Every finding on record at Lancaster Health and Rehabilitation

Based on review of facility policy, observation, and interview, the facility failed to ensure foods that are stored in the cooler/refrigerators and dry food storage were appropriately sealed, labeled, dated with a use by date and/or discarded after the manufacturer's expiration date, for 1 of 1 kitchen reviewed.Findings include:Review of the facility policy dated 10/15/2025, titled Food Safety in Receiving and Storage, revealed, Refrigerated Storage Guidelines . 12. Refrigerated, ready to eat Time/Temperature Control for Safety Foods (TCS) are properly covered. Labeled, dated with a use-by-date, and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded .Review of the facility policy dated 10/15/2025, titled Safe Food Handling, revealed, .There is no bare hand contact.During an observation on 07/26/2026 at 10:20 AM, the walk-in cooler revealed walls and shelves with an accumulation of a black and brown moldlike substance.Further observation at 10:23 AM, of the walk-in cooler revealed the following food items stored beyond their used by date:1 - large pan of ready-to-eat sandwiches with prep date 07/22/26, use by date 07/24/26.1 - large pan of ready-to-eat sandwiches with prep date of 07/23/26, use by date 07/25/26.1 - Ziploc bag of sliced deli meat with no prep date and no use by date.1 - large container marked chicken salad with prep date 07/23/26 use by date 07/25/26.2 - small salad bowls with no prep date and no use by date.During an observation on 07/26/2026 at 11:07 AM, the dry food storage room revealed the following:1 - 25-pound (lb.) bag of grated panko breadcrumbs dated 06/04/2026, no open or use by date.1 - package of egg noodles with prep date 05/28/2026 and use by date 06/28/2026.3 - bags of cereal open and not properly closed with no open or use by date.During an observation of staff preparing for lunch and plating trays on 07/26/2026 at 12:20 PM, revealed a kitchen employee plating dinner rolls with her bare hands.During an interview on 07/26/2026 at 12:21 PM, the Assistant Dietary Manager (ADM) revealed that staff does not use gloves when plating and serving meal trays. The ADM further explains that staff should use tongs to place bread on trays and that they should not touch food with their bare hands. The ADM further revealed that food items in the refrigerators/coolers and freezers should be date labeled and then they should be tossed after three (3) days and if expired.

Based on review of facility policy, observation, interview, and record review, the facility failed to ensure expired medications were removed from the 100 Hall Medication Cart and discarded per facility policy. Specifically, Resident (R)109 had a medication card of Midodrine 5 mg that expired on 07/21/26 and was still on the medication cart on 07/27/26, for 1 of 5 medication carts reviewed for medication storage. Findings include: Review of the facility policy titled, Pharmacy Services Policies and Procedures Section8-Medication Storage with a revision date of 04/01/22, revealed, Policy: . 1. Medications and biologics are stored safely, securely and properly following manufacturer's recommendations or those of the supplier . Procedures: . 5. Medications with manufacturer's expiration date expressed in month and year (e.g., May, 2019) will expire on the last day of the month. (unless a sooner expiration date has been placed on the package by pharmacy).Review of R109's Face Sheet revealed R109 was admitted to the facility on [DATE], with diagnoses including but not limited to, heart failure, dementia, schizoaffective disorder and other specified extrapyramidal and movement disorders. Review of R109's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R109 was cognitively intact. Review of R109's Orders revealed an order for Midodrine 5 mg 1 tablet, Special Instructions: Give one tablet by mouth three times a day. Hold if systolic blood pressure is greater than 110.During an observation and interview of the 100-Hall A Medication Cart on 07/27/26 at approximately 4:00 PM, revealed a medication card for R109 for Midodrine 5mg tablets with an expiration date of 07/21/26. Licensed Practical Nurse (LPN2) verified the expiration date of 07/21/26.During an interview on 07/27/26 at 3:32 PM, the Director of Nursing (DON) revealed that the nurse that is administering the medication should be checking the expiration date before administering the medication to a resident. If the medication is expired, it should be removed from the medication cart and disposed of per facility policy.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide Resident (R)24 with Activities of Daily Living (ADL) Care, specifically fingernail care, for 1 of 1 resident reviewed for ADL care. Findings include: Review of the facility policy titled, Activities of Daily Living, Optimal Function with a revision date of May 5, 2023, revealed, Definition: Activities of daily living (ADLs), refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing and communication system. Policy: . The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. Review of R24's Face Sheet revealed he was admitted to the facility on [DATE], with diagnosis including but not limited to, dementia, major depressive disorder, and Epilepsy. Review of R24's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/26, revealed R24 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, suggesting that he has no cognitive impairment. Further review of the MDS revealed R24 was dependent for toileting, showering, lower body dressing, and putting on and taking off footwear. Also, R24 needs set up clean up assist with personal hygiene.Review of R24's Care Plan with a revision date of 05/14/26, revealed that R24 requires staff assistance with ADL's related to decreased range of motion in bilateral lower extremities, cognitive impairment and bowel and bladder incontinence. Staff provides assistance with shaving, mobility, oral care, bathing and toileting hygiene. The Care Plan also states that R24 will receive all necessary assistance to maintain clean, well-groomed appearance through next review. During an observation on 07/26/26, revealed R24 was in his room, in bed and wearing a hospital gown. R24's finger nails on both hands were noted to have black matter underneath all finger nails. During an observation and interview on 07/27/26 at an unspecified time, R24 was in his room wearing a hospital gown. R24's finger nails on both hands were still noted with black matter underneath all finger nails. R24 stated that his nails were never in this condition when he was able to take care of himself.During an interview on 07/28/26 at approximately 11:30 AM, Certified Nursing Assistant (CNA)1 revealed, I am not really sure how often we are supposed to do nail care on residents. If they start looking bad I do it. I really clean resident's nails once a month or as needed. He [R24] would need help with nail care.During an interview on 07/28/26 at 11:50 AM, Licensed Practical Nurse (LPN)1 revealed, He [R24] depends on the CNAs for most of his care. Nail care is done weekly during showers.During an interview on 07/28/26 at 12:02 AM, LPN1 revealed, I saw black dirt under his fingernails, on his left hand mostly.During an interview on 07/28/26 at 2:52 PM, the Director of Nursing (DON) revealed, the CNAs should perform nail care twice a week on the resident's shower days.

Based on review of the facility policy, observation, interview, and record review, the facility failed to ensure that staff demonstrated the required competencies to provide safe tube-feeding management for 1 of 1 resident (Resident (R)5). Specifically, the facility failed to ensure that nursing staff possessed and demonstrated the necessary competencies to manage tube feedings safely. The lack of competency resulted in the tube feeding being administered while the resident was laying flat in a supine position. This failure resulted in the resident receiving tube feeding in a supine/flat position at zero (0) degrees, thereby placing the resident at risk for aspiration, abdominal distention, nausea, and avoidable discomfort. Findings include:Review of the facility policy titled Sample Guidelines for Writing Enteral Orders, Standard Gravity Bolus Tube Feeding Order with a complete revision date of May 5, 2023, states to elevate HOB (head of bed) 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped.Review of R5's Face Sheet revealed the resident was admitted to the facility on [DATE] with an extensive medical history, including but not limited to diagnoses of: hemiplegia and hemiparesis, acute cough, chronic obstructive pulmonary disease (COPD), pain, anxiety disorder, dysphagia, long-term opiate analgesic, vascular dementia, seizures, and gastro-oesophageal reflux disease (GERD), warranting absolute total care as noted on the resident's face sheet notes.Review of R5's physician's orders indicated a tube feed order to keep R5's head of his bed elevated every shift. Days 07:00 AM - 07:00 PM and Nights 07:00 PM - 07:00 AM.Review of R5's Care Plan and Medication Administration Record (MAR) revealed an order dated 11/19/2025 for Glucerna 1.5 at 60 cc/hour x 22 hours/day along with a monitoring approach noted to observe for and report signs and symptoms of aspiration, congestion, coughing, elevated temperature, and abdominal distention.Review of R5's MAR indicated to keep head of bed elevated every Shift 10/27/2025 - open-ended.Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 10/15/2025 revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating R5's cognition to be severely impaired.During an interview with Resident (R)6, who is R5's roommate, on 11/19/25 at approximately 3:45 PM, R6 stated he had been waiting approximately one hour for staff to assist his roommate with elevating the head of his bed. R6 further explained that R5 was unable to speak up for himself and that he wanted to advocate not only for himself but also on behalf of his roommate.During an observation on 11/19/25 at approximately 3:45 PM, R5 was witnessed laying flat in a supine position while actively receiving his tube feeding, which initiated an immediate nurse notification. The nurse and Administrator promptly repositioned R5 and verified tube feeding, as appropriate. R5 appeared to be in no apparent distress, as indicated by his flat affect and lack of behaviours.During an interview on 11/19/25 at approximately 4:39 PM, R5's floor nurse, Licensed Practical Nurse (LPN)1 revealed R5 was last seen sitting with the head of his bed elevated at an appropriate position for feeding (30 to 45 degrees). LPN1 further stated that she believed the agency Certified Nursing Assistant (CNA), last seen with the resident, may have repositioned the resident while providing care and left without elevating his head. Although she was unable to definitively state when R5 was laid supine, LPN1 further explained that it is expected that all CNAs round every two (2) hours.During an interview on 11/19/25 at approximately 4:45 PM, CNA1 revealed when changing or adjusting residents with tube feedings, the feeding pump is placed on hold, head of the bed lowered, the bed is adjusted and/or the resident is changed as needed, and then the head of the bed and feeding pump are turned back on. CNA1 reports 1st shift CNA changed R5 at the end of the 1st shift. CNA1 stated she had not made her rounds yet to R5's room; however, she was made aware of the head of bed not being elevated during tube feed by other staff after being discovered by two surveyors.During an interview on 11/19/25 at approximately 4:55 PM, the Director of Nursing (DON) revealed nurses are responsible for tube feeding management. Administration enters orders, and nursing staff are expected to check rates and flush tube feeding, as appropriate. Additionally, CNAs are expected to round every two (2) hours, and nonverbal residents are under constant supervision. The DON further stated that CNAs hold tube feeding while residents are being repositioned.

Based on interview, record review, Center for Disease Control (CDC) guidance and policy review, the facility failed to evaluate antibiotic usage for four of six residents (Resident (R)76, R53, R49, and R14) reviewed for antibiotic usage out of 27 sample residents. This failure had the potential to affect all 126 residents in the facility related to antibiotic usage. Findings include: Review of an undated, untitled CDC document located at http://uprevent.[NAME].com/2855wp/wp-content/uploads/2018/01/nh-hac_mcgreercriteriarevcomp_2012-1.pdf; revealed, The Core Elements of Antibiotic Stewardship for Nursing Homes indicated .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority .Antibiotic stewardship refers to a set of commitments and actions designed to 'optimize the treatment of infections while reducing the adverse events associated with antibiotic use' .CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use .Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors . Review of the facility's policy titled, Antibiotic Stewardship Program dated 07/08/21 revealed, The facility has a formal Antibiotic Stewardship Program (ASP) to optimize the treatment of infections, reduce the risk of adverse events, including the development of antibiotic-resistant organisms and employs a facility-wide system to monitor the appropriate use of antibiotics .When signs or symptoms are present that may indicate an associated infection, a licensed nurse initiates and completes a Suspected Infection Situation, Background, Assessment, and Recommendation (SBAR) tool, prior to contacting the licensed independent practitioner .Facility provides education to providers on the use of SBAR and methodologies employed to eliminate unnecessary testing and inappropriate antibiotic use. 1. Review of R76's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed R76 was admitted to the facility on [DATE]. On 02/03/25, R76 had purulent drainage from two areas to the right of the g-tube with orders pending. On 02/04/25, R76 had new orders for Amoxicillin 875 milligram (mg) one tab every 12 hours x (times)14 days and Doxycycline 100mg one tab every 12 hours x 14 days. The wound culture was received by the lab on 02/05/25 and reported to the facility on [DATE] which showed strep viridans group. 2. Review of R53's Admission Record located under the Profile tab of the EMR revealed R53 was admitted to the facility on [DATE]. On 03/11/25, an order was received for Augmentin 874-125mg x 10 days related to a bacterial infection. An order for a urinalysis with culture and sensitivity (UA and C&S) was received on 03/11/24 and collected. 3. Review of R49's Admission Record located under the Profile tab of the EMR revealed R49 was admitted to the facility on [DATE]. On 03/12/25 a wound culture was sent to the lab for an abscess on the right second finger and areas to the sacrum and right hip. An antibiotic was started on 03/12/25 of doxycycline hyclate 100 mg twice a day. Lab results returned on 03/15/25 with proteus mirabilis. On 03/17/25, R49 was started on one amonicillin-pot clavulanate 875-125 mg every 12 hours. 4. Review of R14's Admission Record located under the Profile tab of the EMR revealed R14 was admitted to the facility on [DATE]. On 03/14/25, an order for UA and C&S was given and levofloxacin 750mg twice a day for five days started. The results from the lab came back on 03/16/25 showing more than three organisms present in the urine and to please recollect. The repeat UA and C&S was not completed. Interview on 05/07/25 at 2:25 PM with the Infection Preventionist (IP) revealed We have an issue with the nurse practitioners (NP) ordering antibiotics without culture results or an x-ray. I do not say anything to the NP's or the Medical Director about starting an antibiotic before receiving results or following McGeer's criteria. On 05/08/25 at 9:25 AM, interview with the Administrator revealed This was brought to our attention at a February Quality Assurance and Performance Improvement (QAPI) meeting. We asked our Medical Director to talk to the two NPs about antibiotic stewardship, and she stated that she would. Phone interview on 05/08/25 at 10:06 AM with NP2 revealed The Medical Director did talk to me about antibiotic use. If a resident has two symptoms, then I can start an antibiotic before the culture returns. I was given a paper about what to do, but I do not know if it was McGeer criteria. I will start an antibiotic according to resident symptoms because I do not want them to go south. On 05/08/25 at 11:37 AM, a phone interview with NP1 revealed The Medical Director did talk to about antibiotics. I treat empirically without culture results if I feel that treatment will be delayed. Interview with the Administrator on 05/08/25 at 11:48 AM revealed We do not have a Suspected Infection SBAR for these four residents. It was not done.

