accurately coded for Resident (R)5, who was receiving an antidepressant and antipsychotic, for 1 of 17 resident reviewed for MDS accuracy.Findings Include:Review of R5's Electronic Health Record (EHR) revealed that R5 was admitted to the facility on [DATE], with a diagnoses including but not limited to, major depressive disorder, recurrent unspecified, borderline personality disorder, and bipolar disorder.Review of R5's physician orders revealed that she was ordered/prescribed: Citalopram Hydrobromide Oral Tablet 40 MG (Citalopram Hydrobromide) Give 1 tablet by mouth one time a day for anxiousness/depression, with a Start Date of 04/27/2026, Rexulti Oral Tablet 4 MG (Brexpiprazole) Give 1 tablet by mouth one time a day for Bipolar with Depression, with a Start Date of 07/18/2026, and Rexulti Oral Tablet 4 MG (Brexpiprazole) Give 1 tablet by mouth one time a day for Depression, with a Start Date of 04/27/2026 0900 and a discontinued date of 07/17/2026. Review of R5's Quarterly Minimum Data Set with an Assessment Reference Date (ARD) of 06/23/2026, revealed no indication that resident R5 was taking an antipsychotic or an antidepressant. During an interview on 07/22/2026 at 9:32 AM, the MDS coordinator reviewed R5's medication orders and confirmed that R5 was taking an antipsychotic and antidepressant. The MDS Coordinator reviewed R5's Quarterly MDS dated [DATE] and confirmed that it was incorrectly coded with not marked that the resident is taking an antipsychotic and antidepressant.During an interview on 07/22/2026 at 9:44 AM, the Administrator revealed that her expectations are that staff ensure that the residents MDS is accurately coded.

Based on review of facility policy, observation, and interview, the facility failed to ensure that chemicals were secured and not accessible to residents in the hallway, for 1 of 1 housekeeping carts reviewed.Findings include:Review of the facility policy titled, Hazard Communication Program, implemented on 01/06/25, revealed, It is the policy of this facility to implement a hazard communication program to ensure that information about the dangers of all hazardous chemicals used in this facility is known by all affected employees.During an observation on 07/20/26 at 2:00 PM, revealed multiple chemical sanitation bottles were stored in the door compartment of the housekeeping cart and not secured. No staff member was present with the cart at the time of the observation, and residents were present in the hallway nearby.During an interview with the Housekeeping Supervisor on 07/22/26 at 2:15 PM, revealed that each housekeeper is responsible for one side of the hallway and takes only the chemicals needed to clean each bedroom, leaving the remaining bottles secured in the cart. They stated the facility is in the process of obtaining new locks and keys for the housekeeping carts because the previous supervisor lost the originals. The Housekeeping Supervisor stated she was not aware that chemicals had been left unattended with the cart door open on Monday. She confirmed that housekeeping staff receive training on chemical storage and transport upon hire and through ongoing re education. She stated her expectation is that the cart door should remain closed any time staff walk away, regardless of whether chemicals are present, to ensure resident safety.During an interview with the Administrator on 07/22/26 at 4:15 PM, revealed that the expectation during transport of hazardous chemicals is that any chemicals not directly in use or being carried with the cart must be shut and locked away. It was confirmed that if chemicals were observed unattended in a cart without staff present, this would not meet facility expectations, as the cart should have been secured at all times to ensure resident safety.

Based on review of facility policy, observation, interview, record review, and review of manufacturer's specifications for administering insulin via a pen, the facility failed to ensure a medication administration error rate of less than 5 percent. The medication error rate was 7.41 percent for 2 out of 27 opportunities observed for error. Findings include: Review of the facility policy titled, Medication Administration, implemented on 12/04/2025, states, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of facility policy titled, Medication Errors, implemented on 06/16/2026, states, Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services. #4. The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: a. Medication administered not in accordance with the prescriber's order. Examples include, but not limited to: i. Incorrect dose, route of administration, dosage form, time of administration; ii. Medication omission; iii. Incorrect medication. b. Medication administered not in accordance with the manufacturer's specifications regarding the preparation and administration of the medications or biological. Examples include, but not limited to: iii. Administering medications without adequate fluids, without food or antacids. c. Medications administered not in accordance with professional standards and principles. Review of the Manufacturer's Specifications and recommendations, step by step guide on priming an insulin pen for Lantus states, This quick how to guide has been designed to help you more easily learn how to inject the right amount of insulin every time, avoiding getting too little or too much insulin, which can affect your blood sugar levels. Step I - Remove the pen cap with clean hands. Step 2 - Wipe the pen tip (rubber seal) with an alcohol swab and apply the needle. Step 3 - Dial a test dose of 2 units. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that the insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. Step 4 - Dial up the dose of insulin required by the results from the blood sugar. Step 5 - Clean the site with an alcohol swab. Keep the pen straight, and insert the needle into the skin. Use your thumb to press the injection button all the way down and hold for 10 seconds. This will ensure you get the correct dose of insulin. Review of R5's Face Sheet revealed the facility admitted R5 with a diagnosis including but not limited to Diabetes Mellitus Type 2. During an observation on 07/21/2026 at 7:30 AM, Licensed Practical Nurse (LPN)1 removed the cap from the Lantus insulin pen, she wiped the hub and placed the needle. LPN1 then left the needle cap on and held the insulin pen horizontal and dialed up the 2 units to prime the pen and then pressed the injection button. LPN1 had not removed the needle cap and held the pen vertical not horizontal and could not ensure R5 received the correct dose of insulin. During an interview on 07/21/2026 at 07:34 AM LPN1 verified that she had primed the pen with the needle cap on the pen, and had not held the pen vertical to insure no air bubbles and to ensure R5 received the correct dose of insulin per the physician's order. Review of R26's Face Sheet revealed the facility admitted R26 with diagnosis including but not limited to, chronic obstructive pulmonary disease. During an observation on 07/21/2026 at 8:40 AM, LPN2 was preparing to administer a physician ordered inhaler. The inhaler container stated, After the inhalation rinse and do not swallow. LPN2 administered the inhaler, but she did not provide water for R26 to rinse her mouth out. During an interview on 07/21/2026 at 8:42 AM, LPN2 verified that she had not provided the water for R26 to rinse her mouth after using the inhaler, per the physician's order.

Based on review of facility policy, observation, and interview, the facility failed to ensure all medications were stored and safely secured in Medication Cart 1. Specifically, Licensed Practical Nurse (LPN)1 left the medication cart unlocked on 2 occasions while in a resident's room administering medications on 1 of 2 halls.Findings include: Review of the facility policy tiled, Medication Storage, implemented on 01/06/2025, states, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and or medication room according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines. i. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. c. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. During an observation on 07/21/2026 at 7:10 AM, revealed, Licensed Practical Nurse (LPN)1 preparing medication for room [ROOM NUMBER]. LPN1 prepared the medications and then walked away from the medication cart, she walked into room [ROOM NUMBER] and left the medication cart unlocked and out of her sight. LPN1 forgot something from the cart and went back out to the cart and came back into the room, leaving the medication cart unlocked again. LPN1 then walked to the opposite side of the bed with the cart still unlocked. There were visitors, one ambulatory resident and residents in wheel chairs in the area of the cart. During an interview on 07/21/2026 at 7:10 AM, LPN1 confirmed that she had left the cart unlocked outside the room and then returned to the resident's room leaving the cart unlocked a second time. She stated she should have ensured the medication cart was locked and secured.

Based on observation and interview, the facility failed to ensure that the exterior garbage disposal lid remained closed, for 1 of 1 garbage dumpsters reviewed.Findings include:During an observation on 07/22/26 at 9:00 AM, revealed that the green dumpster lid was open with no staff present, and a foul odor coming from it.During an interview on 07/22/26 at 2:15 PM, the Certified Dietary Manager (CDM) revealed that garbage containers are expected to remain fully closed at all times, including both the doors on the dumpsters and the lids on top, and there should be no loose trash present. Staff are expected to open containers only when actively disposing of waste and ensure they are closed immediately afterward. Compliance is monitored throughout the day, especially on truck delivery days, Mondays and Thursdays, when staff frequently go out to discard items. During these checks, staff close any open containers they find and also remind nurses and other team members to keep the dumpsters closed when they use them.During an interview with the Administrator on 07/22/26 at 4:15 PM, revealed that garbage containers outside the facility is that they always remain closed, except when someone is actively disposing of waste, to maintain odor control, environmental cleanliness, and infection prevention. Staff are expected to follow proper waste disposal and sanitation practices consistently, and any container found left open would not meet facility standards. If this occurs, the staff member who notices it should immediately close the container and report the incident to the department manager, who can then provide additional education or corrective guidance to the individual responsible.

