Every finding on record at Magnolia Manor - Greenwood

Based on observations, interviews, record reviews and policy review, the facility failed to ensure food was palatable for three residents (Resident (R) 8 and R54) of 27 residents reviewed during the Initial Pool. This failure had the potential for residents who disliked a meal to experience nutritional problems or dissatisfaction with their meals. Findings include:Review of the facility's policy titled, Safe Food Temperatures dated 10/15/25, on page one of three, Food temperatures will be maintained and acceptable levels during food storage, preparation, holding, serving, delivery, cooling, and reheating. The steam table may not be used to reheat food. On page one of one, procedure number six, Hold hot foods at 135 degrees Fahrenheit or higher during meal service (on [NAME] tray line). Hold cold foods at 40 degrees Fahrenheit or lower during meal service (on the tray line). 1. Record review of R8's quarterly Minimum Data Set (MDS) found under the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 04/29/26 indicated R8 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she is cognitively intact. During initial rounds on 07/13/26 at 11:00AM, R8 reports that the food is cold, pretty much every meal. The resident stated staff would not reheat the food due to them passing trays. 2. Record review of R54 quarterly MDS found under the MDS tab of the EMR with an ARD of 06/17/26 indicated R54 has a BIMs score of 15 out of 15 indicating she is cognitively intact. During initial rounds, on 07/13/26 at 11:30AM R54 reports that the food is cold, for every meal. The resident stated staff would not reheat the food due to them passing trays. The lunch menu for Wednesday, 07/15/26, found on the Special Occasion Menus Week 4, printed on 07/14/26, submitted by the Dietary Manager, documented the following for a regular diet:-Mushroom Swiss burger;-Seasoned Fries;-Creamy coleslaw;-Sugar cookie;-Sweet tea;-Water Observation on 07/15/26 at 11:42 AM, the Dietary Manager (DM) checked the temperature, while using the facility's food thermometer, of the hot food on the steam table:-Burger patty 172 degrees Fahrenheit-Seasoned fries 169 degrees Fahrenheit Observation on 07/15/26 at 12:01 PM, DM and [NAME] 3 began plating the first three plates for the [NAME] facility unit. Placed the three plates on top of the counter on top of the steam table, while [NAME] 2 was making coffee, then proceeded to look around for the containers of condiments ketchup, mayonnaise, and mustard. [NAME] 2 was unable to locate the containers of condiments immediately and the three plates of food sat on the counter on top of the steam table uncovered for seven minutes,. On 07/15/26 at 12:36 PM, a test tray of the regular menu was evaluated with the Kitchen Manager:-The seasoned fries' temperature was 129 degrees Fahrenheit.-The burger patty's temperature was 108 degrees Fahrenheit.-The creamy coleslaw's temperature was 65 degrees Fahrenheit. On 07/15/26 at 12:38 PM, the DM confirmed the food was no longer at temp and that she has not heard of any complaints from the residents about the food being cold.

Based on observation, record review, and interviews, the facility failed to ensure one of one resident (Resident (R) 6) reviewed for range of motion (ROM) out of a sample of 27 residents received restorative services to ensure ROM did not worsen in the upper extremities, palm guard devices were in place, and failed to ensure staff were educated on placement of splint devices. This failure had the potential for the resident's ROM to worsen, cause pain, skin break down and potentially develop a general decline in health. Findings include: Review of the Face Sheet located in the Residents tab of the electronic medical record (EMR) revealed R6 was admitted to the facility on [DATE] with diagnosis of vascular dementia, type II diabetes, legal blindness, and contracture on right hand. Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/15/26, located in the EMR under the Resident Assessment Instrument (RAI) tab, revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated that his cognitive function was severely impaired. R6 required substantial/maximal assistance with eating and bed and chair mobility. The MDS indicated no split or brace was in place. Review of R6's care plan problem located under the RAI tab of the EMR initiated on 04/13/26, with a focus of Restorative, updated on 07/09/26 by Registered Nurse (RN)2, revealed that R6 was at risk for loss of functional ROM due to recent illness and hospitalization. Long term goal in place, updated by RN2 on 07/09/26, resident will regain prior level of functional ROM as evidenced by requiring extensive assistance with activities of daily living (ADLs). Intervention or approach indicated as of 07/09/26, updated by RN2, Doff/donn right palm guard as tolerated by patient. Review of R6's Occupational Therapy Discharge summary dated [DATE] signed by Occupational Therapy Assistant (OTA) 1, located under the tab Resident Documents, revealed Short-Term Goals: Patient will safely wear a palmar guard on right hand for up to six hours with minimal signs and symptoms of redness, swelling, discomfort, or pain. Long-Term Goal: Patient will safely wear a palmar guard on right hand for up to eight hours with minimal signs and symptoms of redness, swelling, discomfort, or pain. R6's Progress and Response to Skilled services treatment: Patient tolerates right palm guard for four-hour intervals. Discharge recommendations: Right palm guard for four-hour intervals as tolerated by patient. Restorative Program Established/Trained: Restorative Splint and Brace Program, Restorative Splint and Brace Program Established/Trained: Doff/donn right palm guard as tolerated by patient. Review of R6's Physicians' Orders under the Orders tab of the EMR revealed that R6 had an order starting on 07/06/26 without an end date, to doff/donn right palm guard as tolerated by patient, once a day at 8:00 AM and restorative to monitor and encourage active ROM exercises to bilateral upper extremities for a minimum of 15 minutes per day, six days per week. Review of the document Point of Care History under Restorative Nursing, on pages 41 of 123 and 42 of 123, revealed that R6 was being provided Restorative Nursing (RNA) Services by Student Nurse Aide (SNA), Certified Nurse Aide (CNA) 1, Restorative Aide (RNA) 1, and RNA2 for the dates of 04/13/26 through 07/12/26. Observation on 07/13/26 at 1:38 PM, R6 was observed sitting in a geri chair in the feeding assisted dining room, without the palm guard in his right hand. R6 stated, I know I'm supposed to wear a thing for my right hand. I don't know where it is. Observation on 07/14/026 at 12:58 PM, R6 was sitting in a geri chair in the feeding assisted dining room with a blanket on him. R6 showed both hands and nails continue to be untrimmed and contracted right hand continues to not have the right palm guard on. Observation on 07/14/26 at 2:09 PM, R6 was observed in bed and CNA3 stated, That palm guard only gets put on his right for 30 to 45 minutes at a time. I know that the palm guard is here in his closet or in his nightstand. Therapy usually is the one who puts it on him. They would know where the palm guard is at. I don't know why it isn't in here right now. During an interview on 07/14/26 at 2:19 PM, the Rehab Director (RHD) stated, .the Restorative Director (ResD) runs the RNA program and RNA1 is usually the one doing the exercises with the residents that have an order for it. R6 was discharged from occupational therapy on 07/06/26 and should have the palm guard on him because he is supposed to have it on all day unless he being bathed. No, we don't have the palm guard in the therapy room and it should be in his right hand all day anyway. During an interview on 07/15/26 at 2:31 PM, RNA1 stated, .If we had an order for active ROM for R6, the ResD would let us know but I never got an order to apply the palm guard or to do active ROM with R6. During an interview on 07/15/26 at 2:42 PM, ResD stated, .Therapy will give me a referral sheet, with the resident's last covered date and they would let know which residents they would like to have restorative services. I review the restorative orders and update the care plan. The thing with R6, I didn't get a referral for the palm guard. The RHD discontinued it yesterday. I am aware that he has a contracture, but I also never got an order for the palm guard or restorative services and there was no way for RNA1 to check on the chart. I am the one who reviews the orders for restorative services because we need to make sure the physician agrees with the recommendations from therapy and for billing purposes also. During an interview on 07/15/26 at 4:31 PM, the Director of Nursing (DON) stated, .I have a restorative nurse, the Assistant Director of Nursing (ADON) is the (ResD) and she is responsible for this and the RHD is the one that makes the referral over to Restorative Nursing. It is the ResD's responsibility to monitor the Restorative Nursing orders and referrals and she checks this monthly.

Based on record review, observations, interviews, and facility policy review, the facility failed to ensure appropriate Activities of Daily Living (ADLs) to maintain appropriate hygiene for two residents (Resident (R) 6 and R58) reviewed for ADLs out of a total sample of 27 residents. This failure had the potential for the residents to have unmet hygiene needs and affect resident care.Findings include:Review of the facility's policy titled, Nursing Policies and Procedures, Activities of Daily Living, Optimal Function dated 05/05/23, on page one of one, Policy: The Facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. 1. Review of the Face Sheet located in the Residents tab of the electronic medical record (EMR) revealed R6 was admitted to the facility on [DATE] with diagnosis of vascular dementia, type II diabetes, legal blindness, and contracture on right hand. Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/15/26, located in the EMR under the Resident Assessment Instrument (RAI) tab, revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated that his cognitive function was severely impaired. R6 required substantial/maximal assistance with personal hygiene. Review of R6's care plan located under the RAI tab of the EMR revealed a focus initiated on 07/09/26, which indicated that R6 required substantial/maximal assistance with ADL that involved personal hygiene including nail care preferences as needed. R6's care plan goal was to maintain a sense of dignity by being clean and well-groomed through 10/01/26 (goal date). This intervention or approach was to be done by the certified nurse aide. Observation on 07/13/26 at 1:36 PM, R6 was observed with untrimmed nails and stated, I haven't asked anybody, I don't bother anybody to cut my nails. Observation 07/14/26 at 2:09 PM, R6 was observed with untrimmed nails. Registered Nurse (RN) 1 present in room and stated, .He wants his nails trimmed, we will trim his nails. The Certified Nurse Aides (CNAs) are the ones responsible for keeping the patients' nails clean and trimmed. It's been a while since I've taken care of [R6] I haven't been monitoring if his nails are trimmed. 2. Review of the Face Sheet located in the Residents tab of the EMR revealed R58 was admitted to the facility on [DATE] with diagnosis of vascular dementia, chronic obstructive pulmonary disease, and cerebral infarction. Review of R58's quarterly MDS with an ARD of 06/08/26, located in the EMR under the RAI tab, revealed a BIMS score of seven out of 15, which indicated that his cognitive function was severely impaired. R58 was dependent on staff members for personal hygiene. Review of R58's care plan focus located under the RAI tab of the EMR, initiated on 11/01/23, revealed that R58 required substantial/maximal assistance with ADL that involved personal hygiene including nail care preferences as needed. R6's care plan goal was to maintain a sense of dignity by being clean and well-groomed through 08/27/26 (goal date). This intervention or approach was to be done by the certified nurse aide. Observation on 07/13/26 at 1:04 PM, R58 was observed with untrimmed nails and stated, Nobody comes to cut my nails. I ask them to cut my nails, but no one comes to cut my nails. Look at my nails. These nails are long. Observation 07/14/26 at 2:16 PM, R58 was observed with untrimmed nails. RN1 present in room and stated, .I have [R58] today. His right hand has very thick nails I think the nurse practitioner needs to be notified so we can get the nails on his right hand trimmed. We will trim the nails on the left hand. During an interview on 07/15/26 at 4:31 PM, the Director of Nursing (DON) stated, .the CNAs are responsible for ADLs and for keeping residents' nails trimmed. The nurses on the floor are responsible for monitoring this.

Based on interview, record review, and facility policy review, the facility failed to ensure that Resident (R)1 had adequate supervision to prevent a successful elopement on 04/05/2026.On 04/20/26 at 4:25 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 04/05/26. The IJ was related to 42 CFR 483.25 - Freedom from Accidents and Hazards.On 04/20/26 the facility provided an acceptable IJ Removal Plan. On 04/20/26 the survey team, validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The SA is considering this IJ at Past Noncompliance as of 04/07/26. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care.Findings include:Review of the facility policy titled, Elopement with a last revision date of 11/01/17, revealed, To safely and timely redirect patients/residents to a safe environment. Review of facility timeline of events dated 04/05/26 revealed:11:30 AM RESIDENT WAS OBSERVED IN ROOM BY HOUSEKEEPER.11:45 AM NURSE OBSERVED RESIDENT PROPELLING HIS WHEELCHAIR ON HIS HALLHEADED FROM HIS ROOM TOWARD THE DINING ROOM.11:55 AM NURSE WENT TO RESIDENT'S ROOM TO GIVE HIM MEDICATION. IT WAS NOTED THAT THE RESIDENT WAS MISSING.12:10 PM A CODE WHITE WAS CALLED. A SEARCH BEGAN IMMEDIATELY OF THE ENTIRE BUILDING INSIDE and OUTSIDE. A LAUNDRY WORKER NOTED THE RESIDENT ACROSS THE STREET FROM THE (FACILITY) BETWEEN A CARDIOLOGIST OFFICE AND A RETINAL SPECIALIST OFFICE. THE RESIDENT AGREED TO COME BACK TO THE FACILITY WITHOUT INCIDENT (HE SAID HE WAS GOING TO 905 [NAME] STREET) HE RETURNED WITH THE RESIDENT AT APPROXIMATELY 12:18 PM. A BODY AUDIT WAS COMPLETED NO INJURY WAS NOTED. A WAUNDERGARD BRACELET WAS APPLIED.Review of R1's medical record revealed diagnoses including but not limited to, urinary tract infection, vascular dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, wandering, other visual disturbances, and pyogenic arthritis.Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/26, revealed R1 had a BIMS score of 3 out of 15, indicating severe cognitive impairment. Further review revealed the resident had not exhibited any wandering behaviors and the resident does not wear wander/elopement alarm daily. Review of R1's Elopement Risk Assessment on 03/27/25, revealed no score but indicated the resident is low risk for elopement.Review of R1's Progress Note by Social Services Director on 04/05/26 at 12:10 PM, revealed, STAFF NOTED NOT TO BE IN HIS ROOM. CODE WHITE WAS CALLED, AND SEARCH OF FACILITY WAS CONDUCTED. RESIDENT WAS FOUND OUTSIDE OF FACILITY AND CODE WHITE WAS CALLED OFF. RESIDENT HAS NOT BEEN PREVIOUSLY IDENTIFIED AS AN ELOPEMENT RISK. A WANDERGUARD WILL BE PLACED ON RESIDENT FOR HIS SAFETY TO PREVENT POSSIBLE ELOPEMENT. SSD CALLED RP AND ADVISED OF INCIDENT AND NEED FOR WANDERGUARD. RP HAD NO OBJECTIONS TO DEVICE BEING PLACED ON RESIDENT, AS IT'S FOR HIS SAFETY. SSD WILL ADJUST CARE PLAN TO INCLUDE ELOPEMENT/WANDERGUARD.Review of R1's Progress Note by Nurse Practitioner (NP)1 on 04/06/26, revealed, He does not make clear why he he was wandering outside or how he got outside. Patient does report that he is interested in going outside again. Wandering guard is noted on his left wrist at the time of this encounter. He is afebrile. VSS. No other concerns expressed by patient or nursing staff at this time. Patient does seem to be more altered at this time compared to visit on 04/01/2026. I will consider this an isolated event and raises concerns for altered or worsening mental status. Patient has not expressed previous behaviors of elopement prior to this encounter. Patient will be checked for urinary tract infection as well as elevated ammonia levels to rule out possible encephalopathy.Attempted interview with Resident Representative (RP) on 04/20/26 at 1:45 PM and 5:15 PM was unsuccessful. Message left on both attempts. No return call. During an interview with Certified Nursing Assistant (CNA)1 on 04/20/26 at 1:50 PM, revealed, I heard the code white and went to look for the resident. I went out the front door and met another aide. We searched the parking lot and close buildings such as the pharmacy and the assisted living building. That is when we seen [laundry staff name] in laundry coming across the street with the resident. [laundry staff name] and the resident were between the Advanced Cardiology office and the building beside it. I took over from [laundry staff name] and pushed the resident in his wheelchair back to the building. I asked him where he was going and he said home, 905 [NAME] Street. He was in no distress. He was ok. He did not fight coming back into the building. I took him to his nurse. I went back to my side of the building. I do not work on that wing.During an interview on 04/20/26 at 2:15 PM, the Director of Social Services revealed, I was manager on duty. It was a regular Sunday. I was doing work in my office when I heard the nurse on B wing call a code white. I checked for the resident up front. I used my key to check in the admissions office, the MDS office and the scheduler/central supply office. Everyone was looking inside. I went out the front door. Staff was looking outside as well. The laundry guy got in his truck and went to the right. I got into my car and went to the left. By the time I got to the end of the property, I saw [laundry staff name] pushing the resident in his wheelchair between the Cardiologist Office and the Retina Specialist Office across the road. [Laundry staff name] pushed the resident in his wheelchair to two CNA's that brought the resident back into the building. A wander guard was applied to resident's left wrist as soon as the resident returned to the building. We check the wander guard every day, every shift. This resident had never exhibited this behavior before.During an interview with CNA2 on 04/20/25 at 2:29 PM, revealed, The nurse was fixing to give him medication. They called a code white. I went out to the parking lot with [CNA name]. [Staff name] the nurse supervisor went out too. Me and [CNA name] walked down to the stop sign. By that time [laundry staff name] was coming back to the building with the resident from across the street. Me and [CNA name] took over and brought the resident back to the building. The resident stated that he was going to 902 [NAME] Street. He was in no distress. He was very calm and talkative.During an interview with the Director of Nursing (DON) on 04/20/26 at an unspecified time, revealed that elopement risk assessments are conducted upon admission, with any change in condition, and when behavioral changes occur. Residents identified as high risk are care planned accordingly and provided with a Wander Gard device worn on the wrist or ankle. All exit doors are equipped with alarms that emit a loud sound when a wander guard - wearing resident approaches. Clinical staff are responsible for monitoring the devices, while maintenance is responsible for door alarm functionality. The DON stated, The nurse went to give [R1] his medication and could not locate him. The usual places that he likes to visit in the afternoon were checked. He could not be located. We called a code white. The staff searched inside and outside for the resident. [Laundry staff name] got in his vehicle and located the resident around the corner. He pushed the resident toward the facility and two CNAs took over and brought resident back into the building. Body audit was completed. Resident was evaluated for a wander guard. Wander guard was placed. He recited an address where he was going which is uncharacteristic for [R1].During an interview with the Licensed Nursing Home Administrator (LNHA) on 04/20/26 at 3:38 PM, revealed R1 frequently self-propelled his wheelchair throughout the facility but had never shown clear exit-seeking behavior. By the time I was notified, it was over and staff had located the resident with no injury. It only took about six minutes.On 04/20/26 the facility provided an acceptable IJ Removal Plan, which included the following:Resident #1 without injury. Head to toe assessment completed on 4/5/26 with no injuries identified.Elopement Risk evaluation completed on resident #1 on 4/5/26 to reflect current status. New interventions include wander guard. Responsible party and provider notified of new interventions and order recieved.Residents at risk for elopement have the potential to be affected.Current residents in the facility had Elopement Risk Observations updated by 4/7/26 by Licensed Nurse. Residents identified as elopement risk were placed in the elopement binder and had care plans and profiles updated by Director of Nursing/Designee by 4/7/26.Clinical Leadership team were reeducated by the Clinical Consultant by 4/6/26 on Elopement including:Completion of Elopement Risk Observation processImplement interventions immediately based on risk identified through Elopement Risk AssessmentFacility Staff were reeducated by the Director of Nursing/Designee by 4/7/26 on Elopement includingIdentifying behaviors indicating elopement or exit seeking and implementing interventions immediatelyAny staff not receiving this education by 4/7/26 will receive prior to their next scheduled shift.New admission elopement risk assessments are being reviewed in Clinical Morning Meeting Monday - Friday by the Director of Nursing/Designee to validate accuracy and interventions validated if indicated. Quarterly Elopement risk assessments will be reviewed weekly following the MDS schedule to validate accuracy and interventions validated if indicated by the Director of Nursing/Designee.Ad Hoc QACPI was held on 4/7/26Medical Director was notified of the incident and plan on 4/7/26 and 4/20/26Results of these audits will be presented in Quality Assurance and Performance Improvement Committee meeting for review and recommendations for 3 months.AOC date: 4/7/26

