Every finding on record at J F Hawkins Nursing Home

Based on observation, interview, and review of the facility policy, the facility failed to ensure staff consistently maintained catheter drainage bags covered and positioned appropriately to maintain resident dignity for 2 of 2 residents (R22 and R51) reviewed. This deficient practice had the potential to create diminished dignity, and contamination risk. Findings include: Review of the facility's policy, Catheter Care Procedure - Urinary, last revised 12/28/23, revealed staff are expected to maintain catheter drainage to gravity without kinks or loops, keep privacy bags covering the drainage bags while in use, and uphold resident dignity. On 04/14/26 at 11:32 AM, R51 was observed ambulating in the hallway with a physical therapist, who was assisting the resident by holding an uncovered urinary catheter drainage bag filled with amber-colored urine visible to others. A second observation revealed R22 at 11:43 AM on 04/14/26 resting in bed with their catheter drainage bag uncovered and visible to all passing by. On 4/15/26, a follow-up observation again at 8:46 AM revealed R22's catheter drainage bag uncovered, while sleeping. During an observation and interview on 04/16/26 at 11:08 AM, R51 was observed again in the day room seated in a wheelchair speaking with another resident; their urinary drainage bag remained uncovered and visible in a public setting. During an interview at 4:19 PM, Licensed Practical Nurse (LPN)2 stated staff are trained to keep catheter bags covered and off the floor and explained, There was a cover last week, I am not sure what happened to it this week. On 4/16/26 at approximately 4:30 PM, the Director of Nursing (DON) viewed the placement of R22's catheter drainage bag resting on the floor. The DON noted that although the bag was covered on that date, its placement was now not appropriate, as the resident's bed was positioned low to the floor, resulting in the catheter drainage bag resting directly on the surface of the floor. The DON stated, It is not acceptable for the catheter bag to be on the floor.

F759 - Free of Significant Medication ErrorsBased on review of the facility policy, observation, interviews, and record review, the facility failed to ensure medications were administered in accordance with manufacturer instructions and professional standards for 2 of 3 residents (R39 and R100) reviewed for medication administration. The facility crushed medications labeled as delayed-release and extended-release and failed to ensure a resident rinsed their mouth after administration of an inhaled corticosteroid, resulting in significant medication errors with the potential for altered drug absorption, reduced therapeutic effect, and avoidable infection risk.Findings include:Review of the facility's policy titled, Medication Administration, dated 10/30/20 and reviewed 1/17/23, revealed medications are to be administered in accordance with manufacturer specifications and professional standards of practice, and staff are not to crush medications identified as do not crush.Review of physician orders for R39 dated 03/28/25 at 12:27 PM, included the instruction, May crush allowable meds. During an interview at 1:39 PM on 04/15/26, the Pharmacist clarified that extended-release (XR), delayed-release (DR), sustained-release (SR), and enteric-coated medications are not considered allowable for crushing under any condition.During an observation on 04/15/26 at approximately 8:30 AM, Licensed Practical Nurse (LPN)4 was observed administering medications to R39. After verifying the rights of medication administration, the nurse placed multiple medications into a pouch, including Aspirin Delayed-Release and Potassium Chloride Extended-Release (KCl-ER), crushed them together, and administered them in applesauce.On 04/15/26 at 12:36 PM, LPN3 was observed administering Breo Ellipta (fluticasone-vilanterol) to R100 without prompting or assisting the resident to rinse and spit after inhalation.During an interview on 04/16/26 at 10:50 AM, the Director of Nursing (DON) confirmed that enteric-coated, delayed-release, and extended-release medications are not to be crushed.Record review of the physician order on 04/16/26 at 3:24 PM revealed an order for R100, which indicated: Breo Ellipta 200-25 mcg, 1 puff daily; rinse mouth with water and spit after use for Chronic Obstructive Pulmonary Disease.Record review of R100's care plan on 04/16/2026 at approximately 3:33 PM revealed, behaviors related to traumatic brain injury (TBI), including hoarding items, making accusatory statements, refusing showers, and becoming belligerent when staff attempt to clean the room; however, there was no documentation addressing refusal to rinse and spit after inhaler use (initiated 9/18/23; revised 01/17/24).During a follow-up interview on 04/16/26 at 3:49 PM, the DON stated that R100 typically refuses to rinse and does not like to spit out their water after inhaler use; however, she could not verify that a refusal occurred at the time of observation and stated the refusal behavior would be addressed and reflected in the resident's care plan going forward. A subsequent review of the updated care plan on 04/16/26 at approximately 4:48 PM revealed the same behavioral concerns with the addition of documentation that the resident refuses to swish and spit after oral inhaler medication (revised 04/16/26).

Based on observation, interview, record review, and facility policy, the facility failed to ensure that a resident who required assistance with Activities of Daily Living (ADLs) received necessary care and services, specifically nail care and facial grooming, for 1 of 2 residents reviewed for ADL care (Resident (R)78). This deficient practice had the potential to affect the resident's dignity and personal hygiene.Findings include: Review of the facility policy titled Activities of Daily Living, last revised 12/28/23, revealed the following: Policy: The facility takes measures to minimize the loss of residents' functional abilities, including Activities of Daily Living (ADLs). ADLs include the ability to bathe, dress, and groom. A resident who is unable to carry out Activities of Daily Living receives the necessary services to maintain proper nutrition, grooming, and personal and oral hygiene.Review of the facility policy titled Nail Care, last revised 08/20/24, revealed the following: Policy: The purpose of this procedure is to provide guidelines for the care of a resident's nails to promote good grooming and health. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, including trimming and filing, will be provided on a regular basis and as the need arises.Record review of R78's Face Sheet revealed R78 was admitted to the facility on [DATE] with diagnoses including but not limited to: aphasia following cerebral infarction; hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the right dominant side; morbid (severe) obesity due to excess calories; arthritis, left hand; and primary osteoarthritis, unspecified hand. According to the Quarterly Minimum Data Set (MDS) dated [DATE], R78 has a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicates she is cognitively intact.Record review of R78's Care Plan, last revised 02/17/26, revealed the following: is at risk for altered activity patterns/pursuits related to being nonverbal. [R78] uses a tablet to communicate. Resident has an ADL self-care performance deficit related to CVA/TIA, depression, hemiplegia, and psychoactive drug use.A review of resident progress notes dated 11/01/25 through 04/15/26 revealed no documentation of refusals of ADL care or any charting related to nail care or facial hair grooming.An initial observation and interview with R78 on 04/15/26 at 9:20 AM revealed long hairs on her chin and long nails, with some dirt underneath and a yellow, grimy appearance. The resident stated via iPad that she would like her nails trimmed and her facial hair shaved. On the iPad, she indicated that this makes her feel sad.An observation and follow-up interview with R78 on 04/15/26 at 2:39 PM revealed the same observations.A follow-up interview with R78 via iPad revealed that her fingernails have not been cut since she has been at the facility; this included her facial hair as well. When asked how often staff trim her nails and facial hair, the resident stated, never. She also stated via iPad that her hair is washed every few months. When asked if she felt her personal care needs were being met, the resident stated, sometimes, depending on who works. When asked what happens when she requests help, she stated that staff came to change her clothes and provided a bed bath that day; however, they did not address her nails. She further stated that a nurse indicated he does not feel comfortable performing nail care. The resident stated related her facial hair, she does not remember the last time it was done.An observation on 04/15/26 at 5:05 PM revealed the same observations.An observation on 04/16/26 at 1:23 PM revealed the same observations.An interview with Licensed Practical Nurse (LPN)1 and Certified Nursing Assistant (CNA)1 on 04/16/26 at 1:45 PM revealed they both provide care for R78. LPN1 works part-time, and CNA1 works full-time, five days a week, and regularly cares for R78. LPN1 stated that nurses or aides can cut nails and trim facial hair; however, for diabetic residents, nurses perform nail care. LPN1 acknowledged R78's facial hair and nails and stated she could not remember the last time her nails were cut. LPN1 stated R78 does not refuse care and is nonverbal, with communication via iPad. LPN1 further stated R78 is encouraged to participate in ADLs and that refusals would be documented on the Kardex. LPN1 stated she has observed R78's nails and facial hair; however, the resident has not requested nail care, and she has not offered it. CNA1 stated R78 does not refuse ADL care. CNA 1 also stated he has observed her nails and facial hair but has not offered assistance. LPN1 and CNA1 stated they would address the concern.An interview with the Director of Nursing (DON) on 04/16/26 at 2:00 PM confirmed she could not find any progress notes indicating refusals. The DON stated the resident did not participate in any activities related to manicures, based on review of the medical record. The DON further stated that progress notes related to nail care are typically documented only for residents who receive podiatry services every three months. Her expectation is for staff to offer residents assistance.

Based on observations, interviews, and policy review, the facility failed to ensure a portable compressed oxygen cylinder was safely stored in a secured device for one (Resident (R) 113) of three sampled residents reviewed for oxygen use. The deficient practice had the potential for severe physical harm if the pressurized cylinder was to be knocked over and explode. Findings included: Review of the facility's policy titled, Oxygen Safety, revised 01/01/2022 indicated, Safety is the responsibility of all staff. Hazards or other conditions that could develop into a hazard must be reported to a supervisor. as soon as practical. Anyone may report a hazard or potential hazard. Staff. will be educated on oxygen safety precautions in accordance with their roles and responsibilities related to the use and storage of oxygen. When small-size (A, B, D, or E) cylinders are in use, they shall be attached to a cylinder stand or to a medical equipment designed to receive and hold compressed gas cylinders. Protect cylinders from damage by not storing in locations where heavy objects may strike them or fall on them, or where they can be tipped over by foot traffic or door movement. Observation on 02/03/25 at 12:36 PM revealed the Oxygen (O2) cylinder (Type E) in R113's room was not attached to a cylinder stand or other medical equipment designed to hold a compressed gas cylinder. The compressed O2 cylinder was free standing upright on the floor behind R113 who was in her wheelchair. Observation on 02/02/25 at 12:40 PM of R113's O2 cylinder, Licensed Practical Nurse (LPN)1 verified the O2 cylinder should be in a secure device to prevent the cylinder from tipping over. LPN1 stated that R113 just finished therapy. During an interview on 02/05/25 at 9:43 AM, Unit Manager (UM) 1 stated R113 had just returned from therapy and the therapist didn't put a new holder on the wheelchair. UM1 stated the O2 cylinder could be knocked over if not secured and could explode. During an interview on 02/05/25 at 9:59 AM, Director of Physical Therapist (DPT) stated residents have portable O2 cylinders in their room. Once the resident is transferred to their wheelchair, we disconnect them from the O2 concentrator and connect them to the O2 cylinder. DPT stated if a cylinder securing device was not available, they would locate one or hold onto the cylinder. DPT stated the O2 cylinder could tip over if not kept in a secure device. DPT stated O2 cylinders are not to be left standing up without being secured. During an interview on 02/05/25 at 10:10AM, OTR/L stated R113's O2 cylinder was found not in a secure device upon entering R113's room. OTR/L stated he was rushed and figured the cylinder would be situated soon and left it as it was found. OTR/L stated he knew the cylinder needed to be kept in a secure device to keep it from being knocked over. OTR/L stated the cylinder should have been removed from the room. OTR/L stated that if the O2 cylinder fell over, it could become a missile and go shooting During an interview on 02/05/25 at 11:39 AM, the Administrator stated O2 cylinders are required to be kept in a secure device.

