Every finding on record at Lakes At Litchfield

Based on the facility policy, record reviews and interviews, the facility failed to ensure Resident (R)15 and RA received the CMS form 10055 for Medicare Part A services. Specifically R15 and RA received CMS form R-131 for Medicare Part B Services for 2 of 2 residents that were discharged from Medicare Part A services and remained in the facility. Findings include: Review of the facility policy titled, Medicare Advance Bebeficiary and Medicare Non-Coverage Notices, states as the Policy Statement, Residents are informed in advance when changes will occur to their bills. Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055). 1. If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service (s), the resident (or representative) is notified in writing whey the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). 2. The facility issues the Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) for the following triggering events: a. Initiation - In the situation in which the director of admissions or benefits coordinator believes Medicare will not pay for extended care items or services that a physician has ordered, a SNF ABN is issued to the beneficiary before those non-covered extended care items or services are furnished to the beneficiary. b. Reduction - In the situation in which the facility proposes to reduce a beneficiary's extended care items or services because it expects that Medicare will not pay for a subset of extended care items or services, or for any items or services at the current level and/or frequency of care that a physician has ordered, the SNF ABN is issued to the beneficiary before such extended care items or services are terminated. c. Termination - In the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF ABN is issued to the beneficiary before such extended care items or services are terminated. 3. The resident (or representative) is informed that they may choose to continue receiving the skilled services that may not be paid for by Medicare, and assume financial responsibility. The facility admitted R15 and RA with physician orders to receive therapy services. Both residents received the form, CMS 10023, notice of non coverage for Medicare Part A services timely. Both R15 and RA remained in the facility with Medicare Part A days remaining. During SNF Beneficiary Notification Reviews, neither resident R15 nor RA received the correct form, CMS-10055 for an appeal, for the Medicare Part A services ending and whether or not R15 or RA would like to continue the Part A skilled services for Medicare. Both residents, R15 and RA received CMS form R-131 which was for Medicare Part B services and not CMS form 10055 for part A services. During an interview on 03/10/2025 at 01:00 PM with the facility Social Service Director, she provided the forms for R15 and RA and confirmed they were the CMS-R-131 for Medicare Part B services and not the CMS-10055 that both residents should have received.

Based on record reviews and interviews, the facility failed to ensure Resident (R)1 received all medications ordered by the physician. Specifically, R1 did not receive Trelegy Ellipta (a prescription medicine used long term to treat COPD, including chronic bronchitis, emphysema, or both and to treat asthma in adults) or Linzess (a prescription medication used to treat irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) in adults) as ordered, for 1 of 1 residents reviewed for medication administration. Findings include: Review of R1's Face Sheet revealed the facility admitted R1 on 11/08/23 with diagnoses including but not limited to: chronic obstructive pulmonary disease, pneumonia, oxygen dependence, nasal congestion and constipation. R1 left the facility against medical advice (AMA) on 11/15/23. Review of R1's medical record revealed Physician Orders for Trelegy Ellipta 100 micrograms (mcgs) - 62.5 mcgs - 25 mcgs powder for inhalation, one puff one time daily. Further review of R1's medical record revealed the ordered medication was not administered on 11/09/23, 11/10/23, 11/11/23 and 11/12/23. Review of R1's Comprehensive Plan of Care indicated the following, Resident is at risk for altered respiratory status related to COPD, (chronic obstructive pulmonary disease), oxygen dependence and nasal congestion. The goal stated, resident will remain free from respiratory distress and have no unrelieved shortness of breath. The interventions included, Assess and monitor respiratory status and signs/symptoms of complications (dyspnea, rate/depth of respirations and cyanosis). Administer medications as ordered . Further review of R1's Comprehensive Plan of Care revealed the following problems, Resident is unable to maintain oxygen saturation. and Resident has potential for chronic pain and pain management related to . irritable bowel syndrome. During an interview on 11/28/23 at 11:15 AM, the Director of Nursing (DON) stated that there was a complaint that R1 has not received any medications since admission. The DON provided a copy of the Medication Administration Record (MAR) and stated R1 has received all medications as ordered except the Trelegy Ellipta and the Linzess. The DON went on to say that the nurses and the Nurse Practitioner (NP) had asked R1's family to bring in these medications. During an interview on 11/28/23 at 1:20 PM, Registered Nurse (RN) stated, the pharmacy did not send those medications because the family was going to bring them in. When the family did not bring the medications the RN stated that she spoke with the NP, but the orders were not changed or clarified. During an interview on 11/28/23 at 1:45 PM, the NP stated that she was not aware that R1 had not received the Trelegy Ellipta and the Linzess as ordered. The NP stated that she had spoken with the family to bring in the medications and was not aware they had not.

Based on interviews, record review, and facility document review, the facility failed to treat a resident with dignity and respect for 1 (Resident #2) of 8 residents reviewed for dignity and respect. Specifically, Resident #2 indicated Certified Nursing Assistant (CNA) #1 intimidated them. Findings included: A review of a Face Sheet indicated the facility admitted Resident #2 to the facility on [DATE] with diagnoses that included hypokalemia, fall, hypertension, weakness, and pain. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/11/2023, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene, was independent with setup help only for eating, and was totally dependent on staff for bathing. A review of an Initial 2/24-Hour Report, dated 05/26/2023, indicated the Administrator became aware of an allegation of verbal abuse on 05/26/2023 from the previous night (05/25/2023). On 05/25/2023 at 7:30 PM, Resident #2 alleged that CNA #1 was loudly arguing and raised her voice at the resident. Resident #2 also reported that CNA #1 took several clean towels and threw them on the floor of the resident's bathroom. After the Administrator became aware of the allegation, an investigation was initiated. A review of the undated Facility Investigation Summary Report revealed Resident #2 was alert and oriented, both pre and post incident, with a BIMS of 15. The incident occurred in Resident #2's room. CNA #1 reportedly raised her voice at Resident #2 and threw towels around the room. The facility launched a thorough and fact-finding investigation into the allegation made by Resident #2, and as a result of the investigation, the facility substantiated that CNA #1's actions constituted verbal abuse. During a telephone interview on 07/25/2023 at 8:37 PM, Registered Nurse (RN) #3 indicated Resident #2 informed him around 7:30 PM on 05/25/2023 that CNA #1 approached the resident's room and said rudely, I heard you want a shower. Resident #2 said the chalk board indicated that the resident should get a shower because it was Thursday. RN #3 said Resident #2 told him CNA #1 said she could read and was getting loud and argumentative with Resident #2. RN #3 indicated that Resident #2 said he/she did not want CNA #1 back in his/her room. RN #3 indicated he told CNA #1 that she could never raise her voice or argue with a resident. During an interview on 07/26/2023 at 9:17 AM, the Social Worker (SW) indicated the next morning (05/26/2023) CNA #6 said Resident #2 was upset about something that happened the previous night. The SW said she talked to Resident #2. The SW said Resident #2 told her that CNA #1 asked from the doorway of their room if he/she was refusing his/her shower and started throwing towels at the bathroom. The SW indicated Resident #2 directed CNA #1 to the chalk board in the resident's room where it listed shower days as Monday and Thursday. CNA #1 told Resident #1 she could read. Resident #2 reported CNA #1 was shouting at him/her. During a telephone interview on 07/26/2023 at 10:22 AM, Resident #2 indicated CNA #1 said rudely from the room doorway, I hear you want a shower. Resident #2 said he/she pointed to the chalk board in his/her room that indicated the resident's shower days were Monday and Thursday. The resident indicated that when he/she pointed to the chalk board, CNA #1 got louder. Resident #2 told the CNA she did not have to give him/her a shower with all the loud talking and screaming. Resident #2 indicated that CNA #1 had towels in her hand and threw them on the bathroom floor and marched out of the room mumbling something. Resident #2 said she reported the incident to RN #3. Resident #2 said he/she was disappointed. Resident #2 said CNA #1 had given the resident a shower before and there were no problems other than she did not do a good job. During a follow-up telephone interview on 07/26/2023 at 5:36 PM, Resident #2 indicated the resident did not feel that she/he was abused or threatened. Resident #2 said the resident felt intimidated and did not want CNA #1 to take care of him/her after the way the CNA behaved. During an interview on 07/26/2023 at 7:17 PM, the Director of Nursing (DON) indicated that it was her expectation that staff treated residents with respect and dignity. During an interview on 07/26/2023 at 7:36 PM, the Abuse Coordinator revealed that it was his expectation that staff treated residents with respect and dignity. During an interview on 07/26/2023 at 7:45 PM, the Administrator indicated that it was his expectation that staff treated residents with respect and dignity.

