Every finding on record at Linville Court At The Cascades Verdae

Based on review of facility policy, observation, and interview, the facility failed to ensure proper handling and transportation of resident laundry for 1 of 1 residents observed. Findings include: Review of the facility policy titled, Laundry and Bedding, Soiled, documents, Policy Interpretation and Implementation Transport . 5. Separate carts are used for transporting clean and contaminated linen. Otherwise, carts that are used for transport of dirty linen are thoroughly cleaned and disinfected before being used to transport clean linen. 6. Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness . Storage 1. Clean linen is stored separately, away from soiled linens, at all times. During an observation on 03/11/25 at 11:35 AM, the Laundry Attendant removed covered dirty linen basket from room [ROOM NUMBER]. Laundry Attendant took the dirty linen basket to the hallway outside of the laundry room. The laundry attendant donned gloves and removed clean linen from the dryer. She folded a pair of pants and a blanket and placed the clean laundry on top of the resident's dirty linen basket. The laundry attendant did not clean and disinfect the dirty linen basket before placing the clean linen on top of the dirty laundry basket. The Laundry Attendant removed her gloves. She donned an apron and a new pair of gloves. She removed the soiled laundry from the dirty linen basket and placed it in the washing machine. The washing machine was started. The clean linen was transported back to the resident's room uncovered, on top of the dirty linen basket. The Laundry Attendant confirmed that she always transports linen like this. During an interview on 03/11/25 at 12:13 PM, the Director of Facilities revealed that dirty linen should be bagged, sealed off and transported. There should be a separate cart for dirty linen and a separate cart for clean linen. Both the clean and the dirty linen should be covered for transport because you do not know what kind of viruses are floating around. During an interview on 03/11/25 at 12:36 PM, the Executive Director revealed their expectations are that clean linen should never come in contact with dirty linen or dirty surfaces. Clean linen and dirty linen should be covered during transport.

Based on review of facility policy, record review, observation, and interview, the facility failed to ensure that Resident (R)17 had an active order for the use of a Cervical Thoracic Orthosis (CTO) neck brace, for 1 of 1 resident reviewed for positioning/range of motion (ROM). Findings include: Review of the facility policy titled, Medication and Treatment Orders, with a last revision date of July 2016, documented, Orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of the facility policy titled, Assistive Devices and Equipment, with a last revision date of February 2014, documented, Our facility maintains and supervises the use of assistive devices and equipment for residents. The policy also documented, The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment: a. Appropriateness for resident condition; b. Personal fit; c. Device condition; d. Staff practices. Review of R17's Face Sheet revealed that R17 was admitted to the facility with diagnoses including, but not limited to: Traumatic Subarachnoid Hemorrhage Without Loss of Consciousness, Intracranial Injury with Loss of Consciousness, Epidural Hemorrhage with Loss of Consciousness, Nontraumatic Subarachnoid Hemorrhage, Nondisplaced Fracture of the 2nd Cervical Vertebra, Multiple Fractures of Ribs, Left Side, Stable Burst Fracture of the Fourth Thoracic Vertebra, and Stable Burst Fracture of the Third Thoracic Vertebra. Review of R17's undated Care Plan documented ADL - [R17] relays a goal to improve her abilities in self-care. She has difficulties with movement, generalized weakness, and unsteady balance due to a recent hospitalization from a fall from her attic (about 15 feet) directly onto her head. This caused significant injuries, including subarachnoid hemorrhage, scalp laceration, left frontoparietal cranial fracture, epidural hematoma, left C2 lamina fracture, left rib fractures (1st, 3rd, 4th, 9th), left pneumothorax, L4 pars defect of unknown chronicity, and a three-column fracture at T3-T4. She has a CTO brace that should remain in place to prevent extreme changes in the position of the neck. She also prefers to lie flat for comfort, but this causes headaches. She was treated for her acute needs at the hospital but remains fatigued and restricted in her movements, requiring staff assistance with transfers, toileting, and incontinence care. She was referred to rehab to improve her functional activities without physical assistance, address impaired dynamic and static balance, and improve strength and balance. Review of the Prisma Health Progress Note with a visit date of 02/24/25, revealed the patient was admitted to the hospital for multiple traumas, including Traumatic Brain Injury (TBI), Subdural and Subarachnoid Hemorrhage (brain bleed), multiple broken ribs, and a spinal fracture. Additionally, the document revealed, 2/24/25 Continue CTO [Cervical Thoracic Orthosis] brace for 3 months. Review of R17's Orders on 03/10/25 at 3:00 PM, did not reveal an active order for the use and/or indication for a CTO brace. During an interview on 03/09/25 at 12:42 PM, R17 revealed that she suffered a head-first fall at home, resulting in multiple fractures to her spine, neck, and ribs. The resident stated she was hospitalized for treatment and sent to the facility for rehab. She was told to leave her neck brace on until she sees her spinal doctor and neuro team later in the week. The resident indicated that she wears the brace at all times except when bathing. During an interview on 03/11/25 at approximately 4:30 PM, with Registered Nurse (RN)1 and Interim Director of Nursing (DON). RN1 stated that it was her understanding that R17 should have her CTO brace on at all times. An observation was made with RN1 and the DON of the resident's current order set, and no active order could be found in regard to the use and rationale for the use of R17's CTO brace. The DON acknowledged that the lack of an order could potentially lead to safety concerns and possible harm to the resident. The DON also stated that an order should have been placed for the CTO brace use. During an interview on 03/11/25 at 5:23 PM, the Medical Director (MD)1 stated based on R17's hospital discharge instructions, the CTO brace should be worn at all times until the resident is seen by the neurosurgeon on 03/13/25. MD1 thought there was an order in place for R17's CTO brace in the electronic health record (EHR). MD1 explained that the resident should have an order for the CTO brace to ensure resident safety and protect the resident from further injury. MD1 further explained that typically, the admissions nurse is responsible for reviewing hospital discharge paperwork and transferring any relevant orders to the resident's EHR under the medical director's name. During an interview on 03/11/25 at 5:32 PM, RN2, who serves as the admissions nurse, stated that when a resident is admitted from the hospital, she is responsible for ensuring that any medications and treatment orders specified by hospital providers are entered into the resident's EHR. The admissions nurse will place the orders under the MD's name. RN2 recalled reading a note from the hospital that stated the resident needed to wear the brace at all times. RN2 explained that when the resident was admitted , she was handling four other admissions simultaneously, and the order for the CTO brace was not entered into the system, possibly because it was overlooked. RN2 believes the order for the CTO brace should have been placed upon admission. During an interview on 03/11/25 at 5:44 PM, the Executive Director (ED) confirmed that, based on the admissions nurse's role in ensuring that orders are properly placed during admission, proper procedures were not followed, and the order for R17's CTO brace should have been placed.

Based on interview, observation, and record review, the facility failed to prevent the potential for accidents/accident hazards for 1 of 3 residents. Resident (R)2 eloped from the facility on 04/20/2023 at approximately 4:38 PM. The facility's failure placed R2 at a potential risk of suffering a fall when walking over uneven or unfamiliar territory. Additionally, R2 had the potential of suffering from injuries or death as a result of wandering into traffic or bodies of water, or as a result of exposure to inclement weather. On 04/27/2023 at approximately 12:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 04/27/2023 at 1:00 PM the Administrator and the Director of Nursing (DON) were notified that the elopement of R2 constituted IJ at F689 with an effective date of 04/20/2023. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. The findings include: Review of the March 2019 facility policy titled Wandering and Elopements revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Parkinson's disease, dementia, aphasia, chronic kidney disease (stage 3), and major depressive disorder. R2's Brief Interview for Mental Status (BIMS) assessment on 04/12/2023 revealed, R2 scored an 8 out of 15 indicating R2 was moderately cognitively impaired. Review of R2's Wandering / Elopement Risk screening, dated 04/11/2023, revealed R2 scored a Total Elopement Risk Assessment Score of 0 out of 9, indicating the behavior did not occur. Review of Maintenance Worker (MW)1's witness statement dated 04/20/2023, revealed MW1 was in the back parking lot next to the trash compactor on 04/20/2023 at approximately 4:45 PM. MW1 indicated he saw R2 walking down the sidewalk. Staff asked if the resident was ok, and the resident responded he was looking for someone. Staff walked the resident back inside and to his room. An interview with MW1 on 04/27/2023 at 10:45 AM confirmed MW1 written statement. MW1 stated he saw an older gentleman and wasn't sure if he was a resident or a visitor. MW1 asked the resident how he was, and the resident said he was waiting for his daughter. MW1 realized he was a resident and walked R2 back inside the facility. A walkthrough with MW1 on 04/27/2023 at approximately 10:50 AM, to retrace R2's elopment, revealed R2 was discovered behind the facility outside the door between units [NAME] and [NAME]. R2 was found on the sidewalk across the parking lot. The doorway between [NAME] and [NAME] does not alarm if used by someone without a wander guard device. Review of timeanddate.com revealed the weather on 04/20/2023 at 4:53 PM was 83 degrees Fahrenheit and sunny. Review of facility camera footage revealed R2 exited the facility on 04/20/2023 at approximately 4:38 PM. R2 was returned to his unit the same day at approximately 4:42 PM. An interview with the Nursing Manager (NM) on 04/27/2023 at 10:55 AM revealed there is nothing to stop a resident without a wander guard from exiting the door between [NAME] and [NAME] units. Furthermore, there is no alarm system to alert staff the doorway has been used. The primary uses for the door are for fire emergencies and trash disposal. It is not ordinarily used by residents or visitors. An interview with the Administrator on 04/20/2023 at 11:21 AM confirmed there is no way of knowing if a resident without a wander guard uses the door between [NAME] and [NAME] units. The Administrator stated, if maintenance had not found the resident, his Certified Nursing Aid (CNA) and nurse would not have been aware of his exit. Based on facility policy, his absence would not have been noticed till approximately 30 minutes later when dinner was served to the residents. Review of Licensed Practical Nurse (LPN)1's witness statement dated 04/20/2023 revealed, she was notified R2 was observed in the parking lot in front of the resident's room by another staff member. An interview with CNA1 on 04/27/2023 at approximately 11:42 AM revealed she was watching another resident in the dining area at the time of the incident. After R2 was found, R2 told CNA1 he had been searching for his wife because she didn't call him back after her visit. An interview with CNA2 on 04/27/2023 at approximately 12:00 PM revealed she was R2's CNA on 04/20/2023. CNA2 had seen R2 approximately 20 minutes before he eloped the facility. At that time, he was in his chair with his call light in reach. His wife had just left after visiting. After R2 was found, he told CNA2 that he had been looking for his wife. An interview with R2 on 04/28/2023 at approximately 9:00 AM revealed R2 was not able to answer questions regarding the elopement, but R2 did express a desire to leave the facility. The facility's removal plan included: Audible door alarms were placed on all exit doors on 04/27/2023. R2 was issued a wander guard prior to survey. During survey, R2 was moved to a room further from the door between [NAME] and [NAME]. In-service of Elopement Policies and Procedures and new door alarm procedures with floor staff was begun on 04/27/2023. A mass communication was sent out on 04/27/2023 to all nursing staff regarding the in-services. All staff that were not in facility during survey will complete in-services on Elopement Policies and Procedures and new door alarm procedures prior to their next shift. An audit on Wander/Elopement risk was completed on all residents. Ten residents were identified at possible risk and wander guards were applied on 04/27/2023 with notifications sent out to family, residents, and physician. An audible audit will be completed daily for 4 weeks to include date, time, door location, if working correctly, and the person responding to the alarm. The facility will review QAPI monthly starting on 05/17/2023. The facility will review 3 months of QAPI or longer until continuous compliance. When a resident scores a BIMS below 10/15, the facility will reassess their wandering risk. An exit alarm that requires a key to reset was placed on the door between [NAME] and [NAME] on 04/27/2023.