Based on record review, interviews, and facility policy, the facility failed to protect confidentiality for Resident (R)1 for one of one resident reviewed for resident's rights. Certified Nursing Assistant (CNA)1 recorded R1 on her cellphone and the video was posted on the social media platform- Snapchat. On 09/25/24 at 4:57 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations could cause psychosocial harm. On 09/25/24 at 4:57 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 09/11/24. The IJ was related to 42 CFR 483.10 (a) (1) - Resident Rights. On 09/26/24, the facility provided an acceptable IJ Removal Plan. On 09/26/24 at 1:30 PM, the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Non-Compliance as of 09/18/24. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F550, constituting substandard quality of care. Findings include: Review of the facility policy titled, Social Media with a revision date of 01/01/22 revealed, Policy: The Company respects the desire of employees to use Social Media (see definition below) for personal expression. However, employees' use of Social Media can pose risks to the Company's and residents' confidential, proprietary and sensitive information, can harm the Company's reputation in the community, can expose the Company to discrimination and harassment claims, and can jeopardize the Company's compliance with business rules and laws, including but not limited to the Company's compliance with the Health Insurance Portability and Accountability Act (HIPAA) and related laws and regulations protecting, residents' protected health information (PHI). Protected Health Information: 1. Standards for Compliance with Related Policies and Agreements b. Social Media should never be used in a way that violates any of the Company's policies or employee obligations. Protecting Resident's PHI 2. Employees are absolutely prohibited from using Social Media in any way that would violate HIP AA or otherwise disclose or compromise residents' PHI. This includes but is not limited to the following: a. DO NOT use Social Media to post, upload, send, or otherwise share or disclose a photo or video of any resident without prior written permission of the resident or the resident's authorized agent as required by applicable law. You must use the Company's authorization form to obtain such prior written permission. This prohibition includes photos and videos where the resident is not easily identifiable It also includes photos or video where the resident is easily identifiable, whether in the photo or video itself or through a caption. 3. Personal electronic devices, including, but not limited to, cellular phones, PDAs, electronic games, MP3 players, iPods, CD/DVD players and pagers will not be allowed in the work area without prior written approval of the Administrator.This includes resident rooms 9. Personal use of Social Media is never permitted on working time. Review of the facility's policy titled, Promoting/Maintaining Resident Dignity with a revision date of 02/12/24 revealed, Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain dignity and respect resident rights. 12. Maintain resident privacy. Review of the facility policy titled, Media Release Agreement dated 12/07/21 revealed, .In accordance with the Health Insurance Portability and Affordability Act of 1996 (HIPAA), the photographs, names or written/verbal testimonials given by the above named resident or on behalf of the resident's family members will not be used in a manner that would disclose protected health information, except for the fact that the resident resides at the Facility, unless agreed otherwise . The Facility may use the media for all of the following that are checked off by the Resident/Legal Representative: . Facility Controlled Social Media (e.g. Facebook) . R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: dementia, anxiety disorder, major depressive disorder and bipolar disorder. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/03/24 revealed a Brief Interview of Mental Status (BIMS) Score was not completed due to the resident is rarely/never understood. Review of the facility's Personnel Action Request (PAR) form date 09/11/24, revealed CNA1 was involuntary terminated. During an observation and interview on 09/25/24 at 11:20 AM, R1 was observed in bed holding a baby doll. R1 appeared clean and well groomed. R1 was alert but confused and became tearful and stopped talking or answering questions during the conversation. A complete interview was unable to be obtained. During an interview on 09/25/24 at 10:35 AM, the Administrator revealed that they received the video from a third-party source on 09/11/24, inquiring if they knew the CNA in the video. Both the Administrator and the Director of Nursing (DON) revealed that the CNA was a part time employee, who worked whenever they could pick up days. The Administrator explained that the time frame of when the video was taken, was uncertain. The CNA reported that she may have recorded the video in January, but after they reviewed the schedule, the CNA had not been scheduled for any days during that time. Both the Administrator and DON further explained that the CNA was suspended and terminated at the same time and has not been allowed to come back into the building. During an interview on 09/25/24 at 11:25 AM, Licensed Practical Nurse (LPN)1 revealed that she is normally the nurse that works with R1 but was not assigned to them today. LPN1 further explained that she was made aware of a CNA taking a video, when she received a call inquiring if they had seen the video. LPN1 stated she was informed that the CNA stated she took the video originally to prove how the resident reacts during care. LPN1 stated she never saw the video. Attempts were made to contact CNA1 with no success. Review of the video recording showed R1 lying in bed, receiving care by CNA1. R1 is kicking her legs, while CNA1 continues to provide a brief change. R1 then sits up and appears to be fussing at CNA1, who continues to provide care, instead of ceasing. During an interview on 09/25/24 at 3:56 PM, R1's Resident Representative (RR) revealed that the resident has a diagnosis of dementia and Alzheimer's, and their disposition can vary from day to day. The RR revealed that they were notified of the incident on 09/11/24 around 3:00 PM and they came to the facility, once they received the call. The RR continued to explain that they did not provide consent for the resident to be videoed in this manner and that if the resident is a very private person and would not have consented to being videoed in this manner either, even if they were in their right mind. The RR continued to explain that they felt R1's rights were breached by the capturing and posting of the video to social media. The RR further explained that during conversations with the Administrator and DON, she was made aware that the CNA is a student, and that the DON made a statement asking why the CNA was by herself. The RR also revealed that the facility did not discuss any interventions that they put in place to protect the resident from this happening again. The facility's removal plan included the following: Resident Names: R1 - BIMS of 1 Description of Quality Concern - On 9-11-24, the administrator received a video of CNA1 providing care to a resident. The video of CNA1 providing care was to a JFH resident, which was later identified as R1. CNA1 is a PT/PRN employee with her employment beginning on 6-22-22. The video was put on a social media platform (Snap Chat) by an unknown source and was shared third hand to the administrator. The video showed CNA1 providing care during a brief change in which the resident was combative. 1. What improvement actions) will be done for residents found to have been affected by the concern(s)? Resident - R1 - Monitor for any changes in behavior/mood. On 9-18-24 the Social Services Director reviewed the resident's behaviors for the prior 30 days and noted there was no change in the resident's baseline. Head to toe assessment was completed by the DON on 9-11-24 and they were no findings of abuse or neglect. Notifications were made to the RP by the facility administrator on 9-11-24. The primary physician, medical director, police, Department of Public Health and the Ombudsman on 9-11-24 by the Director of Nursing. Resident has interventions in place for behaviors, the residents care plan was reviewed by Inter Disciplinary Team and updated on 9-13-24 by the Inter Disciplinary Team. The employee was immediately suspended and terminated on 9-11-24. 2. How facility will identify other residents having potential to be affected by practice AND what improvement action will be taken. On 9-11-24, residents with a BIMS of 8 or greater were interviewed by the DON, ADON/ IP and charge nurses regarding abuse and the staff use of cell phones in patient rooms and staff taking video or pictures of residents. No other issues were identified. On 9-11-24, residents with a BIMS 7 and lower all had body and skin assessments and no signs of abuse noted on residents by the DON, ADON and charges nurses. Staff interviews were conducted between 9-11-24 and 9-13-24 and they asked if they had ever witnessed any type of abuse, HIPPA Violations and social media use. These interviews were conducted by DON and ADON. No issues were identified. The DON reviewed incidents in the last 30-days for any trends and patterns for abuse on 9-14-24 and no concerns were identified. 3. What measures will be put in place or what systemic changes you will make to ensure that the practice does not recur. The DON, ADON/IP, admissions, social services will re-educate all staff in relation to abuse, HIPPA, cell phones and social media. This was started on 9-11-24 when the facility was made aware of the video and continued with shift-to-shift education to ensure education for all employees completed by 9-13-24 with no employee working after 9-13-24 without receiving this education. New hires will receive this education in orientation. A posttest was issued to all employees and was completed by 9-17-24 and all employees had a passing score of 100%. The posttest was completed by the DON, ADON/IP, admissions, and social services for all staff. Administrator reviewed abuse, social media policy and HIPPA policy on 9-12-24 and no concerns were identified. 4. How the corrective action(s) will be monitored to ensure the practices will not recur. i.e. what quality assurance program will be put in place. An Ad HOC QAPI meeting held on 9-13-24 to review facility past non-compliance for concern identified where staff taking pictures/videos of residents and posting on social media which included Administrator, DON, ADON/infection preventionist, Medical Director, Social Services, Marketing and Admissions and MDS. Social Services and the Activity Director will interview/questionnaire five staff members weekly for twelve weeks, to monitor that staff understands the abuse, HIPPA and Social Media Policy. Social Services and the Activity Director will interview/questionnaire five residents weekly for twelve weeks, to monitor that residents do not have any concerns with abuse, HIPPA and Social Media Policy. Starting the week on 9-16-24. Audit findings will be reported by the administrator at QAPI on a monthly basis, for three months or any time concerns are identified for review and further recommendations as deemed appropriate. The QAPI committee will consist of a minimum of the Administrator, DON, ADON/infection preventionist, Medical Director, Social Services, Marketing and Admissions and MDS. Administrator & DON are responsible for overall compliance. The facility alleges substantial compliance on 9-18-24.

Based on record review, interviews, observations and review of facility policy, the facility failed to provide a safe, functional, and comfortable environment for 7 of 21 rooms located on Unit 2. Specifically, the facility failed to maintain resident room temperatures at a safe and comfortable level. Findings Include: Review of the facility policy titled, Safe and Homelike Environment with a revised date of 01/01/22, documented, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, . Definitions: Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents . Policy Explanation and Compliance Guidelines: 7. The facility will maintain comfortable and safe temperature levels. a. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. b. If and when a resident prefers his or her room temperature be kept below 71 degrees Fahrenheit, or above 81 degrees Fahrenheit, the facility will assess the safety of this practice on the resident and the resident's roommate. Observation, with the Administrator, of room temperatures on 07/21/23 at approximately 5:00 PM revealed the following temperature readings (the Administrator used an air thermometer to record these readings): room [ROOM NUMBER] - 82.3 room [ROOM NUMBER] - 81.4 room [ROOM NUMBER] - 84.4 room [ROOM NUMBER] - 81.2 room [ROOM NUMBER] - 84.1 room [ROOM NUMBER] - 82.3 room [ROOM NUMBER] - 84.7 During an interview on 07/21/23 at 1:28 PM, the Administrator revealed the HVAC unit has been out since about April. The Administrator stated, We are currently working with DHEC's Construction (CON) Department to get approval to replace the entire unit. We had to get our engineers involved. It is going to cost a little over one million dollars to replace the unit. We have purchased and rented portable air conditioning units in the meantime. During an interview on 07/24/23 at 5:25 PM, Certified Nursing Assistant (CNA)1 and CNA2 revealed the residents do complain about it being too hot, mostly at night. The CNAs stated sometimes it is because the residents have unplugged the unit, or changed the settings, or closed the vent. During an interview on 07/24/23 at 6:18 PM, the Director of Nursing (DON) revealed staff are to keep the water pitchers filled up. They are constantly providing hydration. The DON further revealed that she has never heard any residents complaining about it being too hot. During an interview on 07/24/23 at 6:18 PM, the Administrator revealed, We are running eight industrial units and with all the portable units we are reaching our maximum power capacity, it's tripped fuses and we've had to go in and reset the breaker. The air conditioner broke down in the spring, we started the industrial units in April and the portable units in May. I submitted an application to DHEC's CON due to the cost or replacing the system. I am expecting this project to be completed sometime in September.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure a comfortable, homelike environment for 2 of 38 residents residing on Unit 2. Specifically, the facility failed to maintain resident room temperatures at a safe and comfortable level for Resident (R)1 and R2. Findings Include: Review of the facility policy titled, Safe and Homelike Environment with a revised date of 01/01/22, documented, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, . Definitions: Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents . Policy Explanation and Compliance Guidelines: 7. The facility will maintain comfortable and safe temperature levels. a. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. b. If and when a resident prefers his or her room temperature be kept below 71 degrees Fahrenheit, or above 81 degrees Fahrenheit, the facility will assess the safety of this practice on the resident and the resident's roommate. Review of R1's Face Sheet revealed, R1 was admitted to the facility on [DATE] with diagnoses to include but not limited to; dementia, atril fibrillation, nocturnal polyuria, and anemia. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/05/23, revealed a Brief Interview for Mental Status (BIMS) was not conducted due to R1 being rarely/never understood. Review of R2's Face Sheet revealed, R2 was admitted to the facility on [DATE] with diagnoses to include but not limited to; Huntington's Disease, osteoarthritis, atherosclerotic heart disease, and dementia. Review of R2's Quarterly MDS with an ARD of 04/17/23, revealed a BIMS was not conducted due to R2 being rarely/never understood. Observation of room [ROOM NUMBER], which R1 and R2 shared, on 07/24/23, revealed the Administrator took the temperature of the room with an air temperature thermometer, and the reading was 84.1 degrees Fahrenheit. During an interview on 07/24/23 at 5:20 PM, R1 stated, It is hot overnight and I sweat. Sometimes I can't sleep. During an interview on 07/24/23 at 5:21 PM, it was determined that R2 was non-interviewable. During an interview on 07/24/23 at 5:25 PM, Certified Nursing Assistant (CNA)1 and CNA2 revealed some of the residents do complaint that it is too hot, mostly at night. During an interview on 07/24/23 at 6:18 PM, the Administrator stated, the resident's [R1] son was here visiting and threatened to call DHEC. I'll add another unit in there.