Based on interviews, record review, and facility policy and document review, the facility failed to ensure an allegation of verbal abuse was reported to the facility's Abuse Coordinator, Administrator, and the state survey agency within two hours of the allegation being received for 1 (Resident #2) of 8 sampled residents reviewed for abuse. Findings included: A review of a facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The Reporting Allegations to the Administrator and Authorities section in the policy revealed, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as; a. within two hours of an allegation involving abuse or result in serious bodily injury. A review of a Face Sheet indicated the facility admitted Resident #2 to the facility on [DATE] with diagnoses that included hypokalemia, fall, hypertension, weakness, and pain. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/11/2023, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene, was independent with setup help only for eating, and was totally dependent on staff for bathing. A review of an Initial 2/24-Hour Report, dated 05/26/2023, indicated the Administrator became aware of an allegation of verbal abuse on 05/26/2023 from the previous night (05/25/2023). On 05/25/2023 at 7:30 PM, Resident #2 alleged that Certified Nursing Assistant (CNA) #1 was loudly arguing and raised her voice at the resident. Resident #2 also reported that CNA #1 took several clean towels and threw them on the floor of the resident's bathroom. A review of a fax result report revealed the facility did not submit the Initial 2/24-Hour Report to the state survey agency until 05/26/2023 at 11:31 AM, which was approximately 16 hours after the allegation was made. A review of the undated Facility Investigation Summary Report revealed the incident occurred in Resident #2's room. CNA #1 reportedly raised her voice at Resident #2 and threw towels around the room. The report indicated that Registered Nurse (RN) #3 reported the incident timely to their supervisor, but their supervisor (the previous Director of Nursing) did not report the allegation timely to the Abuse Coordinator. A review of an email correspondence from the Human Resources Director to the Abuse Coordinator, dated 05/29/2023, revealed on 05/26/2023 the Abuse Coordinator became aware of an allegation of abuse that the previous Director of Nursing (DON) was notified of but had not reported to him. The email indicated the Human Resources Director and the Abuse Coordinator spoke with the previous DON about the concern of not reporting the allegation to the Abuse Coordinator, and the previous DON said she did not think it was abuse, and if she had, she would have reported it. During an interview on 07/25/2023 at 4:50 PM, the Abuse Coordinator indicated the previous DON never reported the incident to him. The Abuse Coordinator said he heard it from the Social Worker (SW) on 05/26/2023 between 8:30 AM and 9:00 AM. The Abuse Coordinator indicated that it was his expectation that staff reported abuse allegations immediately to the nurse on duty or to the DON, Administrator, or directly to the Abuse Coordinator. He indicated there was information posted throughout the facility indicating who to report abuse to with phone numbers included. During a telephone interview on 07/25/2023 at 8:37 PM, RN #3 indicated Resident #2 informed him around 7:30 PM on 05/25/2023 that CNA #1 approached the resident's room and said rudely, I heard you want a shower. Resident #2 said the chalk board indicated that the resident should get a shower because it was Thursday. RN #3 said Resident #2 told him CNA #1 said she could read and was getting loud and argumentative with Resident #2. RN #3 said he called the previous DON immediately and reported the incident, and the previous DON said she had strep throat and would handle it. During an interview on 07/26/2023 at 9:17 AM, the SW indicated the next morning (05/26/2023) CNA #6 said Resident #2 was upset about something that happened the previous night. The SW said she talked to Resident #2. The SW said Resident #2 told her that CNA #1 asked from the doorway of their room if he/she was refusing his/her shower and started throwing towels at the bathroom. The SW indicated Resident #2 directed CNA #1 to the chalk board in the resident's room where it listed shower days as Monday and Thursday. CNA #1 told Resident #1 she could read. Resident #2 reported CNA #1 was shouting at him/her. The SW said she immediately sent the DON and the Abuse Coordinator a group text notifying them of the allegation. During an interview on 07/26/2023 at 7:17 PM, the current DON indicated that it was her expectation that staff call the DON immediately for any abuse concerns and if nothing happened, to call the Abuse Coordinator. During an interview on 07/26/2023 at 7:36 PM, the Abuse Coordinator revealed that it was his expectation that staff immediately report all abuse allegations to the DON or the Abuse Coordinator and then report the allegation to the state survey agency within the required 2-hour timeframe. During an interview on 07/26/2023 at 7:45 PM, the Administrator indicated that it was his expectation that all abuse allegations be reported immediately to the nurse working on the floor and then to the DON or supervisor to give the person guidance on what to do.

Based on facility policy review, record review, and staff interviews, the facility failed to ensure 1 out of 3 Residents, (R)1, was free from abuse related to misappropriation of resident property. Specifically, R1 was involved in a forgery of a financial transaction from a staff employee, Certified Nursing Assistant (CNA)1, resulting in misappropriation of property. Findings include: Review of the facility's revised, April 2021 policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .the resident abuse, neglect and exploitation prevention program consists of a facility wide commitment . 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to . 6. Provide staff orientation and training/ orientation programs . 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Review of an undated Face Sheet on the electronic medical record (EMR), revealed R1 was admitted to the facility on [DATE] with a diagnosis of fracture head of right femur and limitation of activities due to disability. R1 was discharged from the facility on 05/16/22. Review of R1's Minimum Data Set (MDS) obtained from the EMR under the MDS tab with an Assessment Reference Date (ARD) of 05/08/22 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates R1 is cognitively intact. Review of an Accident/Incident Reporting Form of Bureau of Health Facilities Licensing, 10 Day Report provided by the facility and dated 06/01/22, indicated a neglect or exploitation, suspected or confirmed abuse, took place on 05/16/22 between R1 and CNA1. The 10-day report indicates that, On 05/16/22 resident made allegation that someone had used her personal credit card located in her room to make approximately $1,400 worth of purchases. Facility immediately reported it to Georgetown County Sheriff's office, DHEC, and Ombudsman. Facility submitted follow up report on 05/22/22 to the department stating the facility was unable to substantiate the allegations based on internal investigation but overall investigation was pending outcome from GCSO's investigation. GCSO came to facility today (06/01/22) and reported that their investigation of bank records showed that [name of CNA 1], facility CNA, made the fraudulent charges. GCSO arrested [name of CNA1] on those charges and allegation was officially substantiated. Review of an, Incident Report, provided by the Georgetown County Sheriff's Department on 05/16/22, Case number 22014042, entails that, On May 16, 22 at 11:41 AM, I [Name of Officer] responded to 120 unit 407 Lakes of [NAME] Dr in Pawleys Island Area of Georgetown County in regards to a fraud call. Upon Arrival I met with the male complainant who is the husband and he states that his wife's South State Bank debit card number had been used in several unauthorized transactions within the past several days. The complainant tells me that he was notified by his bank that his wife's debit card had some activity and when he checked her bank account statement, he noticed approx six unauthorized charges. This deputy was informed that the female victim/wife had been in the skilled unit of Lakes of [NAME] since May 02, 22. Review of an undated copy of R1's bank charges that were frauduantly made include: 05/12/22 $126.00 to Southern Finance, 05/12/22 $133.40 to World Finance, 05/12/22 $382.70 to World Finance, pending date $203.98 to Geico, pending date $444.28 to Geico, pending date $239.80 to [NAME] Electric, totaling $1530.22. Review of a facility provided witness statement on 05/16/22 referenced, The following employees verbally stated they have no knowledge of a credit card belonging to resident in room [ROOM NUMBER]. Included the name of CNA1. Review of the employee record of CNA1 disclosed, Abuse & Neglect: How to recognize the Signs/Timely Reporting: Elder Justice Act, Bill of Rights for LTC/Resident Rights Confidentiality; HIPPA was completed by CNA 1 on 11/03/2021. Resident Abuse/ Neglect in-service completed and signed by employee, CNA1, 05/04/22. During an interview on 11/08/22 at 11:55 AM, the Administrator indicated that he was informed by R1's husband that there were some charges that were made on R1's account, as he was notified by the bank. R1's husband provided the charges to the facility, and they began an investigation. He explains that they asked all staff to complete a witness statement about using or having seen a credit card that belonged to R1. All staff denied and the facility administrator was not aware of the findings until Georgetown County Sheriff's Department came in to arrest their employee, CNA1. The Administrator states, CNA1 was walked out by the sheriff's department, and she was able to resign on the phone because she knew she was going to be charged. The facility Administrator was unable to provide documentation of a grievance or that the employee, CNA1, was placed on the state nurse aide registry. During a telephone interview on 11/08/22 at 1:12 PM, R1 was asked if she would provide the details on the incident that had taken place in reference to money being taken from her debit card. R1 stated, I think it was about $14.00 and that has been a while ago, we can just drop it, it doesn't matter at this point. R1 did not want to go into further detail about the incident. On 11/08/22 at 1:35 PM and 1:50 PM attempts were made to contact CNA1 via phone number provided in employee record, attempts unsuccessful.

