Every finding on record at Magnolia Manor - Spartanburg

Based on interviews, record review, and review of facility policy, the facility failed to ensure R4 was free from verbal abuse for 1 of 1 residents reviewed for abuse. Specifically, a Certified Nursing Assistant (CNA1) engaged in a verbal disagreement with R4 and called R4 a big, black, b****.Findings include:Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Mistreatment, on page 1, indicated The facility's leadership prohibits neglect, mental, physical and/or verbal abuse.Review of R4's Face Sheet revealed that the resident was admitted to the facility on [DATE], with diagnoses that included but was not limited to altered mental status, major depressive disorder, anxiety disorder, and psychosis.Review of R4's Care Plan revealed R4 was care planned for having mood and behavior needs related to anxiety, depression and psychosis, and monitoring for psychosocial and psychosocial wellbeing related to history of alcohol and substance abuse.Review of R4's Physician Orders revealed consult with psychiatry and psychology as needed.Review of R4's progress note, dated 07/03/2026 and 07/06/2026, revealed SW spoke with resident r/t recent verbal abuse allegation .Review of R4's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/02/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that R4 does not have any cognitive impairments. During review of a R4's written witness statement, done on 07/01/2026, it was revealed that after an interaction with the NP, CNA4 bursted into R4's bedroom yelling what do y'all want from me? Because I'm on break, and they began to argue with one another. During the argument, CNA1 called R4 a big black b**** and R4 responded by calling CNA1 a crackhead. CNA1 then responded your mami before leaving out of the room and slamming the door.During an interview on 08/25/2026 at 11:04 AM with R6, a witness resident that was on the hall during the incident, it was revealed that she heard R4 call CNA1 a b**** first, but CNA1 did respond back to R4 with profanity.During an interview on 08/25/2026 at 11:15 AM with R5, a witness resident that resided in the bedroom next to where the incident occurred, it was revealed that she heard CNA1 call R4 a b****. She stated that prior to the use of profanity, CNA1 and R4 were already engaging in a back-and-forth verbal disagreement because CNA1 appeared to be upset with R4.During an interview on 08/25/2026 at 11:27 AM with LPN2, it was revealed that on the day of the incident, she was in the neighboring room providing care to another resident when she heard commotion. She believed CNA1 had entered R4's room to empty the bedside commode. LPN2 entered the room after CNA1 and R4 began arguing. She attempted to get CNA1 to leave the room and stop responding to R4; however, the two continued going back and forth. LPN1 stated that CNA1 called R4 a big black b***, and R4 called CNA1 a crackhead in response. CNA1 then left the room.During an interview on 08/25/2026 at 12:02 PM with the Administrator, it was revealed that CNA1 was terminated because of this incident. She revealed that R4 called CNA1 a crackhead and she responded by calling her a b****. It was revealed that CNA1's behavior was not within the expectations of the facility. The administrator stated that CNA1 should have walked away and reported the residents verbal abuse to the charge nurse instead of engaging in a back-and-forth argument.

Based on observations, record review, and interviews, the facility failed to ensure that infection prevention and control measures were followed for four sampled residents (Resident (R) 58, R88, and R76) identified as being on enhanced barrier precautions (EBP) out of a sample of 25 residents. This deficient practice had the potential to spread infectious organisms between residents, staff, and the environment, resulting in avoidable infections. Findings include: Review of the facility's policy titled Infection Prevention and Control Policies and Procedures, revised 05/15/23, under Subject: Transmission Based/Standard Precautions, and Enhanced Barrier Precautions, indicated: Enhanced Barrier Precautions expand the use of PPE (gowns and gloves) during high-contact resident care activities that provide opportunities for transfer of MDROs [Methicillin Drug Resistant Organisms] to staff hands and clothing . EBP will be implemented for All residents with the following: . Infection or colonization with an MDRO when Contact Precautions do not otherwise apply . Wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status . EBP will be implemented during the following high-contact resident care activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toilet, Device care or use: central lines, urinary catheter, feeding tube, tracheostomy/ventilator. 1. Review of R58's Face Sheet, located under the Resident tab of the electronic medical record (EMR), revealed R58 was admitted to the facility on [DATE]. Review of R58's Physician's Orders, located under the Resident tab of his EMR revealed an order dated 08/07/25 for Enhanced Barrier Precautions for Vancomycin-resistant Enterococci (VRE) and Extended spectrum beta lactamase (ESBL). During an observation on 07/08/26 at 2:40 PM, a family member was standing outside of R58's room and reported that staff were in the room changing R58. A personal protective equipment (PPE) holder containing gowns and gloves was located on the door to the room, and EBP signage was in the top pocket of the holder indicating R58 was on EBP. The EBP signage indicated, STOP. EVERYONE MUST: Clean their hands before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities . bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting . Continued observation on 07/08/26 at 2:40 PM revealed that as the door to the room opened, Certified Nurse Aide (CNA) 1 and CNA11 were observed gathering dirty linen and trash from the room. Neither CNA wore a gown. CNA1 and CNA11 were asked if they had just provided incontinence care for R58. Both stated that they had. When asked if they wore the PPE for EBP, both CNAs said they did not and were unaware that they should. 2. Review of R88's Face Sheet, located under the resident tab of the EMR, revealed R88 was admitted to the facility on [DATE]. Further review a diagnosis of (ESBL) resistance-in urine. Review of R88's Physician's Orders, located under the Resident tab of the EMR, revealed an order dated 07/14/25 for Enhanced Barrier (precautions) for Extended-spectrum beta-lactamase (ESBL) in the urine. During an observation on 07/09/26 at 10:26 AM, a PPE holder containing gowns and gloves was located on the door to R88's room, and EBP signage was in the top pocket of the holder indicating R88 was on EBP. CNA14 was observed inside of the room providing assistance to R88 in R88's bathroom. CNA14 was not wearing a gown. After assisting R88 with incontinence care, CNA14 washed out R88's pants in the sink in R88's bathroom. CNA14 was asked if she was aware that R88 was on EBP. CNA14 stated that she was not aware. 3. Review of R76's Face Sheet, located under the Resident tab of the EMR, revealed R76 was admitted to the facility on [DATE]. Review of R76's Physician's Orders, located under the Resident tab of the EMR, revealed an order dated 07/08/26 for Enhanced Barrier Precautions related to wounds. During an observation on 07/09/26 at 10:56 AM, a PPE holder containing gowns and gloves was located on the door to R76's room, and EBP signage was in the top pocket of the holder indicating R76 was on EBP. CNA14 was observed providing incontinence care to R76 in R76's room. CNA14 was not wearing a gown. During an interview with Licensed Practical Nurse (LPN) 9 on 07/09/26 at 11:00 AM, LPN9 was asked how staff were made aware of which residents were on EBP. LPN9 stated it was by the notice on the door with the supplies. LPN9 was notified that CNA14 had entered R76's room without putting on the required PPE. LPN9 then entered the room and notified CNA14 of the required use of PPE for R76. When exiting the room, LPN 9 verified CNA14 was providing care for R76 and was not wearing a gown. During an interview with the Infection Preventionist (IP) on 07/10/26 at 12:07 PM, the IP said that training was annually and in initial orientation for the use of PPE. She said that she was in the process of identifying things that needed to be addressed first and that she herself had not trained staff on EBP.

Based on observations, record review, interviews, and review of facility policy and procedures, the facility failed to ensure appropriate and timely incontinence care for 1 of 1 resident reviewed for bladder and bowel incontinence (Resident (R) 58) out of a sample size of 25 residents. This deficient practice had the potential to result in development of a urinary tract infection or skin related issues.Findings include: Review of the facility policy titled Perineal and Incontinence Care dated 05/05/23, revealed, Staff will perform perineal/incontinent care with each bath and after each incontinent episode. The procedure indicated a reference to Lippincott Nursing Procedures, 9th Ed (edition), Perineal Care, pages 651-653. The provided reference stated, Perineal Care, which includes care of the external genitalia and the anal area, should occur during the daily bath and if the patient is incontinent for urine or stool . Put on gloves, gown and mask as needed . Help the patient into a supine position. Placed a fluid-impermeable pad under the patient's buttocks to protect the bed from stains and moisture . Drape the patient with a towel, bath blanket, or sheet exposing only the perineum, to minimize exposure and embarrassment . If you're using disposable cleaning cloths or a prepackaged bath product, open the packages and obtain the wet cloths .For a male patient . Wash the penis with the washcloth, beginning at the tip and working in a circular motion from the center to the periphery . to avoid introducing microorganisms into the urethra. Use a clean section of the washcloth for each stroke to prevent the spread of contaminated secretions or discharge . Clean the top and the sides of the scrotum; rinse thoroughly and pat dry . Clean the bottom of the scrotum and anal area . Review of R58's Face Sheet, located under the Resident tab of the electronic medical record (EMR), indicated that R58 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease and unspecified dementia with mood disturbance. Review of R58's quarterly Minimum Data Set (MDS), located under the Resident Assessment Instrument (RAI) tab with an Assessment Reference Date (ARD) of 05/14/26, indicated that R58 had a Brief Interview for Mental Status (BIMS) score of one out of 15, indicating severely impaired cognition. The MDS indicated that R58 was always incontinent of bowel and bladder. Review of R58's Care Plans, located under the Care Plans tab of the EMR, revealed a problem, [R 58] is incontinent of bladder and bowel and is at risk for skin breakdown. It included the goal, dated 05/17/26, that [R58] will remain clean, dry and have no occurrence of skin breakdown thru next review date. Approaches included, monitor for incontinence and change promptly. During continuous observations on 07/10/26 beginning at 5:35 AM until 7:10 AM, R58 was observed lying in bed on his back, uncovered. R58 had on a hospital gown with an incontinence brief. A strong urine odor was present during the continuous observations from the room into the hallway, which could be noticed by any staff walking past. During an interview on 07/10/26 at 7:10 AM, Certified Nurse Aide (CNA) 5 entered R58's room. The surveyor asked CNA5, who stated that she was the CNA assigned to R58 from 11:00 PM to 7:00 AM, when R58 had last been changed. CNA5 said R58 was last changed at 2:30 AM. When CNA5 was notified that the surveyor wanted to observe incontinence care provided to R58, CNA5 stated that R58 would be soaking wet as he always is. During an observation on 07/10/26 at 7:10 AM, CNA5 put on a gown and gloves to provide care for R58. A clean hospital gown and sheets were on R58's bedside table prior to CNA5 entering the room. A strong urine odor was present in the room. As CNA 5 was removing the resident's gown, brief, and sheets from R58 and his bed, the CNA confirmed the resident's gown and sheets were wet. When asked how far up the resident's back the sheets were wet, CNA5 demonstrated by placing her hand at the mid back of the resident. The brief, observed saturated with urine, was removed from the resident and placed in the trash can at the resident's bedside. The sheets were also observed to be saturated with urine as they were removed from the bed and a clean brief placed under the resident. The resident was observed to be dripping urine as the care was being provided. The CNA attempted to have the resident roll to the side, but he would not turn for her. CNA5 stated she usually had help but did not turn on the call light or ask anyone to come in to assist her with providing care for the resident. CNA5 was observed to use incontinence wipes to clean the lower buttocks only, without turning the resident to ensure that the urine was cleansed from the resident's back or upper buttocks. The resident's perineal area was also not cleaned to remove the urine from the penis and scrotum or between his legs. The CNA secured a clean brief on the resident. At the end of the incontinence care observation, CNA5 agreed that she did not provide care in a manner to ensure that the urine was cleaned from the resident's skin. During an interview on 07/10/26 at 2:25 PM, the Administrator was asked about her expectations of staff to provide timely incontinence care. The Administrator said that she expected the residents to be taken care of as if they were family. During an interview on 07/10/26 at 2:30 PM, the Director of Nursing (DON) was asked for her expectations of CNAs providing incontinence care. The DON said they should follow what they were taught in CNA training and provide the care as required.

Based on observations, record review, and interviews, the facility failed to ensure that fall investigations were thorough and that interventions were developed and implemented to address identified fall risk factors including cognitive impairment and wandering behavior for one of four residents reviewed for falls (Resident (R) 9) out of a total sample of 25 residents. This failure had the potential to result in recurrent falls.Findings include: Review of R9's Face Sheet, located in R9's electronic medical record (EMR) under the Residents tab, indicated R9 was admitted to the facility on [DATE] with diagnoses including but not limited to vascular dementia moderate, with other behavioral disturbance. Review of R9's quarterly Minimum Data Set (MDS) assessment, located under the Resident Assessment Instrument (RAI) tab of the EMR with an Assessment Reference Date (ARD) of 03/05/26, revealed R9 had a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating severe cognitive impairment. The assessment indicated R9 had not exhibited any wandering behavior and required supervision for toileting hygiene. Review of a Bone or Joint Fracture report submitted by the facility to the State Agency (SA) after R9 was found on the floor in front of her wheelchair on 04/10/26 at 5:00 PM, revealed the facility investigated the fall and determined R9 had attempted to independently transfer herself from her wheelchair to her bed. Review of the Care Plan located in R9's EMR under the Care Plan tab identified a problem start date of 12/17/21 which indicates [R9] is at risk for falling . An approach with a start date of 04/13/26 was added to Place dycem [a tacky, non-slip material] to top of wc [wheelchair] cushion and an approach was added on 04/15/26 for Dycem to w/c underneath cushion . No new fall interventions were documented after 04/15/26. Review of a Patient/Resident Incident/Accident Investigation Worksheet, provided by the Director of Nursing (DON), with an incident date of 05/17/26, indicated, Resident was observed on floor in room. Review of the Falls Investigation Worksheet revealed the unwitnessed fall occurred at 1:00 PM; the resident did not call for help and was using a wheelchair. In the Medical Considerations section, under Psychiatric/Cognitive, wandering and cognitive impairment were checked. In the Recommendations/Interventions section of the worksheet, the documented intervention was, Encourage resident to seek assistance to bed or bathroom. This intervention was not added to the care plan. Review of a Patient/Resident Incident/Accident Investigation Worksheet, provided by the DON, indicated that on 05/25/26 at 1:30 PM, R9 was found sitting on her buttocks on the floor in another resident's room, which was R9's previous room. The resident told staff she was trying to go to the bathroom. Documented follow up/steps taken to prevent reoccurrence on the worksheet included, Offer rest periods after lunch. This intervention was not added to the care plan. Review of R9's Progress Notes, located under the Resident tab of the EMR and dated 05/26/26 at 11:27 AM, revealed, Resident has a new order to offer rest periods after meals q [every] shift r/t [related to] recent fall. During an observation on 07/09/26 at 10:15 AM, R9 was observed in bed. R9's wheelchair was placed at the end of her bed. A blue Dycem mat was observed in the seat of R9's wheelchair; however, there was no cushion observed in the seat of the wheelchair. On 07/10/26 at 10:50 AM, Licensed Practical Nurse (LPN) 4 was interviewed about the Dycem in R9's wheelchair. LPN4 stated there was Dycem in the chair, but there was no cushion in the chair with Dycem on top. LPN4 asked R9 if she could go with her to her room to look for the chair cushion. R9 agreed to go with LPN 4 to look for the cushion; however, the cushion and Dycem could not be located in R9's room. LPN 4 stated R9 should have a wheelchair cushion and stated she would obtain one. On 07/10/26 at 11:57 AM, the resident was sitting in the dining/activity area across from the nurse's station. There was no cushion observed in the resident's wheelchair. During an interview on 07/10/26 at 12:00 PM, Certified Nurse Aide (CNA) 12 stated this was the first day she had taken care of R9. CNA12 stated R9 was a one-person assist with transfers and was incontinent. When asked if she had seen a cushion for R9's chair, CNA12 stated she had not. During an interview with the DON on 07/10/26 at 12:00 PM, the DON was asked if the intervention after the 05/17/26 fall to encourage the resident to seek assistance to the bed or bathroom was appropriate considering R9's cognitive status, the DON stated it was not appropriate. The DON was asked if the indication of wandering identified for the fall that occurred on 05/17/26 was addressed and if interventions related to wandering were implemented since the 05/25/26 fall occurred in R9's previous room. The DON confirmed that wandering had not been addressed.