Based on review of facility policy and procedure, record review, and interviews, the facility failed to ensure one of 4 residents (R)4 were free from misappropriation of resident's property. Specifically, the facility failed to ensure physican ordered medications were not diverted by facility staff. This failure placed the resident at risk for Abuse/Neglect/Exploitation related to drug diversion. Findings include: Review of facility policy titled Controlled Substance Administration & (and) Accountability revised date [DATE] revealed .6. Controlled substances must be stored under double lock, in the medication room in a locked container. separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents .10. All destructions must be conducted in the presence of 2 (two) licensed nurses or pharmacist. 11. Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services or His/her designee immediately. Documentation should be made on the shift verification sheet . Review of facility policy titled Abuse, Neglect, and Exploitation revised date [DATE] revealed III. Prevention of Abuse, Neglect and Exploitation. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: .B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; . Review of R4's face sheet revealed R4 was admitted to the facility for the following diagnoses including [MEDICAL RECORD OR PHYSICIAN ORDER] . Futher review of the medical record revealed observations and interview could not be conducted to due R4 expired on [DATE]. Review of admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating R4 was cognitively impaired. Review of R4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R4's care plan dated [DATE] revealed The resident has/is at risk for acute/chronic pain related to (no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Remove/limit causes where possible. Monitor/record/report to nurse any signs or symptoms of non-verbal pain . Further review of care plan revealed R4 was not care planned for anxiety. Review of R4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:00 PM, a review of R4's Controlled Drug Record revealed the following: On [DATE] at 9:00 AM, R4 was administered 0.25ml of [MEDICATION(S)] ([MEDICATION(S)]) [MEDICATION(S)] (liquid medication). The amount remaining was 29.25. On [DATE] at 8:30 AM, R4's amount remaining was 10.25 ml. The count was verified by previous Director of Nursing (DON) and Licensed Practical Nurse (LPN)3. Review of Police Incident Report dated [DATE] at 5:09 PM revealed Theft of Medication, R/O (Reporting Officer) responded to the above location in reference to an employee possibly diverting medication .[DATE], 0855 date/time of arrest . An interview on [DATE] at 3:20 PM with the current Director of Nursing (DON) revealed she was the ADON (Assistant Director of Nursing) on [DATE] when the narcotics were reported missing. The DON stated on [DATE] the previous DON reported the drug diverson and did a medication audit on all the narcotics in the facility. The DON stated before this incident she would periodically do an audit of the narcotic medication and verify each number on the narcotic sheet were correct and accounted for. The DON stated it is her expectation that nurses verify with another nurse immediately if medications are wasted. The DON stated there were no other residents identified of having medications diverted. The DON further stated Registered Nurse (RN)2 was suspended immediately on [DATE] and was terminated for drug diversion after the investigation. A telephone interview on [DATE] at 3:36 PM with the previous DON revealed on [DATE], the on-call nurse was called because the count was off for R4's liquid [MEDICATION(S)]. The previous DON stated RN2 was interviewed and she denied taking the medications. The previous DON stated RN2 revealed R4's [MEDICATION(S)] was spilled on [DATE], but did she did not note it on the narcotic logs.The previous DON stated the Police were called and the company's management were notified. The previous DON stated that when she left, R4's [MEDICATION(S)] was locked up in her office. The previous DON stated that she was notified by the police, RN2 was questioned and was to be charged with drug diversion. The previous DON revealed RN2 was reported to the State Board of Nursing. The previous DON stated she conducted random audits of the narcotic medication after the incident and did not find any additional discrepancies related to drug diverson. The previous DON stated that the Consultant Pharmacist also conducted an audit and did not identify any discrepancies that she was aware of. An interview on [DATE] at 3:49 PM with LPN3 revealed she works at the facility PRN (as needed). LPN3 stated on [DATE] she went to do a medication audit on the narcotics and noticed there was a significant amount of R4's liquid [MEDICATION(S)] missing. LPN3 stated other nurses usually go off the number on the side of the bottle but she measured R4's [MEDICATION(S)] with a medicine cup and the count was still off. LPN3 revealed she asked RN2 if R4's medication spilled because the count was off and RN2 stated no. LPN3 stated she was called to the medication room by the ADON and during this time is when RN2 revealed the medication had spilled. LPN3 further stated she has brought her concerns with how other nurses verify liquid narcotics to the previous DON's attention, however nothing was done about it. A telephone interview on [DATE] at 10:38 AM with RN2 revealed she was working on [DATE] when R4's liquid [MEDICATION(S)] was spilled. RN2 stated she did not document the medication was spilled and believe the facility was trying to black ball her from a previous incident years ago. RN2 revealed LPN2 spilled R4's medication and she covered for her. RN2 stated she noticed something odd about LPN2, but did not report this to the DON or ADON. RN2 stated that she had some issues years ago when she took medications from residents for personal use. RN2 further stated the facility was aware of the problem and it using it to frame her. A telephone interview on [DATE] at 11:14 AM with the Consultant Pharmacist (CP) revealed she has done most of her medication regimen reviews remotely. The CP stated she has onsite visits at the facility once a month for Quality Assurance Performance Improvement (QAPI), [CONDITION(S)] medications review, medication cart audits, medication storage audits, and removing expired supplies. The CP stated during the random narcotic audits, she would review 3 residents every month and the pharmacy destroys medications once a month or every other month. The CP stated she notifies the DON, ADON, and any other pertinent staff on the discrepancies that are found during the medication audits. The CP revealed nurses should document if one or two doses of medications are wasted and verify by a witness. The CP stated narcotics are to be wasted with two signatures. The CP stated she was aware of the drug diversion in January. The CP revealed she recommented that the facility contact Drug Control and notify the police. The CP further stated after she was made aware of the incident, she contacted her Pharmacy Director and the facility's corporate Director of Pharmacy. An interview on [DATE] at 4:40 PM with the Administrator revealed RN2 was suspended and terminated after the investigation. The Administrator stated he was made aware of the situation on [DATE] by the previous DON. The Administrator stated a thorough investigation was conducted and it was determined that RN2 had diverted R4's [MEDICATION(S)]. The Administrator stated the facility did everything that they could have done given the situation. The Administrator stated it is his expectation that nurses adhere to the facility's policy regarding controlled subtances. Several attempts were made on [DATE] and [DATE] via telephone to contact LPN2 with no success.

Based on observations, record review and interview, the facility failed to maintain an effective pest control program to ensure the facility is free of pests (roaches). Findings include: Review of the facility's policy, date reviewed/revised 8/14/20 and date implemented 01/01/21, titled Pest Control Program Policy: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Definition: Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats). During a walk through the facility to identify pest control issues with the Maintenance Manager and Medical Record Coordinator (MRC) on 11/22/21 at 11:00 AM, the following was observed: 1. In the electrical utility room-one large sized and one small sized dead roaches 2. In the therapy room-two medium size dead roaches 3. At the nurse's station of unit (100)-one tiny bug (roach) crawling around the nurse's station. The MRC grabbed it in a paper towel, killed it, and put it in the trash can. 4. Room 5 (empty)-a large sized roach crawling on the bathroom floor. The MRC grabbed it in a paper towel and killed it. 5. Room 29 - one medium sized roach crawling behind the resident's nightstand 6. Room 33- one medium sized roach dead on the left side to the resident's bed 7. Room 19-two small roaches crawling on the floor next to the resident's bed In an interview with Resident (R)1 (room 33) on 11/22/21 at 11:45 AM, s/he said his/her room has roaches. S/he has seen them crawling on the floor. S/he said that the administration knows and that they have sprayed before, but the roaches still coming. In an interview with R2 (room 29) on 11/22/21 at 11:50 AM, s/he stated that s/he sees roaches in her room. S/he has seen them crawling on the floor and walls. Interview with R3 (room 17) on 11/22/21 at 11:55 AM, s/he stated that the facility has been having some serious issues with roaches. In an interview with the Administrator and the Maintenance Manager on 11/22/21 at approximately 1 PM, they acknowledged that the facility has a pest control (roaches) infestation. The Administrator added that s/he is getting a new pest control contract with a different company.

Based on observation, interview, resident record review and review of the facility's policy, the facility failed to ensure the resident received care to prevent development of a pressure ulcer for one (1) of 19 sampled residents. Resident #190 was discovered to have a skin breakdown on the right outer heel on 7/16/21. The facility failed to, monitor the resident's skin to prevent the development of an unstageable pressure ulcer. This standard is cited at harm level. The findings include: 1. Review of the facility's policy titled Pressure Injury Prevention and Management date reviewed/revised 1/30/20 revealed, in part, the following documentation: 'To prevent avoidable pressure injuries and the promotion of healing of existing pressure injuries.' The policy defines: Avoidable means that the resident developed a pressure ulcer/injury that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with the resident's needs; goals, and professional standards of practice, monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. 2. The policy compliance guidelines: 2. The facility will establish and utilize a systematic approach for pressure injury prevention and management. a. Licensed nurses will conduct a pressure injury risk assessment, using Norton or Braden tool on all residents upon admission/re-admission, weekly x4 weeks, then quarterly or whenever the resident's condition changes significantly. b. Licensed nurses will conduct a full body skin assessment on all residents upon admission/ re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. c. Assessments of pressure injuries will be performed by licensed nurse and documented in the medical record. d. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task. 3. 4. Intervention for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for revention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g. moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk for pressure injury. Basic or routine care interventions could include, but are not limited to: (i) Redistribution of pressure (such as repositioning, protecting and/or offloading heels, etc) (ii) Minimize exposure to moisture and keep skin clean, especially of fecal contamination. (f.) Interventions will be documented in the care plan and communicated to all relevant staff. The National Pressure Ulcer Advisory Panel (NPUAP) defines an unstageable ulcer as, full thickness and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Sloughing and/or eschar may be visible. If eschar or sloughing occur the extent of the tissue loss is an unstageable pressure injury. If the slough or eschar is removed a Stage III or Stage IV Pressure Ulcer will be revealed. Resident #190 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident admitted having a left lower leg venous ulcer. Review of Resident #190's Annual Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) was assessed as six (6) indicating severely impaired cognition. The resident was assessed as having no demonstrated behaviors and requiring limited assistance of one (1) person with bed mobility and walking. Resident #190 required extensive assistance of one (1) with transfer, movement on the unit, dressing, and personal hygiene. The resident had no upper or lower extremity impairment with range of motion. The admission assessment revealed that the resident was at risk for pressure, the intervention treatments were implemented; pressure reducing device for chair and bed. Review of Resident #190's Pressure Care Area Assessment (CAA) dated 4/29/21 revealed the triggers indicating the resident was at risk for developing pressure ulcers. The resident required assistance with activities of daily living, limited assistance with bed mobility, frequent urinary incontinence. The CAA indicated the resident would be care plan for pressure ulcers. Review of Resident #190's most recent Quarterly MDS assessment was in progress dated for 7/26/21. Review of the admission Braden Scale for Predicting Pressure Score Risk dated 4/23, 4/30, 5/7, 7/13, 7/16/21 revealed Resident #190's Braden scale score was (15-17) indicating at risk for pressure. Review of Resident #190's facility's Skin assessment dated ,d+[DATE], 6/26, 7/3, 7/10/21 revealed the resident's admitted with a left lower leg (rear) open area, which was vascular in nature and was treated according to the physician orders. Review on 7/16/21of Resident #190's Pertinent Charting revealed a right outer heel pressure ulcer had developed and measured 1.7x1.2x2 centimeter (cm). The charting noted, tissue around the resident's heel pressure ulcer was intact. However, no documentation noted regarding drainage or the description of the pressure ulcer. The facility's implemented interventions were applied heel boots to float heels. The charting indicated, physician and Responsible Party (RP) were notified. The physician ordered the right heel pressure ulcer, to be clean with wound cleanser, apply skin prep to wound edges, apply honey gauze, cover with ABD pad, and wrap with Kerlix. Review of Resident #190 Certified Nursing Assistant's (CNA) plan of care dated from 7/10/21 through 7/16/21 revealed the resident's skin was observed, with no identified open area until 7/16/21. On 7/16/21, the care plan identified; the resident's right outer heel had an open area. Review of the Event Recommendation Form dated 7/16/21 at 11:30 AM revealed a staff noted an area to Resident #190's right outer heel. The wound measurements (1.7x1.2.02) were obtained. The wound was described to be 100% necrotic. The surrounding wound tissue was without peeling, no odor noted. The resident denies pain. The facility obtained witness statements to include CNA #4 and LPN #4. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 7/16/21 clean wound with wound cleanser, pat dry. Apply Honey gauze, skin barrier wipe to peri wound. Cover with ABD and wrap with Kerlix. 7/18/21 clean wound with wound cleanser, pat dry. Apply Honey Alginate, skin barrier wipe to peri wound. Cover with ABD and wrap with Kerlix. 7/18/21-7/25/21 [MEDICATION(S)] Capsule (cap) 500mg one (1) cap by mouth four (4) times a day for infection/wound to back of left lower leg related to asymptomatic varicose veins of bilateral lower extremities x seven (7) days. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During initial tour on 07/20/21 10:28 AM, Resident #190 was upright in recliner eyes closed, not easily aroused, oxygen at two (2) liters per nasal cannula. The resident was wearing appropriate clothing and bilateral heel boots. The mattress had a pressure reducing device to the bed and chair. On 7/21/21 at 9:45 AM revealed Resident #190 sitting upright in recliner, alert able to answer general questions appropriately. S/he was wearing appropriate clothing and bilateral heel boots. Further observation at 11:45 AM resident showed resident remained in the same position. On 7/21/21 at 1:15 PM observation was made of the Infection Preventionist (IP) and Director of Nursing (DON) assessing Resident #190's right outer heel pressure. DON removed the Kerlix wrap, small amount of serous drainage noted. The IP described right outer heel as being round and size of nickel, no odor, wound edges with eschar and wound bed has sloughing. Interview on 7/21/21 at 10:15 AM with Certified Nursing Assistant (CNA) #3 revealed the resident is normally dressed, up in the recliner when s/he starts her/his day. CNA #3 last cared for Resident #190 on 7/15/21 and revealed to her/his knowledge the resident had no skin concerns. S/he revealed CNAs are trained to report any skin concerns to the licensed nurse immediately. S/he confirmed the resident did not utilize heel boot prior to 7/16/21. Interview on 7/21/21 at 11:10 AM with CNA #4 described the resident to have limited mobility and sat in recliner most of the day. The CNA recalled caring for Resident #190 on 7/16/21, when the resident requested a shower. The shower was completed, while drying off, the resident s/he complained of discomfort at the right outer heel. The CNA observed the right heel closer, to her/his surprise, the resident's right foot had a dark wound with seeping drainage. The CNA immediately notified the nurse. CNA #4 revealed the resident did not have heel protector until after the wound was identify. Phone interview on 7/21/21 at 11:40 AM was conducted with License Practical Nurse (LPN) #4 revealed the facility trains the CNAs to report any skin concerns to the licensed nurse immediately. LPN #4 revealed the licensed staff assess and monitors residents' skin weekly for sign and symptoms of breakdown. The LPN further revealed when a skin breakdown is identified, the resident's care plan should be developed/updated with interventions. LPN #4 revealed the CNAs are responsible for monitoring skin during showers and anytime care is provided. The LPN indicated observing the unit, making frequent rounds, and communicating with CNAs is how s/he ensures resident's care needs are met. The LPN revealed CNA#4 notified her/him of Resident #190's right outer heel pressure. LPN #4 immediately assessed the resident, notified the physician, DON and responsible party. S/he described the right outer heel tissue as being dark in color, but the surrounding tissue was intact. The LPN revealed investigating as to why the foot ulcer occurred, and s/he concluded it was the resident's shoe. Phone interview was conducted with CNA #6 on 7/21/21 at 9:40-9:47 PM revealed the facility trained her/him to observe a resident skin during showers, and whenever care is being provided. The CNA was knowledgeable of Resident #190's care needs. S/he revealed the resident is usually up in the recliner, wearing a hard-sole shoe with the back heel open. Further stated the resident would sit up in the recliner with her/his right foot straight out. The CNA revealed the resident normally goes to bed around 6:30 PM. CNA#6 stated she/he had not cared for the resident for several days prior to the discovery of the foot ulcer. Phone interview was conducted with RN #1 on 7/21/21 at 9:48-9:55 PM revealed being responsible for Resident #190's weekly skin assessments. S/he revealed on 7/10/21 the resident's weekly skin assessment was intact. The nurse indicated the resident sits in recliner with heels dug into the floor. S/he revealed floating the heels even though it was not a care plan intervention. The RN revealed working night shift on 7/12 and 7/13 and was unaware of any skin concerns. Interview on 7/22/21 with Wound Nurse on 7/22/21 at 11:20 AM revealed on 7/21/21 Resident #190's wound was assessed as right heel as un-stageable pressure (with sloughing and/or eschar). S/he indicated Resident #190's un-stageable heel pressure was a result from intense and/or prolonged pressure on the heel. The Wound Nurse revealed pressure interventions should have been developed. Phone interview was conducted on 7/22/21 at 2:42 PM with Resident #190's physician, revealed the resident has vascular impairment. The physician revealed the resident was a heavy smoker and oxygen dependent. The physician indicated the right heel wound was a pressure ulcer. He/she indicated the pressure ulcer should heal with consistent treatment. In an interview with the MDS Coordinator on 7/22/21 at 3:10 PM revealed the MDS Coordinators expectations are to develop, update, revise the care plan, participate in IDT meetings, capture and care plan resident care needs. The Coordinator revealed the initial pressure care plan was developed but cancelled when the vascular wound care plan was developed. She/he indicated along with the vascular care plan a pressure prevention care plan should have been implemented. Interview with the DON on 7/22/21 at 3:30 PM revealed being made aware of Resident #190's acquired pressure. S/he indicated immediate pressure prevention and skin assessment retraining were implemented. The DON indicated a pressure preventive care plan should have been developed. Phone interview was conducted with the family of Resident #190 on 7/22/21 at 6:25 PM revealed visiting the resident at least twice a week. He/she revealed the resident did not wear protected heel boots until after the pressure developed. Resident #190's family member was notified of the pressure ulcer and that it developed from the resident's shoe.