Based on review of facility policy, record review, and staff interviews, the facility failed to ensure that Resident (R)1 was adequately supervised to prevent elopement. R1 was noted to have eloped on 12/13/2025. R1 was last seen by facility staff in the facility at approximately 5:30 PM. Facility was made aware that R1 was found outside the facility at 6:06 PM by first responders. According to weather.com, the weather in [NAME], SC on 12/13/25 was a high of 65 degrees Fahrenheit (F) and a low of 49F with sunset at 5:19 PM.As a result of Complaint #2697173, on 12/30/2025 at 2:40 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations could cause psychosocial harm.On 12/30/2025 at 3:08 PM, the survey team provided the Administrator with a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 12/13/2025. The IJ was related to F689 Free of Accident Hazards/Supervision/Devices.On 12/30/25 at 6:20 PM, the facility provided an acceptable IJ Removal Plan. On 12/30/25 at 6:35 PM, the survey team validated the facility's corrective actions and determined the facility put forth due diligence in correcting their deficiencies, determining the IJ to exist at Past noncompliance with a completion date of 12/14/25. The survey team validated completion as of 12/14/25An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care.Findings include:Review of the facility policy titled, Elopement, revealed it is the facilities goal to, safely and timely redirect patients/residents to a safe environment. Review of R1's face sheet revealed documented diagnoses indicate a history that includes but is not limited to: Wandering, psychosis not due to a substance or known physiological condition, anxiety disorder, paranoid schizophrenia, schizoaffective disorder (bipolar type), and epilepsy.Review of R1's care plan reveals resident was care planned for elopement risk on 05/30/2021. Interventions include, Approach: R1 has a wander guard, Approach: When R1 begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). Approach: Maintain a calm environment and approach to the R1. Approach: Approach from the front. Walk in step with R1 first before redirecting. Approach: Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents).Review of R1's Annual Minimum Data Set (MDS) completed on 12/4/2025 indicates R1 has a Brief Interview for Mental Status (BIMS) score of 9, consistent with some cognitive impairment. The MDS section E0900 (Wandering - Presence and Frequency) reflects a score of 3, indicating wandering behavior occurs daily.Review of R1's orders identified R1 as being at risk for falls, elopement, and wandering since 7/16/2020. Further review of R1's physician orders reveal an active order for a wander guard bracelet applied to the right wrist. Review of R1's Treatment Administration Record (TAR), for 12/13/25 revealed R1 was identified to have a fully functioning wander guard during time of elopement. Review of nursing progress note by Licensed Practical Nurse (LPN)1 dated 12/13/2025 at reveals, This nurse was notified by the Aide on 12/13/25 that the 911 officer called the facility and spoke to other staff nurse inquiring about a missing resident. This resident was unaccounted for. Code white procedure initiated, and facility administration notified. During the external search by staff, it was verified that resident was located and with EMS/Police in attendance. The Administrator/Director of Nursing (DON) arrived on premises and to notify MD/RP. 1048pm, call received from SRHC ER and reported that the resident with no injuries and would be returning to facility when transport available.Review of nursing progress note by DON dated 12/13/2025 reveals, 12/13/2025 at 621pm-Received pc from Administrator that resident had left the facility without staff supervision. During transit to facility, received call from Administrator, at 627pm that resident had been located and was safe. Upon arrival at facility, at 645pm, ADM present and report received from staff that the CODE WHITE process had been initiated. Resident had been transported by EMS to SRHC ER for eval and treatment. Attempted to notify RP with no answer and could not leave VM r/t had not been set up per automated response. Medical Doctor (MD)1 notified of events.Review of Nurse Practitioner progress note 12/15/25 revealed, Chief Complaint / Nature of Presenting Problem:Seen today for exit seeking .Staff reports patient exited the facility last night, was found quickly.Patient is seen today walking around the unit, redirected him back to his room for exam. He is alert, confused at his baseline per staff. Patient has wander guard bracelet on right wrist. Discussed exit seeking with staff, recommend increased rounding on patient and monitor closely. Continue wander guard. VSS. No other concerns expressed by patient or nursing staff at this time. MAR reviewed.Review of social service progress note on 12/18/2025 reveals, RESIDENT ELOPED FROM BUILDING ON DECEMBER 13TH FOR APPROXIMATELY THIRTY MINUTES. SSD HAS HAD DAILY INTERACTION WITH RESIDENT FROM DECEMBER 14TH - DECEMBER 18TH. BASED ON SSD'S OBSERVATIONS AND INTERACTIONS WITH RESIDENT, NO NEGATIVE EFFECTS RELATED TO THE ELOPEMENT HAVE BEEN OBSERVED. HE ALSO WAS SEEN BY PSYCH SERVICES ON DECEMBER 17TH.Review of facility document titled, TIMELINE, dated 12/13/2025 revealed: 12/13/20255:00 pm - R1 at B-Wing nurse's station speaking to assigned nurse. Nurse accompanied to his room and took BP and 02 sats related to him stating not feeling well.5:30 pm - Assigned nurse exited room [ROOM NUMBER] on R1's hall. She passed R1 in the hall walking toward his room.6:06 pm- Per Officer 1-911 received call6:08 pm- Per Officer 1-911 called facility6:16 pm- Administrator received notification of elopement from facility nurse6:16 pm- Facility staff arrived at resident's location. EMS and Police response team present.6:19 pm- Facility staff on scene informed on call nurse who spoke with EMS per telephone giving pertinent resident information (name, DOB, diagnoses)6:22 pm- On call nurse notified administrator of resident's location and condition. Stated EMS taking to hospital per protocol.6:39 pm- Administrator spoke with Officer to gather/confirm information6:42 pm- Administrator and DON spoke with family member, facility visitor who recognized resident in route to facility6:50 pm- Administrator and DON initiated meeting with staff on duty individually to obtain statements regarding the incident7:59 pm- Administrator reported incident via telephone to DPH @ 803 545 42818:10 pm- DON notified physician. Notification of RP initiated- no answer and no voice mail set up.10:48 pm- Staff nurse received call from ER stating resident had no injury and would be returning to facility when transport available4:35 am- Resident returned to facility via EMS. Per licensed staff nurse wander guard bracelet on right wrist. Tested and functioning properly. Licensed nurse performed body audit with no injury observed and initiated q[every]30 minute visual checks of resident.12/14/2511:51 am - Administrator attempted to reach RP unsuccessfully on cell and at work11:56 am - Administrator texted RP to call her on cell4:06 pm- RP returned call and was informed of incident and no injury12/15/20257:00 am- q30 minute visual checks of resident concluded.Review of Emergency Department Provider note by Nurse Practitioner (NP)1, dated 12/13/25-12/14/25 reveals: Resident presented to the ED with Pain with breathing. Note further states, Pt resident of Mag Manor found walking near hospital parking lot. States right sided pain to upper chest all day. Arrived with EMS. Resident had imaging and laboratory test completed. Chest pain is musculoskeletal in nature likely from recurrent coughing. Naproxen prescribed and Robitussin for cough. First doses given at the ED. Telephone interview conducted with LPN1 on 12/30/25 at 12:00 PM reveals, LPN1 stated she was the nurse assigned to R1 on the day in question. LPN1 reported that at approximately 5:00 PM, the resident requested that 911 be called, stating he did not feel well, R1 was assisted back to his room, assessed, and found to have stable vital signs with no signs of acute distress, and Tylenol was administered per R1's request. LPN1 further reported that at approximately 5:30 PM, she observed R1 ambulating in the hallway, smiling, and not exhibiting exit-seeking behaviors. At approximately 6:00 PM, LPN1 was informed by a Certified Nursing Assistant (CNA) that police had contacted the facility to inquire about a missing resident, at which time a Code White/elopement was initiated, all residents were accounted for except R1, a search was immediately initiated, and the LNHA was notified. Staff searched the facility grounds and surrounding area. Some staff members even searched by car and observed police and EMS presence at a nearby Subway parking lot, where it was confirmed R1 was being evaluated by emergency services. R1 was transported to the emergency room. LPN1 reveals that R1 had a functioning wander guard during the day in question. LPN1 reveals she did not hear any alarms go off between 5 PM and 6 PM and states that she may have been in a resident room providing care if one did go off. LPN1 later received notification from the hospital that the resident had no injuries and no abnormal test results, with only a cough noted and a prescription will be sent for the cough, the hospital further reported they were awaiting transportation availability for R1's return to the facility, LPN1 reveals R1 did not come back during her shift.Interview with R1 on 12/30/2025 at 12:20 PM revealed R1 somewhat recalls the incident in question and reported that he left the facility because he wanted to go shopping. He stated that he did not inform anyone of his departure and was outside for approximately one hour until stopped by the police and ambulance. R1 reported requesting transport to the hospital because he thinks he had chest discomfort and indicated that he does not remember additional details from that day. The resident denied any current concerns.Interview with Licensed Nursing Home Administrator (LNHA) and DON on 12/30/25 at 1:00 PM indicates the resident exhibits multiple behaviors related to documented psychiatric diagnoses, including frequent wandering, ambulating throughout the facility, and limited ability to be redirected at times. Per the LNHA, prior to the elopement event, R1 had an active care plan addressing exit-seeking behaviors, an order for a wander guard device, and ongoing psychiatric follow-up with the facility's psychiatric provider. The LNHA further reported that, due to the complexity of the resident's behaviors and continued exit-seeking despite interventions in place, the facility made multiple attempts to transfer the resident to a facility with a secured/locked unit, as the current facility does not have such a unit; however, one potential receiving facility declined acceptance after reviewing the resident's medical history, and the transfer did not proceed due to his diagnosis. During the incident in question, the LNHA's investigation it was determined that R1 ambulated approximately 700 feet from the facility to a nearby parking area. A family member of another resident, who also volunteers at the facility, observed R1 away from the facility while driving in and stopped to check on him. Per the LNHA, a nurse from a neighboring facility also observed the interaction and stopped to assess the situation, at which time followed their own protocol to call emergency services for R1. Emergency services were contacted by the nurse from the other facility, and emergency personnel subsequently contacted the facility to inquire about a missing resident, at which time a Code White/elopement was initiated and R1 was identified as unaccounted for. Facility staff were informed that the resident had been transported to the hospital for further evaluation, and nursing staff notified the Administrator and Director of Nursing. Per the LNHA's investigation, the resident was unaccounted for approximately 30 minutes. R1 later returned from the hospital with no documented injuries and no acute findings from tests. R1 had a new order related to congestion; a post-return body audit was completed with no injuries noted, and the resident was placed on every 30-minute observations for the days immediately following the elopement. The LNHA reported that on the day in question, the door alarm was activated at approximately 5:15 PM, and a CNA responded. The CNA observed another resident with a wander guard near the door and assumed that resident triggered the alarm. The CNA reported looking out the door and scanning the immediate area but did not observe any residents in her line of sight. R1 was wearing a wander guard upon his return from the hospital and set off the alarm as he was brought back into the facility.Attempts were made to contact the CNA with no success.Attempts were made to conduct an interview with the facility visitor, who initially identified R1 to be outside facility grounds, with no success. Interview with [NAME] Police Department Records Employee (GPD) on 12/30/25 at 2:18 PM reveals that the police officer who responded to the incident in question was not on duty during time of interview. GPD reveals that company policy prohibits them from sharing personal telephone numbers to the public. GDP was able to provide police officer's email. Email was sent officer to inquire about the incident in question on 12/30/25 at 2:35 PM. Interview with Police Officer (PO) on 12/30/25 at 3:16 PM reveals he remembers being dispatched to respond to a situation where a volunteer recognized a patient outside of a facility who seemed a little out of it. When PO arrived at the seen he saw R1 with no apparent injuries and appeared to be well kempt. PO denies seeing any obvious signs of neglect. PO also reveals that a nurse from [NAME] Regional Rehab was at the scene with the patient. R1 told PO he has some chest pain. Facility staffers from Magnolia Manor [NAME] arrived at the scene and stated the resident is known to fabricate things. Per protocol, PO reveals resident was sent to the hospital for further evaluation. PLAN OF CORRECTION REVIEWPOC MM [NAME] 12-13-25Resident #1 transported to hospital ER per EMS 12/13/25. Per EMS verbal report via telephone to facility on call nurse, resident without injury. Resident #1 returned to facility from ER [DATE] at 4:35 am. Upon reentry assigned nurse verified resident #1 wander guard bracelet was in place, intact and functioning on right wrist. Assigned nurse performed body audit with no injury noted and documented body audit results in residents medical record 12/14/25 at 5:02am. Review of Emergency Department Provider note by Nurse Practitioner (NP) 1, dated 12/13/25-12/14/25 reveals: Resident presented to the ED with Pain with breathing. Note further states, Pt resident of Mag Manor found walking near hospital parking lot. States right sided pain to upper chest all day. Arrived with EMS. Resident had imaging and laboratory test completed. Chest pain is musculoskeletal in nature likely from recurrent coughing. Naproxen prescribed and Robitussin for cough. First doses given at the ED. 12/14/25 body audit reviewed. No acute changes injury or concerns noted. Observation of R1 on 12/30/2025 at 12:20PM, resident observed to be in taking a nap. Resident easily arousable to voice. Resident appeared well kempt and dressed in clean and unstained and non-odorous clothing. Resident observed to have a wander guard on his right wrist. No distress, negative behaviors, or exit seeking tendencies exhibited. 12/14/2025 04:57 AM Resident returned from ER at 4:35 am on 12/13/25. Resident returned with wander guard in place on his right wrist. Residents wander guard is functioning. Resident is resting in bed watching tv. Resident does not complain of pain or discomfort at this time. Call light is within reach and bed is in lowest position. LPN Elopement Risk Observation repeated on 12-18-25. 12/18/25 Elopement Observation completed by RN reveals, Intervention WANDER GUARD BRACELET TO WRIST AND CHECKED WEEKLY. R1 EXIT SEEKS DAILY AND IS FREQUENTLY REDIRECTED BY STAFF. Maintenance Director/Designee performed an audit on 12-18-25 to ensure facility exits alarms were functioning. No concerns identified at this time. Review of maintenance director calendar log reveals wander guard audits were completed on 12/18/25, 12/22/25, 12/23/25, 12/24/25, 12/29/25 and 12/30/25. Observation of maintenance director on 12/30/2025 between 1-3PM reveals maintenance director completing wander guard audit by placing spare wander guard within proximity of exit doors. No concerns noted. A Residents at risk of elopement have the potential to be affected. Eight residents with wander guard intervention identified. Placement and function verified by DON for each 12/13/25 at 9:50pm. Elopement Risk Observations done in the past 90 days on current residents in facility reviewed by nursing managers for accuracy. Residents identified at risk will be reviewed for appropriate interventions. Educate facility staff regarding Wander guard System with emphasis on determining cause of alarm if sounding. Any member of target audience not receiving this by this date will receive prior to next scheduled New admissions will be reviewed in morning meeting daily Monday thru Friday as part of the clinical morning meeting process. Elopement Risk Observations will be reviewed for accuracy and interventions validated if indicated. Quarterly assessments will be reviewed as part of the MDS/Care planning process. New admission documentation reviewed from 12/23/25 to 12/30/2025 reveals facility had 2 new admissions, assessment reveals both residents did not exhibit any exit behaviors, no further interventions required as no risk noted. The Director of Nursing will randomly audit a minimum of 5 Elopement Risk Observations weekly for 4 weeks then monthly for 2 additional months to validate accuracy. Review of facility document titled, Wander Guard Monitoring, on 12/13/2025, 12/17/25 and 12/24/25 by DON reviewed. 9 Residents identified with wander guard, no concerns noted. The Maintenance Director/designee will inspect facility doors with wander guard system 3 times weekly for 4 weeks then weekly for 2 additional months. Review of maintenance director calendar log reveals wander guard audits were completed on 12/18/25, 12/22/25, 12/23/25, 12/24/25, 12/29/25 and 12/30/25. Audit completed with LNHA for each date. Observation of maintenance director on 12/30/2025 between 1-3 PM reveals maintenance director completing wander guard audit by placing spare wander guard within proximity of exit doors. No concerns noted. The Facility Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with maintenance director to validate that doors are functioning properly. Review of maintenance director calendar log reveals wander guard audits were completed on 12/18/25, 12/22/25, 12/23/25, 12/24/25, 12/29/25 and 12/30/25. Audit completed with LNHA for each date. Ad hoc QAPI held on 12-15-25. Review of ADHOC QAPI on 12/15/25 reveals meeting was attended by Medical director, LNHA, DON, ADON, SDC, IP, Housekeeping supervisor, Activities Director, Maintenance supervisor, Social services, Nurse assessments coordinator, Dietary Manager, Medical Records, and other staff members. Subject discussed involved the resident elopement. Medical Director was notified of the incident and plan for improvement on 12-13-25 ( MD1) and 12-18-25(MD2). 12/13/2025 06:45 PM [Recorded as Late Entry on 12/14/2025 04:20 PM] 12/13/2025 at 621pm-Received pc from Administrator that resident had left the facility without staff supervision. During transit to facility, received call from Administrator, at 627pm that resident had been located and was safe. Upon arrival at facility, at 645pm, ADM present and report received from staff that the CODE WHITE process had been initiated. Resident had been transported by EMS to SRHC ER for eval and treatment. Attempted to notify RP with no answer and could not leave VM r/t had not been set up per automated response. MD1 notified of events. This process will be reviewed in QAPI for a minimum of 3 months. Only been 2 weeks since last QAPI meeting, interventions will be discussed on the next QAPI meeting in January. Observation of exit doors completed with DON on 12/30/25 at 5:30PM. Alarms are functioning and send off loud alarms when in proximity of a wander guard. Doors are locked.

Based on review of the facility policy, record review, and interviews, the facility failed to ensure appropriate post-fall interventions were developed and implemented through care plan revision for 1 of 3 residents reviewed for falls Resident (R)2. This failure had the potential to place the resident at risk for additional falls and injury.Findings include:Review of the facility's policy titled, Care Plan Process, Person Centered Care with a revision date of 05/05/23 revealed, Policy: The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards and quality care. The facility will coordinate the development of the person-centered care plan within the required timeframes. Procedures: 9. Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictates the need such as but not limited to falls and pressure ulcer development.Review of R2's Electronic Medical Record (EMR) Face sheet revealed R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, fracture of the neck of the right femur, encephalopathy, other disorders of bone density and structure, rhabdomyolysis, dysphagia and cognitive communication deficit. Review of R2's significant change Minimum Data Set (MDS) dated [DATE] revealed R2 has severe cognitive impairment and scored a 06 on the Brief Interview for Mental Status (BIMS) assessment, indicating R2 was not cognitively intact.Review of the facility's incident documentation indicated that R2 experienced a fall on 08/27/25 at approximately 06:00 PM in his room. Post-fall documentation indicated that the resident was assessed, and no serious injury was identified.Review of R2's EMR comprehensive Care Plan revealed the care plan was not updated to include new or revised interventions related to the fall, identification of causative or contributing factors, enhanced supervision or environmental modifications, or any evidence of individualized fall-prevention strategies implemented following the resident's fall with fracture on 08/27/25. During an interview on 12/30/25 at 11:26 AM with the Registered Nurse (RN)/MDS Coordinator, revealed, The resident has had two fractures. We may have resolved the one for August. Let me look. The MDS Coordinator revealed,I ran the history from 09/01/25 until today,12/30/25, but I don't see the care plan for the fracture in August 2025. There is nothing in August because he went out to the hospital on [DATE] and returned on 09/02/25. We did a significant change on 09/07/25. That should have alerted us to update the care plan, but I do not see any care plan updates for August or September 2025.During an interview on 12/30/25 at 12:20 PM with the Director of Nursing revealed, My expectation is that the care plans are updated with a significant change in a resident. Upon readmission to the facility from the hospital, the care plan should be updated.