Based on observation, interviews, and review of facility policy, the facility failed to prepare and serve food and store kitchen dishware and pans in a sanitary manner and failed to discard leftovers within the scheduled timeframe during two (2) of two (2) observation days of the dietary department. Findings include: Review of the policy titled, Food Preparation and Service, dated 10/2017 revealed food preparation staff would adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Review of the policy titled, Dry Storage-Dishes and Utensils, dated 2/1/12 revealed, dishes must be stored to promote air drying i.e., use dish racks or trays with plastic mesh that allow air to circulate, and air dry the dishes. Review of the policy titled, Trayline Refrigerated Leftover Storage, dated 2014 revealed, leftover foods should not be saved and re-used for human consumption if there was any doubt of wholesome quality. The timeframes listed were not only used to control sanitation but the quality of the food also. Observation during the initial tour of the kitchen on 8/17/21 from 10:58 a.m. to 11:50 a.m. revealed the staff stored the serving and cooking utensils uncovered and upright directly above the three (3) compartment sink. Interview with the Executive Chef at that time revealed the staff used the three (3) compartment sink to clean the serving trays and the beverage dispensers. The Executive Chef confirmed the storage of the utensils above the three (3) compartment sink. Observation at 11:20 a.m. revealed a random sample of 38 steam table pans stacked together with water and/or dried food present inside the pans. Observation at 11:31 a.m. revealed a staff member drying a storage container with a towel. Interview with the Executive Chef at that time revealed he/she did not know that staff should not dry the dishes or cooking utensils. Further observation during the initial tour of the kitchen on 8/17/21 from 10:58 a.m. to 11:50 a.m. revealed the walk-in cooler contained two (2) packages of salami, one (1) package of swiss cheese and one (1) package of turkey with labels documenting the shelf life (day to discard) as 8/15/21; a container of liquid chicken stock with a label indicating the shelf life as 8/16/21; container of blue cheese with the label indicating the shelf life of 8/11/21; an uncovered steam table pan of black beans with no label; a steam table pan of panini pasta with the plastic covering the pan torn and not labelled; uncovered and unlabeled steam table pan of cut onions; steam table pan of corn with the shelf life of 8/12/21; and a plastic container of bow tie pasta with the shelf life of 8/12/21. Observation of the dry storage area revealed a container of batter mixture with the opened date of 5/1/21. The facility's label on the container documented the mixture was good for 90 days. Interview with the Executive Chef on 8/17/21 at 11:18 a.m. revealed he/she was responsible for ensuring the leftovers were discarded by the shelf-life date. The Executive Chef also stated if the leftovers were cooked, they would keep them for seven (7) days and if the leftovers were uncooked, they were kept for three (3) days. He/she confirmed the items listed above should have been discarded by the shelf-life date. Observation of the kitchenette on the [NAME] Unit on 8/17/21 at 11:57 a.m. revealed 27 out of 27 plastic cups stacked together with water between them and five (5) plates or bowls with dried food present where the food would be placed. Observation on 8/17/21 at 12:03 p.m. of the kitchenette on the [NAME] Unit revealed 27 out of 27 glasses stacked together with water between them. Observation on 8/17/21 during the lunch meal service on the [NAME] Unit revealed at 12:12 p.m. the Certified Dietary Manager (CDM) placed his/her ungloved finger inside a salad bowl being used. At 12:29 p.m. Dietary Cook #2 with gloves on touched the menu list, Styrofoam containers, microwave buttons and handles, counters and itched his/her arm and then without changing gloves pushed the lettuce down into the bowls. Further observation during the lunch meal from 12:47 p.m. to 12:55 p.m. revealed Dietary Cook #2 pushed his/her glasses up, held his/her hands on the back of his/her shirt, touched his/her pen and then touched the inside of the plate where food was placed without changing his/her gloves. Observation on 8/19/21 from 11:34 a.m. to 11:48 a.m. revealed Dietary Cook #2 prepared the pureed food. Further observation revealed with gloved hands Dietary Cook #2 pulled up his/her mask, touched the recipe book, the thickener container, warmer cabinet handles and without changing his/her gloves, touched the robot coupe's (industrial blender) beaters prior to making the pureed tortellini. Dietary Cook #2 also, without changing his/her gloves, placed spinach that had landed on the rim of the robot coupe into the robot coupe. Interview with Dietary Cook #2 on 8/19/21 at 11:48 a.m. regarding the dietary training he/she had received, revealed the Registered Dietician (RD) came to the facility on e (1) time a month. The RD would test them on different things, such as sanitization or making ground or pureed diets. Interview with the CDM on 8/19/21 at 11:52 a.m. confirmed the Dietary Cook should change gloves after touching other items and then touching the food or items that came in contact with the food. The CDM stated the RD came monthly and on occasion the RD would do training for the staff. He/she further stated on hire the new kitchen staff would shadow someone in the kitchen that held the same position as the new person would have. The CDM stated there was no formal list as to what the new person was trained on. Further observation on 8/19/21 at 11:52 a.m. revealed the dietary staff were preparing and plating food and two (2) females in street clothes with no hair nets on, entered the kitchen and went to the beverage area. Upon the surveyor asking, the CDM stated the females were activity staff and confirmed that they should not be in the kitchen without hair nets on. Observation revealed no staff approached the activity staff until the surveyor continued to ask questions about them being in the kitchen without hair nets on. The CDM then called a dietary staff member over and by that time the activity staff had left the kitchen. Interview with the RD via phone on 8/20/21 at 9:15 a.m. revealed the facility did the training for the kitchen staff. The RD stated he/she utilized a company wide sanitization check-off sheet when assessing the kitchen and dietary staff.

Based on observation, record review, and interviews, the facility failed to follow the menu for the items served and for the serving sizes for one (1) of one (1) meal observed. Findings include: Review of the Dietary Guide Sheet for 8/17/21 revealed the residents should receive hearty beef stew, mashed potatoes, braised stew vegetables, assorted breads, assorted desserts, and the salad of the day. Observation on 8/17/21 beginning at 12:03 p.m. and ending at 12:55 p.m. of Dietary Cook #2 serving the lunch meal on [NAME] Unit revealed the residents did not received the braised stew vegetables. Interview on 8/17/21 at 12:34 p.m. with the Certified Dietary Manager (CDM) regarding why the residents did not receive the braised stew vegetables, he/she was unaware the vegetables were not being served. The CDM then asked Dietary Cook #2 the same question. Dietary Cook #2 stated the vegetables were in the stew, plus they received mashed potatoes. Dietary Cook #2 also stated he/she did not usually make/serve additional vegetables if something else being served contained vegetables. Review of the Diet Guide Sheet for 8/17/21, revealed the residents that received a regular diet should receive eight (8) ounces of the beef stew, and four (4) ounces of the mashed potatoes, braised stew vegetables and salad. The residents that received a pureed diet should receive eight (8) ounces of the pureed hearty beef stew and four (4) ounces of the pureed mashed potatoes, braised stew vegetables, and soft mixed vegetables (in place of the salad). The residents that received a ground diet would receive eight (8) ounces of the ground hearty beef stew, four (4) ounces of the mashed potatoes and braised stew vegetables and four (4) ounces of the mixed vegetable (in place of the salad). Further observation on 8/17/21 of the lunch meal on [NAME] Unit beginning at 12:03 p.m. and ending at 12:55 p.m. revealed Dietary Cook #2 used a four (4) ounce scoop to serve the beef stew and number 12 scoops to serve the mashed potatoes, pureed spinach (in place of the lettuce salad), and pureed beef stew. Dietary Cook #2 did not measure the lettuce salad. Interview with Dietary Cook #2 on 8/17/21 at 12:25 p.m. revealed he/she did not know how many ounces a number 12 scoop was. Further interview with the CDM on 8/17/21 at 12:34 p.m. confirmed the staff should serve the residents eight (8) ounces of the beef stew and instructed Dietary Cook #2 to serve the eight (8) ounces and serve four (4) ounces of the mashed potatoes, and pureed spinach. Further observation on 8/17/21 at 12:35 p.m. revealed Dietary Cook #2 served four (4) additional residents only four (4) ounces of the beef stew. The CDM on 8/17/21 at 12:41 p.m. provided documentation that a #12 scoop size was only 2 and 3/4 ounces and not the four (4) ounces documented for the mashed potatoes and the pureed vegetable. Further observation of the lunch meal on 8/17/21 beginning at 12:03 p.m. and ending at 12:55 p.m. on [NAME] Unit revealed the residents that received a pureed diet did not receive the pureed bread. Observation on 8/17/21 from 12:58 p.m. to 1:30 p.m. of the lunch meal on [NAME] Unit revealed, Dietary Cook #2 did not measure the pureed spinach when serving the residents that received a pureed or ground diet. Dietary Cook #2 also served five (5) residents four (4) ounces of the beef stew before serving the required amount of eight (8) ounces. Interview with the CDM during the observation of the lunch meal on 8/17/21 at approximately 1:00 p.m., as to why the residents that received a pureed or ground diet did not receive the pureed bread revealed the CDM did not know and then asked Dietary Cook #2. Dietary Cook #2 stated they were out of the pureed bread mix. The residents on the [NAME] Unit also did not receive the braised stew vegetables as listed on the Diet Guide Sheet. Interview with the CDM on 8/19/21 at 2:45 p.m. revealed the Registered Dietician (RD) told him/her the facility did not have a policy for following the menu or scoop sizes. The RD stated staff should follow the spreadsheet (Diet Guide Sheet). Interview with the RD via phone on 8/20/21 at 9:15 a.m. confirmed the staff should follow the spreadsheet for the items served and the serving size.

Based on observation, interviews and facility policy review, revealed the facility failed to date insulins when opened and moved to the medication cart for use on one (1) of two (2) medication carts. Findings include: Review of the facility's policy titled, Administering Medications, dated 12/2012, revealed the following: - Item #9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. Observation of the medication cart on [NAME] Hall on 8/17/21 at 10:45 a.m. with Unit Manager (UM) #4, revealed five (5) insulin injection pens were not dated when removed from the refrigerator and placed on the cart. Continued observation revealed that these five (5) insulin injection pens were as follows: two (2) [MEDICATION(S)] Kwik pen, one (1) [MEDICATION(S)] insulin [MEDICATION(S)] injection pen, one (1) [MEDICATION(S)] insulin injection pen, and one (1) [MEDICATION(S)] [MEDICATION(S)] insulin [MEDICATION(S)] injection pen. Interview on 8/17/21 at 2:30 p.m. with the Director of Nursing (DON) s/he stated that these insulins should have the date on them when placed on the medication cart for use. S/he stated it is the responsibility of the nurse that takes the insulin from the refrigerator to immediately date the insulin when they place it on the medication cart. Interview on 8/19/21 at 9:10 a.m. with the facility's pharmacist, s/he confirmed these insulins are to be dated when open or in use, s/he stated, these insulin injection pens containing prefilled insulin, are to be dated when removed from the refrigerator and placed on the medication cart. Once placed on the medication cart they have an expiration of 28 to 30 days.