Based on observation, interviews, and record review the facility failed to ensure proper handling of food storage and holding temperatures in the main kitchen and one of one satellite serving kitchen. This failure had the potential to cause foodborne illness for all six residents of the facility who received food served from the main and/or satellite kitchen. Findings include: On [DATE] at 9:21 AM, observation of the dry storage room revealed: an opened jar of cashew butter that expired [DATE], an opened jar of roasted peanuts not dated when opened, stir fry sauce not dated when opened, and a foiled, unidentified item that was not dated or labeled. Additionally, these items were opened and were not sealed or covered: yellow cake mix box, large box of dried cranberries, and a large bag of chickpeas. The freezer in the main kitchen also contained several items not dated when opened: thousand island dressing, balsamic vinaigrette, a jar of horseradish, and jar of banana peppers. Additionally, in the freezer, there was not an inside thermometer observed. At this time, the Director of Food Services verified there was no thermometer inside the freezer, and stated the staff always measured the temperature using the built-in thermometer on the outside of the freezer. On [DATE] at 11:50 AM, observation of lunch food preparation and service in the serving kitchen showed that food holding temperatures were outside of acceptable ranges. The Dietary Manager (DM) measured the holding temperatures prior to and/or during meal service. The smoked salmon BLT tempted at 60 degrees Fahrenheit, egg salad at 60F, chicken tenders at 80F, and onion rings at 80F. The DM did not take any action to remediate the holding temperatures before serving the foods. On [DATE] at 3:30 PM, during an interview, the Director of Food Services said that he expected his staff to know the holding temperatures and what action should be taken to bring food to its proper temperature. He also indicated that staff should know how to properly label, date, and properly seal items when they are opened and remove them when expired. The facility's Food Receiving and Storage and Food Preparation and Service policies addressed proper food storage and food holding temperatures. Food Receiving and Storage: 7. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (used by date). Food Preparation and Service: 6. Previously cooked food must be reheated to an internal temperature of 165 Fahrenheit (F) for at least 15 seconds. 8. Mechanically altered hot foods prepared for modified consistency diet must stay above 135F during preparation or they must be reheated to 165F for at least 15 seconds.

Based on observation, interview, and review of facility policy and procedure the facility failed to ensure expired supplies were removed from the patient care areas and the narcotics disposal form contained all pertinent information needed for disposal. Findings include: 1. During an observation of the medication supply room on [DATE] at 11:50 AM revealed four vacuette blood collection tubes expired on [DATE]. During an interview on [DATE] at 11:50 AM with LPN1 stated, The night shift is responsible for checking supplies for the medication room. 2. During an observation on [DATE] at 12:49 PM of the treatment cart revealed the following: forty-four vaseline [MEDICATION(S)] gauze strips expired [DATE], twenty-two steri-strips expired ,d+[DATE], sixteen [MEDICATION(S)] films 4 inch x 4 ,d+[DATE] inch expired ,d+[DATE], one [MEDICATION(S)] blue [MEDICATION(S)] wound dressing expired ,d+[DATE], and thirty [MEDICATION(S)]-iodine prep pads expired ,d+[DATE]. During an interview on [DATE] at 12:55 PM with RN stated, Night shift is responsible for checking for expired supplies. It should be checked every night. During an interview on [DATE] at 2:59 PM with the Interim Director of Nursing (DON) stated, There should be no expired supplies on the floor and we do not have an expired supplies policy. 3. Review of facility policy titled Discarding and Destroying Medications revised date ,d+[DATE] revealed, .4. Schedule II, III, and IV (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous controlled medications .11. The medication disposition record will contain the following information: a. The resident's name; b. Date medication disposed; c. The name and strength of the medication; d. The name of the dispensing pharmacy; e. The quantity disposed; f. Method of disposition; g. Reason for disposition; and h. Signature of witnesses . During a review of the facility Narcotics Disposal form on [DATE] at 9:55 AM revealed the form failed to include the resident's full name, strength of the medication to be disposed, and method of disposal of the controlled medications. During an observation of the controlled medication file cabinet on [DATE] at 09:55 AM revealed the following controlled scheduled narcotics with the potential for abuse with an acquisition form wrapped around them: [MEDICATION(S)], Fentayl patches, [MEDICATION(S)] pills, [MEDICATION(S)] liquid, and [MEDICATION(S)] pills. The acquisition sheet was attached to the medications with the initials of the DON by the remaining number in the pill pack or liquid solutions. During an interview on [DATE] at 10:00 AM with the DON stated, The pharmacist and I will complete the disposal sheet together for the meds (medications). The nurses and I will put the information on the removal forms that is located in their books on the carts and we keep those sheets. Pharmacy comes at least quarterly for us to dispose of the meds. I am the only person with a key to the narcotics cabinet and probably the pharmacist. I'm not sure. During an interview on [DATE] at 12:06 PM with the Pharmacist stated, I usually come every three months to waste narcotics. I came right in September during the last DON. I always destroy the meds (medications) with the DON or his/her designee. The process for destroying the narcotics when I arrive is when the person is discharged or deceased , they (the facility) state the information on the sheet and then I sign off on that sheet. That form goes into the records with all of the other sheets. I check accuracy of the meds by double checking the lists and my signature details what I destroy. I do not have access to the file cabinet where the meds are located. During an interview on [DATE] at 1:50 PM with the DON stated, Narcotics that need to be wasted are removed from the cart with the acquisition sheet and initialed with my signature and placed in the file cabinet in the medication room. We do not have any other system or use a form for what is in the cabinet until the pharmacist arrives for us to destroy it. We only use the narcotic disposal form that I provided to you earlier. I am the only one with a key to the cabinet and we have never had an issue with drug diversion in the building. This process has always worked for us.

Based on observation, interview, and review of facility policy and procedure the failed to ensure staff properly donned personal protective equipment (PPE) while delivering lunch to Resident (R) 59, who was on transmission based precautions. Findings include: Review of facility policy titled Isolation-Categories of Transmission-Based Precautions revised date 10/18 revealed, .5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC (Centers for Disease) precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room .Contact Precautions .4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room .5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed . During an observation during lunch tray delivery on 12/13/21 at 12:06 PM revealed a Certified Nursing Assistant (CNA)1 enter into R59's room without a gown and/or gloves donned while delivering R59's lunch. CNA1 handed R59 her salt, pepper, and butter off of her tray and then exited the room without washing and/or performing hand hygiene. Observation of R59's door revealed a sign Contact Precautions and See nurse prior to entering resident room. Thank you. During an observation on 12/13/21 at 12:49 PM revealed CNA1 re-entered R59's room to re-collect the meal tray without a gown and/or gloves donned. No hand washing and/or hygiene performed post exiting the room. During an interview on 12/13/21 at 1:00 PM CNA1 stated, We only have to put on a gown and gloves when we are delivering some type of care to her. Just delivering her meals, we aren't required to put on the gown and gloves. During an interview on 12/13/21 at 4:05 PM with the Director of Nursing (DON) stated, The staff is only required to don PPE if they are providing care to the resident. Delivering meal trays they do not have to put on the PPE.

Based on record reviews, interviews, and review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Committee, the facility failed to implement an effective QAPI program to ensure deficiencies cited during the recertification survey were corrected. (Cross refer F812 and F880) Findings include: A review on 2/9/22 at 11:45 AM of the facility's QAPI committee meeting for 1/26/22 did not include the deficiencies cited (F812 and F880) during the recertification survey, which was part of the facility's plan of correction. As a result, F812 and F880 was cited during the revisit, and the facility remained out of compliance. An interview on 2/9/22 at 11:47 AM with the Director of Nursing confirmed that the deficiencies cited during the recertification survey was not in the monthly meeting minutes as documented on the plan of correction dated 1/13/22. Review on 2/9/22 at 11:55 AM of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Committee, under the Committee Audit Process. 1. The QAPI Committee will scrutinize all department reports and summarize the findings in the committee minutes. 2. The QAPI Committee shall help various departments, committees, disciplines and individuals develop and implement plans of correction and monitoring approaches. These plans and approaches should include specific time frames for implementation and follow-up. 3. The committee shall track the progress of any active plans of correction. 4. The committee shall advise the administration of the need for policy or procedural changes and, as appropriate, monitor to ensure that such changes are implemented.