Based on observations, record review, staff interviews, and facility policy review, the facility failed to ensure dietary interventions were implemented in accordance with physician orders and residents' care plans, failed to ensure a timely Registered Dietitian (RD) assessment was completed, and failed to ensure meals were served consistent with the menu and resident preferences for two of six residents reviewed for nutrition (Resident (R) 21 and R31) out of 25 sample residents. This failure had the potential to result in inadequate nutritional intake, unplanned weight loss, and worsening malnutrition.Findings include: Review of the facility's policy titled, Nutritional Assessment/Evaluation, last revised 10/15/25, revealed, With the assistance of Facility's Certified Dietary Manager (CDM) or its Dietetic Technician, registered (DTR) Facility's Registered Dietitian Nutritionist (RDN) will complete a comprehensive nutritional assessment upon the patient's/resident's admission, annually and whenever a significant change in status occurs . Review of the facility's position description for Clinical Dietician, last revised 04/16/12, revealed Responsible for the nutritional care of the residents/patients in accordance with current applicable federal, state, and local standards, guidelines and regulations, Facility established policies and procedures, and in coordination with the Nutrition Services Director (NSD) to ensure that quality nutritional care and food service is provided at all times . Ensures that a current, legible tray ticket with the patient's/resident's name, room number, diet order, food preferences, and any other pertinent information is available for all patients/residents who receive meals and is updated as needed . Ensures that diet changes and new diet orders as received from nursing services are processed and accurately reflect physician orders . Completes a nutritional assessment upon admission and at least annually thereafter, or as otherwise necessary . Ensures that all charted progress notes are informative and descriptive of the services provided and of the patient's/resident's response to the service . Visits patients/residents routinely to evaluate the quality of meals served, meal intake, preferences, etc. Monitors food temperatures and food quality at point of service and delivery in the dining rooms, lounges, and patient/resident rooms via test trays, completing a meal appeal score, at least monthly . Develops and maintains a good working rapport with nutrition services personnel, as well as other departments within the facility to ensure that the nutrition services can be properly maintained to meet the needs of the patients/residents. Review of the facility's position description for Dietary Manager, last revised 04/16/12, indicated, The Dietary Manager is responsible for planning, organizing, developing, and directing the overall operation of the Dietary Services Department in accordance with current applicable federal, state, and local standards, guidelines and regulation . Plans and reviews the therapeutic and regular diet plans and menus and ensures that they are in compliance with physician orders. Ensures an accurate menu or tray card is available for each meal for each patient/resident . 1. Review of R21's Face Sheet, located under the Resident tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, moderate protein-calorie malnutrition, dietary calcium deficiency, and diabetes mellitus type two. Review of R21's Care Plan, located under the Care Plan tab of the EMR, dated 07/23/25, indicated a problem area that the resident was at risk for pressure injury related to incontinence. On the care plan were interventions that included encouraging foods high in protein and calories and for the RD to assess nutritional status and make recommendations. Further review revealed a problem area of nutrition status which indicated the resident was underweight and received hospice care. Interventions included monitoring and encouraging food and fluid intake and offering alternates if intakes were less than adequate, initiated 07/23/25, provide a house, honey, and pureed diet, dated 11/12/25, and include a frozen nutritious treat (Magic Cup) at lunch and dinner, dated 02/04/26. Review of R21's Physician Orders, located in the EMR under the Orders tab, revealed orders for a House, Pureed, Honey diet, dated 11/12/25, Frozen Nutritious Treat (Magic Cup) lunch and dinner, dated 02/03/26, and an order, dated 02/05/26, to admit to Hospice Services r/t [related to] Primary protein calorie malnutrition secondary to Parkinsons. Review of the Progress Notes, located in the EMR under the Progress Notes tab, revealed the last RD note for R31 was on 04/20/26, which stated, . He has been Hospice Pt [patient] since February . He feeds himself Pureed diet .He gets high protein ice cream supplements with trays . Continue nutrition orders. Review of R21's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/26, located under the Resident Assessment Instrument (RAI) tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated significant cognitive impairment. The MDS documented that R21 received staff's assistance with setup or cleanup for eating Further review revealed that R21 weighed 106 pounds (lbs), had not gained or lost weight, and received a mechanically altered diet. During an observation on 07/08/26 at 12:36 PM, R21 was observed receiving lunch in his room. The resident received pureed ham, pureed black-eyed peas, mashed potatoes (without gravy), and a watered-down applesauce. The unedited meal ticket stated pureed baked ham and pureed black-eyed peas but also documented one ounce (oz) of sauce for the ham and half a cup of pudding. R21 did not receive the pudding or sauce as noted on the meal ticket but instead received mashed potatoes and applesauce that were not on the meal ticket. The meal ticket did not include the Magic Cup, and R21 did not receive a Magic Cup for lunch. Review of the list of residents requesting alternates for lunch on 07/08/26 revealed R21 had not requested an alternate meal. During an observation on 07/09/26 at 12:31 PM, R21 was observed receiving lunch in his room. The resident received pureed pork chop, pureed green beans, mashed potatoes (without gravy), and a watered-down applesauce. The unedited meal ticket stated pureed smothered pork chop, pureed fluffy rice, pureed fresh baked roll, margarine, and pureed whipped strawberry delite. R21 did not get the rice, roll, or the strawberry delite but did receive mashed potatoes and applesauce that were not on the meal ticket. R21's meal ticket did not include the Magic Cup, nor was it provided for lunch. Review of the list of residents requesting alternates for lunch on 07/09/26 revealed R21 had not requested an alternate meal. During an observation on 07/10/26 at 12:28 PM, R21 was observed receiving lunch in his room by Licensed Practical Nurse (LPN) 1. The resident received a pureed hot dog, pureed baked beans, pureed cabbage, and watered-down applesauce. The unedited meal ticket stated pureed hot dog on bun, pureed baked beans, pureed cabbage, and a pureed fruit cup. R21 did not get the fruit cup but instead received applesauce. R21's meal ticket did not include the Magic Cup, nor was it provided for lunch. Review of the list of residents requesting alternates for lunch on 07/10/26 revealed R21 had not requested an alternate meal. During an interview on 07/10/26 at 12:28 PM, LPN1 stated that she was not aware if R21 was supposed to receive a Magic Cup with his meals but stated she could get one. Upon review of R21's physician orders, she confirmed that he had an active order to receive a Magic Cup for lunch and dinner. She stated that she was not sure why it had not shown up on the resident's meal ticket or lunch tray. 2. Review of R31's Face Sheet located under the Resident tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses including spastic quadriplegic cerebral palsy, protein-calorie malnutrition, muscle wasting and atrophy, and dysphagia (difficulty swallowing). Review of R31's Care Plan, located under the Care Plan tab of the EMR, dated 07/15/20, indicated the resident was at risk for alteration in nutrition. Interventions included for the RD to monitor the skin report, weight, and nutrition-related labs, and to consult as ordered, dated 01/12/23, and to provide a house, mechanical soft diet, dated 12/04/25. Review of R31's quarterly MDS with an ARD of 05/14/26, located under the RAI tab of the EMR, revealed a BIMS score of 15 out of 15, which indicated no cognitive impairment. R31 received staff's assistance with setup or cleanup assistance for eating. R31 weighed 154 lbs. with weight gain of 5% or more in the last month or gain of 10% or more in the last six months (not on physician prescribed weight gain regimen) and received a mechanically altered diet. Review of R31's EMR revealed there had not been an annual nutritional assessment completed by the RD from June 2025 through July 2026. During an observation on 07/08/26 at 12:22 PM, R31 was observed receiving lunch in his room. The resident received mechanically baked ham, mechanical black-eyed peas, mashed potatoes (without gravy), a fruit cup, and apple juice. The unedited meal ticket stated mechanically baked ham with extra gravy or sauce, mechanical black-eyed peas, a half a cup of sherbet, and cranberry juice. R31 did not get gravy for the ham nor the sherbet or cranberry juice. R31 did get mashed potatoes and the fruit cup that were not on the meal ticket, as well as apple juice. R31 stated that he would have liked to have had the gravy with his meal and did not know why he did not receive it. Review of the list of residents requesting alternates for lunch on 07/08/26 revealed R31 had not requested an alternate meal. During an observation on 07/09/26 at 12:35 PM, R31 was observed receiving lunch in his room. The resident received a cheese sandwich, tomato soup, strawberry delite, and two containers of grape juice. The unedited meal ticket stated mechanical smothered pork chop with extra gravy, rice, green beans, baked roll, strawberry delite, and cranberry juice. The resident did not receive a pork chop, rice, green beans, the roll, or cranberry juice. The resident did receive the cheese sandwich, tomato soup, and grape juice that were not on the meal ticket. Review of the list of residents requesting alternates for lunch on 07/09/26 revealed R31 had requested an alternate meal of chef salad and vegetable soup. During an observation on 07/10/26 at 12:35 PM, R31 was observed receiving lunch in his room. The resident received a mechanical burger, baked beans, mandarin oranges, and grape juice. The unedited meal ticket stated mechanical hot dog on a bun, baked beans, pureed creamy coleslaw, chilled fruit cup, and cranberry juice. The resident did not receive the hot dog, pureed coleslaw, or cranberry juice. R31 did receive the burger and grape juice that were not on the meal ticket. R31 said that he did not know why he did not get the coleslaw, but it would have been nice to have had. Review of the list of residents requesting alternates for lunch on 07/10/26 revealed that R31 had requested an alternate meal of hamburger and fries. During an interview on 07/10/26 at 7:50 AM, the Administrator stated that the RD had last seen R21 for a nutritional review in April 2026, but she could not find any recent documentation that the RD had seen R31. During an interview on 07/10/26 at 10:25 AM, the RD stated that she completed nutritional assessments remotely via telehealth visits by phone with the facility's residents since she resided in Wisconsin. She added that she also provided telehealth services when nurses asked her to look at someone. The RD said she completed weekly reports with the Dietary Manager (DM), including the completion of supplement order recommendations. The RD said that she completed initial nutritional assessments in the first week for new residents and completed annual assessments at the six-month mark for every resident. The RD said that she was made aware when residents had assessments due by reviewing the EMR dashboard. She confirmed the DM completed the quarterly nutritional assessments. Upon review of R31's EMRs she confirmed that she had not completed an annual nutritional assessment in the past year for the resident, but that she should have completed one in May 2026. The RD stated that upon review, the DM had completed a quarterly dietary assessment instead. The RD stated that R21 should continue the nutritional interventions, including the Magic Cup, because it was good for a honey thick diet. During an interview on 07/10/26 at 12:39 PM, Certified Nurse Aide (CNA) 10 stated that residents could choose hot dogs or hamburgers and either beans or coleslaw for this lunch. CNA10 said that residents were asked in the morning if they wanted the alternate or not, and then the changes had to be marked on the meal ticket. During an interview on 07/10/26 at 1:31 PM, the DM stated that she completed the quarterly nutritional assessments for the facility residents. She said that she did the resident interviews, gathered information, and documented allergies, and the RD completed her portion. DM said that she and the RD collaborated by email and phone. The DM said that when the nurses and RD put an order into the EMR, it transferred over to the meal tickets. She said that the nurses provided supplements including Med Pass and Ensure, but the kitchen supplied house shakes, protein Jello, and the Magic Cups. Upon record review for R21, the DM confirmed there was an active order for Magic Cup for lunch and dinner. The DM reported being unaware of the order, or why it had not transferred to R21's meal ticket. The DM confirmed that what was on the meal tickets for the residents was what should be on the plates. If a resident requested an alternate for a meal, the substitute items should be written on that specific meal ticket. During an interview on 07/10/26 at 3:32 PM, the Director of Nursing confirmed that R21 had an order for Magic Cup since February 2026 and stated she was not sure why it had not transferred to the resident's meal ticket. The Director of Nursing stated that whatever was documented on a resident's meal ticket during meal service was what should be on the tray.

Based on interviews, record review, document review and facility policy review, the facility failed to ensure allegations of abuse were thoroughly investigated and documented for two of four residents (Resident (R)101 and R46) reviewed for potential incidents of abuse out of 25 sampled residents. This failure had the potential to contribute to further unidentified or staff to resident abuse incidents within the facility.Findings include: Review of the facility's policy titled, Leadership Policies and Procedures, under Subject: Abuse, Neglect, Exploitation, or Mistreatment, revised 10/23/19, revealed, . Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions . Written summaries of interviews with individuals having first-hand knowledge of the incident. NOTE: Employees/witnesses are not to write out statements. Employees/witnesses will be interviewed by designated facility staff, and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer . All documents pertaining to the investigation must be compiled and stored in the administrator's office . 1. Review of R101's Face Sheet, located under the Resident tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including anterior dislocation of right humerus (upper arm bone), traumatic ischemia of muscle, bilateral primary osteoarthritis, and history of falling. R101 discharged on 05/18/26. Review of R101's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/26/25, located under the Resident Assessment Instrument (RAI) tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. The MDS indicated that R101 had limited range of motion to an upper extremity on one side, was dependent on staff for toileting hygiene and mobility, and required substantial/maximum assistance for showering. Review of R101's Grievance Report list, provided by the facility, revealed the resident filed multiple grievances related to activities of daily living (ADL) and care on five separate occasions. The facility accumulated the allegations and reported the concerns to the State Agency (SA) as a Facility Reportable Incident (FRI) on 12/18/25. The following were reviewed: -The first grievance, dated 12/09/25, revealed the resident had her legs tangled in her sheet at night, so she put her call light on. The Certified Nurse Aide (CNA) then came to her doorway and stated, What do you want? and when the resident explained, the CNA said, What do you expect me to do? -The second grievance, dated 12/10/25, revealed R101 alleged that she turned her light on at approximately 9:00 PM because she needed to be changed. R101 stated that no one came to check on her to see if she needed to be changed until lunchtime the next day. -The third grievance, on 12/15/25, stated that R101 was lying on her left side and asked the CNA to put her on her back. R101 stated that the CNA tried to move her but was unable to and said, I'm not pulling on you and left. R101 stated that she laid on her side for eight hours before someone came to help her turn over. -The fourth grievance, dated 12/16/25, alleged the staff turned off her call light around 10:30 – 11:00 PM and R101 did not see any staff members until 5:30 – 6:30 AM. -The fifth allegation, dated 12/18/25, revealed that a CNA changed her on the third shift, around 2:00 AM. R101 indicated she did not see any CNAs to provide care until therapy staff came in around 10:00 AM; she only saw the nurse to get her medications. Review of R101's Facility Incident Report Form, the initial report to the SA, dated 12/18/25 at 1:52 PM and provided by the Administrator, revealed, Allegation of neglect. Investigation initiated. Review of the Five-Day Follow-up Report, dated 12/23/25 and provided by the Administrator, revealed, Resident reported that she is not being changed. Resident stated that she needs to wait hours for someone to come in and change her . The investigation summary revealed that the facility interviewed CNAs and nurses, but the Resident(s) Involved Statement was not included in the investigation. Review of the FRI investigation, provided by the facility, revealed that 26 nurses, CNAs, facility administration, and agency staff were interviewed about the allegations identified by R101, and statements were written. Further review of the FRI investigation failed to reveal that any monitoring or evaluations occurred during the night shift to ensure compliance with call light response times, ADL care, or repositioning. The investigation failed to document a follow-up interview from R101 regarding the five grievances related to the care she had received, to ensure all information was reviewed and comprehensive during the facility investigation. Review of the FRI investigation for R101 revealed that the Social Services Director (SSD) used the Safe Survey Tool on an Excel spreadsheet and interviewed seven residents on 12/18/25. The only question documented on the Excel spreadsheet was, Do you feel safe in this facility? There was a y placed next to the resident rooms. There was no documented statement from the residents that identified if there were concerns with the night staff, call light response times, repositioning, or concerns with any specific facility staff providing care. No resident statements were documented. During an interview on 07/10/26 at 11:02 AM, the SSD said that when the facility reported an incident she spoke to the resident and the roommate. She completed follow-ups, which included safe survey questions, such as do you feel safe here? The SSD said that the questions depended on the situation being reported and confirmed that the Excel spreadsheet with the y or n for resident interviews was the current form used when talking to residents. The SSD stated that the other residents interviewed during the investigation were selected because they resided on the same hallway as R101 and were alert and received care from the same CNAs. SSD confirmed that she was told to ask only the one question about feeling safe. During an interview on 07/10/26 at 3:32 PM, the Director of Nursing (DON) stated that to ensure a thorough investigation, the facility obtained witness statements from every staff member and alert and oriented resident that was there the day of the incident. The DON stated that when they interviewed residents during an investigation, they wanted to know whatever the resident could tell them, they just wanted them to open [up] and freely [say] what they know. The DON said that they would write down whatever the residents told them, for a thorough investigation. Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Mistreatment, last revised 11/01/17, revealed, The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation or mistreatment and will implement immediate action to safeguard resident . The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated . Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions . Interview individuals having first-hand knowledge of the incident and write summaries of the interviews . Depending on the incident, other residents in the facility may be interviewed. 2. Review of R46's Face Sheet, located under the Resident tab in the EMR, revealed R46 was admitted on [DATE] with diagnoses including other chondrocalcinosis (buildup of calcium crystals in the joint cartilage) of the right knee, polyneuropathy (neurological disorder which can cause pain), and major depressive disorder. Review of R46's Care Plan, dated 02/06/26 and located under the RAI tab of the EMR, revealed R46 was at risk for psychosocial well-being and at risk of negative outcomes related to allegations of abuse. Interventions included having the interdisciplinary team (IDT) monitor for changes and restlessness. Review of R46's quarterly MDS, with an ARD of 05/14/26 and located under the RAI tab of the EMR, revealed a BIMS score of 14 out of 15, indicating intact cognition. Review of the facility's FRI and investigation, dated 02/06/26 and provided by the facility, revealed R46 alleged that CNA13 pulled on her wrist and blessed her out. The resident felt like the CNA was physically and verbally abusive at the time of the incident. Further review revealed that the alleged perpetrator was interviewed; however, her interview was not included in the facility's five-day report sent to the SA. Further review of the investigation revealed no staff interviews were included. During an interview on 07/09/26 at 9:03 AM, the Administrator stated the previous Director of Nursing (DON) completed staff interviews during the investigation but failed to put them with the other reportable data. During an interview on 07/09/26 at 1:45 PM, the Administrator stated the facility's investigation of the FRI did not include the staff interviews conducted by the previous DON. The Administrator confirmed the investigative file was incomplete due to not including a record of the interviews which were conducted. She was able to provide pages from a note pad that indicated staff interviews were done; however, the notes did not indicate which employees were interviewed.