Based on observation, interview, resident record review and review of the facility's policy, the facility failed to develop a pressure ulcer care plan in accordance with professional standard of quality for one (1) of 19 sampled residents. Resident #190 was assessed to be at risk for developing a pressure ulcer. On 7/16/21 the resident developed an unstageable right outer heel pressure ulcer. The facility failed to develop a care plan with interventions to prevent the development of a pressure ulcer. This standard is cited at harm level. The findings include: 1. Review of the facility's policy titled Comprehensive Care Plan date reviewed/revised 10/19/20 and implemented date 1/1/21 revealed, in part, the following documentation: the care plan is individualized, and resident centered. The compliance guidelines 1. The care plan development process will include a complete assessment of the resident's care needs. 2. The care plan will be developed in seven (7) days after the completion of comprehensive Minimum Data Set (MDS) assessment. All Care Assessment Areas (CAA) triggers are considered in developing the plan of care. 4. The comprehensive care plan will be reviewed and revised by the Interdisciplinary Team (IDT) after each comprehensive and quarterly MDS assessment. Resident #190 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted having a left lower leg venous ulcer. Review of Resident #190's Annual MDS dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) was assessed as six (6) indicating severely impaired cognition. The resident was assessed as having no demonstrated behaviors and requiring limited assistance of one (1) person with bed mobility and walking. Resident #190 required extensive assistance of one (1) with transfer, movement on the unit, dressing, and personal hygiene. The resident had no upper or lower extremity impairment with range of motion. The admission assessment revealed that the resident was at risk for pressure ulcers, the intervention treatments were implemented; pressure reducing device for chair and bed. Review of Resident #190's Pressure Care Area Assessment (CAA) dated 4/29/21 revealed the triggers indicating the resident was at risk for developing pressure ulcers. The resident required assistance with activities of daily living, limited assistance with bed mobility, frequent urinary incontinence. The CAA indicated the resident would be care plan for pressure ulcers. Review of Resident #190's most recent Quarterly MDS assessment was in progress dated for 7/26/21. Review of Resident #190's initial care dated 4/23/21 revealed the resident was at risk for developing a pressure ulcer. However, on 4/23/21 the pressure care plan was cancelled. Instead a left leg venous area care plan was initiated dated 4/23/21. The interventions were 1. Monitor for sign and symptoms of infection, failure to heal and maceration. 2. Measure and document measurement of each skin breakdown, type of exudate and notable changes. Review of the admission Braden Scale for Predicting Pressure Score Risk dated 4/23/, 4/30, 5/7, 7/13, 7/16/21 revealed Resident 190's Braden scale score was (15-17) on 4/23/21 indicating at risk for pressure ulcer. Review of Resident #190's facility's Skin assessment dated ,d+[DATE], 6/26, 7/3, 7/10/21 revealed the resident's admitted with a left lower leg (rear) open area, which was vascular in nature and was treated according to the physician orders. Review on 7/16/21 of Resident #190's Pertinent Charting revealed a right outer heel pressure had developed and measured 1.7x1.2x2 centimeter (cm). The charting noted, tissue around the resident's heel pressure was intact. However, no documentation noted regarding drainage or the description of the pressure ulcer. The facility's implemented interventions were to apply heel boots to float heels. The charting indicated, physician and Responsible Party (RP) were notified. The physician ordered the right heel pressure, to be clean with wound cleanser, apply skin prep to wound edges, apply honey gauze, cover with ABD pad, and wrap with Kerlix. Review of Resident #190 Certified Nursing Assistant's (CNA) plan of care dated from 7/10/21 through 7/16/21 revealed the resident's skin was observed, with no identified open area until 7/16/21. On 7/16/21 the care plan identified; the resident's right outer heel had an open area. Further review of the CNA's care plan revealed no heel preventive intervention were noted. Review of the Event Recommendation Form dated 7/16/21 at 11:30 AM revealed a staff noted an area to Resident #190's right outer heel. The wound measurements (1.7x1.2.02) were obtained. The wound was described to be 100% necrotic. The surrounding wound tissue was without peeling, no odor noted. The resident denies pain. The facility obtained witness statements to include CNA #4 and LPN #4. During initial tour on 07/20/21 10:28 AM, Resident #190 was upright in recliner eyes closed, not easily aroused, oxygen at two (2) liters per nasal cannula. The resident was wearing appropriate clothing and bilateral heel boots. The mattress has a pressure reducing device to the bed and chair. On 7/21/21 at 9:45 AM revealed Resident #190 sitting upright in recliner, alert able to answer general questions appropriately. She/he was wearing appropriate clothing and bilateral heel boots. Further observation at 11:45 AM resident showed resident remained in the same position. Interview on 7/21/21 at 10:15 AM with CNA #3 revealed the resident is normally dressed, up in the recliner when s/he starts her/his day. Last cared for Resident #190 on 7/15/21; s/he revealed to her/his knowledge the resident had no skin concerns. S/he revealed CNAs are trained to report any skin concerns to the license nurse immediately. S/he confirmed the resident did not utilize heel boot prior to 7/16/21. Further stated the nurse will inform the CNA when new interventions are developed. Interview on 7/21/21 at 11:10 AM with CNA #4 revealed being knowledgeable of Resident #190's care needs. The CNA described the resident to have limited mobility and sat in recliner most of the day. The CNA recalled caring for Resident #190 on 7/16/21, when the resident requested a shower. The shower was completed, while drying off the resident complained of discomfort at the right outer heel. The CNA observed the right heel closer, to her/his surprise, the resident's right foot had a dark wound with seeping drainage. The CNA immediately notified the nurse. CNA #4 revealed the resident did not have heel protectors until after the wound was identified. Phone interview on 7/21/21 at 11:40 AM was conducted with License Practical Nurse (LPN) #4 revealed the facility trains the CNAs to report any skin concerns to a licensed nurse immediately. LPN #4 revealed the licensed staff assess and monitors residents' skin weekly for sign and symptoms of breakdown. The LPN further revealed when a skin breakdown is identified, the resident's care plan should be developed/updated with interventions. LPN #4 revealed the CNAs are responsible for monitoring skin during showers and anytime care is provided. The LPN revealed CNA#4 notified him/her of Resident #190's right outer heel pressure. S/he indicated the MDS Coordinator was responsible for developing the care plan. Phone interview was conducted with CNA #6 on 7/21/21 at 9:40-9:47 PM revealed the facility trained her/him to observe a resident skin during showers, and when ever care is being provided. The CNA was knowledgeable of Resident #190's care needs. S/he revealed the resident is usually up in the recliner, wearing a hard-sole shoe with the back heel open. Further stated the resident would sit up in the recliner with her/his right foot straight out. The CNA revealed the resident normally goes to bed around 6:30 PM. CNA#6 stated the resident had no specific skin care interventions to follow. Phone interview was conducted with RN #1 on 7/21/21at 9:48-9:55 PM revealed being responsible for Resident #190's weekly skin assessments. S/he revealed on 7/10/21 the resident's weekly skin assessment was intact. The nurse indicated the resident would sit in the recliner with heels dug into the floor. S/he revealed floating the heels even though it was not a care plan intervention. The RN revealed working night shift on 7/12 and 7/13 and was unaware of any skin concerns. Interview with the Wound Nurse on 7/22/21 at 11:20 AM revealed on 7/21/21 Resident #190's wound was assessed as right heel as un-stageable pressure (with sloughing and/or eschar). S/he indicated Resident #190's un-stageable heel pressure was a result from intense and/or prolonged pressure on the heel. The Wound Nurse revealed pressure interventions should have been developed. Phone interview was conducted on 7/22/21 at 2:42 PM with Resident #190's physician, he/she revealed the resident has vascular impairment. The physician revealed the resident was a heavy smoker and oxygen dependent. The physician indicated the right heel wound was a pressure ulcer. He/she indicated the pressure ulcer should heal with consistent treatment. An interview with the MDS Coordinator on 7/22/21 at 3:10 PM revealed the MDS Coordinators expectations are to develop, update, revise the care plan, participate in IDT meetings, capture and care plan resident care needs. The Coordinator revealed the initial pressure ulcer care plan was developed but cancelled when the vascular wound care plan was developed. S/he indicated along with the vascular care plan a pressure prevention care plan should have been implemented. In an interview with the Director of Nursing (DON) on 7/22/21 at 3:30 PM revealed being made aware of Resident #190's acquired pressure. S/he indicated immediate pressure prevention and skin assessment retraining were implemented. The DON indicated a pressure preventive care plan should have been developed. A phone interview was conducted with the family of Resident #190 on 7/22/21 at 6:25 PM revealing they visited the resident at least twice a week. He/she revealed the resident did not wear protected heel boots until after the pressure developed. The family voiced being very pleased with Resident #190's the care. Resident #190's family member was notified of the pressure and that it developed from the resident's shoe.