Based on record reviews, interviews, and review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Committee, the facility failed to include in the monthly QA meeting the deficiencies cited during the recertification survey as part of the facilities plan of correction. Findings include: A review on 2/9/22 at 11:45 AM of the facility's QAPI committee meeting for 1/26/22 did not include the deficiencies cited during the recertification survey, which was part of the facility's plan of correction. An interview on 2/9/22 at 11:47 AM with the Director of Nursing confirmed that the deficiencies cited during the recertification survey was not in the monthly meeting minutes as documented on the plan of correction dated 1/13/22. Review on 2/9/22 at 11:55 AM of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Committee, under the Committee Audit Process. 1. The QAPI Committee will scrutinize all department reports and summarize the findings in the committee minutes. 2. The QAPI Committee shall help various departments, committees, disciplines and individuals develop and implement plans of correction and monitoring approaches. These plans and approaches should include specific time frames for implementation and follow-up. 3. The committee shall track the progress of any active plans of correction. 4. The committee shall advise the administration of the need for policy or procedural changes and, as appropriate, monitor to ensure that such changes are implemented.

Based on interviews and record review, the facility failed to ensure identified irregularities in the drug regimen for one (Resident (R) 7) of six residents reviewed for unnecessary medications were acted upon. Specifically, the physician did not document the clinical rationale for refusal to implement the recommendations from the pharmacist. This failure placed R7 at risk for use of unnecessary [CONDITION(S)] medications, which could cause negative side effects such as oversedation, dizziness and loss of balance, uncontrollable involuntary movements, or drug interactions. Findings include: Review of R7's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/11/21, revealed the resident did not have any signs of depression or mood symptoms, but displayed other behavioral symptoms not directed toward others on a daily basis R7 scored a zero out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. Review of R7's 07/30/21 Drug Regimen Review by the pharmacist revealed a gradual dose reduction (GDR) was requested of the medications [MEDICATION(S)] and [MEDICATION(S)]. A review of the physician's Progress Notes and the response documented on the 07/30/21 Drug Regimen Review showed that the GDR was denied by R7's physician with no reason or rationale documented, and the resident continued with the same doses of the [MEDICATION(S)] and [MEDICATION(S)]. During an interview on 12/14/21 at 1:02 PM with LPN3, she stated R7 was diagnosed with late-stage Alzheimer's disease and exhibited some behavioral symptoms related to the dementia. During a phone interview on 12/15/21 at 11:09 AM with the resident's physician, he stated that he did not agree with the GDR recommended by the Pharmacist on 7/30/21 due to not wanting the resident to have increased behaviors, because that has happened in the past. He just forgot to document it specifically in the resident's record. During an interview on 12/14/21 at 3:02 PM with the Director of Nursing, she was shown the blank GDR request from the consultant pharmacist. When asked why the request form blank was, she stated that is normally how they process their paperwork for GDRs and it is understood between staff that a blank sheet of paper means that there are no changes to be made. She then went on to state as a nurse this is how I expect it to be done.

Based on record review, interview, and review of the facility's policies on Abuse and Neglect, the facility failed to implement its policies related to preventing misappropriation of resident property for 1 of 1 resident reviewed for Misappropriation. (Resident #8) The findings included: The facility admitted Resident #8 on 10/10/19 with [DIAGNOSES REDACTED]. Record review revealed the facility submitted an Initial 24-Hour Report of an allegation of Misappropriation of resident property to the State Agency on 10/23/19 concerning Resident #8. The report indicated, Resident had money in possession on admission 10/10/19. Money was locked in medication cart until someone could pick up. Money was found to be missing 10/23/19. Investigation initiated, unsure if money was picked up by friend/family at this time. The Five-Day Follow-Up Report for Resident #8 indicated the resident had a 'pouch' which contained money, a credit card and Medicare card. There was no one that was able to pick up money at time of admission; therefore pouch was locked in medication cart for safety. Money was found to be missing (entire pouch) 10/23/19. Review of the Summary Report of Facility Investigation revealed, Resident was reimbursed missing money by facility. Social Services & appropriate insurance company notified for replacement cards. Investigation could not prove or identify anyone taking money. Review of the Social Services documentation dated 10/24/19 indicated, Late Entry for 10/23: On the afternoon of 10/23/19, it was reported to SW (Social Worker) by nursing staff that Resident had a large amount of money locked in the narcotics cart which had been placed there upon admission. Resident inventory checklist done at time of admission which includes notation of 2 credit cards and $481.00 in cash. Nursing staff then told SW in that same conversation that the bag containing (Resident #8's) items and money was no longer in the drawer. SW interviewed (Resident #8) who stated (he/she) did not authorize anyone to remove (his/her) belongings from the drawer. The notation further indicated that the Sheriff's office was notified, and an officer responded to the facility to take a report. Statement taken from resident in presence of SW where (he/she) stated there was a ( .) bag that contained (his/her) wallet with Medicare card, credit cards, and cash. Review of the Police Incident Report indicated that the resident states (he/she) gave no one permission to take (his/her) money. Review of the facility's policies on Abuse and Neglect revealed the policy entitled, Abuse Prevention Program indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Review of the policy entitled, Investigating Incidents of Theft and/or Misappropriation of Resident Property stated under Policy Interpretation and Implementation 1. Residents have the right to be free from theft and/or misappropriation of personal property. and 2. 'Misappropriation of resident property' is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. During an interview on 3/12/20 at approximately 11:00 AM, the Director of Nursing (DON) stated that Resident #8 had confirmed that no one had pick-up the bag for him/her. The DON further confirmed that the facility had been unable to determine what had happened to Resident #8's missing bag and property.

Based on record review and interview, the facility failed to protect residents from Misappropriation of property for 1 of 1 resident reviewed for Misappropriation. (Resident #8) The findings included: The facility admitted Resident #8 on 10/10/19 with [DIAGNOSES REDACTED]. Record review revealed the facility submitted an Initial 24-Hour Report of an allegation of Misappropriation of resident property to the State Agency on 10/23/19 concerning Resident #8. The report indicated, Resident had money in possession on admission 10/10/19. Money was locked in medication cart until someone could pick up. Money was found to be missing 10/23/19. Investigation initiated, unsure if money was picked up by friend/family at this time. The Five-Day Follow-Up Report for Resident #8 indicated the resident had a 'pouch' which contained money, a credit card and Medicare card. There was no one that was able to pick up money at time of admission; therefore pouch was locked in medication cart for safety. Money was found to be missing (entire pouch) 10/23/19. Review of the Summary Report of Facility Investigation revealed, Resident was reimbursed missing money by facility. Social Services & appropriate insurance company notified for replacement cards. Investigation could not prove or identify anyone taking money. Review of the Social Services documentation dated 10/24/19 indicated, Late Entry for 10/23: On the afternoon of 10/23/19, it was reported to SW (Social Worker) by nursing staff that Resident had a large amount of money locked in the narcotics cart which had been placed there upon admission. Resident inventory checklist done at time of admission which includes notation of 2 credit cards and $481.00 in cash. Nursing staff then told SW in that same conversation that the bag containing (Resident #8's) items and money was no longer in the drawer. SW interviewed (Resident #8) who stated (he/she) did not authorize anyone to remove (his/her) belongings from the drawer. The notation further indicated that the Sheriff's office was notified, and an officer responded to the facility to take a report. Statement taken from resident in presence of SW where (he/she) stated there was a ( .) bag that contained (his/her) wallet with Medicare card, credit cards, and cash. Staff interviews conducted, and ongoing investigation of security footage is occurring. Report to be filed to appropriate agencies. SW will continue to monitor and assist. Additional documentation indicates that, In the future, money/valuable items will be given to the Business Office Manager to keep in safe until family can retrieve to take home. Social Worker re-educated staff on abuse/neglect to include misappropriation of property. The facility provided a copy of a receipt dated 10/25/19 showing re-imbursement of the missing money to Resident #8. Review of the Police Incident Report indicated that the resident states (he/she) gave no one permission to take (his/her) money. Record review further indicates that the SW assisted Resident #8 to contact the insurance companies, the bank, and credit card company on 10/24/19. SW followed-up with Resident #8 after discharge from the facility, and the resident reported that nothing has changed with (his/her) accounts and that he/she had received a replacement debit card and was waiting for the replacement credit card in the mail. The facility interviewed staff members who worked during the timeframe that Resident #8's property was discovered missing. No staff had any knowledge related to the missing property. The facility provided inservice training related to misappropriation of property to all staff following the incident. During an interview on 3/12/20 at approximately 11:00 AM, the Director of Nursing (DON) stated that Resident #8 had confirmed that no one had pick-up the bag for him/her. The DON further confirmed that the facility had been unable to determine what had happened to Resident #8's missing bag and property.