Based on review of facility policy, observation, and interview, the facility failed to ensure proper hand hygiene, while administering medications. Specifically, Licensed Practical Nurse (LPN)1 failed to wash or sanitize her hands after touching the medication cart and before applying gloves during medication pass.Findings include: Review of the facility policy titled, Infection Prevention and Control Program, revised on 02/15/2024 states, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 4. Standard Precautions: b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. During an observation on 07/21/2026 at 7:21 AM, during medication administration, LPN1, was observed putting her bare hands on the top of the medication cart, preparing to administer medications. LPN1 then donned a pair of gloves to administer an inhaler to a resident. LPN1 then went into the residents room, and administered the medication. During in interview on 07/21/2026 at 7:28 AM, LPN1 confirmed that she had not cleaned her hands after touching the medication cart and before applying gloves prior to administering oral medications and an inhaler.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure palatability for residents' food being served at an appropriate temperature for 3 of 3 residents (Resident (R)29, R31, and R30) out of 13 sampled residents. This failure had the potential to affect all 34 residents (2 puree, 11 mechanical textures, and 21 regular) in the facility, who received food that was cold and undesirable to eat. This had the potential to create dissatisfaction with meals and decrease the residents' quality of life. Findings include: Review of the facility's undated policy titled, Food Temperatures, indicated, Foods will be maintained at proper temperature to ensure food safety. The point of service temperature to residents will be within the range of 120-140 degrees based on the resident's preference. The following range of temperatures is recommended for food at point of tray assembly. Broth, soup, hot beverages 180-190 degrees F [Fahrenheit] 160 Meat, portioned for service degrees F, Casserole dishes, creamed items, creamed soup 160 degrees F, Potatoes and vegetables 160 degrees F and Chilled food and beverages 40 degrees F or below. 1. Review of R29's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed that R29 was admitted to the facility on [DATE], with a diagnoses that included but was not limited to: age-related osteoporosis without current pathological fracture, and scoliosis, unspecified. Review of R29's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/25, located under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R29 was cognitively intact. During an interview on 04/01/25 at 11:02 AM, R29 revealed that the food was very cold. R29 stated in the mornings, My butter will not melt in the grits, they are so cold. R29 stated everybody wanted to have hot grits, just hot food in general. R29 stated they were not sure why they could not keep the food warm coming from the kitchen to their rooms. 2. Review of R31's Face Sheet located in the EMR under the Profile tab revealed that R31 was admitted to the facility on [DATE], with diagnoses that included but was not limited to: adult failure to thrive,. Further review revealed R31 was on hospice. Review of R31's quarterly MDS with an ARD of 01/11/25, located under the MDS tab revealed a BIMS score of 14 out of 15, which indicated R31 was cognitively intact. During an interview on 04/01/25 at 11:10 AM, R31 indicated the food could be hotter, didn't know how many people were working in the building, but could do a better job making sure they got hot food. 3. Review of R30's EMR located in the Profile tab indicated the R30 was admitted on [DATE], with a diagnoses including but not limited to: chronic kidney disease. Review of R30's significant change MDS with an ARD of 02/26/25, indicated R30 had a BIMS of 14 out of 15, which indicated R30 was cognitively intact. During an interview on 04/01/25 at 11:56 AM, R30 revealed the food was usually cold, and on dialysis days, I do not get a hot breakfast; it is usually cereal and applesauce. Review of Resident Council Meeting Minutes, dated 07/01/24, revealed a complaint/grievance report that food was cold. The findings included by Dietary Manager (DM)1 revealed, The food leaves the kitchen at the proper temperature. The cooks take temperatures and document as necessary. Plan to resolve the complaint/grievance, residents who specify will have there [sic] trays heated before giving directly to them. Expected results of actions, this action will eliminate the complaint of the food not being warm enough. Signed by DM1 on 07/24/24. Further review of the Resident Council Meeting Minutes revealed on 01/06/25 and 02/05/25, complaints of meals being cold. During lunch observations on 04/02/25 at 11:27 AM, the menu included beef tips and rice, mixed vegetables, fruit, roll, coffee, and milk. The tray line was observed at 11:50 AM with meat at 148 degrees Fahrenheit (F), puree 130 degrees F, mechanical was 176 degrees F, vegetables was 146 degrees F, puree vegetable was 144 degrees F, and rice was 148 degrees F. The test tray left the kitchen at 12:07 PM. During an observation and interview on 04/02/25 at 12:24 PM, the test tray was evaluated with DM1, the beef tips were 114 degrees F, and the vegetables were 100 degrees F. The food was tested together, and DM1 confirmed that the food was not very warm. DM1 revealed that the cart was not heated, the food was taken from the steam table, placed onto the plates, and covered with the dome. DM1 stated, We are trying to figure out a way to get the food to the residents while it is still hot. During an observation and interview on 04/03/25 at 11:45 AM, in the kitchen, the menu and temperatures for the day was smothered turkey in gravy 180 degrees F, mashed potatoes 160 degrees F, puree 160 degrees F, mechanical soft 160 degrees F, vegetable (carrots) 175 degrees F, and puree vegetable 160 degrees F. The test tray left the kitchen at 12:11 PM. The test tray was evaluated at 12:25 PM with DM1 and DM2, which revealed the meat was 110 degrees F, potatoes 130 degrees F, and carrots 118 degrees F. Both DMs confirmed that there was a huge drop with temperatures and the food for the residents needed to be warmer. During an interview on 04/03/25 at 10:57 AM, the Registered Dietician (RD) explained that they ensured food temperatures were maximized before leaving the kitchen. Specifically, regarding the beef tips, the dietician admitted that the temperature should have been higher at the time of plating. The RD stated although they had not received recent complaints about cold food, she would recommend implementing temperature checks over several days to monitor the situation more effectively. During an interview on 04/03/25 at 3:50 PM, the Administrator indicated they had been working on getting new carts, which would hold the temperatures of the food. The Administrator acknowledged being aware of the food temperature problem since they had received multiple complaints from the same group of people.

Based on observations, interviews and facility policy review, the facility failed to ensure a handwashing sink was available, personal protective equipment (PPE) was available, failed to maintain the wall space around the dryer vents which left openings in the wall large enough for pests or small rodents to enter, failed to prevent cross contamination from dirty areas to clean areas within the laundry room, failed to provide a system to enable staff to fold clothing on a surface that could be sanitized, failed to store clean clothing, assorted pillows, and towels in an area to maintain cleanliness, and failed to maintain cleanliness and maintenance of two washing machines for one of one laundry room. This failure had the potential to affect infection control measures for 34 of 34 census residents. Findings include: Review of the facility's policy titled, Laundry with a review date of 07/14/24, indicated: 1. Aligning with principles of standard precautions, staff should consider all previously worn clothing and used linens as potentially contaminated. 2. The facility's laundry area will provide hand washing facilities and products as well as PPE. 3. Soiled laundry shall be kept separate from clean laundry at all times. During a laundry room observation on 04/02/25 at 1:10 PM, there were no handwashing sinks for laundry staff to use in the area and no PPE (gowns, goggles, facemasks) for laundry staff. There was an opening in the wall behind the two dryers that had not been closed leaving space for pests and small rodents to enter the laundry room. Clean clothes were hanging on a rack that was pushed up to the dirty washer and clothing, pillows, towels were placed in a laundry basket on the floor. Further observation revealed socks on top of the dryer and no surface for folding clean clothing. Observation of the washing machines revealed dust, lint, gritty appearance, on the underside of the washing machine lids and around the openings of both washers. Observation of the bleach dispenser compartment on the top of the washer housing above the drum (the area that holds the garments) and the circumference of the washer housing revealed a dark, dry, brown substance (rust-like in appearance) in varying degrees. During an interview on 04/02/25 at 1:10 PM, Laundry Aide (LA)1 stated that she did not have PPE to wear when handling dirty clothing and did not usually wear PPE, stated that she had seen a gecko (lizard) in the laundry room, and that the clothing, pillows, and towels in the laundry basket on the floor were clean. When asked if she had a schedule for cleaning the washing machines, she stated she did not. During an interview on 04/02/25 at 2:00 PM, the Administrator stated that she did not know the condition of the laundry and had only done spot checks. The Administrator stated she did not know that there was an opening large enough for pests and small rodents to enter the area, and that there was no handwashing sink, PPE, or surface to fold clean clothes on. The Administrator stated that a new supervisor would begin in two weeks. The Administrator stated that she would try to find information that would describe the specific job duties of a laundry aide and maintenance logs for the laundry. None were provided. During a follow up interview on 04/02/25 at 3:53 PM, the Administrator stated that the Maintenance Director would oversee the equipment in the laundry and that the facility team was discussing new strategies going forward that maintain a focus on infection control, cross contamination, re-educating the staff, and ensuring that residents receive clean clothing back in a timely manner.