Based on interview, record review, and facility policy review, the facility failed to ensure ongoing monitoring of [CONDITION(S)] vascular access and ensure ongoing communication with the [CONDITION(S)] center for two (2) of two (2) sampled residents (Resident #72 and Resident #78) reviewed for [CONDITION(S)]. Findings include: Review of the facility's titled Care Planning Special Needs - [CONDITION(S)] reviewed/revised on 10/30/2020 and implemented on 1/1/21 revealed Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental and psychosocial needs of residents receiving [CONDITION(S)]. Policy Explanation and Compliance Guidelines: 3. Interventions will include, but not limited to: a. Documenting and monitoring of complications b. Pre- and post-weights c. Assessing, observing, and documenting care of access sites, as applicable 4. Nursing staff will provide a report to the [CONDITION(S)] provider regarding the resident's condition and treatment provisions each [CONDITION(S)] treatment day, and as needed. 5. If no written report is received upon return from [CONDITION(S)], nursing staff will call the [CONDITION(S)] provider to receive a report . Review of Resident #72's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #72's Brief Interview for Cognitive Score (BIMS) was 15 indicating the resident was cognitive in skills for daily decision-making. Resident #72 was assessed as requiring limited physical assistance of one (1) staff for bed mobility, dressing, toilet use and personal hygiene; extensive physical assistance of two (2) or more staff for transfers; and physical help limited to transfer only of two (2) or more staff for bathing. Resident #72 was assessed as always continent bladder and bowel. He/she was assessed as having no pressure ulcers and receiving [CONDITION(S)] while/while not a resident. Review of Care Plan initiated on 6/24/21 and revised on 7/2/21 revealed Focus: Resident #72 has hemodialysis related to CKD ([CONDITION(S)]) Stage V. Goal: The resident will have no S/S (signs/symptoms) of complications from [CONDITION(S)]. Interventions: -do not draw blood or take B/P (blood pressure) in arm with graft. -receives [CONDITION(S)] at the (sic) [CONDITION(S)] center on Monday, Wednesday and Friday. Review of Resident #72's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 6/25/21 - resident has [CONDITION(S)] on M (Monday) - W (Wednesday) - F (Friday) at (sic) Kidney Center 7/12/21 - change dressing to cath (catheter) after shower every day shift every Mon (Monday), Wed (Wednesday) and Fri (Friday). Make sure resident has full tank of O2 (oxygen) before [CONDITION(S)]. Further review revealed no orders for monitoring of catheter site. 7/25/21 - Vital signs every shift. Review of Resident #72's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #72's Nurses Notes from 6/24/21 to 7/21/21 revealed no documentation of ongoing monitoring and care of the resident vascular access (fistula, graft or central venous catheter). Review of Resident #72's June 2021 and July 2021 Medication Administration Records (MARs) revealed no documentation of ongoing monitoring of the resident's vascular access (fistula, graft or central venous catheter). Review of Resident #72's [CONDITION(S)] Communicate Sheets from June 2021 to July 2021 revealed the following: 7/19/21 - [CONDITION(S)] section incomplete; no signature. 7/12/21 - [CONDITION(S)] section incomplete; no signature. 7/7/21 - [CONDITION(S)] section incomplete. 7/21/21 - [CONDITION(S)] section incomplete; no signature. 6/30/21 - [CONDITION(S)] section incomplete. No [CONDITION(S)] Communication Sheets were found for 7/9/21, 7/14/21 and 7/19/21. Review of Pre- and Post-[CONDITION(S)] Communication Record revealed documentation for 6/30/21, 7/5/21, 7/7/21, 7/12/21; no documentation noted for 6/28/21; 7/2/21; 7/14/21; 7/16/21; 7/19/21. Resident #78 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Quarterly MDS dated [DATE] revealed Resident #78's Brief Interview for Mental Status score was seven (7) indicating the resident was moderately impaired in cognitive skills for daily decision-making. He/she was assessed as requiring supervision of one person for bed mobility, dressing, toilet use and personal hygiene, independent with supervision for eating and the physical help of one staff in part of bathing activity. He/she was assessed has having no range of motion limitations in the upper or lower extremities. He/she was assessed as occasionally incontinent of bladder and always continent of bowel. He/she received a scheduled pain medication regimen. He/she had no swallowing disorders and no significant weight loss/gain. Resident #78 was at risk for developing pressure ulcers but has no unhealed pressure ulcers. He/she received [CONDITION(S)] while a resident. Review of Care Plan initiated on 9/16/19 and revised on 4/29/20 revealed: Focus: Resident #78 needs [CONDITION(S)] r/t renal failure Goals: The resident will have immediate interventions should any s/sx of complications from [CONDITION(S)] occur through the review date. Target date: 9/9/21 The resident will have no S/S of complications from [CONDITION(S)] through the review date. Target date: 9/9/21 Interventions: - Vital signs per protocol. Notify MD of significant abnormalities. - check and change dressing daily at access site. Document. - diagnostic work as ordered. Report results to MD and follow-up as indicated. - do not draw blood or take B/P in arm with graft. - encourage resident to go for the scheduled [CONDITION(S)] appointments. - monitor for dry skin and apply lotion as needed. - monitor intake and output. - report to MD PRN for s/sx (signs/symptoms) of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. - report to MD PRN for s/sx of the following: bleeding, hemorrhage, bacteremia, septic shock. - report to MD PRN new/worsening peripheral [CONDITION(S)]. - report to MD s/sx of infection to access site: redness, swelling, warmth or drainage. - work with resident to relieve discomfort for side effects of the disease and treatment. (cramping, fatigue, headaches, itching, [CONDITION(S)], bone demineralization, body image change and role disruption.). Review of Resident #78's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed orders for monitoring vascular access added on 7/22/21 after Surveyor intervention. Review of Nurses Notes from November 2019 to July 2021 revealed: 3/5/21 - Nurses Note: heard resident yelling, looked down hall and noted resident coming down the hall bleeding from shunt. pressure was applied until bleeding stopped and new pressure dressing applied. resident stated it was bleeding through the dressing and then it came off. resident was assisted back to his room. voices no C/O (complaint of) at this time. NP (Nurse Practitioner) made aware 3/5/21 - Nurses Note: received return call from NP; new order for HGB (Hemoglobin) x 1, lab drawn from right hand x 1 stick; resident tolerated well. RP (Responsible Party) informed. 4/16/20 - Nurses Note: Return from Nephrology for fistulagram. Dressing clean and intact, no signs of bleeding. 3/30/20 - Nurses Note: Resident returned from [CONDITION(S)] at 1545. No s/s (signs/symptoms) of pain or discomfort stated or noted. Dressing dry and intact. 1/24/20 - Nurses Note: Surgical site of left arm ( Fistula) checked Dressing noted intact with no drainage noted. Denied pain or discomfort. No documentation noted of ongoing monitoring and care of the resident's vascular access (fistula, graft, or central venous catheter). Review of Resident #78's June 2021 and July 2021 Medication Administration Records (MARs) revealed no documentation of ongoing monitoring of the resident's vascular access (fistula, graft or central venous catheter). Review of the facility's Pre- and Post- [CONDITION(S)] Communication Records revealed no documentation for the following days: No Pre- or Post- [CONDITION(S)] Communication Record for 7/19/21, 7/14/21, 7/9/21, 7/5/21, 6/25/21, 6/21/21, 6/18/21, 6/16/21, 6/11/21, 5/28/21, 5/26/21, 5/24/21, 5/19/21, 5/14/21, 5/5/21, 4/30/21, 4/26/21, 4/21/21, 4/12/21, 4/7/21, 3/26/21, 3/24/21, 3/10/21, 3/5/21, 3/1/21, 2/24/21, 2/19/21 No Post-[CONDITION(S)] Communication Record for 6/9/21, 5/17/21, 5/7/21, 4/14/21, 3/22/21, 3/19/21 No Pre-[CONDITION(S)] Communication Record for 6/7/21, 5/10/21. Review of the facility's [CONDITION(S)] Communication Sheets revealed no documentation for the following days: 7/16/21, 7/9/21, 6/25/21, 6/23/21, 6/16/21, 6/14/21, 5/24/21, 5/21/21, 5/19/21, 5/5/21, 3/31/21, 3/17/21, 3/8/21, 2/24/21, 2/19/21, 2/3/21. Interview on 7/22/21 at 12:00 p.m., RN - Unit Manager #1 stated when a resident goes to [CONDITION(S)], a [CONDITION(S)] Communication Sheet is completed and sent with them. He/she stated the top section of the sheet is completed by the facility and the bottom should be filled out by the [CONDITION(S)] center. He/she stated most of the time, We are lucky if it returns back. He/she stated if the sheet does not come back with the resident or is not completed by the [CONDITION(S)] center, the nurses are to call and get the information. He/she stated, after the sheet is completed, the nurse is to go into Point Click Care and complete the Pre and Post Communication Record. He/she stated this should be done for each day the resident goes to [CONDITION(S)]. He/she stated as for daily care, the nurses should be monitoring the site and checking for thrills and bruits. He/she stated Resident #78 has a [CONDITION(S)] fistula and Resident #72 has a catheter. He/she stated the monitoring and checking should be documented on the MARS (Medication Administration Record. RN - Unit Manager #1 looked into Point Click Care for the documentation but was unable to find any. He/she stated he/she thought the night shift was responsible for monitoring and documenting regarding the residents' vascular access sites. Interview with the DON on 7/22/21 at 1:40 p.m. revealed the nurses should be monitoring the resident's vascular sites daily. He/she stated documentation should be done on what they found. He/she stated vital signs should be taken. He/she stated this is what s/he knows regarding taking care of [CONDITION(S)] fistulas and catheters. He/she stated he/she will in-service the nurses and develop a PIP (Performance Improvement Plan) regarding [CONDITION(S)].

Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent residents from falling. The facility was unable to develop precise fall-prevention interventions for residents at risk of falls, impaired mobility, and inability for self-care. Resident #1 fell from the bed and suffered a [MEDICAL CONDITION] after being turned to (his/her) left side and left unsupervised for a short period. Resident #2 fell from the bed and suffered a laceration to the forehead. This included two of four sampled residents reviewed for accidents. Findings: The facility admitted Resident #1 on 2/20/2020 with [DIAGNOSES REDACTED]. The facility incident report stated that Resident #1 experienced a fall from bed resulting in a left femur fracture. The Minimum Data Set (MDS) assessment dated [DATE] and reviewed 3/20/2020 at approximately 9:00 AM, revealed that Resident #1 scored a 12 (moderately impaired) in the brief interview for mental status (BIMS). The MDS required 2 or more staff to assist with bed mobility, toilet use, personal hygiene, and transfer. Care plan review on 3/19/2020 at 9:58 AM revealed that resident #1 needed assistance with activities of daily living (ADLs) and is at risk for falls related to debility, [MEDICAL CONDITION], cerebral hemorrhage, right below-the-knee amputation, acute [MEDICAL CONDITION], and [MEDICAL CONDITION]. Interventions included a mechanical lift with two or more staff assistance for transfer, Bed in the lowest position when providing care. and easy to remove clothing for toileting. Nurse's notes, reviewed on 3/19/2020 at 10:44 AM, noted that on 3/3/2020 at 4:48 PM, the licensed practical nurse (LPN) #1, called the duty Physician Assistant (PA) with a verbal report of the fall. New orders were received and processed to send resident to the hospital for evaluation of left lower extremity (LLE) related to complaints of left knee pain. In a phone interview with Certified Nursing Assistance (CNA) #1, on 3/19/20, at 1:15 PM, (s/he) stated that (s/he) went to the resident's room to answer the call light. Resident #1 requested to be turned on (his/her) left side. S/he wanted to be turned to ease bowel elimination (a brief on). The CNA turned resident to the left side with the resident's assistant. The resident pulled on the side rails, which were up during this time, to help with turning. Once the CNA turned the resident, (s/he) stepped out of the room to give the resident some privacy. A few minutes later, the CNA checked on the resident and asked (his/her) if she was done. The resident stated (s/he) was still trying to go. Shortly after that, the CNA heard a loud sound and the call light. S/he went into the resident's room and found Resident #1 on the floor and on her right side. When asked how the resident fell considering Resident #1's condition of missing a limb, impaired mobility, and both side-rails up. The CNA stated that (s/he) did not know. The CNA believed Resident #1 pushed the call light at the same time (s/he) fell . In an interview with the MDS coordinator and the DON on 3/20/2020 at approximately 11:00 AM, the MDS coordinator acknowledged that the information gathered during the MDS assessment was provided by nursing staff and that Resident #1 needed extensive assistance with two-plus persons for bed mobility and toilet use. The DON agreed that the resident required extensive assistance with two or more staff to assist with bed mobility and toilet use, but (s/he) believed that only applied if the resident was up and out of bed. The facility admitted Resident #2 on 7/4/2013 with [DIAGNOSES REDACTED]. The facility incident report investigation reviewed on 3/19/2020 at 11: 00 AM stated that on 1/1/2020 at approximately 10:30 AM, Resident #2 sustained a fall from bed during peri-care resulting in a laceration to left temporal regions requiring sutures. According to the facility report, the certified nursing assistant (CNA) #2 noted Resident #2's right leg to be jerking sporadically and (his/her) body turning farther on to her left side. The CNA was unable to stop the resident before falling from the left side of the bed. Care plan reviewed on 3/20/2020 at 11:16 AM revealed that Resident #2 is at risk of falls related to cognition, medications, musculoskeletal impairment, and history of falls. Fall prevention interventions included: call light within reach, two or more staff assistance with activity of daily living (ADLs), bed mobility, fluids (unless contraindicated) within reach, and frequently used items within reach. Self-care deficit and interventions related to cognitive deficits included: resistance to ADLs, weakness, Diabetic [MEDICAL CONDITION], severe DJD. The interventions required at least two staff whild providing baths and bedtime care. The progress notes, reviewed on 3/20/2020 at 11:37 AM, noted that on 1/1/2020 at 10:30 AM, Resident #2 was sent to the emergency room because staff were not able to stop bleeding without holding pressure on the laceration. The resident had lacerations to the right temporal area. The resident returned from the ER with 6 sutures to the right temporal area. In an interview with CNA #2 on 3/20/2020 at 11:45 AM, S/he stated that while performing resident care to Resident #2, the resident fell off the bed and (s/he) was not able to prevent the resident from falling. According to the CNA, (s/he) raised the resident's bed to the level (s/he) felt comfortable while providing care to the resident. S/he had all the supplies necessary within reach. The CNA was by (him/her) self, and the bed did not have side rails. After providing care to front of Resident #2's body, the CNA turned the resident to (his/her) left side and as (s/he) noticed the resident's right leg jerked. Then the resident's right leg went over the left leg, and then fell to the floor. S/he tried to grab the resident but was unable prevent the fall. S/he stated everything happened very fast. The CNA called for help and the nurse came to assist. In a phone interview with LPN #2, (s/he) stated that (s/he) heard CNA #2 calling for assistance and went to the room. When LPN#2 entered the room (s/he) saw Resident #2 face down on the floor. Resident #2 and saw the Resident bleeding from a laceration on her forehand. LPN #2 provided care and called the doctor. The resident was sent to the ER. The CNA told the LPN that (s/he) could not stop the resident from falling. In an interview with the DON on 3/20/2020 at approximately 11:05 AM, the surveyor shared concerns regarding Resident #2, who was care-planned for self-care deficit and required assistance by 2 or more staff for bathing, morning and bedtime care. During the interview the DON acknowledged Resident #2 only had one CNA performing care when the fall took place.