Based on observation and interview, the facility failed to ensure that the dietary staff maintained proper food storage and quality. The facility was also unable to keep the ice maker's drainage pipe adequately installed and free from buildup and the emergency food supply free from expired foods. The findings included: On [DATE] at 6:54 AM during the initial kitchen tour with the facility administrator, the walk-in cooler contained various foods items, including a large package of hot dogs, a couple of chicken tender bags, several bags of sweet potato fries, and broccoli without a label or use by/expiration date. The walk-in cooler also had trash/food debris. The ice-maker pipe was disconnected with black buildup around it and the condensation/water accumulated on the kitchen floor. The emergency food supply contained 2.5 cases of cans of chicken and dumplings dated [DATE]. The facility administrator and the food/nutrition director witnessed the above findings on the first day of the survey on [DATE].

Based on record review, interview, and review of the facility agreement with Hospice, the facility failed to ensure coordination of care with Hospice for Resident #2 related to skilled nursing visits. The facility further failed to integrate the facility Plan of Care and the hospice Plan of Care to ensure coordination of care for 1 of 1 residents reviewed for Hospice. The findings included: The facility admitted Resident #2 for Hospice Care and Services on 1/25/2018 with [DIAGNOSES REDACTED]. Review on 12/19/2018 at approximately 9:44 AM of the Hospice visits from Skilled Nursing revealed visits that were completed by the hospice Registered Nurse (RN). The assessments completed by the RN are not left in the facility to coordinate care with the nursing staff. The assessment is taken with the Hospice Nurse to his/her office and then signed at a later date and then sent to the facility. The findings are as follows: The skilled nursing visit dated 7/3/2018 was signed on 7/5/2018 and then sent to the facility. The visit for 7/11/2018 was signed on 7/16/2018, 7/17/2018 signed on 8/1/2018, and 7/24/2018 signed on 8/6/2018. The skilled nursing visit for 7/31/2018 was signed on 8/5/2018, 8/7/2018 signed on 9/4/2018, 8/15/2018 signed on 9/3/2018, 8/21/2018 signed on 9/3/2018, and 8/27/2018 signed on 9/3/2018. The skilled nursing visit for 9/17/2018 was signed on 9/19/2018, 9/19/2018 signed on 10/1/2018, 9/24/2018 signed on 9/26/2018, 10/1/2018 signed on 10/8/2018, 10/5/2018 signed on 10/8/2018, 10/9/2018 signed on 10/10/2018, and 10/24/2018 signed on 11/4/2018. The skilled nursing visit for 10/30/2018 was signed on 11/5/2018, 11/5/2018 signed on 11/19/2018, 11/19/2018 signed on 12/3/2018, and 11/26/2018 signed on 12/3/2018. The information was not in the facility from the Hospice Skilled Nurse until it was signed and then sent to the facility. Review on 12/19/2018 at approximately 10:00 AM of the facility Care Plan Report for Resident #2 dated 1/1/2018 to present did not include Hospice Care and Services to include the frequency and interventions of the RN, the Certified Nursing Assistant, the Social Worker, and the Chaplain. No mention was made of the [DIAGNOSES REDACTED]. Further review on 12/19/2018 at approximately 10:05 AM of the Hospice Plan of Care revealed it did not include care for Resident #2 by the facility. No documentation could be found on either Plan of Care to ensure the care plans were integrated to ensure coordination of care for Resident #2. An interview on 12/19/2018 at approximately 11:15 AM with the Care Plan Coordinator confirmed that the Plan of care from Hospice and the facility were not integrated and the facility Plan of Care Report did not include interventions by Hospice for Resident #2 such as the [DIAGNOSES REDACTED]. During an interview on 12/19/2018 at approximately 11:40 AM with the RN Unit Manager, he/she stated when the Hospice Nurse comes to do the visits the assessment and notes are not left in the facility when he/she leaves, but they send it at a later date. The RN Unit Manager went on to say that the Hospice Nurse would talk with him/her before they leave with the assessment and notes. No documentation could be found in the medical record nor the Hospice notebook to ensure the Hospice Nurse gave any type report to the RN Unit Manager to ensure coordination of care with Hospice and the facility. Review on 12/19/2018 at approximately 11:50 AM of the facility Agreement with Hospice revealed, the definition of the plan of care by hospice is, A written plan prepared for each Hospice patient containing an assessment of the patient's needs, identification or services to be provided and a detailed description of the scope and frequency of services needed to meet the patient's and family's needs. Section IV. Preparation and Maintenance of Records states, A. The SNF (Skilled Nursing Facility) shall prepare and maintain medical records for each Hospice patient receiving services pursuant to this agreement. The medical records shall consist of progress notes and clinical notes describing all inpatient services and events.

Based on observations and interview, the facility failed to provide an ongoing program of activities for Resident #2, #3, and #6 based on his/her preferences designed to support residents in their choice of activities, and to meet the interests of and support the physical, mental and psychosocial well-being of each resident for 3 of 3 residents reviewed for activities. The findings included: The facility admitted Resident #2 on 10/30/2017 with [DIAGNOSES REDACTED]. Review on 12/18/2018 at approximately 5:33 PM of the Activity Attendance Sheets for (MONTH) for Resident #2 revealed one to one activities in (MONTH) on 10/3/2018, 10/10/2018, 10/17/2018, and 10/31/2018. No documentation could be found to ensure the content of the activity and the length of time spent with Resident #2. Review on 12/18/2018 at approximately 5:33 PM of the Activity Attendance Sheets for Resident #2 for (MONTH) (YEAR) revealed 2 activities only, and included Ice Cream Socials on 11/4/2018 and 11/10/2018. No other activities were documented for (MONTH) (YEAR) for Resident #2. Review on 12/18/2018 at approximately 5:33 PM of the Activity Attendance Sheets for Resident #2 for (MONTH) (YEAR) revealed one to one activities on 12/8/2018 and 12/15/2018 with no documentation of the content of the one to one activity and the amount of time spent with Resident #2. No other documentation could be found to ensure Resident #2 was offered activities nor provided activities for (MONTH) (YEAR). The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Anxiety Disorder, Vitamin Deficiency, Calcium Metabolism Disorder and is receiving Hospice Services. Review on 12/18/2018 at approximately 5:45 PM of the Activity Attendance Sheets for Resident #3 for (MONTH) (YEAR) revealed one to one activities on 10/3/2018, 10/10/2018, and 10/31/2018 with no documentation to ensure what the activity included and how much time was spent with Resident #3. Review on 12/18/2018 at approximately 5:45 PM of the Activity Attendance Sheets for Resident #3 for (MONTH) (YEAR) included 3 group activities on 11/9/2018 and 2 activities on 11/19/2018. No other activities were offered or provided for (MONTH) (YEAR). Review on 12/18/2018 at approximately 5:45 PM of the Activity Attendance Sheets for Resident #3 for (MONTH) (YEAR) revealed 1 activity documented for 12/10/2018. No other documentation could be found to ensure Resident #3 was offered or provided activities. The facility admitted Resident # 6 on 10/31/2018 with [DIAGNOSES REDACTED]. Review on 12/18/2018 at approximately 5:50 PM of the Activity Attendance Sheets for (MONTH) (YEAR) for Resident #6 revealed one to one activities on 11/21/2018 and 11/23/2018 with no documentation to ensure what the one to one activity consisted of and how long it was provided for Resident #6. Review on 12/18/2018 at approximately 5:50 PM of the Activity Attendance Sheets for (MONTH) (YEAR) for Resident #6 revealed 1 activity on 12/2/2018 and 3 activities on 12/9/2018. No other documentation could be found for (MONTH) (YEAR) to date to ensure Resident #6 was offered or provided activities. During an interview on 12/18/2018 at approximately 2:30 PM with the Activity Director confirmed minimal activities offered to Residents #2, #3, and #6 and that there was no documentation to support the one to one activities for each of these residents. The Activity Director did bring in the Activity Assistant and he/she stated they would start documenting the one one activities with the content of the activity and the duration.

Based on observation and interview, the facility failed to maintain clean oxygen concentrator filters for 2 of 2 sample residents reviewed for respiratory care (Residents #3 and #7). The findings included: The facility admitted Resident #7 on 11/30/18 with [DIAGNOSES REDACTED]. During the initial observation on 12/17/2018 at 11:45 AM an oxygen concentrator in Resident #7's room was inspected for cleanliness. The inspection revealed a substantial amount of dust accumulated on the concentrator filter. During another observation on 12/17/18 at 2:00 PM, Certified Nursing Assistant #1 confirmed the above finding. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Anxiety Disorder, Vitamin Deficiency, Calcium Metabolism Disorder and is receiving Hospice Services. An observation on 12/18/2018 at approximately 9:30 AM of the oxygen concentrator in use for Resident #3 revealed a large build up of dust and debris on the back of the machine at the vent leading to the internal filter that was not visible. An interview on 12/18/2018 at approximately 9:30 AM with Registered Nurse (RN) #2 confirmed the large build up of dust and debris on the back of the oxygen concentrator and stated he/she would notify the unit manager. On 12/18/2018 at approximately 10:30 AM, the RN Unit Manager came to the conference room and informed this surveyor that he/she had cleaned the dust and debris from the back of the oxygen concentrator at the vent site, in use by Resident #3.