Based on observation, resident interviews, staff interviews, and facility policy review, the facility failed to prevent misappropriation of narcotic medications 3 of 3 residents (R) reviewed, R1, R2, and R3. Findings included: Review of the facility's policy titled, Administration of Scheduled Controlled Medications, revised date 04/17/2024, revealed, Administration of Scheduled controlled substances will be consistent with the policies for general medication administration with the additional of logging all doses on a controlled drug receipt/record/disposition form for each controlled substance order. The following procedures included: 2. All Scheduled controlled medications removed from storage for the purpose of administering doses to the resident will be entered onto the resident's-controlled drug receipt/record/disposition form. 3. The licensed nurse/authorized staff member will then count or measure the remaining drug quantity in stock and enter the amount remaining onto the resident's-controlled drug receipt/ record/disposition form. 4. Any discrepancies in the resident's-controlled drug record/disposition form must be immediately reported to the Director of Nursing and/or per facility policy. Review of the facility's policy titled, Storage and Reconciliation of Controlled Substances, revised 04/17/2024, revealed, the Facility will have systems in place to ensure the safe and secure storage of Controlled Substance Medications and the facility will conduct routine reconciliations of all controlled substances to prevent any potential loss or diversion. The following procedures included: D. The nurse/authorized staff member visually checks this number against the Inventory Record Sheet. Review of R1's Face Sheet revealed admitted to facility on 03/04/2024 with diagnoses including but not limited to: acute respiratory failure with hypoxia, chronic systolic (congestive) heart failure, chronic pain, dependence on oxygen, and pain. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/2024 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R1 cognitive response is intact. Review of R1's Care Plan with a start date of 03/21/2024 and an edit date of 07/01/2024 documented, R1 is currently taking [x] Analgesic. Further review of the Care Plan revealed the following approach, Licensed Nurse will monitor vital signs including temperature, blood pressure, pulse, respirations, oxygen saturation, and pain each shift. Review of R1's Physician Orders dated 03/04/2024 revealed the following order Every Shift (3) Check resident for level of pain utilizing numeric rating scale 0-10 or verbal descriptor scale (M)Mild, (MO)Moderate, (S)Severe, (VS)Very Severe Other Test (). Review of R1's Physician Orders dated 08/20/2024 revealed the following order Lorazepam-Schedule IV tablet; 0.5 mg [milligrams]; amount to administrator: 1 tablet oral. Review of R1's Progress Note dated 08/29/2024 revealed the following Resident continues with Ativan 0.5 mg twice daily PRN [as needed] for anxiety. No acute changes. Review of R2's Face Sheet revealed admitted to facility on 08/12/2024 with diagnoses including but not limited to: long term (current) use of opiate analgesic, chronic systolic (congestive) heart failure, pain, and acquired absence of right leg, above knee. Review of R2's Admission MDS with an ARD of 11/14/2024 revealed R2 had a BIMS score of 15 out of 15, indicating R2 cognitive response is intact. Review of R2's Care Plan with a start date of 11/29/2022 documented, R2 has potential for pain Related To (R/T) mobility, pressure injury and arterial ulcers, chronic pain. Further review of the Care Plan revealed the following approach, Administer pain medication as ordered. Document response/effectiveness of medication and/or interventions and collaborate with Medical Doctor (M.D.) if pain control measures currently ordered are ineffective. Review of R2's Physician Orders dated 08/12/2022 revealed the following Every shift checking resident for level of pain utilizing numeric rating scale 0-10 or verbal descriptor scale (M)Mild, (Mo)Moderate, (S)Severe, (VS)Very Severe Other Test:(). Review of R2's Progress Note dated 10/10/2024 revealed Debrox continue for impacted Cerumen in left ear. Resident denied pain or discomfort, No other pain related notes reviewed. Review of R3's Face Sheet revealed admitted to facility on 09/18/2023 with diagnoses including but not limited to: Unspecified fracture of fifth of fifth lumbar vertebra, sequela (Primary), Displaced comminuted fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing (History of), and pain, unspecified. Review of R3's Admission MDS with an ARD of 09/25/2024 revealed R2 had a BIMS score of 15 out of 15, indicating R3 cognitive response is intact. Review of R3's Care Plan with a start date of 10/12/2023 documented, R3 is at risk for pain r/t right arm fracture, bursitis of right knee. He needs pain monitoring by skilled nurse to manage pain and promote rehab potential. Further review of the Care Plan revealed the following approach, Administer medications as ordered. Evaluate/record/report effectiveness and any adverse side effects. Review of R3's Care Plan with a start date of 10/12/2023 documented, Monitor and record any complaints of pain: location, frequency, intensity, affect on function, alleviating factors, aggravating factors. Report to MD any new or worsening pain, or if pain management not effective for relief of pain. Review of R3's Physician Orders dated 09/18/2023 revealed the following Every shift checking resident for level of pain utilizing numeric rating scale 0-10 or verbal descriptor scale (M)Mild, (Mo)Moderate, (S)Severe, (VS)Very Severe Other Test:(). Review of R3's Progress Note dated 08/12/2024 revealed PT/OT progress. The resident is one assist with care and two to transfer. Resident is incontinent of bowel and is able to use the urinal. Residents is on pain management for back pain and generalize pain. Resident is able to feed self and tolerate his meals well. Resident take his meds whole with no complication. Resident corporates well with the staff and his roommate. Blood sugar monitor daily with coverage. Resident lungs are clear and respiratory effort normal. ABT Amoxicillin in progress. No ADR. PO fluids encourage. PRN eye drops given for dry eyes. Will continue to monitor. Review of R1's Controlled Drug Receipt/Record/Disposition Form on 12/11/2024 at 3:20 PM, revealed R1's oxycodone/APAP tab 10/325mg 1 tablet removed with each occurrence on the following days: 08/27/2024 at 12:00 AM, the count decreased from 47 to 43 pills. The count decreased by 4 pills. 08/25/2024 at 12:00 AM, the count decreased from 63 to 58 pills. The count decreased by 5 pills. 08/20/2024 at 06:00 PM, the count decreased from 87 to 79 pills. The count decreased by 8 pills. 08/16/2024 at 06:00 PM, the count decreased from 110 to 108 pills. The count decreased by 2 pills. 08/17/2024 at 12:00 AM the count decreased from 108 to 102 pills. The count decreased by 6 pills. 08/03/2024 at 05:02 PM the count decreased from 46 to 44 pills. The count decreased by 2 pills. 07/21/2024 at 05:03 PM, the count decreased from 104 to 102 pills. The count decreased by 2 pills. 07/29/2024 at 05:00PM, the count decreased from 75 to 72 pills. The count decreased by 3 pills. Review of R2's Controlled Drug Receipt/Record/Disposition Form on 12/11/2024 at 3:20 PM, revealed R2's oxycodone/APAP tab 10/325mg 1 tablet removed with each occurrence on the following days: 07/05/2024 at unknown time, the count decreased from 27 to 25 pills. The count decreased by 2 pills. 07/09/2024 at 02:00PM, the count decreased from 14 to 12 pills. The count decreased by 2 pills. 07/19/2024 at 02:00 PM, the count decreased from 72 to 70 pills. The count decreased by 2 pills. Review of R3's Controlled Drug Receipt/Record/Disposition Form on 12/11/2024 at 3:20 PM, revealed R3's oxycodone/APAP tab 10/325mg 1 tablet removed with each occurrence on the following days: 08/25/2024 at 06:00 AM, the count decreased from 28 to 25 pills. The count decreased by 3 pills. 08/22/2024 at 05:00 PM, the count decreased from 48 to 42 pills. The count decreased by 6 pills. 07/29/2024 at 12:00 PM, the count decreased from 40 to 38 pills. The count decreased by 2 pills. 07/19/2024 at 06:00 PM, the count decreased from 75 to 73 pills. The count decreased by 2 pills. During an interview on12/11/2024 at 3:10 PM, Licensed Practical Nurse (LPN)1 stated, I think one day I came to work, the Nurse Practitioner (NP) wrote a script and I was going to give the resident her medication. When I called the pharmacy, they said LPN1 you should have at least six to nine pills left. That is when I called the nurse manager (LPN2). I didn't know it was a problem. I called about R2 and the pharmacy told me they couldn't send any additional meds. I didn't notice anything out of the norm. There is a nurse who works alot. She appeared tired a lot, but nothing out of the norm. It appears someone forged my signature on 08/11/2024 at12 Noon and 08/11/2024 at 06:00 PM. I don't use military numbers, nor do I work on Sundays. During an interview on 12/11/2024 at 03:31 PM, LPN1 stated, My signature is forged. I don't work on Sunday's referencing 08/11/2024. During an interview on 12/11/2024 at 3:39 PM, LPN1 stated, I always write 1 tab. I never just put 1. During an interview on 12/11/2024 at 4:24 PM, LPN2 stated, We do random audits on the medication carts. We do it three times a week. We had a plan in action for the form. Pharmacy comes in and look at the cart also. Pharmacy comes once a month. The pharmacy rotates reviewing the carts along with the refrigerators. I heard about the diversion, but I was not involved. The unit managers review the audits for their medication carts. I am also responsible for checking the medication carts. I usually look at insulin and expired medications. I did not see any suspicious activity on the controlled drug disposition form. I had no suspicion of Registered Nurse (RN)1. She is a good nurse. She worked the third shift. So, I didn't see her unless in passing in the morning. We don't have a designated supervisor at night. During an interview on 12/11/2024 at 4:46 PM, RN1 stated, I don't know what happened. The Director of Nursing (DON) stated it look like someone set me up. The numbers looked changed or altered. RN1 stated, As long as my count is right, I don't go back to review the count, because my count is right. Apparently, the number before I pulled was altered. The protocol for suspicion is everyone on the cart should be drug tested . Everyone was not drug tested or suspended. I never had a problem with the count being off. The DON & Staff Development Coordinator (SDC) called me on the phone. I couldn't understand what they were saying, so I told them I would come in person. I came in person and talked with the DON, ADON, & SDC in the office. When we count, and they call out the number and it match, I don't question the count. The DON kept saying it looks like someone set you up. I am not quite sure. I took a drug screen. My drug screen was negative. They terminated me before my drug screen came back. During an interview on 12/11/2024 at 1:28 PM, DON stated, The South Carolina Department of Labor, Licensing and Regulation (LLR) requested copies of the Medication Administration Record (MAR). This is my first time having to investigate this type of misappropriation of medications. It was hard following the MAR. I had just written her up for medication administration. During an interview on 12/11/2024 at 1:43 PM, DON stated, I noticed several pills were missing from the Narcotic sheet the way it was written. RN1 was written up prior for not documenting appropriately when she removed a narcotic. We assessed the residents. The residents didn't complain of having pain. DON stated RN1 would tell me she would give the medication and then document it later. Therefore, since I talked to her about her documentation, we had to give her a written warning. During an interview on 12/11/2024 at 5:19 PM, DON stated, We do not have cameras. During an interview on 12/11/2024 at 5:56 PM, the Assistant Director of Nursing (ADON) stated, I am responsible for printing out all medication delivery inquires by the end of the month; it would be the delivery for the month of September. During an interview on 12/11/2024 at 06:23 PM, Administrator stated, I wasn't here for the alleged diversion. The only thing I am aware of is the audits. The number of medications match the narcotic sheets. The audits are being done twice a week. I am unsure of the number of weeks we completed.

Based on observations, interviews, and facility policy review, the facility failed to properly label, store and discard expired foods in 1 of 1 kitchen. Findings include: Review of the facility's Cold Storage Chart revised on [DATE], revealed, references to food products with proper storage temperatures and length of storage for (opened, unopened, and cooked) foods, in the refrigerator and freezer. During an observation on [DATE] at 10:32 AM, an initial kitchen walkthrough with the Dietary Manager (DM) revealed the following: (1) one bag of iceberg lettuce discolored, opened not dated or labeled. (1) one package of sliced bologna, expired [DATE]. (1) one large metal serving pan of chicken salad sandwiches, pinto salad sandwiches, and peanut butter and jelly sandwiches, not dated or labeled. (1) container of coleslaw, expired [DATE] cornbread in saran wrap, expired [DATE]. During an interview on [DATE] at 10:32 AM, the DM stated the food truck came every Monday and Thursday. When inventory was received the items are labeled with the date before being put away. Staff were to label food items opened, pulled for use, or thawed, with the date and time. The leftover food that would be used again, were to be labeled with what the items were, the date, time, and the expiration/use by date. The DM stated that staff were aware of how to properly label and store food items because there was a chart posted in both the dry storage and refrigeration areas of the kitchen which stated the number of days a food item could be stored or with the use by date.