(2.) Based on review of the facility policy, observations, record reviews and interviews, the facility failed to ensure R131 was free from potential accidents, related to smoking on facility grounds for 1 of 4 residents identified for smoking. R131 being observed smoking unsafely, on the property of a smoke-free facility on 06/13/2025. On 06/13/2025 at 1:31 PM, the SA presented the Administrator with an IJ template related to this incident. On 06/13/2025 at 5:00 PM, the facility presented an acceptable IJ removal plan. Verification of the plan revealed the facility implemented their removal plan as of 06/16/25 at 6:30 PM. The facility remained out of compliance at a lower scope/severity level of D. Findings include: A review of the facility policy titled, Smoking Policy, Guidelines with a revision date 11/01/2017 states: Policy:Facility's Leadership will establish and enforce a specific smoking policy for Facility patients/residents, visitors and employees, outlining the parameters, if any, under which patients/residents, visitors and employees may be permitted to smoke on Facility's property. Procedures 6. ALL patients/residents are prohibited from keeping any type of smoking materials (lighter, matches, cigarettes, etc.) in their rooms or on their person . 10. Smoking by any person, including, without limitation, patients/residents, employees or visitors, in non-designated areas of the building or on Facility property, is strictly prohibited. Review of R131's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to, chronic obstructive pulmonary disease, nicotine dependence, and cognitive communication deficit. Review of R131's admission MDS with an ARD of 06/04/2025 revealed R131 had a BIMS score of 15 out of 15, indicating intact cognitive function. During an observation on 06/13/2025 at 07:40 AM, R131 self-propelled in a wheelchair, behind a cement column, in the courtyard. R131 was observed smoking a cigarette. During an interview on 06/13/2025 at 07:42 AM, Registered Nurse (RN)2 was asked about R131 smoking in the courtyard. RN2 stated, We are a smoke-free facility. She is not supposed to be smoking. During an interview on 06/13/2025 at 08:58 AM, the Nurse Practitioner stated, She is currently on the Nicotine patch. I was not aware of her smoking. I was just informed. The patch is not holding her. I will place her on the lozenges today. During an interview on 06/13/2025 at 10:32 AM, Administrator stated, I have spoken with R131 and the resident voluntarily gave me her cigarettes and lighter. I did the education for smoking with her. She will get discharged on Monday. This is a previously planned discharge. During an interview on 06/13/2025 at 11:00 AM, Certified Nursing Assistant (CNA)5 stated, I did not know she was a smoker. During an interview on 06/13/2025 at 11:05 AM, RN4 stated, I knew she had a Nicotine patch, I didn't know she was a current smoker. During an interview on 06/13/2025 at 11:37 AM, R131 stated, I've been smoking for 41 years. I have been smoking since I got here on Wednesday. Alot of people here smoke, they just don't get caught. A pack would last me about a week. Someone would bring me cigarettes. I kept my cigarettes, lighter, and vape in my little bag, and my bag always stays with me. I go out to the courtyard to smoke. None of the staff ever came out there. A lot of people didn't know. During an interview on 06/13/2025 at 11:43 AM, the Social Worker (SW) stated, Apparently this morning she was smoking, and our Administrator went out and talked to her and took the cigarettes from her and re-educated her. About 20 mins ago, I saw her vaping and took that away from R131. I wasn't aware that she was smoking prior to today. During an interview on 06/13/2025 at 11:49 AM, the Director of Nursing (DON) stated, I was not aware of any smokers prior to today. I'm not sure if she was a tobacco user upon her admission. It is possible that residents smoke when they go out on a leave of absence. We don't routinely ask them upon return from a leave of absence if they have smoking supplies. During an observation on 06/13/2025 at 1:15 PM, R131 was observed in the entryway to her room, crying. She stated, I don't know how I am going to be able to go a few more days without smoking anything. I have been smoking for years. During a follow-up interview with the Administrator on 06/13/2025 at 1:45 PM, she was made aware of the interview with R131. The Administrator stated they had identified a total of 4 residents in the facility, who currently smoked, however, none had any smoking paraphernalia on their person or in their rooms. The facility's removal plan included: Resident (R)131 smoking materials were given to the administrator for storage in administrator's office. Residents currently residing in the facility were asked by facility leadership if they currently are smokers on 06/13/2025. Four residents identified as current smokers. Two of the four declined cessation products and stated that they sign out and leave the premises with their family and smoke off site. The other two residents requested smoking cessation products. One of these residents does not have order or smoking cessation products and will be referred to NP on 06/13/2025 from the provider for smoking cessation product change. The Administrator will review on 06/13/2025 with the residents, that have self-identified as smokers, the admission policy including the smoking policy which states the facility is a non-smoking the facility and any smoking materials must be turned into the administrator for storage in administrators' office. RP/family will be notified and requested to pick up. Residents who have smoking materials will be asked to turn in those smoking materials to the administrator for storage in administrator's office on 06/13/2025. No residents had smoking materials. Smoking Cessation products will be offered to any resident that has identified as a smoker. If they chose to utilize smoking cessation products, the physician will be notified and orders obtained on 06/13/2025. Facility staff will be reeducated on 06/13/2025 regarding the Smoking Policy including that the facility is a nonsmoking facility and that smoking residents are prohibited from keeping any type of smoking materials in their rooms or on their persons. Any staff not receiving this education by 06/13/2025 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation and for agency staff. The Director of Nursing will randomly interview a minimum of 2 staff and 2 interviewable residents weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with the admission and smoking policy. Administrator/designee will round in resident rooms 2 times per day for 5 days, then daily for 3 additional weeks then monthly for 2 additional months to validate thru observation and interview that there are no smoking materials in resident's rooms or on their persons. Administrator/designee will round in the courtyard 2 times a day for 5 days, then daily for 3 additional weeks then monthly for 2 additional months to validate no smoking is occurring in this area. Any concerns will be addressed at time of discovery. The Medical Director was notified on 06/13/2025 of the Immediate Jeopardy. Ad Hoc quality Assurance Performance Improvement Meeting was held on 06/13/2025 to discuss contents of this plan. Administrator will oversee compliance of this plan for three months. Based on review of the facility policy, record review, and interviews, the facility failed to ensure that Resident (R)78 was free from elopement from the facility on 03/23/25, at an unknown time. On 06/13/2025 at 1:20 PM the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations could cause psychosocial harm. On 06/13/2025 at 1:21 PM, the survey team provided the Administrator with a copy of the Centers for Medicare and Medicare Services (CMS) Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 03/23/2025, when Resident (R)78 eloped from the facility. The IJ was related to 42 CFR 483.25 -Quality of Care, related to F689- Free of Accident Hazards/Supervision/Devices. On 06/16/2025 at 3:56 PM, the facility provided an acceptable IJ Removal Plan related to R78's elopement. The survey team validated the facility's implementation of the removal plan related to the elopement on 06/16/2025. The IJ was removed and lowered to a scope/severity level of D. Findings include: Review of the facility's policy titled, Elopement revised 11/01/2017 revealed, To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. The facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/resident. Procedures: 1. Once it has been established that a patient/resident is missing, all employees are notified immediately by paging overhead______ (insert code name). 2. The DON/designee completes a missing resident profile. 4. The entire search process of the facility and grounds, from the time the patient/resident is missing, will be completed within (30) thirty minutes. Review of the facility's policy titled, Against Medical Advice (AMA)- Day Outings/Therapeutic Leaves of Absence revised 6/9/2023 revealed Under Procedures: 3. C. If the resident/legal representative still wishes to leave, the facility designee will ask the resident/legal representative to sign the Against Medical Advice Waiver and Release for Day Outings/Therapeutic Leaves of Absence form (Waiver). 1. If the patient/resident can make his/her own healthcare decisions, as documented in the medical record by the treating physician, resident will sign the Waiver. Review of R78's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to; muscle wasting and atrophy, and abdominal aortic aneurysm, without rupture. Review of R78's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/23/25 revealed a Brief Interview for Mental Status (BIMS) score was not recorded. Further review of the MDS revealed R78 has impairment of the upper extremity on one side, is at risk for falls, and need partial/moderate assistance for sit to stand mobility, to walk 10 feet and walking 50 feet with two turns as not attempted due to medical condition or safety concerns. Review of R78's Electronic Medical Record (EMR) did not reveal any documentation reflecting R78 was capable of making her own healthcare decisions. Review of Accuweather.com revealed that on 03/23/25, the high was 57 degrees Fahrenheit and the low was 28 degrees Fahrenheit, in regards to the temperature. Review of the facility's document titled, Release of Responsibility for Leave of Absence did not include any completed documents for R78. Review of R78's Nursing- Elopement Risk Observation dated 03/22/25 indicated Does the patient/resident have safe decision-making capabilities?. This question is answered as No. During an interview on 06/12/25 at 3:51 PM, Licensed Practical Nurse (LPN)2, provided the following account regarding an incident on 03/23/25 involving R78, a newly admitted resident. She stated, At the start of her shift on 03/23/25, another nurse reported to LPN2 that R78 had received her medication and was outside on the front porch with family. The resident was expected to sign the leave of absence log if she left the facility. LPN2 stated that she did not personally see the resident during her shift. Around 7:30 PM to 8:00 PM, during routine rounds, LPN2 noticed that R78 was not in her room. A search was conducted in common areas including the activity rooms, dayroom, dining room, courtyard, and the front parking lot, but R78 was not found. LPN2 attempted to contact both the resident and the resident's representative by phone, but neither answered. LPN2 informed the Director of Nursing (DON) of the situation. The DON advised continuing attempts to contact the resident and representative, with a plan to call again the following day. LPN2 stated that, per her training, when a resident is missing, staff are instructed to contact the family. LPN2 reported that no follow-up was made with her about the incident. Upon reflection, she believed she should have checked for the resident earlier, confirmed who the resident was with, and contacted the police when the resident could not be located. During an interview on 06/12/25 at 6:02 PM, the Administrator stated, On the 21st of March, R78 left on Sunday. I believe she was a smoker and wanted to leave because she couldn't smoke. I do know we assessed everyone for smoking on admission. LPN2 did follow up to reach R78. She wasn't at risk for elopement or disappeared. She was at no risk for elopement. She was told she needed to sign herself out and she did not. Someone in the building knew she was going to leave. She said she was going to the store. Our door locks on an automatic lock at 9 PM. Those who are confused, they wear a wanderguard. We tell the residents they have to sign out, we can't make them. We tried to call and the next day the Social Worker attempted to call the family. The Speech Language Pathologist (SLP) saw her on Sunday. I am unsure if the Physician was notified. During an interview on 06/13/2025 at 09:08 AM, Medical Director stated, I can not confirm or deny my awareness R78 left against medical advice. During an interview on 06/13/2025 at 9:09 AM, Certified Nursing Assistant (CNA)1 revealed that she was assigned to work with R78 on 03/23/2025. CNA1 stated, I assisted R78 with personal care around 1:00 PM and no later than 2:15 PM. R78 was dressed in a short sleeve green shirt, black leggings and some non-skid yellow socks, with no shoes or undergarments and her legs were covered, with a sheet. CNA1 further explained, I last saw R78 sitting inside the building at the front door around 2:30 PM or 2:40 PM. CNA1 stated that the resident had an issue with her right arm, but was able to use a wheelchair, she never walked but was able to stand and pivot to a chair. CNA1 further revealed that she left for the day around 2:55 PM or 3:00 PM and the resident was no longer at the door, she was unaware where the resident was and that she did not know that the resident had left the facility until she returned to work on Monday, 03/24/2025. During an interview on 06/13/25 at approximately 01:15 PM, the Administrator revealed that upon admission to the facility, the resident was made aware of the facility's policy regarding leaving the facility and acknowledged understanding by signing the admission handbook. During the survey, the Administrator stated that R78 had a BIMS of 14, she was cognitive and she had told staff that she would be leaving to go to the store with family and that the resident had a right to leave. The Administrator acknowledged at the time of the incident and currently, the whereabouts of the resident remained unknown, the facility had not considered this an elopement, so they did not notify the local authorities and/or continue to look for R78. Facility provided the following removal plan: Resident 78 no longer resides at the facility. The Social Worker attempted to call the resident & her son on 3/24/25. Voice message was left for both contacts and no call back were received. Adult protective services were notified to do welfare check on 06/16/25. Police department was notified to do wellness check on 06/16/25. . Elopement Risk evaluations done in the past 90 days on current residents inhouse will be reviewed by Director of Nursing/Designee for accuracy by 6/13/25. Residents identified at risk will be reviewed for appropriate interventions including placement in the Elopement Binder and validated care plans have interventions listed. The Director of Nursing was reeducated by the Clinical Consultant on 6/13/25 on Accidents and Incidents and Resident Care including: o Elopement risk o validating that when a resident is leaving and or expressing the desire to leave the facility the nurse is aware and the resident and/or responsible party has signed the resident out for leave of absence o elopement risk assessment process and putting interventions in place based on risks identified. Validation with in service attendance sheet signature. Facility Staff will be reeducated by 6/13/25 by the Director of Nursing/Designee on Accidents and Incidents including: o elopement risk o validating that when a resident is leaving the facility and or expressing the desire to leave the facility the nurse is aware and the resident and/or responsible party has signed the resident out for leave of absence Any staff not receiving this education by 6/13/25 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation. Nursing Staff will be reeducated on 6/13/25 by the Director of Nursing/Designee on Accidents and Incidents and Resident Care Including: o Elopement Risk o Validating that when a resident is leaving the facility and or expressing the desire to leave the facility the nurse is aware and the resident and/or responsible party has signed the resident out for leave of absences o Elopement risk assessment process accuracy o Checking for residents needs approximately every 2 hours o Notifications to Charge Nurse or Director of Nursing as indicated when a resident is not located Any staff not receiving this education by 6/13/25 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation. An elopement drill will be completed on 6/13/25 that includes: o The Administrator will notify the Charge Nurse, Director of Nursing and Social Service Designee that a resident is missing. The Director of Nursing/designee will announce Code [NAME] to signal the Elopement Drill Procedure o The Director of Nursing/designee will organize an immediate and thorough search of the center and surrounding grounds. The entire search process will be completed within 30 minutes o If the search fails to locate the missing resident in the allotted time, the Administrator/designee will place a mock telephone call to the appropriate community agencies, resident's legal representative and attending physician. Staff will provide the mock police with all the physical identifying information o The Search will continue if resident not located to include 2 staff members searching the surrounding streets by care for a 2 mile radius o When the volunteer resident is located the Charge Nurse will complete a head to toe assessment. The Social Services Designee will assess the resident for emotional distress. The Director of Nursing will notify the appropriate community agencies, attending physician and the resident's legal representative. o The facility's Quality Assurance Committee will investigate the incident and implement interventions to prevent reoccurrences o When the missing resident is found, an announcement will be made, Code [NAME] all clear. The Director of Nursing will randomly interview a minimum of 2 staff daily to validate understanding of elopement risk and elopement binder for 5 days, then weekly for 3 weeks then monthly for 2 additional months. The Director of Nursing/Designee will validate elopement risk assessments for accuracy beginning 6/13/25 in clinical morning meeting. The Medical Director was notified on 6/13/25 of the Immediate Jeopardy. A review of the facilities policy and procedures on leave of absence, resident's signing out, and Elopement was conducted on 6/13/25. No loopholes or changes were identified or needed during the review. An Ad Hoc Quality Assurance and Performance Improvement Meeting was held on 6/13/25 to discuss contents of this plan. Administrator will oversee compliance of this plan.

Based on review of the facility policy, observations, and interviews, the facility failed to ensure foods that were stored in the freezer, refrigerators and dry food storage were appropriately sealed, labeled, dated with a use by date, and/or discarded after the manufacturer's expiration date. This had the potential to affect all residents who received meal trays from the kitchen. Findings include: Review of the facility's policy titled, Food Safety in Receiving and Storage, with a revision date of 6/20/2023 revealed, Receiving Guidelines 6. Check expiration dates and use by dates to assure dates are within acceptable parameters; General Food Storage Guidelines 3.) .Label both the container and its lid with the common name of the contents, the date, it was transferred to the new container and the discard date; Dry Storage guidelines 2. Tightly seal open packages to prevent contamination or place food in covered container. Review of the facility's policy titled, Dating and Labeling Food Guidelines, updated 2/4/2024, revealed .when opening food in dry storage, make sure food has a label with date opened/one month expiration date. Six months for condiments; All opened frozen foods returned to the freezer needs to be bagged/labeled. During an observation on 06/10/25 at 10:24 AM, the kitchen's dry food storage revealed one 5-pound (lb.) bag of self-rising corn meal opened and not labeled with an open or use by date and one 16-ounce (oz.) box of lasagna noodles opened and not sealed properly or labeled with an open or use by date. The walk-in cooler revealed one 1-gallon (gal.) container of dill pickle chips marked open 3/15/25 out 5/15/25; one 16 oz. container of ham base marked open 2/27 and an ilegible out date. The walk-in freezer revealed one box containing 4 open bags of churros, not properly sealed and not labeled with an open or use by date. During a follow-up observation on 06/12/25 at 1:56 PM, the walk-in freezer revealed one 1-gal. size Ziploc bag of meatballs, marked with an open date of 3/29/25 and use by date of 5/29/25. During an interview on 06/12/25 at 2:31 PM, the Dietary Manager revealed that the food is handled by the kitchen and dietary staff to make sure there is nothing expired. During an interview on 06/16/25 at 07:31 PM, the Administrator revealed that it is her expectations that foods that are expired are discarded. The Administrator also stated that any foods in the dry food storage, refrigerators or freezers that have been opened, should also be dated. The Administrator further revealed that sometimes things are mislabeled with dates that exceed the required date.

Based on a review of the facility policy, record reviews, and interviews, the facility failed to report to the State Survey Agency an incident that occurred on 03/23/2025. The facility neglected to identify R78 was no longer in the facility, or was her whereabouts known to facility staff. Findings include: A review of the facility policy titled Abuse, Neglect, Exploitation or Mistreatment with a complete revision date of 11/01/2017 stated, The Facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures . Review of R78's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to: muscle wasting and atrophy, and abdominal aortic aneurysm, without rupture. Review of R78's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/23/25 revealed a Brief Interview for Mental Status (BIMS) score was not recorded. Further review of the MDS revealed R78 has impairment of the upper extremity on one side, is at risk for falls, and need partial/moderate assistance for sit to stand mobility, to walk 10 feet and walking 50 feet with two turns as not attempted due to medical condition or safety concerns. Review of R78's Electronic Medical Record (EMR) did not reveal any documentation reflecting R78 was capable of making her own healthcare decisions. Review of the facility's document titled, Release of Responsibility for Leave of Absence did not include any completed documents for R78. Review of R78's Nursing- Elopement Risk Observation dated 03/22/25 indicated Does the patient/resident have safe decision-making capabilities?. This question is answered as No. During an interview on 06/12/25 at 3:51 PM, Licensed Practical Nurse (LPN)2, provided the following account regarding an incident on 03/23/25 involving R78, a newly admitted resident. She stated, At the start of her shift on 03/23/25, another nurse reported to LPN2 that R78 had received her medication and was outside on the front porch with family. The resident was expected to sign the leave of absence log if she left the facility. LPN2 stated that she did not personally see the resident during her shift. Around 7:30 PM to 8:00 PM, during routine rounds, LPN2 noticed that R78 was not in her room. A search was conducted in common areas including the activity rooms, dayroom, dining room, courtyard, and the front parking lot, but R78 was not found. LPN2 attempted to contact both the resident and the resident's representative by phone, but neither answered. LPN2 informed the Director of Nursing (DON) of the situation. The DON advised continuing attempts to contact the resident and representative, with a plan to call again the following day. LPN2 stated that, per her training, when a resident is missing, staff are instructed to contact the family. LPN2 reported that no follow-up was made with her about the incident. Upon reflection, she believed she should have checked for the resident earlier, confirmed who the resident was with, and contacted the police when the resident could not be located. During an interview on 06/12/25 at 6:02 PM, the Administrator stated, On the 21st of March, R78 left on Sunday. I believe she was a smoker and wanted to leave because she couldn't smoke. I do know we assessed everyone for smoking on admission. LPN2 did follow up to reach R78. She wasn't a risk for elopement or disappeared. She was at no risk for elopement. She was told she needed to sign herself out and she did not. Someone in the building knew she was going to leave. She said she was going to the store. Our door locks on an automatic lock at 9 PM. Those who are confused, they wear a wanderguard. We tell the residents they have to sign out, we can't make them. We tried to call and the next day the Social Worker attempted to call the family. The Speech Language Pathologist (SLP) saw her on Sunday. I am unsure if the physician was notified. During an interview on 06/13/2025 at 09:08 AM, Medical Director stated, I can not confirm or deny my awareness R78 left against medical advice. During an interview on 06/13/25 at approximately 01:15 PM the Administrator revealed that upon admission to the facility, the resident was made aware of the facility's policy regarding leaving the facility and acknowledged understanding by signing the admission handbook. During the survey, the Administrator stated that R78 had a BIMS of 14, she was cognitive and she had told staff that she would be leaving to go to the store with family and that the resident had a right to leave. She confirmed it was not reported to the State Survey Agency that the resident did not return.

Based on review of the facility policy, observations, record reviews and interviews, the facility failed to notify Resident (R)7 and R78 or their resident representative (RR) of bedholds, including bed reserve payments 2 of 2 residents. Findings include: Review of the facility policy titled, Facility's Policy and State Requirements for Temporary Leave Bed-Hold revised 06/2009 revealed If a resident leaves the facility for temporary hospitalization or therapeutic leave, the resident or his/her representative may ask the Facility to hold the resident's bed until the resident is ready to return (bed hold). The resident and/or his/her representative will be given a copy of the Facility's bed-hold policy before the resident actually leaves for his/her temporary leave or hospitalization. In the case of an emergency hospitalization, the bed hold policy may accompany the resident to the hospital or will be given to the resident or his/her legal representative within twenty-four (24) hours of the resident's hospitalization. Review of R78's Face Sheet R78 was admitted to the facility on [DATE] with diagnoses including, but not limited to multiple rib fractures, weakness, type 2 diabetes mellitus without complication, and dementia. Review of R78's comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/02/2025, revealed R78 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated the resident has moderate cognitive impairment. Review of 78's Electronic Medical Record (EMR) did not reveal a bed hold notification. During an interview on 06/12/25 at 02:10 PM, R78's RR stated, No, I did not receive a call or anything in writing about a bed hold. Review of 7's EMR revealed R7 was admitted to the facility on [DATE] with diagnoses including but not limited to: encephalopathy, dysphagia, parkinsonism, chronic respiratory failure with hypoxia, Dementia, and altered mental status. Additional record review revealed R7 had the following hospitalizations: 5/10/24-5/18/24- Bedhold 1/28/25-1/31/25- Bedhold 5/23/25-5/28/25- Bedhold During an interview on 6/12/25 at 10:49 AM, Registered Nurse (RN)4 stated, We have a form we send with the resident by transport. The nurses call the family to inform them the resident is being sent to the hospital. The DON and business office takes over from there. During an interview on 06/12/25 at 01:59 PM, Business Office staff stated, The bed holds are sent out in real time by the nursing department. The Social Worker (SW) is my back up. The admission Department gets a verbal consent from the RR. That is the only way we do it. It is not an actual form we fill out. During an interview on 06/16/25 at 12:56 PM, SW stated, I don't have a bedhold for R78. I did not know the notice of transfer is something that I needed to do it. During an interview on 06/16/25 at 05:52 PM, the Director of Nursing (DON) stated, The SW handles the bed hold. I did the bed hold in-service with the SW. We became aware she was not sending them out. I am unsure if we told her to do the bed hold. When we found out the bed holds were not getting completed, we put a plan in place to correct the bed hold notifications. I think it wasn't being completed within the last couple of months due to her being a new employee.

Based on review of the facility policy, observations, record review and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent. The medication administration error rate was 8 percent for 2 out of 25 opportunities observed for error. Findings include: Review of the facility's policy titled, Medication Management Program revised 05/05/2023, revealed, Policy: The facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. Security and Safety Guidelines: 16. Medications are dispensed at the time of administration. Pre-pouring or dispensing for a later administration is not permitted. Administering the Medication Pass 7. The authorized staff member prepares one resident's medication at a time. B. Do not touch the medication when opening a bottle or unit dose package C. If a medication which is not in a protective container is dropped, it should be discarded according to policy. 15. If a medication is unavailable, contact pharmacy and document accordingly. Notify the physician for possible alternatives available in e-kits at time of discovery. 16. Once removed from the package or container, unused doses should be destroyed following facility policy and documenting the destruction according to facility policy. During an observation on 06/11/2025 at 03:30 PM, Registered Nurse (RN)3 placed Reglan and Buspirone in her bare hands and placed in a medication cup. During an interview on 06/11/2025 at 03:36 PM, RN3 stated, That is ridiculous. It is going to take too long placing the medication directly in the medicine cup. The medicine will end up on the medicine cart more than in the medicine cup. I washed my hands. No one else does it that way. During an observation on 06/11/2025 at 03:45 PM, R22's medication was removed from the medication cart included Tylenol 500 mg [milligrams] by mouth (PO) and Tramadol 50 mg PO. Gabapentin 600 mg PO and hydroxyzine HCL 50 ml were not available. RN3 proceeded with medication pass. During an interview on 06/11/2025 at 03:45 PM, RN3 stated, I don't see R22's Gabapentin or Hydroxyzine, I guess he doesn't have any in this cart. During an observation on 06/11/2025 at 03:55 PM, RN3 offered R26 his medication in the hallway. The resident was slumped slightly to the right in the wheelchair. The resident attempted to take the medications, but one pill dropped on the floor. RN3 picked it up and stated, One pill dropped on the floor. I guess I can get another one not unless you want to take this one. R26 responded, I can take that one. After intervention of the surveyor, RN3 responded, I'll go get you another one. During an observation on 06/11/2025 at 04:03 PM, RN3 placed the dropped pill in the trash can on the medication cart. RN3 proceeded to prepare another pill for R26. During an interview on 06/11/2025 at 04:03 PM, RN3 stated, I do not know what pill I dropped. I think I know what it is. I will compare it to Baclofen by what it looks like. This medication is not an opioid. Since it is an antibiotic, it should be ok to discard it in the trash can. No, I do not know what the policy says on discarding non opioid medications. During an interview on 06/11/2025 at 04:19 PM, the Director of Nursing (DON) stated, RN3 works here often. She is agency staff. She knows our policies. I expect all medications to be given per our policies. She will be placed on the Do Not Return (DNR) list. The DON was also asked about medication availability. She stated, We have those medications to give. I expect all medications to be given as per our policies.

Based on review of the facility policy, observations and interviews, the facility failed to ensure expired medication and biologicals, and 4 loose unidentified pills were removed from 2 of 2 medication carts. The facility further failed to remove open and expired items from 1 of 2 treatment carts. Findings include: Review of the facility's policy titled, 8.2 General Guidelines for Storage of Medication and Biologicals, revised [DATE], revealed Policy: Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. In accordance with State and Federal laws, the facility will store all drugs and biologicals in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. Procedures: 5. Medications with manufacturer's expiration date expressed in month and year (e.g., May, 2019) will expire on the last day of the month. (unless a sooner expiration date has been placed on the package by the pharmacy). 6. Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates of opened medications. 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the Pharmacy, if replacements are needed. During an observation on [DATE] at 12:23 PM of [NAME] Medication Cart revealed; 2 loose yellow unidentified pills and 1 white unidentified pill, floor Stock Vitamin D3, 10 mcg [microgram] (400 IU) Plus Phar Lot# 63376 expired on 04/25, Iron 27 mg [milligram] Geri Care Lot# 724W03, Expired 04 2025, and 3 Bisacodyl 10 mg medicated Laxative Suppositories OTC [over-the-counter] Stock Lot# ZD006, Expired 04/2025. During an interview on [DATE] at 12:49 PM, Registered Nurse (RN)1 stated, Floor Nurses and Manager usually check the cart. For the loose medications, we have a drug buster we place loose pills in. The suppositories and Vitamin D3 will be discarded in a big trash can in the Director of Nurses (DON's) office. The Vitamin D3 will go to the DON office for disposal. During an observation on [DATE] at 12:49 PM, RN1 disposed of the medications in the black receptable bin in the DON's office. During an observation on [DATE] at 01:20 PM, Birch Medication Cart B revealed 1 loose yellow pill, Humalog Kwik Pen dated 05/04 expired 4/28 from the open date, and Albuterol Sulfate aerosol 90mcg, Lot# 1820164 expired on 12/2023. During an interview on [DATE] at 01:24 PM, Licensed Practical Nurse (LPN)1 stated, The Assistant Director of Nursing (ADON) and LPN3 checks the carts. I am an agency staff member. During an observation on [DATE] at 01:24 PM, LPN1 discarded the Aspirin in the drug buster. The insulin and inhaler medications were discarded in the medication needle box on the side of the medication cart. During an observation on [DATE] at 04:52 PM, The [NAME] Park Treatment cart revealed the following: [NAME] Valve, non-sterile package, open Rf M9000 ICU Medical Lot 5584922 expired [DATE] and the Ready Prep PVP povidone iodine 10% solution Lot# 11kJAO40E, expired 10/24. During an interview on [DATE] at 06:34 PM, the DON stated, RN2 uses the cart when she does wounds and making rounds. LPN3 checks the [NAME] wing. The nurses are responsible for checking the medication carts for expiration dates.