Based on observations, resident and staff interviews, record review, and review of the facility's policy and procedure, the facility failed to house and provide dedicated staff for a resident positive with COVID-19 separate from the Persons Under Investigation (PUI), to prohibit access to the designated quarantine area by residents from the general population of the facility, failed to maintain a 14 day quarantine, and failed to ensure staff followed transmission-based precautions requiring the use of full Personal Protective Equipment (PPE) (gloves, gowns, face mask, goggles or face shield) while providing care to PUI. Specifically, residents' positive for COVID-19 were housed and staffed on the same unit as the PUI. Therapists did not provide in room therapy to people identified as PUI and facility staff wore only a face mask and gloves while providing care to the PUI. Failure to appropriately quarantine residents and implement transmission-based precautions with full PPE increased the risk of COVID-19 transmission to the 33 residents residing in the facility. Findings include: Per Centers for Disease Control (CDC), Responding to Coronavirus (COVID-19) in Nursing Homes, updated 04/30/20, . Considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19 . Determine the location of the COVID-19 care unit and create a staffing plan before residents or HCP (Health Care Personnel) with COVID-19 are identified in the facility. This will allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit . Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19. Depending on facility capacity (e.g., staffing, supplies) to care for affected residents, the COVID-19 care unit could be a separate floor, wing, or cluster of rooms. Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility . Per Centers for Disease Control (CDC), Preparing for COVID-19 in Nursing Homes, dated 06/25/20, indicated, . Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown . Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (Health Care Professionals) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected . Review of the facility's policy titled, Community Information/COVID-19, dated as revised 10/05/20, indicated, . Admissions/Re-Entry to Care Services . Effective immediately, for the first 10 days of any new admission, re-admission, re-entry or [MEDICAL TREATMENT] (offsite) for Skilled Nursing, Long Term Care . The 10-day Quarantine/Isolation can be waived with 2 negative COVID-19 test results . Place all new admissions in the same area . Use only one CNA (Certified Nursing Assistant/RN (Registered Nurse) each shift to care for the new admissions only (if possible) N95 masks to be worn and re-used as per policy) . Resident is to eat in room for all meals . Therapy is to be delivered in room . Gown can be kept in resident room to conserve (per COVID-19 guidelines) . Gown not required if; no order for isolation and not currently experiencing cough, fever or shortness of breath . During the entrance conference on 10/14/20 at 8:45 AM, the Administrator stated the facility had four previous residents identified with COVID-19. One resident (Resident #11) who was identified as positive COVID-19 was sent to the hospital due to respiratory distress and passed away during his/her stay at the hospital in July 2020. The Administrator stated staff wore face mask, gown, face shield/goggles, and gloves to provide care to the former positive COVID-19 residents. Resident #11 was placed on the new admissions unit (Asher Unit). The Administrator stated the previous positive COVID-19 residents were no longer in the facility. During this interview, the Administrator identified seven residents as new admissions to the Asher Unit, which is the designated rehabilitation unit and confirmed this was the location of the former positives in the past. In addition, there was one resident (Resident #5) identified on the(NAME)Unit, which is the designated long-term care unit. The Administrator stated the facility had three Infection Control Preventionists (ICP). Two of them work full-time and one works as needed (PRN). The residents on the Asher Unit are short term rehabilitation residents. During an interview on 10/14/20 at 9:38 AM, with Central Supply, she confirmed she stocked supplies on the unit for new admissions and stated she only supplied gloves and face masks. The staff member stated she did not supply gowns or a face shield unless there was a positive COVID-19 resident. During an interview on 10/14/20 at 10:25 AM, Registered Nurse (RN/ICP) #1 stated staff go into the rooms of new admissions with a face mask and gloves only. During an interview on 10/14/20 at 11:14 AM, Certified Nursing Assistant (CNA) #6 stated he/she was to wear gloves and a face mask into the rooms of new admissions (under 10 days). During an interview on 10/14/20 at 11:50 AM with the Nurse Practitioner (NP) confirmed he/she enters the rooms of new admissions and wears a face mask. He/she stated if there was a positive COVID-19 patient then staff would don gown, gloves, face mask, and face shield. The NP stated residents who were on the Asher Unit must either have two negative COVID tests or fulfill their 10 days of quarantine. 1. Per review of the Electronic Medical Records (EMR), Face Sheet, revealed Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a paper document titled, Timeline, for Resident #11, identified a staff member tested positive on 06/18/20 for COVID-19 and this staff member worked on the Asher Unit. All 17 residents on this unit were tested for COVID-19. Resident #11 came back negative. On this same date, the resident went to a community based medical appointment. The timeline identified a second staff member was tested for COVID-19 on 07/06/20 and came back positive on 07/08/20. The last day of work, on the Asher Unit, for this staff member was on 06/26/20. On 06/30/20, the resident was tested for COVID-19 based on his/her symptoms. The resident was sent to the local hospital due to respiratory distress and was eventually admitted to the hospital on [DATE] for COVID-19 and respiratory distress. Review of the EMR Hospital Course, dated 07/03/20, Resident #11 was admitted to the hospital to treat the resident with severe [MEDICAL CONDITION] and was unresponsive. Resident #11 passed away on 07/06/20 [MEDICAL CONDITION] and acute [MEDICAL CONDITION]. 2. Review of the EMR, Face Sheet, indicated Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Face Sheet revealed the resident was admitted on the Asher Unit. Observation on 10/14/20 at 9:37 AM of Resident #6 in his/her room sleeping. On the wall on the outside of the resident's room there was a green sign that indicated staff were to use, Contact Precautions.Please Use Protective Equipment While Assisting Member . mask . gloves . The sign did not mention the staff were to don a gown and a face shield or goggles when entering the resident's room. During an interview on 10/14/20 at 12:07 PM, Resident #6 confirmed he/she had been admitted to the facility within the past 14 days. The resident stated staff always enter his/her room with a face mask and gloves on. The resident confirmed therapy staff will take him/her for walks outside of his/her room and in the hallways of the Asher Unit. During this interview CNA #6 was observed to bring the resident soup. The staff member had a face mask and gloves on but did not have a gown or face shield/goggles on. 3. Review of the EMR, Face Sheet for Resident #9, indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Face Sheet revealed the resident was admitted on the Asher Unit. Observed on 10/14/20 at 9:40 AM, two random therapy staff were observed to walk Resident #9 on the Asher Unit. All three of them had a face mask on only. 4. Review of the EMR, Face Sheet, for Resident #4, indicated the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Face Sheet revealed the resident was admitted on the Asher Unit. Observed on 10/14/20 at 9:42 AM, the outside of Resident #4's door, there was no sign that indicated the resident was under a 14-day quarantine. The resident's room was on the Asher Unit. 5. Review of the EMR, Face Sheet., for Resident #5, indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Face Sheet revealed the resident was admitted to the(NAME)unit. During an interview on 10/14/20 at 11:02 AM, CNA #5 confirmed he/she provided personal care to Resident #5. CNA #5 stated he/she just wears a face mask and gloves, no gown or face shield. During an interview on 10/14/20 at 12:15 PM, Resident #5 stated staff, who enter his/her room, wear a face mask and gloves but no gown or face shield/goggles. Observation on 10/14/20 at 12:20 PM, Licensed Practical Nurse (LPN) #16 entered the room of Resident #5. LPN #16 wore a face mask and no other PPE. The staff member assisted the resident to a common area, close to the dining area to obtain the resident's weight. During an interview at 12:25 PM, LPN #16 stated Resident #5 tested negative twice from COVID-19 test and therefore, no longer required quarantine. 6. Review of the EMR, Face Sheet, for Resident #3, indicated the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Face Sheet revealed the resident was admitted on the Asher Unit. During an interview on 10/14/20 at 11:21 AM, Physical Therapist Assistant (PTA) #8 confirmed he/she just left the room of Resident #3, who was considered a quarantined resident (under 10 days). PTA #8 stated she wears a face mask and gloves and not a gown and face shield/goggles with new admissions. During this observation PTA #8 was observed to wear a face mask only. 7. Review of the EMR, Face Sheet indicated Resident #8 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. During an interview on 10/14/20 at 11:24 AM, the physician stated he/she enters the rooms of new admissions with a face mask on. The physician stated he/she would don a gown and gloves if he/she were to provide a physical exam. Observation on 10/14/20 at 11:40 AM, the physician was observed in the room of Resident #8, with a face mask on and no gown, gloves, and face shield/goggles. 8. Review of the EMR, Face Sheet, indicated Resident #7 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Observation on 10/14/20 at 11:08 AM, Resident #7 was observed to walk in the main hallway of the Asher Unit with a Physical Therapist (PT). The resident and the PT were observed with a face mask on. The PT was interviewed after this observation and stated the resident was not on a 10-day quarantine and confirmed contact precautions were to be used for new admissions. The PT said contact precautions were the use of gloves and a face mask and not a gown and face shield/goggles. During an interview on 10/14/20 at 12:27 PM, RN #1 was observed to transport a resident to room [ROOM NUMBER] located on the Asher Unit. RN/ICP #1 stated the resident was a new admission. RN #1 was observed with a face mask on and not a gown or face shield/goggles. During an interview on 10/14/20 at 1:14 PM, RN/ICP #2, stated he/she was hired in September 2020. RN/ICP #2 confirmed residents who were placed on the Asher Unit, were there for short term rehabilitation. RN/ICP #2 confirmed staff have been trained on contact precautions. The staff member stated he/she did not provide the training. RN/ICP #2 confirmed staff were to wear gloves and face masks for contact precautions. During an interview on 10/14/20 at 1:50 PM, RN/ICP #1, said he/she was hired in July 2020. RN/ICP #1 said it was his/her responsibility to ensure staff had the proper PPE and that staff knew how to don the PPE. The RN/ICP #1 said he/she worked at the facility when they had two positive COVID-19 residents. The staff member stated the two positive residents were in the corner of the unit. The staff member stated there were designated staff, a nurse and a CNA. RN/ICP #1 said the designated staff would also provide care to the other residents on the Asher Unit, but as least as possible. He/she stated the nurse would schedule the COVID-19 positive residents' medication pass to be completed last on the shift. The staff member said full PPE for both positive residents, included the use of gowns, gloves, N95 and goggles/face shields. Droplet precautions. RN/ICP #1 stated the CDC protocol was for the two negative COVID-19 tests or the 10 days quarantine. Therapy completes therapy in the resident room under the 10-day quarantine. The ICP stated the Administrator provides all the updates on the CDC guidelines for COVID-19. During an interview on 10/14/20 at 2:10 PM, the Medical Director stated staff were to follow CDC guidelines. The Medical Director stated he/she did not know why residents, who were under a 14-day quarantine were permitted to come out and participate in skilled therapy. The Medical Director stated the residents were to remain in their rooms during quarantine. During an interview on 10/15/20 at 9:59 AM, the Medical Director stated he/she did not agree with the facility's decision to not quarantine residents, who were new admissions or readmissions, for less than 14 days. Observation on 10/15/20 at 11:50 AM, the doors to the Asher Unit and(NAME)Unit were closed. During an interview on 10/15/20 at 11:50 AM, the Housekeeping Supervisor stated staff are to don gowns, gloves, goggles and a face mask prior to entering the room of a new admission. The staff member stated he/she also provided training to his/her department on the new process of donning PPE. During an observation on 10/15/20 at 11:55 AM, on the Asher Unit, the nine residents identified as new admissions/PUI, were moved to a section of the Asher Unit (rooms 308 through 317), including Resident #5, who resided previously on the(NAME)Unit. Each room had containers of PPE stationed in front of each room, with gowns, gloves, googles, and gloves. Red signs were posted on the outside of each room, which stated the following PPE were to be donned prior to entering a PUI room, goggles, gown, gloves, and face masks. Most of the doors in this area were now closed. Central Supply was observed at 11:65 AM to don a gown, goggles, and gloves prior to entering a resident room. At 12:05 PM, CNA #6 was observed in a gown, gloves, goggles, and face mask and to transport a resident to a newly assigned room. During an interview on 10/15/20 at 12:00 PM, CNA #12 stated staff are to don gowns, gloves, goggles and face masks prior to entering the room of new admissions. In addition, the staff member confirmed new admissions were to remain in their rooms for 14 days. During an interview conducted on 10/15/20 at 12:03 PM, CNA #5 confirmed he/she received training on new admissions and to don a gown, gloves, goggles, and face mask prior to entering the room.