Based on observation, interviews, and review of facility policy, the facility failed to ensure that one of 25 sampled residents (Resident (R) 73) was treated with dignity and respect by allowing the resident's body to be exposed to public view and by permitting a staff member to provide care in a disrespectful manner, including failing to explain care and pulling the resident backward in a geri chair. This failure had the potential to cause embarrassment, humiliation, emotional distress, and diminished psychosocial well-being. Findings include:Review of the facility's policy titled Social Services Policies and Procedures, revised 06/09/23, revealed, Quality of life begins with the preservation of a sense of dignity and individuality. Review of R73's Resident Face Sheet, located in the resident's electronic medical record (EMR) under the Resident tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that included altered mental status. Review of R73's admission Minimum Data Set (MDS), located in the resident's EMR under the Resident Assessment Instrument (RAI) tab with an Assessment Reference Date (ARD) of 06/29/26, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R73 was moderately cognitively impaired. The MDS further revealed that R73 required maximum assistance with all activities of daily living (ADLs). During an observation on 07/10/26 at 4:45 AM from outside of the facility looking in through the front door's two-foot by three-foot window, R73 was observed sitting in his geri chair (geriatric chair, designed for elderly and mobility challenged individuals) approximately 10 feet from the front door. R73 faced the door and was observed wearing only a t-shirt and an incontinent brief. A blanket was on the floor. Upon entering the facility, R73 was observed wearing non-skid socks, one of which had what appeared to be dried blood splatters on the heel. R73 spoke with unidentifiable words and occasionally said, let's go. Certified Nurse Aide (CNA) 3 stated that R73 was in the hall because he likes to fall. CNA3 then came behind R73 and, without acknowledging him or letting him know what was happening, CNA3 pulled R73 backward in the geri chair to his room. During an interview on 07/10/26 at 9:30 AM, the Social Services Director (SSD) stated dignity was defined as treating residents respectfully, calling them by name, never pulling their chair backward, and speaking to them about cares regardless of whether the resident makes sense when speaking. She stated what CNA3 did was not respectful or dignified. During an interview on 07/10/26 at 10:38 AM, the Director of Nursing (DON) stated CNA3 treated R73 like he was on an assembly line. She stated staff need to communicate with residents about what cares they are going to provide, interact with the residents, and never pull a resident's chair backward during transport. During an interview on 07/10/26 at 11:16 AM, R73's family member (FM1) stated when she arrived at the facility on 07/09/26 at 6:30 PM, R73 was sitting in front of the front door without pants on. She stated, I think they just keep him in the chair, so they don't have to deal with him. During an interview on 07/10/26 at 1:04 PM, the Administrator stated she expected residents who were seated in the hallway without pants to be covered with a blanket and that staff should speak to residents in a kind and respectful manner. The Administrator confirmed that CNA3's interactions with R73 did not demonstrate care provided with respect and dignity.

Based on review of the facility policy, observation, record review and interview, the facility failed to ensure ordered fall devices were in place for 1 Resident (R)11, reviewed for accidents. Findings include Review of the facility policy titled, Fall Management with a revision date of May 5, 2023 revealed under the policy, The facility will identify each resident who is at risk for falls and will plan care and implement interventions to manage falls. The facility provides assistive devices based onindividual resident needsto facilitate mobility and prevent falls. Record review of R11's facesheet revealed he was admitted to the facility on [DATE] with diagnoses that include but are not limited to; displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Record review of R11's Quarterly Minimum Data Set (MDS) with an Assesment Reference Date (ARD) of 12/02/24 revealed he had a Brief Interview Mental Status (BIMS) score of 13 out of 15, indicating he was cognitively intact. During an observation and interview on 03/03/25 at 10:00 AM, R11 was observed lying in bed. R11 stated, The lights went off. I got up to turn the lights back on. I started walking and I fell backwards. He pointed to his right leg, and said, This is the leg I fractured. Additional observation revealed there were no non-skid strips at his bedside. There were no anti-roll back on his wheelchair (W/C). His wheelchair was locked at his bedside, directly by his bed toward the foot of the bed. Record review of R11's progress notes dated 11/25/24 at 01:48 AM revealed On arrival R11 was observed on the floor at the foot of B bed. Resident stated that he was going to the bathroom and his wheelchair slipped backward. Wheelchair was found in the locked position on both sides. On assessment of resident, he was able to move both arms but unable to move right leg due to pain in right hip. On-call provider, notified. Order received to send resident to Emergency Department (ED) for evaluation. Message left for Director of Nurses. (DON). 911 called and resident was transported to ED. Record review of R11's progress noted dated 12/16/24 at 10:58 AM revealed, Received order for [NAME] to be applied to w/c for use at all times. [NAME] has be applied. Patient is aware. Record review of R11's physician orders revealed on 11/26/24, an order for Anti-roll back device to wheelchair. Additionally, on 12/07/24 an order for Nonskid strips to floor by bed. There was not an order for a Dycem. Record review of R11's care plan with a revision date of 01/21/25 for falls revealed an approach to, apply dycem to W/C as ordered. On 03/03/25 at 2:55 PM, an interview with Certified Nursing Assistant (CNA)15 revealed, I'm not sure he is a fall risk. Most times the wheelchair is by the bed. He gets up on his own, but we ask him to please call staff to observed just in case. I helped him this morning. He got in his W/C. She pointed to his W/C, it did not have the anti-rollbacks. CNA15 said she was not aware of his safety measures. She said, We could check the computer. She said she's not aware if it would be there. She clicked on resident profile, and it did show the anti-rollbacks to his W/C and the non skid strips at bedside. She said, I didn't know I could see this. On 03/03/25 at 3:05 PM, an interview with Licensed Practical Nurse (LPN)13 revealed, R11 has anti rollbacks to his W/C because he is a fall risk. She said she did not realize his W/C did not have antiroll backs. She walked down to R11's room to observe the W/C at R11's bedside and said, The W/C may have got mixed up with his roommates W/C. On 03/04/25 at 10:00 AM, an observation revealed LPN13 was in the room with R11. He had the correct W/C at bedside with the anti-rollbacks. LPN13 stated, They had the W/C's mixed up yesterday and I also went back to review his orders. He was supposed to have the anti-skid strips on the floor. They got them put down; it was my fault for not checking. The anti-skid strips were observed at R11's bedside on the floor. On 03/04/25 at 10:20 AM, an interview with the DON revealed, For falls, all ordered safety measures should be in place for any resident.

Based on review of facility policy, record review and interview, the facility failed to notify the provider of a dehisced wound for 2 days, which caused Resident (R)8 to return to the hospital, for 1 of 1 residents reviewed. Findings include: Review of the facility policy dated 06/01/15, titled, Surgical Incisions documents, The clinician will follow specific physicians orders for treatment of these wounds. Obtain clarification orders if the initial orders are not specific. These wounds are usually covered with dry dressings. Based on review of facility policy, record review and interview, the facility failed to notify the provider of a dehisced wound for 2 days, which caused Resident (R)8 to return to the hospital, for 1 of 1 resident reviewed. Findings include: Review of the facility policy dated 06/01/15, titled, Surgical Incisions documents, The clinician will follow specific physician's orders for treatment of these wounds. Obtain clarification orders if the initial orders are not specific. These wounds are usually covered with dry dressings. Review of R8's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including but not limited to acquired absence of right leg above knee (AKA), peripheral vascular angioplasty status with implants and grafts, Type 2 diabetes mellitus with diabetic neuropathy and phantom limb syndrome with pain. Additionally, it recorded a last qualifying hospital stay dated 12/30/24 - 01/06/25. Review of R8's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/24, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating he was cognitively intact. Review of progress noted dated 12/28/24 at 06:19 PM revealed, R8 in bed, incision to right AKA open draining blood, pain to touch. Reported findings to Director of Nursing, (DON) and placed in Medical Doctor (MD) for assessment. Area cleanse with wound cleanser with calcium alginate and a foam dressing until being assessed by Nurse Practitioner (NP). Review of an additional progress note dated 12/30/24 at 09:55 AM of R8 revealed, Received order from facility NP to send patient to emergency room (ER) for eval of the right AKA as it is draining large amount of copious greenish bloody drainage. Record Review of hospital records dated 12/30/2024-12/31/2024 Hospital Day 1, recorded, Assessment/Plan: Principal Problem: Wound Dehiscence, Active Problems: Wound Infection, Physical Exam: Extremities: Right AKA dehiscence of the wound and drainage. X- Ray Femur Impression: status post recent AKA. Little soft tissue material appears to cap the tip of the femoral osteotomy, correlate for wound breakdown clinically. During an interview on 03/03/25 at 2:41 PM with Licensed Practical Nurse (LPN)12 revealed, The Certified Nurse Assistant (CNA) had been telling the nurses that R8 had an open wound, his amputation site. I knew about because I went to lunch. Another nurse came to my cart and told me a CNA reported that the resident he had an open wound on his surgical site, there was no dressing. I was on lunch. I told her I'm taking my break. I gave pain medication; he was in a lot of pain. He was probably at an 8. I called the DON; she was not aware of it. I facetimed the DON. She told me what dressing to put on it. She told me she was going to take care of the order. I don't think I called the NP or the MD. It was very pink, a mod amt of blood. It was not purulent at that time. I did not notify his family. I asked if I needed to do an incident report, she said no. During a telephone interview on 03/03/25 at 3:27 PM with the treatment nurse revealed, I did remove his staples, he handled it well. I believe his wound dehisced over the weekend. He was sent out. I wasn't there. A nurse came to me on the Friday before, it was draining a little on the right lateral side. After the staples, I left it open to air. She asked me to look at it. It was still closed then. I wrapped it. It wasn't draining after I looked at it. During an interview on 03/03/25 at 2:06 PM with LPN13 revealed, R8 came back with the AKA. The wound nurse removed the staples. Towards the end of the week, it was bleeding a little. I told the wound nurse about it. She did not apply steri-strips initially after the sutures were removed. She did apply steri-strip, at the end of the incision where it started bleeding, it was not open, that was Friday. It held through the weekend into the following week. Towards the middle of the following week, there was still 1 steri-strip on there. That Friday the 27th, I left the one steri-strip, and it looked fine. A CNA text me, over the weekend, on Saturday the 28th. She told me his leg was draining, she said it looks infected and open, and I told her to tell his nurse. She said the nurse had an attitude. I told her I am off today, and I'll look at it on Monday. The CNA wrote that she asked the nurse for a patch to put over it and she said she can't do it right now. I told her fine, I was just making sure I let you know. I did not call anyone to report this. I mentioned the text to my DON and UM when they questioned me. It does concern me that he was bleeding from the wound, and he was on Eliquis. I saw the wound when I returned. It was the first thing I did. There was an improper dressing with an ABD pad wrapped with tape around his stump. I don't remember a date. I removed the dressing, the wound was dehisced, about 2 inches, from the end where I noted it the previous Friday. The drainage was brown and yellow. I called NP immediately. He came to come and look at it and made the decision to send him out to the hospital. He was concerned as why it wasn't addressed over the weekend. During an interview on 03/03/25 at 2:33 PM with CNA14 revealed, I went into the room to do R8's hygiene. We had an agency nurse. I told her his right wound was open and bleeding. It was like fresh, new blood. The steri-strips were hanging off a bit. I went back to go and check on him, and she hadn't done anything yet. I went and got another nurse who works every weekend. She spoke to the agency nurse. During a telephone interview on 03/03/25 at 4:30 PM with LPN15 revealed, I only worked on Saturday and Sunday. I addressed R8 with the nurse on duty. I never actually did the dressing change. The wound had dehisced, it was a surgical incision. The CNA came and got me, I looked at it. I went to the nurse on the floor. I said to her you can send him out or put a wet to dry dressing on it and wait for the doctor until Monday. During an interview on 03/03/25 at 3:39 PM with the Nurse Practitioner (NP) revealed, R8 had a wound that dehisced. I was asked to see him. It looked infected to me; it was more than we were capable of. He was probably going septic, and he need Intravenous (IV) antibiotics (ABT). The weekend staff should have called the on-call provider. The NP confirmed it was the Monday after the wound dehisced that he observed the wound. During an interview on 03/03/25 at 5:20 PM with the Clinical Services Director (CSD) revealed, They did not have any orders for monitoring of R8's surgical wound when he returned from the hospital, only his abdominal wound, not the right AKA. He should have had orders to monitor his surgical amputation site. The CSD confirmed there were no orders in R8's medical record relating to the right AKA. During an interview on 03/04/25 at 10:20 AM with the DON confirmed R8's dehiscent wound. She stated, I can't recall completing education on dehiscent wounds. For a new amputation, the site should be monitored. If orders were not received by the hospital, contact the NP or surgeon for orders.

Based on review of facility policy, observation, interview and record review, the facility failed to report an allegation of physical abuse, involving Resident (R)2, within the required timeframe, for 1 of 4 residents reviewed for abuse. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment revised on 10/23/19, documents, The facility's Leadership prohibits neglect, mental, physical, and or verbal abuse . and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment . are reported immediately. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including but not limited to: chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, unspecified depression and cerebrovascular accident. Review of R2's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/02/24, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R2 had moderate impaired cognition. Review of R2's Progress Note dated 09/10/24 at 2:17 PM, written by the Social Worker revealed, Spoke with resident related to allegations of physical abuse from a certified nurses assistant. Resident laying in bed, alert and pleasant at time of conversation. Resident informed SW of his abuse allegation and stated he would not remember the exact day but was able to state the alleged abuse occurred this past weekend and named the staff member. Review of Licensed Practical Nurse (LPN)1's Suspension Pending Investigation dated 09/11/24, revealed LPN1 was suspended pending investigation for, Failure to report an allegation of abuse per policy. Review of Certified Nursing Assistant (CNA)1's Corrective Action Form dated 09/17/24, documented a performance/behavioral as, Discharge, for, Violation of policy for failure to report combative resident incident to supervising nurse and failure to cooperate in an investigation. Review of LPN1's Corrective Action Form dated 09/17/24, indicated a performance/behavioral as, Final Warning . Employee did not follow facility policy for reporting an allegation . Employee is expected to notify the administrator-who is the facility abuse coordinator, and or Director of Nurses (DON) at the time of any suspected or reported suspicion of abuse or neglect so that proper actions can be taken and a thorough investigation initiated to ensure the safety of residents. During an interview on 11/26/24 at 10:47 AM, LPN2 stated, [R2] just kept calling my name one day. I went into his room and asked him what he needed. He said something like, someone had hit him, she hit me. I asked who, he said, [CNA1]. I don't know her, she worked weekends. He said she was mean to him. I went to tell my DON and Administrator. He told her the same thing. She had hit him on his left side. During an interview on 11/26/2024 at 12:11 PM with LPN1. She stated, I am aware of reporting any allegations of abuse. I would immediately report to my DON/Administrator. I think it was Sunday. It never came up again until Tuesday. I was asked to come in or speak to an officer. She placed me on suspension over the phone until it was figured out. I didn't see any marks on him. I never asked him directly if anyone had hit him. During an interview on 11/26/24 at 12:58 PM, the DON stated, It was over the weekend that it occurred, not sure if it was the 7th or the 8th of September. It was reported to us on 09/10/24 and we started an investigation. [R2] alleged [CNA1] slapped him on the side of his face and verbal remarks of hanging him from a tree. [LPN1] was the nurse on that weekend. She should have reported that to us, administration, immediately. We suspended her for that. We reported it after we found out. During an interview on 11/26/24 at 1:50 PM, the Administrator stated, I am the abuse coordinator. I reported it when I was notified. He said someone had hit him. I called the cops and completed a body audit. The staff are supposed to call me immediately. [LPN2] let me know that day when she was notified. After we started our investigation, we found out that this was reported to staff over the weekend.