Based on review of facility policy, observations, record review, and interviews, the facility failed to follow a procedure during wound cleaning for Resident (R)103 and R121 to prevent the likelihood of infection for 2 of 3 residents reviewed with pressure ulcers. Findings include: Based on the facility policy titled Performing A Dressing Change states as the policy: A dressing change will follow specific manufacturer's guidelines and general infection control principles. The Procedures listed are: NOTE: (Wash hands before and after donning gloves). 1. Don gloves. 2. Remove old dressing and packing (if present). (Change gloves) 3. Cleanse the wound of drainage, debris, or dressing/filler residue. (Change gloves) 4. Assess the wound (measuring done here). (Change gloves) 5. Pack the dead space of large wounds. (Change gloves - if needed). 6. Apply a cover dressing - date and initial cover dressing, place a time reference on it. (Remove gloves, discard waste). 7. Provide the patient/resident and caregiver education. 8. The clinician documents all procedures performed as well as the patient's/resident's/caregiver's response. 9. Follow manufacturer's guidelines (available on the wound care product's package insert and physician orders when using any wound care product. Review of a document titled Staff Education/Orientation Policies and Procedures Nursing Competency: Dressing, Simple: Application Of revealed #38. states, Cleanses wound as ordered. No other instructions included on the correct procedure in cleaning a wound/wound bed. Review of the Lippincott Nursing Manual provided by the facility revealed on page 801, on caring for wound, states: For an open wound, clean the wound in a full or half circle, beginning in the center and working outward. Use a new pad for each circle. Clean at least 1 inch (2.5 cm) beyond the end of the new dressing. Review of R103's Face Sheet revealed the facility admitted R103 with diagnoses including, but not limited to: Alzheimer's/Dementia and acquired a stage 4 pressure ulcer while residing in the facility. Review R103's Physician Order revealed an order for, daily dressing changes to stage 4 pressure ulcers. The order stated, to cleanse the left buttock with normal saline and apply alginate and cover with border gauze daily. An order for wound care to the coccyx stated to cleanse the coccyx with normal saline and apply mesalt and alginate and cover with border gauze daily. During observation of wound care for R103 on 04/03/2024 at 8:40 AM went as follows: Licensed Practical Nurse (LPN)1 performed the wound care and a Certified Nursing Assistant (CNA) assisted. R103 is on advanced barrier precautions due to the open wounds. The LPN and the CNA knocked on R103's door and asked permission to enter. The LPN explained the procedure to the resident. The LPN and the CNA proceeded to wash their hands, and this surveyor asked permission to observe the nurse performing wound care and she nodded, indicating that it would be ok. Privacy was provided. The LPN opened a plastic bag of supplies and placed a drape on the over bed table. She taped 2 clear plastic bags, one on each end of the table, one for trash and one for soiled linen used during the dressing change. The CNA applied a gown, due to the advanced barrier precautions, washed her hands and applied gloves. The CNA then aided the resident to position onto her right side. The LPN then washed her hands, applied a gown and gloves, and opened the supplies, cleaned the scissors and placed them on the drape on top of the table. The LPN removed her gloves and gown, washed her hands and applied gloves and placed 4x4's into 2 plastic cups. She poured normal saline into one cup of 4x4's. The LPN then further aided the CNA in positioning the resident further over in the bed making the wound more accessible for the wound care. The LPN then removed the soiled dressing from the coccyx and while in hand pulled the glove over the soiled dressing and discarded it into the trash. The wound bed is beefy red with a scant amount of drainage. No odor. The LPN then removed her gown and washed her hands and then applied a gown and gloves and took the normal saline soaked gauze and cleaned down the outside of the wound, each side using a clean 4x4 soaked with normal saline. The LPN then cleaned inside the wound bed with a saline soaked 4x4 x1, going from top to bottom, starting outside the wound bed at the top and continuing beyond the outer edges of the open wound bed. The LPN removed her gloves and gown and washed her hands, she applied a gown and gloves and applied a small cut piece of mesalt and alginate into the wound bed and applied the border gauze. The LPN removed her gloves and gown, washed her hands and applied a gown and gloves and removed the soiled dressing from the left buttock, taking the soiled dressing into her right gloved hand and removing her gloves so that the soiled dressing went inside the glove and then placed the soiled gloves into the trash. LPN1 then removed her gown and washed her hands. The LPN applied a gown and gloves for the wound care of the left buttock. She cleaned the wound with normal saline. First cleansing each outer side of the wound with one swipe and discarding the soiled 4x4. The wound bed has a small amount of slough, and is small in size. The LPN then removed her gloves and gown, washed her hands and applied a gown and gloves. Using a saline soaked gauze she wiped from top to bottom of the wound, bringing the outside area of the wound through the wound bed. The LPN then removed her gloves and gown and washed her hands and applied a gown and gloves and placed a small amount of alginate into the wound bed and covered it with bordered gauze. The LPN then took a marker and wrote the date and initials on the clean dressing. The LPN aided the CNA in making the resident comfortable. She placed the soiled linen and the trash in the soiled linen room and washed her hands and then charted the treatment. Review of R121's Face Sheet revealed the facility admitted R121 with diagnoses including, but not limited to: Alzheimer's Disease and a pressure ulcer of the left and right buttocks. During observation of wound care for R121 on 04/03/2024 at 9:13 AM went as follows: LPN1 performed the wound care and CNA assisted. Review of the physician's order states, Cleanse the left and right buttocks with normal saline and apply Alginate and cover with a border gauze. The LPN knocked on the resident's room door, asked permission to enter, the LPN informed this surveyor that R121 is usually non verbal. R121 is also on Advanced Barrier Precautions. This surveyor asked permission to observe the wound nurse providing wound care and she said, yes. LPN1 explained the procedure to the resident. The LPN and the CNA washed their hands, provided privacy. The CNA applied PPE which consisted of a gown and gloves. The LPN went to the treatment cart to get 2 trash bags and came back into the room and taped the 2 bags to the over bed table, taped one on each end of the table. The LPN applied gloves and applied a drape on top of the over bed table and opened the supplied, removed her gloves and washed her hands and applied a gown and gloves. She placed 4x4's into 2 plastic cups and in one cup of 4x4's she poured the normal saline. LPN1 then removed her gloves and gown and washed her hands and applied a gown and gloves. The CNA raised the bed, and both aided the resident in turning and positioning onto her right side. Then the LPN unfastened the resident's brief and removed the soiled dressing from the left buttock. The wound bed is pink, with debris, with pieces of alginate that has stuck to the outer edges. The wound bed is long, the surrounding tissue is dark in color. The LPN then removed her gloves and gown and washed her hands, she wiped the outer right side of the wound 1x with normal saline soaked gauze from top to bottom and then discarded the soiled gauze. The LPN took another saline soaked gauze and wiped from top to bottom of the wound 2x taking care not to go beyond the wound bed and onto the surrounding edges to drag the outside tissue of the wound into the wound bed, bringing debris and germs. The LPN then removed her gloves and gown and washed her hands and applied a gown and gloves, and applied alginate to the wound bed and covered the wound with border gauze. She then removed her gloves and gown and washed her hands. She then applied a gown and gloves and removed the dressing from the right buttock. The wound bed is round in size with a small amount of slough, and 3 other small peeling raw areas. The surrounding tissue is dark in color and is easily peeling off. The LPN removed her gloves and gown and washed her hands. She then applied a gown and gloves and took saline soaked 4x4's and cleaned the surrounding tissue and the wound bed at the same time, wiping from top to bottom 3x. The small quarter size wound peeled as she wiped from the top of the wound and as she kept wiping, the open wound peeled even more. The wound bed was cleaned in a circular motion from the center to the outside edges. The LPN then removed her gloves and gown and washed her hands, applied a gown and gloves and opened the alginate and applied it to the wound bed and then applied the border gauze. The LPN then removed her gloves and gown and washed her hands and applied a gown and gloves and wrote the date and her initials onto the border gauze of each of the 2 wounds. She aided the CNA in making the resident comfortable. The LPN then removed her gloves and washed her hands and bagged the trash and the soiled linen and carried it to the soiled utility room and washed her hands and charted the treatment. During an interview on 04/03/24 at 9:30 AM, LPN1 confirmed that she had cleaned the wounds from top to bottom, cleaning the outside first and then the wound bed dragging debris and outer tissue into the wound beds.

Based on review of facility policy, record review, and interviews, the facility failed to ensure Resident (R)88, with mental illness, was screened and evaluated for a PASARR Level II. The facility further failed to ensure R102, with a diagnosis of Paranoid Schizophrenia, was screened and evaluated for a PASARR Level II for 2 of 4 residents reviewed with diagnosis that warrant screening and evaluation. Findings include: Based on the facility policy titled PASARR Documentation Policy General Guidelines for PASAR states: 1. PASARR requires that: A. All applicants to a Medicaid-certified nursing facility are evaluated for mental illness and or intellectual disability, prior to admission and; B. Offered the most appropriate setting for their needs which may be in the community, a nursing facility, or an acute care setting, and; C. Receive necessary services in those settings to address any specific need related to the diagnosis of mental illness or intellectual disability. 10. The facility must notify the state-designated mental health or intellectual disability authority promptly when a resident with mental disability (MD) or intellectual disability (ID) experiences a significant change in mental or physical status. PASARR CARE PLAN: 6. Any resident with newly evident or possible serious mental disorder, ID or a related condition must be referred, by the facility to the appropriate state-designated mental health or intellectual disability authority for review. Examples of individuals who may not have previously been identified by PASARR to have MD, ID or a related condition include: - A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). - A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. Review of an undated document provided by the facility on PASARR Level II screening states: The federal definition of Mental Illness and possible indicators for a level II for PASARR is best understood in terms of the four D's: 1. A diagnosis or suspicion of a major mental illness such as schizophrenia, bipolar disorder, major depression, or an anxiety disorder. 4. A particular level of disability. The individual's Mental Illness must have resulted in functional limitations in major life activities within the past 3 to 6 months. The individual need not have received treatment. The severity of the impairment and how recently it occurred are important, not whether the individual was hospitalized or was seen by a mental health professional. Review of R88's Face Sheet revealed R88 was admitted to the facility on [DATE], with diagnoses including, but not limited to: pain, neuromuscular dysfunction of the bladder, and systolic congestive heart failure. Review of R88's PASARR Level 1 dated 09/07/22 revealed the following diagnosis not listed on the PASARR Level 1, bipolar disorder. Review of R88's Physician Orders revealed the antipsychotic medication Latuda 20 milligrams daily (used to treat certain mental/mood disorders such as schizophrenia, and depression associated with bipolar disorder). Further review of the Physician Orders revealed an order for Trintellix 15 milligrams at bedtime for major depressive disorder and Hydroxyzine for anxiety. Review of R88's Comprehensive Care Plan dated 04/17/23 revealed the following problems: Resident has potential for injuries, adverse reactions and side effects related to antipsychotic, anxiety and antidepressant medication use for bipolar. An additional problem dated 12/26/22, revealed, Resident has signs and symptoms of behavior/mood distress as evidenced by, verbalizing feeling down and bad about self, tearful at times. Resident has history of making sexually inappropriate suggestions/comments to female staff. Resident refuses showers and getting out of bed due to manipulating staff that are assisting him by providing false reasons as to why he cannot get out of bed. Review of R102's Face Sheet indicated the facility admitted R102 on 02/13/24, with diagnoses of but not limited to: anxiety disorder, dementia, psychotic disturbance, mood disturbance, and anxiety, and paranoid schizophrenia. Review of R102's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/24, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident was moderately cognitively impaired. Review of R102's PASARR Level I dated 02/01/24, revealed the PASARR Level I was incomplete. The diagnoses section was not completed and Part II screening for mental illness indicators listed a diagnosis of Paranoid Schizophrenia. Section IV: Recommendation of Reviewer was not completed. Also, no PASSAR Level II was completed for mental illness diagnosis of paranoid schizophrenia. During an interview on 04/03/24 at 10:03 AM, Social Services (SS) stated that they had not had R102 evaluated for a Level II PASSAR despite diagnosis of Schizophrenia. The resident had displayed no symptoms or behaviors that would warrant such. During an interview on 04/04/24 at 10:05 AM, SS stated that she had not filled out any paperwork for screening or evaluation for R88 for a PASARR Level II. 47812