Based on record review, staff interview, policy review, and observation of video surveillance, the facility failed to provide adequate supervision for a resident in a weakened physical state from multiple medical conditions. The facility also failed to implement safety measures to protect Resident (R)149 from harm (1 of 8 residents reviewed for accidents). Based on the information received and reviewed (listed above), it was determined on [DATE] at approximately 3:05 AM, that Immediate Jeopardy and/or Substandard Quality of Care existed. The facility census at the time of the incident was 34. After completing the required paperwork, the Administrator was notified of the Immediate Jeopardy on [DATE] at approximately 1 PM. The immediate Jeopardy existed on [DATE] when the exit door of the facility locked behind R149 upon exiting the facility and prevented the resident's re-entry to the building on [DATE] at 3:05 AM. Staff found R149 two hours later, at 5:05 AM, was face down on the ground. R149 was pronounced dead at 5:37 AM. The facility provided an Immediate Jeopardy Removal Plan that was accepted on [DATE] at approximately 10 AM and the Immediate Jeopardy at F689 was removed at 12:08 PM with an effective completion date of [DATE] with the Scope and Severity of the citation lowered to a D. The findings included: Review of the facility's policy titled Elopement Prevention dated ,[DATE], revealed the facility was to ensure the assessment, identification of, and supervision of at risk residents. This included residents who deliberately wander due to confusion .Missing resident is identified as someone who cannot be in their area and is not signed out in the facility's sign out book. The policy specified: Response to a missing resident: All community staff shall respond immediately to a missing resident alert. Staff shall perform a search carefully yet quickly, to preserve the resident's safety, dignity and privacy .If a missing resident is not found in 60 minutes of notification it is considered an elopement. Review of the facility's policy titled Safety and Supervision of Residents, revised (MONTH) (YEAR), revealed, .2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring .identify any specific accident hazards or risks for individual residents . Review of the facility's Move-In Packet Skilled Care with a revised date of ,[DATE], with the facility Administrator present, on [DATE] at 11:22 AM, confirmed there was no information given to any member (resident) that the exit doors lock automatically upon exit and will not allow re-entry back through the door into the facility. During a tour of the facility on [DATE] at 5:00 PM, with the Administrator and the Executive Director, an observation of the room previously occupied by Resident (R)149, which was near the exit door the resident used to leave the building on [DATE] at 3:05 AM. The Administrator verified the door locks automatically after exit preventing re-entry into the building. The Administrator confirmed no alarms were on the exit door to alert staff a resident had exited the building, The Administrator confirmed there was no doorbell to alert staff a resident wanted back in the building. The Administrator said on [DATE] R149 walked away from the door he exited, toward the parking lot after he was unable to get back in the building. The Administrator said R149 must have walked off the sidewalk because he was found by staff lying face down on the grass about 60 feet from the sidewalk by the window of room [ROOM NUMBER]. The Administrator stated the resident was nonresponsive, and the staff initiated CPR (Cardiopulmonary Resuscitation) but the resident did not respond. The Administrator said the nurse then called 911. An observation on [DATE] at 5:15 PM of the exit door the resident used, revealed the wall near the door, now had a posting that warned those seeking to exit that the doors lock on exit, and no re-entry can be made without a fob (digital devices that acts as a key). The Administrator stated he posted the signs warning Doors lock and no reentry . on [DATE], after the incident with R149. The warning signs were observed at each exit door of the skilled unit. Observation of the facility security video by two surveyors, and with the Administrator and Executive Director present, on [DATE] at 5:35 PM, revealed R149 standing at the exit door between Asher and Duncan Units on [DATE] at 3:05 AM (time and date stamp on the video). The resident opened the exit door and walked out. No staff were seen in the area on the video. R149 was fully dressed and his nasal canula was in place, but the oxygen tubing was draped behind him and not connected to the oxygen tank. The resident was wearing his shoes and had his glasses on. The resident stood outside on the sidewalk by the door for about 5 seconds with his back to the door. When he turned around to face the door leading back inside the building, he was slightly off balance and leaning to one side. R149 tried to open the door to re-enter the building, but the door would not open. The resident was not observed to knock on the door or call out for assist. The resident stood there looking in the door for a time. There were no staff noted to be in view during the piece of the security footage of the incident shown to the surveyors. The video ended with the resident just standing facing the door. The facility shared this short piece of the video, but no other footage. A request made for a copy of the video but was not provided. The video paused and did not reveal the resident walking away from the building. Review of an undated Face Sheet located in the Electronic Medical Record (EMR), revealed R149 was admitted to the facility on [DATE] with the primary medical [DIAGNOSES REDACTED]. Review of the Clinical Notes Report, of the EMR, dated [DATE] 2:38 PM revealed: Registered Nurse (RN) 1: Member (resident) admitted to skilled nursing. Member arrived to the unit via EMS, a [AGE] year-old male admitted to GHS (Greenville Hospital) for acute [MEDICAL CONDITION] with [MEDICAL CONDITION]/pulmonary nodules, [MEDICAL CONDITIONS], exacerbation, and concern of aspiration pneumonia. Member found to be hypoxic placed on 3 L of oxygen via NC, productive cough, [DIAGNOSES REDACTED], aortic regurgitation, [MEDICAL CONDITION], [DIAGNOSES REDACTED], throat/[MEDICAL CONDITION], irritable bowel syndrome. Member on 5 Liters of oxygen via NC (nasal canula) .member transfers with moderate assistance times one, with the use of the rolling walker .staff will continue to monitor. Review of the Occupational Therapy Initial Evaluation (OT), completed for R149 on [DATE] revealed, Medical Diagnosis: [REDACTED]. Treatment: Muscle weakness. Patient Interview/Chart Review. Reason for referral: Patient referred to skilled OT due to new onset of impaired ADL performance, impaired balance, impaired functional activity tolerance, impaired functional mobility, impaired strength and impaired transfers . precautions include aspiration, O2 (oxygen) via NC (nasal canula) at 5 L (liters) and monitor SAT (oxygen saturation) during treatment, pt (patient) verbalized he is a DNR (do not resuscitate) code status .Performance Skills-Functional Activity Tolerance: Sustained Activity Tolerance for Activity of daily living: Severe impairment .Gross Strength: .right/left lower extremity strength-impaired Patient with decreased strength in lower extremity and resident states that I am weak. Review of a Clinical Note dated [DATE] at 9:56 PM, revealed, .Member has not had much of an appetite. No lunch or Dinner x 2 days. Has tried to eat some breakfast, not able to eat much. Review of a Clinical Note dated [DATE] at 2:22 PM, revealed, Member rested throughout the day. A/O (alert and oriented) x 4 able to voice concerns to staff. Pleasant and calm upon approach. Meds taken whole with thin liquids. On continuous oxygen at 5 liters, O2 SAT at 90%. Sitting erect at 90 degrees in bed, labored breathing noted. PT (patient) currently does not voice SOB (shortness of breath). Requires 1 for assistance with ADLs, no exertion noted. Continues with therapy as tolerated. Call light within reach. Review of a Clinical Note documented in the EMR by Licensed Practical Nurse (LPN) 2 on [DATE] entered at 8:27 AM revealed: 5:00 AM (time of incident) I went into members (R149) room to administer medication. Member not in room. Asked the Certified Nursing Assistant (CNA )5 if she knew where (R149) was, or had she seen the member leave the room. She said no. She had seen the patient in the room on her 1 am and 3 am rounds. I then asked her to check the TV area in Duncan. Member was not there. I was with another member, when the CNA came running to tell me that a body was laying outside on the lawn. I quickly ran out of the room and outside. CNA5 and I found the member fully clothed with shoes on, facedown still wearing his oxygen tubing on his face. No pulse detected. Member rolled on to his back. I called EMS and the CNA5 administered CPR. Director of Nursing (DON), Healthcare Administrator and wife notified. Review of the Greenville County Coroner's Office Natural Death Notification Form Date: [DATE] deceased Street Address: (address of the facility). Time of Death 05:37 (AM) Time Pronounced: 05:37 per the Medic Unit MO5, Trip# ,[DATE]. No signs of trauma or foul play .PMHX, (Past Medical History), [MEDICAL CONDITION] . LPN2 was called on [DATE] at 10:00 AM, to confirm the events of [DATE], and a message was left for LPN2 to please return call at number provided. LPN2 did not return call prior to exiting the survey. CNA5 was called on [DATE] at 10:02 AM. A message was left to please return call at given number. No return call was received from CNA5 during the survey. The Administrator said she no longer works at the facility. Further review of the facility's investigation revealed a note by a third staff member present during the incident on [DATE] with R149. A Private Sitter (PS)1 who works for the facility, was on duty providing one on one care for another resident. A phone conversation with PS1 on [DATE] at 9:20 AM, revealed PS1 said, I was asked to help check for named member (R149). Nurse went to room not there. Looked for him in the TV room, wasn't there. Agency aide (CNA5) said she had seen a body out of the window of room (313). Went outside with aide found resident on ground, face down in the grass .we turned him over. He was wet like he had been rained on, but it was not raining at that time, but had rained earlier. The resident didn't make any noise or speak. CNA5 started CPR with compressions. He still had his glasses on. It wasn't cold that night. The area was dark no light out there. PS1 stated the member was found on the grass face down near the window of room [ROOM NUMBER]. I then returned to my assigned member/resident. Review of the Minimum Data assessment (MDS) with an Assessment Reference Date, (ARD) date of [DATE], revealed R149 was admitted on [DATE] from an acute hospital. R149's [DIAGNOSES REDACTED]. The partially completed MDS documented no mood issues, no behaviors, and no behavior of wandering. The assessment revealed R149 could transfer with extensive assist of one. He could walk in room with supervision of one person. He walked in the corridor one or two times with one person physical assist. The resident was able to walk. He was not steady, but he could stabilize himself without staff assist. The resident used a walker. There were no falls prior to admission documented. The document listed R149 had one fall since his admission, but there was no evidence in the record of a fall prior to the incident on [DATE]. Review of the resident's Admission Assessment, completed on [DATE], found the resident was able to recall seasons, staff names and faces, and had no memory problems. Review of the Resident's immediate care plan dated [DATE], did not include documentation the resident was at risk for elopement or wandering. The care plan did find the resident at risk for falls, and indicated he had a respiratory infection. Review of the physician's admission orders [REDACTED]. The resident's code/resuscitation status was not identified on R149's Demographics page in the EMR. The Wandering and Elopement Risk Assessment, dated [DATE] at 2:30 PM, for R149, revealed an elopement risk score of 0. The risk assessment completed by RN1 on admission. In an interview on [DATE] at 9:45 AM, LPN1 stated she worked Asher Unit. She knew R149. Very nice man. Never attempted to go out the doors when I was working. Never considered him a flight risk. Very pleasant .had respiratory issues. LPN1 verified the resident could read. I worked here a year and four months and have never had a resident missing, or any elopement issue. The LPN asked if the resident was informed exit doors locked upon exit and she said, no. In a staff interview on [DATE] at 9:50 AM, RN1 said she did the admission for R149. She described him as alert and oriented x 4, signed all his own paper work for nursing, answered questions. Never considered him a flight risk. The resident was totally cognitively aware of his surroundings. Educated on safety and to call if needed help. RN1 asked if she informed R149 the exit doors lock automatically when you exit, and you will not be able to get back in? The RN answered, no I did not tell him that, just reviewed safety issues, but not that. Review of staffing assignments for [DATE] on the Duncan Hall, where R149 resided, revealed two CNAs on Asher Unit, and two CNAs, one RN and one LPN for the skilled unit. The census on [DATE] at midnight on the skilled unit of the facility was 34. On [DATE] at 1:15 PM an interview with the facility Medical Director (MD) revealed she was to be the primary care physician for R149. The MD stated she had not met with him prior to his death. The Medical Director said she was aware of the details surrounding the death of the resident, but she was not the Medical Director at the time of the incident. The Medical Director said, it's especially important to have a doorbell on the locked exit doors for all residents safety to prevent such incidents. The residents need to be able to let staff know they want to come back into the building. Allegation of compliance date [DATE]. 1. Executive Director/Administrator ordered 10 doorbells for each door at the Linville Court location on [DATE]. Once the doorbell has been activated it sends signals to all pagers carried by staff in building. It will also go to facility monitor in which will prompt efficient response time by staff members. 2. The 10 doorbells were ordered [DATE] to be rush delivered and will be installed the Thursday, [DATE]. In the interim, the administrator/Facility Director installed 4 doorbells from Home Depot on [DATE] on the SNF (skilled nursing facility) section of Linville Court. In addition, the cameras have been turned to monitoring live by entry and exit at each doorway on SNF. This is being monitored by live staff 24 hours a day. The concierge will conduct 15 minute checks until the installation of door-bells. The 15 minute checks will be visual of the cameras covering the 4 exits of the SNF. These check/audits will be monitored by Administrator on a daily basis. 3. Addendum will be made to admission packet stating that door will lock behind individual upon exit. For entry to one of these exit doors, the individual must push doorbell or have Cascade issued door fob. This will be complete by [DATE]. 4. Administrator/DON/Admission Dir. Will educate all staff at the Linville Court location and new admissions about the use and role of the doorbell upon arrival. This education will start on 2nd shift on [DATE] by the shift supervisor. The shift supervisor will be given the direction by (Named DON). The education will be complete on [DATE]. Any staff not educated will be removed from schedule until education occurs. The facility will send out an On-Shift message alerting about education prior to start of shift. 5. All Residents (Members) and Families were educated on [DATE]. The Admission's Director will educate all new admission of new members upon time of admission. 6. Audit will be monitored weekly x 2 for a month. Weekly x 1 for a month and monthly until substantial compliance is complete. The audits will be of doorbell function and delivery system to the facility's emergency alarm system. The monitored audits will have a completion date of [DATE] and ongoing. The audits will be conducted by the DON, Administrator or Designee. On [DATE] at 10:30 AM observations of facility doors on the skilled units revealed all doors had the doorbells installed and an alarm system located on each unit to alert staff of any person exiting the door. The signs warning of doors lock upon exit was posted on all exit doors observed. Changes to the admission packet were made to notify all new residents upon admission exit doors lock upon exit, must use the doorbell for re-entry. Interview of residents, staff and families verified notification provided related to doors lock upon exit and the function of the doorbell system and monitors. Observation of the 3:30 PM staff inservice on the new surveillance and doorbells observed by two surveyors. Eighty staff members signed into the inservice throughout the day. The Removal Plan submitted by the facility on [DATE] implemented by the facility and was in practice, removing the immediacy of the deficient practice. On [DATE] at 12:08 PM the immediacy of the Immediate Jeopardy at F689 was removed and the Administrator notified. The Immediate Jeopardy at F689 was removed with the Scope and Severity of the citation lowered to a D. This citation substantiates complaint SC 37.