Based on record review and interview, the facility failed to develop a plan of care for an ongoing activity program for Resident #2 and Resident #6 based on their interests and preferences to attain and/or maintain his/her highest practicable physical, mental and psychosocial well being for 2 of 3 residents reviewed for activities. The findings included: The facility admitted Resident #2 on 10/30/2017 with [DIAGNOSES REDACTED]. Review on 12/18/2018 at approximately 2:59 PM of the Care Plan Report dated 1/1/2018 to present revealed no goals and interventions for activities with activity preferences and interests for Resident #2. The facility admitted Resident # 6 on 10/31/2018 with [DIAGNOSES REDACTED]. Review on 12/19/2018 at approximately 12:52 PM of the Care Plan Report dated 10/31/2018 to present revealed no goals and interventions for activities with activity preferences and interests for Resident #6. During an interview on 12/19/2018 at approximately 11:15 AM with the Care Plan Coordinator, he/she reviewed the Care Plan Reports and confirmed that the activities for Resident #2 and #6 were not on the Care Plan Reports. The Care Plan Coordinator went on to say that the Activities Director was responsible for developing the care plan for residents regarding activities.

Based on observation, interview and review of the facility policy titled, Quality of Life - Dignity, the facility failed to promote care for Resident #6, #59, and #3 in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his/her individuality. Staff failed to knock on 3 of 4 resident room doors during medication administration and entered without waiting for permission to enter on 1 of 1 units. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. An observation on 12/18/2018 at approximately 9:03 AM, during medication administration, revealed Registered Nurse (RN) #2 walking into Resident #6's room with medications without first knocking and waiting for permission to enter. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. An observation on 12/18/2018 at approximately 9:15 AM, during medications administration, revealed RN #2 entering Resident #3's room without first knocking and waiting for permission to enter to administer medications. The facility admitted Resident #59 with [DIAGNOSES REDACTED]. An observation on 12/18/2018 at approximately 11:50 AM, during medication administration, revealed RN #2 walking into Resident #59's room to check a blood sugar without first knocking and waiting for permission to enter. An interview on 12/18/2018 at approximately 12:15 PM with RN #2 confirmed that he/she had not knocked on the residents' room doors and waited for permission to enter. RN #2 did say that he/she did call out to the resident while entering the room. Review on 12/19/2018 at approximately 9:40 AM of the facility policy titled, Quality of Life - Dignity, the Policy Statement reads, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Number 6 under, Policy Interpretation and Implementation states, Residents' private space and property shall be respected at all times. a. Staff will knock and request permission before entering residents' rooms.

Based on observation, interview, and review of the facility policy titled, Medication Storage In The Facility, the facility failed to ensure medications were securely stored out of reach from residents and visitors during medication administration on 1 of 2 medication carts on 1 of 1 units. The findings included: An observation on 12/18/2018 at approximately 11:30 AM of 1 of 2 medication carts revealed pills belonging to a resident, loose and in a medicine cup on the top of the medication cart, unattended. The nurse administering the medications from the cart was in a resident room. An interview on 12/18/2018 at approximately 1:39 PM with Registered Nurse #2 confirmed the medications were not secured in the medication cart before he/she went into a resident's room. Review on 12/18/2018 at approximately 2:20 PM of the facility policy titled, Medication Storage In The Facility, states under Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Under Procedures: B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts and medication supplies are locked or attended by persons with authorized access.

On the days of the Complaint Inspection, based on record review and interviews the facility failed to prevent a significant med error for 1 of 7 sampled residents. Resident #4 received three times the ordered dose of medication for three (3) days. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Physician's Telephone Orders revealed an order dated 8/23/13 for [MEDICATION NAME] (diuretic) 20 milligrams (mg) every AM for [MEDICAL CONDITION]. On 8/28/13 orders were written to increase the [MEDICATION NAME] to 40 mg each day and [MEDICATION NAME] 2.5 mg every AM, for [MEDICAL CONDITION] was added. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] 7.5 mg po (by mouth) Q (every) AM X 7 days". The dosage transcribed was three times the dosage ordered. The resident received 40 mg of [MEDICATION NAME] and [MEDICATION NAME] 7.5 mg, both diuretics. The medication was signed as given on 8/29, 8/30 and 8/31/13. The 24 hour chart check dated 8/28/13 did not note a discrepancy between the ordered dose and the transcribed dose. Review of the Nurse's Notes for 8/31/13 at 1400 (2:00 PM) stated, "Called to room per CNA (Certified Nursing Assistant). CNA stated s/he heard someone yelling "help" entered the room and noted the resident lying on the floor on "knees and hands". Resident states s/he is unsure if she "fell " or "blacked out and fell ". The resident obtained a "small hematoma with laceration on forehead." The resident was sent to the hospital at 2:30 PM. A Nurse's note at 1920 (7:20 PM) stated, call received from (hospital). Resident return back to the facility with dx (diagnoses): [MEDICAL CONDITION] and hypokalemia. N.O. (new order) for K-DUR (potassium supplement) 40meq (milliequivalents). Review of the Vital Signs Record revealed the resident's blood pressure dropped on 8/29/13 after s/he received her/his first dose of [MEDICATION NAME]. On 8/29/13 her B/P was 94/63, 8/30/13 98/65 and 8/31/13 94/66. Previous to the administration of the increase in the [MEDICATION NAME] and the [MEDICATION NAME] on 8/28/13, the resident's blood pressure ranged from 110/70 to 140/68. Review of the hospital records dated 8/31/13 revealed the resident was found to have [MEDICAL CONDITION] (low sodium) and HypoKalemia (low potassium). Review of the resident's lab reports, a Comprehensive Metabolic Profile performed on 8/16/13, (eleven days before [MEDICATION NAME] started), revealed the resident's sodium level was 134 (normal limits 133-145) and the potassium level was 4.0 (normal 3.5-5.1) The surveyor on 12/17/13 interviewed the Director of Nursing and Administrator at approximately 2:20 PM. They stated the physician following the fall of the resident reviewed the medication. The physician discovered the medication error while reviewing the resident's medications and discontinued the medication.