Based on observation, record review, interviews, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for 3 of 5 residents (Residents (R)102, R121, and R122) reviewed. Findings include: Review of the facility policy titled, Minimum Data Set revised on 05/05/23, revealed, Policy Statement: An MDS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident, using the RAI process. Facility staff complete a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences, and offer guidance for further assessment once problems have been identified. The comprehensive assessment is completed initially and periodically. Each staff member will note their liability for the accuracy of the data recorded by signing (electronically) their name and identifying the MDS sections and questions to which they provided responses. Review the resident's medical record. This review may include pre-admission activities. Identify resident status, care and services rendered during the Observation Period or the current assessment. Review is to include, but not be limited to pre-admission, admission, and transfer notes; current plan of care, physician's orders, progress notes, history and physical; nursing, dietary, activity, social service, and therapy notes and assessments; medication administration records and treatment records. 1. Review of R102's Face Sheet indicated the facility admitted R102 on 02/13/24, with diagnoses including but not limited to: metabolic encephalopathy, anxiety disorder, dementia, psychotic disturbance, mood disturbance, Parkinsonism, epilepsy, and paranoid schizophrenia. Review of R102's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/24, revealed R102 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating the R102 was moderately cognitively impaired. Further review of the MDS revealed, Section N: Medications, R102 was coded as taking antipsychotic medication and Section V: Care Area Assessment Summary revealed the care area and care planning decision for psychotropic drug use was triggered. Review of R102's Physician Orders revealed, Olanzapine 5 MG tablets were discontinued on 02/15/24 and Risperidone 3 MG tablets were discontinued on 02/15/24. Review of R102's Care Plan dated 02/13/24, revealed R102 was not care planned for psychotic/antipsychotic medication use. 2. Review of R121's Face Sheet revealed R121 was admitted to the facility with diagnoses including but not limited to: constipation, diarrhea, nausea with vomiting, pain, restlessness and agitation, major depressive disorder, and dementia without behavioral disturbance. Review of R121's Admission MDS with an ARD of 02/19/24, did not indicate the use of oxygen therapy. Review of R121's Care Plan indicated continuous oxygen therapy and to administer O2 as ordered. Review of R121's Physician Orders with a start date of 02/15/24 indicated, O2 at 2L liters per minute via nasal cannula as needed . During an observation on 04/01/24 at approximately 12:47 PM, and on 04/02/24 at approximately 12:30 PM and 3:07 PM, revealed that R121 was receiving oxygen therapy via nasal cannula. 3. Review of R122's Face Sheet revealed R122 was admitted to the facility with diagnoses including but not limited to: metabolic encephalopathy, hemiplegia and hemiparesis, dementia, hypertensive heart disease with heart failure, pressure ulcer of sacral region, stage 3, major depressive disorder, and muscle weakness. Review of R122's Scheduled 5-day MDS with an ARD of 03/12/24, indicated no difficulty in normal conversation, social interaction, or listening to TV. Review of R122's Care Plan did not indicate hearing problems, goals, or approaches. Review of R122's Physician Progress Note dated 12/13/23 at 5:39 PM, indicated R122 continued to have difficulty hearing but could answer most questions. Review of R122's Physician Progress Note dated 03/06/24 at 12:33 PM, indicated R122 had a significant hearing deficit. During an observation on 04/01/24 at approximately 11:08 AM and on 04/04/24 at approximately 2:00 PM, revealed R122 required elevated voice levels and repetition of statements to hear adequately. During an interview on 04/03/24 at approximately 10:15 AM, the MDS Coordinator indicated that she pulls MDS information from but is not limited to, resident documentation, doctor notes, and interviews with resident and resident representatives, social services, and dietary. The MDS Coordinator further stated that if a resident has hearing concerns, it should be indicated on the MDS. The MDS Coordinator further stated that she is aware that R122 can be hard of hearing sometimes, but when she interviewed him, she used a normal tone, and he was able to understand everything that she said. The MDS Coordinator confirmed that adequate hearing was selected for Section B - hearing abilities on his MDS. During an interview on 04/03/24 at approximately 1:00 PM, the MDS Coordinator stated that if a resident uses oxygen, it would be included under section O - Special Treatments, Procedures, and Programs. The MDS Coordinator confirmed that oxygen use is not checked off under Section O because the order was never signed off by a nurse on the MAR (Medication Administration Record). If an order is not signed off on the MAR, then it won't be included in the MDS. During an interview on 04/03/24 at 3:11 PM, the MDS Coordinator stated R102 was admitted on [DATE] and had to be sent back out the hospital on 02/14/24. At that time some of the resident's medications were discontinued. Upon R102's return to the facility on [DATE], Section N (medications) of the Admission MDS assessment that was completed on 02/20/24 was miscoded. The MDS Coordinator further stated, the resident was no longer taking any antipsychotic medications. The MDS Coordinator confirmed R102's MDS should not have been coded or triggered for antipsychotic medications at the time of admission. During an interview on 04/04/24 at 12:47 PM, the Administrator stated that MDS documentation should be accurate, and coordinators pull information from patient observations and documentation. The Administrator further stated that if MDS information is documented incorrectly, the coordinators should create a correction MDS with the correct information and supporting documentation. 48834

Based on review of facility policy, record review and interviews, the facility failed to ensure Resident (R)138 or her personal representative received a copy of the bed hold policy with bed hold rate and the duration of the bed hold in a timely manner for 1 of 5 residents reviewed for hospitalization . Findings include: Review of the undated facility policy titled, Discharge/Transfer states under policy, The patient/resident will be discharged /transferred (home/another entity) by order of his/her attending physician. Facility will include the patient/resident and family in developing a safe discharge plan to address the patient's/resident's individual needs. Procedures: 2 states, Notify the patient/resident, or his/her legal representative, if any, or an interested family member and document the discharge. Number 3, Types of discharges: B. Emergency: 1) Complete emergent transfer form. 2) Send the patient's/resident's face sheet, Advance Directive, bed hold policy, physician orders, MAR, TAR, and any state specific records in accordance with state regulations with the patient/resident. If unable to complete the information, verbally communicate the necessary information and fax when complete. C. Resident-Initiated Discharge to another health care agency such as a hospital or nursing facility: 1) Complete the Resident Transfer Form when the patient/resident is discharged to another health care agency such as a hospital or nursing facility. E. Involuntary Discharge: 1) d) Complete and provide a written notice of transfer/discharge to the patient/resident and, if known, a family member or legal representative, and the Office of the State Long-Term Care Ombudsman. The facility admitted R138 on [DATE] with diagnoses including, but not limited to: end stage renal disease, atherosclerotic cardiac disease and dialysis dependence. Review of R138's Progress Notes dated [DATE] revealed, Called to resident room by family member at 03:55 PM. Family member states resident went out. Upon arriving in the room, noted resident is not breathing and has no pulse. Code blue called and CPR began, EMS notified at 4:00 PM. CPR in progress. EMS arrived at 04:10 PM. EMS took over CPR. EMS left with resident at 04:17 PM on stretcher with CPR in progress. Resident was last seen by this nurse at 03:45 PM checking FSBS (finger stick blood sugar). Residents personal representative/family notified by visiting family member. Review of R138's Electronic Medical Record revealed no documentation could be found the R138's personal representative received a copy of the bed hold policy with the bed hold rate and the duration of the bed hold in a timely manner. During an interview on [DATE] at 3:05 PM, the Administrator stated the documents of the transfer and the bed hold are sent in a packet to the hospital along with other documents for the hospital staff. The Administrator provided a copy of the bed hold policy with R138's name and date she was sent to the hospital. But no documentation to ensure it was sent to the personal representative notifying her of the bed hold and the amount of the bed hold if R138 was hospitalized beyond the duration of the bed hold, in a timely manner. During an interview on [DATE] at 3:20 PM, the Business Office Manager, confirmed there was no documentation to ensure the Bed Hold Policy was sent to the personal representative in a timely manner.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to provide and document oxygen therapy for Resident (R)121 at the appropriate levels as ordered by the physician. Findings include: Review of the facility's policy titled Initiation of Oxygen Therapy, Concentrator dated 04/01/22, indicated, The licensed staff will provide the prescribed amount of oxygen therapy to the patients/residents as prescribed by the physician and per facility procedures. Review of R121's Face Sheet revealed R121 was admitted to the facility with diagnoses including but not limited to: constipation, diarrhea, nausea with vomiting, pain, restlessness and agitation, major depressive disorder, and dementia without behavioral disturbance. Review of R121's Physician Order Sheet created on 02/15/24, indicated orders for oxygen at 2 liters (L) per minute via nasal cannula as needed. Review of R121's April 2024 Treatment Administration Record (TAR) revealed no documentation for the use of oxygen on 04/01/24 and 04/02/24. During observations on 04/01/24 at approximately 12:47 PM, and on 04/02/24 at approximately 12:30 PM and 3:07 PM, revealed R121's oxygen level was set at four liters instead of two liters as ordered by the physician. During an interview on 04/02/24 at 2:30 PM, the Administrator confirmed that R121's oxygen was set at four liters and had nursing staff turn it down to two liters. During an interview on 04/03/24 at approximately 11:10 AM, Licensed Practical Nurse (LPN)4 stated that R121's current physician orders were for two liters. LPN4 stated that she frequently had to encourage R121 to wear their oxygen because they liked to take it off and play with the nose area. LPN4 further stated that she did not know why the TAR was not signed off on 04/01/24 and 04/02/24 because she was not on shift until 04/03/24. During an interview on 04/03/24 at approximately 12:49 PM, Registered Nurse (RN)3 stated she did not know why the TAR was blank, and the order for the oxygen should have been signed as being administered.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure the nurse followed policy regarding dispensing controlled medication for 1 of 3 medication carts. Findings included: Review of a facility policy titled 2.2 Administration of scheduled controlled medications dated 04/01/22, revealed, administration of scheduled controlled substances will be consistent with the policies for general medication administration with the additional requirement of logging all doses on a controlled drug receipt/record/disposition form for each controlled substance order. 2. All scheduled controlled medications removed from storage for the purpose of administering doses to the resident will be entered onto the resident's-controlled drug receipt/record/disposition. Review of an Admission Record indicated the facility admitted Resident (R)122 on 03/05/24 with diagnoses including but not limited to: cellulitis of right upper limb, rheumatoid bursitis, elbow, edema, rheumatoid bursitis, pelvic and perineal pain, and pressure ulcer of sacral region, stage 3. A review on 04/03/24 at 1:01 PM, of R122's Controlled Drug Receipt/Record/Disposition Form dated 04/01/24, revealed, Oxycontin 20mg tablet count listed on record 25 pills on 04/02/24, however, the narcotic box contained 24 pills. During an interview on 04/03/23 at 1:26 PM, Licensed Practical Nurse (LPN)4 stated the nurses are expected to utilize the five rights when administering medications. Prior to administering a narcotic, we are to check orders and when the narcotic is pulled the expectation is to sign it out from the narcotic book. On the Electronic Medication Administration Record (EMAR) we are to select prep and once it is given, we select administered on the EMAR. If there is a discrepancy on the narcotic sheet, we immediately discuss with the nurse that worked the cart, and then administration if not corrected. The supervisor must be involved immediately to resolve discrepancies. During an interview on 04/03/24 at 1:32 PM, Assistant Director of Nursing (ADON) revealed that her expectation is that narcotics are given in a timely manner, per order and review order to ensure accuracy. Once the narcotic is pulled the card is immediately returned and the narcotic is signed out of the narcotic book. The Matrix is set up to prep and once medication is administered select given. The nurse is to also complete five patient rights with patient administration.

Based on observations, record reviews, interviews, and facility policy review, the facility failed to ensure Resident (R)122 received an audiology consult as needed per physician orders. Findings include: A review of the facility policy titled, Leadership Policies and Procedures- Medical Services- Vision and Hearing Services, revised 11/01/17, indicated that The facility will assist the resident, when necessary or requested, in locating and utilizing available resources for the provision of vision and/or hearing services the resident needs. This includes A. Making appointments . Review of R122's Face Sheet revealed R122 was admitted to the facility with diagnoses including but not limited to: metabolic encephalopathy, hemiplegia and hemiparesis, dementia, hypertensive heart disease with heart failure, pressure ulcer of sacral region, stage 3, major depressive disorder, and muscle weakness. Review of R122's Physician Progress Note dated 12/13/23 at 5:39 PM, indicated R122 continued to have difficulty hearing but could answer most questions. Review of R122's Physician Progress Note dated 03/06/24 at 12:33 PM, indicated R122 had a significant hearing deficit. Review of R122's Physician Order Sheet created on 03/05/24, indicated an, Audiology consult and treat as needed. During an interview on 04/01/24 at 11:08 AM, R122 stated that they had hearing and some vision issues before admission to the facility. R122 further stated that they did not have hearing aids but would like some. During an interview on 04/03/24 at approximately 11:10 AM, Licensed Practical Nurse (LPN)4 stated she was unaware of hearing concerns for R122, the resident could understand what she said when she spoke to them in a normal tone. LPN4 further stated if she ever noticed any concerns related to R122's hearing, she would inform her supervisor, and document it in the book that was used for nurses to relay messages of any concerns that they had. LPN4 concluded stated she was unsure if R122 had ever been scheduled for an audiology appointment. During an interview on 04/03/24 at approximately 1:00 PM, Social Services stated that she was unaware of any audiology referrals made for R122, and she had not been made aware of any concerns related to R122's hearing. During an interview on 04/04/24 at 2:00 PM, R122 stated that they informed staff members of their hearing concerns but could not remember who they spoke to. R122 further stated that staff members must repeat questions frequently for them to properly hear what was being said.