Based on record review, interview, and review of facility files, the facility failed to implement its abuse policy related to reporting for Residents #144, 142, 39, 143, 145, 7, 27, 147, 148, 150, and 20 (12 of 15 reportable incidents reviewed). The facility did not report in the required time frames per facility policy. The findings included: The facility admitted Resident #144 with [DIAGNOSES REDACTED]. Review of facility files on 9/12/19 at 10:15 AM, revealed on 4/24/19 Resident #144's family member made an allegation of neglect related to personal care. The facility failed to report the results of their investigation within 5 working days. Review of faxed documents, on 9/12/19 at 10:15 AM, revealed the facility sent the results of the investigation to the State Survey Agency on 5/3/19, the 7th working day after the allegation was made. During an interview with the Director of Nursing (DON) on 9/12/19 at 10:45 AM, the DON confirmed results of the facility's investigation were not reported to the State Survey Agency until 5/3/19. Review of the facility's Abuse Reporting policy revealed it is facility policy to report results of all investigations to the State Survey Agency within 5 working days of the incident. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. The resident was able to make his/her own decisions. During record review on 9/10/19 the DON was asked for the investigative file the facility did on their concerns reported to the State Agency related to Fall of Unknown Etiology on 10/2/2019. Facility also presented a copy of their Abuse Policy. The facility did develop abuse policies; however, the facility did not follow their policy or the implementation of their policy by not reporting timely and investigating thoroughly. The facility submitted a 24 Hour Report but did not submit a 5 Day Facility Investigation Report as required. The DON stated on 9/11/19 at 10:00 AM that she could find no documentation supporting the fact that a 5 Day report had been sent to the State Agency. The facility admitted Resident #39 with [DIAGNOSES REDACTED]. The facility did not implement their Abuse Policy and Protocols as written related to not sending a Five Day Investigation Report nor including complete information related to the resident fall/accident. The DON stated, No documentation that any other reports were sent to the state agency. The facility admitted Resident #145 with [DIAGNOSES REDACTED]. The facility did not implement their Abuse Policy and Protocols related to Reporting per Regulations. The facility did not send in a 5 Day report with no evidence of facility investigation. Incomplete information was submitted to the State Agency related to no resident name and only initials. There was sketchy information related to the actual incident. Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of 5 - Day reportable on 9/11/19 at approximately 11:38 AM revealed the date of the reportable incident was 6/12/19. The 24 hour report to Health Certification could not be found. Interview with Director of Nursing (DON) on 9/11/19 at approximately 2 PM revealed s/he was unable to find the 24 hour report to Health Certification. Resident #143 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of 24 Hour Report on 9/11/19 at approximately 9:41 AM revealed the report was sent to Health Certification on 3/15/19. Review of facility investigation on 9/11/19 at approximately 9:52 AM revealed a 3/9/19 statement from the resident, alleging that nurses would not answer call lights timely and that someone was rough during transfer. No specific times or names were offered. Interview with the Director of Nursing on 9/11/19 at approximately 10:48 AM revealed the only documented fax of the 24 hour report to health certification was on 3/15/19 which was 6 days after the resident reported it. Review of Abuse Reporting Policy on 9/11/19 at approximately at 3:41 PM revealed all alleged violations of abuse, neglect, exploitation or mistreatment including injuries of unknown origin, misappropriation of property will be reported by the facility Administrator or his/her designee, to the state licensing / certification agency responsible for surveying / licensing the facility (among other persons and agencies). Alleged violations will be reported within 2 hours if they involve abuse or serious bodily injury, or 24 hours if it does not involve abuse or serious bodily injury. 7. Resident (R)20 was admitted to the facility on [DATE]. The undated Face Sheet indicated a [DIAGNOSES REDACTED]. Review of R20's nursing notes dated 05/04/19 at 2:10 PM, revealed the alert and oriented resident required extensive assist of two nurse aides with bed mobility, transfers and toileting. The resident continued to have sitter throughout day. R20 was interactive with staff during lunch, trying to offer the nurse a piece of lemon bar hanging from her thumb. The resident laughed when staff refused. R20 was calm and pleasant during the shift and voiced no complaints of pain or discomfort. Safety measures were in place for R20. Review of the Nurse's Monthly Summary Report for 05/20/19 indicated the resident had problems related to her mood and had behaviors that impacted the resident's ability to receive care and her ability to perform activities of daily living. Review of the facility's Accident/Incident Reporting Form completed on 05/04/19, for R20, revealed the resident had an injury of unknown origin. The resident had a small scratch above her left eyebrow and the injury was investigated. The resident is known to adjust her glasses and has fingernails. The staff stated they thought she scratched herself with her nails. Review of the facility's report (with a transmittal date time stamp) indicated a 24-hour notice of the incident was sent to South [NAME]ina DHEC Certification agency on 05/06/19 at 5:03 PM and the 5-day report was transmitted on 05/14/19 at 12:36 PM. The 5-day transmittal was 8 days after the 24 hours report was sent and was not in compliance with federally mandated reporting timeframes. In an interview on 09/11/19 at 10:38 AM, with the DON, she confirmed the 5-day report to DHEC was eight days late and the facility failed to follow their policy related to notification of incidents and mandated reporting timeframes. This facility failure substantiated complaint #SC 733. 8. R20 was admitted to the facility on [DATE]. The admission face sheet indicated a [DIAGNOSES REDACTED]. Review of R20's Nursing Notes dated 05/03/19 at 3:07 PM, revealed the resident required extensive assist of 2 with bed mobility, transfers and toileting. The resident was incontinent of bowel and bladder and had confusion. On this date R20 was refusing care. The Certified Nurse Aide (CNA) informed the nurse the resident had refused care. The nurse assisted the CNA with transferring the resident from bed to wheelchair and no were problems noted. The resident had no complaints pain this shift, no acute distress noted. Review of the Nurse's Monthly Summary dated 05/20/19 revealed R20 had problems related to her mood and had behaviors that impacted the resident's ability to receive care and her ability to perform activities of daily living. Review of the facility reported incident completed on 05/03/19 indicated that on 05/03/19 the resident had an injury of unknown origin. The residents' daughter reported to the facility the resident had a bruise on her wrist and on the front of her legs. The facility developed a care plan to address the resident's behaviors during activities of daily living care. The incident/tracking report completed on 05/03/19 indicated an investigation was completed regarding the bruise on R20's wrist and legs. Interviews with the facility staff reported the resident was combative and refused care. She grabbed assists rails and shook her hands and wrists between the rails bumping them. Staff also reported she jerked her feet forward and backward while sitting in her wheelchair. R20 has been observed to propel herself in the wheelchair with her feet while the foot rests are down, bumping her shins and legs. Review of the facility's report transmittal date indicated a 24-hour report of the incident was sent to DHEC Certification on 05/03/19 at 1:32 PM and the 5-day report was sent to DHEC on 05/14/19 at 12:12 PM. The 5-day transmittal was 11 days after the 24 hours report was sent and failed to comply with the facility's policy and reporting timeframes. Interview with the DON on 09/11/19 at 10:38 AM, confirmed the 5-day report to the Certification agency was 11 days late and the facility failed to implement their policy regarding timely notification to the Certification agency. 9. R27 was admitted to the facility on [DATE]. The undated admission face sheet indicated R27 had [DIAGNOSES REDACTED]. R27's quarterly Minimum Data Set (MDS) completed on 08/01/19 indicated the resident required assistance of one staff for transfers, bed mobility and the resident used a wheelchair for locomotion. The resident was not identified as a fall risk and had no falls reported in the facility since admission. A complaint was filed on 04/03/19 for an injury of unknown origin for R27. A complaint investigation completed on 09/12/19 revealed the following: Review of the Nursing Notes dated 04/03/19 at 7:24 AM, revealed as the CNA was making her last rounds on the morning of 04/03/19 R27 was dressed by the CN[NAME] The CNA noticed that the resident had swelling in her right wrist with discoloration. The nurse asked the resident what had happened, but the resident was not sure what happened. The nurse notified the Nurse Practitioner (NP) and received an order to get an x-ray (XR) of R27's right wrist and hand. The NP also told the nurse to add this to Medical Director's book so the resident would be seen on that day. The nurse notified R27's daughter and explained the resident's right wrist had swelling and will be x-rayed. The nurse was to notify the daughter when the XR results came back. The nurse also notified the DON. On 04/03/19 at 9:56 PM, the nurse documented R27 was confused, was incontinent of bowel and bladder, and required assist of 2 people with transfers and bed mobility. Resident returned to facility from the local urgent care with family by her side. Results from right wrist x-ray (wrist anterior and posterior and lateral right) revealed an old healed wrist fracture and modest [MEDICAL CONDITION] but no current fracture or dislocation (these results are from Mobile X). The urgent care paper work documented [DIAGNOSES REDACTED]. R27 had a soft bandage to the right wrist. The resident had a sitter by her side this shift and voiced no complaints of pain and no facial grimacing. A functioning tab alert (alarms when weight is shifted with an attempt to rise) was attached when R27 was out of bed in a wheelchair and when she was in bed. No signs or symptoms of any bleeding r/t aspirin therapy. Resident was well in bed with call light w/in reach. The facility's Accident/Incident Reporting form was completed on 04/03/19. The report stated an investigation was completed after speaking with the sitter and the CNA who provided the resident's care. It was reported that when turning and repositioning the resident, R27 bumped her wrist on the rail attached to the bed. Padding was applied to the positioning assist rail to prevent further incidents. There was no evidence of a fall or abuse. Review of the facility's report transmittal date indicated a 24-hour report of the incident was sent on 04/03/19 and the 5-day investigation report had a transmittal date of 04/11/19 and was 3 days late. Interview with the DON on 09/09/19 at 2:20 PM, confirmed the facility did not implement the policy for reporting injuries of unknown origin, and they had not reported the incident within five days of the incident as required. This citation substantiated complaint #SC 593. 10. R147 was admitted to the facility on [DATE]. The undated admission face sheet indicated a [DIAGNOSES REDACTED]. Review of a Clinical Note dated 01/04/19 at 3:35 AM, indicated R147 had a fall during the evening shift. The resident complained of pain in her left arm, with a pain level of 8 from a 0-10 scale. Tylenol was administered as ordered and was documented to be effective. The on-call NP was notified and ordered an X-ray with 2 views of the resident's left shoulder, left elbow and left wrist. The X ray results were reported to the on-call NP. An order was received for the facility to monitor patient and follow up with the orthopedic physician in the morning. The resident was noted to be in bed resting, bed in the lowest position, with a tab alert present and functioning. Review of a Clinical Note dated 01/04/19 at 11:59 AM indicated R147 sustained a fall during the night and sustained an injury to her left wrist. The Medical Director (MD) was called and orders were given. The staff were informed the resident would need a sitter and an aide to accompany her to the Dr.'s office. The MD informed the resident that she would be going to the emergency room (ER) for a head scan and to have her left wrist splinted. R147's daughter was called and notified of situation, the daughter verbalized understanding. At 9:00 PM the emergency room called to give report. The resident would be coming back to facility, per ER nurse the head scan was negative, and her arm was in a splint. The emergency mobile squad will transport R147 back to the facility. The daughter was notified of situation and verbalized understanding. R147's daughter understood the resident tries to get up without calling for help. The facility's staff was educated to make frequent rounds on R147. Review of the facility's Accident/Incident Report form dated 01/03/19 revealed the resident stated she fell in the bathroom hitting her head and left arm. The resident has a history of weakness. X-rays were ordered and the resident was diagnosed with [REDACTED]. Review of the facility's report transmittal date indicated a 24-hour notice of the incident was sent to DHEC Certification agency on 01/04/19 at 12:15 PM. There was no evidence the 5-day investigation report had a transmitted to the certification agency as required. Interview with the DON on 09/11/19 at 10:42 AM, confirmed there was no five-day investigation report as required and the facility's policy for notification of incidents to DHEC Certification was not followed. This investigation substantiated complaint #SC 099. 11. R148 was admitted to the facility on [DATE]. The undated admission face sheet indicated a [DIAGNOSES REDACTED]. The admission MDS assessment completed on 01/25/19 identified the resident as having short and long term-memory problems. A complaint was filed on 01/21/19 for Resident/Patient/Client Neglect. The complaint investigation completed on 09/12/19 revealed the following: A Clinical Note written by RN3 dated 01/20/19 at 3:05 PM, indicated R148's daughter-in-law asked staff if they could put R148 back to bed from the recliner, while lunch was being served. The staff told the resident's daughter-in-law that they could put R148 back in bed when they finished serving the residents food. R148 told her family that the facility staff are not moving her. The staff had gotten R148 dressed and up in the chair that morning. The resident wants badly to leave the facility. The resident says her family dumped her here and she believes she will not make it home again. R148 also stated, her son doesn't have to be concerned with her now. The nurse did tell the daughter-in-law that R148 has some manipulative behaviors. The daughter-in-law stated that she knows her mother-in-law can be very manipulative. A Clinical Note RN3 01/21/19 at 10:28 PM, indicated the resident was alert with increased intermittent confusion. She was a maximum assist of two staff and required the use of a mechanical lift for transfers. R148 was incontinent of bowel and bladder. The resident had no verbal complaints of pain, shortness of breath, dyspnea, or any other discomfort at this time. R148 continues to yell out and wants her door closed. The resident's family brought her a supplement and is resting well in bed with call light within reach. The facility's Accident/Incident Report form completed by the DON stated R148 was an [AGE] year-old female who was admitted with a [DIAGNOSES REDACTED]. She had slight short and long-term memory loss with a Brief Interview of Mental Status (BIMS) score of 14, which indicated she was alert and oriented. R148's daughter-in-law stated, she just had a feeling she is being neglected and that the girls are being rough with R148. The resident stated to the DON that she does not feel abused, she just does not want to be here, and thinks her son just dumped her here. She is very unhappy to be here. The investigation was completed, statements were obtained from the staff and residents and the facility was unable to substantiate any neglect or abuse occurred. Review of the facility's report transmittal date indicated a 24-hour notice of the incident was sent to DHEC Certification agency on 01/21/19 at 1:48 AM and the 5-day report had a transmittal date of 01/28/19 at 1:54 AM. The 5-day investigative report was two days late. Interview with the DON on 09/11/19 at 10:42 AM, confirmed the 5-day report was sent two days late and the facility failed to implement their policy related to timely reporting of allegations of neglect. This allegation substantiated complaint #SC 689. 12. Review of the undated Face Sheet for R150, in the admission section of the medical record, revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's annual MDS with an Assessment Reference Date, (ARD) of 09/19/18 revealed a BIMS of 12, which indicated the resident could make her own decisions and had mild cognitive impairment. The assessment revealed no previous falls. The last assessment completed for R150 was a discharge assessment dated [DATE] with one fall identified. Review of a fall (incident) report dated 04/14/19 indicated R150's sustained a skin a laceration as a result of the fall. Review of a Clinical Note revealed on 04/14/19 at 5:00 PM, R150 suffered a fall resulting in a laceration to her head that required the resident to be transported to the emergency room . The laceration required staples to close the injury to her forehead. All the resident's safety measures were in place per her care plan at the time of the fall. This fall is the resident's first fall per review of the MDS assessments. Additional interventions were added to her care plan to prevent any additional accidents. Review of the 24-hour incident report sent to the South [NAME]ina DHEC Certification agency revealed the transmission date on the notification of 04/24/19 at 3:45 PM. This was ten days after the incident occurred. The required five-day report transmitted to the South [NAME]ina DHEC Certification was received on 05/03/19 at 1:28 PM. This was 19 days after the incident occurred. In an interview on 09/09/19 at 2:10 PM, The DON verified the 24-hour report and the five-day investigation report for incident which occurred on 04/14/19 were reported after mandated reporting timelines. The DON confirmed the facility policy included an initial report of incidents with injury to DHEC Certification within 24 hours and the completed investigation to DHEC Certification within five days. This citation substantiates complaint SC 94.