Based on a review of the facility policy, record reviews, and interviews, the facility failed to ensure a resident had a safe and orderly discharge from the facility, for 1 of 1 resident. Specifically, Resident (R)60 was transported and discharged from the facility on 06/12/24 to the [NAME] Housing Authority, 62 miles from the facility. The [NAME] Housing Authority was not able to receive R60 due to financial issues. Furthermore, the facility failed to obtain a physician order for the discharge. On 06/13/24 at 7:19 PM, the Administrator and the Director of Nursing (DON) were notified that the failure to ensure a resident had a safe and orderly discharge from the facility constituted Immediate Jeopardy (IJ) at F624. On 06/13/24 at 7:30 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 06/12/24. The IJ was related to 42 CFR 483.15 - Admission, Transfer, and Discharge. On 06/14/24 at 8:57 AM, the facility provided an acceptable IJ Removal Plan. On 06/14/24 at approximately 10:00 AM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F624 at a lower scope and severity of D. Findings include: Review of the facility policy titled Discharge/Transfer with a complete revision date of 11/01/2017 states, The patient/ resident will be discharged /transferred (home/another entity) by order of his/her attending physician. The facility will include the patient/resident and family in developing a safe discharge plan to address the patient's/ resident's individual needs. Procedures: 1. Obtain a discharge order from the physician. 2. Notify the patient/resident, his/her legal representative, if any, or an interested family member and document the discharge. Types of discharges: Planned discharge to the patient's/resident's home/private residence. Obtain an order for discharge/transfer from the patient's/resident's physician. Arrange community resources identified by the interdisciplinary team/patient/resident and/or family. Provide written Discharge Instructions for care to the patient/resident and/or family when discharging the patient home or to a community setting such as assisted living. Complete the Discharge Summary, documenting the patient's/resident's assessment at time of discharge and a summation of the patient's/resident's stay. Place a copy of the completed forms in the patient's/resident's medical record. Refer to Social Services Policy on Discharge Planning. Review of R60's Face Sheet revealed that R60 was admitted to the facility on [DATE], with diagnoses including but not limited to: Schizophrenia, chronic obstructive pulmonary disease, moderate persistent asthma, hyperlipidemia, Type 2 diabetes mellitus without complications, shortness of breath, and acute on chronic systolic (congestive) heart failure. Review of R60's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/18/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R60 was cognitively intact. Review of R60's Decisional Capacity Form dated 05/31/24, revealed R60 does not meet all the criteria for decisional capacity and therefore cannot make healthcare decisions for himself. Review of R60's Discharge Summary dated 06/12/24 revealed, This resident is being seen today for discharge assessment and is set to discharge from this facility later today, this patient will be going home with family care later today. The Discharge Summary further revealed, R60 was discharged to Section Housing through [NAME] Housing Authority on 06/12/24 and R60 signed his own discharge. Review of R60's Physician Orders revealed an order dated 04/12/24 which stated, I certify that this resident requires continuing placement in a long term care facility. Further review of R60's Physician Orders revealed there was no order for R60's discharge. Review of R60's Care Plan dated 04/16/24 revealed the following: Problem: R60 has discharge potential to a less restrictive environment. A safe discharge plan will be developed to allow him/her to return to the community or less restrictive or alternate environment. R60's stated discharge goal is to return home to [NAME]. R60 is working with [NAME] Housing Authority on alternate residences. Problem: R60 has schizophrenia. Problem: R60 has the risk of respiratory issues related to congestive heart failure, asthma, COPD. He has trouble with SOB when lying flat at times. Problem: R60 appears to have a recall deficit as evidenced by: : [ ] Short-term recall, [ ] Long-term memory recall, [ ]inability to understand commands/communication [ ]Poor decision-making Related to the diagnosis of: [ ]Intellectual Disability, [ ]Dementia, [ ]Traumatic Brain Injury, [ ]Parkinson's Disease, [ ]Late effect of CVA, Others: schizophrenia with periods of inattentiveness and disorganized thinking. Review of R60's Progress Notes revealed the following: 06/12/2024 11:26 AM [Recorded as Late Entry on 06/13/2024 11:26 AM] Resident discharged from facility via Ambustar transport. All discharge paperwork, medications, Rx and belongings sent with resident. 06/07/2024 11:11 AM SW called and left message with resident's sister, informing her of resident's dc plans and requesting a return call with any questions. SW will continue to observe and assist PRN. 06/07/2024 10:55 AM SW spoke with resident's CLTC caseworker via phone and informed her that resident will be discharging next week. She stated she did not need a new referral since resident's case was still open. [CLTC caseworker] stated she only needs resident's discharge date and new address. SW emailed this information to caseworker per her request. SW will continue to observe and assist PRN. During an interview on 06/13/24 at 1:42 PM, R60 stated, When I got to the house yesterday, they were requesting a deposit, which I didn't have. No one told me I needed a $900.00 deposit. Transport dropped me off and left. I slept in a motel last night. I'm talking to you on the phone and I'm walking, trying to find a place to stay. I'm hot. My sister lives in New Jersey, I don't think she knows I left. During an interview on 06/13/24 at 2:16 PM, Social Services (SS) confirmed she knew the resident and assisted him with his discharge. SS stated that R60 requested to be discharged because he was ready to go. SS stated that the resident's family members were contacted on April 2024 shortly after admission and they agreed and requested [NAME] SC. SS stated she spoke with a cousin, who contacted the housing authority on 05/06/24. No NOMNC was issued because the resident was only on Medicaid. SS stated Housing Authority set up water and electricity provided by [NAME] (Housing Authority Representative). SS stated she called the resident's sister related to the discharge and left a voicemail, no actual conversation. SS stated she was not aware that the resident did not have a decisional capacity to make his own decisions. SS stated that R60 is not his own responsible party. SS stated I was going off his BIMS and it's a 15. An attempt to interview the Ombudsman on 06/13/24 at 2:52 PM, was unsuccessful, a voicemail was left for a return call. An attempt to interview the Medical Doctor on 06/13/24 at 3:02 PM, was unsuccessful, a voicemail was left for a return phone call. During an interview on 06/13/24 at 3:27 PM, the Housing Authority Representative ([NAME]) confirmed housing plans were made with the facility social worker and the resident. The resident's appointment was not on 06/12/24, so he was not to report there. His appointment was today 06/13/24 at 2:00 PM. They are currently working on the resident's housing, but he will be staying in a motel until housing is available. The [NAME] stated she did not call the facility today to report that housing fell through. The [NAME] states she cannot provide any more information due to the Privacy Act. During an interview on 06/13/24 at 3:48 PM, the Ambustar Transport Driver (TD) stated, I took him [R60] to downtown [NAME] SC, it was an old building. I do not know the exact building. Once I came to the city limits, the resident took over with directions and said there it is. The facility did not give me a form with the address, they didn't give me anything, just his belongings. We have an app we use, with an address for him. He didn't have any equipment. He walked fine and carried a few bags. When we arrived, [R60] stated, This is it and he never opened the front door. He said, I got it, and everything is fine. I took everything out of the van and the resident requested me to put his belongings on the porch. He didn't knock on the door or ring the doorbell. He was just standing there, it looked like he was walking towards the diner across the street. He looked like he knew what he was doing, so I left. During an interview on 06/13/24 at 5:06 PM, the Administrator (FA) and Director of Nursing (DON) stated for a resident-initiated discharge, the resident's representative is to be notified. Social Services gets involved and get a doctor's order. We talk to family to discuss discharge and where the placement would be. The sister was difficult to get in touch with. The FA and DON confirmed they were not aware of R60's decision-making capacity form. The FA and DON stated common practice is to call the RP and verify his documents before discharge. The FA stated that she felt bad and that was not right. The FA confirmed no discharge order in the records at 5:11 PM. On 06/14/24 at 8:57 AM, the facility provided an acceptable IJ Removal Plan, which included: Residents who have been discharged in the past 30 days have been reviewed to validate safe, orderly discharge including living arrangements by the Director of Social Services or designee. The Administrator, Director of Nursing, and Interdisciplinary Team including the Social Worker will be reeducated by the Clinical Consultant on 6/13/24 on discharge planning including: Obtaining an order for discharge from the resident's physician. Validating community resources that are identified by the interdisciplinary team, resident, and/or family have been arranged. Providing written discharge instructions for care. Notifying the resident's legal representative, if any, or an interested family member regarding the upcoming discharge. Licensed Nurses will be reeducated on 6/13/24 by the Director of Nursing/Designee on the discharge process which includes Obtaining an order for discharge from the resident's physician. Providing written discharge instructions for care. Notifying the resident's legal representative, if any or an interested family member regarding the discharge. Licensed Nurses not receiving this reeducation by 6/13/24 will receive prior to their next scheduled shift. Anticipated discharges will be reviewed in the Clinical Morning Meeting Monday - Friday by the Interdisciplinary Team to validate preparation for a safe discharge is in place including living arrangements, family and/or responsible party notification, and physician order for discharge.

Based on observation, record review, interviews, and review of facility policy, the facility failed to ensure that staff used proper Personal Protective Equipment (PPE) while providing colostomy care to 1 of 8 residents, Resident (R)17. Findings include: Review of the facility policy titled, Transmission Based/Standard Precautions, and Enhanced Barrier Precautions, revised on May 15, 2023 stated, Policy: 2. Healthcare worker (HCW) will implement Universal/Standard Precautions whenever there is the occupational exposure to blood and body fluids, 4. The type of PPE (personal protective equipment) and precautions implemented depends on the potential for exposure, route of transmission, and the infectious organism/pathogen, 5. Health care workers will implement enhanced barrier precautions according to policy with additional measures to protect residents and staff from Multidrug-resistant Organisms (MDROs) MDROs refers to microorganisms predominantly bacteria that are resistant to one or more classes of antimicrobial agents. Procedures: Enhanced Barrier Precautions (EBP) 1. Enhanced Barrier Precautions expand the use of the 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 caterer, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status B. EBP will be implemented during the following high-contact resident care activities: 6. Changing briefs or assisting with toilet 7. Device care or uses: central lines, urinary catheter, feeding tube, tracheostomy/ventilator C. EBP requires the following PPE: 1. Gloves 2. Gown 3. Face Protection is performing activity with risk of splash or spray 4. All PPE is donned (put on) and doffed (removed) with appropriate hand hygiene and disposable after individual use or when visibly soiled. Review of R17's Admission Record revealed R17 was admitted to the facility on [DATE], with diagnoses including but not limited to: Schizophrenia, unspecified viral Hepatitis C without hepatic coma, anxiety disorder, major depressive disorder, Streptococcus group A as the cause of diseases classified elsewhere, carrier or suspected carrier of Methicillin resistant Staphylococcus aureus, and pressure ulcer of sacral region Stage 4. Review of R17's Physician Order Report for the month of June 2024, revealed an order with a start date of 09/25/23 for, Enhanced Barrier Precaution r/t (related to) MRSA start date of 09/25/23 to empty colostomy bag q (every) shift. May be emptied by CNA. Review of R17's Care Plan with a revised date of 05/22/23, revealed the resident is continent of bladder, foley catheter, bowl and is at risk for skin breakdown r/t (related to) catheter and colostomy. Interventions initiated on 05/22/23, revealed to change colostomy wafer and bag every 3 days and prn (as needed), empty colostomy bag every shift and prn, may be emptied by nsg (nursing) assistant, observe colostomy site every shift and prn for evidence of redness and breakdown. Review of R17's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/29/23, revealed R17 had Brief Interview for Mental Status (BIMS) of 15 out of 15, indicated the resident was cognitively intact. Further review of the MDS revealed R17 had an indwelling catheter and Ostomy (colostomy). During an observation on 06/12/24 at 11:25 AM, Certified Nursing Assistant (CNA)1 was observed entering R17's room, which signage indicated Enhanced Barrier Precautions. CNA1 entered R17's room without sanitizing their hands, or putting on proper PPE. CNA1 proceeded to check R17's colostomy bag. During an interview on 06/12/24 at approximately 11:35 AM, CNA1 revealed, I should have put on a gown. CNA1 explained the proper procedure for providing direct care in regard to emptying R17's colostomy, they should have worn a gown, gloves and a mask while providing care. CNA1 concluded, I just wasn't thinking. During an interview on 06/14/23 at 4:15 PM, the Director of Nursing (DON) and the Administrator revealed that staff should use proper PPE when providing direct care to residents on EBP. The DON and the Administrator explain that direct care includes transfers, incontinent care, and bed baths. Both the DON and the Administrator state that it is their expectation that staff perform hand hygiene by washing their hands or using alcohol based sanitizer and dress out in the proper PPE provided.

Based on observations, interviews, and record review, the facility failed to ensure Certified Nursing Assistants (CNA)s and Licensed Practical Nurses (LPN)s were provided needed competency training for colostomy care and maintenance. Specifically, a CNA provided skilled nursing care to Resident (R)23's colostomy wafer that was beyond their scope of practice, for 1 of 2 residents observed for colostomy care. This failure had the potential to cause harm to R23's stoma. Findings include: Review of the Nurse Aide Candidate Skill Checklist also known as Skills Listing South Carolina Nurse Aide Candidate Handbook dated 07/01/23 reveals no competency skills or training for stoma assessment, care, and/or colostomy wafer changes. Review of R23's Face Sheet revealed R23 was admitted to the facility on [DATE], with diagnoses including but not limited to: Schizophrenia, urinary incontinence, psychotic disorder with delusions, hallucinations, Bell's Palsy, colostomy, and intellectual disabilities. Review of R23's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/29/24 revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating R23 had moderate impaired cognition. This MDS revealed that R23 required partial to extensive assistance of one person support with Activities of Daily Living (ADLs). Review of R23's Care Plan revealed, [R23] requires the use of a colostomy history of bowel obstruction. [R23] picks and takes off colostomy resulting in multiple colostomy during the day by nurse. [R23] cannot change colostomy related to cognitive impairment. [R23] does not clean hands appropriately causing feces to be smeared at times. Goals are: [R23] will not have any skin breakdown, will remain clean and remain patent/functional thru next review date. Approaches to meet goals include, Provide ostomy care per order to keep ostomy patent without leakage. The nurse checks colostomy every shift and change as needed. Change colostomy as needed, if more than once a shift. Notify physician of any abnormal findings. Monitor site for swelling, pain, and/or redness. Document ostomy care in clinical record. Review of R23's Physician Orders revealed, Change colostomy appliance as needed and if needed more than twice in shift. Check resident colostomy for appropriate adherence every shift and change if needed. Change colostomy wafer and bag twice a day. During an observation and interview on 06/14/24 at 10:25 AM, surveyor observed CNA3 tell CNA2 that she is to do R23's colostomy. CNA3 agreed to help her with this task since she was being interviewed. CNA2 continued interview with surveyor and revealed changing the colostomy wafer and bag is a regular task for the CNAs. During an observation and interview on 06/14/24 at 10:38 AM, surveyor observed CNA3 taking Medi pore tape off R23. R23 was lying supine on the bed with his shirt up and a green yellowish substance leaking around the tape that had not been taken off. CNA3 cut Medi pore tape on the bedside table with wafer. CNA3 stated this is not a task she should be doing but was directed by the nurse to complete. During an interview on 06/14/24 at 10:56 AM, LPN1 revealed she works at the facility 2-3 times a week. LPN1 reveals that since employed six months ago certified nursing assistants have been providing total colostomy care to residents. No one told her any different, so she thought it was fine. LPN1 reports that a CNA changed his bag this morning already but did not want to give the name. LPN1 verified telling CNA2 and CNA3 to do R23's colostomy wafer and care. LPN1 further stated she does not sign off on treatment administration if the CNAs complete the treatment. LPN1 revealed she does the colostomy treatments from time to time and only then will she sign the treatment administration record. During the interview LPN1 showed this surveyor a note saying she does not want to get in trouble, but the CNAs do dressing changes too. During interview on 06/14/24 at 11:08 AM, CNA3 revealed she has changed and witnessed several CNAs do dressing changes and change colostomy wafers and bags. CNA3 states she was told by nurse weekend supervisor, she had to do it. CNA3 states if a surveyor would not have stopped this process, she would have done it today. CNA3 verified LPN1 told her or CNA2 to do the colostomy care with the wafer and bag. During an observation and interview on 06/14/24 at 11:15 AM, surveyor observed R23 with his curtain open and his shirt still up exposing his stomach. R23 was laying across the bed supine. R23 states a CNA was changing him but stopped. Can one do it now? R23 was rubbing his head visibly upset. R23's bag and dressing was exposed with several cut pieces of Medi pore tape on the bedside table. A yellow greenish hue colored substance was leaking from the wafer, soiling the tape. During an interview on 06/14/24 at 11:20 AM, CNA2 revealed she has done colostomy wafers and bag changes. CNA2 stated she did not know the wafer or stoma required measurements. CNA2 explained that she normally put it against him and cut a hole in the thing. CNA2 further stated, I have changed dressings all the time if it is a dry dressing or do not have ointment or anything. The nurses give us the dressings because the treatment carts are locked so how are we getting it? They are the only ones with the key. During an interview on 06/14/24 at 11:34 AM, the Director of Nursing (DON) revealed not being aware that CNAs were doing the dressings or colostomy treatments. The DON stated there is a policy in place and staff know how to work within their scope of practice. The DON revealed that she will follow up with the CNAs. The expectation is that CNAs do not work outside their scope of practice.