Based on observations, interviews, and review of the facility policy, the facility failed to ensure foods that are stored in the freezer, refrigerators and dry food storage were appropriately sealed, labeled, dated with a use by date and/or discarded after the manufacturer's expiration date. Findings include: Review of the facility's undated policy titled, Food Safety Requirements, showed that food will be stored, prepared, distributed and served in accordance with professional standards for food service safety. Policy Explanation and Compliance guidelines: Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. Labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by date, or frozen (where appl)/discarded. During an observation on 03/05/24 at 10:58 AM, the kitchen refrigerator revealed one 1-gallon jug of ranch dressing not fully closed and dressing on outside of lid; 1 package of 160 slices pasteurized process American yellow cheese slices (individual slices, not individually wrapped) opened and not properly sealed nor dated with an opened date or use by date; 2 large bags of salad mix with a use by date of 3/4/2024. The kitchen freezer revealed 1 open bag of frozen pancakes containing 9 pancakes that was not dated with no open or use by date; 1 bag of frozen potato wedges with a use by date of 12/5/2023. During an observation on 03/05/24 at 11:26 AM, 1 pan of Jello gelatin was observed in the freezer, undated and unlabeled, 1 bag of frozen biscuits- open, undated and unlabeled, 1 box dated 2/26 containing a 10 lb (pound) bag of chopped chicken, opened and not properly sealed. During an observation on 03/05/24 at 11:35 AM, the dry food storage revealed an 11.8 lb bag of basic American foods potato pearls, opened and not sealed, 1 24 oz (ounce) bag of AM fruit punch drink mix, opened and not sealed, 1 package of chicken flavored gravy mix, opened, wrapped in saran wrap, and undated, 1 5 lb bag of thick & easy instant rice, opened and not properly sealed with a date marked 1/29, 1 5 lb bag of curly, extra wide egg noodles, opened and undated, 1 5 lb bag of ziti cut, macaroni noodles, opened and undated. Observation of the small, refrigerated cooler on 03/05/24 at 11:57 AM revealed 1, 1 1/2 gallon jug of buttermilk with a use by date of 2/29/24. During an interview on 03/07/24 at 11:12 AM, Dietary Manager (DM) stated, All staff should check dates, but the cooks are responsible for checking the dates, as well as the manager. Food storage dates are routinely checked twice a week and sometimes more. The dietary manager revealed that it is her expectation that food be labeled and dated and prepared food only be held for three days. During an interview on 03/07/24 at 11:49 AM, the Director of Nursing (DON) revealed that dates on food should be checked daily by everyone but ultimately the DM is responsible. The DON stated that her expectation is that food should be sealed, labeled and dated in the kitchen, and the nursing staff ensure food items are safe at the nursing station. During an interview on 03/07/24 at 11:55 AM , the Administrator stated that her expectation of staff when it comes to food storage, is that the person responsible for opening an item is the person that should date and label the item. She revealed that the DM is responsible for monitoring the dates and food storage. The Administrator also revealed that she oversees that kitchen and performs checks monthly to ensure that the kitchen staff is following protocol.

Based on facility policy, record review and interviews the facility failed to provide written notices of hospitalization to the Responsible Party (RP) and/or the Resident (R) and failed to ensure that the Ombudsman was notified for (R)3 in a timely manner for 1 of 2 residents reviewed for hospitalization s. The findings include: The facility admitted R3 with diagnoses including but not limited to, cirrhosis of liver, dementia, and history of falling. Review of Nurses Notes for hospitalization s on 02/28/24 revealed documentation from 06/28/2023 at 6:24 PM, Resident stated she wanted to be sent to Emergency Department (ED). This nurse and [another] nurse assessed [patient] pt. Abnormal [vital signs] v/s. Resident states I don't feel good she also stated that her body was aching all over. Resident was slurring her speech and had periodic episodes of rolling her eyes back and screaming I want to go now. Showing [signs and symptoms] s/s of anxiety while waiting on [Emergency Medical Service] EMS. Resident have been experiencing [Nausea, Vomiting, Diarrhea] NVD the past few days. [Nurse Practitioner] NP notified. New order to send to ED. [Left Voicemail] LVM for [Responsible Party] RP. Documentation from nurse's note on 06/28/2023 at 6:41 PM, EMS arrival and departed @ 6:40 PM to transfer resident to [Spartanburg Regional Medical Center] SRMC. Documentation from nurse's note on 07/18/2023 at 12:00 PM, readmitted to room [ROOM NUMBER]-4 from hospital. Alert to name and place. Up in [wheelchair] w/c with assistance of [one] 1, ate 25% of lunch. Meds verified per [Nurse Practitioner] NP. Documentation from nurse's note on 7/23/2023 07:45 AM, Resident alert and oriented x 3, started screaming saying her legs hurt and she is going to hospital. Offered to contact on call to obtain pain medication, but resident said no she wants to go to SRMC. Therefore contacted all disciplines needed and transferred to SRMC via stretcher. Documentation from nurse's note on 7/28/2023 at 8:30 PM, Resident returned from SRMC via stretcher and readmitted to room [ROOM NUMBER]-4 from hospital. Alert to name and place. Up ambulates with assistance of [one] 1. Meds verified per on call and NP to reassess Monday currently continue with all meds as ordered. Documentation from 10/12/2023 at 3:00 PM, Call light came on. [Certified nursing assistant] CNA went in, bad alarm was sounding. Resident on floor in front of wheelchair (w/c), hit knees when fell . I came in to check resident. Resident stated I was going to bathroom and fell . Hit my knees and they hurt. Neuro check [within normal limits] WNL. Check skin - intact. Moving all extremities. Lift used to put resident in bed. With CNA and me present. Call light in place, bad alarm in place and functioning. Resident told not to get [out of bed] OOB without calling for help . Vital signs are good. Alert and answering appropriately. Will monitor closely. Documentation from nurse's note on 10/15/2023 at 3:25 PM, Hospital. Documentation from nurse's note on 10/24/2023 at 4:29 PM Resident returned to facility via EMS from SRMC. Resident transferred to bed x2 assist. Condition stable. Call bell within reach, will continue to monitor. Documentation from nurse's note on 11/27/2023 at 2:18 PM, Resident weak, not eating slow to respond. NP in building and gave order to transport to SRMC for [Evaluation] eval and treat. Message left for RP to call facility. Documentation from 11/28/2023 at 12:23 PM, Call placed to SRMC, resident remains in [emergency room ] ER at this time, has been admitted and is waiting on an available bed. Admit [Diagnosis] dx: elevated Ammonia level (176) and [Urinary Tract Infection] UTI. Documentation from 12/5/2023 at 3:33 PM, Resident returned from SRMC via stretcher. Resident transferred to w/c x2 [Medical Technician] med techs. Resident condition stable. Resident request to use resident phone to call nephew to bring her a hot dog. Will continue to monitor. During an interview on 03/06/24 at 1:44 PM the Social Worker (SW) provided the bed hold policy but reported that there was not one completed for the resident for the following hospitalization s: 11/27/23, 10/15/23, 7/23/23, and 06/28/23. She stated that family was notified but not informed about the bed hold. In reviewing documentation for notification of the Ombudsman in a binder, the SW reported that the resident did not show up on her report that was sent to the Ombudsman at the end of each month. During an interview on 03/06/24 at 2:03 PM the Director of Nursing (DON) reported the procedure for residents transferring or being discharged was to notify the family/representative and document using the Situation, Background, Assessment, and Recommendation (SBAR) or at least in a nurses note. The DON reported that the bed hold policy is signed on admission, the ombudsman is notified monthly and social services does this part. During an interview on 03/06/24 at 2:07 PM the Administrator reported the procedure for residents transferring or being discharged was to notify family/representative. She reported that the bed hold policy is signed on admission and social services sends a monthly report to the Ombudsman. When asked if this procedure was for all residents whether they were admitted to the hospital or transferred but then returned in short time frame, she stated she believed so but would check.