Based on record review and interview, the facility failed to report timely to the State Agency all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin, and misappropriation of resident property (12 of 15 [MEDICATION NAME] reviewed). The facility did not report in the required time frames. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. The resident was able to make his/her own decisions. During Record review on 9/10/19 the Director Of Nursing (DON) was asked for the investigative file the facility did on their concerns reported to the State Agency related to Fall of Unknown Etiology on 10/2/2019. Facility also presented a copy of their Abuse Policy. The facility did develop abuse policies; however, the facility did not follow their policy or the implementation of their policy by not reporting timely and investigating thoroughly. The facility submitted a 24 Hour Report but did not submit a 5 Day Facility Investigation Report as required. The DON stated on 9/11/19 at 10:00 AM that she could find no documentation supporting the fact that a 5 Day report had been sent to the State Agency. The facility admitted Resident #39 with [DIAGNOSES REDACTED]. The facility did not implement their Abuse Policy and Protocols as written related to not sending a Five Day Investigation Report nor including complete information related to the resident fall/accident. DON stated, No documentation that any other reports were sent to the state agency. The facility admitted Resident #145 with [DIAGNOSES REDACTED]. The facility did not implement their Abuse Policy and Protocols related to Reporting per Regulations. The facility did not send in a 5 Day report with no evidence of facility investigation. Incomplete information was submitted to the State Agency related to no resident name and only initials. There was sketchy information related to the actual incident. The facility admitted Resident #144 with [DIAGNOSES REDACTED]. Review of facility files, on 9/12/19 at 10:15 AM, revealed on 4/24/19 Resident #144's family member made an allegation of neglect related to personal care. The facility failed to report the results of their investigation within 5 working days. Review of faxed documents, on 9/12/19 at 10:15 AM, revealed the facility sent the results of the investigation to the State Survey Agency on 5/3/19, the 7th working day after the allegation was made. During an interview with the DON, on 9/12/19 at 10:45, AM the DON confirmed results of the facility's investigation were not reported to the State Survey Agency until 5/3/19. Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of 5 - Day reportable on 9/11/19 at approximately 11:38 AM revealed the date of the reportable incident was 6/12/19. The 24 hour report to Health Certification could not be found. Interview with DON on 9/11/19 at approximately 2 PM revealed s/he was unable to find the 24 hour report to Health Certification. Resident #143 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of 24 Hour Report on 9/11/19 at approximately 9:41 AM revealed the report was sent to Health Certification on 3/15/19. Review of facility investigation on 9/11/19 at approximately 9:52 AM revealed a 3/9/19 statement from the resident, alleging that nurses would not answer call lights timely and that someone was rough during transfer. No specific times or names were offered. Interview with the Director of Nursing on 9/11/19 at approximately 10:48 AM revealed the only documented fax of the 24 hour report to health certification was on 3/15/19 which was 6 days after the resident reported it. 7. Resident (R)20 was admitted to the facility on [DATE]. The undated Face Sheet indicated a [DIAGNOSES REDACTED]. Review of R20's nursing notes dated 05/04/19 at 2:10 PM revealed the alert and oriented resident required extensive assist of two nurse aides with bed mobility, transfers and toileting. The resident continued to have a sitter throughout day. R20 was interactive with staff during lunch, trying to offer the nurse a piece of lemon bar hanging from her thumb. The resident laughed when staff refused. R20 was calm and pleasant during the shift and voiced no complaints of pain or discomfort. Safety measures were in place for R20. Review of the Nurse's Monthly Summary Report for 05/20/19 indicated the resident had problems related to her mood and had behaviors that impacted the residents' ability to receive care and her ability to perform activities of daily living. Review of the facility's Accident/Incident Reporting Form completed on 05/04/19, for R20 revealed the resident had an injury of unknown origin. The resident had a small scratch above her left eyebrow and the injury was investigated. The resident is known to adjust her glasses and has fingernails. The staff stated they thought she scratched herself with her nails. Review of the facility's report transmittal date indicated a 24-hour notice of the incident was sent to South [NAME]ina DHEC Certification agency on 05/06/19 at 5:03 PM, and the 5-day report was transmitted on 05/14/19 at 12:36 PM. The 5-day transmittal was eight days after the 24 hours report was sent and was not in compliance with federally mandated reporting timeframes. In an interview on 09/11/19 at 10:38 AM, with the DON, she confirmed the 5-day report to DHEC was eight days late and the facility failed to follow their policy related to timely notification of incidents and reporting timeframes. This facility failure substantiated complaint #SC 733. 8. R20 was admitted to the facility on [DATE]. The undated Face Sheet indicated a [DIAGNOSES REDACTED]. Review of a Clinical Note for R20, dated 05/03/19 at 3:07 PM, revealed the resident required extensive assist of 2 with bed mobility, transfers and toileting. The resident was incontinent of bowel and bladder and had confusion. On this date R20 was refusing care. The Certified Nurse Aide (CNA) informed the nurse the resident had refused care. The nurse assisted the CNA with transferring the resident from bed to wheelchair and no were problems noted. The resident had no complaints pain this shift, no acute distress noted. Review of the Nurse's Monthly Summary dated 05/20/19 revealed R20 had problems related to her mood and had behaviors that impacted the resident's ability to receive care and her ability to perform activities of daily living. Review of the facility reported incident completed on 05/03/19 indicated that on 05/03/19 the resident had an injury of unknown origin. The residents' daughter reported to the facility the resident had a bruise on her wrist and on the front of her legs. The facility developed a care plan to address the resident's behaviors during activities of daily living care. The incident/tracking report completed on 05/03/19 indicated an investigation was completed regarding the bruise on R20's wrist and legs. Interviews with the facility staff reported the resident was combative and refused care. She grabbed assists rails and shook her hands and wrists between the rails bumping them. Staff also reported she jerked her feet forward and backward while sitting in her wheelchair. R20 has been observed to propel herself in the wheelchair with her feet while the foot rests are down, bumping her shins and legs. Review of the facility's report transmittal date indicated a 24-hour report of the incident was sent to DHEC Certification agency on 05/03/19 at 1:32 PM and the 5-day report was sent to DHEC on 05/14/19 at 12:12 PM. The 5-day transmittal was 11 days after the 24 hours report was sent and failed to comply with the facility's policy and reporting timeframes. Interview with the DON on 09/11/19 at 10:38 AM, confirmed the 5-day report to the Certification agency was 11 days late and the facility failed to implement their policy regarding timely notification to the Certification agency. 9. R27 was admitted to the facility on [DATE]. The undated Face Sheet indicated R27 had [DIAGNOSES REDACTED]. R27's quarterly Minimum Data Set (MDS) completed on 08/01/19 indicated the resident required assistance of one staff for transfers, bed mobility and the resident used a wheelchair for locomotion. The resident was not identified as a fall risk and had no falls reported in the facility since admission. A complaint was filed on 04/03/19 for an injury of unknown origin for R27. A complaint investigation completed on 09/12/19 revealed the following: Review of a Clinical Note dated 04/03/19 at 7:24 AM, revealed as the CNA was making her last rounds on the morning of 04/03/19, R27 was dressed by this CN[NAME] The CNA noticed that the resident had swelling in her right wrist with discoloration. The nurse asked the resident what had happened, but the resident was not sure what happened. The nurse notified the Nurse Practitioner (NP)and received an order to get an x-ray (XR) of R27's right wrist and hand. The NP also told the nurse to add this to Medical Director's book so the resident would be seen on that day. The nurse notified R27's daughter and explained the resident's right wrist had swelling and will be x-rayed. The nurse was to notify the daughter when the XR results came back. The nurse also notified the DON. On 04/03/19 at 9:56 PM, the nurse documented R27 was confused, incontinent of bowel and bladder, required assist of 2 people with transfers and bed mobility. Resident returned to facility from the local urgent care with family by her side. Results from right wrist x-ray (wrist anterior and posterior and lateral right) revealed an old healed wrist fracture and modest [MEDICAL CONDITION] but no current fracture or dislocation (these results are from Mobile X). The urgent care paper work documented [DIAGNOSES REDACTED]. R27 had a soft bandage to the right wrist. The resident had a sitter by her side this shift and voiced no complaints of pain and no facial grimacing. A functioning tab alert (alarms when weight is shifted with an attempt to rise) was attached when R27 was out of bed in a wheelchair and when she was in bed. No signs or symptoms of any bleeding r/t aspirin therapy. Resident was well in bed with call light w/in reach. The facility's Accident/Incident Reporting form was completed on 04/03/19. The report stated an investigation was completed after speaking with the sitter and the CNA who provided the resident's care. It was reported that when turning and repositioning the resident, R27 bumped her wrist on the rail attached to the bed. Padding was applied to the positioning assist rail to prevent further incidents. There was no evidence of a fall or abuse. Review of the facility's report transmittal date indicated a 24-hour report of the incident was sent on 04/03/19 and the 5-day investigation report had a transmittal date of 04/11/19 and was three days late. Interview with the DON on 09/09/19 at 2:20 PM, confirmed the facility did not implement the policy for reporting injuries of unknown origin, and they had not reported the incident within five days of the incident as required. This citation substantiated complaint #SC 593. 10. R147 was admitted to the facility on [DATE]. The undated Face Sheet indicated a [DIAGNOSES REDACTED]. A Clinical Note dated 01/04/19 at 3:35 AM indicated R147 had a fall during the evening shift. The resident complained of pain in her left arm, with a pain level of 8 from a 0-10 scale. Tylenol was administered as ordered and was documented to be effective. The on-call Nurse Practitioner (NP) was notified and ordered an X-ray with 2 views of the resident's left shoulder, left elbow and left wrist. The X ray results were reported to the on-call NP. An order was received for the facility to monitor patient and follow up with the orthopedic physician in the morning. The resident was noted to be in bed resting, bed in the lowest position, with a tab alert present and functioning. Review of a Clinical Note dated 01/04/19 at 11:59 AM, indicated R147 sustained a fall during the night and sustained an injury to her left wrist. The Medical Director (MD) was called and orders were given. The staff were informed the resident would need a sitter and an aide to accompany her to the Dr.'s office. The MD informed the resident that she would be going to the emergency room (ER) for a head scan and to have her left wrist splinted. R147's daughter was called and notified of situation, the daughter verbalized understanding. At 9:00 PM the emergency room called to give report. The resident would be coming back to facility, per ER nurse the head scan was negative, and her arm was in a splint. The emergency mobile squad will transport R147 back to the facility. The daughter was notified of situation and verbalized understanding. R147's daughter understood the resident tries to get up without calling for help. The facility's staff was educated to make frequent rounds on R147. Review of the facility's Accident/Incident Report form dated 01/03/19 revealed the resident stated she fell in the bathroom hitting her head and left arm. The resident has a history of weakness. X-rays were ordered and the resident was diagnosed with [REDACTED]. Review of the facility's report transmittal date indicated a 24-hour notice of the incident was sent to DHEC Certification agency on 01/04/19 at 12:15 PM. There was no evidence the 5-day investigation report had a transmitted to the certification agency as required. Interview with the DON on 09/11/19 at 10:42 AM, confirmed there was no five-day investigation report as required, and the facility's policy for notification of incidents to DHEC Certification was not followed. This investigation substantiated complaint #SC 099. 11. Resident (R)148 was admitted to the facility on [DATE]. The undated admission face sheet indicated a [DIAGNOSES REDACTED]. The admission MDS assessment completed on 01/25/19 identified the resident as having short and long term-memory problems. A complaint was filed on 01/21/19 for Resident/Patient/Client Neglect. The complaint investigation completed on 09/12/19 revealed the following: A Clinical Note written by RN3 dated 01/20/19 at 3:05 PM, indicated R148's daughter-in-law asked staff if they could put R148 back to bed from the recliner, while lunch was being served. The staff told the resident's daughter-in-law that they could put R148 back in bed when they finished serving the residents food. R148 told her family that the facility staff are not moving her. The staff had gotten R148 dressed and up in the chair that morning. The resident wants badly to leave the facility. The resident says her family dumped her here and she believes she will not make it home again. R148 also stated, her son doesn't have to be concerned with her now. The nurse did tell the daughter-in-law that R148 has some manipulative behaviors. The daughter-in-law stated that she knows her mother-in-law can be very manipulative. A Clinical Note from RN3 01/21/19 at 10:28 PM, indicated the resident was alert with increased intermittent confusion. She was a maximum assist of two staff and the use of a mechanical lift for transfers. R148 was incontinent of bowel and bladder. The resident had no verbal complaints of pain, shortness of breath, dyspnea, or any other discomfort at this time. R148 continues to yell out and wants her door closed. The resident's family brought her a supplement and is resting well in bed with call light within reach. The facility's Accident/Incident Report form (completed by the DON) stated R148 was an [AGE] year-old female who was admitted with a [DIAGNOSES REDACTED]. She had mild short and long-term memory loss with a Brief Interview of Mental Status (BIMS) score of 14, which indicated she was alert and oriented. R148's daughter-in-law stated she just has a feeling she is being neglected and that the girls are being rough with R148. The resident stated to the DON that she does not feel abused, she just does not want to be here, and thinks her son just dumped her here. She is very unhappy to be here. The investigation was completed, statements were obtained from the staff and residents and the facility was unable to substantiate any neglect or abuse occurred. Review of the facility's report transmittal date indicated a 24-hour notice of the incident was sent to DHEC Certification agency on 01/21/19 at 1:48 AM and the 5-day report had a transmittal date of 01/28/19 at 1:54 AM. The 5-day investigative report was two days late. Interview with the DON on 09/11/19 at 10:42 AM, confirmed the 5-day report was sent two days late and the facility failed to implement their policy related to timely reporting of allegations of neglect. This allegation substantiated complaint #SC 689. 12. Review of the medical record section, Clinical Notes, revealed on 04/14/19 at 5:00 PM R150 suffered a fall resulting in a laceration to her head that required the resident to be transported to the emergency room . The laceration required staples to close the injury to her forehead. All the resident's safety measures were in place per her care plan at the time of the fall. This fall is the resident's first fall per review of the MDS. The resident's care plan included updated interventions to prevent additional falls. Due to the fall with injury the facility must report the incident (which occurred on 04/14/19 at 5:00 PM) within 24 hours to the DHEC Certification Unit. This incident with injury also met the requirement for reporting the completed investigation within five-days of the incident. Review of the 24-hour report sent to the South [NAME]ina DHEC Certification department revealed the transmission date on the notification of 04/24/19 at 3:45 PM. This was outside the federally mandated reporting timeframe at ten days after the incident occurred. The five-day report transmitted to the South [NAME]ina DHEC Certification department was received on 05/03/19 at 1:28 PM. This was 19 days after the incident occurred. In an interview on 09/09/19 at 2:10 PM, the DON confirmed the 24-hour report and the five-day investigation report for the incident which occurred on 04/14/19 were reported to the authorities after the mandated reporting timeframes. The DON verified the submission of the reports to DHEC Certification initial report in 24 hours and complete the investigation with detail and send to DHEC Certification within five days were not in compliance with the federal regulation for mandatory reporting timeframes. This citation substantiates SC 94.

Based on record review and interview, the facility failed to provide adequate quality of care for 1 of 5 residents reviewed for unnecessary medications. The facility failed to notify primary care of Resident #37's elevated blood sugars as ordered by the physician. The findings included: Resident #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of orders on 9/10/19 at approximately 10:32 AM revealed the 0 - 14 units of [MEDICATION NAME] three times daily. If blood sugars were below 70 or greater than 350, the facility was ordered to notify physician. Review of blood sugars on 9/10/19 at approximately 11:39 AM revealed elevated blood sugars for at least four days including the following: 1. 9/8/19 blood sugars of 391 and 363 2. 9/7/19 blood sugar of 368 3. 9/4/19 blood sugar of 383 4. 9/1/19 blood sugars of 357 and 374 Review of nursing notes on 9/10/19 at approximately 4 PM revealed no notifications to the physician. Review of chart found no notifications. Interview with Director of Nursing (DON) on 9/10/19 at approximately 4:03 PM confirmed there were no documented notifications for the elevated blood sugars 9/8/19, 9/7/19, 9/4/19, and 9/1/19. Review of notification policy on 9/12/19 at approximately 10:56 AM revealed the nurse will notify attending or physician on call when there has been .specific instructions to notify the physician of changes in the resident's condition.

Based on record reviews and interviews, the facility failed to ensure a resident on hospice received services that were coordinated through an interdisciplinary group to provide a specific plan of care for 1 of 1 sampled resident reviewed for hospices services. Resident #10 had no facility care plan that was integrated with hospice services and the hospice care plan was not in the facility. The findings included: The facility admitted Resident #10 on 12/12/17 with [DIAGNOSES REDACTED]. A review of the electronic medical record on 8/14/18 at approximately 9:30 AM revealed the resident hospice services was initiated on 7/03/18. Further record review revealed the facility care plan did not address a coordinated plan of care for hospices services. The facility care plan addressed the Do Not Resuscitate order will be followed. A review of the hospice book kept in the facility had no hospice care plan to indicate what services will be provided by hospice. An interview on 8/14/18 at approximately 9:52 AM with the facility's Executive Director and Licensed Practical Nurse (LPN) #1 confirmed the hospice care plan was not in the electronic medical record or hospice book on the unit. LPN stated after reviewing the facility's care plan, hospice services were not addressed. An interview on 8/15/18 at approximately 11:20 AM with the facility Consultant revealed the hospice agency care plan was provided today (8/15/18).