Based on review of facility policy, observations, and interviews, the facility failed to ensure the useof gowns during catheter and wound dressing changes 2 of 2 residents reviewed, Resident (R)35and R57. Findings include: Review of the facility's policy titled, Transmission Based/Standard Precautions, and Enhanced Barrier Precautions revised on 05/15/23 revealed, Policy: 1. The facility will use transmission-based precautions when the routes of transmission is not completely interrupted using standard precautions alone. These are applied as needed based on the epidemiology of the infecting organism or infectious disease syndrome. There may be some diseases that have multiple routes of transmission which more than one transmission-based precaution may be required. Transmission-based precautions will always be used in addition to standard precautions. 2. Health care workers (HCW) will implement Universal/Standard Precautions whenever there is occupational exposure to blood and body fluids. Procedures: Enhanced Barrier Precautions (EBP) 1. Enhanced Barrier Precautions expand the use of PPE (gowns and gloves) during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A. EBP will be implemented for All residents with the following: 2) Wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tube,tracheostomy/ventilator) regardless of MDRO colonization status B. EBP will be implemented during the following high-contact resident care activities: 7) Device care or use: central lines, urinary catheter, feeding tube, tracheostomy/ventilator F. The facility will post clear signage on the door or wall outside of the room indicating the type of precautions and required PPE (gowns and gloves) G. The facility will post signage that clearly indicates the high-contact resident care activities that require the use of gown and gloves. H. The facility will provide gowns and gloves immediately outside of the resident's room and position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing car for another resident in the same room. Standard Precautions vs. Transmission Based Precautions 4. Rationale for Transmission-Based Precautions 5. Signs a) Confidentiality is to be maintained as much as possible while still following all applicable regulations. Health Insurance Portability and Accountability Act (HIPPA) regulations are applicable. Review of R35's Face Sheet revealed R35 was admitted to the facility on [DATE] with diagnoses including but not limited to; pressure ulcer of sacral region and pressure ulcer of unspecified elbow,stage 4. Review of R35's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/25 revealed R35 had a Brief Interview for Mental Status (BIMS) score of 09 out of 15, indicating moderate cognitive impairment. Review of R35's Physician Orders dated 06/04/25, revealed the following order for woundtreatment: Location sacrum keep sacral open area clean and dry. Insert alginate wound dressinginto wound. Apply foam dressing to cover area. Change Monday (M)-Wednesday (W)-Friday (F). Review of R57's Face Sheet revealed R57 was admitted to facility on 05/12/25 with diagnoses including but not limited to; unspecified injury of external genitals, subsequent encounter andother specified injuries of external genitals, subsequent encounter. Review of R57's admission MDS with an ARD of 05/27/25 revealed R57 had a BIMS score of 03 outof 15, indicating severe cognitive impairment. Review of R57's Physician Orders dated 04/23/25, revealed the following order, Urethral cathetercare every shift may be completed by certified nursing assistant (CNA) or nurse. During an observation on 06/12/25 at 10:56 AM, observation of R57 ' s room showed no EBP signageon the door. CNA2 and CNA3 washed their hands and applied gloves. CNA2 and CNA3 did not use agown during catheter care for R57. CNA2 and CNA3 took off their gloves and sanitized their hands. During an interview on 06/16/25 at 07:47 PM, CNA3 stated, R57 ' s EBP signs are not up on the door. Itreally depends on when we would put a gown on for resident care. We had a 1 on 1 in-service in January,and we have a skills fair coming up. During an observation on 06/12/25 at 11:11 AM, observation of R35 ' s room did not have EBPsignage outside of room door. RN2 washed her hands and applied gloves. RN2 changed R35 ' ssacral dressing. RN2 removed her gloves and washed hands. During an interview on 06/12/2025 at 11:30 AM, RN2 stated, I thought about the gown after theprocedure. I had it out and everything. I forgot to put it on. During an interview on 06/12/25 at 11:36 AM, the Director of Nursing (DON) stated, The EBP signsare inside the closet doors with supplies. We do not put them on the doors to help withconfidentiality. This is a small town, and a lot of people know each other. So, the confidentialitywould not be confidential with the EBP signs on the door.

Based on interview, record review, observation and facility policy review, the facility failed to supervise 1 (Resident (R)6) of 3 sampled residents reviewed for accidents. Specifically, the facility failed to supervise R6, who the facility determined was high risk for falls and required staff assistance with showers/bathing, during a shower on 10/06/24. R6 fell from a shower chair when staff left the resident in the shower room unattended and the resident sustained redness to the knees. Findings include: Review of a facility policy titled, Fall Management, revised 05/05/23, indicated, 1. The facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. 2. Qualified staff will complete the Fall Risk Evaluation to determine if patient/resident is a fall risk. 3. The fall management program includes education for staff in creative, functional strategies while recognizing patients/resident's rights and highest practicable level of function. Review of a Resident Face Sheet revealed the facility admitted R6 on 10/04/24. According to the Resident Face Sheet, the resident had a medical history that included diagnoses including but not limited to: chronic obstructive pulmonary disease, urinary tract infection, unsteadiness on their feet, repeated falls, and dependence on supplemental oxygen. The Resident Face Sheet revealed the facility discharged the resident home on 10/06/24, two days after admission. Review of an occupational therapy (OT) Initial Evaluation, dated 10/02/24, (during a hospital admission prior to admission to the facility) revealed R6 had decreased endurance and decreased balance. The OT evaluation revealed that the resident required supervision for static sitting balance (the ability to maintain the body in a specific position) and required contact guard assistance for dynamic sitting balance (the ability to maintain balance while moving the body in a sitting position). The OT evaluation indicated a goal was for R6 to bath with stand by assistance. Review of R6's nursing Resident Progress Notes dated 10/04/24 at 6:04 PM, revealed the facility admitted the resident at 12:21 PM. The notes revealed the resident was alert and responsive, had incontinent episodes, and staff assisted with activities of daily living. Review of R6's Morse Fall Scale, dated 10/04/24, revealed that R6 was high risk for falls. Review of a PT [Physical Therapy] Discharge Summary for dates of service from 10/04/24 through 10/06/24, revealed R6 was discharged from therapy due to being discharged to the hospital. Per the summary, the resident had muscle wasting and atrophy in the left and right lower leg, was unsteady on their feet, and had repeated falls. Review of R6's Baseline Care Plan, included a problem statement dated 10/04/24, that revealed the resident was a new admission to the facility. Interventions directed staff that the resident was a fall risk and to encourage the resident to use the call light (initiated 10/04/24). Interventions also directed staff to assist the resident with bed mobility, eating, toileting, transfers, and ambulation (initiated 10/04/24). The care plan did not address the level of assistance R6 required for bathing/showers. Review of R6's Resident Profile, indicated the resident was at risk for falls and required assistance with ambulation, transfers, and toileting (started 10/04/24). The Resident Profile did not address the level of assistance the resident required for bathing/showers. Review of a discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/06/24, revealed R6 had modified independence in cognitive skills for daily decision making and had no short-term memory problems per a staff assessment of mental status (SAMS). The MDS revealed the resident required substantial/maximal assistance (the helper did more than half the effort) with showers/bathing. According to the MDS, tub/shower transfers had not been attempted due to medical condition or safety concerns. Review of a nursing Resident Progress Note, dated 10/06/24 at 10:49 AM, revealed Registered Nurse (RN)9 documented that R6 was found on the floor in the shower room at 8:30 AM. The note revealed R6 was laying in front of a shower chair. According to the note, R6 stated that they hit their head but there were no signs of injury. Per the note, R6's knees were red. The note revealed the nurse contacted the Nurse Practitioner (NP) on call, who wanted staff to continue checking the resident's vital signs. The note revealed RN9 called the NP back with vital changes at 10:24 AM. According to the note, RN9 notified the resident's Responsible Party (RP) of the fall and that R6 was being transferred to the emergency department (ED). Review of R6's Neurological Evaluation Flow Sheet revealed on 10/06/24 at 10:00 AM, the resident's blood pressure was 162/74 millimeters of mercury (mm/Hg) (an increase from 123/75 mm/Hg at 9:25 AM) and the resident's pulse rate was 79 beats per minute (bpm) (a decrease from 91 bpm at 9:25 AM). Review of an undated facility Summary of Investigation report revealed the facility admitted R6 from a hospital for rehabilitation pending restoration of electrical power at home. The report revealed R6 was alert and oriented and per the hospital therapy notes, R6 was ambulatory with a rolling walker, able to stand with minimal assistance, required minimal assistance with bathing/dressing, and was able to feed themselves (The facility's Summary of Investigation did not address that the hospital therapy notes also revealed that the resident required contact guard assistance for dynamic sitting or that a goal for the resident was to provide stand by assistance with bathing). The report revealed R6 had an unwitnessed fall in the community bathroom on 10/06/24, at approximately 8:30 AM, with no observed injuries. Per the report, RN9 notified the resident's family and the NP, who instructed the nurse to monitor R6's vital signs/neurological checks. According to the report, at approximately 10:00 AM, the resident's vital signs reflected a significant increase in systolic blood pressure and decrease in pulse rate. The note revealed that the NP was notified, and orders were obtained to send the resident to the ED for an evaluation. Per the report, ED notes reflected a computed tomography (CT) scan of the resident's head that showed no injury related to the fall. The note revealed the resident's family took the resident home following the ED evaluation as their power had been restored at home. The Summary of Investigation also revealed the facility reeducated the assigned Certified Nursing Assistant (CNA) regarding Shower Room Safety. Review of R6's CT scan results dated 10/06/24, revealed the resident had no fractures and there were no intracranial findings. During an interview on 11/08/24 at 3:14 PM, CNA8 stated that she gave R6 a shower as soon as she came on the 7:00 AM to 3:00 PM shift. CNA8 stated R6 had feces and urine on them and the resident agreed to take a shower. CNA8 stated that R6 could walk and was alert and oriented. CNA8 stated that during the shower, R6 held out their hand for the washcloth and said they wanted to bathe themselves. CNA8 stated that she stepped across the hall to R6's room to get clothing. CNA8 stated that prior to leaving, she asked R6 if it was okay, and they said yes. CNA8 stated she came back to the shower to check on the resident and they were still washing. CNA8 stated she stepped back out to get sheets from a linen cart and tossed them on R6's bed. CNA8 stated when she got back to the shower R6 was sitting on the shower floor with their legs crossed and their head leaning on the wall. CNA8 stated she opened the shower door and called RN9. CNA8 stated that RN9 assessed R6, and there were no injuries. CNA8 stated R6 did not complain of pain. CNA8 stated she and RN9 assisted the resident back to the shower chair, and she finished R6's shower and dressed them. Review of a typed statement dated 10/07/24, and signed by RN9 revealed R6 stated they fell out of the shower chair and was lying on their right side on the rubber mat in front of the shower chair. RN9's statement revealed the resident had reddened knees. During a telephone interview on 11/08/24 at 3:25 PM, RN9 stated that she was passing medications down the hall and saw CNA8 come out of the shower room. RN9 stated that the resident should not have been left in the shower unsupervised. During an observation on 11/08/24 at 5:05 PM, revealed the shower room was across the hallway from the room where R6 resided. An observation of the shower room revealed there were two shower stalls with a call bell in each stall. Shower chairs were also observed in the shower room. During an interview on 11/08/24 at 5:51 PM, the Director of Nursing (DON) stated that she expected the resident's preference to be honored, depending on the resident's capability and safety to be in the shower alone. The DON stated she felt that R6 was safe to be in the shower alone. During an interview on 11/08/24 at 6:07 PM, the Administrator stated that it was her expectation that all residents be afforded the opportunity for safe bathing depending on their preference and capabilities.

Based on interview, record review, and facility policy review, the facility failed to ensure resident care plans were updated to include revised appropriate fall interventions for 3 (Residents (R)1, R2, and R3) of 3 sampled residents reviewed for falls. Findings include: Review of a facility policy titled, Fall Management, revised on 05/05/23, revealed, 6. The care plan reflects individualized interventions that are reassessed and revised as needed. Review of a facility policy titled, Care Plan Process, Person-Centered Care, revised on 05/05/23, revealed, 9. Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictates the need such as but not limited to falls and pressure ulcer development. 1. Review of a Resident Face Sheet revealed the facility admitted R1 on 11/03/23, with diagnoses including but not limited to: altered mental status, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, muscle weakness, lack of coordination, hemiplegia and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side, dementia, and cognitive communication deficit. Review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/05/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had two or more falls with no injury and one fall with an injury since their prior assessment. Review of R1's Care Plan included a problem statement initiated on 11/14/23, that indicated the resident was at risk for falls as evidenced by physical impairment with left-sided weakness, unsteady gait, and muscle weakness. Interventions directed staff to use a bed alarm for monitoring the resident to prevent falls (initiated 06/27/24), place a chair alarm to the resident's chair to alert staff when the resident is attempting to exit the chair unassisted (initiated (06/23/24), instruct the resident to request assistance or supervision while ambulating for safety and reduce fall risk (initiated 03/07/24), provide adequate lighting and ensure areas are free of clutter (initiated 11/14/23), provide prompt assistance (initiated 11/14/23), ensure the call light is within reach and answer promptly (initiated 11/14/23), encourage activities and socialization (initiated 11/14/23), encourage the resident to ask for assistance from the staff (initiated 11/14/23), and have therapy evaluate and treat the resident per the resident's orders (initiated 11/14/23). Review of a Falls Investigation Worksheet, dated 05/20/24, revealed R1 had an unwitnessed fall on 05/25/24 at 6:00 AM. The worksheet revealed the resident had no injuries. The worksheet revealed recommended interventions were to request an evaluation for placement of a bed and chair alarm due to confusion and impulsiveness and to increase staff rounding to address the resident's need for toileting. Review of a Falls Investigation Worksheet, dated 06/04/24, revealed R1 had an unwitnessed fall on 05/28/24 at 4:35 AM. The worksheet revealed the resident had no injuries. The worksheet revealed recommended interventions were to increase staff rounds to every 30 to 60 minutes, to initiate a toileting program, and to evaluate for the placement of a chair and bed alarm. Review of an undated Falls Investigation Worksheet, revealed R1 had a witnessed fall on 06/02/24 at 2:00 AM. The worksheet revealed the resident had no injuries. However, an Emergency Department Note, dated 06/02/24, revealed the resident had a 7.0 centimeter (cm) in length by 5.5 cm in width subcutaneous hematoma on their left hip. The Falls Investigation Worksheet revealed that it was unknown what the resident was attempting to do at the time of the fall and that the resident was standing up with their hand on the wall. The worksheet revealed interventions included the resident was provided care and then assisted to the dayroom next to the nursing station, and staff provided the resident with food and drink. Review of a Five-Day Follow-Up Report, dated 06/07/24, revealed interventions by the facility to prevent future injury included continuing occupational and physical therapy as appropriate and for the resident to be evaluated by the psychiatric physician's assistant at their next visit on 06/05/24. Review of R1's Resident Progress Notes, dated 07/09/24, revealed the resident was found on the floor by their bed, on their knees. The note revealed the resident stated they were trying to go to the bathroom. The note revealed no obvious injuries were noted. Review of a Falls Investigation Worksheet, dated 07/20/24, revealed R1 had an unwitnessed fall on 07/18/24 at 4:40 PM. The worksheet revealed the resident had no injuries. The worksheet revealed recommended interventions included daily checks of the bed and chair alarms for function and placement. During an interview on 07/26/24 at 1:59 PM, the Care Coordinator (CC) stated that she was responsible for updating the resident care plans. The CC stated that falls were discussed weekly with the interdisciplinary team (IDT). The CC stated the interventions that were on the Falls Investigation Worksheet were interventions that were immediately placed or recommendations for the team to discuss. The CC further stated she only updated the care plan when she was instructed to do so and for R1's falls on 05/25/24, 05/28/24, 06/02/24, 07/09/24, and 07/18/24. The CC concluded she was not instructed to update the care plan even though interventions were put in place. 2. Review of a Resident Face Sheet revealed the facility admitted R2 on 08/05/22, with diagnoses including but not limited to: altered mental status, muscle wasting and atrophy, dementia, and unsteadiness on feet. Review of a Quarterly MDS, with an ARD of 03/17/24, revealed a Staff Assessment for Mental Status (SAMS) determined R2 had short and long-term memory problems and severely impaired cognitive skills for daily decision making. The MDS revealed the resident was rarely/never understood and rarely/never understood others. Review of R2's Care Plan included a problem statement initiated on 08/18/22, that indicated the resident was at risk for falls as evidenced by cognitive impairment, muscle weakness/wasting, physical impairment, and unsteady gait. Interventions directed staff to apply bolsters to the resident's bed to define the perimeter of the bed (initiated 06/14/24), ensure the bed is low and a fall mat to floor (initiated 09/21/22), provide adequate lighting and ensure areas are free of clutter (initiated 08/19/22), provide prompt assistance (initiated 08/19/22), ensure the call light is within reach and answered promptly (initiated 08/19/22), encourage activities and socialization per guidelines (initiated 08/19/22), and encourage the resident to ask for assistance from staff (initiated 08/19/22). Review of an undated Falls Investigation Worksheet, revealed R2 had an unwitnessed fall on 01/06/24 at 6:30 AM. The worksheet revealed the resident had no injury. The worksheet revealed that another resident had attempted to assist R2 in ambulation and was reeducated on R2's inability to ambulate. Review of an undated Falls Investigation Worksheet revealed R2 had an unwitnessed fall on 07/24/24 at 5:15 PM. The worksheet revealed the resident had no injury. The worksheet revealed that the recommended interventions were to re-educate staff on making frequent rounds for safety. During an interview on 07/26/24 at 1:59 PM, the Care Coordinator (CC) stated that she was responsible for updating the resident care plans. The CC stated that falls were discussed weekly with the interdisciplinary team (IDT). The CC stated the interventions that were on the Falls Investigation Worksheet were interventions that were immediately placed or recommendations for the team to discuss. The CC further stated she only updated the care plan when she was instructed to do so and for R2's falls on 01/06/24 and 07/24/24, she was not instructed to update the care plan even though interventions were put in place. During an interview on 07/26/24 at 2:40 PM, Certified Nursing Assistant (CNA)5 stated that she worked with R2 frequently. CNA5 stated that R2 was not able to use the call light or understand others so interventions that encouraged the use of the call light and the resident to ask for assistance from staff were inappropriate. CNA5 stated that an intervention that was implemented by the nursing staff after the resident's last fall was to keep the resident in high visibility areas throughout the day to monitor the resident. CNA5 stated that the CNAs had access to the care plans but a lot of the interventions that were implemented were not on the care plan. CNA5 stated R2's fall interventions were passed down from the nurses and from the CNAs during their meetings at shift change. CNA5 stated there were a lot of agency staff that worked at the facility, and it was hard for the agency staff to keep up with the interventions if the interventions were not documented on the care plan. 3. Review of a Resident Face Sheet revealed the facility admitted R3 on 03/14/22, with diagnoses including but not limited to: cerebral infarction (stoke), dementia, muscle wasting and atrophy, history of falling, cognitive communication deficit, unsteadiness on feet, other abnormalities of gait and mobility, and muscle weakness. Review of a Quarterly MDS, with an ARD of 06/21/24, revealed the resident had a BIMS score of 0 out of 15, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had one fall with injury since their prior assessment. Review of R3's Care Plan included a problem statement initiated on 03/25/22, that indicated the resident was at risk for falls as evidenced by unsteady gait and muscle weakness. Interventions directed staff to remind the resident to lock their wheelchair when they are going to stand up for safety precautions (initiated 03/12/24), provide adequate lighting and areas are free of clutter (initiated 03/25/22), anticipate the resident's needs and provide prompt assistance (initiated 03/25/22), ensure the call light is within reach and answered promptly (initiated 03/25/22), entourage activities and socialization (initiated 03/25/22), encourage the resident to ask for assistance from staff (initiated 03/25/22), and have therapy evaluate and treat the resident per orders (initiated 03/25/22). Review of an undated Falls Investigation Worksheet revealed R3 had a witnessed fall on 06/12/24 at 7:15 PM. The worksheet revealed the resident had a skin tear to their left elbow. The worksheet revealed recommended interventions included for staff to try and keep the resident occupied at all times to help with the resident's wandering, the resident will continue wearing slip-resistant socks, the resident was educated on not standing alone, and therapy was consulted. During an interview on 07/26/24 at 1:59 PM, the Care Coordinator (CC) stated that she was responsible for updating the resident care plans. The CC stated that falls were discussed weekly with the interdisciplinary team (IDT). The CC stated the interventions that were on the Falls Investigation Worksheet were interventions that were immediately placed or recommendations for the team to discuss. The CC further stated she only updated the care plan when she was instructed to do so and for R3's fall on 06/12/24, she was not instructed to update the care plan even though interventions were put in place. During an interview on 07/26/24 at 2:51 PM, the Director of Nursing (DON) stated that care plans were updated by the CC. The DON stated fall interventions were discussed during their weekly meetings and the CC should be updating the care plan with the interventions that had been implemented. The DON stated she did not review the care plans to ensure interventions were updated. During an interview on 07/27/24 at 12:29 PM, the Administrator stated that the facility took a team approach to determining what fall interventions were appropriate. The Administrator stated falls were discussed weekly and appropriate interventions for those falls were determined by the IDT, and the CC was responsible for updating the care plan with those interventions.