Based on facility policy, record review, and interviews, the facility failed to provide the bed hold document to Resident (R)3 and/or Resident Representative (RR) in a timely manner for 1 of 2 reviewed for hospitalization . Findings include: Review of the facility policy titled, Bed Hold and Therapeutic Leave Policy, undated, revealed Before the Center transfers a Resident to a hospital ., the Center must provide this written information to the Resident or the Resident Representative that specifies the Center's bed hold and therapeutic/temporary leave policy. The following applies to all residents. Medicaid Residents-Bed Hold: If the Resident leaves the Center for hospitalization , the Center will reserve or hold a bed available for the Resident for up to ten (10) consecutive calendar days per medically necessary hospital stay when the Resident is expected to return to the Center per South Carolina Medicaid. If the Resident is hospitalized for a period longer than ten (10) days, the Resident will be discharged . Bed holds for leaves of absence of more than 10 days are considered non-covered services and not paid by South Carolina Medicaid. The Resident may elect to pay the full Medicaid daily rate to continue the bed hold for up to thirty (30) calendar days. If the Resident does not elect to pay to hold the bed and the leave exceeds the bed hold period of 10 days, the Resident may return to the Center to their previous room, if available, or immediately upon the first availability of a bed in a semi-private room, if the Resident: a0 requires the services provided by the Center and b.) is eligible for Medicare or Medicaid nursing facility services. Review of R3's Electronic Medical Record (EMR) revealed R3 was admitted to the facility on [DATE] with diagnoses including but not limited to, cirrhosis of liver, dementia, delusional disorders, urinary tract infection, and history of falling. Review of R3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 06/21/22 revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating R3 has moderate cognitive impairment. Review of R3's electronic medical record (EMR) revealed R3 was discharged to the hospital on 06/28/23, 07/23/23, 10/15/23, and 11/27/23. There was no documentation of a bed hold notification given to the resident and/or responsible party prior to R3's transfer to the hospital on any of the above dates. During an interview on 03/06/24 at 1:44 PM the Social Worker (SW) provided the bed hold policy but reported that there was not one completed for the resident for the following hospitalization s: 11/27/23, 10/15/23, 07/23/23, and 06/28/23. She stated that family was notified but not informed about the bed hold. In reviewing documentation for notification of the Ombudsman in a binder, the SW reported that the resident did not show up on her report that was sent to the Ombudsman at the end of each month. During an interview on 03/06/24 at 2:03 PM, the Director of Nursing (DON) reported the procedure for residents transferring or being discharged was to notify the family/representative and document using the Situation, Background, Assessment, and Recommendation (SBAR) or at least in a nurses note. The DON reported that the bed hold policy is signed on admission, the Ombudsman is notified monthly and Social Services does this part. During an interview on 03/06/24 at 2:07 PM, the Administrator reported the procedure for residents transferring or being discharged was to notify family/representative. She reported that the bed hold policy is signed on admission and social services sends a monthly report to the Ombudsman. When asked if this procedure was for all residents whether they were admitted to the hospital or transferred but then returned in short time frame, she stated she believed so but would check. During an interview on 03/06/24 at 2:10 PM, the Executive Director reported that on admission the bed hold policy is signed but once a resident is discharged /transferred a conversation takes place to discuss payment etc. on the day of the discharge/transfer or shortly thereafter in cases involving a weekend for example. She confirmed that the Ombudsman is notified at the end of the month.

Based on observations, interviews, record review, and facility policy review, the facility failed to provide services to residents who were unable to carry out activities of daily living (ADL) necessary to maintain good grooming and personal hygiene for Resident (R)9; 1 of 4 reviewed for assistance with ADL care. Findings include: Reviewed the facility's undated policy titled, Activities of Daily Living (ADLs), revealed, Policy Explanation and Compliance Guidelines 3. a resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review the facility's undated policy, titled, Nail Care, revealed, Policy Explanation and Compliance Guidelines: 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises. Review of the face sheet revealed the facility admitted R9 on 01/02/2024 with diagnoses that included but were not limited to:hemiplegia, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, and major depressive disorder. Review of an Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 01/10/24 revealed R9 was coded for functional Limitation in Range of Motion with upper extremity on one side and lower extremity impairment on one side with wheelchair mobility. Review of R9's Care Plan revealed, The resident has an ADL self-care performance deficit Fatigue, Hemiplegia, Impaired balance, Limited Mobility. The goal was: the resident will maintain the current level of function through the review date. Interventions included: BATHING/SHOWERING: The resident requires extensive assistance by (1) staff with bathing/showering. PERSONAL HYGIENE/ORAL CARE: The resident requires extensive assistance by (1) staff with personal hygiene and oral care. TOILET USE: The resident is totally dependent on (1) staff for toilet use. During an observation on 03/05/2024 at 01:02 PM, R9 was observed sitting in a chair beside her bed with the call light in reach. R9's hand were observed with brown debris underneath her nails on both hands. During an observation and interview on 03/06/2024 at 08:15 AM, R9 was observed lying in the bed in the supine position. R9 stated she was waiting for breakfast. Additional observation of R9's hands revealed her fingernails were dirty with brown debris underneath. During an interview on 03/06/2024 at 11:34 AM, R9 ' s family member revealed R9's nails were dirty because staff did not cut up R9 ' s meat and when R9 feeds herself, she gets food underneath the fingernails. During an interview on 03/06/2024 at 01:36 PM, Certified Nursing Assistant (CNA)1 revealed R9 was scheduled to get showers on the 2nd shift. CNA1 revealed that hand hygiene was completed before and after each meal and nail care was completed randomly by the CNAs or the activity CNA . CNA1 accompanied the surveyor to R9 ' s room and observed R9 ' s hands with identified food debris between the fingers and brown debris underneath the fingernails on both of the resident ' s hands. CNA1 revealed R9 sometimes complains of pain in her hand, especially in left hand. CNA1 revealed R9 ' s hands were dirty because they had just finished lunch and used her hands to feed herself. CNA1 revealed she would use a warm washcloth to clean R9 ' s hands and get a tool to clean R9 ' s fingernails. During an interview on 03/03/2024 at 02:09 PM, the Director of Nursing (DON) revealed nail care was to be done daily during ADL care. The DON revealed staff were expected to check residents ' nails daily when washing their face and hands and clean nails as needed. During an interview on 03/07/2024 at 11:55 AM, the Administrator revealed nail care should be provided daily by the staff, or nurse. The Administrator also stated the unit manager is responsible for monitoring staff to ensure nail care was done.

Based on review of facility policy, observations, interviews, and record review, the facility failed to administer oxygen per physician's orders for 1 of 1 residents reviewed for respiratory care, Resident (R)17. Findings include: Review of the facility's policy titled, Oxygen Administration dated 2024 revealed, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and resident's goals and preferences. Definitions: 'Oxygen therapy' is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia. 'Hypoxia' means decreased perfusion of oxygen to the tissues. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician . 2. Personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists. 3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. Review of R17's Electronic Medical Record (EMR) revealed R17 was admitted to the facility on [DATE] with diagnoses including but not limited to; chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, anxiety disorder, chronic pain syndrome, paroxysmal atrial fibrillation, major depressive disorder. Review of R17's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 01/18/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R17 has cognition intact. Review of R17's Care Plan documented, the focus The resident has altered respiratory status/difficulty breathing. Further review of the Care Plan revealed the following goal, The resident will have no [signs and symptoms] s/sx of poor oxygen absorption through the review date. The care plan also documented intervention: OXYGEN SETTINGS: [Oxygen] O2 via nasal prongs @ 4 [Liters] L continuously. Humidified. Review of R17's Physician Order documented, Oxygen at 4 L/[minute] min [by] via [nasal cannula] n/c continuous [related to] R/T Chronic respiratory Failure with hypoxia. every shift. During an observation of R17's room on 03/05/24 at 11:00 AM, the oxygen concentrator was noted at 3 1/2 L/min via nasal cannula. Resident reported that the rate was supposed to be at 4 L/min. During an observation of R17's room on 03/06/24 at 8:25 AM, the oxygen concentrator was noted at 4 L/min. via nasal cannula. During an observation of R17's room on 03/07/24 at 8:18 AM the oxygen concentrator was noted at 4 L/min. via nasal cannula. During a staff interview on 03/07/24 at 10:35 AM, Licensed Practical Nurse (LPN)1 stated, R17's physician order for oxygen was for 4 L/min. She looked at R17's physician order in electronic medical record and confirmed the oxygen concentrator was to be set at 4 L/min. LPN1 then went to room and verified oxygen setting on concentrator and confirmed 4 L/min. During a staff interview on 03/07/24 at 10:42 AM, the Director of Nursing (DON) stated that her expectation for nurses is to verify orders and to check daily during their assessment to ensure that oxygen setting was at the correct setting.