Based on review of facility policy, record review, observation and interview the facility failed to implement care plan interventions related to pressure ulcer prevention for Resident (R)19. The facility further failed to develop and implement care plan interventions for R65 for related to Activities of Daily Living (ADL) function and right sided limitations for 2 of 3 residents. Findings include: Review of a facility policy titled Person-Centered Care Plan revised on 06/09/23. Policy and procedure states, 3. The person-centered care plan is interdisciplinary and created to guide facility staff in providing treatment care, and service necessary for the patient/resident to obtain and maintain the highest physical, mental, and psychological well-being possible. Review of R19's face Sheet revealed R19 was admitted to the facility on [DATE] with diagnoses including, but not limited to: muscle weakness (generalized), contracture right and left knees, human immunodeficiency virus, and pain. Review of R19's Quarterly Minimum Data Set with an Assessment Reference Date of 02/22/24, revealed R19's Brief Interview of Mental Status (BIMS) score was not conducted due to resident's cognitive skills are severely impaired. Further review of the MDS revealed no rejection of care behavior exhibited by R19. Review of R19's Physician Ordered revealed an order to float feet on pillow while in bed as resident will tolerate monitor every shift. Review of R19's Care Plan revealed, [R19] has a potential for skin breakdown related to history of pressure wounds, impaired bed mobility and incontinence, resident has peg-tube and colostomy. Intervention/Approach: Float feet on pillow while in bed as resident will tolerate. monitor every shift. Goal: [R19] will remain free of pressure ulcers/skin breakdown with current interventions thru next review. Review of R65's Face Sheet revealed R65 was admitted to the facility on [DATE] with diagnoses including, but not limited to: stage 3 chronic kidney disease, type 2 diabetes mellitus with diabetic neuropathy, cerebrovascular disease, hemiplegia, and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, lack of coordination, and pain. Review of R65's Quarterly MDS with an ARD of 01/30/24 revealed R65's BIMS score of 7 out of 15 indicating the resident was severely cognitively impaired. Further review of the MDS revealed no rejection of care behavior exhibited by R65. Review of R65's Electronic Medical Record on 04/02/24 revealed no physician orders, no progress notes, and no care plan that addressed right hand swelling and assistive device (splint) to aid in ensuring the affected hand is in neutral functional position, promoting joint alignment. During an observation 04/01/24 at 11:11 AM, R19 had no floating heels, no pillow under or between contracture bilateral knees while laying bed. During an observation and interview on 04/01/24 at 12:20 PM, R65 revealed his right arm does not move due to him having a stroke years ago. R65's right hand was swollen, facing downward, and laying on the right side of resident's girthy stomach close to the metal side of wheelchair. R65 states that the swelling started years ago. There was no splint or assistive devices noted for right hand. During an observation on 04/02/24 at 11:41 AM, R19 was laying in semi-Fowler's position (resident is seated in a semi-sitting position and may have knees either bent or straight) with bilateral contracture knees hanging on the side of the bed without floating heels, no pillow between knees, or under knees. During an observation and interview on 04/02/24 at 12:15 PM, R65 revealed that he had a splint, but it is at his sister's house but someone from therapy told him that they would order him a splint. R65 was watching television with his right hand swollen, being held by his left hand, and resting on his stomach. During an interview on 04/02/24 1:21 PM, the Assistant Director of Nursing (ADON) revealed R19's floating heel boots should have been discontinued. The ADON stated, I am doing that right now as we speak. This wound care treatment could have been for the side of her foot to not break down, but I will have to follow up with the wound nurse. There should be a pillow between her legs. I will have to follow up with the wound care nurse. The expectation is that the staff are following her care plan. During an interview on 04/02/24 at 01:08 PM, the ADON revealed that she is familiar with R65 but states that it had to be therapy that spoke with the resident regarding a splint. The ADON states that admission assessments as well as weekly skin assessments are performed on each resident. The ADON is not aware of right-hand edema. It is expected that any abnormal findings will be recorded and reported to the MD. During an interview on 04/02/24 at 1:14 PM, the Director of Rehabilitation (DOR) revealed that she is familiar with resident R65, and there is no goal for a splint on his right hand. The DOR states that she can add it and will have the department look at it. She will call and speak with the Occupational Therapist (OT), to see if she spoke with him Saturday regarding the splint. The DOR will follow up on this with the OT this week. He has been in our care since 01/24/24. During an interview on 04/02/24 1:26 PM, Licensed Practical Nurse (LPN)1 revealed that R19 bilateral lower extremity is contracture and R19 treatment is for feet floated, air overlay to reduce pressure, pillows under to raise her feet and between her legs. LPN1 stated that this is done to help prevent pressure sores. The expectations are that the plan of care is being carried out by all staff. During an observation and interview on 04/03/24 at 10:08 AM, R65 was in a wheelchair, moving self with a resting splint on right hand in place secured by Velcro straps. R65 tolerating well. R65 states therapy just gave it to him and denies any issues at this time. During an interview on 04/03/24 at 12:35 PM, Occupational Therapy Assistant (OTA) revealed that she knew R65's right hand looked different than his left hand for months but was unsure if it had been addressed. It should have been put in the occupational therapist's initial evaluation if it was an issue. OTA reported that she has reported the swelling to nursing several times, and she does not remember who she spoke with on these occasions. OTA stated that R65 denied any pain or discomfort during 4 to 5 times a week session and this is a routine question asked during sessions. OTA stated that she had not spoken with the Occupational Therapist (OT) about his swollen right hand because it was there when he first came. R65 did not mention that he had a splint being used at home. We had one here, so we placed one on him today. During an interview on 04/03/24 at 12:46 PM, OT revealed there was a difference in R65's right hand during initial evaluation in January. He did report that he used a right-hand splint at home, and I wanted to give him the opportunity to get that device from home. When seen on Saturday 03/30/24 I noticed that he did not have the splint. We spoke about it briefly and activities of daily life. I forgot to chart this for the visit on Saturday because I see so many residents. When called by DOR I remembered, and I placed an order for a resting hand splint. During an interview on 04/04/24 at 11:53 AM, the ADON revealed R65 has right sided hemiplegia and staff is expected to follow and execute intervention and approaches. The care plan reflects resident's needs and preferences. It is patient centered and not generalized. The care plans are revised as there are changes in condition. It should be reasonable, measurable with short- and long-term goals with timeframes present as it relates to each discipline. R65's profile also gives information on what assistance this patient needs, it was previously called the Kardex.

Based on observation, interview, and manufacturer's recommendations review, it was determined the facility failed to ensure the proper storage and labeling of blood glucometer testing strips for 10 of 56 Residents (R) (R28, R36, R63, R72, R69, R76, R87, R96, R116, and R122) requiring blood glucose checks, creating the potential for inaccurate blood glucose readings. Findings include: Review of the manufacturer's recommendations for the Even Care G2 Blood Glucose Test Strips revealed, under storage and handling, that the test strips should be used within six months after first opening the container. (P/N 9 Rev. 11/18) An observation on 05/19/22 at 4:35 PM of a glucometer check on R28 on the 500 Hallway by Licensed Practical Nurse (LPN)2 revealed the glucometer test strip bottle was not dated as to when it was opened. (Exp 2023-03-31, Lot 6). An interview with LPN2 on 05/19/22 at 4:37 PM revealed the residents have their own individual glucometer and glucometer equipment in a labeled bag on the medication cart. LPN2 stated the glucometer test strip bottle should always be dated and initialed when opened to ensure the accuracy of the blood glucometer test strips and blood glucometer accucheck blood sugar reading result for the resident. On 05/19/22 at 4:45 PM, an observation of the 500-hallway medication cart revealed the glucometer test strip bottles of R36 (Exp 2023-03-31 Lot 6), R76 (Exp 2023-03-31 Lot 6), R87 (Exp 2023-03-31 Lot 6), R69 (Exp 2023-03-31 Lot 6) and R63 (Exp 2023-03-31 Lot 6) were not dated or initialed as to when the bottles were opened. On 05/19/22 at 5:00 PM, an observation of the 100-hallway medication cart revealed the glucometer test strip bottle of R72 (Exp 2023-03-31 Lot 06) was not observed to be dated or initialed as to when the bottles were opened. On 05/19/22 at 5:15 PM, an observation of the 200-hallway medication cart revealed the glucometer test strip bottles of R122 (Exp 2023-07-05 Lot 3) and R116 (Exp 2023-05-31 Lot 6) were both dated when they were opened however the writing was smudged and not legible. On 05/19/22 at 6:09 PM, an observation of the 300-hallway medication cart revealed the glucometer test strip bottle of R96 (Exp 2022-10-12 Lot 2) was labeled as being opened on 04/12/21, which exceeded the manufacturer's guidelines of six months. An interview with Registered Nurse (RN)2, a staff nurse on 300-Hallway, on 05/19/22 at 6:15 PM revealed she was the nurse on the 300-Hallway. RN2 stated that the glucometer test strip bottle for R96 should be discarded because it looks like it is over a year old, but somebody probably just put the wrong year on it. An interview with the Director of Nursing on 05/20/22 at 1:15 PM revealed she had only been in her position for a few months and was still catching up with everything. She stated it was her expectation that all the staff nurses follow the manufacturers' recommendation of the care and storage of the glucometer test strips when they are opened to ensure the accuracy of the glucometer blood sugar testing on all the residents in the building.

Based on observation, record review, facility policy review, staff interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one of two residents receiving hospice services out of 33 sampled residents (Resident (R) 83). Specifically, the facility failed to accurately code the MDS for hospice services for R83 in which the resident had a terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility's policy titled, Nursing Policies and Procedures Minimum Data Set (MDS) Accuracy MDS 3.0 Audit revised 10/01/2019 revealed, Note discrepancies and schedule a meeting with the MDS nurse to discuss noted differences. Make appropriate modifications, resubmit and let the business office know of changes. Review of the MDS-3.0-RAI-Manual-v1.17.1 under Section J1400 Prognosis: Code 1 yes: if the medical record includes physician documentation: 1) that the resident is terminally ill, or 2) the resident is receiving hospice services. The RAI Manual then indicated, Steps for Assessment-Review the medical record for documentation by the physician that the resident's condition or chronic disease may result in a life expectancy of less than 6 months, or that they have a terminal illness .Review the medical record to determine whether the resident is receiving hospice services. During an observation on 05/18/22 at 2:00 PM, R83 was observed to be sleeping in bed and not able to communicate. Review of R83's undated Face Sheet, identified in R83's paper medical record, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Care Plan identified in R83's paper medical record, dated 03/31/22, indicated, Resident requires Hospice AEB (as evidenced by) end-stage disease, six or fewer months to live, unspecified [CONDITION(S)] disease. Family has elected to use [name of Hospice Agency]. Review of a hospice binder located at the nurse's station for R83 revealed [name of Hospice Agency], an initial plan of care indicated the election of Hospice benefits and initial Hospice Start of Care was 03/30/22. Review of a Facility Patient Level of Care document located in the hospice binder dated 03/30/22, indicated a primary hospice diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Hospice Physician Verbal Order, identified in the hospice binder, dated 03/30/22, indicated, The Medical Director/Hospice Physician certified that the patient's prognosis is six months or less if the disease runs its normal course. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Hospice Certification and Plan of Care, identified in the hospice binder, indicated the start of care was 03/30/22. It further indicated from the physician I certify/recertify the patient is terminally ill with a life expectancy of six (6) months or less if the disease process runs its normal course. Review of a significant change Minimum Data Set (MDS) revealed an Assessment Reference Date (ARD) of 04/05/22. The MDS revealed R83 is receiving hospice services while being a resident at the facility. However, the MDS also documented R83 did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. Review of a Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 05/06/22, indicated from the hospice physician, I have reviewed the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Non-ambulatory, cognitive decline, limited verbal communication, dependent for all Activities of Daily Living (ADLs), prognosis <6 months. During an interview on 05/19/22 at 12:16 PM, Licensed Practical Nurse (LPN) 5 (who completed R83's MDS on the hospice sections) confirmed that R83 is receiving hospice services. LPN 5 stated, I did the Sig (significant) change MDS on 04/02/22. When asked what documentation she reviews when a resident is receiving hospice services, LPN5 stated, I look at our documentation from the ADL tracking sheets, nursing notes and Dr. notes. LPN5 then stated, As far as any hospice documentation, the hospice nurse comes in and communicates with us. I look at the doctor's orders and we usually have a doctor's order section when they are admitted to hospice. When the Significant Change MDS was reviewed with LPN5 regarding the section on terminal prognosis and receiving hospice services, LPN5 stated, It should be coded yes. It should say yes and she [R83] has a life expectancy of less than 6 months. I realize the sections of the MDS should be coded correctly. She is on hospice, and they are providing services. She is end of life. It was an oversight on my part and I will correct that. It was just a quick click of the button, that's all. During an interview on 05/19/22 at 12:33 PM, Registered Nurse (RN)2 stated, She [R83] is receiving hospice services and it should be on the hospice order that she has a terminal diagnosis. During an interview on 05/19/22 at 12:41 PM, the Director of Nursing (DON) stated, My expectation of the staff would be to check the progress notes from the doctor or whatever the pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a phone interview on 05/19/22 at 12:53 PM, RN3 (from the Hospice Agency) stated, She [referring to R83] went onto hospice services on 03/30/22 and does have a terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, record review, staff interviews and review of facility policy, the facility failed to ensure side effects of [CONDITION(S)] medications were being monitored and documented for one resident (R)102 out of five residents reviewed for the use of [CONDITION(S)] medications, creating the potential that the resident would experience adverse reactions that were not recognized. Findings include: Review of facility's policy titled, Nursing Policies and Procedures Subject: [CONDITION(S)] Drugs-Use of, revised 01/20/20 indicated, Qualified staff will monitor the patient/resident for potential undesirable side effects that are associated with the use of the [CONDITION(S)] drug according to CMS, State specific rules and regulations, and Facility Practice Guidelines . 1.B. Antipsychotics: Targeted behaviors, number of behavior episodes, intervention, outcome and side effects will be monitored by qualified staff each shift and the total number of behaviors will be totaled for each shift at the end of the month. Review of R102's Admission Record, from the electronic medical record (EMR) Profile tab, showed an admitted [DATE] with medical diagnoses that included [CONDITION(S)], [CONDITION(S)], major depressive disorder, and manic episodes. Review of R102's Minimum Data Set (MDS) quarterly assessment, with an Assessment Reference Date (ARD) of 03/30/22 showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicative of R102 being cognitively intact. Further review of R102's EMR Orders indicated that he was prescribed [MEDICATION(S)] (an antipsychotic medication used to treat certain mental/mood conditions such as [CONDITION(S)], [CONDITION(S)], sudden episodes of [CONDITION(S)] or depression associated with [CONDITION(S)]) 100 milligrams (mg) by mouth (PO) daily at 3:00 PM; [MEDICATION(S)] 200 mg PO at bedtime; and [MEDICATION(S)] 50 mg PO every morning. The medical record did not show any documentation for monitoring side effects for the medication. In an interview on 05/19/22 at 5:49 PM with Licensed Practical Nurse (LPN)1 revealed that side effects of [CONDITION(S)] medications were not listed on R102's Medication Administration Record (MAR) or the Treatment Administration Record (TAR) to be monitored or documented. LPN1 stated that the side effects of psychotropics should be checked every shift. An interview on 05/19/22 at 5:56 PM with the Director of Nursing (DON) revealed that it is her expectation that staff monitor side effects of [CONDITION(S)] medications. During the interview, the DON verified that monitoring side effects for R102's [CONDITION(S)] medications were not in place.