Based on record review and interview, the facility failed to hold insulin as ordered for Resident #5, 1 of 5 sampled resident's reviewed for Unnecessary Medications. Resident #5, received insulin when it should have been held based on blood sugar results. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. In addition, the order specified to hold the insulin if the blood sugar was less than 90. Record review of the Treatment Record on 8/15/2018 at 12:06 PM, revealed the resident's 8:00 AM blood sugar was 88 on 6/16/2018. Record review of the Medication Administration Record [REDACTED]. During an interview with the NHA on 8/15/2018 at 1:26 PM, the NHA confirmed Resident #5 received insulin with a blood sugar of 88. The NHA stated the orders were not followed and the insulin should have been held due to the blood sugar being less than 90. Review of blood sugar results and Nurse's Notes revealed the resident did not have any adverse reaction from receiving the insulin.

Based on record review and interview the facility failed to identify irregularities in the medication regimen for 1 of 5 residents reviewed for unnecessary medications. The pharmacist failed to identify that Resident #1 received as needed [MEDICAL CONDITION] medications for longer than 14 days without justification for extended use or intended duration. The findings included: Resident #1 was admitted to the facility 1/30/17 with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. This medication had been ordered since 6/7/18. Review of record showed no documentation that extended use of as needed [MEDICAL CONDITION] had been justified medically or clarified with intended duration. Interview with the Medical Director on 8/15/18 at approximately 1:05 PM revealed the physician didn't review the use of as needed [MEDICAL CONDITION] use until 8/7/18. At this point the as needed usage of [MEDICATION NAME] was given a medical justification and an intended duration of 60 days. Review of policy for as needed [MEDICAL CONDITION] use on 8/15/18 at approximately 2:16 PM revealed the policy stated as needed orders for [MEDICAL CONDITION] medications used beyond 14 days require the practitioner to document the rationale for the extended order and indicate the duration in the order.

Based on record review and interview, the facility failed to follow physician's orders related to weight monitoring for resident #17, 1 of 1 sampled resident reviewed for [MEDICAL TREATMENT]. The physician was not notified of weight increases as ordered. The findings included: The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Record review of the physician orders on 8/15/2018 at 9:21 AM, revealed an order to notify the provider if weight increases by 2 pounds from day to day or if the patient has over a 5 pound increase in 7 days. Review of the weights for Resident #17 on 8/15/2018 at 9:52 AM, revealed the resident had a weight gain of 2 pounds or more in one day and/or a 5 pound or more increase in 7 days on 7/19, 7/24, 7/27, 7/30, 8/6, 8/8, 8/13, and 8/15. On 7/19, the resident had a 5 pound gain in one day. On 7/24, the resident had a 6.1 pound gain in one day. On 7/27, the resident had a 11.8 pound gain in one day. On 7/30, the resident had a 6.6 pound gain in one day. On 8/6, the resident had a 3.7 pound gain in one day. On 8/8, the resident had a 2.8 pound gain in one day. on 8/13, the resident had a 6.8 pound gain in one day. On 8/15, the resident had a 2.6 pound gain in one day. There was no documentation in the record to indicate the provider had been notified of the weight increases, as ordered. During an interview with the Nursing Home Administrator (NHA) on 8/15/2018 at 11:05 AM, the NHA confirmed the provider was not notified of the weight increases. The NHA stated that many of the weight increases were weights before [MEDICAL TREATMENT], but should have been reported to the provider, as ordered.

Based on observations, interview and review of the facility's Oxygen Administration policy, the facility failed to ensure that a resident receiving respiratory care had oxygen filters in oxygen concentrator and water in humidifier bottle for 1 of 1 sampled resident reviewed. Resident #3's oxygen concentrator had no filters and the oxygen humidifier bottle was empty. The findings included: The facility admitted Resident #3 on 2/05/18 with [DIAGNOSES REDACTED]. An observation on 8/13/18 at approximately 6:39 AM revealed resident in room in bed with oxygen concentrator in place with no filters in the slots on either side of the concentrator and no water in the humidifier oxygen concentrator bottle. There was a build up of lint noted covering the air holes in the slots on either side of the concentrator. An observation on 8/13/18 at approximately 8:13 AM revealed the resident in room in bed with the oxygen contractor in place with no filters and no water in the oxygen humidifier bottle. An interview and observation on 8/13/18 at approximately 8:57 AM with Licensed Practical Nurse (LPN) #2 confirmed the findings. LPN #2 further stated the night shift was suppose to ensure the humidifier bottle and filters were in place. There was a date of 8/13/18 placed on the oxygen tubing to indicate when the tubing was changed which was confirmed by LPN#2. A review of the facility's Oxygen Administration policy under Steps in the Procedure under #12 and #14 revealed: #12 Check the mask, tank, humidifying jar, etc. to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and the water level is high enough that the water bubbles as oxygen flows through. #14 Periodically re-check water level in humidifying jar.

Based on record review and interview the facility failed to identify irregularities in the medication regimen for 1 of 5 residents reviewed for unnecessary medications. Resident #1 received as needed [MEDICAL CONDITION] medications for longer than 14 days without documented medical justification or a clarification of intended duration. The findings included: Resident #1 was admitted to the facility 1/30/17 with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. This medication had been ordered since 6/7/18. Review of record showed no documentation that extended use of as needed [MEDICAL CONDITION] had been justified medically or clarified with intended duration. Interview with the Medical Director on 8/15/18 at approximately 1:05 PM revealed the physician didn't review the use of as needed [MEDICAL CONDITION] use until 8/7/18. At this point the as needed usage of [MEDICATION NAME] was given a medical justification and an intended duration of 60 days. Review of policy for as needed [MEDICAL CONDITION] use on 8/15/18 at approximately 2:16 PM revealed the policy stated as needed orders for [MEDICAL CONDITION] medications used beyond 14 days require the practitioner to document the rationale for the extended order and indicate the duration in the order.

Based on record reviews and interview, the facility failed to provide written notice to the Office of the State Long-Term Care Ombudsman related to 2 of 2 sampled residents reviewed for transfer/discharge. Resident #3 and #74 with hospital transfers and no system in place to notify the Ombudsman Office of the transfers/discharges. The findings included: The facility admitted Resident #3 on 2/05/18 with [DIAGNOSES REDACTED]. A review of the electronic medical record on 8/13/18 at approximately 11:03 AM revealed Resident #3 had a discharge from the facility to the hospital on [DATE] due to elevated blood pressure. The resident returned to the facility on [DATE]. Further record review revealed the resident discharged to the hospital from the facility on 6/17/18 due to nose bleed that could not be controlled. The resident returned to the facility on [DATE]. There was no documentation in the medical record to indicate the facility notified the Office of the State Long-Term Care Ombudsman of the hospital transfers. The facility admitted Resident #74 on 12/04/17 with [DIAGNOSES REDACTED]. A review of the electronic medical record on 8/14/18 at approximately 11:36 AM revealed the resident transferred to hospital from the facility on 12/25/17 due to a fall and was readmitted back to the facility on [DATE]. Further record review revealed the resident discharged home on[DATE]. There was no documentation in the records to indicate the facility notified the Office of the State Long-Term Care Ombudsman of the hospital transfer or discharge home. An interview on 8/14/18 at approximately 4:21 PM with the facility Administrator confirmed the findings. The Administrator stated there was no system in place for transfers/discharges because he/she was not aware of the new changes.

Based on record review and interview, the facility failed to follow the care plan for Residents #5 and #17, 1 of 5 sampled residents reviewed for unnecessary medications and 1 of 1 reviewed for [MEDICAL TREATMENT]. The care plan for Resident #17 was not followed related to monitoring weights. The care plan for Resident #5 was not followed related to insulin administration. Cross refer to F696 and F757 The findings included: The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Record review of the care plan on 8/15/2018 at 9:30 AM, revealed an intervention to monitor weights as ordered by the nephrologist and/or primary care physician. Record review of the physician orders [REDACTED]. Review of the weights for Resident #17 on 8/15/2018 at 9:52 AM, revealed the resident had a weight gain of 2 pounds or more in one day on 7/19, 7/24, 7/27, 7/30, 8/6, 8/8, 8/13, and 8/15. There was no documentation in the record to indicate the provider had been notified of the weight increases as ordered per the care plan. During an interview with the Nursing Home Administrator (NHA) on 8/15/2018 at 11:05 AM, the NHA confirmed the provider was not notified of the weight increases. In addition, the NHA confirmed the weights were not monitored as ordered, per the care plan. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Record review of the care plan on 8/15/2018 at 12:18 PM, revealed an intervention to administer insulin as ordered. Record review of the physician's orders [REDACTED]. In addition, the order specified to hold the insulin if the blood sugar was less than 90. Record review of the Treatment Record on 8/15/2018 at 12:06 PM, revealed the resident's 8:00 AM blood sugar was 88 on 6/16/2018. Record review of the Medication Administration Record [REDACTED]. During an interview with the NHA on 8/15/2018 at 1:26 PM, the NHA confirmed Resident #5 received insulin with a blood sugar of 88. The NHA stated the orders were not followed and the insulin should have been held due to the blood sugar being less than 90.

Based on record reviews and interviews, the facility failed to ensure that flu/pneumonia education was provided and documented for five of five sampled residents reviewed. Residents #3, #7, #9, #73 and #174 had no documentation the flu/pneumonia education was provided. The findings included: An interview on 8/14/18 at approximately 9:03 AM with the facility Consultant and Licensed Practical Nurse (LPN) #1 reviewed newly admitted residents documentation of flu/pneumonia education would be paper form and older residents flu/pneumonia education would be attached to the electronic medical records. Resident #3 admitted on [DATE], Resident #7 admitted on [DATE], Resident #9 admitted on [DATE], Resident #73 admitted on [DATE] and Resident #174 admitted [DATE] did not have electronic or paper documentation flu/pneumonia education being provided. An interview on 8/14/18 at approximately 9:45 AM with the facility's Executive Director confirmed the findings that there no documentation to indicate the flu/pneumonia education was provided.

On the days of the survey, based on record reviews, review of the FDA (Federal Drug Administration) guidelines for [MEDICATION NAME] and interviews, the facility failed to provide services to meet the professional standards of quality for of 11 resident reviewed for medication transcription and administration. Resident # 19, 29, 129 and 141 did not have medications transcribed to the new monthly Medication Administration Records (MARS) resulting in multiple missed doses of either antidepressant medication or pain management medication. The findings included: On 5/8/13 at 11:50 AM record review for Resident # 19 revealed a hand written April 2013 Medication Record for the resident's readmission on 4/8/13. Admitting orders for Tylenol were "[MEDICATION NAME] 500 mg (milligrams) PO (by mouth) TID (three times a day) for pain." Physician/Prescriber Telephone Orders revealed an order on 4/9/13 for "Increase Tylenol 1 gm (gram) PO TID." The April 2013 Medication Record correctly transcribed the increase in Tylenol from 500 mg to 1 gm. The May 2013 Medication Record sent preprinted from the pharmacy revealed "NAPAP ([MEDICATION NAME]) 500 mg Tablet. Take 1 tablet by mouth three times daily. DX: Pain" The May 2013 Medication Record revealed 22 does of Tylenol 500mg given in error from May 1, 2013 to May 8, 2013. On 5/8/13 at 12:20 PM interview with the Interim Director of Nursing confirmed incorrect dosage of Tylenol on May 2013 Medication Record. On 5/8/13 at 1:00 PM in an interview, the surveyor reviewed the April and May 2013 Medication Record and Physician/Prescriber Telephone Orders with the Consultant Registered Pharmacist and the error was confirmed. Reconciliation of medication administration on 5/8/13 at 9:45 AM, revealed that Resident #141 had been ordered Tylenol 650 milligrams (mg) on 4/30/13 to be given 3 times a day (TID). The resident was given one dose of Tylenol on the evening of 4/30/13. However, review of the May 2013 Medication Administration Record (MAR) revealed that the Tylenol had not been transcribed to the May MAR and therefore was not administered as ordered. Review of the facility's policy entitled Monthly Physician order [REDACTED]. "Policy: Physician orders [REDACTED]...4.2 The licensed nurse will review the previous month's printed orders and orders that were written in this time frame (telephone, verbal,written orders). 4.2.1 The newly printed orders will then be compared to previous and recently generated orders to ascertain accuracy and completeness. 4.2.2 Corrections (additions and deletions) will be made at the time of discovery to ensure the newly printed orders are accurate and complete. A copy of the corrections is sent to the pharmacy or other designated provider." In an interview with Registered Nurse (RN) #1, Unit Supervisor, she/he verified that the Tylenol TID was ordered 4/30/13 but not transcribed to the MAR for May resulting in the resident not receiving Tylenol 650 mg tid and missing 22 doses. She/he also verified that the order was not faxed to the pharmacy. The nurse stated that the process was to compare the new MARs against the old MARs and to check all the physician's telephone and verbal orders to ensure all medications were written in the pervious month were on the current MAR. The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Record review revealed a physician's Telephone Order dated 3/19/13 to decrease [MEDICATION NAME] to 12.5 mg daily. Review of the April and May 2013 Medication Administration Records (MARs) indicated staff handwrote a notation on these documents to discontinue rather than decrease this medication. Review of the Federal Drug Administration guidelines for [MEDICATION NAME] revealed: "If you suddenly stop taking [MEDICATION NAME], you may have side effects such as trouble sleeping or trouble staying asleep ([MEDICAL CONDITION]), nausea, and vomiting." Review of the Nurses Notes dated 4/1/13, 4/15/13, 4/26/13, 4/28/13, and 5/3/13 indicated the resident exhibited "increased anxiety," "behaviors," "agitation," and "confusion." Review of the physician progress notes [REDACTED]." A notation from the Nurse Practitioner indicated "[MEDICATION NAME] (decreased) middle of March monitor behaviors." The facility admitted Resident #129 with [DIAGNOSES REDACTED]. Review of the physician's Telephone Orders dated 4/25/13 indicated an order for [REDACTED]. Review of the April 2013 MAR indicated the resident received the medication three times daily for four days, once daily for one day, and did not receive the medication at all one day out of the seven days prescribed. .