Based on interview, record review, and facility policy review, the facility failed to ensure staff followed the facility policy for fall management and conducted neurological evaluations and post fall nursing documentation for 72 hours for 3 (Residents (R)1, R2, and R3) of 3 sampled residents reviewed for falls. Findings include: Review of a facility policy titled, Fall Management, revised on 05/05/23, revealed, 7. Neurological evaluations will be performed for a resident who sustains an unwitnessed fall, regardless of the resident's cognitive status at the time of the incident. The policy revealed, 9. Post fall nursing documentation for 72 hours, every shift will be completed to monitor the development of late effect or complications of the fall. Review of a facility policy titled, Neurological Checks (Neuro Checks), revised 05/05/23, revealed, The licensed nurse will perform neurological checks following any type of actual or suspected head injury of for changes in level of consciousness. The policy revealed, 1. Neurological checks are performed following an actual or suspected head injury or change in level of consciousness per physician ordered frequencyOR [sic]: A. Initially, then B. Every 15 minutes for 1 hour, then C. Every 30 minutes for 2 hours, then D. Every 1 hour for 2 hours, then E. Every shift for 72 hours. The policy revealed, 3. Documentation is completed on the Neurological Evaluation Flow Sheet, via the Glasgow Coma Scale. Follow directions on the form and reference for accurate scoring. 1. Review of a Resident Face Sheet revealed the facility admitted R1 on 11/03/23, with diagnoses including but not limited to: altered mental status, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, muscle weakness, lack of coordination, hemiplegia and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side, dementia, and cognitive communication deficit. Review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/05/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had two or more falls with no injury and one fall with an injury since the resident's prior assessment. Review of R1's Care Plan included a problem statement initiated on 11/14/23 that indicated the resident was at risk for falls as evidenced by physical impairment with left-sided weakness, unsteady gait, and muscle weakness. Review of R1's Active Orders revealed an order with a start date of 11/03/23 that indicated the resident was at risk for falls, elopement, and wandering. Review of R1's Resident Progress Notes, dated 05/25/24 at 6:03 PM, revealed the resident was heard yelling from their room for help. The note revealed the caregiver went to assist the resident and reported the resident was on the floor. The note revealed the resident had an unwitnessed fall. Review of a Neurological Evaluation Flow Sheet for R1's fall on 05/25/24, revealed that staff did not complete the pupils, reflexes, and movement sections of the flow sheet for 05/25/24 at 6:00 PM through 05/25/24 at 11:00 PM. The flow sheet revealed that staff did not complete the vital signs section of the flow sheet on the second and third shift on 05/26/24 and the first shift on 05/27/24. Review of R1's Resident Progress Notes revealed that staff did not document post-fall nursing documentation on every shift for 72 hours after the fall on 05/25/24. Review of a Falls Investigation Worksheet, dated 06/04/24, revealed the resident had an unwitnessed fall on 05/28/24 at 4:35 AM. Review of R1's medical record revealed no documented evidence that neurological evaluations were performed after the unwitnessed fall on 05/28/24. Review of R1's Resident Progress Notes revealed that staff did not document post-fall nursing documentation on every shift for 72 hours after the fall on 05/28/24. Review of a Falls Investigation Worksheet, dated 06/24/24, revealed the resident had an unwitnessed fall on 06/23/24 at 4:30 PM. Review of a Neurological Evaluation Flow Sheet for the resident's fall on 06/23/24 revealed that staff did not complete the vital signs section of the flow sheet on 06/23/24 at 5:30 PM and 06/23/23 at 10:30 PM. The flow sheet revealed that staff did not complete the movement section of the flow sheet on 06/23/24 at 10:30 PM through 06/24/24 at 5:30 AM. Further review revealed the last documented neurological evaluation was on 06/24/24 at 5:30 AM. There was no documentation to show that staff completed the neurological evaluations on every shift for 72 hours. Review of an undated Falls Investigation Worksheet revealed the resident had an unwitnessed fall on 06/27/24 at 4:45 AM. Review of R1's medical record revealed no documented evidence that neurological evaluations were performed after the unwitnessed fall on 06/27/24. Review of R1's Resident Progress Notes, dated 07/09/24, revealed the resident was found on the floor by their bed, on their knees. The note revealed the resident stated they were trying to go to the bathroom. The note revealed no obvious injuries were noted. Review of R1's Resident Progress Notes revealed that staff did not document post-fall nursing documentation on every shift for 72 hours after the fall on 07/09/24. 2. Review of a Resident Face Sheet revealed the facility admitted R2 on 08/05/22, with diagnoses including but not limited to: altered mental status, muscle wasting and atrophy, dementia, and unsteadiness on feet. Review of a Quarterly MDS, with an ARD of 03/17/24, revealed a Staff Assessment for Mental Status (SAMS) determined R2 had short and long-term memory problems and severely impaired cognitive skills for daily decision making. Review of R2's Care Plan included a problem statement initiated on 08/18/22, that indicated the resident was at risk for falls as evidenced by cognitive impairment, muscle weakness/wasting, physical impairment, and unsteady gait. Review of an undated Falls Investigation Worksheet revealed R2 had an unwitnessed fall on 01/06/24 at 6:30 AM. Review of R2's medical record revealed no documented evidence that neurological evaluations were performed after the unwitnessed fall on 01/06/24. Review of R2's Resident Progress Notes revealed that staff did not document post-fall nursing documentation on every shift for 72 hours after the fall on 01/06/24. Review of a Falls Investigation Worksheet, dated 06/14/24, revealed R2 had an unwitnessed fall on 06/14/24 at 12:25 AM. Review of R2's Resident Progress Notes, dated 06/14/24 at 12:56 AM, revealed the resident was sent to the emergency room . Review of R2's Resident Progress Notes, dated 06/14/24 at 6:31 AM, revealed the resident returned from the hospital. Review of R2's medical record revealed no documented evidence that neurological evaluations were performed after the resident had returned from the hospital on 06/14/24 at 6:31 AM. Review of R2's Resident Progress Notes revealed that staff did not document post-fall nursing documentation on every shift for 72 hours after the fall on 06/14/24. Review of an undated Falls Investigation Worksheet revealed R2 had an unwitnessed fall on 07/24/24 at 5:15 PM. Review of R2's medical record revealed no documented evidence that neurological evaluations were performed after the unwitnessed fall on 07/24/24. 3. Review of a Resident Face Sheet revealed the facility admitted R3 on 03/14/22, with diagnoses including but not limited to: cerebral infarction (stroke), dementia, muscle wasting and atrophy, history of falling, cognitive communication deficit, unsteadiness on feet, other abnormalities of gait and mobility, and muscle weakness. Review of a Quarterly MDS, with an ARD of 06/21/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had one fall with injury since their prior assessment. Review of R3's Care Plan included a problem statement initiated on 03/25/22, that indicated the resident was at risk for falls as evidence by unsteady gait and muscle weakness. Review of an undated Falls Investigation Worksheet revealed R3 had an unwitnessed fall on 03/12/24 at 1:30 PM. Review of R3's medical record revealed no documented evidence that neurological evaluations were performed after the unwitnessed fall on 03/12/24. Review of R3's Resident Progress Notes revealed that staff did not document post-fall nursing documentation on every shift for 72 hours after the fall on 03/12/24. During an interview on 07/26/24 at 12:53 PM, Unit Manager (UM)2 stated when a resident had a fall the nurses were to complete a fall packet, which included the Falls Investigation Worksheet. UM2 stated the nurses would then put the packet in a folder at the nurse's station for him to review. UM2 stated he made sure the fall was documented on the 24-hour nurses' report. UM2 stated he did not complete audits to ensure that the nurses completed the neurological evaluations after unwitnessed falls or post fall nursing documentation on every shift for 72 hours after the resident had a fall. UM2 stated he was new to the UM position; he started in the position in December 2023 and was still learning the process for falls. UM2 further stated he made sure the fall investigation was completed and the recommendations for interventions were put on the Falls Investigation Worksheet. He stated he believed the Director of Nursing (DON) was responsible for ensuring the nurses completed the neurological evaluations after unwitnessed falls and post-fall documentation on every shift for 72 hours after the resident had a fall. During an interview on 07/26/24 at 2:51 PM, the Assistant Director of Nursing (ADON) stated that the facility used a lot of agency nurses, and it was difficult to get the agency nurses to document as they should. The ADON stated that she received the fall packets that included the fall investigation but did not audit the fall packet to verify if the nurses had completed the neurological examinations after unwitnessed falls or post-fall nursing documentation on every shift for 72 hours after the resident had a fall. The ADON stated that it was the responsibility of the Unit Managers to ensure the nurses were completing those tasks. During an interview on 07/26/24 at 4:12 PM, UM1 stated that she started in her position as the UM three to four months ago. UM1 stated she was responsible for completing the Falls Investigation Worksheet. UM1 stated that she had noticed that the nurses were not completing the post-fall documentation on every shift for 72 hours after the resident had a fall and had been trying to remind the nurses to complete their documentation. UM1 stated that she did not complete record reviews to verify if the nurses had completed the neurological evaluations after unwitnessed falls. During an interview on 07/27/24 at 8:30 AM, the DON stated that after reviewing the falls of R1, R2, and R3 since December 2023, the DON determined nursing staff had not been completing neurological evaluations and post-fall documentation per the facility's policy. The DON stated that it was the responsibility of the UM to ensure that the tasks outlined in the Fall Management policy were completed. During an interview on 07/27/24 at 10:02 AM, the Nurse Practitioner (NP) stated she expected the nurses to complete neurological evaluations per the facility policy for unwitnessed falls. She stated it was important to monitor the resident after an unwitnessed fall since it was unknown if they hit their head; the neurological evaluations would help to monitor for latent injuries. During an interview on 07/27/24 at 12:29 PM, the Administrator stated it was her understanding that the Unit Managers were responsible for checking the completion of the tasks outlined in the Fall Management policy, and if they were not completed, the Unit Managers were to follow up with the nurse that failed to complete the task.

Based on interview, record review, and facility policy review, the facility failed to ensure staff conducted fall risk assessments and accurately coded fall risk assessments for 3 (Residents (R)1, R2, and R3) of 3 sampled residents reviewed for falls. Findings include: Review of a facility policy titled, Fall Management, revised on 05/05/23, revealed, 1. Qualified staff evaluates all patient/residents for fall risk at a minimum upon admission, quarterly, with a significant change, and post-fall. 2. The Fall Risk Evaluation assist in identifying the appropriate preventative interventions that will be recorded on the patient/resident's care plan. 1. Review of a Resident Face Sheet revealed the facility admitted R1 on 11/03/23, with diagnoses including but not limited to: altered mental status, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, muscle weakness, lack of coordination, hemiplegia and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side, dementia, and cognitive communication deficit. Review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/05/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident had severe cognitive impairment. Review of R1's Care Plan included a problem statement initiated on 11/14/23, that indicated the resident was at risk for falls as evidenced by physical impairment with left-sided weakness, unsteady gait, and muscle weakness. Review of a Falls Investigation Worksheet, dated 05/29/24, revealed R1 had an unwitnessed fall on 05/25/24 at 6:00 AM. The worksheet revealed the resident had no injuries. Review of a Falls Investigation Worksheet, dated 06/04/24, revealed R1 had an unwitnessed fall on 05/28/24 at 4:35 AM. The worksheet revealed the resident had no injuries. Review of an undated Falls Investigation Worksheet revealed R1 had a witnessed fall on 06/02/24 at 2:00 AM. The worksheet revealed the resident had no injuries. However, an Emergency Department Note, dated 06/02/24, revealed the resident had a 7.0 centimeter (cm) in length by 5.5 cm in width subcutaneous hematoma on their left hip. Review of a Falls Investigation Worksheet, dated 06/24/24, revealed R1 had an unwitnessed fall on 06/23/24 at 4:30 PM. The worksheet revealed the resident had no injuries. Review of an undated Falls Investigation Worksheet revealed R1 had an unwitnessed fall on 06/27/24 at 4:45 AM. The worksheet revealed the resident had no injuries. Review of R1's Resident Progress Notes, dated 07/09/24, revealed the resident was found on the floor by their bed, on their knees. The note revealed the resident stated they were trying to go to the bathroom. The note revealed no obvious injuries were noted. Review of a Falls Investigation Worksheet, dated 07/20/24, revealed R1 had an unwitnessed fall on 07/18/24 at 4:40 PM. The worksheet revealed the resident had no injuries. Review of R1's Observation History for the timeframe from 12/01/23 through 07/26/24, revealed that a fall risk evaluation was not documented as completed after the resident had sustained a fall on 05/25/24, 05/28/24, 06/02/24, 06/23/24, 06/27/24, 07/09/24, and 07/18/24. 2. Review of a Resident Face Sheet revealed the facility admitted R2 on 08/05/22, with diagnoses including but not limited to: altered mental status, muscle wasting and atrophy, dementia, and unsteadiness on feet. Review of a Quarterly MDS, with an ARD of 03/17/24, revealed a Staff Assessment for Mental Status (SAMS) determined R2 had short and long-term memory problems and severely impaired cognitive skills for daily decision making. Review of R2's Care Plan included a problem statement initiated on 08/18/22, that indicated the resident was at risk for falls as evidenced by cognitive impairment, muscle weakness/wasting, physical impairment, and unsteady gait. Review of an undated Falls Investigation Worksheet revealed R2 had an unwitnessed fall on 01/06/24 at 6:30 AM. The worksheet revealed the resident had no injury. Review of a Falls Investigation Worksheet, dated 06/14/24, revealed R2 had an unwitnessed fall on 06/14/24 at 12:25 AM. The worksheet revealed the resident had a hematoma to their right forehead. Review of an undated Falls Investigation Worksheet revealed R2 had an unwitnessed fall on 07/24/24 at 5:15 PM. The worksheet revealed the resident had no injury. Review of R2's Observation History for the timeframe from 12/01/23 through 07/26/24, revealed that a fall risk evaluation was not documented as completed after the resident had sustained falls on 01/06/24, 06/14/24, and 07/24/24. Additionally, there was no documentation that a fall risk evaluation had been completed quarterly. 3. Review of a Resident Face Sheet revealed the facility admitted R3 on 03/14/22 with diagnoses including but not limited to: cerebral infarction (stoke), dementia, muscle wasting and atrophy, history of falling, cognitive communication deficit, unsteadiness on feet, other abnormalities of gait and mobility, and muscle weakness. Review of a Quarterly MDS, with an ARD of 06/21/24, revealed the resident had a BIMS score of 0 out of 15, which indicated the resident had severe cognitive impairment. Review of R3's Care Plan included a problem statement initiated on 03/25/22, that indicated the resident was at risk for falls as evidenced by unsteady gait and muscle weakness. Review of an undated Falls Investigation Worksheet revealed R3 had an unwitnessed fall on 03/12/24 at 1:30 PM. The worksheet revealed the resident had a skin tear to their left elbow. Review of an undated Falls Investigation Worksheet revealed R3 had a witnessed fall on 06/12/24 at 7:15 PM. The worksheet revealed the resident had a skin tear to their left elbow. Review of R3's Observation History for the timeframe from 12/01/23 through 07/26/24, revealed that a fall risk evaluation was not documented as completed after the resident had sustained falls on 03/12/24 and 06/12/24. During an interview on 07/26/24 at 2:51 PM, the Assistant Director of Nursing (ADON) stated that the facility used a lot of agency nurses, and it was difficult to get the agency nurses to document as they should. The ADON stated that she received the fall packets, which included the fall investigation, but she did not audit the fall packet to verify if the nurses had completed the fall risk evaluations. The ADON stated that it was the responsibility of the unit managers (UM) to ensure the nurses were completing that task. During an interview on 07/26/24 at 4:08 PM, UM2 stated that he was not aware that the fall risk evaluations had to be completed after every fall. UM2 stated he did not know who was responsible for ensuring the fall risk evaluations were completed. During an interview on 07/26/24 at 4:12 PM, UM1 stated that she started in her position as the UM three to four months ago. UM1 stated she was responsible for completing the Falls Investigation Worksheet. UM1 stated that she did not complete record reviews to verify if the nurses had completed the fall risk evaluations. UM1 stated she was unaware that ensuring the fall risk evaluations were completed by the nurses was her responsibility. During an interview on 07/27/24 at 8:30 AM, the Director of Nursing (DON) stated that after reviewing the falls of R1, R2, and R3 since December 2023, the DON determined nursing staff had not been completing the fall risk evaluations per the facility's policy. The DON stated that it was the responsibility of the UM to ensure that the tasks outlined in the Fall Management policy were completed. During an interview on 07/27/24 at 12:29 PM, the Administrator stated it was her understanding that the UMs were responsible for checking the completion of the tasks outlined in the Fall Management policy and if they were not completed the UMs were to follow up with the nurse that failed to complete the task.

Based on interview, record review, and facility policy review, the facility failed to ensure staff notified the resident's physician and/or the resident's responsible party (RP) of a fall for 2 (Resident (R)1 and R3) of 3 sampled residents reviewed for falls. Findings include: Review of a facility policy titled, Fall Management, revised on 05/05/23, revealed, 8. The physician and family are promptly notified, and an incident report is completed. Review of a Resident Face Sheet revealed the facility admitted R1 on 11/03/23. According to the Resident Face Sheet, R1 was admitted to the facility with diagnoses including but not limited to: altered mental status, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, muscle weakness, lack of coordination, hemiplegia and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side, dementia, and cognitive communication deficit. Review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/05/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident had severe cognitive impairment. Review of R1's Care Plan included a problem statement initiated on 11/14/23 that indicated the resident was at risk for falls as evidenced by physical impairment with left-sided weakness, unsteady gait, and muscle weakness. Review of a Falls Investigation Worksheet, dated 05/29/24, revealed R1 had an unwitnessed fall on 05/25/24 at 6:00 AM. The worksheet revealed the resident took themselves to the restroom unassisted. The worksheet revealed the box indicating whether the resident's physician was notified was unchecked. Review of R1's Resident Progress Notes, dated 05/25/24 at 6:03 PM and written by Licensed Practical Nurse (LPN)3, revealed the resident was heard yelling from their room for help. A caregiver went to assist and reported the resident was on the floor. The note revealed the resident stated they were attempting to take themselves to the restroom. The note revealed the fall was unwitnessed, vital signs were taken, and the incident was reported to the RP. The note did not reveal that the resident's physician was notified of the fall. During an interview on 07/27/24 at 9:24 AM, LPN3 stated the time of the fall on the Falls Investigation Worksheet for the fall on 05/25/24 was incorrect and the fall occurred during her shift at 6:00 PM. LPN3 stated that she documented the fall in R1's progress notes. LPN3 stated she could not remember if she notified the resident's physician and that she would have documented it in the resident's progress note. Review of a Falls Investigation Worksheet, dated 06/04/24, revealed R1 had an unwitnessed fall on 05/28/24 at 4:35 AM. The worksheet revealed the box indicating whether the resident's physician was notified was unchecked. Review of R1's Resident Progress Notes, dated 05/28/24 at 5:49 AM, revealed the resident was yelling out help me. The note revealed the nurse discovered the resident on the floor in the entry way of their room. The note revealed the on-call nurse, the Director of Nursing (DON), and the family were notified. The note did not reveal that the resident's physician was notified of the fall. Review of an undated Falls Investigation Worksheet revealed R1 had a witnessed fall on 06/02/24 at 2:00 AM. The worksheet revealed the box indicating whether the resident's physician and RP were notified was unchecked. Review of R1's Resident Progress Notes dated 06/02/24 revealed no documentation by staff to indicate that the resident's physician and RP were notified of the resident's fall on 06/02/24 at 2:00 AM. R1's Resident Progress Notes dated 06/02/24 at 7:30 PM, revealed that the resident had a large purple/black discoloration on their left hip. The resident complained of pain and the family wanted the resident sent to the emergency room for an x-ray. The note revealed the on-call nurse and medical doctor were notified, and emergency medical services were called to transport the resident. During an interview on 07/26/24 at 2:51 PM, the DON stated that she reviewed the Falls Investigation Worksheet and the Resident Progress Notes for R1 for the resident's falls on 05/25/24, 05/28/24, and 06/02/24. The DON stated the staff failed to notify the resident's physician and/or RP of the resident's falls. 2. Review of a Resident Face Sheet revealed the facility admitted R3 on 03/14/22, with diagnoses including but not limited to: cerebral infarction (stoke), dementia, muscle wasting and atrophy, history of falling, cognitive communication deficit, unsteadiness on feet, other abnormalities of gait and mobility, and muscle weakness. Review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/21/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident had severe cognitive impairment. Review of R3's Care Plan included a problem statement initiated on 03/25/22, that indicated the resident was at risk for falls as evidenced by unsteady gait and muscle weakness. Review of an undated Falls Investigation Worksheet revealed R3 had an unwitnessed fall on 06/30/24 at 4:30 AM. The worksheet revealed the box indicating whether the resident's physician and RP were notified was unchecked. Review of R3's Resident Progress Notes dated 06/30/24 revealed no documentation by staff to indicate that the resident's physician and RP were notified of the resident's fall on 06/30/24 at 4:30 AM. The Resident Progress Notes dated 06/30/24 at 10:05 PM, revealed the resident was sent to the emergency room upon the start of the shift due to a verbalized fall from the off-going nurse and the resident's RP wanted the resident sent out to the hospital for an evaluation due to the resident complaining of back pain. Review of a Complaint/Grievance Roll-Up report for the timeframe from 07/01/24 through 07/26/24 revealed that on 06/30/24, R3's RP reported a grievance related to fall notification. During an interview on 07/27/24 at 8:02 AM, the Administrator stated the nurse that worked on 06/30/24 at the time of R3's fall was Registered Nurse (RN)4. The DON stated that RN4 did not notify the resident's representative or the resident's physician of the resident's fall. The Administrator stated RN4 said she had passed the information along to the first shift nurse to report. The Administrator stated she spoke with the nurse that received the report from RN4 and confirmed that the nurse who received the report did not report the fall to the resident's RP or physician. During a telephone interview on 07/27/24 at 10:02 AM, the Nurse Practitioner (NP) stated that they relied on the nurses to notify the provider when a resident had a fall. The NP stated she worked at the facility every Monday through Friday and was on call. The NP further stated on the weekends and during the times that she was off there was an on-call provider service available for the nurses to call and report falls to a provider. During a telephone interview on 07/27/24 at 10:30 AM, the Medical Director (MD) stated that it was his expectation that staff notify the provider when a resident had a fall. The MD stated that there was a NP at the facility during the week and there was a 24-hour on call provider service that staff could report falls to. During a follow-up interview on 07/27/24 at 12:29 PM, the Administrator stated the nurse that was on duty during the time of the resident's fall was responsible for notifying the resident's physician and RP. The Administrator stated it was her expectation that the resident's RP and physician were notified after each fall.

Based on interview, record review, and facility policy review, the facility failed to ensure staff accurately coded a Minimum Data Set (MDS) for 1 (Resident (R)2) of 3 sampled residents reviewed for falls. Findings include: Review of a facility policy titled, Minimum Data Set (MDS), revised on 09/28/23, revealed, A licensed nurse will conduct or coordinate each assessment with the interdisciplinary team. An MDS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident, using the RAI [resident assessment instrument] process. Facility staff complete a comprehensive assessment of each resident's need, strengths, goals, life history, and preferences, and offer guidance for further assessment once problems have been identified. The policy revealed, 1. Review the resident's medical record. This review may include pre-admission activities. Identify resident's status, care and services rendered during the Observation Period for the current assessment. Review is to include, but not be limited to pre-admission, admission, and transfer notes; current plan of care, physicians'' orders, progress notes, history and physical; nursing, dietary, activity, social service, and therapy notes and assessments; monthly summaries lab and x-ray reports, consultations, medication administration records, treatment administration records, and resident, staff and family interviews. The policy revealed, 9. Each assessment must represent an accurate picture of the resident's status during the observation period of the MDS. Review of a Resident Face Sheet revealed the facility admitted R2 on 08/05/22, with diagnoses including but not limited to: altered mental status, muscle wasting and atrophy, dementia, and unsteadiness on feet. Review of an undated Falls Investigation Worksheet revealed R2 had an unwitnessed fall on 01/06/24 at 6:30 AM. Review of R2's Resident Progress Notes, dated 01/06/24 at 6:57 AM, revealed the resident was observed on the floor beside their bed with no injury present. Review of a quarterly MDS, with an Assessment Reference Date (ARD) of 03/17/24, revealed the MDS was not coded to reflect the resident had sustained a fall with no injury since their prior assessment. During an interview on 07/26/24 at 1:59 PM, the Care Coordinator (CC) stated she reviewed R2's medical record and the resident fell on [DATE] and it should have been documented on the resident's quarterly MDS with the ARD of 03/17/24. The CC stated that when coding the falls section of the quarterly MDS with the ARD of 03/17/24, she did not review R2's falls investigation worksheets, but she did review the progress notes and missed that R2 had a fall on 01/06/24. During an interview on 07/27/24 at 12:29 PM, the Administrator stated that it was her expectation that MDS assessments were accurate.