Based on observation, interviews, record review, and review of the facility's Dialysis Contract, the facility failed to ensure communication with the dialysis center for 1 of 1 resident (Resident (R)75) reviewed for dialysis. Findings include: Review of the facility's Dialysis Contract titled, Long Term Care Facility Dialysis Services Agreement, dated October 25, 2012, states under section 2B, Care facility agrees to furnish at the time of referral and request for acceptance of any Resident as a patient of Dialysis Center all appropriate medical and administrative information relating to resident condition, including without limitation the following. Resident's name, address, date of birth, and Social Security Number. Name, address, and telephone number of Resident's next of kin. Appropriate Payor information for Resident. Appropriate medical records of Resident, including the history of Resident's renal illness and record of laboratory and x-ray findings. Statement of current treatment including medications. Name, address, and telephone number, of the physician referring Resident, who is a physician with admitting privileges at Dialysis Center; and Advance Directives, if any, executed by the resident. Under Section 4. Care Facility Obligations stated, (a) Care Facility will provide to Dialysis Center . all information described in Section 2(b) above relating to any Resident accepted for dialysis services which is necessary or useful in connection with the provision of dialysis services to such Resident. (c) Care Facility will have the responsibility for arranging . transportation . Care Facility will be responsible for determining that Resident is in a medical condition to undergo any such transportation to Dialysis Center . Review of R75's Face Sheet revealed R75 was admitted to the facility on [DATE], with diagnoses including but not limited to: end-stage renal disease (ESRD) and was dependent on hemodialysis. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/24, revealed R75 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R75 was cognitively intact. In addition, the assessment revealed R75 was receiving dialysis and had no skin issues. Review of R75's Dialysis Care Plan revealed problem start date 05/07/24. [R75] is receiving: [x ] Hemodialysis, [ ] Peritoneal dialysis Due to End Stage Renal Disease. He goes to Carolina Dialysis M-W-F at 5:30 am chair time. Review of the R75's dialysis communication book revealed there were only three (3) communication forms in the book, with the following dates: 05/31/24, 06/10/24, and 06/12/24. During an interview on 06/12/24 at 2:33 PM, R75 revealed that he goes to dialysis three (3) days a week, Monday, Wednesday, and Friday, for four (4) hours a day. R75 states there is no good communication between dialysis and the facility because the dialysis center tries to get the facility to do so many things such, as communication forms, for weeks and weeks they didn't do it. The dialysis center called and complained that the third shift would give attitudes to them. The communication sheets address blood pressure, but they are not doing it. They write something down. There have only been a few times I took a form with me, but normally I go with nothing, just snacks. During an interview on 06/14/24 at 10:42 AM, Licensed Practical Nurse (LPN)1 states she is an agency nurse who has been employed with the facility for six (6) months. LPN1 stated for residents who attend dialysis, there is a communication book for each resident. Residents are supposed to take the book to dialysis, with a new communication form with vitals, and medication list, and are to check the resident's port before leaving the facility. For residents who have early dialysis chair time prior to 6 am, it is the third shift's responsibility to make sure they are ready to go. When a resident comes back from dialysis, nurses are responsible for obtaining another set of vitals upon return from the dialysis facility, and ensuring the resident has their communication book. During an interview on 06/14/24 at 11:04 AM, R75 stated, I don't have my book, I didn't take it today. I don't know where my paper is at. During an interview on 06/14/24 at 11:10 AM, LPN2 confirmed she was R75's nurse for the 1st shift and she is an agency nurse. LPN2 stated, I came in at 7 this morning, the previous nurse told me he was LOA to dialysis and didn't communicate any vitals from him being sent out. When the resident came back at 10:57 he didn't have a paper, I followed him to his room and took his vitals. He should have been sent out with a form, and I would have filled out the bottom portion of the form that would have been kept in the binder. During an interview on 06/14/24 at 11:13 AM, the Director of Nursing (DON) confirmed she was familiar with R75's care, including dialysis. The DON states her expectations of facility staff, specifically nurses, is to ensure any resident who goes out to dialysis has a communication form each time a resident goes out via transport. The communication form should address all vitals such as blood pressure, temperature, pulse, and if the resident has taken their medication prior to leaving the facility. The forms are to be kept in the resident's communication book and the resident is to take the book with them, and upon return from dialysis, nurses should repeat vitals and document at the bottom of the form. Staff are to ensure all communication forms of all visits are kept in the book. During an interview on 06/14/24 at 10:01 AM, the Facility Administrator (FA) stated she and the DON could not locate R75's dialysis book. The FA stated normally the book would be at the nurse's station, or the resident took it with him. At 11:27 AM, the FA stated she would ask a medical records staff member to look for the resident's dialysis communication forms. At 12:38 PM, the FA provided R75's communication book along with a dialysis contract. The FA stated that the expectation of her staff, specifically nurses, is to ensure all communication forms are in the resident's book. The FA concluded she does not have an explanation as to why they aren't doing what is expected of them.

Based on observations, interview, record review, and facility policy review, the facility failed to ensure a nurse followed physician orders and manufacturer's guidelines for administering an inhaled corticosteroid for 1 out of 29 opportunities of medication administration. Findings include: Review of a facility policy titled, Nursing Policies and Procedures, dated 05/05/2023, revealed, 6. The authorized staff member reads the label on the medication three times. A. Before removing the medication from the drawer, before dispensing the medication, and after dispensing the medication. 13. The authorized staff member administers medications according to accepted standards of practice and in compliance with regulatory requirements. Review of the GlaxoSmithKline instructions for use of Trelegy Ellipta, with a revised date of December 2022, revealed under Step 6, Rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water. Review of an Admission Record indicated the facility admitted Resident (R)87 on 06/04/24 with diagnoses including but not limited to: multiple sclerosis, insomnia, hypertension, chronic respiratory failure with hypoxia, anemia, dependence on supplemental oxygen, and chronic kidney disease. Review of R87's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/10/24, revealed R87 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had no cognitive impairment. Review of R87's prescription order with a start date of 06/04/24, revealed Trelegy Ellipta (fluticasone-umeclidin-vilanter) blister with device; 100-62.5-25 mcg; amt: 1 puff (1 Blister); inhalation with special instructions: Rinse mouth after use. Once A Day. During an observation on 06/13/24 at 8:50 AM, Registered Nurse (RN)1 administered inhaler without instruction to exhale prior to inhaling medication. Immediately following, R87 did not rinse and spit per physician's order and manufacturer's guidelines. R87 was given by mouth medications with a cup of water to ingest. During an interview on 06/13/24 at 8:56 AM, RN1 admits to not seeing the instructions on the label and on the electronic medication administer record.

Based on observations, record review, interviews, and review of the facility policy, the facility failed to follow physician orders for oxygen administration for 1 of 1 residents reviewed for respiratory care, Resident (R)41. Findings include: Review of the facility's policy titled, Respiratory Policy & Procedures dated 02/12/2024 revealed, Subject: Oxygen Therapy-Oxygen administration helps relieve hypoxemia and maintain adequate oxygenation of tissues and vital organs. Oxygen administration increases blood oxygen content so that the heart doesn't have to pump as much blood per minute to meet tissue demands. Indications: Hypoxemia, Heart failure . Procedures: A. Verify the provider's order for the oxygen therapy . Review of R41's Face Sheet revealed R41 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory failure with hypoxia, chronic cough, nasal congestion, chronic systolic (congestive) heart failure, obesity, cardiomyopathy, essential (primary) hypertension, unspecified atrial fibrillation, and weakness. Review of R41's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 04/15/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R41 was cognitively intact. Review of R41's Care Plan with a start date of 02/28/24 and a target date of 07/15/24 documented, problem [R41] .is at risk for respiratory distress/SOB due to Dx of: CHF. Documented goal [R41] .will not exhibit or develop respiratory distress as evidenced by no SOB, O2 sat at or above 95%. Documented approach revealed, standard chest x ray with start date 06/04/24, ask resident if having trouble breathing while lying flat. Document with start date 02/28/24, monitor vital signs q shift and PRN. Document with start date 02/28/24, Apply O2 as ordered. Change O2 tubing/nasal cannula/mask/humidification system weekly. Change tubing/mask weekly. Keep O2 cannula/mask/tubing and bagged when not in use with start date 02/28/24, Encourage/teach how to cough and deep breath with start date 02/28/24, Elevate head of bed as needed with start date 02/28/24, Administer medications as ordered. Monitor adverse reaction. Contact MD if noted with start date 02/28/24, Monitor respiratory status daily during treatment period. Respiratory distress s/sx: -Shortness of breath. -Fast breathing, or taking lots of rapid, shallow breaths. -Fast heart rate. -Coughing that produces phlegm. -Blue fingernails or blue tone to the skin or lips. -Extreme tiredness. -Fever. -Crackling sound in the lungs with start date 02/28/24. Review of R41's Medication Administration Record (MAR) for 06/01/24 - 06/24/24, revealed an order for O2 at 2 liters per minute via nasal cannula, check O2 sats Q shift, Every Shift, Third, First, Second. Review of R41's Physician Order with a start date of 06/12/23 documented, O2 at 2 liters per minute via nasal cannula, check O2 sats Q shift, Every Shift. During an observation and interview on 06/13/24 at 9:52 AM, R41 was wearing oxygen at 1L/min via nasal cannula. Resident stated the oxygen was supposed to be on 1L/min but was working on being weaned off. Oxygen tubing and water bottled was dated 06/12/24. During a record review on 06/13/24 at 10:17 AM, physician orders were verified for oxygen at 2L/min. During an observation on 06/13/24 at 7:27 PM, the oxygen flowrate was set at 1L/min. via nasal canula. During an interview on 06/13/24 at 7:29 PM, Licensed Practical Nurse (LPN)5 verified oxygen orders for R41 and reported that the order was for 2L/min. LPN5 observed the flow rate at eye level. LPN5 began adjusting the flow rate and surveyor asked what was the previous rate. LPN5 confirmed the flow rate was at 1L/min. and was adjusting to match the order to 2L/min. LPN5 explained that the order was for 2L/min. LPN5 concluded, I don't know why it was on 1L/min. During an interview on 06/14/24 at 9:12 AM, the Director of Nursing (DON) revealed nursing expectations to ensure accuracy of oxygen flow rates at the bedside as compared to the orders. The DON stated the nurse should review the orders which provides the flow rate and when validating the order during the shift, the nurse should visualize the flow rate at bedside to ensure accuracy.

Based on review of the facility policy, record review, and interviews, the facility failed to notify the on-call provider regarding a significant change in a resident's (R)1 condition. Specifically, critical lab blood sugar readings were not communicated timely. Findings include: Review of the facility policy titled, Physician and Other Communication/Change in Condition dated [DATE], revealed, To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in patient/resident's condition, and provide guidance for the notification of patient's/residents and their responsible party regarding changes in condition. Section 3 of the policy states, Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. Changes and new approaches will be reflected in the individualized care plan. R1 was admitted to the facility on [DATE], with diagnoses including but not limited to; diffuse traumatic brain injury, type 2 diabetes mellitus without complications, seizures, and muscle weakness. A review of the Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) date of [DATE] revealed R1 had no Brief Interview of Mental Status (BIMS) documented, due to the resident being rarely/never understood. Review of the physician progress notes revealed a noted dated, [DATE] created by Family Nurse Practitioner, FNP, the resident was seen by him due to a new concern. Staff notified the provider of regard to the patient's condition. The nursing staff reported resident with seizure activity and lethargy. FNP noted, per nursing staff, the patient had been lethargic over the weekend and was noted with a brief seizure episode the morning of [DATE]. FNP visited the patient and made an assessment, FNP stated that the resident does not appear to be in any distress. FNP ordered labs to check therapeutic levels of Keppra and check CBC with diff, BMP, and UA with culture and sensitivity. Additional record review revealed a progress noted dated [DATE] at 03:34 PM, Labs ordered for morning, POA aware. An additional progress note dated [DATE] at 06:47 PM CLS Lab called this nurse to inform of critical lab value on glucose, with it being over 500 at the time of blood draw, early this morning. This nurse immediately checked the resident's blood sugar with a reading of 201. Will continue to monitor throughout the shift; the patient is currently only on oral diabetic meds. Will place on MD list for morning for possible need of frequent blood sugar checks and possible sliding scale needs. POA aware. A progress note dated [DATE] at 09:03 AM: SW was notified by DON that the resident passed away at the hospital. A review of R1's vital signs in the medical record regarding blood sugar checks revealed there was no blood sugar results documented. Furthermore, there was no documentation on R 1's EMR that the provider was notified of R1's critical blood sugar level. A review of R1's care plan revealed that Resident is diabetic, and is at risk for elevated blood sugars, low blood sugars, and changes in mental status. Interventions associated with the care plan are as follows: FSBS as needed, report abnormal to MD. if indicated, Document changes in mental status., notify MD. diet as ordered. monitor for thirst, excessive appetite or voiding, change in LOC, mood, perspiring--report to MD. give meds per order for DM. Report abnormal labs to MD. An interview with Licensed Practical Nurse, (LPN)1 on [DATE] at 12:00 PM revealed that she does not particularly remember the incident in regard to R1's decline. LPN1 stated that if she was taking care of a resident with blood sugars outside of normal limits (500), she would re-draw the sugar and report it to the Provider, especially if the resident is experiencing any changes in condition. LPN1 stated that for residents who have a blood sugar of 200, the abnormal reading does not warrant an immediate report to the provider on call. LPN1 stated they typically just write down the findings in the M.D (Medical Doctor) rounding book so the patient can be seen the following day by the provider during rounds. An interview with the facility's FNP on [DATE] at 12:33 PM revealed that FNP was notified of the changes in the resident's condition as far as the resident's frequency of seizures. FNP revealed that he placed orders for the labs to be drawn on [DATE]. FNP revealed that he was not notified of the resident's abnormal labs when CLS called the facility to report the critical lab value on [DATE] at 1711 (5:11 PM) hours. FNP revealed that it is his expectation of staff members to report abnormal findings to him immediately, especially if the resident is having a significant change in status. FNP stated, I have been employed at at this facility for years now and a vast majority of the staff have his phone number and that he has built a good enough rapport with staff that they can call him at any time of the day. FNP stated that if he had been notified of the abnormal lab values, he would have closely looked at the results and made some interventions. FNP stated that he was not made aware of the R1's labs until after the resident had already expired. An interview with the Director of Nursing, (DON) on [DATE] at 1:10 PM revealed that it is her expectation of staff to report any abnormal labs to the provider especially if the resident is exhibiting any changes in condition. DON revealed that typically Providers are reliant on facility staff members in regards to receiving any results of lab draw results after hours. DON stated that if any abnormal findings in regard to resident lab draws are not reported to the Provider, it would be hard for providers to provide further guidance or orders in regard to interventions to resident care. Interview with LPN2, on [DATE] at 2:57 PM revealed that the providers are easily accessible during and after hours. LPN2 states that providers for the facility typically have very quick response times. LPN2 states that providers expect her and other nursing staff in the facility to report any major changes in regards to the resident condition and or any irregularities in labs, imaging studies, vital signs, etc as soon as possible. LPN2 stated she remembers receiving the resident's abnormal lab value from CLS and states she reported the blood sugar reading to the on-call provider. LPN2 states on call provider told her to monitor the resident blood sugars often to report any blood sugars above 250 and to just closely monitor the resident. LPN2 states she remembers taking the resident blood at least every hour for the rest of her shift. LPN2 states that the blood sugar checks during that time ranged between 190 and 210. LPN2 could not produce any documentation that reflects the statement she has made in regard to the resident's blood sugar checks, nor was she able to present any documentation in regard to the interaction she had with the provider indicating that she informed the on-call provider and received an order to check blood sugars often and to report any abnormal findings. LPN2 does not remember why these interactions, blood sugars, and orders were not documented as she states she is typically one to write, novels in regard to her documentation. LPN2 states that she passed off the instruction regarding frequent BS checks and monitoring to the 3rd Shift, LPN3. An interview with the On-call provider service center was attempted on [DATE] at approximately 3:30 PM to verify any communication made between the facility and on-call provider on [DATE] after 5:00 PM to corroborate LPN's recollection of notifying the provider of the resident's abnormal blood sugar reading. The call was unsuccessful, after 25 minute hold. An interview with the Facility Administrator, (FA) on [DATE] at 3:58 PM revealed that it is the Administrator's expectation of staff to report any major changes in regards to resident condition, abnormal labs, imaging studies, etc, to the provider. FA stated that after hours, she expects staff to report any significant changes to the on-call provider and to document any interaction, conversation, or orders staff may have received during the conversation. In this particular case, the FA stated that the LPN should have recorded the orders she received from the physician, as well as the blood sugars LPN2 drew during the shift. FA stated she understands the practice that if something is not charted, it is hard to prove that any aforementioned actions were completed by staff. Attempts were made to interview R1's Representative via telephone on [DATE] at 11:33 AM, 03:52 PM, and 3:55 PM. All three attempts were unsuccessful. An attempt was made to interview LPN3 via telephone on [DATE] at 03:25 PM. A voicemail was left for a return phone call.

Based on review of the facility policy, interview, and record review, the facility failed to ensure staff implemented interventions identified to aid in the prevention of harm with a fall for 1 (Resident (R)1) of 2 sampled residents reviewed for falls. Findings Include: Review of facility policy titled, Fall Management with a revised date of 05/05/23, revealed the facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. Review of R1's face sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to unsteadiness on feet, muscle weakness, difficulty in walking, unspecified dementia, cognitive communication deficit and attention and concentration deficit. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/23, revealed R1's Brief Interview for Mental Status (BIMS) score was incomplete. It was recorded that R1 was dependent on the staff for all areas of daily living. The MDS indicated the resident did not sustain any falls during the assessment period. Review of R1's observations titled Falls - Morse Fall Scale revealed R1 had a history of falling, with a Morse Fall Score of 65 indicating R1 was at a high risk for falls. Review of R1's Care Plan with a start date of 11/17/22 revealed that R1 had a problem of is at risk for falling r/t (related to): weakness decreased mobility psych. med use dx: mood disorder dementia insomnia. Review of R1's Physician Orders revealed an order for Ambulation with assist of 2 with a start date of 10/27/22 and Wheelchair with offloading cushion. Review of R1's progress notes dated 05/05/23 revealed Resident ambulating unassisted into the hall, resident had fall and noted to be laying in hall on right side, no visible injury noted. Resident assisted to chair with assist standing and walking some steps but complained of leg pain. When asked where does it hurt resident began to point to her hands, neck and other body parts. Legs palpated and no indication of pain voiced. When moving right leg resident does indicated pain. NP notified, x-ray of right hip ordered r/t fall with pain, RP called to update of fall and 2nd x-ray and agreed to plan. Review of R1's Admission Note from a local hospital dated 05/05/23 revealed Patient is a 82 y.o. female that presents to the ED after a fall at her nursing facility. It is reported she has had multiple falls today and at least one other within the last week., further review revealed R1 sustained a right hip transcervical femoral neck fracture and a right distal radius fracture. During an interview on 08/23/23 at 2:15 PM, Licensed Practical Nurse (LPN)1 stated that R1 should not have been ambulating and uses a wheelchair. LPN1 further stated R1 would be redirected back to her bed or chair by staff if attempting to ambulate unassisted.