Based on record review and interview, the facility failed to develop and implement a resident-centered care plan to address residents with impaired mobility and self-care deficits for two of four sampled residents reviewed for accidents. Findings: The facility admitted Resident #1 on 2/20/2020 with [DIAGNOSES REDACTED]. The facility incident report stated that Resident #1 experienced a fall from bed resulting in a left femur fracture while being turn to (his/her) left side. The Minimum Data Set (MDS) assessment dated [DATE] and reviewed 3/20/2020 at approximately 9:00 AM, revealed that Resident #1 scored a 12 (moderately impaired) in the brief interview for mental status (BIMS). The MDS required 2 or more staff to assist with bed mobility, toilet use, personal hygiene, and transfer. Care plan review on 3/19/2020 at 9:58 AM revealed that resident #1 needed assistance with activities of daily living (ADLs) and is at risk for falls related to debility, [MEDICAL CONDITION], cerebral hemorrhage, right below-the-knee amputation, acute [MEDICAL CONDITION], and [MEDICAL CONDITION]. Interventions included a mechanical lift with two or more staff assistance for transfer, Bed in the lowest position when providing care. and easy to remove clothing for toileting. In an interview with the MDS coordinator and the DON on 3/20/2020 at approximately 11:00 AM, the MDS coordinator acknowledged that the information gathered during the MDS assessment was provided by the nursing staff. Based on that information, Resident #1 needed extensive assistance with two-plus persons physical assist for bed mobility and toilet use. The DON agreed the resident needed extensive assistance with two or more staff assist for bed mobility and toilet use, but (s/he) believed that that only applies if the resident was up and out of bed. The facility admitted Resident #2 on 7/4/2013 with [DIAGNOSES REDACTED]. The facility incident report reviewed on 3/19/2020 at 11: 00 AM stated that on 1/1/2020 at approximately 10:30 AM, Resident #2 sustained a fall from bed during peri-care resulting in a laceration to left temporal regions requiring sutures. According to the facility report, the certified nursing assistant (CNA) #2 noted Resident #2's right leg to be jerking sporadically and (his/her) body turning farther on to her left side. The CNA was unable to stop the resident before s/he falling fell out of the bed. Care plan reviewed on 3/20/2020 at 11:16 AM revealed that Resident #2 is at risk of falls related to cognition, medications, musculoskeletal impairment, and history of falls. Fall prevention interventions included: call light within reach, extensive assistant with two staff for the activity of daily living (ADLs) to include bed mobility, fluids (unless contraindicated) within reach, and frequently used items within reach. It also stated s/he has self-care deficit related to cognitive deficits, resistance to ADLs, weakness, Diabetic [MEDICAL CONDITION], severe DJD. The interventions included two staff to provide bath with morning and bedtime care. In an interview with the DON on 3/20/2020 at approximately 11:45 AM, (s/h) agreed that the resident needed extensive assistance with two or more staff assist for bed mobility and toilet use, but (s/he) believe that it only applies if the resident was up and out of bed.

Based on record review and interviews, the facility failed to thoroughly investigate accidents/fall injuries for two of four sampled residents reviewed for accidents/fall. Resident #1 was left unattended on a comprising position. Resident #2 acquired hematoma with laceration requiring suture while being provided activity of the daily living (ADL) care. Findings: The facility admitted Resident #1 on 2/20/2020 with [DIAGNOSES REDACTED]. The incident report reviewed 3/19/2020 stated that Resident #1 experienced a fall from bed resulting in a left femur fracture after being turned to the left side in (his/her) bed and left unsupervised. The facility admitted Resident #2 on 7/4/2013 with [DIAGNOSES REDACTED]. The incident report reviewed on 3/19/2020 at 11: 00 AM stated that on 1/1/2020 at approximately 10:30 AM, Resident #2 sustained a fall from bed during peri-care resulting in a laceration to left temporal regions requiring sutures. According to the facility incident report, the certified nursing assistant (CNA) #2 noted Resident #2's right leg to be jerking sporadically and (his/her) body turning farther on to her/his left side. The CNA was unable to stop the resident before falling from the left side of the bed. The review of the facility five-day follow-up report on 3/20/2020 at 10:35 AM indicated that the form was not completed as required. It said see attachments in multiple places. The witness statements begin with leading questions. Such as, was the call light in reach? Yes, was the bed rail up? Yes. The staff involved in the incidents were not suspended pending an investigation, nor were they reeducated. Fall prevention interventions were not included in the report. In an interview with the DON on 3/20/2020 at approximately 11:05 AM, s/he confirmed that the nursing staff were not suspended pending during investigation, and reeducation was conducted after the fall/incident.

Based on observation, record review, and interview, the facility failed to store food in accordance with professional standards for food service safety for 1 of 2 kitchens. Specifically, the facility failed to store cold food items at less than 41 degrees Fahrenheit (F). The findings included: The satellite kitchen was observed on 11/23/19 at 8:30 AM. The tall refrigerator, near the steamtable, had a temperature of 48 degrees F. The satellite kitchen was observed on 11/24/19 at 12:35 PM. The refrigerator temperature was 48 degrees F. The satellite kitchen was observed again on 11/25/19 at 7:03 AM. The refrigerator temperature was 48-50 degrees F. The refrigerator contained two large trays of milk cartons; sandwiches; sliced cheese; glasses of juice; and glasses of thickened milk products. Tray line for breakfast meal started at 7:10-7:15 AM. Tray line ended at 8:10 AM. At 8:10 AM., the food service director (FSD) tested the temperature of two items in the refrigerator. A glass of thickened milk had a temperature of 55 degrees F. A pimento cheese sandwich had a temperature of 47 degrees F. The FSD said the temperature was as low as 45 degrees F for the sandwich. The FSD said they placed items into the refrigerator prior to meal service. The registered dietitian (RD) was interviewed on 11/25/19 at 8:40 AM. She said she completed a sanitation inspection monthly. She said she was not aware of the refrigerator temperatures running high. She said she was not aware the food items needed to be served at proper temperature throughout meal service. At 8:50 AM, the refrigerator temperature was 50 degrees F. There were three thermometers in the refrigerator. The one on the left side measured 50 degrees F. The one in the back measured 48 degrees F. The outside thermometer measured 44 degrees F. The executive chef (EC) was interviewed and he said he was not aware food items needed to be served at the proper temperature. Review of (MONTH) 2019 temperature log revealed the following refrigerator temperatures: -10/21/19: 44 degrees F for the AM temperature -10/29/19: 42 degrees F for the AM temperature Review of the (MONTH) 2019 temperature log revealed the following refrigerator temperatures: -11/1/19: 45 degrees F for the AM temperature -11/8/19: 45 degrees F for the AM temperature -11/23/19: 46 degrees F for the AM temperature

Based on observation, record review, and interview, it was determined the facility failed to provide meaningful activities to 3 of 3 residents reviewed for activities in the secured unit (Residents #52, #39, and #70). The facility identified 19 residents who resided in the secured unit. The findings included: 1a. Resident #52 had [DIAGNOSES REDACTED]. The resident's current care plan, last updated 06/05/19, documented the resident had little group and one on one activities related to decreased social interactions. It had documented interventions that included explain to the resident the importance of social interaction, leisure activity time, and encourage participation in activities. It further documented the facility would explore past interest and encourage participation in those activities. An activities evaluation, dated 03/13/19, documented the resident enjoyed religious activities, painting, tinkering with old cars, exercise, and sports. The evaluation documented the resident enjoyed small group activities, 1:1 activity, and would self-recreate in the afternoon. A quarterly Minimum Data Set (MDS) assessment, dated 09/09/19, documented the resident's cognition was severely impaired, usually made self-understood and was able to understand others. The resident required one-person extensive assistance with bed mobility, walking, locomotion, and dressing. The resident required two-person extensive assistance with transfers. 1b. Resident #39 had [DIAGNOSES REDACTED]. The Admission MDS assessment, dated 01/04/19, documented it was very important for the resident to choose bed time, have family and friends involved in care, use the phone in private, read, and do favorite activities. An activities evaluation, dated 08/01/19, documented the resident enjoyed games, movies, TV, music, and talking. It further documented the resident would self-recreate in the morning. A quarterly MDS assessment, dated 09/16/19, documented the resident was severely impaired with cognition, and required extensive assistance with bed mobility, transfers, and dressing. The resident's current care plan, last updated 09/18/19, documented the resident had little group activity involvement and enjoyed self-initiated activities such as reading all kinds of books and listening to classical music. It had documented interventions that included explain to the resident the importance of social interaction, leisure activity time, and encourage participation in activities. It further documented the facility would explore past interest and encourage participation in those activities. 1c. Resident #70 had [DIAGNOSES REDACTED]. An activities evaluation, dated 01/08/19, documented the resident enjoyed community outings, cooking/baking, cultural events/news, exercise/sports, family/friends, reading/writing, and religious activities. A quarterly MDS assessment, dated 10/07/19, documented the resident's cognition was severely impaired. The resident required two-person extensive assistance with bed mobility, transfers, dressing, and toilet use. The current care plan, last updated 10/10/19, documented the resident was at risk for activity deficit. It further documented the resident required visits to build rapport and develop opportunities to increase activity involvement. The resident enjoyed religious functions and cleaning up around the unit and moving things from place to place. The interventions included to offer mentally stimulating activities to help maintain cognitive strengths such as religious functions, singings, and socials. On 11/23/19 at 9:40 AM, Residents #52, #39, and #70 were observed in the common area of the secured unit while a movie was playing. The residents were observed sleeping while the movie was playing. No staff was observed engaging the residents in attempts to awaken them and/or provide any meaningful activities. On 11/23/19 at 10:03 AM, the activities aide attempted to play some music and bounce a ball with the residents. No residents attempted to participate in the activity. Residents #52, #39, and #70 were not engaged in the activity and remained asleep. No staff was observed arousing the residents and attempting to engage them in the activity. After approximately five minutes, the aides shut the music off and then left the area. The residents remained asleep with no meaningful activities being provided. On 11/23/19 from 2:00 PM through 4:15 PM, the residents were observed in the secured unit. No meaningful activities were being provided. The residents sat in the common area with no music, television or any activities being provided. On 11/24/19 at 8:50 AM, Resident #52 was at the dining room table finishing his breakfast. At 8:53 AM, an aide moved the resident to the center of the common area and left him. There was no music or meaningful activities being provided to the resident. He sat in the common area in silence. Residents #39 and #70 were also in the common area in silence with no activities being provided. Residents #52 and #70 were observed closing their eyes while up in their wheelchairs. On 11/24/19 at 9:06 AM, Activities Assistant #40 was observed reading scriptures. Residents #52 and #70 remained asleep. Resident #39 was across the room and not engaged in the activities. Staff did not attempt to awaken the residents and/or encourage participation in the scripture reading. On 11/24/19 from 9:06 AM through 9:50 AM, the residents remained in the common area, asleep and not participating in the activities. No staff was observed providing meaningful activities to the residents. On 11/24/19 at 9:50 AM, Activities Assistant #40 asked the residents if they wanted to attend the Sunday school starting at 10:00 AM. When Residents #52 and #32 did not awaken and respond, they were not awakened and/or taken to the activity of Sunday school. The residents remained in the common area while Sunday school was provided in the chapel. On 11/24/19 at 10:59 AM, Certified Nurse Aide (CNA) #15 stated Residents #52, #39, and #70 were watched to see if they will participate. She stated they were not forced or really encouraged to participate if they do not. She stated the residents usually sleep during the activities. She then identified all the residents as enjoying religious or spiritual activities and they should be taken to them when they were offered. On 11/24/19 at 11:24 AM, CNA #22 stated the residents did not get anything out of the activities and most of them sleep. She then stated the residents were not encouraged to attend the church activity in the chapel and were not taken when they did not respond. She then stated it was the responsibility of the activities department to make sure the residents were provided activities they enjoyed. She then stated the current activities provided no meaning to the residents because they slept through them. On 11/24/19 at 11:49 AM, Activities Assistant #40 stated she did not force the residents to participate. She then stated the residents were kept busy during the week, but not on the weekends. She then stated the residents do sleep a lot during the activities when they were provided. On 11/24/19 at 3:28 PM, the Activities Director stated the activities that were provided in groups were not necessarily what the residents liked. She stated she noticed a problem the previous day and did not realize it was a problem.