On the days of the survey, based on observations, record reviews, interviews and review of the facility's policy entitled Falls Management, the facility failed to provide sufficient and effective fall prevention interventions for 1 of 3 residents with falls. Resident #68 had 10 falls prior to the days of the survey and 1 fall during the survey without new interventions put in place or evidence of reviewing the interventions that had been put in place, resulting in additional falls for Resident # 68. Cross refer to F 280 related to the failure of the facility to review and revise the careplan for Resident # 68 related to falls. The findings included: Resident #68 was admitted with [DIAGNOSES REDACTED]. Record review on 5/8/13 at 1:25 PM revealed a Fall investigation Worksheet that documented the resident had a fall on 4/25/13 at 2000 (8:00 PM). The report also stated that the resident had 3 falls in the last 30 days and 7 in the last 31-180 days. Review of the resident's Nurses Notes indicated that the resident had 10 falls since admission. The resident also had a fall during the days of the survey. When the surveyor asked for incident reports/fall investigations, the facility provided only seven (7) reports. There were no incident reports for 3/13, 4/1/13 and 2/22/13 per the Administrator. The Nurse's Notes revealed the following falls : 1. 2/19/13 at 1550 (3:50 PM), fell out of wheelchair, denied pain, bruising noted to left hip. 2. 2/20/13 at 1700 (5:00 PM), noted sitting on floor on mat in kneeling position, no injury. 3. 2/22/13 at 2230 (8:30 PM), sitting on floor beside bed, "minor" bruise rear, upper left thigh, mat in place, not witnessed. 4. 3/8/13 at 1700 (5:00 PM), got out of wheelchair, fell , found lying on left side, no injuries noted. 5. 3/8/13 at 2300 (11:00 PM), found sitting on floor on mat beside bed, no signs of injury. 6. 3/12 13 at 1530 (3:30 PM), lying on floor on knees, no injury noted. 7. 4/1/25 at 7:55, alarm sounding, resident on mat on knees, no injuries noted. 8. 4/9/13 at 1730 (5:30 PM), the resident was observed sitting on blue mat on floor, no injury noted. 9. 4/18/13, found lying on right side at 4:00 PM, wheelchair alarm sounding, laceration to right eyebrow, abrasion to right upper cheek, skin tear to right elbow, bruise to right knee. 4/19/13, PT consulted for wheelchair positioning. 10. 4/25/13 at 3:45 PM, found lying in floor mat on floor, alarm sounding, no injury noted. The Fall Risk Assessment and Interventions for the resident were dated 2/5/13 and 4/25/13. On 2/5/13 the resident was assessed as a 32 on the scale which indicated s/he was a high risk for falls and on 4/25/13 a 30. The scale indicated that 7 or higher was a high risk. No interventions were documented on the assessment. The incident reports provided by the Interim Director Of Nursing indicated that on: 2/29/13 the alarm box was turned off but sounded at the system. The fall occurred in the resident's room at 3:50 PM with no apparent injury. Steps taken were noted as "notified maintenance of late alarming, rechecked proper functioning and placement. 2/20/13 at 4:45 PM, the incident occurred in the resident's room. There was no injury and the alarm was functioning properly. Steps taken to prevent recurrence were more frequent checks for 72 hours, post fall follow up. 3/8/13 at 5:00 PM, the incident occurred in the dining area and no alarm was in place. No injury noted and the alarm was placed on the resident. Steps taken to prevent recurrence were "alarm placed". 3/8/13 at 8:13 PM, the fall took place in the resident's room. No injuries were noted. Bed alarm did not sound. Steps taken were "rechecked bed alarm is attached and functioning". 4/1/13 at 7:55 PM, the incident occurred in the resident's room. The report stated that the alarm was sounding, the resident stated that he/she was going to the bathroom and the resident had no injury. Steps taken were to assist resident to bathroom and toilet more frequently. 4/18/13 at 3:20 PM, indicated that the incident occurred in the day room. The presence of the alarm was not noted on the report and the steps taken were to refer to "physical therapy for a possible chair change". The resident was noted to have a laceration to his/her right eyebrow, multiple abrasions to the right upper cheek and a skin tear to the right elbow. 4/25/13 at 3:34 PM the fall occurred in the resident's room. The alarm was sounding. No injury was noted. The steps taken were refer to therapy for pool therapy for decreased anxiety and strengthening. 5/8/13 at 2045 (8:45) PM the incident occurred in the resident's room. He/she had a skin tear to the left elbow and to the right shin. The steps taken were scoop mattress, refer to wellness for ambulation and 1:1. There were no incident reports for 3/13, 4/1/13 and 2/22/13 per the Administrator. Review of the resident's admission Minimum Data Set revealed that the resident had a fall history prior to admission and a BIMS score of 1 (one) indicative of cognitive impairment. Review of the resident's care plan indicated that the fall on 4/25/13 was not on the care plan. The care plan also indicated that there were no new interventions added for each fall and no evidence of evaluation for the interventions which were in place. Review of the physician's telephone orders indicated that an order for [REDACTED].. A hand written therapy note dated 2/26/13 stated that a PT (Physical Therapy) screen was completed for falls on 2/22, 2/20, and 2/19 with no skilled serviced needed at that time. PT notes reviewed for 3/27/13 through 4/27/13 indicated that resident was admitted to PT for gait training and strengthening. The summary indicated that the resident was at risk for falls and further decline with increased dependency on caregivers. The documentation for 4/29/13 through 5/23/13 indicated that on 3/27/13 the resident still had potential for improvement. On 4/26/13 the resident was placed in a Broda Chair and provided services for positioning. The intervention was documented on the back of a falls investigation work sheet on 4/18/13. In an interview with the Physical Therapist, she/he stated that it took a while to get the chair due to medicare not covering the cost and they had to wait until they could reach the family to get approval for the chair. Review of the Physician's Monthly Orders indicated that the resident was to have a bed and chair alarm. Review of the Treatment Administration Records for March, April and May of 2013 indicated that the staff had checked the resident's alarms and that the alarm was in place and functioning properly on the days that the falls occurred. 5/8/13 at 2:20 PM, during an interview with the Interim Director of Nursing, she/he stated the facility did not have a formal fall committee and all falls are reviewed at the morning meetings. S/he also stated that the facility does not use restraints or self release belts. On 5/10/13 at approximately 2:45 PM, during an interview with the physician, she/he stated that she/he was not aware that the resident had had that many falls or the circumstances of the falls. She/he stated that the 9:00 PM dose of Seroquel had been decreased from 25 mg to 12.5 mg and changed from 9:00 PM to 4:00 PM. The physician stated that the staff should be mindful of when alarms were going off and put more staff into place. She/he noted the facility " had used a lot of agency staff lately". Review of the facility's policy entitled Falls Management revealed "Policy: Patients will be assessed for falls risk as a part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce the risk and minimize injury...Practice Standards...3. Develop individualized plan of care. 4. Review and revise care plan regularly... 5.3.2 Resident/patient Incident Report..."

On the days of the survey, based on record review and interview, the facility failed to identify errors in transcription of physician's orders for 1 of 10 residents reviewed for Pharmacy Drug Regimen Review. The Pharmacy Review for Resident #29 failed to identify Seroquel was discontinued by staff rather than reduced per physician's orders. Cross refer to F333 and F 281 as it relates to significant medication errors and professional standards related to medication administration. The findings included: The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Record review revealed a physician's Telephone Order dated 3/19/13 to decrease Seroquel to 12.5 mg daily. Review of the April and May 2013 MARs indicated staff handwrote a notation on these documents indicating the medication had been discontinued rather than decreased. Review of the Nurses Notes dated 4/1/13, 4/15/13, 4/26/13, 4/28/13, and 5/3/13 indicated the resident exhibited "increased anxiety," "behaviors," "agitation," and "confusion." Review of the physician progress notes [REDACTED]." A notation from the Nurse Practitioner indicated "Seroquel (decreased) middle of March monitor behaviors." Review of the Pharmacy Drug Regimen Review dated 3/21/13 noted Seroquel was decreased to 12.5 mg daily on 3/19/13. The Pharmacy Drug Regimen Review dated 4/16/13 contained no documentation related to Seroquel. On 5/9/13 at approximately 3:00 PM, the Director of Nursing (DON) reviewed documentation related to the order for Seroquel and the finding that the medication was not administered during April 2013 and May 2013 to date. The DON reviewed the Pharmacy Drug Regimen Review dated 3/21/13 and 4/16/13 and confirmed that the 4/16/13 review did not note that staff had discontinued the order for Seroquel in error.

The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Review of the March 2013 cumulative physician's orders [REDACTED]. Review of the physician's Telephone Orders dated 3/19/13 indicated an order to decrease [MEDICATION NAME] to 12.5 mg daily. Review of the March 2013 Medication Administration Record (MAR) indicated staff changed the order on the MAR and administered [MEDICATION NAME] 12.5 mg daily per orders from 3/19/13 through the end of March. Review of the Physician's Progress Notes dated 3/19/13 indicated "attempt (decrease) [MEDICATION NAME]" Review of the April and May 2013 cumulative physician's orders [REDACTED]. Further review of these orders and MARs indicated staff handwrote d/c (discontinue) 3/19/13 on the printed orders and MARs for [MEDICATION NAME]. Both the April and May 2013 MARs were blank indicating [MEDICATION NAME] was not administered as ordered for 38 days. Review of the Nurses Notes dated 4/1/13, 4/15/13, 4/26/13, 4/28/13, and 5/3/13 indicated the resident exhibited "increased anxiety," "behaviors," "agitation," and "confusion." Review of the physician progress notes [REDACTED]." A notation from the Nurse Practitioner indicated "[MEDICATION NAME] (decreased) middle of March monitor behaviors." On 5/9/13 at approximately 2:30 PM, the Director of Nursing (DON) was asked to review the physician's orders [REDACTED]. On 5/9/13 at approximately 3:00 PM, the DON concurred that Resident # 29 had not received [MEDICATION NAME] per orders since April 1, 2013. The DON confirmed that the order was discontinued during April and May to current date rather than decreasing the medication as ordered. The facility admitted Resident #129 with [DIAGNOSES REDACTED]. Review of the physician's Telephone Orders dated 4/25/13 indicated "Tylenol 650 mg tid (three times daily) x 7 days for back pain." Review of the April 2013 MAR indicated Resident #129 received Tylenol 650 mg once on 4/25/13, three times daily on 4/26/13, 4/27/13, 4/28/13, 4/29/13, and 4/30/13 with the medication not administered on 4/31/13. Documentation on the MAR indicated the resident did not receive 5 doses of the medication as ordered. On 5/9/13 at approximately 3:00 PM, the DON reviewed the documentation related to the order for Tylenol 650 mg and confirmed that Resident #129 did not receive five doses of the medication as ordered by the physician. Reconciliation of medication administration on 5/8/13 at 9:45 AM, revealed that Resident #141 had been ordered Tylenol 650 milligrams (mg) on 4/30/13 to be given 3 times a day (tid). The resident was given a dose on the evening of 4/30/13. Review of the May 2013 Medication Administration Record (MAR) revealed that the Tylenol had not been transcribed to the May MAR. Review of the facility's policy entitled Monthly Physician order [REDACTED]...4.2 The licensed nurse will review the previous month's printed orders and orders that were written in this time frame (telephone, verbal,written orders). 4.2.1 The newly printed orders will then be compared to previous and recently generated orders to ascertain accuracy and completeness. 4.2.2 Corrections (additions and deletions) will be made at the time of discovery to ensure the newly printed orders are accurate and complete. A copy of the corrections is sent to the pharmacy or other designated provider." In an interview with Registered Nurse (RN) #1, Unit Supervisor, she/he verified that the Tylenol TID was ordered 4/30/13 but not transcribed to the MAR for May resulting in the resident not receiving the medication. She/he also verified that the order was not faxed to the pharmacy. The nurse stated that the process was to compare the new MARs against the old MARs and to check all the physician's telephone and verbal orders to ensure all medications were written in the pervious month were on the current MAR. On the days of the survey, based on record review, interview, and review of Skilled Nursing Facility Nursing Policies and Procedures for Monthly Physician order [REDACTED]. Significant medication errors occurred for Resident #19 and Resident #141 for Tylenol not transcribed correctly from the April to May Medication Record, Resident #29 for an order for [REDACTED]. Cross refer to F 281 as it relates to professional standards related to medication administration. Cross refer to F 428 as it relates to the failure of the pharmacy to identify a [MEDICAL CONDITION] medication was discontinued rather than reduced in dosage. The findings included: Resident #19 was admitted with [DIAGNOSES REDACTED]. On 5/8/13 at 11:50 AM record review revealed a hand written April 2013 Medication Record for the resident's readmission on 4/8/13. Admitting orders for Tylenol were "[MEDICATION NAME] 500 mg (milligrams) PO (by mouth) TID (three times a day) for pain." The Physician/Prescriber Telephone Orders revealed an order on 4/9/13 for "Increase Tylenol 1 gm (gram) PO TID." The May 2013 Medication Record sent preprinted from the pharmacy revealed "NAPAP ([MEDICATION NAME]) 500 mg Tablet. Take 1 tablet by mouth three times daily. DX: Pain" The May 2013 Medication Record revealed 22 does of Tylenol given in error from May 1, 2013 to May 8, 2013. On 5/8/13 at 12:20 PM interview with the Interim Director of Nursing confirmed incorrect dosage of Tylenol on May 2013 Medication Record. On 5/8/13 at 1:00 PM in an interview, the surveyor reviewed the April and May 2013 Medication Record and Physician/Prescriber Telephone Orders with the Consultant Registered Pharmacist and the error was confirmed.