Based on observations, interviews and record reviews, it was determined: 1. The facility failed to isolate COVID-19 (Coronavirus Disease 2019) positive residents in private rooms or cohort COVID-19 positive and COVID-19 negative residents separately. Four rooms in the facility (Rooms 104, 106, 107 and 110) cohorted positive COVID-19 residents (Residents #2, #3, #4, #5, #7 and #11), as well as negative COVID-19 residents (Residents #1, #6, #9 and #16) in the same rooms; 2. The facility failed to utilize personal protective equipment (PPE) properly, which included failure to remove and discard PPE gowns between positive COVID-19 residents and negative COVID-19 residents; 3. The facility failed to provide a properly fitted N95 mask for a staff member and ensure the mask was initially fit tested ; 4. The facility failed to screen visitors/surveyors on facility entry; 5. The facility failed to ensure a COVID-19 positive resident wore a mask for source control when the resident was out of their room and in the facility hallway for one (Resident #2) of twenty-six sampled residents. The facility census was twenty-four. Fourteen residents had tested positive for COVID-19. The first COVID-19 positive resident in the facility had been identified on [DATE]. 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, 483.80 (infection control) at a scope and severity of L. On [DATE] at 1:16 PM, the Administrator and Director of Nursing were informed of the Immediate Jeopardy situation. The findings included: On [DATE] at 8:00 AM, surveyors entered the facility to conduct an unannounced Infection Control Focused survey. 1. On entry to the facility, it was observed that room [ROOM NUMBER] housed four residents: #1, #2, #3 and #5. Three (#2, #3 and #5) of the four residents in this room were COVID-19 positive. One resident (#1) housed in this room was COVID-19 negative. On [DATE] at 3:00 PM, room [ROOM NUMBER] was observed. Two of the residents in the room were seated less than six feet apart. Resident #1 had [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS), dated [DATE], indicated s/he was moderately impaired in cognitive skills for daily decision making and required extensive assistance from staff members with most activities of daily living. A care plan, dated [DATE], indicated Resident #1 was at risk for COVID-19, and the facility's protocol for COVID-19 precautions and social distancing should be followed. A Physician's Progress Note, dated [DATE], indicated, COVID-19 virus not detected. Resident #2 had [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Progress notes documented s/he returned to the facility on [DATE]. A care plan, dated [DATE], indicated the facility's protocol for COVID-19 precautions and social distancing should be followed. A 5-Day MDS, dated [DATE], indicated s/he was moderately impaired in cognitive skills for daily decision making. S/he had exhibited the behavior of wandering one to three days of the last seven days. S/he required supervision with walking. A physician's progress note, dated [DATE], indicated Resident #2 had a [DIAGNOSES REDACTED]. Resident #3 had [DIAGNOSES REDACTED]. A quarterly MDS, dated [DATE], indicated s/he was severely impaired in cognitive skills for daily decision making and required extensive assistance from staff members with most activities of daily living. A care plan, dated [DATE], indicated the facility's protocol for COVID-19 precautions and social distancing should be followed. A Physician's Progress Note, dated [DATE], indicated Resident #3 was COVID-19 positive. Resident #5 had [DIAGNOSES REDACTED]. A 5-Day MDS, dated [DATE], indicated s/he was cognitively intact. S/he required extensive assistance from staff with bed mobility, dressing, toileting and hygiene. S/he required supervision from staff members with transferring, walking, locomotion, and eating. A care plan, dated [DATE], indicated the facility's protocol for COVID-19 precautions and social distancing should be followed. A review of documents provided by the facility, including a list of COVID-19 positive residents, a list of residents with their room numbers, and a floor map with rooms numbered, indicated more than one room in the facility housed both COVID-19 positive and COVID-19 negative residents in the same room. Laboratory results, from nasopharyngeal specimens collected on [DATE], through a local hospital lab indicated the following Residents had results of COVID-19 Detected.: Residents #1, #3, #4, #5, #6, #7, #9 and #16. Laboratory results, from specimens collected [DATE], through a Reference Laboratory indicated the following residents had results of [DIAGNOSES REDACTED]-COV-2 NAA (COVID-19 Virus Nucleic Acid Amplification) Not Detected: Residents #1, #6, #9 and #16. The following residents had results of [DIAGNOSES REDACTED]-COV-2 NAA Detected Critical: Residents #2, #3, #4, #5, #7 and #11. Residents #1, #9 and #16, who had previously tested COVID positive/detected on [DATE], now tested COVID negative/not detected, on [DATE]. On [DATE] at 9:50 AM, the Epidemiology Program Coordinator for the state agency was asked if residents who were currently negative for COVID-19 should be housed in separate rooms from residents who currently tested positive for COVID-19, even if those testing negative had previously tested positive, and s/he said, Yes. When s/he learned it was likely COVID-19 positive and COVID-19 negative residents were being cohorted in the same room, s/he replied, That is inexcusable. On [DATE] at 12:19 PM, the Administrator (ADM) was asked if any rooms in the facility housed both COVID-19 positive residents and COVID-19 negative residents in the same room. S/he stated four rooms in the facility housed both COVID-19 negative and COVID positive residents together. He stated room [ROOM NUMBER] housed Residents #4 and #11 who were COVID-19 positive, as well as Resident #16 who was COVID-19 negative. He stated room [ROOM NUMBER] housed Residents #2, #3 and #5 who were COVID-19 positive as well as Resident #1 who was COVID-19 negative. He stated room [ROOM NUMBER] housed Resident #7 who was COVID-19 positive and Resident #6 who was COVID-19 negative. He stated room [ROOM NUMBER] housed Resident #8 who was COVID-19 positive and Resident #9 who was COVID-19 negative. Resident #15, who also had resided in room [ROOM NUMBER] and tested COVID-19 positive, had been discharged to a local hospital on [DATE]. The ADM was asked the reasoning behind the cohorting of COVID-19 positive and COVID-19 negative residents together, and not separating the residents. S/he stated s/he anticipated retesting all residents on Tuesday, [DATE], for the COVID-19 virus. S/he stated S/he wanted to see those test results before moving residents to different rooms. S/he stated s/he was concerned some of the COVID-19 negative residents may now be positive, as they had been exposed to [MEDICAL CONDITION], and S/he did not want to put the current residents who were COVID-19 negative with other negative residents only to get test results back stating they were really COVID positive. S/he also expressed concern on having enough rooms to appropriately separate the COVID-19 negative and positive residents. On [DATE] at 1:16 PM, the Administrator and Director of Nursing, were informed of the Immediate Jeopardy situation. The Administrator was asked how many residents in the facility had died because of the COVID-19 virus, and s/he said, Seven. In an email, dated [DATE] at 3:43 PM, the Epidemiology Program Coordinator further clarified, The residents who tested negative who previously tested positive [DATE]th (sic. [DATE]) need to be cohorted with negatives and not positives. They have surpassed the time-based strategy by exactly 10 days (it has been 20 days since they tested positive of ,[DATE] (sic. [DATE])). If they have also tested negative ,[DATE] it reinforces the fact. On [DATE] at 8:38 AM, the Medical Director stated there had been a concern with placing residents who had previously tested COVID-19 positive, but now tested COVID-19 negative, with residents who had never tested positive. S/he stated the concern was that [MEDICAL CONDITION] might reactivate in the residents who had a previous positive test result and cause the residents who had never been positive, who were virgin negatives, to become COVID-19 positive. A facility policy titled, Inman Healthcare Policy & Procedures Coronavirus (COVID19), documented: .Current data suggest transmission most commonly happens during close exposure to a person infected with [MEDICAL CONDITION] .Residents with known or suspected COVID-19 .should ideally be placed in a private room with their own bathroom .If a resident has a roommate the facility should move the suspected/confirmed case to a private room if able . 2. A review of the facility's policy, written by the Centers for Disease Control (CDC), provide and adopted adapted by the facility, stated remove PPE (personal protective equipment) before exiting the room except a respirator if worn. Sanitize hands after removing all PPE. During an observation on [DATE] at 9:15 AM, Registered Nurse (RN) #1 was observed passing medications. S/he was observed coming out of room [ROOM NUMBER], where a COVID-19 positive lived (Resident #2). S/he did not remove her/his PPE and s/he returned to the medication cart. S/he was leaning against the cart wearing the same contaminated PPE. During an interview on [DATE] at 9:15 AM, RN #1 confirmed s/he did not remove her/his PPE when s/he left room [ROOM NUMBER]. S/he stated they had been instructed they could wear the same PPE for the entire day. They removed the PPE at the end of their shift and put it in a bag to take home to wash. During an observation on [DATE] at 9:45 AM, RN #2 was observed assessing both COVID-19 positive and COVID-19 negative residents in room [ROOM NUMBER] without changing her/his gowns and gloves between residents. RN #2 was observed leaving room [ROOM NUMBER] at [DATE] at 10:00 AM, without changing gowns, and went to room [ROOM NUMBER]. S/he was seen conducting an assessment using a stethoscope. S/he was wearing full PPE including gloves, shoe covers, gown and hair covering. S/he conducted the assessments on each resident in the room without changing her/his gloves and sanitizing her/his hands in between residents. S/he also failed to disinfect the stethoscope between residents, and s/he placed the stethoscope around her/his neck. There were both positive and negative COVID-19 residents in the same room. An interview was conducted with RN #1 and RN #2 at on [DATE] at 11:00 AM. They were asked how long they wore the same PPE. They stated the wore the same PPE all day. At the end of their shift, they put the PPE in a bag and took it home to wash. RN #1 and RN #2 stated they received a new gown when the gown started to look bad. They had not been provided with the manufacturer's instruction on how to care for the gowns, and stated they were told it was acceptable practice to wear the gowns all day. During an observation on [DATE] at 12:05 PM, Certified Nursing Assistant (CNA) #1 was observed in the hall serving trays to room [ROOM NUMBER]. S/he served Resident #2, a COVID-19 positive resident. S/he was wearing a gown but no gloves. S/he returned to the meal delivery cart in the hallway, wearing the same contaminated PPE s/he had been wearing in the resident's room. She failed to wash her/his hands or use hand sanitizer between the delivery of trays. S/he then removed a food tray from the cart and went back into room [ROOM NUMBER] to serve Resident #1. This resident was COVID-19 negative. S/he assisted the resident to sit up and served the tray. S/he failed to sanitize her/his hands, wear gloves and had the same contaminated PPE on. An interview was conducted with CNA #1 on [DATE] at 12:05 PM. S/he was asked about not changing her/his gown. S/he stated this was how s/he was trained. S/he was observed to have a thin white gown on. When asked how many days s/he wore the same gown, s/he stated s/he had to take the gown off, place it in a bag and take it home to wash. S/he stated s/he washed the gown until the condition indicated s/he needed a new one. S/he stated s/he had been provided training that s/he could wash the gowns and wear them all day. S/he stated s/he knew s/he was supposed to sanitize her/his hands between residents, but s/he forgot. Housekeeping (HSK) #1 was observed moping in residents' room up and down the unit on [DATE] at 10:30 AM. S/he was wearing the same jumpsuit PPE in all rooms, which included COVID-19 positive and COVID-19 negative residents. S/he was then seen mopping in the nurses' station and beauty shop area. During an interview with HSK #1 on [DATE] at 11:15 AM, s/he stated s/he used his jumpsuit for two to three days, then threw it away. S/he stated s/he had worn the jumpsuit while moping in both COVID-19 positive and COVID-19 negative residents' rooms. During an observation on [DATE] at 10:15 AM, Physical Therapy Assistant (PTA) #1 was observed going into room [ROOM NUMBER] to place Resident #2, who was COVID-19 positive, on an exercise machine. When s/he left the room, s/he wore the same PPE down the hallway, and into the physical therapy department. When s/he returned to remove the machine, s/he had the same PPE on. S/he removed the machine, and left the room pushing it down the hallway into the physical therapy department without disinfecting the machine. During an observation on [DATE] at 10:45 AM, PTA #2 was observed out in the hallway coming from a resident's room. S/he went straight into the physical therapy department wearing the same PPE that s/he was wearing when s/he exited the resident's room. S/he was questioned about the observation. S/he stated s/he was not told to change his PPE. PTA #2 was asked about resident assistive belts hanging in room [ROOM NUMBER]. There was a COVID-19 positive resident in this room. S/he stated the physical therapy department stored therapy items and stored its PPE in this room. The Administrator was present during this conversation, and s/he stated s/he was not aware the therapy department still had supplies in the room. During an interview with the Director of Nursing (DON) on [DATE] at 1:30 PM, s/he confirmed s/he knew the staff were wearing the same contaminated gowns in the COVID-19 positive and COVID-19 negative rooms. S/he stated s/he was not aware the staff were taking PPE home to be washed. The DON stated s/he did not know if the manufacturer's instructions for the gowns allowed washing. 3. During an observation and interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 12:05 PM, her/his N95 face mask was observed to have approximately an inch gap around both sides of her/his face and her/his chin. The mask kept sliding down on he/himr nose. When asked if the mask was fit tested , s/he said yes. S/he further stated the individual that conducted her/his fit test indicated s/he needed a smaller mask. S/he stated s/he had been wearing the same mask for two weeks, and no one offered to get her/him another mask. During an interview with the Director of Nursing (DON) on [DATE] at 2:30 PM, s/he stated s/he was not aware CNA #1 was not given a smaller mask. S/he stated they sent the CNA home until s/he can get a new mask. S/he stated the hospital had conducted the fit testing and s/he was not informed they did not have a mask to fit her/him. A review of the Centers for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated [DATE], indicated, Filtering Facepiece Respirators (FFR) including N95 Respirators. A commonly used respirator in healthcare settings is a filtering facepiece respirator (commonly referred to as an N95). FFRs are disposable half facepiece respirators that filter out particles. To work properly, FFRs must be worn throughout the period of exposure and be specially fitted for each person who wears one. This is called fit testing and is usually done in a workplace where respirators are used. FFR users should also perform a user seal check to ensure proper fit each time an FFR is used. A review of CDC's guidelines titled, Preparing for COVID-19 in Nursing Homes, last updated [DATE], indicated, Facilities should have supplies of facemasks, respirators (if available and the facility has a respiratory protection program with trained, medically cleared, and fit-tested HCP), gowns, gloves, and eye protection (i.e., face shield or goggles). Implement a respiratory protection program that is compliant with the OSHA respiratory protection standard for employees if not already in place. The program should include medical evaluations, training, and fit testing. 4. On [DATE] at 8:00 AM, two surveyors knocked on the door of the facility to gain entrance to conduct a COVID-19 Infection Control Focused Survey. The door was opened by the Director of Nursing (DON) and the surveyors were invited into the building. The surveyors were not asked screening questions related to COVID-19, and their temperatures were not taken. They were given access to the facility without screening for COVID-19. One surveyor exited the building for the noon meal. On return, the surveyor was allowed entrance to the building by a member of the housekeeping staff without screening for COVID-19. The surveyors remained in the building until 5:15 PM without being screened for COVID-19 despite three opportunities to do so on entry. On [DATE] at 1:16 PM, the DON was asked why the surveyors had not been screened for COVID-19 on entry. S/he shook her/his head and stated s/he had become nervous on learning surveyors were at the facility. S/he acknowledged it was required to screen all visitors to the facility.5. During an observation on [DATE] at 10:00 AM, Resident #2, a COVID-19 positive resident, was observed out in the facility hallway without a mask. The resident walked past Registered Nurse (RN) #1. After several minutes, Physical Therapy Assistant (PTA) #1 told the resident to go back to her/his room. During an interview on [DATE] at 11:00 AM with the Director of Nursing and RN #1, they stated they knew the resident was supposed to stay in her/his room, but the resident had dementia and s/he was hard to keep in her/his room. A review of CDC's guidelines titled, Preparing for COVID-19 in Nursing Homes, last updated [DATE], indicated, Implement Source Control Measures. Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility. On [DATE] at 12:42 PM, a Removal Plan was submitted by the facility and accepted by the State Agency. It read as follows: POC (Plan of Correction): The facility immediately developed a plan to establish sections of the facility to be used to cohort Covid-19 patients. No Covid-19 positive resident will be cohorted with any non-positive Covid-19 residents. Covid-19 positive residents are being moved to a section of the facility established for positive residents. Non Covid-19 positive residents will reside in the section of the facility set aside for non-positive residents. This move will be completed by [DATE] under the direction of the facility Administrator. The door separating the negative from the positive will be closed until we have something in place to properly separate the sides. The facility social worker has notified all residents and families of the move. A room list for positive and non-positive residents is attached along with a facility diagram indicating the specific areas for positive and non-positive residents. The facility has a system to re-test residents beginning the week ([DATE]). Residents will be assigned rooms based on the results of these tests. The facility DON is responsible for reviewing the test results and assuring that residents are cohorted based on those test results. Any new admissions or re-admission will be tested prior to coming into the facility and reviewed by the DON to determine where in the facility they will be placed based on these pre-admission test results. DON and some staff members will be trained by infection control staff from Spartanburg Regional Hospital before DON will in service this will be completed by [DATE] All Staff will be educated by the DON and Administrator as follows. 1. Beginning on the current shift and continuing on all shifts going forward, the administrator and the DON will train all staff on infection control policies for the proper use of PPE including the importance of changing PPE before moving from a positive to a negative Covid-19 resident, proper donning and doffing of PPE and proper disposal of soiled PPE. This education will include information and diagrams from the CDC training site which are attached to the plan. This training will continue until all staff are trained and completed by [DATE] Training materials are attached. 2. Beginning on the current shift and continuing all shifts going forward, the administrator and the DON will train all staff on infection control policies for the importance using properly fitting masks. This education will include information from the manufacturer and training materials from the CDC training site which are attached to the plan. This training will continue until all staff are trained and completed by [DATE]. Training materials are attached 3. Beginning on the current shift and continuing on all shifts going forward, the administrator and the DON will train all staff on infection control policies for the importance and proper use of eyewear. This education will include information from the manufacturer of the eyewear and training materials from the CDC training site which are attached to the plan. This training will continue until all staff are trained and completed by [DATE] Training materials are attached. 4. Staff had masks fitted on [DATE]. The staff member not wearing the proper size mask was sent home and will not return to work until s/he has been provided and fitted with the proper size mask. The Administrator has been trained on how to fit the masks and will review all staff mask fittings to assure no other staff has the incorrect size mask by [DATE] Beginning on the current shift and continuing on all shifts going forward, the administrator and the DON will train all staff on infection control policies/forms for screening of visitors/surveyors prior to admission to the facility. This education will utilize the facility policy for screening and a copy of that policy will be given to each employee. The policy is attached. 5. The resident outside her/his room without a face mask is not alert and oriented and was immediately returned to her/his room. Beginning on the current shift and continuing on all shifts going forward, the administrator and the DON will train all staff on infection control policies for residents to wear masks when not in their rooms. resident will be monitored by staff and redirected back the room properly and safely. This training will be completed by [DATE]. Any employee not trained by [DATE] will not be allowed to work until they have completed the training. The DON will assure that no one who had not received this training will be placed on the schedule. The Administrator and DON will assure that any new employee or agency employee will receive this training prior to beginning work in the facility. The facility will have dedicated staff for COVID positive and COVID negative in the event that a staff member has to go from the positive side to the negative they will use proper sanitation and proper donning and doffing and disposal of PPE before going to the negative side The screening process will be conducted by the charge nurse or designee they will take the temperature of whoever enters the building and conduct the screening questions. Charge nurse or designee will be reeducated by DON by [DATE] and Administrator will audit daily to make sure this is done The Administrator and DON will monitor the effectiveness of training by conducting daily infection control rounds on alternating shifts and weekends to assure that infection control policies are followed beginning [DATE] and continuing for 90 days. At the end of the 90-day period, the results of these rounds will be reviewed by the QAPI Committee to determine the frequency of these round past the first 90 days. These daily infection control rounds will include observation/monitoring of the following: Staff donning and doffing of PPE Staff wearing properly fitted and sized masks Staff wearing appropriate eyewear Staff observing infection control policies for changing PPE between residents Assuring that residents outside of rooms wear appropriate face masks Assuring that resident are cohorted according to policy and designated units. Documentation of re-education when necessary to assure continued compliance with infection control policies. The facility Regulatory Consultant will review results of daily rounds weekly to assure that monitoring is in place and effective beginning the week of [DATE] and continuing for a minimum of 90 days. Results of these reviews will be discussed at the weekly QAPI meeting in which the consultant will participate. At the end of 90 days the QAPI team will determine the frequency of this monitoring based on the results of the reviews. The QAPI committee will meet weekly to review cohorting of residents, effectiveness of on-going staff education and results of daily infection control monitoring and observations. This plan will be implemented by the Administrator and DON and will be completed by [DATE]. By [DATE] at 9:49 AM, the facility had divided the facility into a COVID-19 positive unit on one end of the facility and a COVID-19 negative unit on the other end of the facility, separated by fire doors, and had moved residents to different rooms as needed to separate COVID-19 positive residents from COVID-19 negative residents. A review of the facility's policy, written by the Centers for Disease Control (CDC), provide and adopted adapted by the facility, stated remove PPE (personal protective equipment) before exiting the room except a respirator if worn. Sanitize hands after removing all PPE. During an observation on [DATE] at 9:15 AM, Registered Nurse (RN) #1 was observed passing medications. S/he was observed coming out of room [ROOM NUMBER], where a COVID-19 positive lived (Resident #2). S/he did not remove her/his PPE and s/he returned to the medication cart. S/he was leaning against the cart wearing the same contaminated PPE. During an interview on [DATE] at 9:15 AM, RN #1 confirmed s/he did not remove her/his PPE when s/he left room [ROOM NUMBER]. S/he stated they had been instructed they could wear the same PPE for the entire day. S/he stated they then removed the PPE at the end of their shift and put it in a bag to take home to wash. During an observation on [DATE] at 9:45 AM, RN #2 was observed assessing both COVID-19 positive and COVID-19 negative residents in room [ROOM NUMBER] without changing her/his gowns and gloves between residents. RN #2 was observed leaving room [ROOM NUMBER] at [DATE] at 10:00 AM, without changing gowns, and went to room [ROOM NUMBER]. S/he was seen conducting an assessment using a stethoscope. S/he was wearing full PPE including gloves, shoe covers, gown and hair covering. S/he conducted the assessments on each resident in the room without changing her/his gloves and sanitizing her/his hands in between residents. S/he also failed to disinfect the stethoscope between residents, and s/he placed the stethoscope around her/his neck. There were both positive and negative COVID-19 residents in the same room. An interview was conducted with RN #1 and RN #2 at on [DATE] at 11:00 AM. They were asked how long they wore the same PPE. They stated the wore the same PPE all day. At the end of their shift, they put the PPE in a bag and took it home to wash. RN #1 and RN #2 stated they received a new gown when the gown started to look bad. They had not been provided with the manufacturer's instruction on how to care for the gowns, and stated they were told it was acceptable practice to wear the gowns all day. During an observation on [DATE] at 12:05 PM Certified Nursing Assistant (CNA) #1 was observed in the hall serving trays to room [ROOM NUMBER]. S/he served Resident #2, a COVID-19 positive resident. She was wearing a gown but no gloves. S/he returned to the meal delivery cart in the hallway, wearing the same contaminated PPE s/he had been wearing in the resident's room. S/he failed to wash her/his hands or use hand sanitizer between the delivery of trays. She then removed a food tray from the cart and went back into room [ROOM NUMBER] to serve Resident #1. This resident was COVID-19 negative. S/he assisted the resident to sit up and served the tray. S/he failed to sanitize her/his hands, wear gloves and had the same contaminated PPE on. An interview was conducted with CNA #1 on [DATE] at 12:05 PM. S/he was asked about not changing her/his gown. S/he stated this was how s/he was trained. S/he was observed to have a thin white gown on. When asked how many days s/he wore the same gown, s/he stated s/he had to take the gown off, place it in a bag and take it home to wash. S/he stated s/he washed the gown until the condition indicated she needed a new one. She stated she had been provided training that she could wash the gowns and wear them all day. She stated she knew she was supposed to sanitize her/his hands between residents, but s/he forgot. Housekeeping (HSK) #1 was observed moping in residents' room up and down the unit on [DATE] at 10:30 AM. S/he was wearing the same jumpsuit PPE in all rooms, which included COVID-19 positive and COVID-19 negative residents. S/he was then seen mopping in the nurses' station and beauty shop area. During an interview with HSK #1 on [DATE] at !1:00 AM, s/he stated s/he used his jumpsuit for two to three days, then threw it away. S/he stated s/he had worn the jumpsuit while moping in both COVID-19 positive and COVID-19 negative residents' rooms. During an observation on [DATE] at 10:15 AM, Physical Therapy Assistant (PTA) #1 was observed going into room [ROOM NUMBER] to place Resident #2, who was COVID-19 positive, on an exercise machine. When she left the room, she wore the same PPE down the hallway, and into the physical therapy department. When she returned to remove the machine, she had the same PPE on. She removed the machine, and left the room pushing it down the hallway into the physical therapy department without disinfecting the machine. During an observation on [DATE] at 10:45 AM, PTA #2 was observed out in the hallway coming from a resident's room. S/he went straight into the physical therapy department wearing the same PPE that s/he was wearing when s/he exited the resident's room. S/he was questioned about the observation. S/he stated s/he was not told to change his PPE. PTA #2 was asked about resident assistive belts hanging in room [ROOM NUMBER]. There was a COVID-19 positive resident in this room. S/he stated the physical therapy department stored therapy items and stored its PPE in this room. The Administrator was present during this conversation, and s/he stated s/he was not aware the therapy department still had supplies in the room. During an interview with the DON on [DATE] at 1:30 PM, she conf (TRUNCATED)