Based on observation, interview, and record review, the facility failed to maintain infection control practices while providing care to one of two residents observed for incontinence care (Resident #56). The findings included: Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident was currently on Hospice and was receiving IM (intramuscular) injections of [MEDICATION NAME] for his UTI. The most recent Minimum Data Set (MDS), dated [DATE], coded this resident as always being incontinent and requiring total assistance from staff for all ADLs (activities for daily living). The resident had both short- and long-term memory loss. On 11/24/19 at 11:08 AM, personal care was observed that was performed by two Certified Nursing Assistants (CNAs). CNA #112 and CNA #9 washed their hands prior to beginning care and applied gloves. The perineal area was cleansed by CNA #112 while CNA #9 assisted by holding and moving the resident. When the cleansing was completed, both CNAs adjusted the resident's clothing and bed covers wearing the same gloves that they had put on prior to the care. CNA #9 gathered the dirty supplies and placed them in a trash bag. CNA #112 emptied the wash basin that was used during the care and placed it on the shelf of the resident's closet. As CNA #9 was preparing to leave the room with the trash, she removed her gloves and put them into the trash bag. CNA #112 adjusted her own clothing while still wearing the same gloves. While still in Resident #56's room at 11:20 AM, both CNA #112 and CNA #9 were asked when they removed or changed their gloves while providing care. Both CNAs replied, When we get finished. The CNAs were asked if they did not feel the dirty gloves should be changed before touching other items in the resident's room including their own clothing. CNA #112 and CNA #9 stated that they probably should have. An interview was conducted with the Director of Nurses (DON) on 11/25/19 at 4:16 PM regarding the observation of the CNAs not changing their gloves at any time while doing the incontinence care. She stated that based on professional standards of care, they should have changed their gloves when going from dirty to clean. She further stated that she would have expected them to change their gloves when they finished cleaning the resident and before touching the resident's clothes and bed covers. A copy of the facility's policies on Handwashing/Hand Hygiene (undated) and Urinary Continence and Incontinence (undated). Neither of these policies specifically addressed the changing of gloves during incontinence care. The DON stated on 11/25/19 at 4:14 PM that she did not have a policy that specifically addressed this.

Based on record review and interview, the facility failed to ensure unnecessary medications were not administered to 1 of 1 reviewed for medication administration (Resident #8). The findings included: Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. (milligrams) at bedtime. The [MEDICATION NAME] was increased to 150 mg twice daily on 5/19/19. Review of the MAR indicated [REDACTED]. During an interview on 11/20/19 at 1:17 PM, the Director of Nursing (DON) confirmed the resident received the [MEDICATION NAME] 150 mg. at 9:00 PM and again at 10:00 PM according to the MAR. The DON also confirmed that was an unnecessary medication.

Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse and establish policies and procedures to investigate any such allegations. The facility did not follow policies related to reporting and/or investigating allegations of abuse for four of twenty-one facility reported incidents reviewed (Residents #5, #2, #8, and #13). The findings included: The facility reported an allegation of resident to resident abuse involving Resident #4 and Resident #5 to the State Agency on 10/23/18. A Certified Nurse Aide (CNA) observed Resident #5 inappropriately touching Resident #4. Review of the facility's Brief Summary revealed on 10/23/18 a CNA reported to nursing staff that as s/he was walking by room s/he witnessed Resident #5 with his/her hand up Resident #4's shorts making a rubbing motion. Resident #5 was removed from the room and nursing staff was alerted of the incident. Resident #4 was interviewed and denied any inappropriate behavior/touching from Resident #5. Resident #5 was reassigned to another room post incident. Resident #5 was unable to state what had occurred but did state I won't do it again, I just want to go back to my room, I am sorry. The facility notified the residents responsible parties, physician and police of the the incident. Review of the facility's files revealed there were no other statements included in the investigative file for the incident. The surveyor asked facility staff if there were any additional statements obtained. The facility provided an additional statement by Licensed Practical Nurse (LPN) #1 that indicated s/he did not witness the incident. Review of the Unit 1 Assignment Sheet for 10/23/18 revealed there were 2 nurses and 3 CNAs assigned to the unit at the time of the incident. In an interview with the administrator and Social Services #1 on 11/20/19 at approximately 3:15 PM they stated the only statement was from the CNA who witnessed the incident and LPN #1. They stated the incident occurred on Unit 1. At 3:45 PM the surveyor talked with the administrator about the facility's policy which indicates to interview all staff who worked with resident at time of alleged incident. The administrator stated they only interviewed witnesses to the incident. Informed administrator that policy states to interview witnesses but also to interview staff who have worked with resident during period of the alleged incident. The facility reported an allegation of physical abuse of Resident #2 by physical therapist #1 to the State Agency on 8/20/19. Review of the Five Day Follow-Up Report dated 8/26/19 revealed at approximately 2:05 PM on 8/20/19 Resident #2 reported to LPN #2 that an older physical therapist lady had entered his/her room and provided care to him/her and then drug him/her out of bed. Resident #2 stated the therapist was hateful, mean and rough with him/her. Resident #2 further stated (s/he) hurt me and jerked me up. Physical therapist was immediately identified and suspended pending further investigation. Two witnesses were listed: physical therapist #1 and Resident #2's roommate. The facility interviewed Resident #2 on 8/20/19 and s/he stated the incident occurred the morning before. Resident #2 stated s/he did not report the incident to any staff. Resident #2 indicated the therapist came into his/her room and started tossing and turning him/her back and forth in the bed. The therapist was putting on his/her clothes. Resident #2 stated s/he told therapist s/he didn't want to get up but s/he put him/her in the chair anyway and took him/her to the hallway. The facility interviewed Resident #2's roommate on 8/21/19. The roommate stated s/he had no concerns with staff in the facility and they are nice. Resident stated s/he was not aware of any type of incident with Resident #2. The surveyor noted that there was no documentation that the roommate was in the room at the time of the alleged incident. The facility interviewed physical therapist #1 on 8/20/19. Physical therapist #1 indicated s/he provided care to Resident #2. S/he dressed the resident and assisted him/her into his/her wheelchair. Physical therapist #1 stated Resident #2 did state s/he did not want to get out of bed. After physical therapist #1 began encouraging Resident #2 s/he agreed to get up in the wheelchair and go to the nurses' station, but did not want to go to the therapy department. Physical therapist #1 stated Resident #2 did not ask him/her to stop changing or dressing him/her. In an interview with the surveyor on 11/18/19 at approximately 1:15 PM, the Director of Nursing (DON) stated s/he may have some other interviews in his/her file. The DON reviewed the investigative file provided to the surveyor. There were three witness statements in the investigative file: physical therapist #1, Resident #2, and Resident #2's roommate. Review of Resident #2's Physical Therapy Treatment Encounter Notes for (MONTH) 2019 revealed physical therapist #1 worked with the resident only 1 time during the month on 8/19/19. Resident #2 was noted with 10 encounters during the month of August. In an interview with the surveyor on 11/18/19 at approximately 1:35 PM the DON stated s/he did not interview any other staff related to the allegation of abuse. When asked why s/he did not interview staff on duty at the time of the alleged incident the DON did not respond to the surveyor. The DON stated s/he interviewed Resident #2, the resident's roommate and the physical therapist. The DON stated s/he interviewed three other residents related to the abuse allegation. The DON stated s/he picked the three residents because they go to therapy. The DON stated s/he was not sure if they had therapy with physical therapist #1 or another therapist. The DON stated they assign residents to therapists randomly and s/he did not pick residents to interview based on if they were assigned to and received therapy from physical therapist #1. The DON stated s/he did not interview any other staff related to the allegation. The surveyor reviewed witness statements for the residents interviewed and all were asked how staff treats them and if they had any concerns with the therapy staff. Review of the Staff Assignment sheet for 8/19/19 revealed there were two nurses and four CNAs on duty on Unit 2, where the resident resided, at the time of the alleged incident. LPN #2 was not one of the two nurse working on the unit at the time of the alleged incident. Review of the facility's Abuse Prevention Program Policy Interpretation and Implementation revealed a section for Abuse Investigations. The policy indicated under 16. The individual conducting the investigation will, at a minimum: .Interview the person(s) reporting the incident; Interview any witnesses to the incident; Interview the resident (as medically appropriate); Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; Interview the resident's roommate, family members, and visitors On 11/19/19 at approximately 2:10 PM, review of the medical record revealed Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. On 11/19/19 at 3:55 PM, review of the Nursing Progress Notes revealed a note dated and timed 5/18/2019 14:20 stating Nurse from Unit 2 called and reported to Nurse that resident was inappropriately touching two residents on that unit. Nurse went to get resident from Unit, when nurse noted that resident was on the way back to Unit 1. Resident is currently sitting at the nurses desk (1430) with Nurses on Unit 1. At 17:18 PM, the nurse notified the Physician Assistant and an order received for [MEDICATION NAME] 150 mg (milligrams) twice a day. Review of all of the reportable incident files provided by the facility upon entrance revealed no file related to the incident involving Resident #8 and two other residents on unit 2 on 5/18/19. The reportable file was requested from the Administrator and the Director of Nursing at approximately 5:00 PM on 11/19/19. During an interview on 11/20/19 at 8:50 AM, the DON confirmed they did not have a file and that the 5/18/19 incident was not reported to the State Agency. The DON further confirmed there was no investigation and stated the facility took all allegations of abuse seriously but they had not been informed of the incident occurring on 5/18/19 until the surveyor informed them on 11/19/19. S/he confirmed the policy had not been followed. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Five-Day Follow-Up Report dated 10/04/19 revealed no documentation that the Five-Day Follow-Up Report was submitted to the State Bureau of Certification. During an interview on 11/20/19, the DON confirmed the documentation indicated the report was faxed to the Bureau of Health Licensing in error and was not to the Bureau of Certification. The Director of Nursing also confirmed the facility did not follow its policy related to reporting. Review of the facility's policy entitled Abuse Prevention Program, page 3, revealed 5. When alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, DON (Director of Nursing), or individuals designated will immediately (not to exceed 24 hours if the event does not result in serious bodily injury. NO LATER THAN 2 HOURS IF THE EVENT IS AN ALLEGATION OF ABUSE OR WHERE THERE IS SIGNIFICANT INJURY, OR NEGLECT WHERE THERE IS SERIOUS BODILY INJURY) notify the following persons or agencies of such 1. The State licensing/certification agency responsible for surveying/licensing the facility; .

On the days of the complaint survey, based on record review, review of the policy for the D.P. "Jabbo" Folk Special Care Unit, criteria for transfer/ discharge and interview, the facility failed to ensure that each resident received adequate evaluation for transfer from a special care unit and supervision/assistance devices to prevent accidents. Resident #1 was transferred from a secure care unit without an adequate assessment and fell after exiting through an unmonitored door that led to a dark courtyard. The findings included: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. 2." Review of the Room Change Notification form dated 8/20/13 indicated Resident #1 moved from the secured unit to Unit 2 because s/he no longer met the criteria for the secured unit. Further review of the form revealed the resident representative notified section was completed but the Doctor notified section was not completed. Review of the Nurse's Notes dated 8/20/13 indicated that Resident #1's responsible party was called "...concerning needing to make room changes in Folk (secure) unit. At present, resident not exit seeking, but at x's (times) will wander..." Review of the Physician's Telephone Orders dated 9/8/13 revealed an order at 9:10 PM "steri-strips to laceration forehead. Transfer to Unit 3." There was another order on 9/8/13 at 10:00 PM to transfer to Newberry Hospital. Review of the facility's Report of Incident/ Accident form dated 9/8/13 indicated, "CNA (Certified Nurse Aide) came to me and asked if I knew where resident was. I asked if dining room door to courtyard was locked. S/he opened the door and we saw resident sitting on sidewalk approximately 20-30 feet from door." The Report of Incident/ Accident form indicated the time of the incident was 8:50 PM. During an interview with the surveyor on 9/17/13 at approximately 4:15 PM CNA #1 stated that on 9/8/13 s/he started looking for Resident #1 to get him/her ready for bed. RN (Registered Nurse) #1 asked CNA #1 if the door to the courtyard was open. They found Resident #1 sitting on the sidewalk outside waving his/ her arms asking for help. CNA #1 stated that it was dark in the courtyard when they found Resident #1. CNA #1 also stated that there was no code box or alarm on the door leading to the courtyard at the time of the incident. During a telephone interview with the surveyor on 9/17/13 at approximately 7:10 PM RN #1 stated that s/he had worked at the facility for approximately 6 weeks and covered all units. RN #1 stated that s/he had not paid attention to the door to the courtyard before. When CNA #1 asked if s/he had seen Resident #1 s/he asked the CNA if the door to the courtyard was locked. CNA #1 stated no so they checked outside and found Resident #1. Review of the Wander Data Collection Tool revealed Resident #1 was assessed for wandering on 5/13/13, and 8/29/13. During an interview with the surveyor on 9/18/13 at approximately 12:05 PM Licensed Practical Nurse (LPN) #1 stated that the nurse from Unit 3 (secure unit) came to Unit 2 and told her/him to discharge Resident #1's wanderguard. LPN #1 completed the Wander Data Collection Tool at that time. Review of Resident #1's Physician's Telephone Orders revealed an order on 8/29/13 at 8:30 AM to discharge wanderguard. During an interview with the surveyor on 9/17/13 at approximately 5:20 PM the facility Administrator stated that there was no wanderguard box on the courtyard doors. The Administrator stated that alarms were added to the courtyard doors after the incident on 9/8/13. During interview on 9/18/13 at approximately 12:10 PM the Administrator stated that there was another resident in the facility who was wandering and exit seeking. There were no beds available in the secure unit and the Interdisciplinary team felt it was safe to transfer Resident #1 off the secure unit because s/he was not wandering. The surveyor asked the Administrator for documentation related to the assessment for Resident #1 to be moved off the secure unit and the conference with the family. The Administrator provided notes from the clinical morning meeting dated 8/21/13 that only indicated that Resident #1 transferred to Unit 2. Review of Resident #1 care plan revealed risk for altered protection related to wandering behavior was identified as a problem area on 11/28/12. Interventions and approaches to this problem area were documented on the care plan and included allow for safe wandering. The care plan was updated after the resident was injured on 9/8/13 to include monitor every 15 minutes for 24 hours. The update on 9/8/13 was the only update noted on the care plan. Review of the facility's policy for the D.P. "Jabbo" Folk Special Care Unit revealed criteria for transfer/ discharge from the Folk Unit. The criteria included "Resident's medical, emotional and/ or mental status becomes more stable and nursing personnel and resident's attending physician feel resident's quality of life would be enhanced by placement in another area of the facility. This information would be shared via a conference with the family member/ significant other/ responsible party and the transfer made as soon as placement would be available." The surveyor asked the facility Administrator for documentation related to the alarms that were added to the courtyard doors. A receipt was provided from Lowe's dated 9/11/13 at 3:56 PM for 2 Techko Security Alarms.