Based in record review, interviews, and review of facility policy, the facility failed to ensure Residents (R)1 and R2 were free from verbal abuse for 2 of 2 residents reviewed. Findings include: Review of the facility's undated policy titled Abuse, Neglect, Exploitation, or Mistreatment revealed, The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse . 1. Definitions as defined by CMS section 483.5: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, depression, and Type 2 diabetes mellitus without complications. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R1 has moderate cognitive impairment. Review of R1's Social Services Progress Note dated 02/16/2024 at 1:37 PM, revealed, Spoke with resident and he states that he is ok and that everything is fine. He does not show any signs of distress and he is happy with having his door open. Review of R1's Social Services Progress Note dated 02/19/24 at 4:36 PM, revealed, SSD spoke with resident on today and there are no signs of any issues with psychosocial wellbeing. Resident has been in good spirits and was involved in daily routine. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE] with diagnoses including but not limited to: dementia, chronic obstructive pulmonary disease with (acute) exacerbation, vascular dementia, and major depressive disorder. Review of R2's Quarterly MDS with an ARD of 01/23/24 revealed a BIMS score of 15 out of 15, indicating R2 is cognitively intact. Review of R2's Social Services Progress Note dated 02/16/24 at 1:04 PM, revealed, [Recorded as Late Entry on 02/19/2024 01:06 PM] SSD spoke with resident and he showed no signs of distress but he stated that something better be done with the nurse. He does not appreciate being hollered at for no reason. Review of R2's Social Services Progress Note dated 02/19/24 at 4:40 PM, revealed, SSD spoke with resident and he was asking questions about the outcome of the incident and he stated that he didn't deserve that type of abuse from anyone. Resident was upset about the situation and continued to talk about it through out the day. SSD asked would he like to discuss his feelings with psych but he declined. R1 was not available for interview, due to hospital admission on 04/01/24. During an interview on 04/08/24 at 10:25 AM, R2 revealed that staff had talked to him mean and offensively. R2 stated The incident happened months ago and it should have been taken care of when it happened and that's all I am going to say about that. During an interview on 04/08/24 at 12:41 PM, Certified Nursing Assistant (CNA)2 revealed that she was in the B wing day room cleaning and picking up breakfast trays when she heard License Practical Nurse (LPN)1 say, keep this f****** door shut. After hearing what LPN1 said she left the day room and went down the B wing hall and she saw the unit manager coming up the hall from the opposite direction. CNA2 stated that R1 was COVID positive and the only resident residing in that room at the time and the nurse had been telling him to keep the door closed. CNA2 stated that LPN1 was usually good with everyone, and she was not sure of what happened that day. CNA2 explained that she did not report the incident because the unit manager was already in the hallway. During an interview on 04/08/24 at 12:59 PM, CNA1 revealed that she was helping gather the breakfast trays on hall B when she saw LPN1 at R1's doorway and heard LPN1 yell when I tell you to keep the f****** door closed, I mean keep the f****** door closed. LPN1 then walked away and went to R2's room and then I heard him say something about respecting him. CNA1 confirmed that R1 was in the room alone. CNA1 stated that Registered Nurse (RN)1 and the staffing development coordinator were in the area as well. During an interview on 04/08/24 at 1:23 PM, LPN1 revealed that R1 was Covid positive but refused to keep his door closed. LPN1 explained that R1 expressed to him that he didn't like to be in his room or have his door closed and he expressed to the resident he understood but explained to him what the policy stated. LPN1 stated R1 needed to stay in his room to keep others safe. LPN1 further stated that he told a unit manager what R1 had expressed to him related to being in his room with the door shut. LPN1 stated R1 came at him and LPN1 stated to him, I will keep closing the f****** door. LPN1 stated, I did speak inappropriately, and I take ownership for what I said. LPN1 then revealed that R2 sent a message to him by a CNA saying, tell the nurse to bring me my g** d*** medicine. LPN 1 revealed that when he entered R2's room, he stated to R2, You are not going to talk to me like I am a d*** child. LPN1 stated I did speak inappropriately, I did say what I said to each of them and I take ownership for what I said. During an interview on 04/08/24 at 2:49 PM, the Administrator revealed that she was notified by the staffing development coordinator as soon as I entered the door. She informed me that LPN1 had flipped out. The staffing development coordinator informed me that they found LPN1 in R2's room and she and RN1 removed him from the room. The Administrator stated they interviewed LPN1 and he stated that he hadn't been sleeping well and he was exhausted, and his nerves were on edge. LPN1 admitted that he should not have reacted the way he did. The Administrator suspended him immediately. He only came back to the building when we called him in to terminate him. The Administrator stated that it's her expectation that all staff treat the residents with dignity, be courteous, be polite and regardless of what the resident is saying and doing to them to make sure the resident is safe. The Administrator states that she has zero-tolerance for abuse and above all else staff is to keep the residents safe.

Based on record review and interview, the facility failed to address weight loss in a timely manner for 1 of 5 sampled residents reviewed for nutrition. Resident #57 sustained continued significant weight loss without evidence of consistent monitoring or new or changes in existing interventions after 10/15/18. The findings included: The facility admitted Resident #57 on 8/7/18 with [DIAGNOSES REDACTED]. Review of weights on 12/11/18 at 11:51 AM revealed that the resident weighed 186 pounds on 8/7/18 (admission). Subsequent weights were recorded as: 9/3=169 (9.1% loss), 10/1=164 (11.8% loss), 11/1=157 (15.6% loss), and 12/4=152 (37 pounds or 18.5% loss since admission). Review of physician's orders [REDACTED]. Review of meal percentage intake for 12/2018 provided by the Assistant Director of Nurses on 12/13/18 revealed that from 12/1/18 through 12/12/18, meal intake was only documented 17 of 36 times-less than 50% of the time. Review of Dietary Notes on 12/12/18 at 2:46 PM revealed that the Nurse Practitioner (NP) was notified of poor intake and weight loss on 10/11/18 via a Nutritional Care Communication form. The NP's response was Labs and [MEDICATION NAME] ([MEDICATION NAME]) ordered. Review of the Medication Administration Records (MARs) on 12/12/18 at 2:36 PM revealed that the percentage of supplement taken had not been documented and the [MEDICATION NAME] had never been started. Continued record review revealed there was no evidence of follow-up by nursing to clarify the NP's statement/order and no further interventions were put in place after 10/15/18 to address continued weight loss. Review of the Care Plan for nutrition on 12/12/18 at 10:06 PM revealed that, although noted as reviewed/revised on 11/12/18 by Registered Nurse #4, there were no changes in approaches since 8/21/18. During an interview on 12/12/18 at 3:15 PM, the MDS (Minimum Data Set) Coordinator verified s/he could not tell how much of the supplement the resident was taking as it was not documented on the MAR. S/he verified that the [MEDICATION NAME] had not been started and stated, They should have followed up when the (Nutritional Care Communication) form was placed in the chart. The MDS Coordinator stated that dietary was responsible for updating the Care Plan related to weight loss. S/he reviewed the Care Plan and confirmed that the Care Plan had been reviewed on 11/12/18, but no new approaches had been added since 8/21/18. During an interview on 12/12/18 at 3:45 PM, the Director of Nurses (DON) verified the NP's response. S/he reviewed Nurses Notes and Physician's Progress Notes and confirmed there was no evidence of follow-up in the record. The DON also verified that no further interventions or changes had been put in place to address the continued weight loss since 10/15/18.

On the days of the complaint and extended survey, based on record reviews, interviews, and review of the policies provided by the facility entitled "Physician Communication/Change in Condition" and "Physician Orders", the facility nursing staff failed to adhere to accepted professional standards of practice for two of four sampled residents reviewed. Resident #1 developed four unstageable wounds to her/his feet after the facility nursing staff failed to schedule a follow up appointment timely with the orthopedist. There was no documentation of a thorough nursing assessment of the resident's splinted legs and toes to show the facility was taking measures to prevent possible complications related to the splint use. Resident #1 was observed on two days of the survey with a possible deep tissue injury (DTI) to her/his right heel with no documentation in the record and no documentation that the physician and family of the resident had been notified. The Physician was not notified timely of Resident #1's admission and medication orders on admission. Resident #1 had hospital discharge orders for medications that were not transcribed accurately on admission, which resulted in the omission of two ordered medications from 4/19/13 until 7/10/13. The monthly cumulative Physician Orders for May 2013 were not transcribed accurately. The Physician and family of Resident #1 were not notified and/or not notified timely of a change in condition on 6/19/13. The nursing staff failed to accurately transcribe and clarify orders for medications for Resident #3 on re-admission. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set Assessment with an Assessment Reference Date of 4/26/13 revealed the resident had a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment at the time of the assessment. According to the assessment, the resident was at risk for the development of pressure ulcers, but had none. There were no venous or arterial ulcers documented; only a surgical wound. Review of the facility self reported incident (Five Day Follow-up Report) received by the State Certification Agency on 7/8/13 revealed, "...Resident admitted [DATE] with non-removable bilateral ace splint (soft casts). Discharge instructions for follow-up appointment with Dr. --. Admitting nurse received packet of admitting information via fax from hospital at 3:43 pm and processed accordingly making follow-up appointment as indicated with Dr. -- whom s/he thought was the orthopedist. At 3:53 pm hospital re-faxed original packet along with Discharge Summary containing instructions for follow up appointment with Dr. -- (orthopedist). Admitting nurse failed to note the ordered follow-up appointment with Dr.-- (orthopedist) in the Discharge Summary. On 6/27/13 resident inquired as to when (her/his) appointment was to get (her/his) casts removed. The calendar was reviewed with no appointment logged. A review of the chart reflected follow-up appointment had not been made. An appointment was obtained for 7/2/13 during which casts were removed with four unstageable wounds observed". According to the follow-up report and the attached Nurse/Physician Communication record, the resident had wounds on the right outer foot measuring 2 x 1.8 x 2 centimeters (cm), one on the right outer toe measuring 1.7 x 2.3 (cm), one on the left heel measuring 3 x 4.5 (cm), and one on the left outer aspect of the foot measuring 1.6 x 1 cm (with) deep tissue damage. Further review of the information included in the facility self report revealed a Physician's Progress Note dated 5/29/13 which stated under "Assessment: ...Bilateral ankle fractures. Discussed with care team to follow up with ortho...". Review of the Hospital's Transfer Summary dated 4/19/13 revealed Resident #1 had bilateral ace splints to bilateral legs. Under "Follow-up Appt" it said to "See discharge summary". Review of the 4/19/13 Discharge Summary revealed the resident suffered bilateral ankle fractures and was to continue in splints, be nonweightbearing in both lower extremities, use ice and elevate, and follow up with (orthopedist) Dr. -- in one weeks time. From the date/time stamp on the top of this Discharge Summary, it appeared as if it had been faxed 4/19/13 at 3:53 PM. During an interview on 7/10/13 at 3:00 PM, Licensed Practical Nurse (LPN) #1 verified s/he had been the admitting nurse for the resident on 4/19/13. LPN #1 stated s/he had been with the facility for 8 years. When asked what had happened relative to the above incident reported to DHEC, LPN #1 stated that s/he had received the discharge information from the hospital on [DATE] at about 3:45 PM. The nurse stated that another fax with additional information that included Resident #1's appointment with the orthopedist had come in after the initial fax from the hospital; and that s/he had only received the discharge information contained in the first packet of faxed information. According to LPN #1, s/he did not know which fax machine the 2nd packet of information came to, who may have removed this information from the fax, or where they may have placed it after removing it. LPN #1 stated that the discharge information s/he had received included a follow-up appointment with Dr.--, whom s/he thought was the orthopedist, but was not. Review of a Patient Discharge Summary for the resident dated 4/19/13 revealed information that the resident had a follow-up appointment with (neurology) Dr. -- in 2-3 weeks, scheduled for 5/6/13 at 10:45 AM. The date/time stamp for this fax was 4/19/13 at 3:44 PM. Review of the appointment calendar with LPN #1 revealed s/he had documented an appointment with (neurology) Dr. -- on 5/6/13. Review for the months of April, May, and June 2013 revealed there was no information on the appointment calendar relative to an appointment with the orthopedist. The surveyor asked LPN #1 to review the 5/29/13 Physician's Progress Note that indicated that the Physician had discussed with the care team to follow up with orthopedics on the ankle fractures. After reviewing the note and the Physician's Telephone Orders for that date, LPN #1 stated that s/he had rounded with the Physician that day. S/he stated that the Physician may have told her/him, but that s/he did not remember having been told this information. During a phone interview on 7/11/13 at 9:15 AM, Resident #1's Orthopedist was not available for interview. The Orthopedist's surgical technician (tech) stated s/he could speak for the doctor. The Surgical Technician stated that the resident initially had a short leg splint placed in the hospital that had plaster on the back with 2 struts on the side made of plaster. The lower extremities had been wrapped with a soft dressing with padding, then the plaster applied, then kling, with an ace wrap covering. According to the surgical tech, the resident should have followed up in one weeks time. At one week s/he would have come in for a wound check, where the splint would have been removed and the incision site checked. The same type of splint would have been placed on the lower extremities again, and the resident would return one week after that for the sutures to be removed. At that time, short leg bilateral casts made of fiberglass would have been placed, and the resident would have been instructed to follow up in 4 weeks. When asked if the Orthopedist believed the resident had developed the wounds from the splint, the surgical tech responded "yes". The tech stated that the resident did develop pressure sores on the heel from the splint. When asked if the Orthopedist felt that the resident developed all 4 wounds related to the delay in follow-up, the surgical tech stated that the doctor felt the resident developed all 4 wounds because she missed the follow-up. The surgical tech verified that the Resident's first follow up with the orthopedist after hospitalization occurred 7/2/13. Review on 7/12/13 at 9:47 AM of the orthopedist's typed Progress Note from the office visit 7/2/13 revealed Resident #1 was 12 weeks out from the fixation of both ankles upon return to the orthopedist for her/his first visit. According to the note, "A discussion was held with the nursing director at (nursing facility). After removal of the splints, the patient has a left heel pressure sore and lateral foot pressure sore on both feet at the level of the fifth metatarsal and neck head... Plan: at this time is to leave the splints off. Debridement is done on the right lateral side of the foot. Eschar is removed. The left lateral foot eschar is also minimally debrided. The heel ulceration is not debrided at this point. We will have (her/him) return to the office in one week. We will continue debridements of all three pressure sores...". During a phone interview on 7/11/13 at 10:25 AM, the resident's facility Physician was informed of the surveyor's concerns related to the wounds that developed as a result of the missed appointment. The Physician stated there had been concerns that s/he and others have had with the accuracy of transfer information and orders from the hospital to all nursing homes (not just this one). The Physician stated this had been discussed with the hospital in the past. When asked about his/her 5/29/13 Progress Note that stated s/he had discussed with the Care Team to follow up with orthopedics; the Physician stated s/he most likely spoke with the nurse who rounded with him/her or the resident's day nurse. The Physician could not recall specifically who s/he had spoken with. When asked if anyone at the facility reviewed his/her Progress Notes, the Physician thought someone did, but didn't know who or to what extent they were reviewed before they were placed on the chart. Observations on 7/10/13 at 9:20 AM with the Unit Manager, Registered Nurse (RN) #1, revealed Resident #1 lying on a specialty air mattress with her/his feet elevated on a pillow and a bed cradle holding the sheet in place above the feet. There was a kling dressing wrapped around the top area of the right foot towards the toes dated 7/9/13. This dressing was not removed at the time of the observation. There were no wounds or eschar on the right heel, just an area of darker skin which looked like a possible deep tissue injury. The resident's left foot had eschar on the outer bottom area of the foot below the pinky toe along with a large amount of black eschar on the left heel. Both feet were dry and scaly with patches of skin. Review earlier on 7/10/13 at 8:50 AM of the resident's July 2013 Wound Treatment and Progress Record revealed no documentation related to a possible right heel deep tissue injury. During an interview on 7/10/13 at 11:00 AM, RN #1 stated that s/he had planned to measure the wounds that day. The last measurements had been done 7/2/13, when the wounds had been discovered. During a second wound observation on 7/10/13 at 11:15 AM, RN #1 removed the dressing to the resident's right foot. Eschar was noted to the outer aspect of the right great toe and also to an area below the pinky toe on the bottom surface of the right foot. The surveyor observed a reddish purple circular area to the right heel that appeared to be a possible deep tissue injury. The surveyor asked the nurse about the resident's right heel. The nurse stated it looked like the heel was red. Review of the Wound Treatment and Progress Record on 7/11/13 revealed entries dated 7/10/13 that documented an unstageable wound to the right outer great toe (eschar) measuring 1.8 x 1.2 cm, an unstageable wound to the right outer foot (eschar) measuring 2.5 x 1.6 cm with surrounding tissue suggestive of deep tissue damage, an unstageable wound to the left bottom foot (eschar) measuring 1.5 x 1 cm with surrounding tissue suggestive of deep tissue damage, and an unstageable wound to the left heel (eschar) measuring 4.7 x 4.5 cm with surrounding tissue suggestive of deep tissue injury. There was no documentation related to a possible deep tissue injury to the right heel. Observation on 7/11/13 at 2:55 PM with RN #1 revealed Resident #1 sitting up in her/his wheelchair. Observation of the right heel revealed a dark area with redness in the center and dark and light brown undertones surrounding the reddened area. RN #1 agreed the area looked like a deep tissue injury (DTI). Review of the resident's wound treatment and weekly skin documentation with LPN #2 after the observation revealed no documentation related to the possible DTI of the right heel. There was no documentation the Physician or family was notified of the concern. RN #1 stated that s/he had been told that the resident's right heel was like that when the resident returned from the orthopedist on 7/2/13 after having the splints removed. LPN #2 agreed with RN #1 and stated that s/he thought there had been some tissue damage noted to the right heel when the resident returned from the appointment. According to RN #1, the resident's Physician looked at Resident #1's feet after the wounds were discovered. Review of the Physician's Progress Note dated 7/3/13 revealed documentation of concerns related to the left heel and minor irritation to the right foot on the extensor surface of the toe; but nothing related to concerns with the right heel. According to the note, the pulses were diminished in both feet. The Physician suspected small vessel disease and possibly even some large vessel disease and would obtain vascular studies. Review of the 7/8/13 Bilateral lower extremities arterial study revealed abnormally diminished flow bilaterally and absence of flow in the posterior tibial artery on the left. Review of Resident #1's skin documentation on 7/10/13 at 12:15 PM revealed a CNA (Certified Nursing Assistant) Daily Skin Inspection Record for April 2013 which documented "Told nurse (LPN #2) (Resident #1) peeled nail +skin from toe area. (Initials CNA) R(ight) area..." During an interview on 7/11/13 at 3:30 PM, LPN #2 stated that s/he had looked at the resident's toe at the time it had been reported and it did not look anything like what was described by the CNA. According to LPN #2, there was just flaky skin at the toe where the resident had tried to scratch - with the nail intact. Review of the Nurse's notes with LPN #2 revealed no documentation related to this assessment. There was no indication from the CNA documentation as to the day in April the skin concern was identified and LPN #2 could not recall. When asked if the nursing staff had done any type of monitoring or checks of Resident #1's feet (like pulse checks for circulation), LPN #2 stated none that s/he knew of. Review of the July 2013 treatment record with LPN #2 revealed it had been documented that the resident was nonweight bearing and had bilateral splints; but there was nothing documented related to any pulse or circulation checks for the resident's feet. Review of the record revealed no nursing assessments of the resident's feet related to the splint use. When asked if anything had been done related to the resident's dry skin on the feet, LPN #2 stated that they were going to see if the resident could use the whirlpool and also if a moisturizer could be applied. Review on 7/12/13 of Weekly Skin Documentation for Resident #1 revealed nursing staff had not documented body audit findings for assessments due 6/11/13 and 6/25/13. Review of the Treatments Flowsheet revealed an entry for a body audit once weekly. The box for the nurse's initials for 6/11/13 was blank which indicated the body audit had not been done. The box for 6/25/13 had been initialed by the nurse which indicated the body audit had been completed. When requested by the surveyor, the facility was unable to locate the body audit assessments for these two dates. Review of the Care Plan for Resident #1 revealed an entry dated 5/1/13 that stated, "Resident is At Risk for Skin Breakdown related to: Incontinence... Bedfast or w/c (wheelchair) bound, Impaired Bed Mobility... Fragile Skin-[MEDICAL TREATMENT] shunt.. Cognitive Impairment... Other-hard non-removable splints to bil(ateral) ankles". Included under "Approaches" was documented to "Assess skin weekly and record findings". Record review on 7/10/13 at 1:50 PM of the hospital's Discharge Medication Reconciliation Report dated 4/19/13 revealed a list of Home Medications and Hospital Medications with notations to continue the medication or not to continue the medication. The medications that were to be continued for home use were compared to the facility's admission orders [REDACTED]. Upon review, it was noted that there were no facility admission orders to be continued medications" that were to be given by mouth (PO). These medications included [MEDICATION NAME] 10 mg (milligrams) daily, Aspirin 81 mg daily, [MEDICATION NAME] 1,000 mg daily, [MEDICATION NAME] 10 mg three times daily, [MEDICATION NAME]-[MEDICATION NAME] 5-500 mg at bedtime, [MEDICATION NAME] 12.5 mg twice daily, [MEDICATION NAME] 75 mg daily, [MEDICATION NAME] 40 mg twice daily, [MEDICATION NAME] 30 mg daily, and [MEDICATION NAME] 50 mg every 6 hours. A comparison of the facility's admission orders continue for home use". These two medications, [MEDICATION NAME] 10 mg and Aspirin 81 mg, both scheduled for once daily, had not been transcribed onto the facility's Medication Flowsheets although all the other "to be continued medications" had been added. Review of the record revealed no documentation to indicate that these two medications should have been stopped. Review of the Medication Flowsheets for April, May, June, and July 2013 revealed Resident #1 had not received the [MEDICATION NAME] and Aspirin from 4/20/13 through 7/10/13. Further review on 7/10/13 revealed there were no MEDICATION ORDERS FOR [REDACTED]. Signature boxes at the bottom of the orders indicated the Physician had signed the the Physician Order Report on 5/2/13, and the nurse had noted the above orders on 5/14/13. There was no signature in the box for either the RN or Pharmacy review. Record review on 7/10/13 at 2:58 PM revealed there were no Physician Order Reports for June or July 2013 in the chart. These were requested and a printed copy, not signed by the Physician, were reviewed. Continued review later on 7/10/13 revealed there was a 5/28/13 Neurology Consult note that was not on the chart. This was requested and on June 11, 2013, the neurology note and June 2013 signed Physician Order Report was provided for review. The July 2013 signed Physician Order Report was not provided for review. An interview was conducted with LPN #1 on 7/10/13 from approximately 3:00 PM to 4:15 PM. LPN #1 was asked how s/he determined which medications should have been continued for Resident #1 upon admission to the facility. LPN #1 stated that usually the Discharge Medication Reconciliation Report is reviewed and the Home medications are continued. However, with this admission, s/he had not received all the discharge information since the hospital had faxed one packet of information for the resident on 4/19/13 at 3:43 PM and then (possibly because there were missing pages) another packet on 4/19/13 at 3:53 PM. The surveyor and LPN #1 reviewed all the facility's documentation related to what had been faxed to the facility by the hospital along with the Prescriptions located in the clinical record. During the review, the medications listed on the Discharge Medication Reconciliation Report, the Prescriptions, and the medications listed on the "Patient Discharge Summary for (Resident #1)" were compared. The medications listed on the "Patient Discharge Summary for Resident #1" matched the "to be continued medications" on the Discharge Medication Reconciliation Report. There were prescriptions for all the medications listed except for the [MEDICATION NAME] and Aspirin. LPN #1 verified there were no prescriptions for these two medications and stated that since they had been listed on the discharge medication list as "to be continued", they still should have been continued on admission. LPN #1 believed that s/he had reviewed and signed the hospital's Discharge Medication Reconciliation Report indicating these were the ordered medications for the resident and had faxed this to the pharmacy along with the resident's prescriptions to be filled. According to LPN #1, the admission medications are written onto a Physician's Telephone Order. When the surveyor asked to see these orders, LPN #1 showed the surveyor some admission telephone orders, however, there were no telephone orders for the oral medications that had been listed as to be continued upon discharge from the hospital. LPN #1 stated that since the admission was on a Friday afternoon, the following Monday, Medical Records would have typed up an Admission Physician Order Report according to any telephone orders. LPN #1 verified there were no oral medications listed on the 4/19/13 through 4/30/13 typed Physician Order Report. LPN #1 verified her/his signature at the bottom of the page indicating s/he had noted those orders on 4/23/13. After reviewing the April 2013 Medication Flowsheets, LPN #1 verified there were no entries for the [MEDICATION NAME] and Aspirin. LPN #1 stated these medications should have been on the sheets and thought that maybe a sheet was missing. After reviewing the May 2013 Physician Order Report, LPN #1 verified the medication orders had not been transcribed accurately and did not include some of the oral medications the resident had received as documented on the May 2013 Medication Flowsheets. LPN #1 stated that s/he had not called the Physician to verify any medication orders prior to faxing them to the pharmacy to be filled. LPN #1 stated that s/he usually called the doctor to let him/her know that the resident was back (had been readmitted ). However, after reviewing the Nurse's Notes and finding no documentation of a call, LPN #1 stated that s/he had faxed the doctor a Nurse/Physician Communication Record and the Discharge Summary Medication list on 4/19/13 at approximately 6:00 PM. This was to inform him/her of Resident #1's admission. LPN #1 agreed that due to the lateness of the hour, the Physician probably did not receive the fax until the following Monday. Review of the Nurse/Physician Communication Record revealed a box for "Major Meds:" in which had been documented "[MEDICATION NAME]". There were no other medications listed. Dr.-- had responded by fax with a notation to "Follow transfer orders. To see Wed(nesday)". The date/time stamp on the fax indicated the Physician had faxed the response back to the facility on [DATE] at 3:30 PM. When asked about any training received on taking off orders and doing admissions, LPN #1 stated that s/he had been instructed verbally by other nurses on how to do them but had never seen anything in writing about how to do an admission prior to this incident having occurred. According to LPN #1, the first time s/he had seen the Admission checklist was this past Wednesday when s/he had been inserviced on the Admission process. During an interview on 7/12/13 at 10:25 AM, the Administrator stated that LPN #1 had received training in orientation related to admission orders [REDACTED]. During a phone interview on 7/11/13 at 10:25 AM, Resident #1's Physician was informed of the surveyor's concerns related to Resident #1's admission medications. When asked which medications should have been continued on admission, the Physician was unsure since s/he did not have the record available for review at the time of the interview. According to the Physician, nursing staff do call and clarify which medications should be continued. Sometimes after s/he reviewed the discharge summary, the physician would occasionally call or send back orders to discontinue or change a medication that had been used in the hospital. "On occasion, I will look at the medlist they send me and discontinue a medication from the onset. On occasion I will actually see the resident face to face first before reconciling the meds." According to the doctor, the difficulty occurs when residents are transferred on Saturdays or in the evenings at 6:00 PM. S/he stated this was never done (routinely) before and that it was a question of logistics. According to the Physician, the Medication Record (orders) should be reviewed when first sent from the hospital and then once the resident is admitted . When this information is faxed to his/her office, it is reviewed once more. S/he will write reviewed on the paperwork with orders to continue the transfer orders. The Physician agreed since the Communication for Resident #1 had not been sent until after hours on Friday 4/19, it probably had not been received/reviewed until Monday. The Physician stated that there were so many forms to fill out and that nursing staff are focused on these. S/he stated that due to a lack of coordination, Unit Managers had been appointed so that they can look at the big picture (this was done prior to the incident with Resident #1). The Physician believed there was a failure on several levels due to the accuracy of the transfer information, the time to transfer, and communication from the hospital to the nursing facility and communication within the facility. During an interview on 7/11/13 at 12:02 PM, the Consultant Pharmacist and Director of Nursing (DON) were present. The DON and Pharmacist reviewed the hospital discharge information and prescriptions along with information faxed at the surveyor's request from the Pharmacy to the facility on [DATE] . This information included "everything that had been faxed on 4/19 for (Resident #1)" by LPN #1 to the pharmacy. The DON stated that this was the first time s/he had seen the information faxed to the pharmacy by LPN #1. Review of this information revealed that on 4/19/13 at 4:40 PM, LPN #1 faxed a "Stat Medication Delivery Request Form" with a note for the pharmacy to "Please send all meds stat" for Resident #1. The information included 2 sheets of the facility's Matrixcare that documented resident demographic information, the resident's prescriptions, and 2 pages of the "Patient Discharge Summary for Resident #1". These 2 pages (listed the home medications) had been signed by LPN #1 and included [MEDICATION NAME] and Aspirin along with the other discharge medications that were to be continued. The hospital "Discharge Medication Reconciliation Report" had not been sent to the pharmacy. After reviewing all the documentation, the DON verified the [MEDICATION NAME] and Aspirin should have been continued on admission. The Consultant Pharmacist stated that since the prescriptions had been faxed, the pharmacy would have filled those medications. However, there were no prescriptions or orders from a Physician for the [MEDICATION NAME] and Aspirin and there was no Physician signature on the list of home medications that had been faxed. According to the the Consultant Pharmacist, the Pharmacy did not have [MEDICATION NAME] or Aspirin listed as ordered medications for Resident #1. When asked if the pharmacy had any obligation to call the facility back to clarify whether the two medications, [MEDICATION NAME] and Aspirin should have been sent (since they were included on the discharge instructions "Home Medications" list), the Consultant Pharmacist stated s/he would need to ask the head pharmacist. During an interview on 7/11/13 at 2:46 PM, the Consultant Pharmacist stated s/he did not have an answer except to say that the stat med request had come in by fax in 2 parts, with the first part having been received by the pharmacy at 4:47 PM with the cutoff for requests at 5:00 PM; and that maybe there was a rush (on the facility's part) to get the information to the pharmacy. According to the pharmacy, the whole packet didn't come until 6:00 PM. The Consultant Pharmacist verified s/he had done the Medication Regimen Review for Resident #1 on 5/14/13 and 6/8/13. The Consultant Pharmacist was questioned as to why s/he had not caught the medication errors with the [MEDICATION NAME] and Aspirin along with the discrepancies between the Medication Records and the orders. According to the Consultant Pharmacist, since the Admission Physician Orders and May (2013) cumulative Physician Orders had not been transcribed accurately and it was unclear what documentation was present on the chart during the reviews, s/he may have had only the prescriptions and telephone orders to go by to compare to the Medication Flowsheets. The Consultant Pharmacist stated that s/he did not routinely read the discharge summaries unless s/he had a concern. When asked if any medication recommendations had been made to the facility for this resident, the Pharmacist said "not with this admission". The Consultant Pharmacist did say that some Performance Improvement recommendations related to documentation had been given to the facility, but that the facility may not be willing to share this information. This information was requested from the DON but none was provided prior to exit. Review of the policy provided by the facility entitled, "Medication Regimen Review" dated 12/01/07, revealed "...2. Facility should ensure that the consultant pharmacist has access to: ...2.2 The resident's records, ...2.4 Physician/prescriber progress notes, nurse's notes, and other documents which may assist the consultant pharmacist in making a professional judgment as to whether or not irregularities exist in the medication regimen... 2.5 Any other necessary information...". During an interview on 7/11/13 at 12:45 PM, the DON stated that Unit Managers (not all the nursing staff) are responsible to get new resident admissions processed. According to the DON, the facility usually does not get new admissions in the evening after regular business hours or on the weekends. However, if there was an after hours admission and there was no Unit Manager available, nursing staff would call the nurse on call or the DON; and there was a good chance one of the three would come in to admit the resident. When asked what training the nursing staff received on admissions, the DON stated that some of the Unit Managers had been there a long time and had been educated on the admission process. Some of the admission process is learned in nursing school. According to the DON, a formal training was held on 7/3/13 with the Administrator providing an inservice on the Admission Checklist. When questioned as to the facility's admission procedures, the DON stated that it was okay for the nursing staff to go by the medication reconciliation sheet for the medications that needed to be continued and that it was okay for the admitting Physician to review these medications on Monday (if the admission was on Friday). According to the DON, the facility's policy didn't give a time frame for confirmation of the orders. When asked if it was okay for the nurse to let the Physician know by fax on Friday at 6:00 PM that the resident had been admitted , the DON stated the nurse would have needed to call him/her. When asked if anyone reviewed the facility Physicians' dictated progress notes, the DON stated that no one at the facility reviewed them as far as s/he knew. Review on 7/11/13 of the policy provided by the facility entitled "Physician Orders" dated 9/2011 revealed that for Admissions, "1. The qualified licensed nurse reviews orders from the transfer record from an acute care hospital or other entity. 2. A call is placed to the physician to confirm the orders and request any additional orders as needed. In the event the physician writing the transfer orders is not credentialed by the facility, the designated attending physician is contacted to confirm the transfer orders and request any additional orders.... Monthly Recap: 1. The licensed nurse reviews the monthly recap of orders