Based on record reviews and interviews, the facility did not ensure that appropriate competent staff was providing nursing related services to residents and assuring safety. A Licensed Practical Nurse (LPN)1 worked in the facility with an expired nursing license from [DATE] until [DATE]. Findings include: Interview with Administrator on [DATE] at 10:15 a.m. revealed LPN1 was working as a Nursing Assistant after the facility was notified that LPN1 license was expired. The Administrator stated that LPN1 was hired on [DATE]. Background check and Reference checks were done. LPN1 was licensed in Kentucky. Kentucky license verification check indicated that LPN1 license original issue date was [DATE] and the expiration date was [DATE]. A temporary South Carolina License was issued on [DATE] which the expiration for the temporary license was [DATE]. The Administrator was asked about the date of LPN1 license being expired as of [DATE] which was pulled from the South Carolina Labor Licensing and Regulation website. The Administrator stated that he did not know anything about that. The Administrator stated that LPN1 did come to him around that time stating that it will be a while before her license come back because there was an error in her application where she put South Dakota on her license application instead of South Carolina and the administrator stated that he told LPN1 if her license were back by [DATE], they were okay. Interview with Human Resource (HR) Director on [DATE] at 11:20 a.m. who stated that LPN1 has not worked as an LPN since [DATE], since they were notified by the corporate office that LPN1 license was expired. HR director stated that LPN1 has been working as a Nursing Assistant. On [DATE] at 11:45 AM, an interview with an employee from SC LLR about LPN1 license revealed that LPN1 original expiration date was [DATE], however, information was received from Kentucky about the license was made known and LPN1 license was immediately suspended on [DATE]. The employee was asked did LLR notify the facility that the license was suspended/expired on [DATE]. LLR employee stated LLR immediately e-mailed and called LPN1 to let her know that her license was expired, and she no longer could practice nursing under that license. Interview with Director of Nursing (DON) on [DATE] at 12:01 PM revealed that the licenses checks are done weekly by their corporate office, however, the last few checks that were done, LPN1 name was not on the list stating that LPN1 license had expired on [DATE]. The DON stated that it was not until Sunday, [DATE]th he checked his email from home and there was the information that LPN1 license was expired. He looked at the schedule and LPN1 was not working the day. LPN1 was immediately called and told she could not work as a nurse because there was a problem with her license. The DON stated that LPN1 was immediately trained as a nursing assistant. RN states that LPN1 did not work as an LPN after the facility was aware that LPN1 was not a licensed nurse. The DON states that the employee worked from [DATE] until [DATE] on an expired license because the facility had documentation the LPN1 was working on her temporary South Carolina license until permanent licenses were issued. DON stated that LPN1 did not disclose to the facility that her license had expired on [DATE]. Interview with RN at 1:10 p.m. about LPN1. RN states that LPN1 was a caring and [MEDICATION(S)] employee. She was a good nurse and did not have any issues with caring for the residents. Multiple attempts were made via telephone to contact LPN1 with no success.

Based on observation, interview and review of facility policy, the facility failed to mark a multi-dose medication vial with the date opened in 1 of 3 medication storage refrigerators observed during the survey. The findings included: Observation of the AB unit medication storage room, on 12/1/20 at 9:40 AM, revealed a [MEDICATION NAME] Purified Protein Derivative, Diluted [MEDICATION NAME] multi-use vial stored in the medication refrigerator. The vial had been opened. Per instructions on the packaging, Once entered, vial should be discarded after 30 days. The vial was not marked with the date opened. During an interview with Registered Nurse (RN) #1, on 12/1/20 at 9:40 AM, RN #1 confirmed the vial was not marked with a date opened. RN #1 stated the medication should be discarded after 30 days, but with no date opened marked on the vial, s/he did not know how long the medication had been in use. Review of the facility's Medication Storage policy revealed Once any multi-dose packaged medication or biological is opened, nursing will mark multi-dose products with the date opened and follow manufacturer/supplier guidelines with respect to expiration dates.