On the days of the survey, based on interview, record review, review of facility policy for Restraints, the facility failed to revise care plans for 3 of 7 sampled residents reviewed for revision of the careplan. Resident #1 was admitted to the facility as a result of repeated falls prior to admission. On admission, the facility assessed the resident as being at high risk for falls. Resident # 1 experienced repeated falls while at the facility and the care plan was not revised in an attempt to maintain the resident's safety. For resident #4 the care plan was not revised for the use of antibiotic therapy and for resident #6 the care plan was not revised for the use of a [MEDICAL CONDITION] (Continuous Positive Airway Pressure) machine. The findings included: Resident #4 admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 3/13/12 at approximately 10:00am revealed admitting physician's orders [REDACTED]. Dx (Diagnosis) UTI". Further review revealed physician's orders [REDACTED]. Review of the interim and comprehensive care plans revealed no documentation of the UTIs or the antibiotics prescribed to treat the UTIs. Interview on 3/13/12 at approximately 1:50pm with the MDS (Minimum Data Set) Coordinator indicated, after review of the chart, that if a resident is admitted with an infection or develops one in the facility, it should be documented on the care plan. She then acknowledge that the resident's care plan did not document either UTI. The facility admitted Resident #6 on 02- 21-12 with [DIAGNOSES REDACTED]. Record review on 03-13-12 at approximately 12:45 PM of the Physician's Telephone Orders dated 02-23-12 revealed the following: "Order clarification: Continuous Positive Airway Pressure ([MEDICAL CONDITION]) at night (HS)". Record review on 03-13-12 at approximately 12:45 PM of Resident #6's Care Plan dated 02-29-12 for "Problem/Strength/Need: Potential for decreased Oxygen (O2) saturations (Sats) related to history (hx) of sleep apnea" revealed it had not been updated to reflect the cleaning of the [MEDICAL CONDITION] machine. Review on 03-13-12 at approximately 5:30 PM of the "[MEDICAL CONDITION] Machines and [MEDICAL CONDITION] Masks Cleaning and Maintenance Schedule" revealed the following, "Weekly care of your [MEDICAL CONDITION] equipment and accessories: i.e....". Record review on 03-14-12 at 9:30 AM of Resident #6's Treatment Record dated 03-01-12 through 03-31-12 revealed no cleaning schedule for the [MEDICAL CONDITION] machine. During an interview on 03-14-12 at approximately 9:40 AM with the Care Plan Coordinator, she, after Care Plan review, verified the Care Plan dated 02-29-12 relating to the [MEDICAL CONDITION] machine had not been updated to reflect the cleaning of the [MEDICAL CONDITION] machine. She stated, "You're right. It should have been care planned. I clean it once a week and when I'm not here, the Director of Nursing will do it". The facility admitted Resident # 1 on 2/16/12 with [DIAGNOSES REDACTED]. Resident #1 on admission was documented as being alert and oriented times 2, but confused at times. On 2/23/12 a brief interview of mental status revealed a score of 7 (moderately impaired cognition). Nurses notes on the day of admission stated the resident "has bruise on left and right hip, bruise on coccyx, right side of face is bruised (with) bump to right forehead, bruise on upper left arm and a bruise on right hand." On discharge from the hospital was a recommendation for the resident to have a CSF (Cerebral Spinal Fluid) Ventriculography to try to determine the cause of the residents recurrent falls. The resident was assessed by the facility on admission to be at high risk for falls. (A score of 19.) During record review on 3/12/12 at approximately 3:10 PM it was noted that Resident #1 had experienced multiple falls since the date of admission (2/16/12) and that interventions were initiated after falls on 2/16/12, 2/17/12, 2/24/12 and 3/1/12. Review of the care plan revealed no new interventions were implemented after the falls on 3/5/12, 3/8/12, and 3/12/12. The resident continued to fall without being reassessed and having new interventions initiated. The falls/incidents of 3/5 and 3/12/12 resulted in orders from the physician to transfer the resident to the emergency room for an evaluation. During an interview with the Director of Nursing (DON) on 3/13/12 at approximately 4:05 PM regarding whether the facility should have assessed and initiated additional interventions after the 3/1/12 fall to prevent further falls the DON stated, "Yes ma'am we should have." An interview with the Physical Therapist (PT) on 3/14/12 at approximately 9:20 AM revealed that Resident #1 was reassessed after each fall, but they didn't document it as a reevaluation. It was documented as gait training versus "reevaluation". When asked if the plan of care was changed after the reevaluations, the PT stated, "The plan of care stayed the same." Further interview revealed that Resident #1 was not evaluated for assistive devices because the facility is a "restraint free" facility per PT. The facility restraint policy stated "alternatives will be tried prior to recommending transfer to a higher level of care." The alternatives were limited to : close observation, reminding the resident not to get up unassisted, place bed in low position and or mat by bed; assess/careplan for fall risk; advise family of risk for harm from fall; color code chart/door to make staff aware of need of close observation; use bed/chair alarm. The residents environment was not evaluated by PT who stated, "The resident's environment did not need to be changed." The PT stated that she recommended that Resident #1's wife should not be getting him up, but to call for Certified Nursing Assistant/staff for assistance when transferring the resident, but the resident's wife chose to ignore the PT recommendation. There was no documentation provided related to the counseling. During the interview, PT was unaware of the total of 9 incidents regarding falls. She indicated was only aware of 3 incidents and the last fall on 3/12/12 prior to the resident leaving the facility. The resident's plan of care did not address the need of the resident for further testing to determine the potential cause of falls. The scheduled CFS (Cerebral Spinal Fluid) Ventriculography. The care plan stated the resident ambulates and transfers with extensive assistance of 1. Under approaches it stated to "encourage resident to get oob (out of bed) and ambulated qd (every day). Give praises for attempts to ambulate... Inform therapy for any decline." There was no careplan for the concerns related to the use of private sitters nor the need for family education,