Based on review of the facility policy, interview, and record review, the facility failed to assure medications were properly accounted and disposed of for 1 of 3 residents, (R)1. On 04/04/23, the Director of Nursing (DON) reported she was reviewing R1's records and noted R1 was administered Hydrocodone (Norco) at a time when R1 was not in the building by Licensed Practical Nurse (LPN)1. Findings include: Review of the facility's policy titled, Medication Management Program, with a revision date of 07/13/21 revealed 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 .Once removed from the package or container, unused doses should be destroyed following facility policy and documenting the destruction according to the facility policy. R1 was admitted to the facility on [DATE] with a diagnosis of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, iron deficiency, other chronic pain, muscle weakness (generalized), difficulty in walking, and unspecified dementia. Review of the medical record for R1 revealed an order for Norco 5/325mg (milligrams)- administer by mouth three times a day dated 3/22/23. Review of the facility's internal investigation revealed LPN1 pulled R1's Hydrocodone-acetaminophen (Norco) for a 4:00 PM administration at 5:04 PM. R1's controlled drug receipt/record was signed out by LPN1 at 5:00 PM on 3/23/23. The DON reported that LPN1 was not drug tested . The DON reported that law enforcement was in the facility to do a report on 04/06/23. Review of LPN1's witness statement dated 04/04/23 revealed that LPN1 did not dispose of the Norco with another nurse, she put the Norco in a sharp's container. During an interview on 04/06/23 at 10:40 AM, the DON revealed she discovered the medication misappropriation on 04/04/23 while reviewing R1's chart. R1 was seen at a medical appointment and was sent to the hospital and did not return to the facility. However, LPN1 recorded on R1's medication administration records (MAR) and narcotic count sheet, the administration of medications when R1 was not in the facility. During an interview with the Administrator on 04/06/23 at 11:02 AM, he revealed the DON was reviewing R1's MAR and noticed that LPN1 documented signing out the medication, Norco, on 03/23/23 at 5:00 PM. However, R1 was not in the facility and when LPN1 was called, she reported she was not aware and reported the medication Norco, was not administered to R1 and was disposed of in the sharps container because she did not have another nurse to witness the disposal of the medication with. During an interview on 04/06/23 at 11:24 AM, LPN1 revealed she was in the facility on 03/23/23 and reported to work for the 3:00 PM - 11:00 PM shift. The staff that gave her report did not give her report that R1 was not in the facility, however, LPN1 could not provide the name of the staff she had gotten report from. She denied pre pulling medication and reported that when she went to administer the medication, Norco, to R1, she was not in her room. At that time, another staff member told her that R1 was in therapy. LPN1 reported she held the medication cup for R1 to return. At 11:00 PM, at the end of her shift, she reported she walked the hall looking for another nurse to waste the medication with and did not find anyone, so she put the Norco in the sharps container on Unit 2. LPN1 could not recall the time this was done. During an interview on 04/06/23 at 1:46 PM, RN1 reported that R1 had a scheduled appointment with her doctor and family was waiting for R1 to arrive. The family then called the facility to see where R1 was, and this is when the facility learned the family had a different appointment time than the facility. RN1 reported the quality department sent up the appointments when the resident admits based on what is documented on the residents' discharge documents. If the discharge summary does not reference a follow up appointment, the facility does not record as they are not aware and rely on the resident or family to disclose this information. RN1 reported that EMS came to the facility to take R1 to her appointment and when she gave report to LPN1 she told LPN1 that R1 was not in the facility and had left via EMS for an appointment. RN1 was asked what the facility's policy is on wasting narcotic medications and she reported someone is to sign and watch the waste of the narcotic. RN1 reported she was not aware of the time she gave report to LPN1, but was sure it was after 3:00 PM.

Based on review of the facility policy, observations, and interviews, the facility failed to provide an accessible call system with functioning devices while residents are in bed, toilet, bath and/or shower for 17 out of 43 residents; 2 out of 3 shower rooms reviewed for resident call systems. On 03/21/2023 at 6:43 PM, the Administrator and the Director of Nursing were notified that the nonoperational call lights constituted Immediate Jeopardy (IJ) at F919, with a start date of 11/01/2022. The facility presented an acceptable plan of removal of the IJ on 03/22/2023 at 10:40 AM. The survey team validated that the IJ was removed on 03/22/2023 at 12:20 PM following the facility's implementation of the plan of removal of the immediate jeopardy. The facility remained out of compliance at F919 at a lower scope and severity of E (pattern with potential for minimal harm) following removal of the IJ. Findings include: Review of the facility's undated policy titled Call Lights - Answering Of revised on 07/01/2023 revealed that staff were meant to leave the call light in the resident's reach prior to exiting the room. The policy did not outline a system of ensuring the call lights were operational. Interview with Resident (R)1 on 03/21/2023 at approximately 1:47 PM revealed the resident remembered the incident, R1 stated she was in pain that day and she wanted some pain medicine, she didn't feel safe because her call lights do not work. R1 further stated the call light has not been working for some time and she must holler for assistance until she is hoarse. R1 concluded her roommate cannot talk because she has a trach, and she must holler for her also. A test of R1's call light revealed, the call light was activated at 1:50 PM on 03/21/2023 and revealed no response or light up feature was present on the appliance outside of the door. The call light button for R1's roommate was located on the floor behind the bed. At approximately 3:22 PM on 03/21/2023, a tour was conducted with the Maintenance Director (MD) to complete a room-to-room assessment for verification and confirmation of inoperable call lights. The tour revealed the following rooms did not to have operable call lights/signal systems: RM102 RM103 RM104 RM106 RM108 RM109 RM110 RM111 RM112 RM113 RM119 RM124 Shower room [ROOM NUMBER]st Floor Observation of the second-floor call system revealed that rooms 201, 203, 209, 212, and 213 and the shower room had no functional call light and no alternative system for requesting assistance from nursing staff. This also affected the residents' bathrooms. The call lights failed to illuminate either above the doorway or at the nursing station. The tour with the MD from 3:34 PM - 3:45 PM on 03/21/2023 confirmed the call lights were not operational. Interview with the MD on 03/21/2023 at approximately 3:44 PM revealed this was his first day at work. The MD stated that the normal procedures if the call light system isn't working would be the use of bells for each resident. Interview on 03/22/2023 at approximately 9:58 AM with the previous Administrator revealed, I was aware of the call light system malfunction on November 1, 2022. The problem with the call light system was it would not make noise or sounds. I needed three quotes before the system could be repaired. But an invoice was requested from Wanderguard, and they informed me at that time, the system was an antiquated (outdated) system. The alternatives that she offered at that time were hand bells. I did not relay this information to the oncoming Administrator because they were not hired before she left the facility. There should be documentation of an invoice from Wanderguard for the purpose of verifying the date. Complaints were received by residents that their call buttons were not working. Problems were noted mostly on the Rehab Hall which is located directly in front of the main entrance. Staff were in-serviced and trained in reference to responding to call lights in a timely manner. R6 resided in room [ROOM NUMBER], admitted on [DATE] with diagnoses including, but not limited to, generalized anxiety disorder (GAD), major depressive disorder (MDD), heart failure, and unspecified intellectual disabilities. R6's 02/02/2023 Brief Interview for Mental Status (BIMS) score was 99, indicating they were unable to complete the interview. She requires extensive assistance with two person assist for Activities of Daily Living (ADLs). R7 and R8 resided in room [ROOM NUMBER]. R7 was admitted on [DATE] with diagnoses including, but not limited to, congestive heart failure, muscle wasting and atrophy, type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD). R7's 01/09/2023 BIMS score was 15/15, indicating R7 was cognitively intact. The resident was independent with ADLs. R8 was admitted to the facility on [DATE] with diagnoses including, but not limited to, anxiety, depression, and type 2 diabetes mellitus (DM2). R8's 02/28/2023 scored 13/15 indicating R8 was cognitively intact. She required 1-person limited assistance with ADLs. R9 and R10 resided in room [ROOM NUMBER]. R9 was admitted on [DATE] with diagnoses including, but not limited to, paroxysmal atrial fibrillation, muscle weakness, epilepsy, scoliosis, and spinal stenosis. R9's 01/23/2023 BIMS score was 10/15, indicating R9 had moderately impaired cognition. He required extensive 1-person assistance for ADLs. R10 was admitted on [DATE] with diagnoses including, but not limited to, chronic kidney disease (CKD), dementia, and muscle weakness. R10's 02/06/2023 BIMS score was 10/15, indicating R10 had moderately impaired cognition and he required 1-person extensive assistance with his ADLs. R4 resided in room [ROOM NUMBER]. R4 was admitted on [DATE] with diagnoses including, but not limited to, cerebral infarction, DM2, muscle wasting, and lack of coordination. R4's quarterly 02/04/2023 BIMS score was 11/15, indicating R4 had moderately impaired cognition. He required 1-person limited assistance with his ADLs. R11 and R5 resided in room [ROOM NUMBER]. R11 was admitted on [DATE] with diagnoses including, but not limited to COPD, end stage renal disease (ESRD), and muscle weakness. R11's 02/28/2023 admission BIMS score was 14/15, indicating R11 was cognitively intact. She required limited 1-person assistance with ADLs. R5 was admitted on [DATE] with diagnoses including, but not limited to, anxiety and DM2. R5's admission 2/15/2023 BIMS score was 15/15, indicating R5 was cognitively intact. She was totally dependent for her ADLs. R12 and R1 resided in room [ROOM NUMBER]. R12 was admitted on [DATE] with diagnoses including, but not limited to, depression, open wound of neck, and gastrostomy. R12's 03/21/2023 BIMS score was 12/15, indicating she was moderately cognitively intact. R1 was admitted on [DATE] with diagnoses including, but not limited to, anxiety, acute osteomyelitis of right ankle and foot, and need for assistance with personal care. R1's 02/15/2023 BIMS score was 15/15, indicating she was cognitively intact. She is a 1-person physical assist for ADLs. R13 and R14 resided in room [ROOM NUMBER]. R13 was admitted on [DATE] with diagnoses including, but not limited to, CKD, depression, dementia, and unspecified displaced fracture of surgical neck of right humerus. R13's 03/20/2023 admission BIMS score was 3/15, indicating R13 had severely impaired cognition. R14 was admitted on [DATE] with diagnoses including, but not limited to DM2, pressure ulcer of sacral region, and CHF. R14's 02/09/2023 BIMS score was 7/15, indicating R14 was mildly cognitively intact. She required extensive 2-person assistance for ADLs. R15 resided in room [ROOM NUMBER]. R15 was admitted to the facility on [DATE] with diagnoses including, but not limited to CHF, CKD, and muscle weakness, and cognitive communication deficit. R15's quarterly 03/09/2023 BIMS score was 9/15, indicating R5 was mildly cognitively intact. She required 1-person limited assistance for ADLs. R16 and R17 resided in room [ROOM NUMBER]. R16 was admitted on [DATE] with diagnoses including, but not limited to, muscle weakness, need for assistance with personal care, and cognitive communication deficit. R16's quarterly 01/02/2023 BIMS scored 13/15, indicating R16 was cognitively intact. He required 1-person extensive assistance with ADLs. R17 was admitted on [DATE] with diagnoses including, but not limited to, heart failure, CKD, cognitive communication deficit, legal blindness, and muscle wasting and atrophy. R17's quarterly 02/14/2023 BIMS scored 15/15, indicating R17 was cognitively intact and he was independent with ADLs. R18 resided in room [ROOM NUMBER]. R18 was admitted on [DATE] with diagnoses including, but not limited to, bipolar disorder, unspecified convulsions, history of falling, and blindness in right and left eye. R18's 02/16/2023 admission BIMS scored 11/15, indicating R18 was moderately cognitively intact and he required limited 1-person assistance for ADLs. R19 and R20 resided in room [ROOM NUMBER]. R19 was admitted on [DATE] with diagnoses including, but not limited to, cerebral infarction, difficulty walking, muscle wasting and atrophy, CHF, DM2 and chronic pain. R19's quarterly 01/02/2023 BIMS score was 14/15, indicating she was cognitively intact. She required 2-person assistance for ADLs. R20 was admitted on [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis affecting unspecified side, delirium due to known physiological condition, and pain. R20's quarterly 01/02/2023 BIMS score was 15/15, indicating she was cognitively intact and she required 2-person assistance for ADLs. R21, R22, and R23 resided in room [ROOM NUMBER]. R21 was admitted on [DATE] with diagnoses including, but not limited to, Alzheimer's disease, delusional disorders, pain, and need for assistance with personal care. R21's quarterly 01/30/2023 BIMS score was 13/15 indicating she was cognitively intact, and she was totally dependent for ADLs. R22 was admitted on [DATE] with diagnoses including, but not limited to, unsteadiness on feet, cognitive communication deficit, COPD, spinal stenosis, schizophrenia, and bipolar disorder with psychotic features. R22's 01/02/2023 BIMS score was 99, indicating the assessment could not be completed. She required supervision only for ADLs. R23 was admitted on [DATE] with diagnoses including, but not limited to, COPD, need for assistance with personal care, reduced mobility, and unsteadiness on feet. R23's 02/20/2023 quarterly BIMS score was 14/15, indicating she is cognitively intact and she was totally dependent for ADLs. R24 and R25 resided in room [ROOM NUMBER]. R24 was admitted on [DATE] with diagnoses including, but not limited to, anxiety, Guillain-Barre syndrome, and heart failure. R24's 01/16/2023 BIMS score was 15/15, indicating he was cognitively intact. He requires extensive 1-person assistance for ADLs. R25 was admitted on [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis affecting right dominant side, cognitive communication deficit, and need for assistance with personal care. R25 quarterly 03/07/2023 BIMS score was 6/15, indicating cognitive impairment. Resident required extensive 1-person assistance for ADLs. R26 resided in room [ROOM NUMBER]. R26 was admitted on [DATE] with diagnoses including, but not limited to, need for assistance with personal care, muscle weakness, and chronic pain. R26's quarterly 03/09/2023 BIMS score was 15/15, indicating he was cognitively intact. He required extensive 1-person assistance for ADLs. R27 and R28 resided in room [ROOM NUMBER]. R27 was admitted on [DATE] with diagnoses including, but not limited to, muscle weakness, multiple sclerosis, intellectual disabilities, and COPD. R27's quarterly 02/24/2023 BIMS score was 99 indicating the assessment could not be completed and he was totally dependent for ADLs. R28 was admitted on [DATE] with diagnoses including, but not limited to, DM2, muscle weakness, multiple sclerosis, and MDD. R28's quarterly 02/20/2023 BIMS score was 11/15, indicating mild cognitive impairment, and he was totally dependent for ADLs. R2 and R29 resided in room [ROOM NUMBER]. R2 was admitted on [DATE] with diagnoses including, but not limited to, COPD, CHF, unsteadiness on feet, need for assistance with personal care, pain, and muscle weakness. R2's quarterly 01/09/2023 BIMS score was 7/15, indicating cognitive impairment. She required extensive 1-person assistance for ADLs. R29 was admitted on [DATE] with diagnoses including, but not limited to, history of falling, schizophrenia, and DM2. R29's annual 02/07/2023 BIMS score was 7/15, indicating cognitive impairment. She required supervision only for ADLs. R30 and R3 resided in room [ROOM NUMBER]. R30 was admitted on unspecified psychosis, CHF, COPD, cognitive communication deficit, and unsteadiness on feet. R30's quarterly 01/30/2023 BIMS score was 99 indicating the assessment could not be completed. She required 1-person limited assistance for ADLs. R3 was admitted on [DATE] with diagnoses including, but not limited to, schizophrenia, muscle wasting and atrophy, need for assistance with personal care, reduced mobility, and pain. R3's 02/06/2023 BIMS score was 14/15, indicating she was cognitively intact. She required 1-person assistance for ADLs. Interview with Certified Nursing Assistant (CNA)2 at 1:58 PM on 03/21/2023 revealed she was not aware of when the call light system stopped working. Interview with CNA1 at 2:05 PM on 03/21/2023 revealed she gave her residents hand bells to ring for assistance. Interview on 03/21/2023 at 2:10 PM with Licensed Practical Nurse (LPN)1, revealed when she started working in the facility in early January 2023, all residents in the facility were already using call bells. LPN1 stated that she and other staff assigned to the unit will do rounds every 2 hours if not more depending on resident needs. LPN stated that residents who do not have a functioning call light have access to bells to make needs known. LPN stated that mostly all residents located on the 2nd floor are verbal and can make their needs known. Interview at approximately 2:20 PM on 03/21/2023 with R2 revealed she stated the call bell system has not worked in 3 months. R2 stated she contacts the staff on her personal cell phone. Interview at approximately 2:22 PM on 03/21/2023 with R3 revealed she doesn't know how long the call lights have been inoperable, but stated probably a month ago. R3 stated her light is not working. Interview at approximately 3:13 PM on 03/21/2023 with R5 revealed she does not even have a call bell system on her wall. R5 stated it has been probably about a month ago when she no longer had a light. Review of facility grievance logs revealed that R5 complained about call light response times on 02/13/2023. The facility found that her call light was not working properly. Review of facility grievance logs revealed that R35 complained of call lights not being answered on 02/13/2023. Review of facility grievance logs revealed that R36 complained of using the call light for over an hour on second shift on 01/09/2023. Review of facility grievance logs revealed that R37 complained of using the call light for over an hour before it was answered on 12/14/2022. This incident occurred on 3rd shift. Interview with MD on 03/21/2023 at an unspecified time revealed he planned to test call lights weekly, but it was his first day that day and he had not been able to check call lights. It was unknown what the previous MD did to assess call light function 46934 37683 The facility's removal plan included: Residents identified in rooms 102, 103, 104, 106, 108, 109, 110, 111, 112, 113, 119, 124, 201, 202, 209, 212, and 213 were provided hand bells on 03/21/2023 to alert nursing staff. Residents receiving showers on Units 1 and 2 will receive 2-person assists. 15-min checks were initiated on 03/21/2023 to monitor residents for needs and will continue until the call light system is repaired. A monitoring tool will be used to document 15-minute checks and will be used until the call light system is repaired. The remaining residents will be provided hand bells on 03/22/23. Resident council meeting will be held on 03/22/2023 to inform residents of plan for alerting staff for assistance and the plan for the repair of the call light system. The administrator will contact companies to obtain quotes for repairs of the call light system on 03/22/2023. Facility employees will be educated on the plan that was initiated. Any employee not receiving this education by 03/22/2023 will receive it before their next scheduled shift. This will include any agency personnel and new hire orientation. The Director of Nursing and Administrator will make rounds throughout the day to validate that resident needs are being met by responsiveness to the hand-held call bell or the 15-minute checks. Any concerns will be addressed at the time of discovery. The medical director was informed of the immediate jeopardy and the contents of this plan on 03/21/2023. An ad hoc Quality Assurance Performance Improvement meeting will be held on 03/22/2023.