Based on observation, record review, interviews and review of the facility's DENTAL SERVICES AGREEMENT, the facility failed to provide medically related social services for 1 of 1 sampled resident review for dental services. Resident #14 with documented complaints of tooth pain since September 2016 did not receive follow up dental care/services after dental assessment was completed on 10/03/16. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. A random observation on 2/07/16 at approximately 3:14 PM revealed the resident's front teeth appeared uneven with some small discolored areas. A review of the medical record on 2/08/17 at approximately 10:39 AM revealed there was no documentation to determine if dental services had been provided. Further record review revealed a nurses' note dated 9/15/16 that indicated Resident #14 complained of toothache and that the nurse practitioner was notified. A nurses' note dated 9/27/16 indicated that a nurse practitioner did acute care due to resident complaint of toothache. The nurses's note further indicated social services was informed about arranging a dental consult. There was a physician's orders [REDACTED]. During an interview on 2/08/17 at approximately 10:51 AM with the Director Of Nursing (DON), the DON stated he/she was aware the resident had a dental assessment completed due to the resident expressed concerns that his/her teeth had been hurting. The DON reviewed the medical record and stated there was no documentation in the medical record to indicate the resident had been evaluated. An interview on 2/08/27 at approximately 10:57 AM with Licensed Practical Nurse (LPN) #2 revealed the facility was in the process of contacting the dentist office to get feedback on the results of the dental consult. An interview on 2/08/17 at approximately 2:36 PM with the Social Services Manager (SSM) revealed a dental assessment was performed by a dental hygienist on 10/03/16 that indicated the resident had two fractured teeth with no additional recommendation. The dental assessment further indicated the resident received Tramadol as needed for pain and Tylenol. The SSM stated he/she just received the report today. There was no documentation to indicate the facility made efforts to obtain the results of the dental assessment until 2/08/17; which was confirmed by the Social Services Manager (SSM). The SSM further stated there was not a referral made for the resident to see a dentist. During an interview on 2/08/17 at approximately 3:19 PM, the SSM provided the surveyor with a different dental assessment that he/she reportedly obtained in an email today from Senior Dental Care office dated 10/03/16. The second dental assessment recommended that the resident be evaluated by a Doctor of Medical Dentistry (DMD). There was no documentation to indicate the facility made an effort to follow up with getting the results of the dental assessment prior to the 2/08/17 at the time of the survey. An interview on 2/08/17 at approximately 4:09 PM with the Administrator who provided a copy of the the facility's dental contract stated there was a breakdown in communication between the facility and dental provider. Review of the facility's dental contract indicated under Responsibilities of Facility section b. Communication. Facility shall cooperate in getting any required authorizations for treatment for [REDACTED]. The contract further indicated under section, d. Coordination. Facility shall designate an employee of Facility as the point-of-contact between the Facility and Provider (Coordinator) and shall notify Provider of the identity and contact information of the Coordinator and any changes thereto. The Coordinator shall have all necessary authority to act on behalf of the Facility in connection with this Agreement. An interview on 2/09/17 at approximately 10:19 AM with the Director of Nursing revealed the resident was documented as experiencing tooth pain on 9/15/16 and 9/27/16. An interview on 2/09/17 at approximately 10:55 AM with the Nurse Practitioner (NP), the NP stated he/she would have a concerns if the resident was experiencing any on going mouth pain and/or abscess. When informed the resident had an assessment on 10/03/16 and was identified as having fractured teeth with the facility not being aware until 2/08/17; the NP stated why was that? The NP stated the resident should have received services after the results of the dental assessment was completed.