Based on observation, interview, clinical record review, review of training records and review of facility policies, the facility failed to ensure that required transmission-based precautions were implemented to prevent the spread of Coronavirus (COVID)-19 on three (3) of five (5) facility halls where three (3) of five (5) contracted housekeeping (HK) staff (HK #2, HK #3 and HK #5) failed to adhere to the Environmental Protection Agency (EPA)-registered disinfectant contact-time instructions when cleaning residents' rooms. The facility also failed to ensure appropriate transmission-based precautions were implemented for two (2) of four (4) sampled residents (Resident #1 and Resident #4) and for one (1) non-sampled resident who were ordered transmission-based precautions to prevent the spread of suspected COVID-19. A Targeted Infection Control Survey was conducted at Lancaster Convalescent Center on June 23-24, 2020. During the survey, the facility was determined not to be in substantial compliance, as evidenced by: On 6/23/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Director of Nursing (DON) was informed of the immediate jeopardy on 6/23/2020 at 4:20 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 5/30/2020. The immediate jeopardy continued through 6/24/2020 and was removed on 6/24/2020 at 11:26 a.m. when the facility implemented a Credible Allegation of Compliance. An IJ remvoal plan was provided and accepted by the SA on 6/24/20. The removal plan was validated and the immediacy of the deficient practice was removed on 6/24/2020 dropping the S/S to E. The immediate jeopardy is outlined as follows: 1. Three (3) of five (5) HK staff (HK #2, HK #3 and HK #5) on facility halls 100, 200 and 300 failed to adhere to the contact-time specified by the Environmental Protection Agency registered disinfectants used to clean and disinfect residents' rooms, including rooms on halls 100, 200 and 300 that required transmission-based precautions for residents suspected positive for COVID-19. The contact-time was the amount of time required for the chemical to remain on the environmental surface being cleaned, in order to breakdown all membranes that surround bacteria [MEDICAL CONDITION]. In addition, HK #2 used a bottled labeled as glass cleaner to clean/disinfect environmental surfaces in residents' rooms. Facility staff were not able to identify the chemical inside the bottle. 2. Facility staff failed to ensure Resident #1's door remained closed while the resident and roommate were under transmission-based precautions for suspected COVID-19. 3. The facility's contracted Nurse Practitioner (NP) failed to don gloves, gown and a face shield when entering a non-sampled resident's room; the resident was on transmission-based precautions for suspected COVID-19. 4. The facility's contracted [MEDICAL TREATMENT] transport staff failed to apply the required personal protective equipment (PPE) when transporting Resident #4 back into his/her room; Resident #4 was on transmission-based precautions for suspected COVID-19. It was determined the above multiple failures placed residents at risk for the likelihood of serious harm, injury or death, by facility staff not adhering to required transmission-based precautions to prevent the spread of COVID-19. The findings included: Interview on 6/23/2020 at 9:30 a.m. with the facility's Director of Nursing (DON) revealed the facility's first case of a resident testing positive for COVID-19 was on 5/30/2020. At the time of the interview, the facility had eight (8) residents positive for COVID-19 (which was down from 27 residents having tested positive for COVID-19, as 19 had been cleared). At the time of the interview, there were 25 residents in the facility who were suspected positive and awaiting test results for COVID-19. 1. Review of the facility's Coronavirus Disease 2019 (COVID-19) Pandemic Prevention and Response Plan dated 3/16/2020 revealed Environmental Services facilitates daily cleaning of all frequently touched surfaces, such as bedrails, over-bed tables, night-stands, door-knobs, handrails, equipment, etc. Review of the facility's Infection Prevention and Control Policies and Procedures: Subject: Coronavirus Disease 2019 (COVID-19), undated, noted Environmental Cleaning and Disinfection: A. Routine cleaning and disinfection procedures are appropriate for [DIAGNOSES REDACTED]-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2), including those patient/resident care areas in which aerosol-generating procedures are performed; and B. EPA-registered hospital-grade disinfectants with an emerging [MEDICAL CONDITION] pathogen are recommended to use against [DIAGNOSES REDACTED]-CoV-2. Review of Quality Control Inspection - Housekeeping completed on 6/16/2020 and 6/17/2020 by the facility's contracted Director of Housekeeping (DOH) revealed Housekeeper (HK) #2 was observed by the DOH and the following was noted: unsatisfactory cleaning of ceiling/walls, windowsill/blinds, heating unit, closet/shelf, bedside table, chairs and waste baskets. The DOH noted on 6/16/2020 - Dusty, window spider web and on 6/17/2020 - Dusty, chair needs cleaning. Review of Quality Control Inspection - Housekeeping completed on 6/8/2020, 6/9/2020, and 6/10/2020 by the facility's contracted DOH revealed HK #3 was observed by the DOH and the following was noted: unsatisfactory cleaning of ceiling/walls, windowsill/blinds, lights/switches, TV/light/table, baseboard/edges, waste baskets, light/mirror and sink/ fixtures. The DOH noted on 6/8/2020 - Stain on wall, stain in trash can. Dusty windowsill, blinds, baseboard edges dusty; on 6/9/2020 - Stain on wall, light dusty, fixture dusty, trash can; and on 6/10/2020 - Wall poop stain, baseboard dusty windowsill dusty. Review of Quality Control Inspection - Housekeeping completed on 6/1/2020, 6/2/2020, and 6/4/2020 by the facility's contracted DOH revealed HK #5 was observed by the DOH and the following was noted: unsatisfactory cleaning of heating unit, TV/light/table, floors, and toilet. The DOH noted on 6/1/2020 - Dusty unit, TV dusty, trash on floor; on 6/2/2020 - Trash on floor, toilet stained; and on 6/4/2020 - toilet stained. Review of the contracted Housekeeping staff's training record revealed HK #2, HK #3 and HK #5 received the following education: 3/10/2020 - EVS (Environmental Services) Chemical Use, Dilution and Hazards Inservice Quiz. 5/26/2020 - COVID - Disinfection of Clothes Hangers in Facilities where COVID-19 is/was Present. 5/26/2020 - COVID - Interim Recommendation for Terminal COVID-19 Isolation Room/Unit Cleaning. Review of information obtained on 6/24/2020 from www.epa.gov (Environmental Protection Agency (EPA) website) noted when disinfecting surfaces, staff must follow the contact time listed on the product's label. The contact time is the amount of time the surface should be visibly wet, in order to breakdown all membranes that surround bacteria [MEDICAL CONDITION]. According to the EPA's website, Virex and AirX disinfectants both have a contact time of 10-minutes. During an interview with the facility's Director of Nursing (DON) on 6/23/2020 at 9:30 a.m., the DON revealed that he/she was also the facility's Infection Preventionist. The DON said housekeeping staff used Virex disinfectant spray to clean residents' rooms. The DON was not sure of the contact-time for the chemical. Observations with the DON present on 6/23/2020 between 10:50 a.m. and 11:35 a.m. revealed the following: the facility's 100 Hall had 18 resident rooms. There were six (6) rooms on the hall with signage indicating transmission-based precautions were required before entering the rooms; the facility's 200 Hall had 18 resident rooms and there were three (3) rooms on the hall with signage indicating transmission-based precautions were required before entering the rooms; and the facility's 300 Hall had 18 resident rooms with four (4) rooms on the hall with signage indicating transmission-based precautions were required before entering the rooms. Interview with the DON at 10:55 a.m. revealed the residents in the transmission-based precaution rooms were suspected to be positive for COVID-19. Observations on 6/23/2020 at 11:00 a.m. revealed HK #2 was with the housekeeping cart outside of room [ROOM NUMBER]. Interview at this time with HK #2 revealed the staff had worked at the facility for five (5) years. HK #2 was asked about the cleaning of residents' rooms and the type of disinfectant used for cleaning. HK #2 stated U1 was the disinfectant used to clean the rooms. When asked if there was a certain time period the disinfectant had to remain on environmental surfaces before it was wiped down, HK #2 said there was no certain amount of time for spray to be on surfaces. When the Surveyor asked to see the bottle of disinfectant used to clean the rooms, HK #2 presented a bottle that was labeled Glance NA - Glass and Multi-Surface Cleaner. HK #2 said the wrong label was on the bottle because the Director of Housekeeping (DOH) did not have labels available to place on the bottle. The housekeeper said that he/she had written U1 on the bottle with a black marker, but the marker had rubbed off. When asked how the housekeeper could be sure of what chemical was in the bottle, HK #2 said he/she had re-filled the bottle at the beginning of the shift. HK #2 said that the chemical in the bottle was used to clean the tables, bedrails, and other surfaces in the residents' rooms. During continued interview with HK #2, the housekeeper said that he/she had received no re-education regarding cleaning and disinfecting rooms since the onset of the COVID-19 pandemic. HK #2 said he/she had already cleaned most of the rooms on the hall. Interview on 6/23/2020 at 11:10 a.m. with the facility's contracted DOH revealed the disinfectants used to clean the residents' rooms were Virex, Comet with Bleach, AirX and U1. The DOH said U1 was not used very often. The DOH said that housekeeping staff filled their disinfectant bottles at the beginning of their shift and all bottles were correctly labeled. The DOH was asked where the U1 disinfectant was stored, and the DOH escorted the Surveyor and DON to a storage closet. After opening the storage closet, the DOH stated that he/she forgot that the U1 disinfectant was not stored in this location. The DOH continued and said that the U1 disinfectant was stored on the COVID-19 unit, and the housekeepers on halls 100, 200, 300 and 400 did not have access to the storage area on the COVID-19 unit. The DOH said HK #2 likely re-filled the bottled with the disinfectant AirX. When asked about the kill-time for the disinfectants, the DOH said that all of the disinfectants used had a kill-time of 10 minutes. The DOH also said that housekeeping staff were monitored daily to ensure the proper cleaning of rooms. Follow-up interview on 6/23/2020 at 11:15 a.m. with HK #2 with the DOH and the DON present revealed that HK #2 repeated that he/she re-filled the bottle with U1 at the beginning of the shift and that U1 was written on the bottle but it came off. The DOH asked HK #2 Where is the plastic sticky label? for the bottle. HK #2 did not respond. When HK #2 was again asked about the amount of time for the disinfectant to remain on the environmental surface before being wiped off, the housekeeper stated there was, no particular time for disinfectant to be used before wiping - I wait about five (5) minutes. HK #2 and the DOH could not confirm what chemical was in the bottle labeled as glass cleaner which was being used to clean residents' rooms on the 200 Hall. During a follow-up interview on 6/23/2020 at 11:17 a.m. with the DON, the nurse stated that if HK #2 did not allow the disinfectant to remain on the surface for the required contact time before wiping off environmental surfaces in residents' rooms, then residents' rooms were not being properly cleaned and disinfected, which increased the potential to spread COVID-19. The DON stated that HK #2 regularly cleaned the rooms on the 200 Hall. Interview on 6/23/2020 at 11:22 a.m. with HK #3 revealed the housekeeper had worked in the position for [AGE] years. HK #3 had cleaned all of the rooms on 100 Hall except for the transmission-based precaution rooms. HK #3 presented a bottle labeled AirX and stated it was the disinfectant used to clean residents' rooms. When asked if there was a certain amount of time the disinfectant spray had to remain on a surface before being wiped off, HK #3 said that he/she sprayed it on and wiped it off. The housekeeper continued and said he/she was never informed that the chemical needed to be left on for a period of time before being wiped off. HK #3 said that residents' rooms were being cleaned the same as before the onset of the COVID-19 pandemic. The housekeeper worked four (4) days per week at the facility. Interview on 6/23/2020 at 11:40 a.m. with HK #5 revealed the staff had the position at the facility for six (6) years. The housekeeper presented a bottle of AirX to the Surveyor when asked about the disinfectant used to clean residents' rooms. HK #5 said he/she sprayed the surfaces in residents' rooms with the disinfectant and then waited approximately 30 seconds before wiping the surface down. HK #5 said he/she had never been told to wait to wipe it down. HK #5 said he/she had already cleaned all rooms on 300 Hall. HK #5 worked regularly on the 300 Hall. Interview on 6/23/2020 at 4:30 p.m. with the facility's DON revealed that the contracted Housekeeping company's Regional Housekeeper informed the DON that U1 had been discontinued and AirX was now in use, and the disinfectant had a contact time of 10 minutes. 2. Review of information obtained from www.cdc.gov on 6/24/2020 noted properly manage anyone with symptoms of COVID-19 or who has been advised to self-quarantine .patients should be isolated (in room) with the door closed. Review of the facility's Coronavirus Disease 2019 (COVID-19) Pandemic Prevention and Response Plan dated 3/16/2020 revealed the Infection Preventionist was responsible for ensuring implementation of appropriate infection control measures/precautions and isolation in accordance with CDC, state/local health department recommendations. Review of Resident #1's clinical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's COVID-19 suspected/possible exposure care plan initiated 6/13/2020, revealed transmission-based precautions for COVID-19 were initiated on 6/13/2020. Observation on 6/23/2020 between 11:50 a.m. and 12:10 p.m. revealed there was a Special Precautions sign outside of Resident #1's door, indicating the Resident(s) inside the room were suspected to be positive for COVID-19. The sign noted Everyone must clean hands when entering and leaving room. Gown, gloves, N-95 and eye protection (must be used). Keep door closed. Use patient dedicated or disposable equipment. Clean and disinfect shared equipment. There was also a PPE cart outside of the room. Resident #1's room door was ajar. Resident #1 was not in the room; however, Resident #1's roommate was lying in a supine position with the head of the bed slightly elevated. The door from the hallway into the room (room door) was observed to be open for twenty-minutes and the Surveyor did not observe any staff member close the door during this period of time. Interview on 6/23/2020 at 11:58 a.m. with Resident #1's Unit Manager (UM) revealed that Resident #1 was currently at his/her [MEDICAL TREATMENT] appointment. The UM confirmed that Resident #1 and his/her roommate were on transmission-based precautions for suspected cases of positive COVID-19. The UM said that Resident #1 and the roommate had both been swabbed for the COVID-19 lab test and both residents in the room were on transmission-based precautions. When asked about the required PPE and whether Special Precaution rooms doors should be opened or closed, the UM stated the door (was) to be closed at all times. Observations after the interview between 11:59 and 12:10 p.m. revealed Resident #1's room door remained opened. During an interview on 6/24/2020 at 4:30 p.m. with the facility's DON, the nurse confirmed that Resident #1's room door should have been closed due to the resident's transmission-based precautions. 3. Review of information obtained from www.cdc.gov on 6/24/2020 noted Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown .Because of higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP (healthcare providers) is newly identified in the facility . Review of the facility's Coronavirus Disease 2019 (COVID-19) Pandemic Prevention and Response Plan dated 3/16/2020 revealed the Infection Preventionist was responsible for ensuring implementation of appropriate infection control measures/precautions and isolation in accordance with CDC, state/local health department recommendations. Observations on 6/23/2020 at 12:11 p.m. on 100 Hall of the facility revealed that the Nurse Practitioner (NP) entered room [ROOM NUMBER]. room [ROOM NUMBER] had a Special Precautions notice on the door and a cart for personal protective equipment (PPE) outside of the room, indicating the resident was on transmission-based precautions and suspected of being COVID-19 positive. The NP was wearing an N-95 mask; however, the NP was wearing no other required PPE. The NP did not don gloves, gown, or face shield before entering the Resident's room. The non-sampled resident was inside the room sitting in a manual wheelchair. The NP stepped approximately two (2) feet inside the room and stood within three (3) feet of the Resident. The NP had a conversation with the resident for approximately one (1) minute and then exited the room. After exiting the room, the NP went directly to the medication cart and used hand sanitizer to clean his/her hands. The NP then walked over to a non-sampled Resident who was sitting across from the nurses' station and stood within less than one (1) foot of the Resident and had a conversation with the Resident for approximately two (2) minutes. Interview with the DON on 6/23/2020 at 12:12 p.m. confirmed the NP was inside the non-sampled Resident's room [ROOM NUMBER] without the required PPE. During an interview on 6/23/2020 at 12: 28 p.m. with the contracted NP, the NP stated he/she didn't realize and thought the resident in room [ROOM NUMBER] was under contact precautions. The NP confirmed that he/she did not use contact precaution when he/she entered the resident's room. The NP confirmed he/she entered the resident's room without using the required PPE. The NP stated, that he/she was in the wrong there. 4. Review of information obtained from www.cdc.gov on 6/24/2020 revealed for newly admitted residents into the facility, Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if respirator is not available), eye protection (i.e. goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Review of Resident #4's clinical record revealed an admission date of [DATE] with an admitting primary [DIAGNOSES REDACTED]. Continued review of the record revealed a physician's orders [REDACTED]. Review of Resident #4's Baseline Care Plan dated 6/15/2020 revealed the facility implemented COVID-19 transmission-based precautions for the newly admitted resident. Observation on 6/23/2020 at 12:20 p.m. revealed two (2) [MEDICAL TREATMENT] transport staff brought Resident #4 back to his/her room. On the outside of Resident #4's room was a sign that read Special Precautions, indicating Resident #4 was on transmission-based precautions for suspected COVID-19. Both [MEDICAL TREATMENT] transport staff were wearing face masks and gloves as they transported Resident #4 into his/her room. The transport staff were not wearing other required PPE (gown and face shield or goggles) as they were transporting Resident #4. During an interview on 6/23/2020 at 9:30 a.m. with the DON, the nurse stated that [MEDICAL TREATMENT] transport staff wore the required PPE when transporting residents with confirmed or suspected COVID-19 to their [MEDICAL TREATMENT] appointments. The DON stated the [MEDICAL TREATMENT] transport staff wore a jumpsuit, along with gloves, goggles and facemask when transporting residents confirmed with COVID-19. The DON said the same process was to be used for residents who were suspected positive for [MEDICAL CONDITION]. Follow-up interview on 6/23/2020 at 12:30 p.m. with the facility's DON confirmed that the [MEDICAL TREATMENT] transport staff should have been wearing all required PPE when transporting Resident #4 back from his/her [MEDICAL TREATMENT] appointment.