Based on review of the facility's policy titled Elopement, record review, and interviews, the facility failed to provide adequate supervision for 1 of 3 residents reviewed for accidents related to elopement. Resident (R)1 had a successful elopement from the facility on 11/4/22 and was without supervision for an extended period. Certified Nursing Assistant (CNA)1 was making rounds at 3:45 AM on 11/4/22 and noticed that R1 was not in his room. He was last noted to be asleep in his room during the 2 AM rounds. R1 was found by the police at a local Krispy Kreme, drinking coffee, at 9:30 AM, approximately 0.7 miles away from facility. On 11/15/22 at 2:55 PM, an Immediate Jeopardy (IJ) template was provided to the facility's Administrator, notifying her that an IJ existed at F689 with an effective date of 11/04/22. On 11/15/22 at 6:10 PM, the facility provided an acceptable IJ Removal Plan. The immediacy of the IJ was removed as of 11/15/22. The IJ was lowered to a scope and severity of D for no actual harm with potential for more than minimal harm that is not immediate jeopardy. An extended survey was conducted on 11/15/22 due to the failure constituting substandard quality of care. The facility's removal plan implemented required facility wide training, in services to be conducted beginning 11/15/22 related to elopement/abuse. All staff will be re-educated by the Assistant Director of Nursing or staff development coordinator by 11/15/22. Implementation of the removal plan for F689 includes elopement risks assessments to be completed on current residents, the residents identified as being at risk care plans will be updated to reflect with interventions in place. Licensed nurses will be re-educated on the elopement risk assessment/process for accuracy and putting interventions in place based on risks identified. All staff will be re-educated on Abuse Policy. The Director of Nursing will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks and all new admissions, re-admissions and quarterly assessments will be reviewed in the morning meetings for 4 weeks beginning November 15, 2022. Implementation of the Removal Plan was verified through observations, staff interviews and record review. Findings include: Review of the facility's undated policy, titled, Elopement, revealed the purpose is to safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if patient/resident is considering missing. The facility will determine a signal code, e.g. Code White to designate a missing patient/resident. A review of the facility's face sheet revealed R1 has diagnoses including, but not limited to; anxiety, hypertension, and chronic obstructive pulmonary disorder. R1 was admitted to the facility for rehabilitation services following a hospital stay for a hip fracture. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/11/22 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15, which indicates that R1 was cognitively intact. Review of R1's Morse Fall assessment dated [DATE] revealed a score of 0 indicating R1 is at low risk for falls. Review of R1's Elopement Risk assessment dated [DATE] revealed resident is at risk for elopement. Review of R1's care plan revealed a problem area of, R1 has the potential for alteration in mood, behavior r/t placement. Goal is for R1 to accept placement as evidenced by; voicing satisfaction with room, staff, and facility related to placement. Approaches added as of 11/04/22 are for R1 to notify the nurse when leaving the floor and R1 to sign self out when leaving the facility. Record review of the nurse's progress notes dated 11/04/22 at 3:45 AM revealed CNA1 notified the nurse that resident in room [ROOM NUMBER] (R1), was not in his room. The nurse and CNA started a search of the Skyview Hall, going from room to room. R1 was not located, so the nurse then notified Unit 2 and Unit 3 of a Code White (Missing Person). An extended search was done in the basement, back stairwell and outer perimeter of the building. Record review of the nurse's progress notes dated 11/04/22 at 4:30 AM revealed the facility's Director of Nursing (DON) and Administrator were notified by phone that R1 was missing. 911 was also called. A record review of the progress note dated 11/04/22 at 4:55 AM revealed, the nurse spoke with a local police officer. Staff searched the entire building with the Police Officer. R1 was not located. The Officer advised the nurse that he could not file a missing person's report because R1 has decisional capacity, but he will continue to ride around and look for him. Record review of the progress notes dated 11/04/22 at 5:09 AM revealed, staff continues to search for R1 without locating him. R1 was located by police on 11/04/22 at 9:30 AM at Krispy Kreme about 0.7 miles from the facility. R1 was transported to Spartanburg Regional Medical Center by ambulance for evaluation, no injuries were noted. During an interview with the Administrator on 11/15/22 at 11:45 a.m. who states she received a telephone call around 4:30 a.m. Along with police, they conducted a search of the entire facility. During an interview with R1 on 11/15/22 at 11:30 AM, R1 stated that he left because he needed to get things done. R1 stated he told 2 employees that he was leaving, but they did not believe him. R1 stated he got on the elevator and walked out the front door. R1 stated he walked to Krispy Kreme to get him a cup of coffee until he decided how he was going to get to Pacolet (a town neighboring Spartanburg). R1 stated that he does not need to be in a nursing home. During an interview on 11/15/22 at 2:05 PM with CNA1 revealed she made rounds around 2:00 AM on 11/4/22 emptying R1's urinal and he was in his room, in the bed asleep, at this time. CNA1 stated that when she went back down the hall, she noticed R1 was not in his bed. She looked in the bathroom and he was not there. CNA1 stated she then went to the Nurse Supervisor and told her that R1 was not in his room, so they both looked in every room on the floor and when he could not be found, LPN called Unit 1 and Unit 2 to alert them of a Code White and we all started to look for R1 inside and outside the building. CNA1 stated that she knows that R1 has told others that he was leaving, but he never told her that. If he did, she would have reported that to the charge nurse. CNA1 also revealed R1 has tried to leave the facility before. During an interview with Social Services Director (SSD) on 11/15/22 at 2:15 PM, she stated that she spoke with R1 about the elopement and states that he informed the CNA that he was leaving, but he did not know the name of the person he told. SSD stated that R1 told her that he was going to Pacolet to see a friend. He went downstairs using the elevator and exited the building using the door, which leads to the loading docks. R1 stated that he held down the handle for 15 seconds until it unlocked and allowed him to exit. SSD stated that R1 told her he knew where he was going and never felt unsafe because he used to be homeless. R1 told SSD that he was unhappy at this facility and needed to get out for a little bit. During an interview with CNA2 on 11/15/22 at 3:35 PM, she revealed this is not the first-time resident has tried to leave therefore they put him on the 3rd floor. CNA2 stated that she checked on R1 throughout the night,however, he left in between rounds because he knew when we were busy. Several attempts were made on 11/15/22 via telephone to contact LPN1 with no success.

Based on review of the facility's policy titled Abuse, Neglect, Exploitation and Mistreatment, record review, and interviews, the facility failed to provide adequate supervision for 1 of 3 residents reviewed for Neglect related to elopement. Resident (R)1 had a successful elopement from the facility on 11/04/22 and was without supervision for an extended period. Certified Nursing Assistant (CNA)1 was making rounds at 3:45 AM on 11/04/22 and noticed that R1 was not in his room. He was last noted to be asleep in his room during the 2 AM rounds. R1 was found by the police at a local Krispy Kreme, drinking coffee, at 9:30 AM, approximately 0.7 miles away from facility. On 11/15/22 at 2:55 PM, an Immediate Jeopardy (IJ) template was provided to the facility's Administrator, notifying her that an IJ existed at F600 with an effective date of 11/04/22. On 11/15/22 at 6:10 PM, the facility provided an acceptable IJ Removal Plan. The immediacy of the IJ was removed as of 11/15/22. The IJ was lowered to a scope and severity of D for no actual harm with potential for more than minimal harm that is not immediate jeopardy. An extended survey was conducted on 11/15/22 due to the failure constituting substandard quality of care. The facility's removal plan implemented required facility wide training, in services to be conducted beginning 11/15/22 related to elopement/abuse. All staff will be re-educated by the Assistant Director of Nursing or staff development coordinator by 11/15/22. Implementation of the removal plan for F600 includes elopement risks assessments to be completed on current residents, the residents identified as being at risk care plans will be updated to reflect with interventions in place. Licensed nurses will be re-educated on the elopement risk assessment/process for accuracy and putting interventions in place based on risks identified. All staff will be re-educated on Abuse Policy. The Director of Nursing will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks and all new admissions, re-admissions and quarterly assessments will be reviewed in the morning meetings for 4 weeks beginning November 15, 2022. Implementation of the Removal Plan was verified through observations, staff interviews and record review. Findings include: Review of the facility's undated policy, titled, Abuse, Neglect, Exploitation and Mistreatment, revealed, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of the facility's face sheet revealed R1 has diagnoses including, but not limited to; anxiety, hypertension, and chronic obstructive pulmonary disorder. R1 was admitted to the facility for rehabilitation services following a hospital stay for a hip fracture. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/11/22 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15, which indicates that R1 was cognitively intact. Review of R1's Morse Fall assessment dated [DATE] revealed a score of 0 indicating R1 is at low risk for falls. Review of R1's Elopement Risk assessment dated [DATE] revealed resident is at risk for elopement. Review of R1's care plan revealed a problem area of, R1 has the potential for alteration in mood, behavior r/t placement. Goal is for R1 to accept placement as evidenced by; voicing satisfaction with room, staff, and facility related to placement. Approaches added as of 11/04/22 are for R1 to notify the nurse when leaving the floor and R1 to sign self out when leaving the facility. Record review of the nurse's progress notes dated 11/04/22 at 3:45 AM revealed CNA1 notified the nurse that resident in room [ROOM NUMBER] (R1), was not in his room. The nurse and CNA started a search of the Skyview Hall, going from room to room. R1 was not located, so the nurse then notified Unit 2 and Unit 3 of a Code White (Missing Person). An extended search was done in the basement, back stairwell and outer perimeter of the building. Record review of the nurse's progress notes dated 11/4/22 at 4:30 AM revealed the facility's Director of Nursing (DON) and Administrator were notified by phone that R1 was missing. 911 was also called. A record review of the progress note dated 11/04/22 at 4:55 AM revealed, the nurse spoke with a local police officer. Staff searched the entire building with the Police Officer. R1 was not located. The Officer advised the nurse that he could not file a missing person's report because R1 has decisional capacity, but he will continue to ride around and look for him. Record review of the progress notes dated 11/4/22 at 5:09 AM revealed, staff continues to search for R1 without locating him. R1 was located by police on 11/4/22 at 9:30 AM at Krispy Kreme about 0.7 miles from the facility. R1 was transported to Spartanburg Regional Medical Center by ambulance for evaluation, no injuries were noted. During an interview with the Administrator on 11/15/22 at 11:45 a.m. who states she received a telephone call around 4:30 a.m. Along with police, they conducted a search of the entire facility. During an interview with R1 on 11/15/22 at 11:30 AM, R1 stated that he left because he needed to get things done. R1 stated he told 2 employees that he was leaving, but they did not believe him. R1 stated he got on the elevator and walked out the front door. R1 stated he walked to Krispy Kreme to get him a cup of coffee until he decided how he was going to get to Pacolet (a town neighboring Spartanburg). R1 stated that he does not need to be in a nursing home. During an interview on 11/15/22 at 2:05 PM with CNA1 revealed she made rounds around 2:00 AM on 11/4/22 emptying R1's urinal and he was in his room, in the bed asleep, at this time. CNA1 stated that when she went back down the hall, she noticed R1 was not in his bed. She looked in the bathroom and he was not there. CNA1 stated she then went to the Nurse Supervisor and told her that R1 was not in his room, so they both looked in every room on the floor and when he could not be found, LPN called Unit 1 and Unit 2 to alert them of a Code White and we all started to look for R1 inside and outside the building. CNA1 stated that she knows that R1 has told others that he was leaving, but he never told her that. If he did, she would have reported that to the charge nurse. CNA1 also revealed R1 has tried to leave the facility before. During an interview with Social Services Director (SSD) on 11/15/22 at 2:15 PM, she stated that she spoke with R1 about the elopement and states that he informed the CNA that he was leaving, but he did not know the name of the person he told. SSD stated that R1 told her that he was going to Pacolet to see a friend. He went downstairs using the elevator and exited the building using the door, which leads to the loading docks. R1 stated that he held down the handle for 15 seconds until it unlocked and allowed him to exit. SSD stated that R1 told her he knew where he was going and never felt unsafe because he used to be homeless. R1 told SSD that he was unhappy at this facility and needed to get out for a little bit. During an interview with CNA2 on 11/15/22 at 3:35 PM, she revealed this is not the first-time resident has tried to leave therefore they put him on the 3rd floor. CNA2 stated that she checked on R1 throughout the night,however, he left in between rounds because he knew when we were busy. Several attempts were made on 11/15/22 via telephone to contact LPN1 with no success.

Based on interview and record review the facility failed to provide the necessary services and care for Resident #1's related to a change in his/her condition. The resident's temperature, increased secretions and oxygen saturations were not monitored related to a change in condition (1 of 5 resident's sampled related to a change in conditon). The findings included: Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] coded the resident's cognitive status as moderately impaired. The resident required the assistance of one for most activities of daily living, was tube fed and used a wheelchair for ambulation. Review of the Nurse's Notes from 03/06/2014 through 03/30/2014 revealed the following: 03/25/2014 3-11 shift "...Resident has had coughing episodes coughing up mucous which is process for resident suctioning required at this time. [MEDICATION NAME] tx (treatment) given...c/o (complaint of) soreness of chest r/t (related to) coughing hard at times per resident. Resident assessed per (2) nurses r/t spouse's concerns. Unit Manager called informed of conversation with wife and other issues. Resident checked on multiple times..." 03/26/2014 11-7 shift "...Resident has a productive cough with thin clear secretions after neb (nebulizer) treatment and several times before and after treatment. HOB (head of bed) is elevated..." 03/28/2014 3-11 shift 10:50 PM "temp elevated to 101. pulse 109 and resident was agitated b/c (because) bp (blood pressure) being taken, PRN (as needed) tylenol given as ordered..." 03/29/2014 11-7 shift "Resident v/s (vital signs) temp (temperature) 99.3 p (pulse) 111 R (respirations) 18 Bp (blood pressure) 158/72... breathing treatments via nebulizer tolerated... continue to monitor." Review of the SBAR Communication Form and Progress Note dated 03/29/2014 noted the physician and RP were notified at 8:45 AM that the resident's temperature was 103 (rechecked 100.6). The physician ordered a "CBC with diff, Chest x-ray, white count 10,000 or greater call MD." 3:50 PM Chest x-ray and CBC results obtained. Results indicated elevated WBC and compatibility (sic) to pneumonia. Notified on call MD new orders. [MEDICATION NAME] 300 mg (milligrams) 1 tab (tablet)... q (every) 12 hrs (hours) x 10 days and [MEDICATION NAME] 100 mg 1 tab q 12 hrs x 10 days. Notified RP while visiting resident..." 7:00 AM - 7:00 PM shift note untimed "Resident noted with temp of 100.8 orally at beginning of shift. Tylenol 325 mg 2 tabs given temp rechecked and was 97.7. Blood sample obtain for CBC, CXR ordered. Resident noted flushed to the face and warm to touch. Placed thin cover and opened window to allow air in room... Will continue to monitor." Review of the SBAR Communication Form and Progress Note dated 03/29/2014 noted the physician was notified at 11:25 PM that the resident had decreased oxygen saturation, his/her heart rate and respirations were increased and s/he was experiencing heavy breathing. The resident was noted to be pale and lethargic. The vital signs noted on the form were BP 129/77, pulse 141, RR (respiratory rate) 45, temperature 98.7 axillary; oximetry % 75 @ time on 2.5 liters oxygen. S/he was noted to have abnormal lung sounds, labored breathing and a cough. "Does not respond to touch..." 7:00 PM - 7:00 AM shift note stated, "Resident was sent out to ...hospital via ambulance per Dr.'s order. Resident was noted by nurse pale in color, swelling in the extremeities (sic) and warm to touch. O2 sat was 70% fluctuated between 70-75%. Heartrate was 141. Resident was breathing heavy with labored breathing. Resident noted with a cough with white thick secretions... When lungs were auscultated rales were heard. Resident did not respond to any questions and only sometimes opened his/her eyes when spoken to... DON (director of nursing) notified of this residents oxygen level decrease. On call doctor was notified at 11:25 PM... Ambulance left with resident at 12 AM..." Review of the Chest X-ray dated 03/29/2014 stated, "...Conclusion: Minimal consolidation adjacent to left heart margin compatible with pneumonia..." Review of the Hematology report showed the resident's white blood count (WBC) was high at 27.4 with the normal range 3.1-9.7 K/cmm (1000/cubic centimeters). Review of the MAR for 03/01/2014-03/31/2014 documented the resident received Tylenol ([MEDICATION NAME]) 2 tablets on 03/28/2014 at 6 AM; 03/29/2014 at 6 AM and 12 PM. On the back of the MAR indicated [REDACTED]..3/29 @ 6 AM Tylenol 325 mg ii tab temp 103 F; 3/29 @ 12 PM Tylenol 325 mg 2 tabs via [DEVICE] r/t temp 99.8. The post pain/temp blanks for those times were blank. The MAR indicated [REDACTED]. In an interview with the surveyor on 08/03/2014 at 4:15 PM Licensed Practical Nurse #1, who worked 03/29/2014, 7 AM-7 PM stated s/he keeps her/his own notes that were not reflected in the nurse's notes. S/he stated s/he assessed the resident. In an interview with the Director of Nursing on 08/03/2014 at 4:45 PM s/he confirmed there was no documentation showing the resident was adequately monitored related to his/her change in condition, elevated temperature, increased secretions, and oxygen saturation.