On the days of the Recertification Survey, based on observation, record review and interviews, the facility failed to recognize, evaluate and manage pain related to pressure ulcer treatments for Resident #2.Resident B recieved medication mixed with water rather than apple juice as ordered by the physician. ( 2 of 12 sampled residents reviewed for necessary care and services) The findings included: The facility admitted Resident #2 on 12/13/10 with [DIAGNOSES REDACTED]. During observation of a pressure ulcer treatment on 3/15/11 at 10:00 AM, Licensed Practical Nurse )LPN) #6 failed to recognize, assess and treat the resident who exhibited both verbal and non-verbal indicators of pain. At 10:03 AM, as LPN #6 began to remove the foam dressing from the wound bed, Resident #2 yelled out and pulled back his foot. LPN #6 continued with the removal of the soiled dressing. At 10:07 AM, as she began to clean the wound bed, the resident again pulled back his foot, kicked and yelled out to "leave it alone." As LPN #6 applied the medicated ointment and re-dressed the wound, Resident #2 continued to kick and yell. At no time did LPN #6 attempt to stop the treatment, ask the resident if he was in pain or offer the resident pain medication. Review of the March Documentation Record revealed the resident had received [MEDICATION NAME] only 1 time during the night shift for the month of March. During an interview with LPN #6 on 3/15/11 at approximately 10:20 AM, she stated she had given the resident [MEDICATION NAME] at approximately 8:00 AM due to a history of resistance during treatments, baths and other care. She confirmed that she had not given him any medication for pain. LPN #6 further verified she had not tried pre-medicating the resident for pain prior to initiating treatments to reduce resistance but further stated that the treatment was usually done on the night shift when resident was just waking and was more compliant. LPN #6 confirmed that a pressure ulcer such as the resident's was most likely painful and stated that, now that it had been brought to her attention, she thought the resident was probably experiencing pain with his treatments. On 3/15/11 at approximately 3:30 PM, the Director or Nursing (DON) stated is sounded as the the resident "was telling her to stop." The DON also verbalized that she would have expected the nurse to stop the treatment, attempt to calm the resident and notify the Physician and the Responsible Party She stated she would expect the nurse to medicate the resident for pain. She further verified that the resident "should have something more than Tylenol for pain" and that the Physician would be contacted for additional orders for pain medication. During an interview on 3/15/11 at 2:00 PM, Resident #2's Responsible Party stated she thought some of resident's agitation was "because he hurts," especially with dressing changes and catheter care. She stated she thought he should have pain medication prior to his dressing changes. On 3/14/2011 at 9:49 AM, LPN #3, administered Polyethylene [MEDICATION NAME] 17 Gram/1 dose powder ([MEDICATION NAME]) 1/2 capful to Resident B. The LPN mixed the Polyethylene [MEDICATION NAME] ([MEDICATION NAME]) in water. Review of the physician's orders [REDACTED]. On 3/14/2011 at 10:22 AM, in an interview with LPN #3, she did not dispute the above observation.

On the day of the inspection, based on record review, interviews, and review of facility files, the facility failed to ensure that services provided by the facility met professional standards of quality for 1 of 1 resident who developed redness, swelling, pain, and an open area under a [MEDICATION NAME] dressing that was not changed for 23 days (Resident #1). Facility staff failed to ensure the resident's treatment order was carried forward to the new month, and failed to thoroughly assess and accurately document the resident's changing skin condition. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The physician found an occlusive dressing on the right lateral ankle dated 09/27/10. There was pus underlying the dressing and an infected open area measuring 1 X 1 cm (centimeter) surrounded by a 3 by 3 cm area of [MEDICAL CONDITION]. The physician ordered wet to dry dressings, and antibiotic treatment with [MEDICATION NAME] 250 milligrams three times a day for ten days. Review of the medical record and the facility's investigative materials revealed none of the staff providing care to the resident (five nurses and thirteen nursing assistants), from 9/27/10 to 10/22/10, noticed the unchanged dressing and the developing decline in the resident's skin condition. CNAs (Certified Nursing Assistants) doing daily skin inspections noted the resident's skin was "clear." Licensed staff documented on the weekly body audits that the resident had a callus on her right ankle. The licensed staff failed to update the monthly cumulative orders for October 2010 to show the dressing change order for [MEDICATION NAME] to the right ankle every three days. This order was initiated on 6/30/10. Licensed staff failed to realize the omission of the order and therefore, failed to provide the resident with the treatment. The staff also failed to provide the appropriate care and ongoing assessment required to manage the resident's skin care. Cross refer to F-314 related to the facility's failure to assess the resident and failure to provide care and services to prevent development of an open area and infection of the site.

On the day of the inspection, based on record review and interview, the facility failed to ensure that a resident received treatment to promote healing, prevent infection, and prevent new sores from developing for 1 of 1 resident reviewed who developed an infected sore when facility staff left a protective dressing in place from 9/27/10 to 10/22/10 (Resident #1). The resident did not have her dressing changed because the treatment order was omitted from the October 2010 orders and treatment record. Facility staff failed to recognize the omission. As the resident's ankle declined in condition, the staff failed to thoroughly assess and accurately document her condition in the medical record. The daily skin inspection and weekly body audit documentation showed no changes in the condition of the resident's ankle. These failures lead to a lack of appropriate interventions. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The physician's progress note, dated 10/22/10 and signed on 11/18/10, stated he found an occlusive dressing on the right lateral ankle "which was dated 09/27 and had pus underlying the dressing." Under the dressing was "a 3 X 3 cm (centimeter) stage 2 ulceration and a 1 X 1 cm stage 3 ulceration with surrounding [MEDICAL CONDITION]." The physician ordered wet to dry dressings, and antibiotic treatment with [MEDICATION NAME] 250 milligrams three times a day for ten days. According to the physician's progress note, it was his understanding the Wound Care team was assessing this wound at least weekly. The physician wanted to know why the dressing had "apparently not been changed for 23 days." He showed the wound to the Unit Manager and wanted to know why the dressing had not been changed. The facility began an investigation to answer the physician's questions. Review of the medical record revealed the resident had an ulcer on her right lateral ankle in February 2010. The pressure ulcer was treated with antibiotics for two weeks and wet to dry dressings for one month. The ulcer healed. Review of the medical record revealed the resident had [MEDICATION NAME] cream applied to her knees twice a day by the licensed staff. Review of the Nurse's Notes showed the resident complained of pain in the right outer ankle on 5/8/10 while receiving her treatment to her knees. The nurse observed a raw area on the ankle and applied barrier ointment. The resident continued to sporadically complain of pain in her ankle. On 5/23/10, a hard callus was observed on the right outer ankle with no open area or redness. On 6/30/10, the physician ordered "[MEDICATION NAME] applied to (R) lateral ankle every 3 days" for treatment. He also ordered padded boots. Review of the physician's progress note of 9/25/10 showed no evidence of a pressure ulcer on the resident's right lateral ankle. Review of the C.N.A. (Certified Nursing Assistant) Daily Skin Inspection Record showed "clear" results for September 1 - 31, and for 10/1 - 22/10. Review of the Body & Skin Audits done by the licensed staff showed results of "callus to R ankle " on 9/1/10, 9/8/10, 9/15/10, and 9/22/10. The body audit on 9/29/10 revealed a checkmark next to "Red/Broken Areas" under the heading ANKLES. The word Red was circled and a handwritten note "(R) ankle Tx (treatment) in progress" was to the side. The body audit on 10/6/10 showed "callus to (R) ankle." On 10/13/10, the audit showed a checkmark by "normal" under the heading ANKLES with a noted under "Abnormal Explanation:" stating "callus to (R) ankle - tx in process." The body audit of 10/20/10 showed "normal" ANKLES with "callus to (R) ankle" written next to that finding. Review of the Nurse's Notes revealed no documentation of the discovery of the ankle ulcer on 10/22/10. The nurse's entry stated the physician made rounds and ordered new treatment. There was no description of the area or notation of the old dressing found on the resident's ankle. Review of the Skin Condition Report showed documentation beginning on 10/22/10 for a right outer ankle ulcer measuring 1.2 cm by 2 cm with a light amount of serous foul smelling drainage. The surrounding area was red, warm, swollen, and tender to touch. Documentation on 10/27/10 showed the resident was in less pain. The ulcer measured 1 by 0.8 cm. No swelling was noted but a slight amount of serous drainage continued. On 11/5/10, the ulcer measured 1 by 1 cm. Treatment was changed to using Santyl daily. The Skin Condition Report for 11/10/10 showed the resident's ulcer was 1.5 by 1.5 cm with a central area measuring 0.8 by 0.8 cm. Review of the Weekly Wound Tracking Worksheet showed the resident's wound was designated an open callus. The physician's progress note of 10/22/10 designated the wound a pressure ulcer. An interview with LPN #1 on 11/18/10 at 12:15 PM revealed she was on duty but was not the resident's assigned caregiver on 10/22/10 when the physician saw the resident. The physician called her over to the resident and asked what type of dressing was on the ankle and what date was on the dressing. The LPN went to the Documentation Record for treatments and did not see any treatment corresponding to the dressing on the resident's ankle. She observed that the dressing had bubbled. The dressing was dated 9/27 and had initials written on it. The resident's foot was swollen and red. After the physician removed the dressing, she saw an open ulcer measuring approximately 1 cm in diameter. An observation of the resident's pressure ulcer on 11/18/10 revealed a sore measuring approximately 1.5 by 1.5 cm with a central area of approximately 0.8 by 0.8 cm. covered with slough. The surrounding skin was darkened in an area approximately 4 centimeters round. There was no swelling, redness, or drainage noted. The resident briefly complained of pain when her ankle was touched and then lay quietly in between manipulations. The facility's investigation found that the resident's direct caregivers failed to accurately document her skin condition on the nursing assistant daily skin inspection and on the weekly body audits. An LPN had signed for the [MEDICATION NAME] treatment as being done on 9/30/10. During the investigation the LPN revealed the resident had refused it and she failed to circle her initials indicating the treatment was not done. The facility's investigation also showed that the treatment order was not carried forward to the October 2010 cumulative orders. Three nurses did body audits, one nurse checked the monthly orders, one nurse signed for a treatment that was not done, and thirteen nursing assistants provided direct care to the resident in the time span of 9/27/10 to 10/22/10. The nurses were terminated and the nursing assistants were all given final warnings. An interview with the Director of Nurses (DON) on 11/18/10 at 11:45 AM revealed night shift nurses were assigned to do resident body audits. The verification of monthly orders in preparation for a new month was assigned to different nurses for completion. When the DON interviewed her staff for the investigation, the nurses said they did the body audits but "didn't see" the dated dressing on the resident's ankle. The nurses also stated they did the treatments listed on the Documentation Record and did not recall the resident had a treatment to her ankle. CNAs told the DON that they "didn't see it" when she asked them about the resident's ankle. Some of the CNAs said the resident's foot was red and she complained of pain. They would tell the nurse and assumed the nurse provided medication for the pain. The DON was asked about the Wound Team. She stated the Unit Managers assessed wounds on a weekly basis and then met with the DON to report. When asked how the Unit Manager missed Resident #1's dressing, the DON stated that the resident's area was not a pressure ulcer but a callus, so the Unit Manager would not have assessed it.

On the day of the inspection, based on record review, the facility failed to ensure medical records were complete and accurately documented for 1 of 1 resident who developed an infected open area under a [MEDICATION NAME] dressing that was not changed for 23 days (Resident #1). On 11/18/10, the physician's progress note of 10/22/10 was not on the record. Facility staff failed to ensure monthly cumulative orders were complete related to treatments ordered, and failed to accurately document the resident's changing skin condition. The findings included: Resident #1 with [DIAGNOSES REDACTED]. On 10/22/10, the resident complained to the physician of pain in her ankle. While examining the resident, the physician found a [MEDICATION NAME] dressing on the ankle 9/27/10. Under the dressing was an open and infected ulcer. Review of the resident's medical record on the morning of 11/18/10 failed to show a physician progress notes [REDACTED]. The physician signed and sent his progress note for 10/22/10 via facsimile on the afternoon of 11/18/10. Review of the Nurse's Notes for 10/22/10 showed no descriptive documentation of the resident's right ankle. The redness, swelling, and open area found by the physician was not included in the nurse's note. The pressure ulcer's characteristics were documented in the Skin Condition Report, but other than the physician's progress note, the medical record did not show that a dressing dated 9/27/10 was found on the resident on 10/22/10. Facility staff failed to note the omission of the [MEDICATION NAME] treatment order on the printed cumulative orders for October 2010. Therefore, the order was not listed on the Documentation Sheet for treatments and the resident did not receive the [MEDICATION NAME] treatment 10/1-22/10. Review of the CNA Daily Skin Inspection Record and the Body & Skin Audits done by the nurses on a weekly basis revealed documentation for September 2010 and up to October 22, 2010 showing no changes in the resident's condition although she was developed swelling, redness, pain, and an open area under the [MEDICATION NAME] dressing on her outer right ankle.