On the days of the complaint and extended survey, based on limited record reviews, interviews, and review of the policies provided by the facility entitled "Physician Communication/Change in Condition" and "Physician Orders", the facility failed to provide services to maintain the highest practicable physical well-being for one of four sampled residents reviewed for care and services. Resident #1 developed four unstageable wounds to her/his feet after facility nursing staff failed to schedule a follow up appointment timely with the orthopedist. There was no documentation of a thorough nursing assessment of the resident's splinted legs and toes to show the facility was taking measures to prevent possible complications related to the splint use. Resident #1 was observed on two days of the survey with a possible deep tissue injury (DTI) to her/his right heel with no documentation of this in the record and no documentation that the physician and family of the resident had been notified. The Physician was not notified timely of Resident #1's admission and medication orders upon admission. Resident #1 had hospital discharge orders for medications that were not transcribed accurately upon admission which resulted in the omission of two ordered medications from 4/19/13 until 7/10/13. The monthly cumulative Physician Orders for May 2013 were not transcribed accurately. The Physician and family of Resident #1 were not notified and/or not notified timely of a change in condition on 6/19/13. There was no documentation of continuing assessment and monitoring of the resident's blood pressures by the nursing staff. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set Assessment with an Assessment Reference Date of 4/26/13 revealed the resident had a Brief Interview for Mental Status score of 12, which indicated moderate cognitive impairment at the time of the assessment. According to the assessment, the resident was at risk for the development of pressure ulcers, but had none. There were no venous or arterial ulcers documented; only a surgical wound. Review of the facility's self reported incident (Five Day Follow-up Report) received by the State Certification Agency on 7/8/13 revealed that Resident #1 was admitted to the facility for rehab following fractures to both ankles, with an order for [REDACTED]. At an appointment on 7/2/13 the casts were removed and four unstageable wounds were noted by the orthopedic surgeon, one on the right outer foot measuring 2 x 1.8 x 2 (cm), one on the right outer toe measuring 1.7 x 2.3 (cm), one on the left heel measuring 3 x 4.5 (cm), and one on the left outer aspect of the foot measuring 1.6 x 1 (with) deep tissue damage. Review of the Hospital's Transfer Summary dated 4/19/13 revealed Resident #1 had bilateral ace splints to bilateral legs. Under "Follow-up Appt" it said to "See discharge summary". Review of the 4/19/13 Discharge Summary revealed the resident suffered bilateral ankle fractures and was to continue in splints, be nonweightbearing in both lower extremities, use ice and elevate, and follow up with (orthopedist) Dr. -- in one weeks time. From the date/time stamp on the top of this Discharge Summary, it appeared as if it had been faxed 4/19/13 at 3:53 PM. During an interview on 7/10/13 at 3:00 PM, Licensed Practical Nurse (LPN) #1 verified s/he was the admitting nurse for the resident on 4/19/13. LPN #1 stated s/he had been with the facility for 8 years. When asked what had happened relative to the above incident reported to DHEC, LPN #1 stated that s/he had received the discharge information from the hospital on [DATE] at about 3:45 PM. The nurse stated that another fax with additional information that included Resident #1's appointment with the orthopedist had come in after the initial fax from the hospital; and that s/he had only reviewed the discharge information contained in the first packet of faxed information. According to LPN #1, s/he did not know which fax machine the 2nd packet of information came to, who may have removed this information from the fax, or where they may have placed it after removing it. LPN #1 stated that the discharge information s/he had received included a follow-up appointment with Dr.--, who s/he thought was the orthopedist, but was not. Review of a Patient Discharge Summary for the resident dated 4/19/13 revealed information that the resident had a follow-up appointment with (neurology) Dr. -- in 2-3 weeks, scheduled for 5/6/13 at 10:45 AM. The date/time stamp for this fax was 4/19/13 at 3:44 PM. Review of the appointment calendar with LPN #1 revealed s/he had documented an appointment with (neurology) Dr. -- on 5/6/13. Review for the months of April, May, and June revealed there was no information on the appointment calendar relative to an appointment with the orthopedist. The surveyor asked LPN #1 to review the 5/29/13 Physician's Progress Note that indicated that the Physician had discussed with the care team to follow up with orthopedics on the ankle fractures. After reviewing the note and the Physician's Telephone Orders for that date, LPN #1 stated that s/he had rounded with the Physician that day and that the Physician may have told her/him but that s/he did not remember. During a phone interview on 7/11/13 at 9:15 AM, Resident #1's Orthopedist was not available for interview. The Orthopedist's surgical technician (tech) stated s/he could speak for the doctor. The Surgical Technician stated that the resident initially had a short leg splint placed in the hospital that had plaster on the back with 2 struts on the side made of plaster. The lower extremities had been wrapped with a soft dressing with padding, then the plaster applied, then kling, with an ace wrap covering. According to the surgical tech, the resident should have followed up in one weeks time. At one week s/he would have come in for a wound check, where the splint would have been removed and the incision site checked. The same type of splint would have been placed on the lower extremities again, and the resident would return one week after that for the sutures to be removed. At that time, short leg bilateral casts made of fiberglass would have been placed, and the resident would have been instructed to follow up in 4 weeks. When asked if the Orthopedist believed the resident had developed the wounds from the splint, the surgical tech responded "yes". The tech stated that the resident did develop pressure sores on the heel from the splint. When asked if the Orthopedist felt that the resident developed all 4 wounds related to the delay in follow-up, the surgical tech stated that the doctor felt the resident developed all 4 wounds because she missed the follow-up. The surgical tech verified that the Resident's first follow up with the orthopedist after hospitalization occurred 7/2/13. Review on 7/12/13 at 9:47 AM of the orthopedist's typed Progress Note from the office visit 7/2/13 revealed Resident #1 was 12 weeks out from the fixation of both ankles upon return to the orthopedist for her/his first visit. According to the note, "A discussion was held with the nursing director at (nursing facility). After removal of the splints, the patient has a left heel pressure sore and lateral foot pressure sore on both feet at the level of the fifth metatarsal and neck head...Plan: at this time is to leave the splints off. Debridement is done on the right lateral side of the foot. Eschar is removed. The left lateral foot eschar is also minimally debrided. The heel ulceration is not debrided at this point. We will have (her/him) return to the office in one week. We will continue debridements of all three pressure sores...". During a phone interview on 7/11/13 at 10:25 AM, the resident's Physician was informed of the surveyor's concerns related to the wounds that had developed as a result of the missed appointment. The Physician stated there had been concerns that s/he and others have had with the accuracy of transfer information and orders from the hospital to all nursing homes (not just this one). The Physician stated this had been discussed with the hospital in the past. When asked about his/her 5/29/13 Progress Note that stated s/he had discussed with the Care Team to follow up with orthopedics; the Physician stated s/he most likely spoke with the nurse who rounded with him/her or the resident's day nurse. The Physician could not recall specifically who s/he had spoken with. When asked if anyone at the facility reviewed his/her Progress Notes, the Physician thought someone did, but didn't know who or to what extent they were reviewed before they were placed on the chart. Observations on 7/10/13 at 9:20 AM with the Unit Manager, Registered Nurse (RN) #1, revealed Resident #1 lying on a specialty air mattress with her/his feet elevated on a pillow and a bed cradle holding the sheet in place above the feet. There was a kling dressing wrapped around the top area of the right foot towards the toes dated 7/9/13. There were no wounds or eschar on the right heel, just an area of darker skin which looked like a possible deep tissue injury. The resident's left foot had eschar on the outer bottom area of the foot below the pinky toe along with a large amount of black eschar on the left heel. Both feet were dry and scaly with patches where it appeared skin had sloughed off. Review earlier on 7/10/13 at 8:50 AM of the resident's July 2013 Wound Treatment and Progress Record revealed nothing had been documented related to a possible right heel deep tissue injury. During an interview on 7/10/13 at 11:00 AM, RN #1 stated that s/he had planned to measure the wounds that day. The last measurements had been done 7/2/13, when the wounds had been discovered. During a second wound observation on 7/10/13 at 11:15 AM, RN #1 removed the dressing to the resident's right foot. Eschar was noted to the outer aspect of the right great toe and also to an area below the pinky toe on the bottom surface of the right foot. The surveyor observed a reddish purple circular area to the right heel that appeared to be a possible deep tissue injury. The surveyor asked the nurse about the resident's right heel. The nurse stated it looked like the heel was red. Review of the Wound Treatment and Progress Record on 7/11/13 revealed entries dated 7/10/13 that documented an unstageable wound to the right outer great toe (eschar) measuring 1.8 x 1.2 cm, an unstageable wound to the right outer foot (eschar) measuring 2.5 x 1.6 cm with surrounding tissue suggestive of deep tissue damage, an unstageable wound to the left bottom foot (eschar) measuring 1.5 x 1 cm with surrounding tissue suggestive of deep tissue damage, and an unstageable wound to the left heel (eschar) measuring 4.7 x 4.5 cm with surrounding tissue suggestive of deep tissue injury. There was no documentation related to a possible deep tissue injury to the right heel. Observation on 7/11/13 at 2:55 PM with RN #1 revealed Resident #1 sitting up in her/his wheelchair. Observation of the right heel revealed a dark area with redness in the center and dark and light brown undertones surrounding the reddened area. RN #1 agreed the area looked like a deep tissue injury (DTI). Review of the resident's wound treatment and weekly skin documentation with LPN #2 after the observation revealed nothing had been documented related to the possible DTI of the right heel. There was nothing noted in the record of having notified the Physician or family of this concern. RN #1 stated that s/he had been told that the resident's right heel was like that when the resident returned from the orthopedist on 7/2/13 after having the splints removed. LPN #2 agreed with RN #1 and stated that s/he thought there had been some tissue damage noted to the right heel when the resident had returned from the appointment. According to RN #1, the resident's Physician had looked at Resident #1's feet after the wounds had been discovered. Review of the Physician's Progress Note dated 7/3/13 revealed documentation of concerns related to the left heel and minor irritation to the right foot on the extensor surface of the toe; but nothing related to concerns with the right heel. According to the note, the pulses were diminished in both feet. The Physician suspected small vessel disease and possibly even some large vessel disease and would obtain vascular studies. Review of the 7/8/13 Bilateral lower extremities arterial study revealed abnormally diminished flow bilaterally and absence of flow in the posterior tibial artery on the left. Review of skin documentation on 7/10/13 at 12:15 PM revealed a CNA (Certified Nursing Assistant) Daily Skin Inspection Record for April 2013 which documented "Told nurse (LPN #2) (Resident #1) peeled nail +skin from toe area. (Initials CNA) R(ight) area..." During an interview on 7/11/13 at 3:30 PM, LPN #2 stated that s/he had looked at the resident's toe at the time it had been reported and it did not look anything like what was described by the CNA. According to LPN #2, there was just flaky skin at the toe where the resident had tried to scratch - with the nail intact. Review of the Nurse's notes with LPN #2 revealed no documentation related to this assessment. There was no indication from the CNA documentation in April when this skin concern was identified and LPN #2 could not recall. When asked if the nursing staff had done any type of monitoring or checks of Resident #1's feet (like pulse checks for circulation), LPN #2 stated none that s/he knew of. Review of the July 2013 treatment record with LPN #2 revealed it had been documented that the resident was nonweight bearing and had bilateral splints; but there was no documentation related to any pulse or circulation checks for the resident's feet. Review of the record revealed no nursing assessments of the resident's feet related to the splint use. When asked if anything had been done related to the resident's dry skin on the feet, LPN #2 stated that they were going to see if the resident could use the whirlpool and also if a moisturizer could be applied. Review on 7/12/13 of Weekly Skin Documentation for Resident #1 revealed nursing staff had not documented body audit findings for assessments due 6/11/13 and 6/25/13. Review of the Treatments Flowsheet revealed an entry for a body audit once weekly. The box for the nurse's initials for 6/11/13 was blank which indicated the body audit had not been done. The box for 6/25/13 had been initialed by the nurse which indicated the body audit had been completed. When requested by the surveyor, the facility was unable to locate the body audit assessments for these two dates. Review of the Care Plan for Resident #1 revealed an entry dated 5/1/13 that stated, "Resident is At Risk for Skin Breakdown related to: Incontinence...Bedfast or w/c (wheelchair) bound, Impaired Bed Mobility...Fragile Skin-[MEDICAL TREATMENT] shunt..Cognitive Impairment...Other-hard non-removable splints to bil(ateral) ankles". Included under "Approaches" was documented to "Assess skin weekly and record findings". A comparison on 7/10/13 of the facility's admission orders continue for home use". These two medications, [MEDICATION NAME] 10 mg and Aspirin 81 mg, both scheduled for once daily, had not been transcribed onto the facility's Medication Flowsheets although all the other "to be continued medications" had been added. Review of the record revealed no documentation to indicate that these two medications should have been stopped. Review of the Medication Flowsheets for April, May, June, and July 2013 revealed Resident #1 had not received the [MEDICATION NAME] and Aspirin from 4/20/13 through 7/10/13. Further review on 7/10/13 revealed there were no MEDICATION ORDERS FOR [REDACTED]. Signature boxes at the bottom of the orders indicated the Physician had signed the the Physician Order Report on 5/2/13, and the nurse had noted the above orders on 5/14/13. There was no signature in the box for either the RN or Pharmacy review. Record review on 7/10/13 at 2:58 PM revealed there were no Physician Order Reports for June or July 2013 in the chart. These were requested and a printed out copy, not signed by the Physician, were reviewed. Continued review later on 7/10/13 revealed there was a 5/28/13 Neurology Consult note that was not on the chart. This was requested and on June 11, 2013, the neurology note and June 2013 signed Physician Order Report was provided for review. The July 2013 signed Physician Order Report was not provided for review. On 7/10/13 after reviewing the April 2013 Medication Flowsheets, LPN #1 verified there were no entries for the [MEDICATION NAME] and Aspirin. LPN #1 stated these medications should have been on the sheets and thought that maybe a sheet was missing. After reviewing the May 2013 Physician Order Report, LPN #1 verified the medication orders had not been transcribed accurately and did not include some of the oral medications the resident had received as documented on the May 2013 Medication Flowsheets. During the interview on 7/10/13, LPN #1 stated that s/he had not called the Physician to verify any medication orders prior to faxing them to the pharmacy to be filled. LPN #1 stated that s/he usually called the doctor to let him/her know that the resident was back (had been readmitted ). However, after reviewing the Nurses Notes and finding no documentation of a call, LPN #1 stated that s/he had faxed the doctor a Nurse/Physician Communication Record and the Discharge Summary Medication list on 4/19/13 at approximately 6:00 PM. This was to inform him/her of Resident #1's admission. LPN #1 agreed that due to the lateness of the hour, the Physician probably did not receive the fax until the following Monday. Review of the Nurse/Physician Communication Record revealed a box for "Major Meds:" in which had been documented "[MEDICATION NAME]". There were no other medications listed. Dr.-- had responded by fax with a notation to "Follow transfer orders. To see Wed(nesday)". The date/time stamp on the fax indicated the Physician had faxed the response back to the facility on [DATE] at 3:30 PM. During a phone interview on 7/11/13 at 10:25 AM, Resident #1's Physician was informed of the surveyor's concerns related to Resident #1's admission medications. When asked which medications should have been continued on admission, the Physician was unsure since s/he did not have the record available for review at the time of the interview. According to the Physician, nursing staff do call and clarify which medications should be continued. Sometimes after s/he reviewed the discharge summary, the physician would occasionally call or send back orders to discontinue or change a medication that had been used in the hospital. "On occasion, I will look at the medlist they send me and discontinue a medication from the onset. On occasion I will actually see the resident face to face first before reconciling the meds." According to the doctor, the difficulty occurs when residents are transferred on Saturdays or in the evenings at 6:00 PM. S/he stated this was never done (routinely) before and that it was a question of logistics. According to the Physician, the Medication Record (orders) should be reviewed when first sent from the hospital and then once the resident is admitted . When this information is faxed to his/her office, it is reviewed once more. S/he will write reviewed on the paperwork with orders to continue the transfer orders. The Physician agreed since the Communication for Resident #1 had not been sent until after hours on Friday 4/19, it probably had not been received/reviewed until Monday. The Physician stated that there were so many forms to fill out and that nursing staff are focused on these. S/he stated that due to a lack of coordination, Unit Managers had been appointed so that they can look at the big picture (this was done prior to the incident with Resident #1). The Physician believed there was a failure on several levels due to the accuracy of the transfer information, the time to transfer, and communication from the hospital to the nursing facility and communication within the facility. S/he stated that even the transcription is an issue due to HIPAA compliance and that it would be better to get this information back sooner. During an interview on 7/11/13 at 12:02 PM, the Consultant Pharmacist and Director of Nursing (DON) were present. The DON and Pharmacist reviewed the hospital discharge information and prescriptions along with information that had been faxed at the surveyor's request from the Pharmacy to the facility on [DATE] . This information included "everything that had been faxed on 4/19 for (Resident #1)" by LPN #1 to the pharmacy. The DON stated that this was the first time s/he had seen the information that had been faxed to the pharmacy by LPN #1. Review of this information revealed that on 4/19/13 at 4:40 PM, LPN #1 had faxed a "Stat Medication Delivery Request Form" with a note for the pharmacy to "Please send all meds stat" for Resident #1. The information included 2 sheets of the facility's Matrixcare that documented resident demographic information, the resident's prescriptions, and 2 pages of the "Patient Discharge Summary for Resident #1". These 2 pages (where the home medications had been listed) had been signed by LPN #1 and included [MEDICATION NAME] and Aspirin along with the other discharge medications that were to be continued. The hospital "Discharge Medication Reconciliation Report" had not been sent to the pharmacy. After reviewing all the documentation, the DON verified the [MEDICATION NAME] and Aspirin should have been continued on admission. The Consultant Pharmacist stated that since the prescriptions had been faxed, the pharmacy would have filled those medications. However, there were no prescriptions or orders from a Physician for the [MEDICATION NAME] and Aspirin and there was no Physician signature on the list of home medications that had been faxed. According to the the Consultant Pharmacist, the Pharmacy did not have [MEDICATION NAME] or Aspirin listed as ordered medications for Resident #1. When asked if the pharmacy had any obligation to call the facility back to clarify whether the two medications, [MEDICATION NAME] and Aspirin should have been sent (since they were included on the discharge instructions "Home Medications" list), the Consultant Pharmacist stated s/he would need to ask the head pharmacist. During an interview on 7/11/13 at 2:46 PM, the Consultant Pharmacist stated s/he did not have an answer except to say that the stat med request had come in by fax in 2 parts, with the first part having been received by the pharmacy at 4:47 PM with the cutoff for requests at 5:00 PM; and that maybe there was a rush (on the facility's part) to get the information to the pharmacy. According to the pharmacy, the whole packet didn't come until 6:00 PM. The Consultant Pharmacist verified s/he had done the Medication Regimen Review for Resident #1 on 5/14/13 and 6/8/13. The Consultant Pharmacist was questioned as to why s/he had not caught the medication errors with the [MEDICATION NAME] and Aspirin along with the discrepancies between the Medication Records and the orders. According to the Consultant Pharmacist, since the Admission Physician Orders and May cumulative Physician Orders had not been transcribed accurately and it was unclear what documentation was present on the chart during the reviews, s/he may have had only the prescriptions and telephone orders to go by to compare to the Medication Flowsheets. The Consultant Pharmacist stated that she/he did not routinely read the discharge summaries unless s/he had a concern. When asked if any medication recommendations had been made to the facility for this resident, the Pharmacist said "not with this admission". The Consultant Pharmacist did say that some Performance Improvement recommendations related to documentation had been given to the facility, but that the facility may not be willing to share this information. This information was requested from the DON but none was provided prior to exit. Review of the policy provided by the facility entitled, "Medication Regimen Review" dated 12/01/07, revealed "...2. Facility should ensure that the consultant pharmacist has access to: ...2.2 The resident's records, ...2.4 Physician/prescriber progress notes, nurse's notes, and other documents which may assist the consultant pharmacist in making a professional judgment as to whether or not irregularities exist in the medication regimen...2.5 Any other necessary information...". During an interview on 7/11/13 at 12:45 PM, the DON stated that Unit Managers (not all the nursing staff) are responsible to get new resident admissions processed. According to the DON, the facility usually does not get new admissions in the evening after regular business hours or on the weekends. However, if there was an after hours admission and there was no Unit Manager available, nursing staff would call the nurse on call or the DON; and there was a good chance one of the three would come in to admit the resident. When asked what training the nursing staff received on admissions, the DON stated that some of the Unit Managers had been there a long time and had been educated on the admission process. Some of the admission process is learned in nursing school. According to the DON, a formal training was held on 7/3/13 with the Administrator providing an inservice on the Admission Checklist. When questioned as to the facility's admission procedures, the DON stated that it was okay for the nursing staff to go by the medication reconciliation sheet for the medications that needed to be continued and that it was okay for the admitting Physician to review these medications on Monday (if the admission was on Friday). According to the DON, the facility's policy didn't give a time frame for confirmation of the orders. When asked if it was okay for the nurse to let the Physician know by fax on Friday at 6:00 PM that the resident had been admitted , the DON stated the nurse would have needed to call him/her. When asked if anyone reviewed the facility Physicians' dictated progress notes, the DON stated that no one at the facility reviewed them as far as s/he knew. Review on 7/11/13 of the policy provided by the facility entitled "Physician Orders" dated 9/2011 revealed that for Admissions, "1. The qualified licensed nurse reviews orders from the transfer record from an acute care hospital or other entity. 2. A call is placed to the physician to confirm the orders and request any additional orders as needed. In the event the physician writing the transfer orders is not credentialed by the facility, the designated attending physician is contacted to confirm the transfer orders and request any additional orders.... Monthly Recap: 1. The licensed nurse reviews the monthly recap of orders against all order changes within the same time frame. 2. Make changes on recap, verify with the physician and make changes as required on MAR/TAR...". Review of Vital Signs (VS) documentation for Resident #1 on 7/11/13 at 11:48 AM revealed documentation of elevated blood pressures (BP) on 6/19/13. On 6/19/13 at 2:41 AM, the Vital Signs were as follows: Temperature (Temp) 100.1 F, Pulse 63, Respirations 18, BP 203/64; at 2:42 AM it was 190/68; at 4:03 AM it was 198/60. Review of a Nurse Physician Communication Record dated 6/19/13 revealed "Reason you are calling/current condition: (Elevated) BP, (Elevated) Temp, c/o (complaints of) pain to L(eft) arm; c/o nausea when eating". It was unclear from the documentation as to when the (left arm and bilateral leg) pain and nausea started. According to the Communication Record, the resident's Vital Signs at 5:30 AM were BP 162/84 with a temp of 98.4 F. [MEDICATION NAME] had been given. Under "Time talked with physician" was documented, "Info(rmation) faxed @ 8:30 AM 6/19/13". There was a blank space for the entry "Outcome/Physician Order". There was also a blank space for the entry, "Family Member Notified:". Further review of nursing notes revealed there were no follow up assessments or documented blood pressures to indicate nursing staff had been monitoring the resident's condition. After the last documented BP on 6/19/13 at 5:30 AM, another BP reading had not been documented until 6/20/13 at 10:31 PM (it was 123/47). Continued review of the nursing notes revealed no documentation of notification of the resident's family of a change in condition on 6/19/13. There was no documentation in the record of a Physician response until 6/20/13 at 9:00 PM, when it was noted in the nurse's notes that the Physician was there with new orders received and transcribed. Review of Physician Orders dated 6/20/13 at 9:00 PM revealed, "VS q (every) shift x 3 days. Notify Temp (greater than 100.5)". Review of physician progress notes [REDACTED]. There was no cough or systemic signs of infection. The primary concern was that s/he was a [MEDICAL TREATMENT] patient. The Plan was to increase vital signs. The concerns with the resident's elevated blood pressure, pain in the left arm, and complaints of nausea were not documented/addressed in the Physician's Progress Note. During an interview on 7/11/13 at 1:28 PM, the DON reviewed the 6/19/13 Nurse/Physician Communication, the 6/20/13 Telephone Order, the 6/20/13 physician progress notes [REDACTED]. The DON verified that from the documentation it appeared the Physician did not respond/see the patient until 6/20/13. The surveyor expressed concerns that there had been a delay in Physician notification and in obtaining a Physician response. The resident's blood pressures were significantly elevated at 2:42 AM and at 4:03 AM with documentation that the nurse notified the Physician by fax at 8:30 AM. Concerns were also expressed related to the lack of documentation related to the monitoring of the resident with follow up blood pressures. When asked if s/he would have expected nursing staff to start acute charting documentation for this event, the DON stated "yes". The DON stated that she would go and check the 24 hour reports and any faxes that may have been sent back from the Physician (related to a response). However, no additional information was provided prior to exit. Review on 7/12/13 of the policy provided by the facility entitled "Physician Communication/Change in Condition" dated 9/2011 revealed that the policy was in place "1. To improve communication between physicians and nursing staff in order to promote optimal patient/resident care. 2. To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition...". Under Procedures, the policy said to, "2. Notify the physician of the change in medical condition. (The physician notification grid may be used as a reference tool regarding acceptable notification time frames.) The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. 3. If the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified...4. The patient's/resident's family member/legal representative will be notified of any change in condition requiring an emergent transfer to the hospital. 6. All attempts to notify the physicians and family members/legal representatives will be thoroughly documented in the patient's/reside