Based on record reviews, interviews, observations, the South Carolina Nursing Standard of Practice SECTION 40-33-110, the South Carolina Nurse Practice Act Laws and Policies, Chapter 33 Section 40-33-20, and the Nursing Code of Ethics Provision 4.3 the facility failed to provide the necessary services and care that meet professional standards of quality for Resident #1 related to a change in his/her condition. The resident's temperature and oxygen saturations were not monitored related to a change in condition (1 of 5 resident's sampled related to a change in condition). The facility failed to ensure that 1 of 1 resident reviewed with a [MEDICAL CONDITION] (trach) was adequately care planned regarding [MEDICAL CONDITION] care and oxygen (Resident #6). The findings included: Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] coded the resident's cognitive status as moderately impaired. The resident required the assistance of one for most activities of daily living, was tube fed and used a wheelchair for ambulation. Review of the Nurse's Notes indicated that Resident #1 on 03/28/2014 at 10:30 PM was documented with a temperature of 101 degrees; Tylenol was administered; the physician was not notified and there was no evidence that the resident's temperature or condition was monitored. On 03/29/2014 at 8:45 AM the physician was notified by the oncoming nurse of an elevated temperature of 103 degrees and an order for [REDACTED]. At 11:25 PM the resident was sent to the hospital when s/he only responded by opening his/her eyes and his/her oxygen saturation was 75%, the only oxygen saturation documented. Review of the Medication Administration Record [REDACTED]. On the back of the MAR indicated [REDACTED]..3/29 @ 6 AM Tylenol 325 mg ii tab temp 103 F; 3/29 @ 12 PM Tylenol 325 mg 2 tabs via [DEVICE] r/t (related to) temp 99.8. The post pain/temp blanks for those times were blank. The MAR indicated [REDACTED]. There was no evidence the resident was adequately monitored regarding his/her elevated temperature and oxygen saturation. Review of the Chest X-ray dated 03/29/2014 stated, "...Conclusion: Minimal consolidation adjacent to left heart margin compatible with pneumonia..." Review of the Hematology report showed the resident's white blood count (WBC) was high at 27.4 with the normal range 3.1-9.7 K/cmm (1000/cubic centimeters). In an interview with the surveyor on 08/03/2014 at 4:15 PM Licensed Practical Nurse #1, who worked 03/29/2014, 7 AM-7 PM stated s/he keeps her/his own notes that were not reflected in the nurse's notes. S/he stated s/he assessed the resident. In an interview with the Director of Nursing on 08/03/2014 at 4:45 PM s/he confirmed there was no documentation showing the resident was adequately monitored related to his/her change in condition. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Resident #6 was observed with a size 6 [MEDICAL CONDITION], oxygen at 3 liters/trach collar, continuous tube feeding, suction machine, head of bed elevated, and [MEDICAL CONDITION] at the bed side. Resident #6 did not attempt to communicate. Record review revealed the interim plan of care did not address the resident's respiratory status and [MEDICAL CONDITION] (trach). Further record review revealed no documentation of what type and size [MEDICAL CONDITION] ordered for Resident #6. The care plan did not address checking oxygen saturation. During an interview on 8/3/2014 at approximately 11:55 AM, the Director of Nursing confirmed the Interim Care Plan did not address what type and [MEDICAL CONDITION] #6 had. Review of the South Carolina Nurse Practice Act Laws and Policies, Chapter 33 Section 40-33-20(62) stated, "... 'Unprofessional conduct' means acts or behavior that fail to meet the minimally acceptable standard expected of similarly situated professionals including, but not limited to, conduct that may be harmful to the health, safety, and welfare of the public, conduct that may reflect negatively on one's fitness to practice nursing, or conduct that may violate any provision of the code of ethics adopted by the board or a specialty." Review of the Nursing Code of Ethics Provision 4.3 stated, "... nurses accept or reject specific roles based upon their education, knowledge, competence and extent of experience."

On the days of the Recertification Survey and Complaint Investigation, based on record reviews, facility files and interviews, the facility failed to provide care and services to maintain 1 of 5 residents with Fingerstick Blood Sugars and 1 of 1 residents with an injury of unknown origin.. Resident #16 did not receive appropriate, timely, treatment for [REDACTED]. The findings included: The facility admitted resident #12 with [DIAGNOSES REDACTED]. Physician's telephone orders of 5/21/13 stated, "Sent to ER (emergency room ) R/T (related to) L (left) Supracondylar Distal Femur Fracture with moderate displacement angulation for further evaluation and treatment". Review of the nurses notes revealed a note dated 5/21/13 at 4:30 PM. The nurse's note stated, "It was brought to my attention that res (resident) had bruising to L leg, bruising is primarily at back of knee where it is dark purple in coloring and this extends up and down leg fading to green and yellow in irregular pattern." The May Weekly Skin Documentation stated on 5/20/13, "Bruise and purplish blue discoloration behind the left knew extended left lower leg. Review of the medical record revealed no documentation the resident had a fall or any known trauma. Review of the facility file on the investigation of the injury of unknown origin revealed, the bruise had been reported and observed on 5/16/13 at approximately 6:00 AM by/to RN (Registered Nurse) #1. There was no documentation of the bruise in the medical record until 5/21/13. The facility investigation also revealed that on 5/18/13 a CNA (Certified Nursing Assistant) had reported the bruise to RN #2. RN #2 did not report the injury or document the injury, "resulting in delayed treatment for [REDACTED]. A telephone interview was conducted with RN #1 by the surveyor on 6/10/13 at approximately 5:53 PM. The RN stated, "On Friday, May 17 th, CNA said look at this. There was an orange size dark purple bruise on the right lower posterior thigh just above the bend of the knee." RN #1 stated s/he reported the area to another nurse and thought the other nurse would report it. RN #1 confirmed s/he did not document the bruise, did not place it on the 24 hour report and failed to do an incident report. The RN stated, "Tuesday at 6:53 they called me about the bruise. I found out after I got to work it was broken." A telephone interview was conducted by the surveyor with RN #2 on 6/11/13 at approximately 7:00 AM. RN #2 stated she worked weekends. "On morning report no one told me anything about him/her (resident #12). One of the CNAs told me that resident had a bruise. I saw an old bruise. It looked like it happened before that day. The RN confirmed s/he had been inserviced on reporting and injuries of unknown origin. A telephone interview was conducted by the surveyor with LPN (Licensed Practical Nurse) #3 on 6/11/13. The LPN was responsible for performing the body audits on resident #12 on 5/20/13. The LPN stated s/he did not finish the body audits on 5/20/13. S/he stated s/he did not do the body audits, s/he just signed them. "On 21st the CNA came back and asked me what happened. I saw the bruise." Resident was noted to have a bruise described as the size of an orange, dark purple blue on the 11-7 shift of 5/16/13. The bruise was again observed and reported to a nurse on 5/18/13. The bruise was not documented, assessed, or reported to administration until 5/21/13. Two RNs and a LPN confirmed that the bruise had been reported to them by several CNAs. The resident was discovered to have a fracture 5 days after the bruise was first identified. The facility admitted resident #16 with [DIAGNOSES REDACTED]. Review of the nurses notes dated 6/9/13 at 9:15 AM stated, "Called to resident's room by CNA (Certified Nursing Assistant) resident unresponsive. BS (Blood sugar) 36 Gluca Gon given." 9:30 AM "BS 50 resident returned to bed". 12:15 PM, "BS checked registered at 50". 12:30 PM, "BS ck'ed by another nurse from unit 3 readings obtained @ 37. [MEDICATION NAME] given by another nurse." Review of the telephone orders revealed an order on 6/9/13 at 12:30 PM to "repeat [MEDICATION NAME] IM inject. now d/t (due to)BS 37". There was no physician's order for treatment of [REDACTED]. There was no physician's order for the [MEDICATION NAME] documented as given in the AM. There was no documentation by the LPN (Licensed Practical Nurse) #1 that the physician had been notified. Review of the Physician's order Report for June revealed the order for Fingerstick blood sugars to be done at 11AM and 8:00 PM routinely. an order for [REDACTED].> (greater than) 500 or < (less than) 60. The resident was not assessed for blood sugar between 9:30 AM and 12:15 PM (2 hours and 45 minutes). The DON was interviewed by the surveyor on 6/12/13 at approximately 10:00 AM. The DON confirmed the nurse had not monitored the resident appropriately nor had the nurse called the physician. The DON confirmed the resident was not assessed until LPN #2 went to the unit to evaluate the situation. LPN #2 was interviewed by the surveyor on 6/11/13 at approximately 3:45 PM. LPN #2 stated s/he was asked to check the blood sugar of resident #11. LPN #2 stated s/he checked the sugar and it was 37. "I gave her [MEDICATION NAME] and it came up to 104." LPN #2 stated the doctor and the family were notified. "When the lady's blood sugar came up s/he was coming back to herself. I told the CNA to feed the resident lunch and make sure s/he ate.

On the days of the Recertification and Complaint Survey, the facility failed to provide services that met professional standards of practice for 4 of 15 residents sampled. Resident #4 and #11's physcian's orders were not followed. Resident #12 was not assessed for injury of unknown origin. Resident # 16 did not receive timely services/assessment for hypoglycemic reaction. The findings included: The facility admitted Resident #12 with [DIAGNOSES REDACTED]. Physician's telephone orders of 5/21/13 stated, "Sent to ER (emergency room ) R/T (related to) L (left) Suprcondylar Distal Femur Fracture with moderate displacement angulation for further evaluation and treatment". Review of the nurses notes revealed a note dated 5/21/13 at 4:30 PM. The nurse's note stated, "It was brought to my attention that res (resident) had bruising to L leg, bruising is primarily at back of knee where it is dark purple in coloring and this extends out up and down leg fading to green and yellow in irregular pattern." The May Weekly Skin Documentation stated on 5/20/13, Bruise and purplish blue discoloration behind the left knee. Review of the medical record revealed no documentation the resident had a fall or any known trauma. Review of the facility file on the investigation of the injury of unknown origin revealed, the bruise had been reported and observed on 5/16/13 at approximately 6:00 AM by/to RN (Registered Nurse) #1. There was no documentation of the bruise in the medical record until 5/21/13. The facility investigation also revealed that on 5/18/13 a CNA (Certified Nursing Assistant) had reported the bruise to RN #2. RN #2 did not report the injury or document the injury, "resulting in delayed treatment for [REDACTED]. A telephone interview was conducted with RN #1 by the surveyor on 6/10/13 at approximately 5:53 PM. The RN stated, "On Friday, May 17 th, CNA said look at this. There was an orange size dark purple bruise on the right lower posterior thigh just above the bend of the knee." RN #1 stated she reported the area to another nurse and thought the other nurse would report it. RN #1 confirmed she did not document the bruise, did not place it on the 24 hour report and failed to do an incident report. The RN stated, "Tuesday at 6:53 they called me about the bruise. I found out after I got to work it was broken." A telephone interview was conducted by the surveyor with RN #2 on 6/11/13 at approximately 7:00 AM. RN #2 stated she worked weekends. "On morning report no one told me anything about him/her (resident #12). One of the CNAs told me that resident had a bruise. I saw an old bruise. It looked like it happened before that day. The RN confirmed she had been inserviced on reporting and injuries of unknown origin. A telephone interview was conducted by the surveyor with LPN (Licensed Practical Nurse) #3 on 6/11/13. The LPN was responsible for performing the body audits on resident #12 on 5/20/13. The LPN stated s/he did not finish the body audits on 5/20/13. S/he stated s/he did not do the body audits, s/he just signed them. "On 21st the CNA came back and asked me what happened. I saw the bruise." Resident was noted to have a bruise described as the size of an orange, dark purple on the 11-7 shift of 5/16/13. The bruise was again observed and reported to a nurse on 5/18/13. The bruise was not documented, or assessed until 5/21/13. Two RNs and a LPN confirmed that the bruise had been reported to them by several CNAs. Licensed Nurses failed to assess the resident's injury for five days. The resident was discovered to have a fracture 5 days after the bruise was first identified. Appropriate treatment was not rendered to the resident until 5/21/13. The facility admitted Resident #11 with [DIAGNOSES REDACTED]. Review of the resident's Medication flowsheet revealed s/he had [MEDICATION NAME]es, 12 mcg (microgram)/hour ordered to be given every three days for pain. The [MEDICATION NAME] Patch was signed as given on 11/17/12. S/he was scheduled to receive the patch again on 11/20/12, 11/23/12 and 11/26/12. The medication was not signed as given. Review of the narcotic declining inventory sheet for November 2012 revealed the medication had not been signed out of the narcotics box. Review of the facility file on the incident revealed that there was no documentation of a reason for withholding the pain medication. There was no evidence Resident # 11 recieved physician ordered pain medication from 11/19 through 11/26/12. The Director of Nursing (DON) was interviewed by the surveyor on 6/12/13 at approximately 10:00 AM. The DON confirmed the resident had not received the ordered pain medication. The DON stated the residents spouse would say the resident was in pain, but the resident did not speak. The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Review of the nurses notes dated 6/9/13 at 9:15 AM stated, "Called to resident's room by CNA (Certified Nursing Assistant) resident unresponsive. BS (Blood Sugar) 36 Gluca Gon given." 9:30 AM "BS 50 resident returned to bed". 12:15 PM, "BS checked registered at 50". 12:30 PM, "BS ck'ed (checked) by another nurse from unit 3 readings obtained @ 37. [MEDICATION NAME] given by another nurse." Review of the telephone orders revealed an order on 6/9/13 at 12:30 PM to "repeat [MEDICATION NAME] IM inject. now d/t (due to) BS 37". There was no physician's order for treatment of [REDACTED]. There was no documentaion by the LPN (Licensed Practical Nurse) #1 that the physician had been notified. Review of the Physician's order Report for June revealed orders for a Fingerstick blood sugars to be done at 11AM and 8:00 PM routinely. an order for [REDACTED].> (greater than) 500 or < (less than) 60. The resident was not assessed for stability of his/her blood sugar between 9:30 AM and 12:15 PM (2 hours and 45 minutes). The DON was interviewed by the surveyor on 6/12/13 at approximately 10:00 AM. The DON confirmed the nurse had not monitored the resident appropriately nor was there evidence the nurse called the physician. The DON confirmed the resident was not assessed until LPN #2 went to the unit to evaluate the situation. LPN #2 was interviewed by the surveyor on 6/11/13 at approximately 3:45 PM. LPN #2 stated s/he was asked to check the blood sugar of Resident #11. LPN #2 stated s/he checked the sugar and it was 37. "I gave her [MEDICATION NAME] and it came up to 104. LPN #2 stated the doctor and the family were notified. "When the lady's blood sugar came up, s/he was coming back to herself. I told the CNA to feed the resident lunch and make sure s/he ate. Resident #16 was noted to be unresponsive. The resident's blood sugar was checked and found to be extremely low at 37. The resident had an order for [REDACTED]. 15 minutes later the resident's blood sugar was noted to be 50, again under 60. The MD was not notified. The blood sugar was not checked again for 2 hours and 45 minutes. At 12:15 pm the blood sugar was again noted to be 50, below 60. Thee was no evidence that the nursenotified the MD of the continuously low blood sugar, nor continued to monitor the resident's blood sugar. The facility admitted resident #4 on 07/8/2011 with [DIAGNOSES REDACTED]. On 06/11/2013, a review of the resident's clinical record revealed a recommendation by the Pharmacy Consultant dated 12/31/2012 to consider discontinuing [MEDICATION NAME] OTC to an alternative therapy. The report further stated that these medications were associated with the risk of Torade de Pointes or prolonged QT waves. The physician signed the recommendation on 01/11/2013 to discontinue the [MEDICATION NAME] OTC and start [MEDICATION NAME] 150 milligrams two times a day. The facility failed to transcribe and implement the order. During an interview on 06/12/2013 at 12:10 PM with the Unit Manager concerning how Pharmacy Recommendations were handled, s/he stated "the nurse on the unit is responsible for carrying out any orders" and confirmed that the resident remained on the [MEDICATION NAME] OTC and [MEDICATION NAME].