On the days of the survey, based on observations, record review, interviews, review of the facility provided policy for Fall Prevention Guidelines (revised 8/10) the facility failed to ensure that the residents environment remained as free of accident hazards as possible. The resident laundry room door was left unsecured for at least 4 hours with chemicals accessible to residents. The facility also failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 3 sampled residents reviewed for falls. Resident #1, a known fall risk with a history of repeated head injuries, continued to fall after his admission to the facility. The falls resulted in injury/emergency room evaluations. The facility failed to implement new interventions after each fall. There was no evidence of coordination of care with the rehabilitation department to identify potential hazards, implement and monitor inventions to prevent additional falls, or educate the resident's family and or paid sitter. The findings included: The facility admitted Resident # 1 on 2/16/12 with [DIAGNOSES REDACTED]. Resident #1 on admission was documented as being alert and oriented times 2, but confused at times. On 2/23/12 a brief interview of mental status revealed a score of 7 (moderately impaired cognition). Nurses notes on the day of admission stated the resident "has bruise on left and right hip, bruise on coccyx, right side of face is bruised (with) bump to right forehead, bruise on upper left arm and a bruise on right hand." On discharge from the hospital was a recommendation for the resident to have a CSF (Cerebral Spinal Fluid) Ventriculography to try to determine the cause of the residents recurrent falls. The resident was assessed by the facility on admission to be at high risk for falls. (A score of 19.) During review of Nurses Notes on 3/12/12 at approximately 3:10 PM revealed that at 11:15 PM on 2/16/12 "Resident #1 was found by Certified Nurses Assistant (CNA) on knees on side of bed." There was a sensor alarm in place and functioning at the time of the nurse's assessment, the call light was within reach and there were no injuries noted according to the documentation. Resident #1's family and physician were notified of the fall. An accident report was completed. The new intervention to prevent further accidents included the resident "being oriented to new surroundings". Nurses notes of 2/17/12 at 5:15AM stated the resident "has been trying to get oob (out of bed) q (every) 30 minutes or more throughout the night. Frequent reminders to utilize call light." Continued review of nurses notes revealed: 2/17/12 at 10:15 AM "Resident #1 lying on floor with face down. Blood noted on the floor." A skin tear was noted on the left side of Resident #1's forehead. An alarm was in place and functioning at the time of the fall. The resident's family and physician were notified of the fall. An accident report was completed. Neuro checks were initiated. On the reverse side of the incident/accident report, the steps taken to prevent further accidents included that the resident would have a private sitter 24 hours a day, 7 days a week. On 2/17/12 the resident was seen by the physician and order written for "fall precautions", Bactroban ointment to the wound and pain medication. 2/18/12 at 4:10 AM "Sitter at bedside who is frequently observed sleeping." A new intervention initiated by staff was to check Resident #1 every 30 minutes for safety. 2/18/12 A skin and neuro assessment documented the resident had a large bruised area to the right side of ace. Bruise starts on right forehead, down eye, cheek, chin to right neck. Two lacerations on head noted. One on front of right forehead with a large bump, is scabbed and healing. The other laceration is stitched and further back on right side of scalp. Incision is clean and approximated. Scattered ecchymotic areas noted to upper back. 2/20/12 at 6:00 AM "Responded to resident's Sara alarm and observed resident ambulating beside bed towards the foot of the bed. Sitter asleep and had to be awakened by the nurse." 2/24/12 at 2:15 AM Restless at times. Alarm sounding several times. Private sitter stated she assisted resident back to bed. A nursing assistant reported the residents right lower leg was bleeding. A pinpoint abrasion was noted. Band-Aid applied. 2/24/12 3AM Resident continues to be awake. Fidgeting with sheets and removing briefs. Frequent attempts to get out of bed unassisted. 2/24/12 at 3:50 AM "Resident was on his knees on the floor beside his bed. Sara alarm sounding low as well as beeper. Private sitter asleep in recliner. As nurse and CNA entered room, sitter had placed resident back in bed. There were no injuries noted to the resident. The resident's family and physician were notified of the fall. An accident report was completed. The steps taken to prevent further accidents included continue every 30 minute safety checks, Sara alarm and bed in low position. 3/1/12 at 4:35 AM "Resident found lying on the floor on his left side by air conditioning unit. Sitter stated resident rolled out of bed." An abrasion was noted to the left side of the resident's forehead. The resident's bed was in the low position. Resident's family and physician were notified of the fall. An accident report was completed. The steps taken to prevent further accidents included; continue Sara alarm, every 30 minute safety checks, leave door open and continue 24 hour sitter. Treatment initiated for head abrasion. 3/1/12 at 1:40 PM (Late entry in Nurses Notes) revealed "Resident found on floor in front of wheelchair after being notified by CNA." Wife states, "He slid out of his wheelchair." There were no apparent injuries. The family was aware and the physician was notified of the fall. An accident report was completed. The steps taken to prevent further accidents included; continue Sara alarm, every 30 minute safety checks, 24 hour sitters and leave door open. Review of the Incident/Accident reports and care plan dated 3/1/12 revealed that there were no new interventions initiated to prevent further accidents. 3/5/12 at 3:00 PM "Resident noted to be on the floor of room, wife present." Resident #1's wife transferred resident to recliner by herself while the resident was standing on a magazine because he didn't want to get his feet dirty. The resident slid to floor. The residents family aware and the physician was notified of the fall. An accident report was completed. The steps taken to prevent further accidents included; continue Sara alarms, every 30 minute safety checks, 24 hour sitter and leave door open. Review of the Incident/Accident reports and care plan dated 3/5/12 revealed that there were no new interventions initiated to prevent further accidents. 3/8/12 at 8:15 AM "After hearing a noise from the hallway. Upon entering the residents bathroom resident observed lying on the bathroom floor on his left side with the sitter present." There were no apparent injuries. However, the resident then complained of left neck pain, The resident's family and physician were notified of the fall. The resident was sent to the emergency room for an evaluation and returned with no new orders. An accident report was completed. The steps taken to prevent further accidents included: continue Sara alarm, 24 hour sitters, every 30 minute safety checks and leave door open. Review of the Incident/Accident reports and car plan dated 3/8/12 revealed that there were no new interventions initiated to prevent further accidents. 3/10/12 Resident #1 was transferred from room 436 to 445 (in front of nurses station) in order to monitor resident more closely. There was no evidence that the resident's family was notified of this room change. 3/12/12 at 2:00 PM "Resident was observed on floor on buttocks." The wife states the resident fell asleep and leaned over and fell . There were no apparent injuries to the resident. The family was present and the physician was notified of the fall. An accident report was completed. The steps taken to prevent further accidents included: continue Sara alarms, every 30 minute safety checks, leave door open and 24 hour sitters. Review of the Incident/Accident report and care plan revealed that there were no new interventions initiated to prevent further accidents. 3/12/12 at 6:00 PM A staff member heard the private sitter for Resident #1, yell from the dining room and upon arriving in the dining room, Resident #1 was observed sitting on the floor. The private sitter had removed the fall alert alarm. There were no apparent injuries to the resident. The family and physician were notified of the fall. An order was received to transfer the resident to the emergency room for an evaluation. An accident report was completed. The steps taken to prevent further accidents included: "Wife decided to take resident back home versus sending the resident to the emergency room for evaluation. The physician was made aware of the wife's decision to have resident sent home and her refusal to send resident to the emergency room . The resident was discharged home with medications". The nurses notes stated "Resident's wife notified of fall and arrived at 1820. Resident's wife refused to allow resident to be transported to ER. Dr...made aware. N.O. (new order) D/C (discontinue) order to send to ER and D/C (discharge) home with med's. During an observation of the evening meal on 3/12/12 at approximately 6:17 PM while this surveyor was approaching the dining room a scream was heard from Resident #1's sitter and it was noted that the sitter had her back to the resident and was looking over her left shoulder as Resident #1 was falling to the floor from his wheelchair. The resident landed on his left side. The resident was assessed by staff and Regional Representative, then assisted to the wheelchair. As the resident was being assisted to his wheelchair, the surveyor heard the sitter state, "I just took my eyes off him for a minute." As the resident was being wheeled back to his room by the sitter, an interview with the Regional Representative revealed that Resident #1 did not have his chair alarm on because that was the purpose of having a 1:1 sitter, so the alarm was not needed. There were no apparent injuries noted to Resident #1 from the fall Review of physician orders [REDACTED]. The facility provided policy for Fall Prevention Guidelines stated: "Resident/family will be instructed about safety measures and rationale, including to call for assistance before getting out of bed...the proper use of canes, walkers, wheelchairs and crutches... Residents at risk for fall will be placed as close as possible to the nursing station. The resident was admitted with a known high risk and a room change was not completed until 3/10/12. Ambulatory resident shall wear proper foot gear; regular shoes or well fitting slippers. Review with resident and his/her family members to determine any factors that may predispose resident for fali(sic) and/or activities that have helped prevent falls in the home environment. Ensure optimal communication regarding the resident's condition and potential for fall with other care providers...with the resident and his/er family about the fall prevention issues and any fall prevention activities to be carried out for the resident. During an interview on 3/13/12 at 4:05 PM and 3/14/12 at 9:40 AM, the Director of Nursing (DON) stated that when the physician ordered "fall precautions" that included screening for falls, applying a Sara alarm and monitoring. When the resident's spouse was present, the wife did not schedule a sitter, but when a family member was unable to be with the resident, a sitter was utilized. The resident's wife chose which agency the sitter was hired through. On the days that the sitters were noticed sleeping, the facility called the agency and had the sleeping sitters replaced at the end of the shift. When asked if the staff should have waited until the end of the shift before notifying the DON that the sitters were found sleeping, the DON stated, "No ma'am, they should have called me and I would have made arrangements to cover the remainder of the shift with a Certified Nurses Assistant until a new sitter could be employed." As the new sitters were hired, they were inserviced by the facility that they were responsible for the safety of the resident. The DON did not interview the sitters or get their statements with each of the falls documented. The DON stated that there was not a discussion or consideration regarding rearranging the resident's room/environment, nor did they consider protective devices for the resident. An interview with the Physical Therapist (PT) on 3/14/12 at 9:20 AM revealed that Resident #1 was reassessed after each fall, but it was not documented it as a reevaluation. It was documented as gait training versus reevaluation. When asked if the plan of care was changed after the reevaluations, the PT stated, "The plan of care stayed the same." Further interview revealed that Resident #1 was not evaluated for assistive devices because the facility is a "restraint free" facility per the PT. The facility restraint policy stated "alternatives will be tried prior to recommending transfer to a higher level of care." The alternatives were limited to : close observation, reminding the resident not to get up unassisted, place bed in low position and or mat by bed; assess/careplan for fall risk; advise family of risk for harm from fall; color code chart/door to make staff aware of need of close observation; use bed/chair alarm. The resident's environment was not evaluated by PT who stated, "The resident's environment did not need to be changed." The PT stated that she recommended that Resident #1's wife should not be getting him up. but to call for Certified Nursing Assistant/staff only for assistance when transferring the resident, but the resident's wife ignored the PT recommendation. There was no documentation related to the counseling provided. During conversation, the PT was unaware of the total of 9 incidents regarding falls. She stated was only aware of 3 and the last fall on 3/12/12 prior to the resident leaving the facility. There was no evidence found that the facility coordinated care with the rehabilitation department to assure the resident received services that evaluated the physical environment; assured proper footwear; educated the family and sitter related to safety; worked with the resident to attempt to improve attentions span or safety awareness in order to attempt to decrease the frequency of falls. Observation of the resident's room revealed there were no mat(s) by the bedside and the bed was free-standing within the room which would allow the resident to roll/fall/exit from either side of the bed. During an interview with the Assistant Director of Nursing (ADON) on 3/14/12 at 9:10 AM revealed that Resident #1 was no longer at the facility. Upon notification that Resident #1 fell in dining room the previous evening, the wife declined sending the resident to the emergency room for evaluation after the fall, she requested that the resident be transported home. The resident was transported home at approximately 7:00 PM on 3/14/12 per the wife's request. During a telephone interview on 3/15/12 at 2:47 PM, the Medical Director (MD) revealed that Resident #1 was originally scheduled to have a Cerebral Spinal Fluid Ventriculography for evaluation of Normal Pressure [DIAGNOSES REDACTED] in 3 weeks due to frequent falls, but the family requested that the evaluation be moved sooner if possible due to continued falls. The resident was to have an evaluation at the hospital on [DATE]. The MD stated he understood fall precautions to include transfer belts, alarms for the bed and chair, but that it was ok to have alarms off when the resident had a 1:1 sitter. The MD stated that he would expect the facility to implement new interventions if the current plan of care was not effective. He stated, "We need to keep working on it." When informed of the interventions and asked if he thought they were enough, the MD stated, "It doesn't sound like it." The MD stated the reason Resident#1 was at the facility was because of previous falls with head injuries. The MD stated that he would have liked to have tried a Geri-chair, but the facility is a restraint free facility and "does not allow them". Observations on 3/12/12 at approximately 1:35pm revealed the door to the resident laundry room unsecured. In the room on the floor next to the laundry sink was a 5 gallon covered bucket of laundry softener/sanitizer, which was part of a dispensing system, labeled "Keep Out of Reach of Children". The active ingredient of the product was ammonium chloride. Observations made at 3:00pm and 4:30pm revealed the above conditions remained in place. Observation and interview at 6:00pm with the Administrator revealed that door remained unsecured. When asked if the door should be unsecured, Administrator stated no due to chemicals in the room and promptly secured the door. There were no cognitively impaired mobile residents present throughout the observation period.