Based on record reviews, interviews and review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, the facility failed to ensure Resident #80 was free from sexual abuse from Resident #239. One of eight residents reviewed for Abuse. The findings included: The facility admitted Resident #80 on [DATE] with [DIAGNOSES REDACTED]. The facility admitted Resident #239 on [DATE]) with [DIAGNOSES REDACTED]. Review of the facility investigation dated [DATE] revealed that on [DATE] shortly after 3pm A Certified Nursing Assistant (CNA) reported that (Resident #239) was in (Resident #80's) room and had (his/her) hands on (Resident #80's) chest area. (CNA) separated them and reported to (her/his) nurse. Review of Resident #80's medical record on [DATE] at approximately 9:00 AM revealed that Resident #239 wandered into (Resident #80's) room and fondled (his/her) breast on [DATE] at 3:00 PM. Review of witness statement on [DATE] at approximately 2:40 PM, CNA #1 stated I went into (Resident #80's) room to put (him/her) to bed and (Resident #239) was in (his/her) room beside (him/her). (Resident #80's) shirt was pulled up over (his/her) head and (Resident #239) was playing with (his/her) (name of body part). I reported it to the Nurse, Supervisor and the Assistant Director of Nursing. No other staff witnessed the sexual abuse or made a statement to the fact. During an interview on [DATE] at approximately 2:47 PM with CNA #1 s/he verified this was his/her statement and confirmed that Resident #239 was in Resident #80's room and was beside him/her in a wheel chair and Resident #80's shirt was pulled up over his/her head and Resident #239 was playing with his/her (Name of body part). CNA #1 stated he/she separated the residents first and then reported to the nurse. During an interview on [DATE] at approximately 3:00 PM with the Director of Nursing (DON), the DON stated that the CNA had come to him/her and told her/him of the sexual abuse. The DON stated that was when we started the 15-minute checks on Resident #239. The DON stated that Resident #239 is a wanderer and that is why he/she is on the locked unit. Review of witness statements on [DATE] at approximately 3:05 PM revealed a statement from the Social Service Director which indicated that Resident #80 was unable to identify Resident #239 as the perpetrator. No other information was offered. Review of Resident #239's Social Service notes on [DATE] at approximately 3:10 PM revealed a Social Service note dated [DATE] Res (resident) moving to secure unit. Res is going into other residents rooms upsetting them. SS (social services) to f/u (follow up) as needed Review of Resident #239's Comprehensive Plan of Care on [DATE] at approximately 3:10 PM revealed a Comprehensive Plan of Care dated [DATE] which states, Resident demonstrates confusion and expresses feeling sad at times, demonstrates inappropriate behaviors as evidenced by history of making comments of sexual nature toward other female residents, attempting to touch other female residents in inappropriate area. Approaches included Approach res positively and in calm, accepting manner, Contact res's spouse as needed regarding res's behaviors, Monitor and document behavior as needed, NCEPS as needed, Provide assistance and redirection as needed, Provide diversional activities, Provide increase in support as needed, Redirect res away from other female residents as needed. Review of Resident #239's medical record revealed an Acute Plan of Care dated [DATE] which states, Grabbing female resident in sexual nature. The goal is, will not exhibit behaviors. The interventions include: Remove residents when exhibiting inappropriate behaviors. Redirect resident when attempting to wander in other rooms. Notify resident's spouse. [DATE] resolved Review of Resident #239's Comprehensive Plan of Care dated [DATE] did not include wandering into resident rooms and exit seeking as a problem with goals and interventions for Resident #239. The care plan for Resident #239 was not followed related to redirecting and safeguarding Resident #80. Review of Resident #239's Individual Resident Daily Participation Record for Activities on [DATE] at approximately 3:15 PM revealed that diversional activities were not provided on [DATE], the day of the encounter of resident to resident sexual abuse. The record revealed that Resident #239 did not take part in any activities on [DATE]. Review of Resident #239's Nurses Notes on [DATE] at approximately 3:30 PM revealed Nurses Notes dated [DATE] through [DATE] which revealed no documentation of inappropriate sexual behavior towards female residents. Resident #239 died in the facility on [DATE]. Review on [DATE] at approximately 10:45 AM of the facility policy titled, Abuse, Neglect And Misappropriation of Property, states, The facility's leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of a patient/resident including misappropriation of property and/or funds.

Based on observations and interview, the facility failed to ensure the Comprehensive Plan of Care was followed for Resident #70 to ensure oral care was provided daily and as needed for one of one residents reviewed for Activities of Daily Living. The facility failed to ensure the Comprehensive Plan of Care was followed for Resident #239 related to offering diversional activities and provide redirection to prevent sexual abuse. The facility further failed to develop a Comprehensive Plan of Care with goals and interventions for Resident #239 related to wandering. One of eight residents reviewed for abuse. The findings included: The facility admitted Resident #70 with [DIAGNOSES REDACTED]. During an observation on 1/28/2018 at approximately 10:54 AM of Resident #70 revealed a foul mouth odor and missing teeth. During a second observation on 1/30/2018 at approximately 12:10 PM of Resident #70 revealed a continued foul mouth odor. During an additional observation on 2/1/2018 at approximately 11:00 AM of Resident #70 revealed a foul mouth odor and his/her teeth and mouth in need of cleaning/oral hygiene. Review on 2/1/2019 at approximately 11:30 AM of the Comprehensive Plan of Care for Resident #70 revealed a problem dated 6/22/2018 and states, Resident at risk for mouth pain and infection related to broken and carious teeth. Further review on 2/1/2019 at approximately 11:30 AM of the Comprehensive Plan of Care revealed an intervention that states, Continue appropriate oral hygiene measures. Assist with oral hygiene after meals and as needed, A second intervention on the Plan of Care states, Observe oral cavity during oral hygiene and report signs and symptoms of infection white patches, [MEDICAL CONDITION], bleeding, tenderness and unusual odors. The care plan had not been followed due to the observation of foul mouth odor. During an interview on 2/1/2019 at approximately 11:40 AM with Registered Nurse #1, Unit Manager confirmed Resident #70's foul mouth odor after this surveyor brought it to his/her attention. The Unit Manger went on to say that staff were doing the needed oral care/hygiene at this time and agreed that Resident #70 needed the oral care/hygiene at this time. The facility admitted Resident #239 on 6/25/2013) with [DIAGNOSES REDACTED]. Review of the facility investigation dated 10/1/2018 revealed that on 9/27/19 shortly after 3pm A Certified Nursing Assistant (CNA) reported that (Resident #239) was in (Resident #80's) room and had (his/her) hands on (Resident #80's) chest area. (CNA) separated them and reported to (her/his) nurse. Review of Resident #80's medical record on 1/29/2019 at approximately 9:00 AM revealed that Resident #239 wandered into (Resident #80's) room and fondled (his/her) breast on 9/27/2018 at 3:00 PM. Review of Resident #239's Social Service notes on 1/29/2019 at approximately 3:10 PM revealed a Social Service note dated 5/31/18 Res (resident) moving to secure unit. Res is going into other residents rooms upsetting them. SS (social services) to f/u (follow up) as needed Review of Resident #239's Comprehensive Plan of Care on 1/29/2019 at approximately 3:10 PM revealed a Comprehensive Plan of Care dated 3/9/2018 which states, Resident demonstrates confusion and expresses feeling sad at times, demonstrates inappropriate behaviors as evidenced by history of making comments of sexual nature toward other female residents, attempting to touch other female residents in inappropriate area. Approaches included Approach res positively and in calm, accepting manner, Contact res's spouse as needed regarding res's behaviors, Monitor and document behavior as needed, NCEPS as needed, Provide assistance and redirection as needed, Provide diversional activities, Provide increase in support as needed, Redirect res away from other female residents as needed. Review of Resident #239's Comprehensive Plan of Care dated 3/9/2018 did not include wandering into resident rooms and exit seeking as a problem with goals and interventions for Resident #239. The care plan for Resident #239 was not followed related to redirecting and safeguarding Resident #80. Review of Resident #239's Individual Resident Daily Participation Record for Activities on 1/29/2019 at approximately 3:15 PM revealed that diversional activities were not provided on 9/27/2018, the day of the encounter of resident to resident sexual abuse. The record revealed that Resident #239 did not take part in any activities on 9/27/18.

Based on record reviews, interviews and review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, the facility failed to implement it's policy to ensure Resident #80 was free from sexual abuse from Resident #239. One of eight residents reviewed for Abuse. The findings included: The facility admitted Resident #80 on [DATE] with [DIAGNOSES REDACTED]. The facility admitted Resident #239 on [DATE]) with [DIAGNOSES REDACTED]. Review of the facility investigation dated [DATE] revealed that on [DATE] shortly after 3pm A Certified Nursing Assistant (CNA) reported that (Resident #239) was in (Resident #80's) room and had (his/her) hands on (Resident #80's) chest area. (CNA) separated them and reported to (her/his) nurse. Review of Resident #80's medical record on [DATE] at approximately 9:00 AM revealed that Resident #239 wandered into (Resident #80's) room and fondled (his/her) breast on [DATE] at 3:00 PM. During an interview on [DATE] at approximately 3:00 PM with the Director of Nursing (DON), the DON stated that the CNA had come to him/her and told her/him of the sexual abuse. The DON stated that was when we started the 15-minute checks on Resident #239. The DON stated that Resident #239 is a wanderer and that is why he/she is on the locked unit. Review of Resident #239's Social Service notes on [DATE] at approximately 3:10 PM revealed a Social Service note dated [DATE] Res (resident) moving to secure unit. Res is going into other residents rooms upsetting them. SS (social services) to f/u (follow up) as needed Review of Resident #239's Comprehensive Plan of Care on [DATE] at approximately 3:10 PM revealed a Comprehensive Plan of Care dated [DATE] which states, Resident demonstrates confusion and expresses feeling sad at times, demonstrates inappropriate behaviors as evidenced by history of making comments of sexual nature toward other female residents, attempting to touch other female residents in inappropriate area. Approaches included Approach res positively and in calm, accepting manner, Contact res's spouse as needed regarding res's behaviors, Monitor and document behavior as needed, NCEPS as needed, Provide assistance and redirection as needed, Provide diversional activities, Provide increase in support as needed, Redirect res away from other female residents as needed. Review of Resident #239's medical record revealed an Acute Plan of Care dated [DATE] which states, Grabbing female resident in sexual nature. The goal is, will not exhibit behaviors. The interventions include: Remove residents when exhibiting inappropriate behaviors. Redirect resident when attempting to wander in other rooms. Notify resident's spouse. [DATE] resolved Review of Resident #239's Comprehensive Plan of Care dated [DATE] did not include wandering into resident rooms and exit seeking as a problem with goals and interventions for Resident #239. The care plan for Resident #239 was not followed related to redirecting and safeguarding Resident #80. Review of Resident #239's Individual Resident Daily Participation Record for Activities on [DATE] at approximately 3:15 PM revealed that diversional activities were not provided on [DATE], the day of the encounter of resident to resident sexual abuse. The record revealed that Resident #239 did not take part in any activities on [DATE]. Review of Resident #239's Nurses Notes on [DATE] at approximately 3:30 PM revealed Nurses Notes dated [DATE] through [DATE] which revealed no documentation of inappropriate sexual behavior towards female residents. Resident #239 died in the facility on [DATE]. Review on [DATE] at approximately 10:45 AM of the facility policy titled, Abuse, Neglect And Misappropriation of Property, states, The facility's leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of a patient/resident including misappropriation of property and/or funds.

On the days of the survey, based on record review, observations, and interviews, the facility fail to notify the physician for a change of condition for 1 of 2 residents reviewed for notification. Resident #8 had complaints of leg pain from 7//6/2012 until 7/8/12. This was reported by the Certified Nursing Assistants (CNAs) to the nurses on multiple shifts. The nurses failed to contact the physician until 7/8/12 at 7:30 AM. The findings included: Review of the medical record revealed Resident #8's [DIAGNOSES REDACTED]. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] coded Resident #8 as having a short-term and long-term memory problem with severely impaired cognitive skills for daily decision-making. The Quarterly MDS also coded Resident #8 as totally dependent for transfers, dressing, hygiene, and bathing with no behaviors coded as occurring during the assessment period. Review of the care plan revealed cognitive loss/dementia related to [MEDICAL CONDITION] was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included "Needs assistance with ADLS due to right [MEDICAL CONDITION], depression, generalized weakness, debility, arthritis, muscle weakness, and [MEDICAL CONDITION]" Interventions included "...PT/OT/ST to eval and treat as indicated...assist with tuning and repositioning every 2-3 hours and as needed to prevent skin breakdown and maintain comfort..." "Activities- Resident enjoys propelling self around facility..." "Wanderer...If resident is wandering away from unit, instruct staff to stay with resident... Review of the Nurses' Progress Notes dated 7/2/12 at 2:00 AM until 7/8/12 at 7:00 AM indicated no entries were made during that time. On 7/8/12 at 7:00 AM, an entry was made to indicate that the resident complained of upper left leg pain and that the area was swollen. At 7:30 AM on 7/8/12, orders were received from the physician to sent Resident #8 to the emergency room for evaluation and treatment and at 8:00 AM the resident was transported to the hospital. Other entries were noted to be placed in the record dated prior to 7/8/12. A 7/6/12 entry at 7:15 PM, indicated that a Certified Nursing Assistant (CNA) reported that the resident had a swollen left thigh to the nurse who assessed the resident and stated "no pain". No entry related to contacting the physician was noted. An entry on 7/7/12 at 5:00 PM indicated that the nurse on that shift was notified by the CNA that Resident #8's left thigh swelling and the resident "appears to be in pain". The note stated that the resident does not complain of being in pain when lying on his back. A note on 7/7/12 timed for 8:00 PM then changed to 6:45 PM stated that the resident had complained of pain but refused to go to his room to let the nurse look at his left leg and did not complain when the left leg was touched. The note also indicated that the am nurse had said that she would call the physician the next morning to see if he would order an x-ray. At 5:00 AM on 7/8/12, the CNA reported to the nurse that the resident "moaned out" during care. The nurse asked the resident if he was in pain and he stated "not now". A nurse's note dated 7/8/12 with late entry for 7/6/12 at 3:35 PM indicated that the resident was transferred from a wheel chair to bed and as he was undressed by the CNA he said "Oh, my leg." The note stated that the resident's left leg muscle was tight with no discoloration or warmth. She also stated that she pressed his leg and the resident did not complain of pain. There were no entries documenting that the physician had been notified of the [MEDICAL CONDITION] or pain in Resident #8's left leg from 7/6/12/until 7/8/12. On 7/31/12, the facility's Medical Director was interviewed by phone. He stated that he would have expected the nurse to contact him on 7/6/12 when the resident's leg pain was brought to their attention. He stated that he was on call that weekend and would have sent the resident to the hospital.