Based on record review and interviews the facility failed to follow up on a physician recommendation for a scan for Resident # 35 to confirm a suspected [MEDICAL CONDITION] hip. ( 1 of 1 resident reviewed for care and services.) The findings included: The facility admitted Resident #35 with diagnoses, including, but not limited to, Anxiety Disorder, Major [MEDICAL CONDITION], Dementia, Cognitive Communication Deficit, and [MEDICAL CONDITION]. Review of the medical record on 2/9/17 revealed incident reports for falls on 9/23/16,10/16/16, and 10/23/16. Notes documented no injuries noted other than skin tear, which was treated. Nurses notes for 10/24/16 at 9:55 AM left facility for Dr (doctor) appointment. On 2/9/17 interview with SSM ( Social Service Manager) at 8:55 AM revealed there was an order for [REDACTED]. Physician wanted to get a scan. The physician stated the office would call facility with date /time for the scan for a possible left hairline [MEDICAL CONDITION] from a fall noted on 10/23/17. SSM and resident returned to facility and told RN #1 (Registered Nurse) and DON (Director of Nursing) they were to follow up with the appointment for scan. Nurse's note dated 10/24/16 at 12:14 AM documented the resident returned form office appointment . Per SSM Orthopedic Associates will schedule further screening and will keep facility informed. The doctor's office did not call facility with a date/time for a scan, and the nurses at the facility did not follow-up with the doctor's office. Although the resident was checked by facility physician on 10/27/16 and 10/31/16 the resident's fall was not addressed. A review of the resident's MAR (Medication Administration Record) revealed that on October 24, 25, 26, and 30/2016 that the resident received a PRN ( as necessary) [MEDICATION NAME] Tablet 5-325 MG ( milligram) 1 tablet at 1614 on 10/24/16 for pain level of 6 ( 1-10), on 10/25/16 at 0937 and 1914 for pain levels of 6. On 10/27/16 at 2109 received med for level 6 pain, and on 10/30/16 at 0929 medication for level 8 pain. The resident continued to receive PRN pain medication on 11/1, 11/2, 11/3, and 11/7/16 for pain levels of 5, 6, and 8. ON 11/7/16 The Medical Director and new facility physician did an acute care visit with the resident due to c/o ( complaints) of left hip pain and ordered mobilex X-Ray for left hip. Nurses note dated 11/7/16 at 20:07 documented radiology report results acute left femoral neck fracture. Resident transported to hospital for further evaluation and treatment for [REDACTED]. A telephone interview with the Medical Director and facility physician on 2/8/17 at 11:55 AM confirmed that He would have expected The nurses to follow -up with the orthopedic doctors when they did not receive a date/ time for the scan to be done. The DON also confirmed that the facility should have followed-up to check on time/date for the scan.