On the days of the complaint and extended survey, based on limited record reviews, interviews, and review of the policies provided by the facility entitled "Physician Communication/Change in Condition" and "Physician Orders", the facility failed to be administered in a manner that ensured staff were trained in procedures relative to the transcription of admission orders [REDACTED]. The findings included: 1. Cross refer to F-281 and F-309. Based on limited record reviews, interviews, and review of the policies provided by the facility entitled "Physician Communication/Change in Condition" and "Physician Orders", the facility failed to ensure that Physician order [REDACTED]. 2. The facility Administration failed to adequately monitor staff that were responsible for performing admission procedures, transcribing Physician orders, and notifying the Physician and Responsible Party changes in the residents condition. Administrative staff failed to ensure nursing staff implemented all components of facility policies related to "Physician Orders" and "Physician Communication/Change in Condition". An Allegation of Compliance dated 7/12/13 was developed by the facility and included the following: F-490 Reportable incident for resident #1 reported to DHEC on 7/5/13. Attending physician and family of resident #1 notified on 7/2/13 of unstageable areas identified by Orthopedist post cast removal. Resident #1 was seen by attending physician on 7/3/13. Attending physician notified of right heel deep tissue damage on 7/10/13 by Director of Nursing while in facility. Resident on Air Fluidized Therapy bed, heels being floated, resident being assessed for pain q shift, CNA daily skin checks and weekly nurse body audits being conducted. Resident seen by orthopedist 7/2/13, 7/11/13 and has return appointment in 2 weeks. Nurse involved in deficient practice suspended 7/2/13-7/3/13 and returned to work 7/4/13 following re-education and disciplinary action. Nurses identified as involved in deficient practices cited during survey suspended pending outcome of investigations. All Admissions/readmissions (23 residents) from 4/1/13 to 7/11/13 identified and 100% of their charts were audited 7/11/13 as follows: -Physician notification of orders upon admission- reviewed nurses notes for timely physician notification of new admission orders [REDACTED] -Cumulative monthly orders review- medication administration records were reconciled for accuracy. -Discharge Summary Review- admission orders [REDACTED]. -Physician notification of change in medical condition (skin issues, wounds, labs, etc)- resident changes in condition audited for physician notification and follow through of orders. -Transcription of orders from physician visits-physician progress notes [REDACTED]. -Post appointment progress note orders- physician progress notes [REDACTED]. All Physicians notified of any change in medical condition and/or orders lacking follow and medication errors. All physician recommendations were implemented. An audit was conducted on 7/11/13 to identify and assess residents with splint appliances (9 residents). Identified residents were assessed for pain, pulse, pallor, paresthesia, and paralysis with documentation of normal or abnormal findings in the treatment administration record. Physician notified of any abnormalities noted. Licensed nurses re-educated 7/11/13 and 7/12/13 regarding proper assessment and documentation of residents with splints/appliances, physician orders [REDACTED]. All licensed staff not in attendance will receive re-education prior to the next scheduled shift. All new licensed nurses hired will receive above education during orientation and prior to resident care. The facility does not utilize agency staff. On 7/12/13, based on review of education provided to facility staff on 7/11/13-7/12/13, observations, interviews, and reviews of policies and procedures, it was determined that the Allegation of Compliance submitted by the facility on 7/12/13 had been implemented by the facility and was in practice as of 7/12/13 removing the immediacy of the deficient practice. The Immediate Jeopardy was removed at F-490 but the citation remained at a lower scope and severity of "D".

On the day of the complaint inspection; based on observation, record review, and interview; the facility failed to ensure that Resident #1 received adequate supervision and assistance devices to prevent accidents. The findings included: Resident #1 was reviewed in reference to a reportable received by this office. Review of Resident #1's Nurse's Notes dated 2/19/13 revealed an entry "Res(ident) found laying at the foot of his/her bed and the wall feet tangled up in his/her bedspread 3 cm (centimeter) x 3 cm bump to forehead nose bleeding small amount of blood raise area to l(eft) cheek bone Dr. and responsible party notified new order received from Dr. send res(ident) to ER (emergency room ) for eval(uation) and tx (treatment)." Review of Resident #1's Radiology report dated 2/20/13 revealed the findings of nondisplaced fracture of the nasal bones and upper nasal septum and minimally displaced type 2 odontoid fracture. Review of Resident #1's care plan revealed at risk for falls was identified as a problem area. Interventions and approaches were documented on the care plan and updated 6/15/12 to include Velcro self-release alarm belt in wheelchair and pressure alarm in bed. The facility's Five Day Follow-Up Report dated 2/26/13 indicated the initial investigation of a fall revealed the nursing intervention of a bed alarm was not in place at the time of the fall. During a telephone interview with the surveyor on 4/10/13 at approximately 4:02 PM CNA #2 stated that s/he put Resident #1 to bed on 2/19/13. CNA #1 walked out of the room and then heard a noise in the resident's room. CNA #1 ran to the room and found the resident on the floor. CNA #1 stated that there was no bed alarm on the bed. CNA #1 stated that resident's should have an icon card over their bed to indicate if they have an alarm and what type. CNA #1 stated that there was no icon card over Resident #1' s bed to indicate that s/he needed an alarm. During a telephone interview with the surveyor on 4/10/13 at approximately 3:45 PM LPN #2 stated that s/he was Resident #1's nurse during the time of the fall on 2/19/13. LPN #2 stated that there was no icon card at the time of the fall, over Resident #1's bed to indicate that s/he needed an alarm. During an interview on 4/8/13 at approximately 5:15 PM the Administrator stated that alarms are nursing interventions that are documented on incident reports. The Risk Manager is responsible for putting icon cards in place over the residents' beds to reflect the intervention. The MDS Coordinator is responsible for updating the residents' care plan.

On the day of the complaint inspection; based on observation, record review, and interview; the facility failed to implement interventions for residents at risk for falls Residents #1 and #2. The findings included: Resident #1 was reviewed in reference to a reportable received by this office. Review of Resident #1's Nurse's Notes dated 2/19/13 revealed an entry "Res(ident) found laying at the foot of his/her bed and the wall feet tangled up in his/her bedspread 3 cm (centimeter) x 3 cm bump to forehead nose bleeding small amount of blood raise area to l(eft) cheek bone Dr. and responsible party notified new order received from Dr. send res(ident) to ER (emergency room ) for eval(uation) and tx (treatment)." Review of Resident #1's Radiology report dated 2/20/13 revealed the findings of nondisplaced [MEDICAL CONDITION] bones and upper nasal septum and minimally displaced type 2 odontoid fracture. Review of Resident #1's care plan revealed at risk for falls was identified as a problem area. Interventions and approaches were documented on the care plan and updated 6/15/12 to include Velcro self-release alarm belt in wheelchair and pressure alarm in bed. The facility's Five Day Follow-Up Report dated 2/26/13 indicated the initial investigation of a fall revealed the nursing intervention of a bed alarm was not in place at the time of the fall. During a telephone interview with the surveyor on 4/10/13 at approximately 4:02 PM CNA #2 stated that s/he put Resident #1 to bed on 2/19/13. CNA #1 walked out of the room and then heard a noise in the resident's room. CNA #1 ran to the room and found the resident on the floor. CNA #1 stated that there was no bed alarm on the bed. CNA #1 stated that residents should have an icon card over their bed to indicate if they have an alarm and what type. CNA #1 stated that there was no icon card over Resident #1' s bed to indicate that s/he needed an alarm. During a telephone interview with the surveyor on 4/10/13 at approximately 3:45 PM LPN #2 stated that s/he was Resident #1's nurse during the time of the fall on 2/19/13. LPN #2 stated that there was no icon card at the time of the fall, over Resident #1's bed to indicate that s/he needed an alarm. Observations during the survey of other resident at risk for falls revealed that Resident #2 was to have an alarm clock icon over his/her bed that indicated clip/bed alarm. CNA #1 stated the icon indicated that Resident #2 should have a clip alarm attached to his/her wheelchair. At approximately 3:40 PM CNA #1 confirmed that Resident #2 did not have a clip alarm on his/her wheelchair. At approximately 4:15 PM LPN #1 entered the room with the surveyor. Resident #2 was noted to be in the bathroom with his/her wheelchair at the doorway. LPN #1 confirmed that the resident did not have a clip alarm on his/her wheelchair. LPN #1 stated that Resident #2 would sometimes remove the alarm from the wheelchair. LPN #1 asked the resident where the wheelchair alarm was and Resident #2 stated the alarm was never put on. LPN #1 located the wheelchair clip alarm in the bottom drawer of the resident's dresser. Resident #2 was coded as having a Brief Interview for Mental Status score of 15 on the Quarterly Minimum Data Set ((MDS) dated [DATE]. Review of the resident's care plan revealed resident at risk for falls was identified as a problem area. Interventions and approaches included clip alarm when up in wheelchair on 2/20/13. The care plan interventions and approaches were updated on 2/23/13 to include pressure pad in wheelchair. There was no care plan for Resident #2 related to the resident removing the wheelchair alarm. During an interview on 4/8/13 at approximately 6:20 PM the Healthcare Services Coordinator stated that Resident #2 sometimes removes his/her clip alarm. The Healthcare Services Coordinator also stated that using a pressure pad would be a double alarm because the resident had a clip alarm. The Healthcare Services Coordinator confirmed that there was no pressure pad to Resident #2's wheelchair. During an interview on 4/8/13 at approximately 5:15 PM the Administrator stated that alarms are nursing interventions that are documented on incident reports. The Risk Manager is responsible for putting icon cards in place over the residents' beds to reflect the intervention. The MDS Coordinator is responsible for updating the residents' care plan.