Based on observation, record review, interviews and review of the facility's DENTAL SERVICES AGREEMENT, the facility failed to provide dental care for a resident with documented oral care concerns for 1 of 1 sampled resident reviewed for dental services. Resident #14 with documented complaints of tooth pain since September 2016 did not receive follow up dental care/services after a dental assessment was completed on 10/03/16. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. A random observation on 2/07/16 at approximately 3:14 PM revealed the resident's front teeth appeared uneven with some small discolored areas. A review of the medical record on 2/08/17 at approximately 10:39 AM revealed there was no documentation to determine if dental services had been provided. Further record review revealed a nurses' note dated 9/15/16 that indicated Resident #14 complained of toothache and that the nurse practitioner was notified. A nurses' note dated 9/27/16 indicated that a nurse practitioner did acute care due to resident complaint of toothache. The nurses's note further indicated social services was informed about arranging a dental consult. There was a physician's orders [REDACTED]. A nurse's note dated 9/28/16 indicated pain medication given related to complaint of toothache. Further review of nurses' note on 9/28/16 revealed resident complained of toothache pain at 10:18 AM and 9:15 PM. A nurses' note dated 9/29/16 indicated the use of mouthwash aided in rinsing food out of resident's tooth cavity. A progress note dated 10/04/16 indicated the resident complained of toothache pain. A nurses' note dated 10/06/16 indicated the resident complained of toothache and had been seen by Senior Dental Care. The nurses' note further indicated the resident was given [MEDICATION NAME] as needed, Listerine mouthwash, Tylenol four times a day and [MEDICATION NAME] as needed. A progress note dated 11/13/16 indicated the resident was to be given 15 milligrams of Listerine liquid every evening and night shift for toothache. During an interview on 2/08/17 at approximately 10:51 AM with the Director Of Nursing (DON), the DON stated he/she was aware the resident had a dental assessment completed due to the resident expressed concerns that his/her teeth had been hurting. The DON reviewed the medical record and stated there was no documentation in the medical record to indicate the resident had been evaluated. An interview on 2/08/27 at approximately 10:57 AM with Licensed Practical Nurse (LPN) #2 revealed the facility was in the process of contacting the dentist office to get feedback on the results of the dental consult. An interview on 2/08/17 at approximately 2:36 PM with the Social Services Manager (SSM) revealed a dental assessment was performed by a dental hygienist on 10/03/16 that indicated the resident had two fractured teeth with no additional recommendation. The dental assessment further indicated the resident received [MEDICATION NAME] as needed for pain and Tylenol. The SSM stated he/she just received the report today. There was no documentation to indicate the facility made efforts to obtain the results of the dental assessment until 2/08/17; which was confirmed by the Social Services Manager (SSM). The SSM further stated there was not a referral made for the resident to see a dentist. During an interview on 2/08/17 at approximately 3:19 PM, the SSM provided the surveyor with a different dental assessment that he/she reportedly obtained in an email today from Senior Dental Care office dated 10/03/16. The second dental assessment recommended that the resident be evaluated by a Doctor of Medical Dentistry (DMD). There was no documentation to indicate the facility made an effort to follow up with getting the results of the dental assessment prior to the 2/08/17 at the time of the survey. An interview on 2/08/17 at approximately 4:09 PM with the Administrator who provided a copy of the the facility's dental contract stated there was a breakdown in communication between the facility and dental provider. Review of the facility's dental contract indicated under Responsibilities of Facility section b. Communication. Facility shall cooperate in getting any required authorizations for treatment for [REDACTED]. The contract further indicated under section, d. Coordination. Facility shall designate an employee of Facility as the point-of-contact between the Facility and Provider (Coordinator) and shall notify Provider of the identity and contact information of the Coordinator and any changes thereto. The Coordinator shall have all necessary authority to act on behalf of the Facility in connection with this Agreement. During an interview on 2/09/17 at approximately 10:26 AM with the Social Services Manager, the Social Services Manager stated he/she was not aware of the resident toothache concerns on 9/15/16 or 9/27/16. There was documentation in the medical record to indicate the resident continued to experience toothache pain after the 10/03/16 dental assessment was completed by the facility's contracted dental hygienist. There was no documentation to indicate the facility attempted to provide additional dental services. An interview on 2/09/17 at approximately 10:55 AM with the Nurse Practitioner (NP), the NP stated he/she would have a concerns if the resident was experiencing any on going mouth pain and/or abscess. When informed the resident had an assessment on 10/03/16 and was identified as having fractured teeth with the facility not being aware until 2/08/17; the NP stated why was that? The NP stated the resident should have received services after the results of the dental assessment was completed.